Inspection Reports for Arnold Walter Nursing & Rehabilitation Center
622 S Laurel Avenue, NJ, 07730
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
151 residents
Based on a February 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census 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 explains the types of information covered, the circumstances under which health information may be used or disclosed, and the legal duties and rights of individuals regarding their health information 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 questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2025
Visit Reason
The inspection was conducted following a complaint alleging that Resident #2 did not receive their prescribed Liothyronine medication as ordered by the physician.
Complaint Details
The complaint was substantiated. The complainant reported leaving the facility AMA on 2/5/25 because they did not receive their Liothyronine medication as ordered.
Findings
The facility failed to ensure that a physician's order to administer Liothyronine medication was followed for Resident #2, resulting in missed doses without proper documentation or physician notification. The medication omissions occurred multiple times, and the facility did not follow policy to notify the physician or obtain alternative medication promptly.
Deficiencies (1)
Failure to ensure a physician's order to administer Liothyronine medication was followed for Resident #2, resulting in missed doses without proper documentation or physician notification.
Report Facts
Missed medication doses: 5
Medication order frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arnold Walter | Name of the nursing and rehabilitation center, no employee role specified. | |
| Licensed Practical Nurse | LPN / UM | Interviewed regarding medication procurement process for new admissions. |
| Director of Nursing | DON | Interviewed regarding medication administration process and expectations. |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 24, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident dignity, environment, care planning, medication administration, respiratory care, pain management, pharmaceutical services, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding assistance, environmental maintenance issues, incomplete and inaccurate care plans, improper medication administration and storage, inadequate respiratory care and documentation, insufficient pain management documentation, and food safety violations in the kitchen and food storage.
Deficiencies (10)
Failed to maintain a resident's dignity while providing feeding assistance by not sitting alongside the resident during feeding.
Failed to maintain the resident's living environment in a clean, comfortable, homelike manner with issues such as standing water in shower, damaged wallpaper, and missing baseboards.
Failed to revise individual comprehensive care plans for residents with floor mats and oxygen use.
Failed to properly change and document dressing changes for a peripherally inserted central catheter (PICC) site.
Failed to properly secure medication during administration and left medications unattended on medication cart.
Failed to label, date, and store respiratory equipment properly; failed to obtain physician's order for oxygen; failed to document vital signs and assessments for nebulizer treatments; and failed to perform tracheostomy care with aseptic technique.
Failed to ensure appropriate pain management including specifying pain level for medication administration and documenting pain assessments and medication effectiveness.
Failed to ensure accountability of narcotic shift count logs and accurate documentation of controlled medication administration.
Failed to properly label opened multidose medications and secure prefilled normal saline syringes.
Failed to ensure food brought in by family and visitors was stored and handled in a safe and sanitary condition.
Report Facts
Residents observed for dignity: 29
Residents reviewed for care plans: 29
Residents reviewed for medication administration: 29
Residents reviewed for respiratory care: 4
Residents reviewed for tracheostomy care: 1
Residents reviewed for pain management: 1
Medication carts reviewed: 4
Facility nursing units reviewed for environmental concerns: 4
Medication administration dates with missing pain documentation: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed leaving medications unattended during medication administration to Resident #127 |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Acknowledged concerns about medication administration and care plan updates |
| Director of Nursing | Director of Nursing (DON) | Acknowledged multiple deficiencies including feeding assistance, environmental concerns, care plan updates, medication administration, respiratory care, and pain management |
| Regional Nurse | Regional Nurse | Acknowledged environmental concerns and respiratory care deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Acknowledged missing narcotic count signatures and medication labeling issues |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Acknowledged missing narcotic count signatures and medication labeling issues |
| Infection Preventionist | Infection Preventionist (IP) | Provided education on infection control and acknowledged deficiencies in respiratory care and trach care |
| LPN #4 | Licensed Practical Nurse | Observed performing trach care without proper hand hygiene and aseptic technique |
| LPN #5 | Licensed Practical Nurse | Provided information on respiratory tubing care and pain management documentation |
| Physical Therapist | Physical Therapist (PT) | Reported resident complaints of pain and pain medication administration issues |
| Certified Nursing Aide #1 | Certified Nursing Aide (CNA) | Reported resident complaints of pain and requests for pain medication |
| Food Service Director | Food Service Director (FSD) | Acknowledged kitchen sanitation issues |
| Regional Food Service Director | Regional Food Service Director (RFSD) | Acknowledged kitchen sanitation issues and food storage violations |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with food safety and kitchen sanitation standards to prevent food borne illness.
Findings
The facility failed to maintain kitchen sanitation in a safe and consistent manner, including issues with hand hygiene practices, improper storage of paper towels, damaged and stained cutting boards, paint chipping on the exhaust hood, and improper storage and condition of food items in the walk-in freezer.
Deficiencies (5)
Trash receptacle positioned under a shelf with clean cups, causing contamination risk.
Paper towels stored improperly on a shelf and appeared wet.
Exhaust hood had paint chipping and needed resurfacing/painting.
Cutting boards were discolored, stained, pitted, and should have been discarded.
Opened boxes of food in the walk-in freezer showed freezer burn and improper packaging.
Report Facts
Hand washing duration: 16
Hand washing duration: 20
Hand washing duration: 30
Dates food opened: Dec 2, 2024
Dates food opened: Jan 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Food Service Director | Observed performing hand hygiene and acknowledged issues with cutting boards and exhaust hood |
| Regional Food Service Director | Regional Food Service Director | Acknowledged freezer burn on food items in walk-in freezer |
| Infection Preventionist | Infection Preventionist | Interviewed regarding hand washing guidelines and infection control practices |
| Director of Nursing | Director of Nursing | Present during interview with Infection Preventionist |
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted based on complaint NJ00168707 to determine compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Complaint Details
Complaint NJ00168707 was substantiated as the facility did not meet minimum CNA staffing ratios on multiple days during the periods 10/08/2023 to 10/21/2023 and 01/28/2024 to 02/10/2024.
Findings
The facility failed to meet the required minimum staff-to-resident CNA ratios for 28 of 28 day shifts and 1 of 1 evening shift during the review periods, indicating noncompliance with state staffing requirements.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident CNA ratios as mandated by the state of New Jersey.
Report Facts
Residents present: 151
CNA staffing deficiency days: 28
CNA staffing deficiency days: 1
Required CNAs: 18
Actual CNAs: 10
Required CNAs: 19
Actual CNAs: 10
Required CNAs: 20
Actual CNAs: 11
Inspection Report
Annual Inspection
Census: 137
Capacity: 169
Deficiencies: 8
Date: Dec 14, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ 156328, NJ 160219, NJ 160755, NJ 161020, NJ 165400, NJ 166083, NJ 166916, NJ 167185 were investigated. Some deficiencies were substantiated related to abuse allegations and medication errors.
Findings
Deficiencies were cited related to reporting of alleged violations, investigation and prevention of abuse, accuracy of assessments, medication administration, pharmacy services, drug regimen review, infection prevention and control, and staffing ratios. A follow-up revisit report dated 2024-01-22 shows all cited deficiencies were corrected.
Deficiencies (8)
Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment in a timely manner.
Failure to thoroughly investigate allegations of abuse and prevent further potential abuse.
Failure to accurately complete the Minimum Data Set (MDS) assessment tool for residents.
Failure to properly transcribe and follow physician's medication orders for residents.
Failure to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of drugs.
Failure to address consultant pharmacist recommendations in a timely manner.
Failure to maintain infection prevention and control standards during wound care treatment.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 137
Total Capacity: 169
Deficiencies cited: 8
Staffing ratios: 16
Staffing ratios: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie | Human Resource Director | Named in staffing deficiency and corrective action plan |
| RNS#2 | Registered Nurse Night-shift Supervisor | Witnessed resident incident and involved in medication administration |
| Interim Director of Nursing | Interim DON | Named in multiple findings including abuse investigation, medication errors, and infection control |
| Licensed Nursing Home Administrator | LNHA | Involved in investigation and corrective action discussions |
| LPN#1 | Licensed Practical Nurse | Involved in wound care and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 14, 2023
Visit Reason
The inspection was conducted in response to complaint #NJ 161020 and other complaints regarding allegations of abuse, failure to investigate abuse allegations, inadequate skin and wound care, and pharmaceutical service deficiencies at Arnold Walter Nursing & Rehabilitation Center.
Complaint Details
Complaint #NJ 161020 involved allegations of abuse and failure to report and investigate. Complaint #NJ166916 involved inadequate skin and wound care. Complaint #NJ166083 involved pharmaceutical service deficiencies related to controlled substance accounting.
Findings
The facility failed to timely report and thoroughly investigate an allegation of abuse involving Resident #93, failed to provide appropriate treatment and care for skin conditions for Resident #287 including lack of physician orders and care plans, and failed to ensure accurate accounting of a controlled substance medication for Resident #187. Multiple interviews, record reviews, and policy reviews confirmed these deficiencies.
Deficiencies (4)
Failed to timely report an allegation of abuse to the New Jersey Department of Health for Resident #93.
Failed to thoroughly investigate an allegation of abuse for Resident #93.
Failed to ensure skin conditions were addressed according to professional standards for Resident #287, including lack of physician orders, care plans, incident reports, and timely hospital transfer.
Failed to provide pharmaceutical services ensuring accurate accounting of dispensed and administered controlled substance medication (lorazepam) for Resident #187.
Report Facts
Residents reviewed for investigations: 5
Residents reviewed for quality of care: 28
Lorazepam tablets received: 42
Lorazepam tablets disposed: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager #1 | LPNUM #1 | Named in skin care deficiency related to Resident #287 |
| Registered Nurse Night-shift Supervisor | RNS#2 | Witnessed fall incident and involved in abuse investigation for Resident #93 and medication administration for Resident #187 |
| Interim Director of Nursing | Interim DON | Interviewed regarding abuse investigation, skin care deficiencies, and medication accountability |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding abuse investigation and facility policies |
| Regional Nurse | Regional Nurse | Interviewed regarding abuse investigation and reinvestigation |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Dec 14, 2023
Visit Reason
The inspection was conducted based on complaint investigations regarding alleged abuse, medication errors, inaccurate assessments, wound care deficiencies, pharmaceutical service issues, and infection control concerns at Arnold Walter Nursing & Rehabilitation Center.
Complaint Details
Complaint #NJ 161020 involved failure to investigate abuse allegations. Complaint #NJ166916 involved failure to provide appropriate skin and wound care and timely hospital transfer. Complaint #NJ166083 involved failure to provide pharmaceutical services ensuring accurate controlled substance accounting.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate an allegation of abuse, inaccurate completion of Minimum Data Set assessments, improper transcription and administration of physician's medication orders, failure to provide appropriate wound care and skin condition management, failure to maintain accurate pharmaceutical records for controlled substances, failure to timely address consultant pharmacist recommendations, and failure to maintain infection control standards during wound care.
Deficiencies (7)
Failed to thoroughly investigate an allegation of abuse for 1 of 5 residents reviewed.
Failed to accurately complete the Minimum Data Set (MDS) for 2 of 27 residents reviewed.
Failed to properly transcribe physician's orders and follow orders for medication administration for 2 of 27 residents reviewed.
Failed to provide appropriate treatment and care for skin conditions including surgical site dressing, leg wound, skin tear, and heel blister for 1 of 28 residents reviewed.
Failed to provide pharmaceutical services to ensure accurate accounting of dispensed and administered controlled substance medication for 1 of 1 resident reviewed.
Failed to ensure licensed pharmacist performed timely drug regimen review and follow-up on recommendations for 1 of 5 residents reviewed.
Failed to maintain infection control standards during wound care treatment for 1 of 1 resident observed.
Report Facts
Residents reviewed for investigations: 5
Residents reviewed for MDS accuracy: 27
Residents reviewed for medication errors: 27
Residents reviewed for skin care: 28
Lorazepam tablets received: 42
Lorazepam tablets disposed: 42
Consultant Pharmacist recommendations response time: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPNUM #1 | Licensed Practical Nurse Unit Manager | Named in failure to notify physician and incomplete skin care documentation for Resident #287 |
| RNS#2 | Registered Nurse Night Shift Supervisor | Witnessed fall incident and involved in medication administration documentation discrepancy |
| Interim DON | Interim Director of Nursing | Provided multiple interviews regarding investigation, medication transcription, and wound care deficiencies |
| RN #1 | Registered Nurse | Reviewed feeding orders and documentation for Resident #388 |
| Regional Nurse | Regional Nurse | Acknowledged reinvestigation and medication review deficiencies |
| LNHA | Licensed Nursing Home Administrator | Participated in meetings regarding investigation and medication transcription issues |
| RMDS | Regional Minimum Data Set Coordinator | Oversaw MDS process and acknowledged assessment inaccuracies |
Inspection Report
Routine
Census: 123
Deficiencies: 0
Date: Aug 19, 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.
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: 5
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Date: Mar 30, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ149829) related to a missing medication for Resident #2 at Arnold Walter Nursing & Rehabilitation Center.
Complaint Details
Complaint # NJ149829. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit. The complaint involved missed medication administration for Resident #2.
Findings
The facility failed to follow professional standards by not accurately administering a prescribed medication to Resident #2 as ordered, failing to notify the physician timely, and not following facility policies on missed medication and nurse charting responsibilities. The medication was missed due to unavailability and lack of proper documentation and notification.
Deficiencies (1)
Failure to follow acceptable professional standards by not accurately following a Physician's Order for medication administration and failure to notify the Physician as required.
Report Facts
Census: 125
Sample Size: 3
Missed Medication Doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practice Nurse (LPN) | Interviewed regarding medication administration and documentation for Resident #2 | |
| Director of Nursing (DON) | Interviewed about medication availability, notification procedures, and documentation | |
| Charge Nurse/LPN | Interviewed about medication unavailability and notification process | |
| Physician | Interviewed post-survey; unaware of missed medication for Resident #2 |
Inspection Report
Routine
Census: 120
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Deficiencies: 1
Date: Aug 19, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on mandatory staffing requirements.
Findings
The facility was found not in compliance with state-mandated minimum direct care staff-to-resident ratios for certified nurse aides during 12 of 42 shifts reviewed. The facility was engaged in ongoing recruitment efforts including open houses, advertising, and bonuses to address staffing shortages.
Deficiencies (1)
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 12 of 42 shifts reviewed (CNA day shifts).
Report Facts
Shifts with staffing deficiency: 12
Dates of deficient shifts: 7/25, 7/26, 7/28, 7/29, 7/30, 7/31, 8/1, 8/2, 8/4, 8/5, 8/6, 8/7/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #16 | Resident | Reported concerns about insufficient staffing during the initial tour |
| Staffing Coordinator | Interviewed about staffing efforts and challenges | |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing shortages and recruitment efforts |
| Human Resources Director | Interviewed about recruitment advertising and outreach efforts |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 19, 2021
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews to investigate complaints and compliance related to pressure ulcers, MDS assessment accuracy, professional standards of practice, and catheter care at Arnold Walter Nursing & Rehabilitation Center.
Complaint Details
The complaint investigation focused on allegations related to pressure ulcer management, MDS assessment accuracy, medication administration, and catheter care. The facility was found to have deficiencies in investigating pressure ulcers, documenting accurate assessments, following physician orders for insulin administration, and proper catheter bag storage and care.
Findings
The facility failed to investigate the root cause of a facility-acquired pressure ulcer for Resident #6, inaccurately coded MDS assessments for Residents #6 and #53, improperly administered insulin for Resident #81, and failed to ensure proper storage and care of urinary leg bags for Resident #74, increasing risk for urinary tract infections.
Deficiencies (4)
Failed to investigate the root cause of a facility-acquired pressure ulcer for Resident #6.
Failed to ensure accuracy of MDS assessments for pressure ulcer risk, behaviors of wandering, and dental assessment for Residents #6 and #53.
Failed to follow professional standards by inaccurately administering insulin dose for Resident #81.
Failed to ensure appropriate storage of urinary leg bag, care plan for leg bag use, and policy addressing leg bag storage for Resident #74.
Report Facts
Pressure ulcer measurement: 1.3
Pressure ulcer measurement: 1.5
MDS BIMS score: 14
MDS BIMS score: 99
Insulin dose: 2
Insulin dose: 4
Blood sugar result: 141
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Administered incorrect insulin dose to Resident #81 and interviewed regarding insulin administration |
| Director of Nursing | DON | Acknowledged findings related to pressure ulcer investigation, MDS inaccuracies, and urinary leg bag storage |
| Licensed Nursing Home Administrator | LNHA | Informed surveyor about investigations and acknowledged findings |
| Regional Nurse | RN | Confirmed MDS inaccuracies and discussed investigation of pressure ulcer origin |
| Certified-MDS Coordinator | Registered Nurse | Confirmed inaccuracies in MDS assessments for Residents #6 and #53 |
| Infection Preventionist | IP | Observed improper storage of urinary leg bag and acknowledged infection risk |
| Certified Nursing Aide | CNA | Interviewed about urinary leg bag storage and care practices |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Apr 19, 2021
Visit Reason
The inspection was conducted in response to complaint #NJ 141501 to assess compliance with regulatory requirements.
Complaint Details
Complaint #NJ 141501 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: 4
Inspection Report
Routine
Census: 87
Deficiencies: 0
Date: Jan 12, 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.
Report Facts
Sample size: 5
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