Inspection Reports for Atlas Healthcare At Daughters Of Miriam
155 Hazel Street, NJ, 07011
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
146% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
35 residents
Based on a October 2025 inspection.
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 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Oct 30, 2025
Visit Reason
The inspection was conducted based on Complaint #185733 regarding concerns about appropriate incontinence care for residents and timely delivery of meal trays in one nursing unit.
Complaint Details
Complaint #185733 (397779) focused on failure to provide appropriate incontinence care and timely meal tray delivery. The complaint was substantiated based on interviews, observations, and record reviews.
Findings
The facility failed to provide appropriate incontinence care for 2 of 3 residents reviewed and failed to deliver meal trays timely in one nursing unit. Additionally, documentation deficiencies were found in residents' care records, including incomplete CNA logs and inaccurate care plans regarding incontinence and double brief use.
Deficiencies (3)
Failure to provide appropriate incontinence care for Residents #1 and #2, including use of double incontinent briefs without proper documentation or care plan updates.
Meal trays were not delivered timely to residents in the 2 [NAME] unit, with trays delivered up to 30 minutes after arrival and unattended distribution.
Incomplete documentation in CNA accountability logs for Residents #1 and #2, with multiple blanks noted for care provided.
Report Facts
Census in 2 [NAME] unit: 35
Residents reviewed for quality of care: 3
Residents affected: 2
Residents affected: 1
BIMS score Resident #1: 12
BIMS score Resident #2: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incontinent care, meal delivery practices, and care plan updates. |
| Licensed Practical Nurse Supervisor | Licensed Practical Nurse Supervisor (LPNS) | Provided information about staffing and incontinence brief practices. |
| Certified Nursing Aide #1 | Certified Nursing Aide (CNA) | Observed distributing meal trays and interviewed about incontinent brief use. |
| Certified Nursing Aide #2 | Certified Nursing Aide (CNA) | Observed assisting Resident #1 and interviewed about incontinent brief use. |
| Registered Nurse | Registered Nurse (RN) | Observed medication preparation and provided information about residents. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Participated in exit conference and discussions about findings. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 18, 2025
Visit Reason
The inspection was conducted based on complaints NJ183033 and NJ173918 regarding failure to notify physician of resident's change in condition and failure to maintain complete and accurate medical records.
Complaint Details
Complaint #NJ183033 involved failure to notify physician timely of Resident #443's condition change. Complaint #NJ173918 involved failure to maintain accurate and complete medical records for Residents #131, #162, #175, and #493.
Findings
The facility failed to ensure timely physician notification for a resident's change in condition resulting in delayed communication until after the resident's death. Additionally, the facility failed to maintain complete, accurate, and accessible medical records for multiple residents, including missing vaccination consents, late physician notes, incomplete documentation of care, and missing signatures on care intervention sheets.
Deficiencies (2)
Failure to ensure physician was consulted and notified immediately of resident's change in condition for Resident #443.
Failure to maintain complete, available, accurate, and readily accessible medical records for Residents #131, #162, #175, and #493.
Report Facts
Residents reviewed: 3
Residents reviewed: 38
Missed documentation opportunities: 35
BIMS score: 9
BIMS score: 3
BIMS score: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Cared for Resident #443 and failed to notify physician timely. |
| LPN #2 | Nursing Supervisor | Supervised nursing staff during Resident #443's expiration and provided instructions on physician notification. |
| Assistant Director of Nursing | ADON | Reviewed notification process and confirmed LPN #1 did not follow policy. |
| Licensed Practical Nurse/Unit Manager #1 | LPN/UM #1 | Interviewed regarding Resident #175's vaccination consent and documentation issues. |
| Registered Nurse Unit Manager | RN/UM | Interviewed about Resident #131's smoking policy education and documentation. |
| Licensed Nursing Home Administrator | LNHA | Participated in exit conferences and provided documentation related to complaints. |
| Regional Director of Clinical Services | RDCS | Participated in exit conferences and confirmed documentation concerns. |
| Director of Nursing | DON | Confirmed documentation deficiencies and participated in exit conferences. |
| Infection Preventionist Nurse | IPN | Provided information about vaccination consent forms. |
Inspection Report
Routine
Census: 203
Deficiencies: 16
Date: Feb 18, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with healthcare facility regulations, including resident care, staffing, infection control, and documentation.
Complaint Details
Complaint NJ175914 and NJ173918 related to care planning, infection control, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy during medication administration, staff license verification, bed hold notification, significant change assessments, timely and accurate Minimum Data Set (MDS) completion and coding, care planning, fall risk assessment and interventions, respiratory care, dialysis care coordination, physician visit documentation, nursing staffing posting accuracy, dietary preference accommodation, infection control practices, and medical record maintenance.
Deficiencies (16)
Failed to treat residents with dignity and provide privacy during medication administration for Resident #39.
Failed to ensure licensed staff credentials were verified upon hire for 1 of 9 newly hired licensed staff.
Failed to notify resident or representative in writing of bed hold policies for Resident #175 during hospitalizations.
Failed to complete a Significant Change in Status Assessment (SCSA) for Resident #18 despite significant cognitive and weight changes.
Late completion and transmission of Minimum Data Set (MDS) assessments for 14 of 38 residents.
Failed to accurately code MDS assessments for Residents #18 and #190.
Failed to develop and implement complete, individualized care plans for Residents #111, #172, #180, and #442.
Failed to ensure routine and accurate psychoactive medication behavior monitoring and interdisciplinary team review for Resident #175.
Failed to ensure fall risk assessments were done quarterly and care plans updated with post-fall interventions for Resident #111.
Failed to monitor enteral feeding volume administration according to physician orders for Resident #172.
Failed to adjust medication and blood sugar monitoring times to accommodate dialysis schedule and clarify duplicate orders for Residents #77 and #121.
Failed to ensure physicians reviewed residents' care, wrote, signed, and dated progress notes and orders at each required visit for 14 residents.
Failed to ensure accurate and timely documentation of resident medical records, including late physician notes for Residents #131, #162, #175, and #493.
Failed to post accurate daily nursing home resident care staffing reports for 2 of 7 days observed.
Failed to ensure resident dietary preferences were honored for Resident #48, who did not receive requested food items.
Failed to follow appropriate hand hygiene, PPE use, disinfecting wipe use, and transmission-based precaution signage for Resident #292 and staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 14
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 14
Residents affected: 4
Days: 2
Residents affected: 1
Staff affected: 3
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 20, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to timely report an injury of unknown origin for Resident 9 and failure to administer physician-ordered medications as scheduled for Resident 6.
Complaint Details
Complaint #165432 involved failure to report an injury of unknown origin for Resident 9. The facility investigation concluded no abuse or neglect but failed to report the injury to the state survey agency as required. Complaint #NJ 164077 involved failure to administer medications on time for Resident 6, confirmed by resident and Director of Nursing interviews.
Findings
The facility failed to report an injury of unknown origin to the state survey agency for Resident 9 despite conducting an internal investigation that concluded no abuse or neglect occurred. Additionally, the facility failed to administer medications on time for Resident 6, with multiple documented late administrations confirmed by the Director of Nursing.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or injury of unknown origin to the state survey agency for Resident 9.
Failure to administer physician ordered medications as scheduled for Resident 6.
Report Facts
Residents sampled: 12
Medication late administrations: 4
Bruising measurements: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Conducted assessment of Resident 9's bruising on 06/24/23 |
| Director of Nursing | DON | Interviewed regarding Resident 9's injury investigation and Resident 6's medication administration |
| Assistant Administrator | Interviewed regarding Resident 9's injury investigation | |
| Regional Clinical Support | Interviewed regarding Resident 9's injury investigation and reporting |
Inspection Report
Complaint Investigation
Census: 192
Deficiencies: 3
Date: Oct 20, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers related to alleged violations at the facility.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility failed to report an injury of unknown origin for Resident 9 and failed to administer medications on time for Resident 6. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Findings
The facility was found not in substantial compliance with federal requirements related to abuse reporting and quality of care. Specifically, the facility failed to timely report an injury of unknown origin for one resident and failed to administer physician-ordered medications as scheduled for another resident. Additionally, the facility did not meet required minimum staffing ratios as mandated by the state.
Deficiencies (3)
Failure to report an injury of unknown origin to the state survey agency for one resident.
Failure to administer physician ordered medications as scheduled for one resident.
Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Survey Census: 192
Sample Size: 12
Deficient CNA staffing shifts: 34
Deficient CNA staffing shifts: 1
Required CNA staffing: 23
Actual CNA staffing: 13
Medication administration times: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 12, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 192
Deficiencies: 0
Date: Aug 12, 2023
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 preparedness 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 to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Atlas Healthcare at Daughters of Miriam following a survey completed on 07/06/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Census: 186
Deficiencies: 0
Date: Jul 6, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Deficiencies: 8
Date: May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including Minimum Data Set (MDS) data submission, resident care and assistance with activities of daily living, hearing aid use, range of motion services, oxygen therapy, medication regimen review, psychotropic medication monitoring, and infection control practices.
Findings
The facility failed to provide timely MDS data submission for one resident, failed to provide adequate personal hygiene and grooming assistance to eight residents, failed to ensure a hearing aid was in place for one resident, failed to consistently provide daily range of motion services for one resident, failed to obtain physician orders and develop a care plan for oxygen therapy for one resident, failed to ensure monthly medication regimen review by a pharmacist for one resident, failed to monitor psychotropic medication efficacy for one resident, and failed to sanitize glucometers between uses resulting in an Immediate Jeopardy that was later removed.
Deficiencies (8)
Failed to provide timely Minimum Data Set (MDS) data submission for one resident (R343).
Failed to provide assistance with grooming and personal hygiene in eight residents (R292, R2, R17, R20, R136, R162, R33, and R72).
Failed to ensure a hearing aid was in place for one resident (R2) to maintain hearing abilities.
Failed to consistently provide daily range of motion (ROM) services for one resident (R126).
Failed to obtain physician orders and develop a care plan with interventions for oxygen therapy for one resident (R292).
Failed to ensure a medication regimen review was completed by a pharmacist at least once a month for one resident (R150).
Failed to ensure psychotropic medication efficacy was monitored for one resident (R157).
Failed to sanitize glucometers between uses for one resident (R111), resulting in Immediate Jeopardy.
Report Facts
Residents reviewed for MDS transmission: 43
Residents reviewed for personal hygiene assistance: 43
Residents reviewed for hearing aid use: 43
Residents reviewed for limited range of motion: 43
Residents reviewed for oxygen therapy: 43
Residents reviewed for unnecessary medications: 43
Residents reviewed for psychotropic medication monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator 2 | MDS Coordinator | Confirmed late MDS data submission for Resident 343 |
| Administrator | Administrator | Acknowledged ongoing issue with timely MDS submission and staffing |
| CNA1 | Certified Nursing Assistant | Provided information on resident shower frequency and refusals |
| RN2 | Registered Nurse | Provided information on shower frequency and hearing aid management |
| DON | Director of Nursing | Provided statements on grooming expectations and medication regimen review |
| Unit Manager 4 | Unit Manager | Unaware of resident not receiving showers and oxygen therapy orders |
| LPN1 | Licensed Practical Nurse | Observed sanitizing glucometer and described cleaning practices |
| RN15 | Registered Nurse | Unable to locate restorative nursing notebook and described restorative therapy process |
| CNA51 | Certified Nursing Assistant | Unaware of restorative nursing plan for resident 126 |
| CNA85 | Certified Nursing Assistant | Unaware of restorative nursing plan for resident 126 |
| Director of Therapy | Director of Therapy | Confirmed restorative therapy order for resident 126 but unable to locate plan |
| Unit Manager 3 | Unit Manager | Acknowledged missing efficacy monitoring for valproic acid |
Inspection Report
Annual Inspection
Census: 179
Capacity: 209
Deficiencies: 15
Date: May 5, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health from 05/01/23 through 05/05/23 to assess compliance with federal and state regulations.
Complaint Details
The survey included a complaint investigation component triggered by allegations related to infection control and resident care deficiencies.
Findings
The facility was found not to be in substantial compliance with several regulatory requirements including infection control, resident assessments, assistance with activities of daily living, medication regimen review, psychotropic drug use, emergency preparedness, and life safety code requirements. Immediate Jeopardy was identified related to infection control practices with glucometer sanitization but was removed after corrective actions. Multiple deficiencies were cited related to resident care, documentation, and facility safety.
Deficiencies (15)
Failure to sanitize glucometers between residents per manufacturer's instructions, resulting in Immediate Jeopardy for infection control.
Failure to provide timely Minimum Data Set (MDS) resident assessments and transmit data as required.
Failure to provide assistance with grooming and personal hygiene to dependent residents.
Failure to ensure proper treatment and care planning for residents with hearing and vision impairments.
Failure to consistently provide daily range of motion (ROM) services for residents with limited mobility.
Failure to obtain physician orders and develop care plans for respiratory care including tracheostomy and suctioning.
Failure to ensure medication regimen review was completed monthly by a pharmacist for all residents.
Failure to ensure psychotropic drug use was properly monitored, including PRN orders and behavioral monitoring.
Failure to provide emergency lighting at the emergency generator transfer switch.
Failure to maintain vertical openings with proper fire-rated doors and latches.
Failure to locate a manual fire alarm box within 60 inches of the exterior exit doors from the auditorium.
Failure to perform smoke detection sensitivity testing every alternate year as required.
Failure to ensure Ground Fault Circuit Interruption (GFCI) protection for electrical outlets within six feet of sinks.
Failure to inspect fire door assemblies annually and maintain inspection records.
Failure to maintain required minimum direct care staff to resident ratios for Certified Nurse Aides (CNAs) on day shifts for 31 of 42 days reviewed.
Report Facts
Survey Census: 179
Total Capacity: 209
Sample Size: 43
Deficient CNA staffing days: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in infection control deficiency related to glucometer sanitization |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including infection control, medication regimen review, and resident care |
| Administrator | Facility Administrator | Named in infection control and staffing deficiencies |
| MDS Coordinator (MDSC2) | MDS Coordinator | Named in deficiency related to resident assessment data submission |
| Maintenance Director | Maintenance Director | Named in deficiencies related to emergency lighting, fire doors, fire alarm system, and electrical safety |
Inspection Report
Routine
Deficiencies: 8
Date: May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including Minimum Data Set (MDS) data submission, resident care and assistance with activities of daily living, hearing aid use, range of motion services, oxygen therapy, medication regimen review, psychotropic medication monitoring, and infection control practices.
Findings
The facility failed to provide timely MDS data submission for one resident, failed to provide adequate grooming and personal hygiene assistance for eight residents, failed to ensure a hearing aid was in place for one resident, failed to consistently provide daily range of motion services for one resident, failed to obtain physician orders and develop a care plan for oxygen therapy for one resident, failed to ensure monthly pharmacist medication regimen review for one resident, failed to monitor psychotropic medication efficacy for one resident, and failed to sanitize glucometers between uses resulting in an Immediate Jeopardy that was later removed.
Deficiencies (8)
Failed to provide timely Minimum Data Set (MDS) data submission for one resident (R343).
Failed to provide assistance with grooming and personal hygiene in eight residents (R292, R2, R17, R20, R136, R162, R33, and R72).
Failed to ensure a hearing aid was in place in one resident (R2) to maintain hearing abilities.
Failed to consistently provide daily range of motion (ROM) services for one resident (R126).
Failed to obtain physician orders and develop a care plan with interventions for oxygen therapy for one resident (R292).
Failed to ensure a medication regimen review was completed by a pharmacist at least once a month for one resident (R150).
Failed to ensure psychotropic medication efficacy was monitored for one resident (R157).
Failed to sanitize glucometers between uses for one resident (R111), resulting in Immediate Jeopardy.
Report Facts
Residents reviewed for MDS transmission: 43
Residents reviewed for grooming and personal hygiene: 43
Residents reviewed for limited ROM: 43
Residents reviewed for oxygen therapy: 43
Residents reviewed for unnecessary medications: 43
Residents reviewed for psychotropic medications: 5
Residents reviewed for medication regimen review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator 2 | MDS Coordinator | Confirmed late MDS data submission for Resident 343 |
| Administrator | Administrator | Acknowledged ongoing issue with timely MDS submission |
| CNA1 | Certified Nursing Assistant | Provided information about resident shower schedule and refusals |
| RN2 | Registered Nurse | Provided information about shower schedule and hearing aid use for Resident 2 |
| CNA3 | Certified Nursing Assistant | Discussed shaving female residents and refusals |
| CNA2 | Certified Nursing Assistant | Reported resident R162 can be combative with ADL care |
| Director of Nurses | Director of Nursing | Discussed expectations for grooming and documentation of refusals |
| Unit Manager 4 | Unit Manager | Unaware resident R292 had not received shower or bath since admission |
| CNA49 | Certified Nursing Assistant | Provided bed bath to resident R292 and discussed showering practices |
| LPN48 | Licensed Practical Nurse | Unaware resident R292 had not received showers or baths |
| RN35 | Registered Nurse | Reviewed restorative checklist and grooming expectations |
| CNA51 | Certified Nursing Assistant | Discussed restorative therapy and grooming practices |
| CNA55 | Certified Nursing Assistant | Discussed restorative therapy and grooming practices |
| CNA85 | Certified Nursing Assistant | Unaware of restorative nursing plan for resident R126 |
| Director of Therapy | Director of Therapy | Confirmed restorative therapy order for resident R126 |
| LPN1 | Licensed Practical Nurse | Observed sanitizing glucometer and performing blood glucose tests |
| DON | Director of Nursing | Discussed glucometer sanitization policy and expectations |
| RN15 | Registered Nurse | Discussed restorative nursing notebook and restorative therapy plans |
| Unit Manager 3 | Unit Manager | Reviewed psychotropic medication monitoring and acknowledged missing monitoring |
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 5
Date: Jan 20, 2023
Visit Reason
Complaint survey triggered by complaint #NJ159325 and a COVID-19 Focused Infection Control Survey due to outbreak status and infection control concerns.
Complaint Details
Complaint #NJ159325 involved allegations of failure to comply with infection control regulations, falsification of staff COVID-19 testing logs, improper PPE use, and failure to maintain an effective compliance and ethics program. The complaint was substantiated based on observations, interviews, and document reviews.
Findings
The facility was found non-compliant with infection control regulations including failure to ensure twice weekly staff COVID-19 testing, falsification of testing logs, failure to ensure proper N95 mask fit testing and use, improper PPE use, and inadequate infection prevention and control program implementation. The facility also failed to maintain an effective compliance and ethics program.
Deficiencies (5)
Failure to ensure staff COVID-19 testing was completed twice weekly as required and falsification of testing logs.
Failure to ensure proper fit testing and use of N95 masks by staff, including agency staff, and failure to ensure proper PPE use.
Failure to maintain an effective infection prevention and control program including cleaning of equipment between resident use.
Failure to ensure COVID-19 testing of residents and staff was conducted according to community transmission levels and regulatory requirements.
Failure to implement and enforce an effective compliance and ethics program, including failure to ensure integrity of reported testing data and falsification of respirator fit testing documentation.
Report Facts
Census: 189
Sample Size: 5
Employees fit tested: 144
Employees overdue for fit testing: 80
Agency staff without fit test: 47
Employees employed: 197
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #10 | Certified Nursing Assistant | Signed a fit test form without being fit tested for the required N95 mask. |
| UC #12 | Unit Clerk | Instructed by NHA to falsify staff COVID-19 testing logs and have employees sign them. |
| LPN #3 | Licensed Practical Nurse | Forgot to test for COVID-19 on a scheduled shift. |
| DON | Director of Nursing | Instructed staff to have CNA #10 sign fit test form; acknowledged lack of training for fit testing. |
| RDO | Regional Director of Operations | Expressed disbelief at falsification of documents and failure to comply with testing requirements. |
| IP Nurse | Infection Preventionist Nurse | Responsible for fit testing and infection control training; admitted incomplete agency staff fit testing records. |
| SC #11 | Staffing Coordinator | Asked CNA #10 to sign a blank fit testing form. |
Inspection Report
Complaint Investigation
Census: 175
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00156684.
Complaint Details
Complaint number NJ00156684 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample size: 15
Inspection Report
Annual Inspection
Census: 144
Deficiencies: 0
Date: May 5, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample records reviewed: 45
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 5, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Atlas Healthcare at Daughters of Miriam following a survey completed on May 5, 2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 4, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The Daughters of Miriam Center was found to be in compliance with the Life Safety Code requirements, including emergency preparedness and fire safety standards. The facility is a multi-phase, multi-story structure divided into 19 smoke zones.
Report Facts
Smoke zones: 19
Stories: 5
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: Jan 20, 2021
Visit Reason
The inspection was conducted in response to complaints NJ: 141897 and 142675 regarding alleged staff to resident abuse involving Resident #1.
Complaint Details
The complaint involved verbal abuse by CNA #1 towards Resident #1, including demeaning language and failure to follow resident's care preferences. The incident was witnessed by CNA #2. The facility did not report the incident to NJDOH within the required 2-hour timeframe, reporting it instead 8 days later. The CNA was suspended and terminated, and staff were re-educated on abuse reporting policies.
Findings
The facility failed to immediately report an allegation of staff to resident verbal abuse involving CNA #1 and Resident #1 to the New Jersey Department of Health as required by policy and regulation. The CNA was suspended and terminated, and staff were re-educated on abuse reporting and investigation procedures.
Deficiencies (1)
Failure to immediately report an allegation of staff to resident abuse involving Resident #1 as required by facility policy and state regulations.
Report Facts
Complaint numbers: 2
Resident census: 145
Sample size: 4
Days late reporting: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in verbal abuse incident and subsequent termination |
| CNA #2 | Certified Nursing Aide | Witness to abuse incident and re-educated on reporting |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident and facility reporting procedures |
| Unit Manager #1 | Unit Manager | Interviewed regarding incident and staff monitoring |
Inspection Report
Abbreviated Survey
Census: 145
Deficiencies: 1
Date: Dec 14, 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 not in compliance with 42 CFR §483.80 infection control regulations due to failure to utilize appropriate personal protective equipment (PPE) by staff, specifically a Certified Nursing Assistant who did not wear a gown while in the COVID-19 positive unit. The facility lacked a policy specifying PPE requirements inside the unit.
Deficiencies (1)
Failure to utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection, specifically a CNA not wearing a gown in the COVID-19 positive unit.
Report Facts
Sample size: 7
Deficiency completion date: Dec 30, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated CNAs were instructed to wear gowns inside the unit and acknowledged lack of a specific PPE policy |
| Registered Nurse Unit Manager | RN/UM | Provided information about PPE requirements outside the COVID-19 positive unit |
| Infection Control Nurse | Infection Control Nurse | Retrained CNA on proper PPE use and conducted staff training on PPE usage |
| Certified Nursing Assistant | CNA | Observed not wearing gown while in COVID-19 positive unit, admitted to improper PPE use |
Inspection Report
Routine
Census: 147
Deficiencies: 0
Date: Nov 18, 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.
Viewing
Loading inspection reports...
