Inspection Reports for The Center For Rehab & Nursing Washington Township
535 Egg Harbor Road, NJ, 08080
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 157
Capacity: 190
Deficiencies: 9
Nov 22, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and review of staffing and care practices.
Findings
The facility was found not in compliance with several federal and state regulations, including resident rights, exercise of rights, reporting of alleged violations, care planning, staffing, infection control, food safety, and abuse prevention. Deficiencies were cited related to dignity in dining, failure to report allegations timely, insufficient nursing staff, inadequate care planning, and infection control practices.
Complaint Details
The survey included complaint investigations for multiple complaint numbers. Findings included failure to report allegations timely, inadequate investigation documentation, and failure to protect residents from abuse and neglect. The complaints were substantiated as evidenced by cited deficiencies.
Severity Breakdown
Level D: 7
Level F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents' dining experience promoted dignity and respect, with residents not served meals simultaneously at the same table. | Level D |
| Failure to document resident's advance directives and preferences on physician's orders. | Level D |
| Failure to report allegations of abuse, neglect, exploitation, or mistreatment timely to appropriate authorities. | Level D |
| Failure to provide sufficient nursing staff to meet residents' needs and maintain highest practicable well-being. | Level F |
| Failure to maintain food safety standards including proper storage and sanitation in kitchen and pantries. | Level F |
| Failure to maintain infection prevention and control program including hand hygiene compliance. | Level D |
| Failure to provide adequate care planning and timely updates to residents' comprehensive care plans. | Level D |
| Failure to ensure residents' rights to refuse or discontinue treatment and participate in advance directives. | Level D |
| Failure to ensure adequate supervision and assistance devices to prevent accidents and injuries. | Level D |
Report Facts
Census: 157
Total Capacity: 190
Deficiencies cited: 9
Staffing ratios: 1.8
Staffing ratios: 1.1
Staffing ratios: 1.14
Certified Nurse Aide staffing: 13
Certified Nurse Aide staffing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in infection control and wound care deficiencies related to hand hygiene and treatment cart handling. |
| RN #1 | Registered Nurse | Named in care planning and investigation deficiencies related to resident care and documentation. |
| CNA #7 | Certified Nursing Assistant | Named in abuse investigation and resident care deficiencies. |
| Director of Nursing | Named in staffing and care plan audit deficiencies. | |
| Administrator | Named in staffing and abuse investigation oversight. | |
| Food Service Director | Named in food safety deficiencies related to food storage and sanitation. |
Inspection Report
Routine
Census: 90
Deficiencies: 15
Aug 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights, Medicaid/Medicare coverage notices, PASARR coordination, care plan revisions, professional standards in care, pharmacy services, food safety, infection control, life safety code compliance, and quality assurance.
Complaint Details
Complaint #NJ00165706 involved failure to maintain minimum direct care staff-to-resident ratios for day shift during 07/02/23 through 07/15/23.
Severity Breakdown
SS=D: 11
SS=E: 5
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility failed to provide privacy and promote dignity during resident assessment in the dining room. | SS=D |
| Facility failed to issue proper Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for residents discharged from Medicare Part A stay. | SS=D |
| Facility failed to conduct new PASARR level 1 assessment after resident was newly diagnosed with a serious condition. | SS=D |
| Facility failed to revise a resident's comprehensive care plan to reflect discontinued use of equipment. | SS=D |
| Facility failed to follow professional nursing standards including obtaining physician orders, clarifying duplicate medication orders, and completing weekly assessments. | SS=E |
| Facility failed to provide required Medicaid/Medicare coverage notices timely and accurately. | SS=D |
| Facility failed to follow professional standards for medication administration and documentation. | SS=E |
| Facility failed to ensure medications were appropriately labeled and checked for expiration prior to administration. | SS=D |
| Facility failed to ensure drug regimen was free from unnecessary drugs and failed to monitor behaviors related to psychoactive medications. | SS=D |
| Facility failed to label and store drugs and biologicals properly and failed to secure medication carts. | SS=D |
| Facility failed to store, label, and date potentially hazardous food and maintain kitchen sanitation. | SS=F |
| Facility failed to comply with licensure requirements including notifying CMS of facility name change and using unapproved facility name. | — |
| Facility failed to maintain required minimum direct care staff-to-resident ratios for day shift during complaint and standard survey periods. | — |
| Facility failed to meet Life Safety Code requirements for egress doors, emergency lighting, exit signage, hazardous area enclosures, fire alarm system installation, sprinkler system installation, and electrical system safety. | SS=E |
| Facility failed to implement infection control protocols including proper hand hygiene during care and meal tray distribution. | SS=E |
Report Facts
CNA staffing deficiency days: 6
CNA staffing deficiency days: 5
Residents census: 90
Milk cartons without expiration dates: 225
Deficient day shifts: 6
Deficient day shifts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed leaving medication cart unlocked during treatment preparation. |
| LPN #1 | Licensed Practical Nurse | Observed improper hand hygiene during treatment and meal tray distribution. |
| CNA #1 | Certified Nursing Assistant | Observed improper hand hygiene during meal tray distribution. |
| DON | Director of Nursing | Interviewed regarding infection control and staffing. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding QAA meetings and facility name change. |
| DBS | Director of Building Services | Interviewed regarding fire safety deficiencies. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 1
Mar 29, 2022
Visit Reason
The inspection was conducted in response to complaint NJ149078 regarding staffing ratios at Jefferson Health Care Center.
Findings
The facility failed to meet the required minimum staffing ratios for Certified Nurse's Aides (CNAs) on 3 of 14 day shifts, specifically on 09/08/21, 09/17/21, and 09/18/21, potentially affecting all residents.
Complaint Details
Complaint NJ149078 was substantiated based on facility document review showing CNA staffing deficiencies on specified dates.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios for Certified Nurse's Aides on 3 of 14 day shifts. |
Report Facts
Census: 113
Deficient shifts: 3
Sample size: 3
Required CNA staffing: 10
Actual CNA staffing: 9
Required CNA staffing: 13
Actual CNA staffing: 12
Required CNA staffing: 13
Actual CNA staffing: 10
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Sep 5, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144196, NJ145401, NJ147032, NJ147323, and NJ147761.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ144196, NJ145401, NJ147032, NJ147323, NJ147761 were investigated and found to be in compliance.
Report Facts
Sample Size: 11
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 4
Jun 25, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to administer medication according to professional standards, failure to maintain a safe environment to prevent accidents, failure to provide appropriate care for bowel/bladder incontinence, and failure to properly dispose of garbage and refuse.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to administer medication in accordance with professional standards; a medication that should not be crushed was crushed and administered to Resident #37. | SS=D |
| Failed to ensure resident environment was free of accident hazards; Resident #28 did not have bilateral floor mats placed as ordered. | SS=D |
| Failed to provide appropriate treatment and services related to bowel/bladder care; Resident #14's care items were observed touching the floor contrary to facility policy. | SS=D |
| Failed to dispose of garbage and refuse properly; garbage container area was littered with debris and one garbage container was uncovered. | SS=D |
Report Facts
Census: 93
Sample Size: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and accident hazard findings |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed administering medication and interviewed regarding resident care |
| Certified Nurse Assistant | Certified Nurse Assistant | Interviewed regarding care of Resident #28 |
| Director of Dietary | Director of Dietary | Interviewed regarding garbage disposal practices |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding garbage disposal practices |
| Clinical Educator | Clinical Educator | Provided education to nursing and housekeeping staff on medication crushing, accident prevention, and bowel/bladder care |
Inspection Report
Life Safety
Deficiencies: 5
Jun 16, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/16/21 and 06/17/21 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including improper signage on delayed egress doors, lack of emergency lighting in mechanical/electrical rooms, inadequate fire alarm notification in one courtyard, deficiencies in sprinkler system maintenance with gaps around sprinkler heads, and smoke barrier doors not fully closing to resist smoke passage.
Severity Breakdown
SS=E: 4
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure that the 15-second delayed egress feature on two exit discharge doors were provided with signs that correctly identified this feature. | SS=E |
| Failed to provide emergency lighting in two mechanical/electrical rooms independent of the building's electrical system and emergency generator. | SS=E |
| Failed to provide notification by audible and visible signals in one enclosed courtyard as required by fire alarm system standards. | SS=E |
| Failed to maintain the sprinkler system by ensuring the ceiling level was smoke resistant; multiple gaps and improper sprinkler head installations were observed in 13 sprinkler system areas. | SS=E |
| Failed to provide smoke barrier wall doors that completely closed to resist the passage of smoke, flame, or gases during a fire; gaps were observed in 2 of 6 sets of smoke doors. | SS=D |
Report Facts
Delayed egress doors with missing signage: 2
Mechanical/electrical rooms without emergency lighting: 2
Sprinkler system areas with smoke resistance issues: 13
Sets of smoke barrier doors with gaps: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and verified findings related to delayed egress door signage, emergency lighting, fire alarm notification, sprinkler system, and smoke barrier doors. | |
| Facility Manager | Responsible for education and audits related to corrective actions for all cited deficiencies. | |
| Administrator | Informed of findings during the Life Safety Code survey exit conference on 06/17/21. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 2, 2021
Visit Reason
The inspection was conducted based on Complaint Intake #NJ138965 regarding failure to ensure staffing ratios were met for 3 of 42 shifts reviewed.
Findings
The facility failed to meet the required certified nursing assistant to resident ratios on 3 shifts (5/26/21, 5/29/21, and 6/2/21), potentially affecting all residents. The facility took multiple corrective actions including increased pay rates, sign-on bonuses, use of agency staff, and a voluntary ban on new admissions.
Complaint Details
Complaint Intake #NJ138965 regarding staffing ratio deficiencies was substantiated as the facility failed to meet staffing ratios on 3 shifts.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 3 of 42 shifts reviewed, specifically not meeting the 8 to 1 CNA to resident ratio on day shifts. |
Report Facts
Shifts noncompliant with staffing ratios: 3
Total shifts reviewed: 42
Staff to resident ratio on 05/26/2021: 9.5
Staff to resident ratio on 05/29/2021: 9.2
Staff to resident ratio on 06/02/2021: 8.7
Inspection Report
Routine
Census: 90
Deficiencies: 0
Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 4
Nov 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to concerns about the facility's compliance with infection control regulations related to COVID-19, specifically regarding identification and management of residents exposed to COVID-19 and appropriate use of PPE.
Findings
The facility failed to implement mitigation strategies to prevent COVID-19 transmission by not appropriately identifying exposed residents as persons under investigation (PUI), not implementing appropriate PPE according to CDC guidelines, not posting proper signage for isolation precautions, and not educating staff on infection control measures. This failure posed an immediate jeopardy to resident safety. The facility submitted and implemented an acceptable removal plan, and education and monitoring were initiated.
Complaint Details
The investigation was complaint-driven due to a COVID-19 outbreak linked to failure in infection control practices, including improper cohorting, PPE use, and staff education. The facility was notified of Immediate Jeopardy on 11/25/2020 and submitted a removal plan on 11/27/2020, which was verified on 11/30/2020.
Severity Breakdown
Immediate Jeopardy: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to appropriately identify residents exposed to COVID-19 as persons under investigation (PUI). | Immediate Jeopardy |
| Failure to implement appropriate PPE according to CDC guidelines after discovery of exposed residents. | Immediate Jeopardy |
| Failure to post proper signage to identify residents exposed to COVID-19 as PUI and the type of isolation precautions necessary. | Immediate Jeopardy |
| Failure to educate staff on appropriate infection control measures upon discovery of exposed residents. | Immediate Jeopardy |
Report Facts
Census: 126
Sample size: 6
Date of survey completion: Nov 30, 2020
Date of survey visit: Nov 25, 2020
Date removal plan submitted: Nov 27, 2020
Date removal plan verified: Nov 30, 2020
Audit frequency: 5
Report
Mar 6, 2025
File
20250306-COMPLAINT-11LU11.pdf
Report
Jan 13, 2022
File
20220113-ROUTINE-EFVK11.pdf
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