Inspection Reports for Trenton Gardens Rehabilitation And Nursing Center
512 Union Street, Trenton, NJ, 08611
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 11, 2025, identified deficiencies related to cleanliness, incontinence care, staffing, infection control amid a cockroach infestation, equipment maintenance, supervision to prevent falls, and behavior health training. Earlier inspections showed a pattern of issues including immediate jeopardy findings for inadequate supervision leading to resident overdoses and smoking violations, as well as deficiencies in care planning, medication administration, food safety, staffing ratios, and life safety code compliance. Complaint investigations substantiated failures in supervision, care planning, and environmental maintenance, with several immediate jeopardy situations that were later resolved through corrective action plans. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in staffing, supervision, infection control, and environmental conditions, with corrective actions addressing immediate jeopardy but ongoing deficiencies noted in recent surveys.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
47 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 7
Date: Dec 11, 2025
Visit Reason
The inspection was conducted based on multiple complaints regarding facility conditions, resident care, pest infestation, staffing, medication administration, and behavior health training.
Complaint Details
Complaint numbers NJ 2587050, NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993, and 2673152 triggered the investigation. Issues included pest infestation, inadequate incontinence care, insufficient staffing, medication administration errors, lack of infection control, inadequate supervision leading to resident injury, and lack of behavior health training.
Findings
The facility was found deficient in maintaining a clean and homelike environment, providing adequate incontinence care, ensuring sufficient staffing, maintaining equipment such as ice machines, implementing infection control programs especially related to a cockroach infestation, providing adequate supervision to prevent falls, and delivering behavior health training to staff. Multiple residents were affected by these deficiencies.
Deficiencies (7)
Failed to maintain a clean, comfortable, and homelike environment including pest control and timely removal of soiled meal trays and resident excrement.
Failed to provide routine and appropriate incontinence care and maintain residents' fingernails in a clean manner.
Failed to ensure adequate supervision to prevent accidents resulting in a resident sustaining a fracture during an unreported episode of restlessness.
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failed to provide and implement an infection prevention and control program to limit transmission of bacteria during a facility-wide cockroach infestation and to ensure water management policies to reduce risk of Legionella.
Failed to keep all essential equipment, specifically ice machines, working safely and maintained in a clean and sanitary manner.
Failed to provide behavior health training consistent with requirements and facility assessment for staff to manage residents with maladaptive behaviors.
Report Facts
CNA staffing deficiency: 15
CNA staffing deficiency: 19
CNA staffing deficiency: 20
CNA staffing deficiency: 18
CNA staffing deficiency: 19
CNA staffing deficiency: 20
CNA staffing deficiency: 19
CNA staffing deficiency: 19
CNA staffing deficiency: 14
CNA staffing deficiency: 17
CNA staffing deficiency: 19
CNA staffing deficiency: 20
CNA staffing deficiency: 20
CNA staffing deficiency: 18
CNA staffing deficiency: 17
CNA staffing deficiency: 17
CNA staffing deficiency: 19
Resident census: 47
Resident BIMS score: 3
Resident BIMS score: 5
Resident BIMS score: 15
Resident BIMS score: 15
Fall risk score: 75
Fall risk score: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in investigation of Resident #114 fall and restlessness incident. |
| LPN #1 | Licensed Practical Nurse | Named in investigation of Resident #114 fall and restlessness incident. |
| LPN #2 | Licensed Practical Nurse | Named in investigation of Resident #114 fall and restlessness incident. |
| RN/UM | Registered Nurse/Unit Manager | Interviewed regarding Resident #114 care and documentation. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding cockroach infestation and ice machine conditions. |
| DON | Director of Nursing | Interviewed regarding staffing, infection control, and behavior health training. |
| MD | Maintenance Director | Interviewed regarding ice machine cleaning and pest control. |
| IP | Infection Preventionist | Interviewed regarding infection control and cockroach infestation. |
| CNA | Certified Nurse Aide | Named in incontinence care deficiencies and behavior incident with Resident #157. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 14, 2025
Visit Reason
The inspection was conducted based on complaint #2620207 regarding a resident (Resident #2) violating the facility's smoking policy by smoking in a resident room with oxygen in use, posing a fire and safety risk.
Complaint Details
Complaint #2620207 was substantiated. The facility was found to have an Immediate Jeopardy situation beginning 09/16/2025 at 8:00 P.M. when Resident #2 was observed smoking in a room with oxygen in use despite revoked smoking privileges. The facility submitted an acceptable Removal Plan on 10/12/2025 and implemented corrective actions including 1:1 supervision and education.
Findings
The facility failed to ensure that Resident #2, whose smoking privileges were revoked, did not have cigarettes or smoke in the facility in the presence of oxygen, creating an Immediate Jeopardy situation. Additionally, the facility's assessment did not identify residents with tobacco or substance abuse history, which could affect care planning.
Deficiencies (2)
Failure to ensure a resident with revoked smoking privileges did not possess cigarettes or smoke in the presence of oxygen, posing immediate jeopardy to resident health or safety.
Failure to conduct and document a facility-wide assessment that evaluated resident population needs related to tobacco or drug and alcohol abuse.
Report Facts
Date of Immediate Jeopardy incident: Sep 16, 2025
Date of survey completion: Oct 14, 2025
Number of smokers in facility: 41
Date of Facility Assessment: May 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Supervisor | Nursing Supervisor | Observed Resident #2 smoking in Resident #1's room and conducted search of wheelchair |
| Director of Nursing | Director of Nursing | Provided information on Resident #2's revoked smoking privileges and facility's corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed Resident #2 and involved in care planning |
| Social Worker #1 | Social Worker | Met with Resident #2 to discuss smoking policy violation |
| Social Worker #2 | Social Worker | Met with Resident #2 regarding vaping incident and smoking violations |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #2 vaping and reported to doctor |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Reported prior incidents of Resident #2 possessing cigarettes and vape |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 29, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding a resident (Resident #3) with a known history of illicit drug use who overdosed in the facility on 7/11/25. The investigation focused on the facility's failure to monitor and supervise the resident to prevent illicit drug use and overdoses.
Complaint Details
Complaint #2562900. The complaint investigation found that Resident #3 overdosed on illicit drugs on 7/11/25, the seventh overdose since November 2024. The facility failed to monitor and supervise the resident adequately, resulting in an Immediate Jeopardy situation. The facility was notified of the IJ on 7/23/25 and submitted an acceptable Removal Plan on 7/25/25, which was verified on 7/29/25.
Findings
The facility failed to ensure the safety of Resident #3 by not adequately monitoring and supervising them despite a history of six previous overdoses in the facility. This failure placed the resident and others at risk of serious harm, resulting in an Immediate Jeopardy situation. The facility implemented a Removal Plan including updated care plans, daily behavioral monitoring, random room checks, and re-education of staff and the resident.
Deficiencies (2)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Failure to monitor and supervise Resident #3 with a known history of illicit drug use and multiple overdoses, resulting in a seventh overdose on 7/11/25.
Report Facts
Number of residents reviewed: 14
Number of overdoses by Resident #3: 7
BIMS score: 13
Date of overdose incident: Jul 11, 2025
Date of survey completion: Jul 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor | RN Supervisor | Called to main lobby regarding Resident #3 found unresponsive and provided initial emergency care |
| Director of Nursing | DON | Informed about the overdose, issued thirty-day discharge notice, and involved in care plan decisions |
| Assistant Director of Nursing | ADON | Discussed drug overdose care plans and interventions during survey |
| Social Worker #1 | SW #1 | Reviewed drug policy with residents and provided support group information |
| Social Worker #2 | SW #2 | Educated residents on drug policy at admission and re-educated violators |
| Licensed Nursing Home Administrator | LNHA | Re-educated Resident #3 on drug policy and involved in discharge notice decisions |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 7, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging failure to maintain a clean environment, failure to report and investigate abuse allegations, failure to prevent drug overdoses, and failure to ensure resident safety and proper care planning.
Complaint Details
Complaints included failure to maintain a clean environment, failure to report and investigate abuse allegations (physical, verbal, sexual), failure to prevent and respond to drug overdoses, and failure to ensure resident safety and proper care planning. Substantiation status is not explicitly stated but Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to maintain a clean and homelike environment, failed to timely report and investigate multiple abuse allegations including physical, verbal, and sexual abuse, failed to update care plans after multiple drug overdoses, failed to prevent illicit drug use and overdoses within the facility, and failed to notify appropriate authorities of incidents. Immediate Jeopardy (IJ) conditions were identified related to abuse investigations and drug overdose management but were removed after corrective actions.
Deficiencies (7)
Failure to maintain a clean and homelike environment in shower areas with visible debris, hair, and substances.
Failure to timely report suspected abuse, neglect, or theft and failure to conduct thorough investigations of abuse allegations.
Failure to respond appropriately to all alleged violations including sexual abuse and drug overdoses, resulting in Immediate Jeopardy.
Failure to develop and update care plans within 7 days of comprehensive assessment and after significant incidents such as drug overdoses.
Failure to ensure services meet professional standards of quality including failure to administer wound care treatment as ordered.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents related to drug overdoses and illicit drug use.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including failure to prevent illicit drug use, conduct thorough investigations, and notify authorities.
Report Facts
Deficiencies cited: 7
Residents affected: 18
Dates of drug overdoses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in sexual abuse allegation involving Resident #3. |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding shower cleanliness and housekeeping responsibilities. |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning responsibilities and substances found in showers. |
| Housekeeper | Housekeeper | Interviewed regarding shower cleaning and nursing staff responsibilities. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding abuse allegations, drug overdoses, and care plan updates. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding abuse investigations, drug overdose reporting, and facility administration. |
| Infection Preventionist | Infection Preventionist | Administered Narcan to Resident #6 during overdose incidents. |
| Unit Manager | Unit Manager | Interviewed regarding wound care treatment expectations. |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Interviewed regarding care plan updates and overdose incidents. |
| Social Worker | Social Worker | Provided education to residents on drug risks and discharge circumstances. |
Inspection Report
Annual Inspection
Census: 144
Capacity: 230
Deficiencies: 12
Date: 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.
Deficiencies (12)
Failed to ensure policy was followed to screen and assess a resident for ability to smoke safely, resulting in inadequate supervision and care planning.
Failed to ensure food was served at safe and appetizing temperatures for 3 of 4 meals observed on one nursing unit.
Failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, including expired and improperly stored food items.
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.
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.
Boiler room sprinkler pipe penetration not sealed with fire rated material.
Failed to ensure sprinkler system control valves, water flow alarms, and tamper switches were inspected and tested annually.
Low voltage wiring under seven feet was not protected in conduit.
Failed to ensure fire doors were inspected annually by qualified personnel and lacked inspection tags.
Failed to ensure electrical outlet testing was conducted annually.
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
Routine
Deficiencies: 4
Date: May 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, food service, infection control, and other care standards at Trenton Gardens Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to follow smoking policies for residents, serving food at unsafe temperatures, improper food storage and labeling, inadequate infection prevention practices including hand hygiene and use of personal protective equipment, and failure to maintain respiratory equipment protocols.
Deficiencies (4)
Failure to ensure the smoking policy was followed to screen and assess a resident for the ability to safely smoke cigarettes.
Failure to ensure safe and appetizing temperatures of food for meals served on the nursing unit.
Failure to store, label, and date potentially hazardous foods properly and maintain sanitary storage areas.
Failure to provide and implement an infection prevention and control program including proper hand hygiene and use of enhanced barrier precautions.
Report Facts
Food temperatures measured: 12
Opened food items with no date or expired: 18
Residents reviewed for smoking policy: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Observed failing to perform hand hygiene before and after medication administration |
| UM/RN | Unit Manager/Registered Nurse | Interviewed regarding smoking policy and hand hygiene practices |
| Director of Nursing | Director of Nursing | Confirmed deficiencies and acknowledged concerns during interviews |
| Dietary Director | Dietary Director | Interviewed regarding food temperatures and kitchen sanitation issues |
| IP/RN | Infection Preventionist/Registered Nurse | Interviewed regarding infection control practices and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene and oxygen tubing handling |
| LPN #4 | Licensed Practical Nurse | Observed not wearing gown during flushing of gastrostomy tube |
| CNA #1 | Certified Nursing Assistant | Observed not performing hand hygiene when feeding resident |
| CNA #2 | Certified Nursing Assistant | Observed not performing hand hygiene when repositioning resident |
| Home Health Aide | Home Health Aide | Observed not performing hand hygiene when delivering care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
The inspection was conducted based on complaints NJ00159167 and NJ00158370 regarding failure to develop a comprehensive person-centered care plan for a resident with a change in skin condition and failure to consistently document Activities of Daily Living (ADL) status and care provided to residents.
Complaint Details
Complaint NJ00159167 involved failure to develop a comprehensive care plan for Resident #4's skin condition. Complaint NJ00158370 involved failure to document ADL care for Residents #1, #2, #3, and #4.
Findings
The facility failed to develop a comprehensive care plan for Resident #4's change in skin condition and failed to document ADL care for four residents on multiple dates and shifts. Interviews with staff confirmed these deficiencies. The facility policy requires care plans to be updated quarterly and documentation of care to be complete.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, specifically for a resident with a change in skin condition.
Failed to consistently document Activities of Daily Living (ADL) status and care provided to residents according to facility policy and protocol.
Report Facts
Residents affected: 1
Residents affected: 4
Dates with missing ADL documentation: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding Resident #4's care plan and documentation responsibilities | |
| Director of Nursing (DON) | Interviewed and acknowledged care plan and documentation deficiencies | |
| Licensed Nursing Home Administrator | Confirmed Resident #4's change in skin condition was never care planned | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about ADL care and documentation practices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about ADL documentation practices |
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
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.
Failed to maintain complete, accurate, and accessible medical records including documentation of residents' activities of daily living for 4 of 4 residents reviewed.
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
Deficiencies: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident elopement incident where Resident #1 exited the facility unnoticed and was found deceased on a local highway.
Complaint Details
Complaint Intake #NJ162088. The complaint was substantiated as the facility failed to prevent elopement of Resident #1, who was found deceased after exiting the facility unnoticed. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to provide adequate supervision and effective audible alarms on exit doors, resulting in Resident #1 eloping and dying. The facility implemented a corrective action plan including policy revisions, staff training, alarm system upgrades, and increased monitoring, which was verified as effective prior to the survey entrance.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement and lack of effective audible alarm on exit door resulting in resident elopement and death.
Report Facts
Residents at risk for elopement: 3
Resident elopement assessment score: 8
Speed limit: 40
Distance from compactor area to highway: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Supervising nurse during Resident #1 elopement; provided witness statement |
| LPN #8 | Licensed Practical Nurse | Staff on duty during elopement; provided interview and witness statement |
| LPN #9 | Licensed Practical Nurse | Charge nurse during elopement; provided interview and witness statement |
| CNA #11 | Certified Nurse Aide | Staff on duty during elopement; provided interview and witness statement |
| CNA #12 | Certified Nurse Aide | Staff on duty during elopement; provided interview and witness statement |
| Administrator | Administrator | Facility administrator involved in incident response and corrective action |
| Maintenance Director | Maintenance Director | Responsible for door alarm checks and maintenance; provided interview |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview regarding elopement risk assessments and corrective actions |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to ensure adequate supervision and effective audible alarms on exit doors to prevent Resident #1 from leaving the facility unnoticed.
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
Date: 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.
Deficiencies (14)
Failed to inform and offer educational material regarding advance directives and ensure life-sustaining treatment wishes were reviewed and documented consistently for residents.
Failed to issue required Notice to Medicare Provider Non-coverage (NOMNC) for residents discharged with benefit days remaining.
Failed to implement care plan interventions for residents, including fall prevention measures and updating care plans after incidents.
Failed to ensure medication administration was properly observed and documented; medications were left unattended.
Failed to provide adaptive eating equipment (Kennedy cup) as ordered for resident meals.
Failed to maintain kitchen sanitation including cleaning of three bay sink, covering trash receptacles, and discarding spoiled bread.
Failed to track and securely document COVID-19 vaccination status for all staff including contracted hires and volunteers.
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.
Failed to provide battery backup emergency lighting above emergency generator transfer switches and generator room.
Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions.
Failed to perform and document monthly visual inspection of fire extinguishers on 4 of 26 extinguishers.
Failed to ensure laundry chute access doors closed and positively latched to maintain 1-hour fire protection rating.
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
Date: 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.
Deficiencies (5)
Failed to ensure continuous illumination of means of egress with two lamps for 2 of 9 exit discharge doors.
Failed to provide battery backup emergency lighting above emergency generator transfer switches and generator room.
Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions.
Failed to perform and document monthly visual inspections on 4 of 26 fire extinguishers as required.
Failed to ensure 2 of 5 laundry chute access doors closed and positively latched to maintain 1-hour fire protection rating.
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 |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 14, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care planning, medication administration, food service, infection control, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including failure to inform residents and their representatives about advance directives, failure to implement and update care plans for residents with falls and infections, failure to administer and document medication properly, failure to provide adaptive eating equipment, failure to maintain kitchen sanitation and food storage, and failure to track and document COVID-19 vaccination status for all staff including contracted hires.
Deficiencies (8)
Failed to inform and offer educational material regarding advance directives and ensure life-sustaining treatment wishes were reviewed and documented for residents.
Failed to issue required Notice to Medicare Provider Non-coverage (NOMNC) for residents discharged with benefit days remaining.
Failed to implement a care plan intervention for a resident with an actual fall, including failure to provide ordered bilateral floor mats.
Failed to update and revise care plans for residents after falls and urinary tract infections.
Failed to ensure prescribed mouthwash (Peridex) was administered and documented in accordance with professional standards; medication was left unattended and signed as given without observation.
Failed to provide adaptive cup as ordered for a resident during meal service.
Failed to maintain kitchen equipment sanitation and properly store food items to prevent microbial growth, including presence of moldy bread and fruit flies, uncovered trash can, and unclean sanitizing sink.
Failed to track and securely document COVID-19 vaccination status for all staff including contracted hires and outside vendors.
Report Facts
Residents reviewed for medication management: 27
Staff vaccination percentage: 95.6
Resident fall risk score: 55
Resident BIMS score: 9
Resident BIMS score: 7
Resident BIMS score: 12
Resident BIMS score: 15
Resident BIMS score: 15
Number of staff on vaccination matrix: 200
Number of contracted hires on vaccination matrix: 1
Number of other staff on vaccination matrix: 2
Number of residents reviewed for falls: 4
Number of residents reviewed for urinary tract infections: 1
Number of residents reviewed for nutrition: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Acknowledged pouring Peridex and leaving it with Resident #39 without observing administration |
| LPN #2 | Licensed Practical Nurse | Acknowledged signing eMAR without observing Resident #39 use Peridex |
| Director of Nursing | Director of Nursing | Acknowledged medication administration protocol and care plan deficiencies |
| Social Worker | Social Worker | Interviewed regarding advance directives education and procedures |
| Director of Social Services | Director of Social Services | Interviewed regarding advance directives education and procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding advance directives education and procedures |
| Licensed Practical Nurse/Unit Manager | Licensed Practical Nurse/Unit Manager | Interviewed regarding care plan and fall interventions for Resident #96 and Resident #112 |
| Certified Nursing Aide #1 | Certified Nursing Aide | Interviewed regarding care for Resident #112 |
| Certified Nursing Aide #2 | Certified Nursing Aide | Interviewed regarding care for Resident #112 |
| Food Service Director | Food Service Director | Interviewed regarding meal tray preparation and food storage |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding floor mat delivery and kitchen sanitation |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding COVID-19 vaccination tracking and kitchen sanitation |
| Unit Manager | Unit Manager | Interviewed regarding care plan updates and fall interventions |
Inspection Report
Routine
Deficiencies: 10
Date: Nov 27, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on environmental conditions and repairs needed in residents' rooms and common areas.
Findings
The facility failed to maintain a clean and sanitary environment on two of four nursing units, with multiple areas showing damage such as torn carpets, cracked floor tiles, exposed substrates, loose molding, broken window blinds, and unrepaired walls. Staff responsible for maintenance had not documented or completed necessary repairs despite awareness of the issues.
Deficiencies (10)
Torn carpet and spackle patches on walls in the fourth floor Activity/Dining room.
Cracked and uneven hallway floor tile between rooms 425 to 427.
Torn wallpaper near the elevator.
Multiple rooms with spackled areas on walls behind beds and near windows.
Loose and not affixed cove base molding with exposed sheet rock in multiple rooms.
Night stand missing trim with exposed substrate in a resident's room.
Broken and missing window blinds in a resident's room.
Loose and torn corner molding near bathroom and door in resident rooms.
Wall paper buckled and peeling over resident's bed due to a previous leak that was fixed but not fully repaired.
Large open hole with exposed pipes in the third floor central bath area.
Report Facts
Number of nursing units with deficiencies: 2
Date of survey completion: Nov 27, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN/UM #1 | Licensed Practical Nurse Unit Manager | Present during observations and interviewed about nursing rounds and reporting responsibilities |
| HD | Housekeeping Director | Present during observations and interviewed about environmental responsibilities |
| MD | Maintenance Director | Present during observations and interviewed about maintenance responsibilities and documentation |
| Administrator | Administrator | Interviewed regarding responsibility for repairs and awareness of unit conditions |
| Director of Nursing | Director of Nursing | Present during Administrator interview about repair responsibilities |
Notice
Deficiencies: 0
Date: 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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