Inspection Reports for The Center For Rehab & Nursing Washington Township

535 Egg Harbor Road, Sewell, NJ, 08080

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Inspection Report Summary

The most recent inspection on November 19, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies related to staffing ratios, infection control, care planning, food safety, and maintaining a safe, homelike environment. Several complaint investigations were substantiated, including issues with pressure ulcer prevention, call bell response, and timely reporting of abuse allegations, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility previously faced an immediate jeopardy finding in November 2020 related to COVID-19 infection control but implemented an acceptable removal plan. The inspection history suggests ongoing challenges in staffing and care processes, though recent findings indicate some improvement.

Deficiencies (last 6 years)

Deficiencies (over 6 years) 7.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

50% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

16 12 8 4 0
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 162 residents

Based on a March 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

60 90 120 150 180 210 Nov 2020 Jun 2021 Jan 2022 Aug 2023 Mar 2025

Notice

Deficiencies: 0 Date: 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
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Complaint Investigation
Census: 162 Deficiencies: 8 Date: Mar 6, 2025

Visit Reason
The inspection was conducted based on complaints NJ182689, NJ182815, and NJ184057 regarding the facility's compliance with regulatory requirements for long term care facilities.

Complaint Details
The complaint investigation was substantiated with multiple deficiencies identified related to complaints NJ182689, NJ182815, and NJ184057. Issues included lack of clean linens, inadequate care plan updates, pressure ulcer prevention failures, food safety violations, infection control lapses, and call bell system failures.
Findings
The facility was found not in substantial compliance with requirements related to safe environment, comprehensive care plans, skin integrity, food safety, infection prevention and control, and resident call system. Deficiencies were identified in maintaining a homelike environment, updating care plans, preventing pressure ulcers, food item dating, infection control practices, and timely response to call bells.

Deficiencies (8)
Failure to maintain a safe, clean, comfortable, and homelike environment including access to clean linens.
Failure to develop and revise comprehensive care plans for residents.
Failure to ensure treatment cart was secured and properly documented during medication administration.
Failure to prevent and heal pressure ulcers consistent with professional standards.
Failure to ensure food safety requirements including proper dating and storage of food items.
Failure to maintain an effective infection prevention and control program, including proper disposal of unused treatment items.
Failure to ensure resident call system communicated calls promptly to staff.
Failure to maintain adequate staffing ratios as required by state regulations.
Report Facts
Census: 162 Sample Size: 8 Deficient CNA staffing shifts: 5 CNA staffing required: 19 CNA staffing actual: 17

Inspection Report

Annual Inspection
Census: 157 Capacity: 190 Deficiencies: 9 Date: 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.

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.
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.

Deficiencies (9)
Failure to ensure residents' dining experience promoted dignity and respect, with residents not served meals simultaneously at the same table.
Failure to document resident's advance directives and preferences on physician's orders.
Failure to report allegations of abuse, neglect, exploitation, or mistreatment timely to appropriate authorities.
Failure to provide sufficient nursing staff to meet residents' needs and maintain highest practicable well-being.
Failure to maintain food safety standards including proper storage and sanitation in kitchen and pantries.
Failure to maintain infection prevention and control program including hand hygiene compliance.
Failure to provide adequate care planning and timely updates to residents' comprehensive care plans.
Failure to ensure residents' rights to refuse or discontinue treatment and participate in advance directives.
Failure to ensure adequate supervision and assistance devices to prevent accidents and injuries.
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
NameTitleContext
LPN #7Licensed Practical NurseNamed in infection control and wound care deficiencies related to hand hygiene and treatment cart handling.
RN #1Registered NurseNamed in care planning and investigation deficiencies related to resident care and documentation.
CNA #7Certified Nursing AssistantNamed in abuse investigation and resident care deficiencies.
Director of NursingNamed in staffing and care plan audit deficiencies.
AdministratorNamed in staffing and abuse investigation oversight.
Food Service DirectorNamed in food safety deficiencies related to food storage and sanitation.

Inspection Report

Routine
Census: 90 Deficiencies: 15 Date: Aug 21, 2023

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

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.
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.

Deficiencies (15)
Facility failed to provide privacy and promote dignity during resident assessment in the dining room.
Facility failed to issue proper Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for residents discharged from Medicare Part A stay.
Facility failed to conduct new PASARR level 1 assessment after resident was newly diagnosed with a serious condition.
Facility failed to revise a resident's comprehensive care plan to reflect discontinued use of equipment.
Facility failed to follow professional nursing standards including obtaining physician orders, clarifying duplicate medication orders, and completing weekly assessments.
Facility failed to provide required Medicaid/Medicare coverage notices timely and accurately.
Facility failed to follow professional standards for medication administration and documentation.
Facility failed to ensure medications were appropriately labeled and checked for expiration prior to administration.
Facility failed to ensure drug regimen was free from unnecessary drugs and failed to monitor behaviors related to psychoactive medications.
Facility failed to label and store drugs and biologicals properly and failed to secure medication carts.
Facility failed to store, label, and date potentially hazardous food and maintain kitchen sanitation.
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.
Facility failed to implement infection control protocols including proper hand hygiene during care and meal tray distribution.
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
NameTitleContext
RN #1Registered NurseObserved leaving medication cart unlocked during treatment preparation.
LPN #1Licensed Practical NurseObserved improper hand hygiene during treatment and meal tray distribution.
CNA #1Certified Nursing AssistantObserved improper hand hygiene during meal tray distribution.
DONDirector of NursingInterviewed regarding infection control and staffing.
LNHALicensed Nursing Home AdministratorInterviewed regarding QAA meetings and facility name change.
DBSDirector of Building ServicesInterviewed regarding fire safety deficiencies.

Inspection Report

Complaint Investigation
Census: 113 Deficiencies: 1 Date: Mar 29, 2022

Visit Reason
The inspection was conducted in response to complaint NJ149078 regarding staffing ratios at Jefferson Health Care Center.

Complaint Details
Complaint NJ149078 was substantiated based on facility document review showing CNA staffing deficiencies on specified dates.
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.

Deficiencies (1)
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

Census: 84 Deficiencies: 0 Date: Jan 13, 2022

Visit Reason
An on-site inspection was conducted following a facility reportable event where a vehicle hit and entered the building and repair work had been completed.

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 on-site visit.

Inspection Report

Complaint Investigation
Census: 80 Deficiencies: 0 Date: Sep 5, 2021

Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144196, NJ145401, NJ147032, NJ147323, and NJ147761.

Complaint Details
Complaint numbers NJ144196, NJ145401, NJ147032, NJ147323, NJ147761 were investigated and found to be in compliance.
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.

Report Facts
Sample Size: 11

Inspection Report

Annual Inspection
Census: 93 Deficiencies: 4 Date: 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.

Deficiencies (4)
Failed to administer medication in accordance with professional standards; a medication that should not be crushed was crushed and administered to Resident #37.
Failed to ensure resident environment was free of accident hazards; Resident #28 did not have bilateral floor mats placed as ordered.
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.
Failed to dispose of garbage and refuse properly; garbage container area was littered with debris and one garbage container was uncovered.
Report Facts
Census: 93 Sample Size: 23

Employees mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding medication administration and accident hazard findings
Licensed Practical NurseLicensed Practical NurseObserved administering medication and interviewed regarding resident care
Certified Nurse AssistantCertified Nurse AssistantInterviewed regarding care of Resident #28
Director of DietaryDirector of DietaryInterviewed regarding garbage disposal practices
Director of HousekeepingDirector of HousekeepingInterviewed regarding garbage disposal practices
Clinical EducatorClinical EducatorProvided education to nursing and housekeeping staff on medication crushing, accident prevention, and bowel/bladder care

Inspection Report

Life Safety
Deficiencies: 5 Date: 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.

Deficiencies (5)
Failed to ensure that the 15-second delayed egress feature on two exit discharge doors were provided with signs that correctly identified this feature.
Failed to provide emergency lighting in two mechanical/electrical rooms independent of the building's electrical system and emergency generator.
Failed to provide notification by audible and visible signals in one enclosed courtyard as required by fire alarm system standards.
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.
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.
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
NameTitleContext
Maintenance DirectorPresent during observations and verified findings related to delayed egress door signage, emergency lighting, fire alarm notification, sprinkler system, and smoke barrier doors.
Facility ManagerResponsible for education and audits related to corrective actions for all cited deficiencies.
AdministratorInformed of findings during the Life Safety Code survey exit conference on 06/17/21.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: 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.

Complaint Details
Complaint Intake #NJ138965 regarding staffing ratio deficiencies was substantiated as the facility failed to meet staffing ratios on 3 shifts.
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.

Deficiencies (1)
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 Date: 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 Date: 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.

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.
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.

Deficiencies (4)
Failure to appropriately identify residents exposed to COVID-19 as persons under investigation (PUI).
Failure to implement appropriate PPE according to CDC guidelines after discovery of exposed residents.
Failure to post proper signage to identify residents exposed to COVID-19 as PUI and the type of isolation precautions necessary.
Failure to educate staff on appropriate infection control measures upon discovery of exposed residents.
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

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