Inspection Reports for Willow Springs Rehabilitation And Healthcare Ctr
1049 Burnt Tavern Road, NJ, 08724
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
145 residents
Based on a December 2024 inspection.
Census over time
Notice
Deficiencies: 0
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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 2
Dec 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00180841 and NJ00180991 regarding medication administration and staffing issues at Willow Springs Rehabilitation and Healthcare Center.
Findings
The facility was found not in substantial compliance with federal requirements due to failure to administer medications according to professional standards and failure to meet minimum staffing ratios on multiple shifts. Deficiencies were related to medication left unattended at resident bedside and inadequate staffing levels affecting resident care.
Complaint Details
Complaint numbers NJ00180841 and NJ00180991 were investigated. The facility was found not in substantial compliance based on these complaints. The medication administration deficiency was substantiated with evidence from observations, interviews, and record reviews. Staffing deficiencies were also identified based on review of staffing records and facility documents.
Severity Breakdown
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to administer medications according to acceptable standards of nursing practice for 1 of 4 residents and failed to follow its policy titled 'Administering Medications'. | Level D |
| Facility failed to ensure staffing ratios met minimum requirements for 13 of 14 day shifts reviewed. | — |
Report Facts
Census: 145
Sample Size: 4
Deficient CNA staffing shifts: 13
CNA staffing levels: 14
CNA staffing levels: 13
CNA staffing levels: 15
CNA staffing levels: 14
CNA staffing levels: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration deficiency for allegedly leaving medications at resident's bedside |
| CNA #1 | Certified Nursing Assistant | Named in medication administration deficiency related to handling medications at resident's bedside |
| Director of Nursing | Director of Nursing | Re-educated LPN #1 on medication administration policy and involved in staffing reviews |
Inspection Report
Routine
Census: 143
Capacity: 164
Deficiencies: 17
Jul 12, 2024
Visit Reason
Standard survey and complaint investigation conducted to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including medication administration timeliness, accident supervision, sufficient staffing, life safety code violations, and fire safety system deficiencies. Deficiencies were cited in medication administration, accident prevention, staffing ratios, fire safety code compliance including egress door locking, smoke detection, fire alarm system, sprinkler system maintenance, and electrical safety.
Complaint Details
Complaint investigations NJ00160508, NJ00160656, NJ00161600, NJ00163636, NJ00168248, NJ00168274, NJ00170646, NJ00170702, NJ00171127, NJ00174029, NJ00174765 were completed. Deficiencies related to complaint allegations were substantiated.
Severity Breakdown
SS=D: 7
SS=E: 5
SS=F: 3
SS=G: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to ensure medications and treatments were administered timely and documented properly for Resident #234. | SS=D |
| Failure to ensure adequate supervision and accident prevention for Resident #534 resulting in injury and hospitalization. | SS=G |
| Failure to maintain sufficient nursing staff to meet resident care needs per state mandated ratios. | SS=F |
| Failure to ensure psychotropic medications were monitored for target behaviors and side effects as ordered for Resident #122. | SS=D |
| Egress doors equipped with thumb turn locks restricting emergency egress. | SS=F |
| Exit stairwell doors not maintaining 1-1/2 hour fire rated construction due to failure to positive latch. | SS=D |
| Failure to provide continuous lighting with two lamps for one designated exit discharge door. | SS=D |
| Failure to provide illuminated exit signs to clearly identify exit access paths in five locations. | SS=E |
| Failure to provide audible and visible fire alarm notification in two outside enclosed courtyards. | SS=E |
| Failure to inspect and test fire sprinkler system piping internally at required five-year intervals. | SS=F |
| Two portable fire extinguishers not mounted at code height and one fire extinguisher lacked documented monthly visual inspections. | SS=D |
| Six corridor doors failed to resist passage of smoke due to gaps, disconnected door closers, or failure to latch properly. | SS=E |
| Two areas open to corridors lacked required smoke detectors. | SS=E |
| Laundry chute door held open by magnetic device and failed to positive latch. | SS=D |
| Electrical outlet near water source lacked required GFCI protection and exposed wiring on PTAC unit not enclosed in junction box. | SS=D |
| Power strip used in patient care vicinity for non-PCREE equipment. | SS=D |
| Emergency generator not tested under load for 30 minutes monthly for May and June 2024. | SS=E |
Report Facts
Deficiencies cited: 16
Resident census: 143
Licensed capacity: 164
Staffing deficiency days: 14
Staffing deficiency days: 7
Staffing deficiency days: 7
Staffing deficiency days: 7
Staffing deficiency days: 14
Staffing deficiency days: 7
Staffing deficiency days: 7
Staffing deficiency days: 14
Staffing deficiency days: 7
Emergency generator load test duration (minutes): 20
Emergency generator load test missing months: 2
Battery operated smoke alarms: 26
Portable fire extinguishers: 28
Corridor doors not smoke resistant: 6
Smoke barrier walls with penetrations: 2
Laundry chute doors tested: 2
Electrical outlets lacking GFCI: 1
Electrical PTAC units with exposed wiring: 1
Power strips in patient care area: 1
Portable fire extinguishers mounted too high: 2
Portable fire extinguishers lacking monthly inspection: 1
Corridor doors with excessive gaps: 3
Corridor doors with disconnected door closers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Provided census and staffing information during inspection. |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Provided information on medication administration and accident supervision. |
| LPN/UM #3 | Licensed Practical Nurse/Unit Manager | Acknowledged lack of orders for monitoring psychotropic medication side effects. |
| CNA #1 | Certified Nursing Assistant | Reported heavy workload and staffing concerns. |
| CNA #2 | Certified Nursing Assistant | Reported on resident fall incident and assessment. |
| Director of Human Resources | Discussed staffing scheduling and challenges. |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 4
Jul 5, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies at the facility, including privacy violations, unsafe environment, medication errors, and staffing shortages.
Findings
The facility was found not in substantial compliance with federal and state regulations. Deficiencies included failure to maintain resident privacy during care, failure to maintain a safe, clean, and odor-free environment, medication administration errors for one resident, and failure to meet minimum staffing ratios for certified nurse aides on multiple days.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ155594, NJ155995, NJ156378, NJ157304, NJ157715, NJ157770, NJ158101, NJ159337, NJ159347, NJ159775, NJ160752). The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure personal privacy of a resident during care, including not pulling privacy curtains during incontinence checks. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment, evidenced by strong odors and dirty linens on one nursing unit. | SS=D |
| Failure to ensure residents are free from significant medication errors; one resident received medication not prescribed to them. | SS=D |
| Failure to meet minimum staffing ratios for certified nurse aides on 14 of 14 day shifts reviewed. | — |
Report Facts
Census: 144
Sample Size: 21
Staffing Deficiency Days: 14
CNA Staffing Deficit: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Re-educated staff on resident privacy and medication administration; conducted rounds and audits to validate compliance. | |
| Administrator | Conducted rounds on units, reviewed staffing, and submitted audit findings to QAPI Committee. | |
| Staffing Coordinator | Reviewed staffing schedules and was re-educated on staffing requirements and retention strategies. |
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint survey identified by complaint number NJ0016085.
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 survey.
Complaint Details
Complaint #: NJ0016085. The facility was found to be in substantial compliance based on this complaint survey.
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 2
Nov 3, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00166191 and NJ00166428 regarding facility compliance with long term care regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically for failure to consistently document Activities of Daily Living (ADL) care for residents and failure to maintain the required minimum direct care staff-to-resident ratio for the day shift.
Complaint Details
Complaint numbers NJ00166191 and NJ00166428 triggered the survey. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to residents, evidenced by incomplete ADL documentation for Resident #1. | SS=B |
| Failure to maintain the required minimum direct care staff-to-resident ratio for the day shift as mandated by the State of New Jersey, deficient in Certified Nursing Assistants (CNA) staffing for residents on 35 of 35 day shifts. | — |
Report Facts
Census: 127
Sample Size: 4
Deficient CNA staffing days: 35
Required CNA staffing: 17
Actual CNA staffing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding ADL care and documentation for Resident #1. | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding ADL documentation and care for Resident #1. | |
| Director of Nursing (DON) | Interviewed regarding ADL care documentation requirements and facility policy. |
Inspection Report
Routine
Census: 135
Deficiencies: 13
Feb 10, 2023
Visit Reason
A Federal Comparative Survey was conducted by CMS at Willow Springs Rehabilitation and Healthcare Center for federal oversight, monitoring, and to determine compliance with 42 CFR Part 483 requirements for Long Term Care.
Findings
The facility was found not in substantial compliance with federal requirements. Deficiencies included failure to maintain resident dignity in storage of medical equipment, failure to assess resident self-administration of medications, unsafe and unsanitary environment conditions, failure to prevent resident abuse, inaccurate resident assessments, failure to meet professional care standards, inadequate respiratory care, failure to post nurse staffing information daily, improper labeling of medications, improper food labeling, improper garbage disposal, and lack of specialized training for the infection preventionist.
Severity Breakdown
SS=D: 10
SS=E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity in storage of medical equipment for three residents. | SS=D |
| Failure to assess ability of resident to self-administer inhalation medication. | SS=D |
| Failure to maintain a clean, orderly, and sanitary environment including medication storage, resident rooms, ice machines, and supplies. | SS=E |
| Failure to prevent abuse resulting in one resident being abused by another resident. | SS=D |
| Failure to accurately complete Minimum Data Set (MDS) for one resident. | SS=D |
| Failure to meet professional standards of care; treatment records documented without administering treatment. | SS=D |
| Failure to provide necessary ADL care to dependent residents including timely out-of-bed care and hygiene. | SS=D |
| Failure to adhere to respiratory care protocols including proper cleaning, dating, and storage of respiratory equipment for four residents. | SS=E |
| Failure to post nurse staffing information daily at the beginning of each shift. | SS=D |
| Medication Bingo cards for one resident had conflicting expiration dates causing confusion. | SS=D |
| Failure to properly label food items stored in the kitchen with 'use by' dates. | SS=D |
| Failure to properly cover garbage dumpsters; lids were open and garbage was exposed. | SS=D |
| Infection Preventionist lacked specialized training in infection prevention and control prior to assuming role; completed training during survey. | SS=D |
Report Facts
Sample Size: 54
Number of cardboard boxes: 7
Number of unlabeled juices: 16
Number of unlabeled vanilla puddings: 7
Number of black hinged lids open: 2
Contact hours: 19.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed dignity cover should be used for resident medical equipment |
| UM #1 | Unit Manager | Confirmed respiratory equipment should be cleaned and dignity covers used |
| UM #2 | Unit Manager | Interviewed regarding resident abuse and staffing |
| DON | Director of Nursing | Acknowledged resident abuse on video and staffing issues |
| MDS Coordinator | Confirmed inaccurate MDS coding for resident | |
| CNA #3 | Certified Nursing Assistant | Reported staffing shortages and inability to complete care timely |
| FSD | Food Service Director | Acknowledged food items not labeled with use by dates and garbage lids open |
| IP | Infection Preventionist | Completed specialized infection prevention training during survey |
| LPN #3 | Licensed Practical Nurse | Admitted signing treatment records without administering treatment |
| LPN #4 | Licensed Practical Nurse | Described respiratory equipment cleaning and storage procedures |
Inspection Report
Original Licensing
Census: 45
Deficiencies: 0
Jan 17, 2023
Visit Reason
State Licensure Certification survey for a Dementia/Alzheimer's Unit to determine compliance with New Jersey administrative code standards for licensure of long term care facilities.
Findings
The facility was found to be in compliance with the applicable standards for licensure of dementia/alzheimer's programs. The facility is not to advertise certification until final approval is provided and must provide ongoing evidence of compliance at future recertification surveys.
Inspection Report
Annual Inspection
Census: 139
Deficiencies: 7
Dec 20, 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 accuracy of assessments, medication storage and labeling, food safety, infection prevention and control, COVID-19 vaccination compliance, staffing ratios, and resident activities.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to accurately complete the Minimum Data Set (MDS) for two residents. | SS=D |
| Facility failed to properly store medications, maintain clean medication storage areas, and properly label opened multidose medications. | SS=E |
| Facility failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen cleanliness, and infection control during food service. | SS=D |
| Facility failed to ensure staff wore appropriate PPE and performed hand hygiene according to guidelines, risking infection transmission. | SS=D |
| Facility failed to ensure unvaccinated staff wore proper PPE to prevent COVID-19 spread. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios for day shift. | — |
| Facility failed to provide resident activities seven days per week as required. | — |
Report Facts
Census: 139
Deficiency count: 7
Staffing ratios: 13
Staffing ratios: 11
Staffing ratios: 14
Staffing ratios: 14
Staffing ratios: 13
Staffing ratios: 11
Staffing ratios: 10
Staffing ratios: 11
Staffing ratios: 11
Staffing ratios: 11
Staffing ratios: 11
Staffing ratios: 14
Staffing ratios: 13
Staffing ratios: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication storage and infection control findings |
| LPN #2 | Licensed Practical Nurse | Named in wound care and infection control findings |
| LPN/IP | Licensed Practical Nurse/Infection Preventionist | Named in infection control and COVID-19 vaccination findings |
| CNA #1 | Certified Nursing Assistant | Named in infection control findings |
| CNA #2 | Certified Nursing Assistant | Named in infection control findings |
| Director of Nursing | Director of Nursing | Named in infection control and staffing findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in medication storage and infection control findings |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Named in infection control and COVID-19 vaccination findings |
| Activity Director | Activity Director | Named in resident activities findings |
Inspection Report
Life Safety
Census: 138
Capacity: 164
Deficiencies: 0
Dec 10, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted to assess compliance with federal regulations and fire safety codes.
Findings
The facility was found to be in compliance with 42 CFR 483.73 for Emergency Preparedness and with 42 CFR 483.90(a) and the 2012 NFPA 101 Life Safety Code requirements.
Report Facts
Occupied beds: 138
Total licensed capacity: 164
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 3
Jun 22, 2022
Visit Reason
The inspection was conducted based on complaints NJ150993, NJ154820, and NJ155605 to investigate alleged deficiencies in medication administration and personal care.
Findings
The facility was found not in substantial compliance with professional standards of care related to medication administration and documentation for Resident #2, and failed to provide timely personal care for Resident #1. Additionally, the facility did not meet staffing requirements for Certified Nursing Assistants (CNAs) on multiple day shifts.
Complaint Details
Complaint investigation based on complaints NJ150993, NJ154820, and NJ155605. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to administer medications according to physician's orders and maintain accurate medication administration documentation for Resident #2. | SS=D |
| Failure to provide timely personal care and incontinent care for Resident #1 during the 7-3 shift. | SS=D |
| Failure to meet minimum staffing ratios for Certified Nursing Assistants on multiple day shifts. | — |
Report Facts
Census: 129
Sample size: 5
Deficiency severity level: 2
CNA staffing deficiency days: 20
Residents requiring CNA staffing: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration documentation error on 4/27/2022 |
| Unit Manager | Licensed Practice Nurse | Interviewed regarding medication administration and personal care issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and staffing issues |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding failure to provide timely personal care to Resident #1 |
Inspection Report
Abbreviated Survey
Census: 127
Deficiencies: 1
May 20, 2022
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 not in compliance with infection control regulations, specifically failing to ensure proper handwashing technique by two employees during the survey. The facility had a COVID-19 outbreak starting 4/25/2022 with the last positive case on 5/18/2022. Corrective actions including staff in-service and audits were planned and implemented.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure handwashing was performed according to facility policy and CDC standards by two employees (Activity Aide #1 and Certified Nursing Assistant #1). | SS=D |
Report Facts
Sample size: 7
Date outbreak started: Apr 25, 2022
Date last positive COVID-19 case: May 18, 2022
Handwashing duration observed: 12
Handwashing duration observed: 5
Handwashing competency dates: AA #1 competency on 3/11/2022, CNA #1 competency on 2/1/2022
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Aide #1 | Named in deficiency for improper handwashing technique | |
| Certified Nursing Assistant #1 | Named in deficiency for improper handwashing technique | |
| Director of Nursing | Director of Nursing | Interviewed regarding handwashing policy and outbreak |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Accompanied surveyor and interviewed staff |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 0
Dec 30, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ148864, NJ149982, NJ150040, and NJ150517.
Findings
The facility was found to be in compliance with the requirements of 42 CFR 483, Subpart B, for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey found the facility compliant with infection control regulations and CMS/CDC recommended practices.
Complaint Details
Complaint numbers NJ148864, NJ149982, NJ150040, and NJ150517 were investigated and found to be in compliance.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 1
Sep 16, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ148031 and NJ146866 regarding staffing ratios and compliance with New Jersey minimum staffing requirements for nursing homes.
Findings
The facility failed to meet the minimum staffing ratios required by New Jersey law for 16 of 42 shifts reviewed, potentially affecting all residents. The Director of Nursing acknowledged staffing challenges due to staff not reporting to work or calling out sick despite scheduling efforts.
Complaint Details
Complaint #: NJ148031 and NJ146866. The complaint was substantiated as the facility did not meet minimum staffing requirements as per the NJDOH memo dated 01/28/2021.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 16 of 42 shifts reviewed, not complying with New Jersey minimum staffing requirements. |
Report Facts
Census: 140
Sample Size: 6
Shifts with staffing deficiencies: 16
Staffing ratios examples: 8
Staffing ratios examples: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided staffing information and acknowledged staffing deficiencies. | |
| Administrator | Involved in re-inservicing on staffing requirements and daily staffing meetings. | |
| Staffing Coordinator | Involved in re-inservicing on staffing requirements and daily staffing meetings. |
Inspection Report
Abbreviated Survey
Census: 138
Deficiencies: 1
Aug 26, 2021
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 failed to ensure proper infection control practices, specifically in donning and doffing personal protective equipment (PPE) according to CDC guidelines, as evidenced by observations of a housekeeper not following proper PPE protocols on a unit housing residents under investigation for COVID-19.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were followed in accordance with CDC guidance for donning and doffing PPE on a unit housing residents under investigation for COVID-19. | SS=E |
Report Facts
Sample size: 5
Deficiency completion date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding PPE requirements and infection control practices | |
| Director of Nursing (DON) | Interviewed and provided facility policies and acknowledged PPE requirements | |
| Housekeeper (HK) | Observed failing to properly don and doff PPE and perform hand hygiene | |
| Registered Nurse (RN) | Interviewed regarding PPE use on the unit | |
| Account Manager/Director of Housekeeping (DHK) | Interviewed about housekeeping PPE requirements and inservicing | |
| Assistant Director of Nursing (ADON) | Interviewed as interim Infection Preventionist regarding PPE compliance and staff competencies |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 2
Jun 18, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint intakes (NJ143724, NJ146017, NJ144700, NJ144134, NJ143427, NJ144790, and NJ145841) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant with resident rights regarding honoring decisions made by resident representatives, specifically related to COVID-19 vaccination consent for Resident #2. Additionally, the facility failed to turn and reposition a dependent resident (Resident #3) every two hours as required for activities of daily living, potentially affecting skin integrity.
Complaint Details
The complaint investigation involved multiple complaint intakes including NJ144700 and NJ144134. The investigation found substantiated issues related to resident rights and ADL care for dependent residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor the decision of the responsible party to decline COVID-19 vaccination for Resident #2 and failed to obtain consent from the responsible party for the vaccination. | SS=D |
| Failed to turn and reposition a dependent resident (Resident #3) every 2 hours as required to maintain skin integrity and prevent complications. | SS=D |
Report Facts
Census: 131
Sample Size: 13
Residents reviewed for immunizations: 3
Residents reviewed for ADLs: 3
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Feb 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 141081.
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.
Complaint Details
Complaint # NJ 141081 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 133
Deficiencies: 0
Feb 5, 2021
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.
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.
Inspection Report
Routine
Census: 123
Deficiencies: 0
Dec 11, 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: 11
Inspection Report
Routine
Census: 132
Deficiencies: 0
Nov 19, 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 and recommended practices for 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.
Loading inspection reports...
