Inspection Reports for Trenton Gardens Rehabilitation And Nursing Center
512 Union Street, NJ, 08611
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Inspection Report
Annual Inspection
Census: 144
Capacity: 230
Deficiencies: 12
May 10, 2024
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 accident hazards, food safety and temperature, infection prevention and control, staffing ratios, use of disposable dishware, and multiple life safety code violations including fire door hardware and sprinkler system maintenance.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure policy was followed to screen and assess a resident for ability to smoke safely, resulting in inadequate supervision and care planning. | SS=D |
| Failed to ensure food was served at safe and appetizing temperatures for 3 of 4 meals observed on one nursing unit. | SS=D |
| Failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, including expired and improperly stored food items. | SS=E |
| Failed to establish and maintain an infection prevention and control program, including failure to perform hand hygiene during medication administration and meal service, and failure to maintain sanitizer dispensers. | SS=E |
| Failed to maintain required minimum direct care staff-to-resident ratios for 14 of 42 shifts reviewed. | — |
| Failed to provide all residents with nondisposable dishware and drinkware for meals. | — |
| Stairway exit door equipped with panic hardware instead of required fire exit hardware. | SS=F |
| Boiler room sprinkler pipe penetration not sealed with fire rated material. | SS=F |
| Failed to ensure sprinkler system control valves, water flow alarms, and tamper switches were inspected and tested annually. | SS=F |
| Low voltage wiring under seven feet was not protected in conduit. | SS=F |
| Failed to ensure fire doors were inspected annually by qualified personnel and lacked inspection tags. | SS=F |
| Failed to ensure electrical outlet testing was conducted annually. | SS=F |
Report Facts
Census: 144
Total Capacity: 230
Shifts with insufficient staffing: 14
Residents receiving disposable containers: 12
Insulated bases counted: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Observed failing to perform proper hand hygiene during medication administration and sterile procedures | |
| Licensed Practical Nurse (LPN #5) | Observed failing to perform hand hygiene before and after medication administration | |
| Certified Nursing Assistant (CNA #1) | Observed failing to perform hand hygiene before and after resident care | |
| Certified Nursing Assistant (CNA #2) | Observed failing to perform hand hygiene before and after resident care | |
| Director of Nursing | Interviewed regarding staffing and infection control policies | |
| Maintenance Director | Interviewed regarding fire safety deficiencies and corrective actions | |
| Dietary Director | Interviewed regarding food service deficiencies | |
| Licensed Nursing Home Administrator | Interviewed regarding staffing and food service deficiencies |
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 3
Jun 14, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00158370 and NJ00159167 regarding compliance with New Jersey Administrative Code and federal regulations for long term care facilities.
Findings
The facility was found deficient in meeting minimum staffing ratios on multiple days, failing to develop and implement comprehensive care plans for residents, and failing to consistently document residents' activities of daily living (ADL) care in the medical records. These deficiencies affected all residents and posed risks to care quality and compliance.
Complaint Details
Complaint numbers NJ00158370 and NJ00159167 triggered this complaint investigation survey. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on these complaints.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure staffing ratios were met for 6 of 28 day shifts reviewed, potentially affecting all residents. | — |
| Failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents reviewed. | SS=D |
| Failed to maintain complete, accurate, and accessible medical records including documentation of residents' activities of daily living for 4 of 4 residents reviewed. | SS=E |
Report Facts
Census: 151
Staffing deficiency days: 6
Sample size: 4
Staffing shortfalls: 1
Staffing shortfalls: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding staffing and care plan deficiencies. | |
| Assistant Licensed Nursing Home Administrator | Interviewed regarding staffing and recruitment efforts. | |
| Human Resources Director | Interviewed regarding staffing and recruitment efforts. | |
| Licensed Practical Nurse/Unit Manager | Interviewed regarding care plan and ADL documentation deficiencies. | |
| Certified Nursing Assistant #1 | Interviewed regarding ADL care and documentation practices. |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Mar 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to an Immediate Jeopardy situation where Resident #1 exited the facility without staff knowledge and was found deceased outside the facility.
Findings
The facility failed to ensure adequate supervision and effective audible alarms on exit doors, resulting in Resident #1 leaving the facility unnoticed and subsequently dying. The facility implemented a corrective action plan including increased supervision, alarm system improvements, staff training, and policy revisions, which were verified as completed prior to the survey entrance.
Complaint Details
Complaint Intake #NJ162088. The Immediate Jeopardy was related to inadequate supervision and accident hazards, specifically the lack of an effective audible alarm on an exit door and failure to prevent Resident #1 from exiting the facility unnoticed, resulting in death.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and effective audible alarms on exit doors to prevent Resident #1 from leaving the facility unnoticed. | SS=J |
Report Facts
Resident census: 145
Sample size: 5
Time of incident: 2145
Speed limit: Speed limit on road where incident occurred (miles per hour, exact number redacted)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Supervising nurse on duty when Resident #1 exited the facility; provided witness statement and involved in corrective action |
| LPN #8 | Licensed Practical Nurse | On duty during incident; provided witness statement and involved in corrective action |
| LPN #9 | Licensed Practical Nurse | Charge nurse on duty during incident; provided witness statement and involved in corrective action |
| CNA #11 | Certified Nurse Aide | On duty during incident; provided witness statement and involved in corrective action |
| CNA #12 | Certified Nurse Aide | On duty during incident; provided witness statement and involved in corrective action |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy situation; involved in corrective action and interviews |
| Maintenance Director | Maintenance Director | Responsible for door alarm checks and maintenance; involved in corrective action |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in resident risk assessments and corrective action |
Inspection Report
Annual Inspection
Census: 132
Deficiencies: 14
Apr 14, 2022
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 advance directives education and documentation, Medicaid/Medicare coverage notices, care plan implementation, medication administration, assistive devices for eating, food safety, COVID-19 vaccination tracking, staffing ratios, resident activities, and life safety code compliance including emergency lighting, fire extinguisher maintenance, hazardous area door closures, and laundry chute door latches.
Severity Breakdown
SS=D: 6
SS=B: 1
SS=E: 5
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to inform and offer educational material regarding advance directives and ensure life-sustaining treatment wishes were reviewed and documented consistently for residents. | SS=D |
| Failed to issue required Notice to Medicare Provider Non-coverage (NOMNC) for residents discharged with benefit days remaining. | SS=B |
| Failed to implement care plan interventions for residents, including fall prevention measures and updating care plans after incidents. | SS=D |
| Failed to ensure medication administration was properly observed and documented; medications were left unattended. | SS=D |
| Failed to provide adaptive eating equipment (Kennedy cup) as ordered for resident meals. | SS=D |
| Failed to maintain kitchen sanitation including cleaning of three bay sink, covering trash receptacles, and discarding spoiled bread. | SS=D |
| Failed to track and securely document COVID-19 vaccination status for all staff including contracted hires and volunteers. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios on 2 of 42 shifts reviewed. | — |
| Failed to provide residents with two evening activity programs per week for 3 months reviewed. | — |
| Failed to provide continuous illumination of means of egress with two lamps for 2 of 9 exit discharge doors. | SS=E |
| Failed to provide battery backup emergency lighting above emergency generator transfer switches and generator room. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions. | SS=E |
| Failed to perform and document monthly visual inspection of fire extinguishers on 4 of 26 extinguishers. | SS=E |
| Failed to ensure laundry chute access doors closed and positively latched to maintain 1-hour fire protection rating. | SS=E |
Report Facts
Census: 132
Sample size: 27
Sample size: 3
Deficiencies cited: 4
Staffing ratio: 15
Staffing ratio: 13
BIMS score: 0
Room size: 375
Fire extinguisher count: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding advance directives education and documentation | |
| Director of Social Services | Interviewed regarding advance directives education and documentation | |
| Assistant Director of Nursing | Interviewed regarding advance directives education and documentation | |
| Licensed Practical Nurse/Unit Manager | Interviewed regarding advance directives and care plan implementation | |
| Director of Nursing | Interviewed regarding advance directives, care plans, medication administration, and meal tray accuracy | |
| Food Service Director | Interviewed regarding meal tray preparation and adaptive equipment | |
| Licensed Nursing Home Administrator | Interviewed regarding staffing, COVID-19 vaccination tracking, and life safety code findings | |
| Director of Facility Maintenance | Interviewed regarding life safety code deficiencies and corrective actions | |
| Licensed Practical Nurse #1 | Interviewed regarding medication administration | |
| Licensed Practical Nurse #2 | Interviewed regarding medication administration | |
| Certified Nursing Aide #1 | Interviewed regarding resident care and transfers | |
| Certified Nursing Aide #2 | Interviewed regarding resident care and transfers |
Inspection Report
Life Safety
Deficiencies: 5
Apr 14, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 04/12 and 04/13/2022 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including illumination of means of egress, emergency lighting, hazardous area enclosures, portable fire extinguisher maintenance, and proper fire protection of laundry chute doors. Deficiencies were identified in emergency lighting at exit discharge doors, battery backup emergency lighting in generator areas, self-closing fire-rated doors, monthly inspection documentation of fire extinguishers, and fire-rated laundry chute doors and latches.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure continuous illumination of means of egress with two lamps for 2 of 9 exit discharge doors. | SS=E |
| Failed to provide battery backup emergency lighting above emergency generator transfer switches and generator room. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions. | SS=E |
| Failed to perform and document monthly visual inspections on 4 of 26 fire extinguishers as required. | SS=E |
| Failed to ensure 2 of 5 laundry chute access doors closed and positively latched to maintain 1-hour fire protection rating. | SS=E |
Report Facts
Exit discharge doors with deficient lighting: 2
Fire extinguishers inspected: 26
Fire extinguishers missing monthly inspection documentation: 4
Laundry chute doors deficient: 2
Medical Records room size: 375
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Facility Maintenance | Interviewed and confirmed findings related to lighting, emergency lighting, fire doors, and fire extinguisher inspections | |
| Licensed Nursing Home Administrator | Interviewed regarding exit discharge door history and informed of findings at exit conference |
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and to describe their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and NJDHSS's legal duties and responsibilities to protect privacy.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights inquiries. |
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