Inspection Reports for
Whiting Gardens Rehabilitation And Nursing Center
3000 Hilltop Road, Whiting, NJ, 08759
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
179% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
81% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 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 details 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 6, 2025
Visit Reason
The inspection was conducted following a complaint and reportable event regarding a resident fall during transfer, where the resident was not transferred according to the care plan requiring two staff members and a mechanical lift.
Complaint Details
The complaint investigation substantiated that the resident was transferred by one staff member instead of two as required, causing a fall and fracture. The CNA accepted responsibility and was terminated.
Findings
The facility failed to ensure a resident dependent on two-person mechanical lift transfer was safely transferred, resulting in the resident falling and sustaining a left proximal humerus fracture. The CNA responsible did not follow the care plan, was terminated, and the facility confirmed policies require two staff for such transfers.
Deficiencies (1)
Failure to ensure a resident dependent on two-person mechanical lift transfer was transferred safely, resulting in a fall and fracture.
Report Facts
Residents affected: 1
Date of fall: Sep 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Responsible for improper transfer causing resident fall; terminated from employment |
| Unit Manager | Interviewed regarding emergency room follow-up and staffing | |
| Director of Nursing | Director of Nursing | Interviewed about transfer procedures and CNA responsibilities |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Present during interviews and survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted based on complaints regarding abuse and inadequate supervision of residents, specifically involving an incident where a staff member used pepper spray on a resident and an elopement incident involving another resident.
Complaint Details
Complaint #NJ00184635 involved abuse where a staff member pepper sprayed Resident #6. Complaint #NJ00183371 involved inadequate supervision leading to elopement of Resident #1. Both complaints were substantiated with immediate jeopardy identified and removal plans implemented.
Findings
The facility failed to ensure the safety of a cognitively impaired resident who was pepper sprayed by a staff member, resulting in chemical conjunctivitis and pain, and failed to provide adequate supervision to a severely cognitively impaired resident who eloped from the facility. Immediate jeopardy was identified and subsequently removed after corrective actions were implemented.
Deficiencies (2)
Use of pepper spray by staff on a resident causing chemical conjunctivitis and pain.
Failure to provide adequate supervision to a cognitively impaired resident resulting in elopement.
Report Facts
Brief Interview for Mental Status (BIMS) score: 12
Brief Interview for Mental Status (BIMS) score: 6
Dates of incidents: Mar 19, 2025
Dates of incidents: Feb 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Staff member who pepper sprayed Resident #6 and was terminated | |
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding the pepper spray incident and stated it was never appropriate to use pepper spray | |
| Licensed Practical Nurse (LPN) #2 | Assigned to Resident #6 on day of incident, stated use of pepper spray was wrong | |
| Director of Nursing (DON) | Interviewed regarding both incidents and immediate jeopardy notifications | |
| Assistant Director of Nursing (ADON) | Interviewed regarding both incidents and immediate jeopardy notifications | |
| Director of Maintenance (DOM) | Interviewed regarding wander guard system and door testing | |
| Administrator | Interviewed regarding elopement incident and facility map | |
| Unit Manager (UM) | Interviewed regarding care planning and monitoring | |
| Certified Nursing Assistant (CNA) #2 | Interviewed regarding familiarity with Resident #1 and elopement incident | |
| Certified Nursing Assistant (CNA) #3 | Interviewed regarding elopement incident shift | |
| Certified Nursing Assistant (CNA) #4 | Interviewed regarding observation practices | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding care plans and observation | |
| Director of Social Services (DSS) | Interviewed regarding elopement drills and family contact |
Inspection Report
Routine
Census: 162
Capacity: 200
Deficiencies: 16
Date: Jan 23, 2025
Visit Reason
Routine standard survey conducted to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident rights, safe environment, professional standards of care, mobility, accident prevention, respiratory care, dialysis communication, physician visit frequency, food safety, life safety code, and emergency preparedness. Deficiencies were cited across these areas.
Deficiencies (16)
Facility failed to ensure residents were treated with dignity while being assisted with meals, including staff standing while feeding residents and serving meals on trays in dining rooms.
Facility failed to follow hold parameters for medication administration for Resident #46, resulting in medication given when it should have been held and vice versa.
Facility failed to ensure Resident #78 received appropriate treatment and services to prevent further decrease in range of motion and proper use of assistive devices.
Facility failed to consistently perform quarterly smoking assessments for residents designated as smokers, including Residents #30, #58, and #127.
Facility failed to maintain catheter tubing off the floor to prevent spread of infection for Resident #261.
Facility failed to implement infection control measures for handling and storage of nebulizer equipment for Resident #53.
Facility failed to ensure consistent communication with contracted dialysis facility for Resident #88, including incomplete documentation of vital signs and treatment information.
Facility failed to ensure attending physician conducted timely face-to-face visits and documented progress notes for 8 sampled residents over several months.
Facility failed to handle potentially hazardous foods safely, including uncovered meat slicer with food debris, wet nesting of pans, and ice buildup with debris in pantry freezer.
Facility failed to maintain emergency illumination that operates automatically along means of egress in accordance with NFPA 101 for 1 of 4 areas observed.
Facility failed to conduct and document required quarterly fire sprinkler inspections and annual fire hydrant inspections.
Facility failed to ensure metal containers with self-closing cover devices were readily available in smoking areas and failed to maintain smoking areas free of combustible materials.
Facility failed to inspect and test piped-in oxygen system annually as required by NFPA 99.
Facility failed to inspect and log patient care related electric beds annually and maintain required documentation.
Facility failed to maintain updated communication records for hospice services for Resident #85.
Facility failed to maintain updated transportation agreements annually for multiple facilities.
Report Facts
Census: 162
Total Capacity: 200
Sample Size: 35
Deficient CNA staffing shifts: 12
Deficient CNA staffing days: 14
Fire alarm inspection overdue: 10
Ice buildup thickness: 0.25
Number of residents affected by corridor door deficiencies: 50
Number of light switches off in day room: 2
Number of cigarette butts observed: 100
Number of metal containers missing self-closing cover: 1
Number of residents seen by physician within required timeframe: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Acknowledged medication administration errors for Resident #46 |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Confirmed nurses were not following physician's hold orders for Resident #46 |
| LPN #1 | Licensed Practical Nurse | Observed improper nebulizer storage for Resident #53 |
| LPN #3 | Licensed Practical Nurse | Described dialysis communication process for Resident #88 |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Discussed physician notes documentation in EMR |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Unaware of responsibility for pantry freezer maintenance |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including resident care, medication administration, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity during meals, improper medication administration practices, inadequate care for residents with contractures, failure to perform timely smoking assessments, improper catheter care, inadequate respiratory equipment handling, inconsistent communication with dialysis centers, failure to ensure timely physician face-to-face visits, unsafe food handling and sanitation practices, and failure to maintain hospice communication records.
Deficiencies (10)
Failure to ensure residents were treated with dignity while being assisted with meals, including staff standing while feeding residents and serving meals on trays.
Failure to follow hold parameters for administration of blood pressure medication Midodrine, resulting in missed doses and inappropriate administration.
Failure to provide appropriate care to prevent further decreased range of motion for a resident with contracture.
Failure to consistently perform quarterly smoking assessments for residents designated as active smokers.
Failure to maintain indwelling urinary catheter tubing off the floor to prevent infection.
Failure to implement infection control measures for handling and storage of respiratory nebulizer equipment.
Failure to consistently ensure communication with contracted dialysis facility according to policy, including incomplete documentation on communication forms.
Failure to ensure attending physicians conducted face-to-face visits and wrote progress notes at required intervals for multiple residents.
Failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including uncovered meat slicer with food debris, wet nesting of pans, and ice buildup with debris in pantry freezer.
Failure to maintain a Hospice Communication Record for a resident receiving hospice services.
Report Facts
Residents reviewed for contracture care: 1
Residents reviewed for smoking assessments: 3
Residents reviewed for catheter care: 2
Residents reviewed for respiratory care: 3
Residents reviewed for dialysis care: 2
Residents reviewed for physician face-to-face visits: 8
Residents reviewed for hospice services: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Acknowledged failure to follow physician's hold parameters for Midodrine |
| Licensed Practical Nurse/Unit Manager #2 | Licensed Practical Nurse/Unit Manager | Confirmed nurses were not following physician's hold order parameters for Midodrine |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed exposed nebulizer mask and stated it should be bagged and labeled |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Described dialysis communication process and documentation responsibilities |
| Licensed Practical Nurse/Unit Manager #1 | Licensed Practical Nurse/Unit Manager | Discussed contracture care and hospice communication record |
| Director of Nursing | Director of Nursing | Discussed physician visit requirements, dialysis communication, catheter care, and hospice communication |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Discussed meal assistance standards, dialysis communication, and physician visit requirements |
| Infection Preventionist | Infection Preventionist | Observed improper catheter tubing touching floor and meal assistance dignity issues |
| Food Service Director | Food Service Director | Observed food service sanitation deficiencies and meat slicer contamination |
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 10
Date: Oct 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers related to allegations of abuse, neglect, and failure to ensure resident safety and care.
Complaint Details
The complaint investigation was based on multiple complaint numbers including NJ00162903, NJ00166982, NJ00168479, NJ00172819, NJ00172820, NJ00173142, NJ00173303, NJ00173888, NJ00175318, NJ00175692, and NJ00177086. The facility was found not in substantial compliance with requirements related to abuse, neglect, exploitation, and failure to ensure resident safety. Immediate jeopardy was identified and removed during the investigation.
Findings
The facility was found not in substantial compliance with federal requirements, with deficiencies related to failure to protect residents from abuse and neglect, failure to ensure adequate staffing, failure to conduct thorough investigations, and failure to implement policies and procedures to prevent abuse and ensure resident safety. Multiple residents were involved in incidents of abuse or neglect, and the facility failed to adequately respond or prevent these incidents.
Deficiencies (10)
Failure to protect residents from abuse and neglect, including failure to ensure supervision and safety.
Failure to ensure adequate staffing ratios for Certified Nursing Assistants (CNAs) on day shifts and overnight shifts.
Failure to conduct thorough investigations of alleged abuse and neglect incidents.
Failure to provide adequate supervision and assistance devices to prevent accidents.
Failure to ensure adequate administration and oversight, including failure to use a registered nurse for required hours.
Failure to provide regular in-service education and performance evaluations for nurse aides.
Failure to maintain quality of care, including assessment and monitoring of residents for delayed complications after falls.
Failure to report alleged violations and incidents in a timely manner to the appropriate authorities.
Failure to investigate, prevent, and correct alleged violations of abuse, neglect, exploitation, or mistreatment.
Failure to administer the facility in a manner that enables effective use of resources and maintains resident well-being.
Report Facts
Survey Census: 157
Sample Size: 29
Deficiency counts: 10
Staffing ratios: 18
Staffing deficiencies: 7
Staffing deficiencies: 6
Staffing deficiencies: 5
Staffing deficiencies: 3
Staffing deficiencies: 8
Staffing deficiencies: 20
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Oct 11, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging physical and verbal abuse, failure to protect residents from abuse, failure to ensure proper supervision and care, and failure to report and investigate abuse allegations.
Complaint Details
The investigation was complaint-driven based on multiple complaint numbers NJ#162903, NJ#173303, NJ#175318, NJ#177086, NJ#166982, NJ#168479, NJ#172819, NJ#172820, NJ#173142, NJ#175692. Substantiated findings included physical and verbal abuse by Resident #14 and staff member LPN #10, failure to protect residents, failure to report abuse timely, and failure to investigate thoroughly.
Findings
The facility failed to protect residents from physical and verbal abuse by other residents and staff, failed to ensure proper supervision and care for residents with behavioral issues, failed to timely report abuse allegations, and failed to conduct thorough investigations. The facility also failed to provide adequate nursing coverage on one day and failed to complete annual performance evaluations for CNAs. Additionally, the facility failed to assess and monitor a resident after a fall and failed to implement effective fall prevention interventions.
Deficiencies (9)
Failure to protect residents from physical and verbal abuse by Resident #14 and staff member LPN #10.
Failure to ensure Resident #10 was free from involuntary seclusion and failure to follow policies on physical restraints and abuse prevention.
Failure to timely report allegations of abuse to the New Jersey Department of Health.
Failure to conduct thorough investigations of abuse allegations and ensure resident safety.
Failure to assess and monitor Resident #11 for delayed complications after a fall and failure to follow fall assessment policy.
Failure to provide adequate supervision to prevent falls and failure to implement effective fall prevention interventions for Resident #11.
Failure to ensure RN coverage for at least eight consecutive hours on 08/29/23.
Failure to complete annual performance evaluations for CNAs for multiple years.
Failure of the Licensed Nursing Home Administrator to ensure residents' safety and well-being, follow policies, and properly manage abuse allegations and staff conduct.
Report Facts
Residents affected by abuse: 4
Residents reviewed for CNA performance: 5
Residents reviewed for falls: 3
RN coverage hours missed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Involved in physical and verbal abuse of residents #13 and #19; suspended and terminated |
| CNA #12 | Certified Nursing Assistant | Witnessed abuse by LPN #10 and reported incident |
| NP #1 | Psychiatric Nurse Practitioner | Provided psychiatric assessments and progress notes for Resident #14 |
| DON | Director of Nursing | Involved in abuse reporting and investigation oversight |
| LNHA | Licensed Nursing Home Administrator | Oversight failure related to abuse prevention and investigation |
| Medical Director | Physician | Provided medical oversight for Resident #14 and Resident #11 |
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 2
Date: Sep 25, 2024
Visit Reason
The inspection was conducted based on complaints NJ00168003 and NJ00172931 to investigate alleged deficiencies related to notification of room changes and care plan implementation.
Complaint Details
Complaint # NJ00172931 was substantiated based on interviews, medical record review, and facility document review showing failure to notify resident's POA of room change and failure to update care plans after incidents.
Findings
The facility was found not in substantial compliance due to failure to notify a resident's power of attorney of a room change and failure to document such notification. Additionally, the facility failed to develop and implement care plan interventions for a resident after an incident, violating resident rights and care plan policies.
Deficiencies (2)
Failure to notify a resident's power of attorney of a room change and document notification in progress notes.
Failure to develop and implement care plan interventions for a resident after an incident.
Report Facts
Census: 160
Sample Size: 3
Audit Sample: 10
Care Plan Incident Reviews: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager (LPN UM #1) | Provided statements regarding family notification and care plan update responsibilities | |
| Director of Nursing (DON)/Designee | Responsible for in-service training and auditing compliance with notification and care plan update requirements | |
| Assistant Director of Nursing (ADON)/Designee | Responsible for in-service training of unit managers and IDC team on timely care plan updates |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00172931 to investigate allegations related to failure to notify a resident's power of attorney of a room change and failure to develop and implement care plan interventions after a resident fall.
Complaint Details
Complaint #NJ00172931 involved failure to notify a resident's power of attorney of a room change and failure to update care plans after a fall. The complaint was substantiated based on interviews, medical record review, and facility document review.
Findings
The facility failed to notify Resident #1's power of attorney of a room change and did not document the notification in progress notes. Additionally, the facility failed to update Resident #3's care plan with interventions after a fall on 09/08/2024, contrary to facility policy and regulatory requirements.
Deficiencies (2)
Failure to notify a resident's power of attorney of a room change and document notification in progress notes.
Failure to develop and implement care plan interventions for a resident after a fall.
Report Facts
BIMS score: 9
BIMS score: 9
Fall date: Sep 8, 2024
Care plan last updated: Jan 29, 2024
Care plan initiation date: Jul 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager (LPN UM #1) | Provided statements regarding family notification and care plan updates | |
| Director of Nursing (DON) | Provided statements regarding family notification, care plan responsibilities, and facility policies | |
| Licensed Nursing Home Administrator (LNHA) | Provided statements regarding family notification and documentation requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted in response to complaint NJ176415 to investigate staffing ratio compliance at Whiting Gardens Rehabilitation and Nursing Center.
Complaint Details
Complaint NJ176415 was substantiated based on interviews and document review showing deficient staffing ratios during the 14-day period prior to the survey. No care issues were identified or reported during this time.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 due to failure to meet required staffing ratios for 12 of 14 day shifts reviewed, potentially affecting all residents. No known care issues were reported during the period reviewed.
Deficiencies (1)
Failure to ensure staffing ratios were met for 12 of 14 day shifts reviewed.
Report Facts
Census: 161
Deficient day shifts: 12
Staffing ratios required: 20
Staffing counts on specific days: 14
Staffing counts on specific days: 17
Staffing counts on specific days: 18
Staffing counts on specific days: 17
Staffing counts on specific days: 18
Staffing counts on specific days: 19
Staffing counts on specific days: 13
Staffing counts on specific days: 13
Staffing counts on specific days: 15
Staffing counts on specific days: 19
Staffing counts on specific days: 18
Staffing counts on specific days: 19
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The inspection was conducted based on Complaint #: NJ171799 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ171799. The facility failed to meet staffing ratios as required by New Jersey statutes, with deficiencies noted in CNA staffing on multiple days in February 2024. The complaint was substantiated with detailed findings.
Findings
The facility was found deficient in meeting staffing ratios for residents on 14 of 14 day shifts and deficient in total staff on 3 of 14 overnight shifts, potentially affecting all residents. No care issues were reported during the identified shifts.
Deficiencies (1)
Failed to ensure staffing ratios were met for residents on 14 of 14-day shifts and deficient in total staff for residents on 3 of 14 overnight shifts.
Report Facts
Census: 148
Deficient day shifts: 14
Deficient overnight shifts: 3
Staffing counts: 11
Staffing counts: 18
Staffing counts: 11
Staffing counts: 16
Staffing counts: 14
Staffing counts: 11
Staffing counts: 18
Staffing counts: 19
Staffing counts: 15
Staffing counts: 12
Staffing counts: 15
Staffing counts: 13
Staffing counts: 14
Staffing counts: 16
Staffing counts: 15
Total staff: 9
Staffing counts: 11
Inspection Report
Annual Inspection
Census: 105
Capacity: 190
Deficiencies: 9
Date: Mar 9, 2023
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with federal regulations and state licensure requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with multiple deficiencies identified including failure to ensure proper documentation of advance directives, notification of changes, accuracy of assessments, care plan revisions, drug regimen reviews, infection control, food safety, and immunizations.
Deficiencies (9)
Failure to ensure the physician completed documentation on the POLST for one of four residents reviewed for advance directives.
Failure to ensure Licensed Practical Nurse notified one resident's legal guardian immediately of a change in condition.
Failure to accurately code the Minimum Data Set (MDS) assessment for one of three residents reviewed for discharge.
Failure to ensure one of three residents reviewed for care planning had timely comprehensive care plans developed and revised.
Failure to conduct monthly drug regimen reviews by a licensed pharmacist for residents.
Failure to ensure residents who have not used psychotropic drugs are not given these drugs unless necessary and other related psychotropic drug requirements.
Failure to maintain the kitchen in a sanitary manner, including ice machines and food storage areas.
Failure to provide influenza and pneumococcal immunizations to residents or their representatives.
Failure to maintain an effective infection prevention and control program.
Report Facts
Survey Census: 105
Total Capacity: 190
Sample Size: 34
Deficiency Completion Dates: Most deficiencies have completion dates of 4/10/2023 or 4/4/2023
Staffing Ratios: 12
Staffing Ratios: 9
Staffing Ratios: 11
Staffing Ratios: 12
Staffing Ratios: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Director of Social Services (DSS) | Interviewed regarding POLST review and documentation |
| MD1 | Attending Physician | Interviewed regarding POLST documentation and orders |
| LPN3 | Licensed Practical Nurse | Interviewed regarding notification of resident's legal guardian and treatment orders |
| LPN4 | Licensed Practical Nurse | Interviewed regarding notification of resident's legal guardian |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification procedures and education |
| Social Worker Assistant | Social Services Assistant (SSA) | Interviewed regarding care conference invitations |
| Medical Director | Medical Director | Interviewed regarding infection control and medication reviews |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding infection prevention program and education |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding kitchen sanitation and food safety |
| Registered Nurse | Registered Nurse (RN) Unit Manager | Interviewed regarding resident medication and care |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Multiple LPNs interviewed regarding medication administration and infection control |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding medication administration and infection control |
| Social Worker | Social Worker | Educates staff physicians and licensed staff on POLST process |
| Administrator | Administrator | Educated social work department on care conferences and QAPI |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 9, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including review of advance directives, notification of condition changes, care planning, medication management, infection control, food safety, and vaccination policies.
Findings
The facility was found deficient in multiple areas including incomplete physician documentation on POLST forms, delayed notification of resident condition changes to legal guardians, inaccurate coding of discharge assessments, failure to invite residents to care plan meetings, inadequate clinical rationale for medication decisions, unsanitary kitchen conditions, failure to implement updated pneumococcal vaccination recommendations, and improper infection control practices during wound care.
Deficiencies (10)
Physician failed to complete all required fields on the Physician's Orders for Life-Sustaining Treatment (POLST) form for one resident.
Licensed Practical Nurse failed to notify a resident's legal guardian immediately of a change in condition requiring physician ordered treatment.
Facility failed to accurately code the Minimum Data Set (MDS) assessment for discharge for one resident.
Facility failed to invite one resident to participate in their quarterly care plan meeting.
Attending physician failed to provide clinical rationale for declining pharmacist's recommendation regarding unnecessary medication for one resident.
Facility failed to ensure adequate indications and behavior monitoring for antipsychotic medication for one resident.
Kitchen and unit pantries were not maintained in a sanitary manner, including ice machines with residue, expired food items, and unlabeled food in refrigerators.
Quality Assurance committee failed to identify and address deficiencies related to pneumococcal vaccination compliance.
Facility failed to perform proper hand hygiene and glove changes during treatment of pressure ulcers, increasing risk of infection.
Facility failed to offer pneumococcal vaccinations in accordance with updated CDC recommendations to five residents.
Report Facts
Residents reviewed: 34
Residents affected: 104
Residents affected: 105
Residents affected: 5
Medication orders reviewed: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD1 | Attending Physician | Named in findings related to incomplete POLST documentation and medication rationale |
| LPN3 | Licensed Practical Nurse | Named in failure to notify resident's legal guardian immediately of condition change |
| LPN2 | Licensed Practical Nurse | Named in infection control deficiency related to wound care |
| CNA1 | Certified Nursing Assistant | Named in infection control deficiency related to wound care |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including care planning and infection control |
| Food Service Director | Food Service Director | Interviewed regarding kitchen sanitation deficiencies |
| Maintenance Director | Maintenance Director | Interviewed regarding ice machine cleaning responsibilities |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding vaccination and infection control deficiencies |
| Medical Director | Medical Director | Interviewed regarding vaccination policies and expectations |
| NP | Psychiatric Nurse Practitioner | Named in medication review and recommendations for resident R73 |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 151061.
Complaint Details
Complaint # NJ 151061 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 5
Inspection Report
Life Safety
Census: 100
Capacity: 200
Deficiencies: 10
Date: Mar 31, 2021
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted by CMS following a New Jersey Department of Health survey. The survey assessed compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found to be noncompliant with several life safety code requirements including egress door locking arrangements, illumination of means of egress, emergency lighting, exit signage, hazardous area enclosure, fire alarm system installation, sprinkler system maintenance, smoke barrier door integrity, electrical system clearance, and gas equipment storage and trans filling. Multiple deficiencies could affect varying numbers of residents, staff, and visitors.
Deficiencies (10)
Egress doors had special locking arrangements with staff-only code access, not readily accessible to residents, violating LSC requirements.
Failed to provide automatic emergency illumination along means of egress with required illuminance during emergencies.
Failed to provide battery backup emergency light above generator transfer switch for required illumination during power interruption.
Failed to properly identify doors that are not exits with 'No Exit' signage as required.
Failed to maintain self-closing devices and hardware on doors to hazardous areas, restricting fire and smoke containment.
Fire alarm system failed to provide audible and visible notification signals in enclosed courtyards.
Failed to maintain sprinkler system with complete smoke resisting ceiling at sprinkler level, impairing sprinkler operation.
Smoke barrier doors had gaps preventing smoke resistance, violating fire safety requirements.
Failed to maintain required clearance around electrical panels and equipment; cardboard boxes stored too close posing fire risk.
Liquid oxygen storage and trans filling room had ignition source (light switch) inside, violating safety standards.
Report Facts
Certified beds: 200
Census: 100
Residents affected: 20
Residents affected: 30
Residents affected: 100
Residents affected: 30
Residents affected: 60
Residents affected: 80
Residents affected: 20
Residents affected: 80
Residents affected: 20
Residents affected: 20
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with the recertification survey to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found not to be in compliance with infection control regulations related to CMS and CDC recommended practices for COVID-19. Two staff members failed to don appropriate Personal Protective Equipment (PPE) while caring for a resident on transmission-based precautions, leading to deficiencies cited in infection prevention and control.
Deficiencies (1)
Two facility staff members failed to don appropriate PPE while in the room of a resident on transmission-based precautions.
Report Facts
Census: 103
Sample size: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Observed failing to wear PPE gown while assisting a resident on contact precautions | |
| Licensed Practical Nurse (LPN) | Observed picking up a food tray from an isolation room without wearing PPE gown and gloves | |
| LPN Unit Manager | Provided information on required PPE for contact isolation | |
| Director of Nursing (DON) | Provided information on staff training and facility policies regarding PPE and isolation precautions | |
| Registered Nurse Infection Preventionist (RN/IP) | Provided information on isolation room identification and PPE requirements |
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
The inspection was a focused infection control survey for COVID-19, triggered by concerns about staff adherence to infection prevention and control protocols, specifically related to the use of Personal Protective Equipment (PPE) for residents on transmission-based precautions.
Findings
The survey found that two facility staff members failed to wear appropriate PPE gowns and gloves while caring for a resident on contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) of the urine, potentially exposing residents and staff to infection. The facility lacked a specific ESBL policy but had a multidrug-resistant organisms policy addressing contact precautions.
Deficiencies (1)
Failure of two staff members to don appropriate PPE gowns and gloves when providing care to a resident on transmission-based contact precautions for ESBL.
Report Facts
Residents Affected: 2
Date of survey completion: Mar 19, 2021
Date of observation: Mar 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Observed failing to wear PPE gown while assisting Resident #43. | |
| Licensed Practical Nurse (LPN) | Observed failing to wear PPE gown and gloves while handling Resident #43's food tray and environment. | |
| LPN Unit Manager (LPN/UM) | Provided statements regarding PPE requirements and staff observations. | |
| Director of Nursing (DON) | Provided statements regarding facility policies and staff training on PPE and isolation precautions. | |
| Registered Nurse Infection Preventionist (RN/IP) | Provided statements on PPE use and infection control practices. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Date: Feb 10, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health due to concerns about infection control practices related to COVID-19 exposure and transmission.
Complaint Details
The visit was complaint-related, triggered by concerns about COVID-19 infection control practices. An Immediate Jeopardy (IJ) situation was identified on 2021-02-10 at 4:32 PM. The facility provided an acceptable IJ Removal Plan on 2021-02-11, which was verified on-site on 2021-02-12.
Findings
The facility failed to appropriately identify residents exposed to COVID-19 as persons under investigation (PUI) and did not implement appropriate transmission-based precautions (TBP) or personal protective equipment (PPE) according to CDC guidelines and the facility's outbreak plan. This posed a serious and immediate threat to resident safety. Additionally, staff failed to properly don and doff PPE on PUI units, including improper handling and disposal of contaminated gowns.
Deficiencies (2)
Failure to identify residents exposed to COVID-19 as PUI and implement appropriate TBP and PPE.
Failure of staff to properly don and doff PPE on PUI units, including improper disposal and reuse of contaminated gowns.
Report Facts
Census: 113
Sample size: 17
Number of COVID-19 positive staff: 4
Resident exposure count: 24
Plan of Correction Completion Date: Apr 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed wearing contaminated gown in hallway and interviewed regarding PPE practices on PUI unit. |
| CNA #5 | Certified Nursing Assistant | Observed taking contaminated gown from stack and interviewed about PPE use on PUI unit. |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Interviewed about contact tracing and PPE practices on LTC unit. |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Interviewed about monitoring residents exposed to COVID-19 positive staff. |
| IP | Infection Preventionist | Interviewed about PUI definitions, PPE requirements, and infection control policies. |
| RD | Regional Director of Nursing | Interviewed about facility policies and local health department guidance. |
| LNHA | Licensed Nursing Home Administrator | Interviewed about facility adherence to local health department guidance. |
| DON | Director of Nursing | Interviewed about facility infection control practices and policies. |
Inspection Report
Routine
Census: 101
Deficiencies: 0
Date: Dec 17, 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
Viewing
Loading inspection reports...
