Inspection Reports for Trenton Gardens Rehabilitation And Nursing Center

Complaint numbers NJ 2587050, NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993, and 2673152 triggered the investigation. Issues included pest infestation, inadequate incontinence care, insufficient staffing, medication administration errors, lack of infection control, inadequate supervision leading to resident injury, and lack of behavior health training.

The facility was found deficient in maintaining a clean and homelike environment, providing adequate incontinence care, ensuring sufficient staffing, maintaining equipment such as ice machines, implementing infection control programs especially related to a cockroach infestation, providing adequate supervision to prevent falls, and delivering behavior health training to staff. Multiple residents were affected by these deficiencies.

Complaint #2620207 was substantiated. The facility was found to have an Immediate Jeopardy situation beginning 09/16/2025 at 8:00 P.M. when Resident #2 was observed smoking in a room with oxygen in use despite revoked smoking privileges. The facility submitted an acceptable Removal Plan on 10/12/2025 and implemented corrective actions including 1:1 supervision and education.

The facility failed to ensure that Resident #2, whose smoking privileges were revoked, did not have cigarettes or smoke in the facility in the presence of oxygen, creating an Immediate Jeopardy situation. Additionally, the facility's assessment did not identify residents with tobacco or substance abuse history, which could affect care planning.

Complaint #2562900. The complaint investigation found that Resident #3 overdosed on illicit drugs on 7/11/25, the seventh overdose since November 2024. The facility failed to monitor and supervise the resident adequately, resulting in an Immediate Jeopardy situation. The facility was notified of the IJ on 7/23/25 and submitted an acceptable Removal Plan on 7/25/25, which was verified on 7/29/25.

The facility failed to ensure the safety of Resident #3 by not adequately monitoring and supervising them despite a history of six previous overdoses in the facility. This failure placed the resident and others at risk of serious harm, resulting in an Immediate Jeopardy situation. The facility implemented a Removal Plan including updated care plans, daily behavioral monitoring, random room checks, and re-education of staff and the resident.

Complaints included failure to maintain a clean environment, failure to report and investigate abuse allegations (physical, verbal, sexual), failure to prevent and respond to drug overdoses, and failure to ensure resident safety and proper care planning. Substantiation status is not explicitly stated but Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to maintain a clean and homelike environment, failed to timely report and investigate multiple abuse allegations including physical, verbal, and sexual abuse, failed to update care plans after multiple drug overdoses, failed to prevent illicit drug use and overdoses within the facility, and failed to notify appropriate authorities of incidents. Immediate Jeopardy (IJ) conditions were identified related to abuse investigations and drug overdose management but were removed after corrective actions.

Deficiencies were cited related to accident hazards, food safety and temperature, infection prevention and control, staffing ratios, use of disposable dishware, and multiple life safety code violations including fire door hardware and sprinkler system maintenance.

The facility was found deficient in multiple areas including failure to follow smoking policies for residents, serving food at unsafe temperatures, improper food storage and labeling, inadequate infection prevention practices including hand hygiene and use of personal protective equipment, and failure to maintain respiratory equipment protocols.

Complaint NJ00159167 involved failure to develop a comprehensive care plan for Resident #4's skin condition. Complaint NJ00158370 involved failure to document ADL care for Residents #1, #2, #3, and #4.

The facility failed to develop a comprehensive care plan for Resident #4's change in skin condition and failed to document ADL care for four residents on multiple dates and shifts. Interviews with staff confirmed these deficiencies. The facility policy requires care plans to be updated quarterly and documentation of care to be complete.

Complaint numbers NJ00158370 and NJ00159167 triggered this complaint investigation survey. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on these complaints.

The facility was found deficient in meeting minimum staffing ratios on multiple days, failing to develop and implement comprehensive care plans for residents, and failing to consistently document residents' activities of daily living (ADL) care in the medical records. These deficiencies affected all residents and posed risks to care quality and compliance.

Complaint Intake #NJ162088. The complaint was substantiated as the facility failed to prevent elopement of Resident #1, who was found deceased after exiting the facility unnoticed. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to provide adequate supervision and effective audible alarms on exit doors, resulting in Resident #1 eloping and dying. The facility implemented a corrective action plan including policy revisions, staff training, alarm system upgrades, and increased monitoring, which was verified as effective prior to the survey entrance.

Complaint Intake #NJ162088. The Immediate Jeopardy was related to inadequate supervision and accident hazards, specifically the lack of an effective audible alarm on an exit door and failure to prevent Resident #1 from exiting the facility unnoticed, resulting in death.

The facility failed to ensure adequate supervision and effective audible alarms on exit doors, resulting in Resident #1 leaving the facility unnoticed and subsequently dying. The facility implemented a corrective action plan including increased supervision, alarm system improvements, staff training, and policy revisions, which were verified as completed prior to the survey entrance.

Deficiencies were cited related to advance directives education and documentation, Medicaid/Medicare coverage notices, care plan implementation, medication administration, assistive devices for eating, food safety, COVID-19 vaccination tracking, staffing ratios, resident activities, and life safety code compliance including emergency lighting, fire extinguisher maintenance, hazardous area door closures, and laundry chute door latches.

The facility was found to be noncompliant with several Life Safety Code requirements including illumination of means of egress, emergency lighting, hazardous area enclosures, portable fire extinguisher maintenance, and proper fire protection of laundry chute doors. Deficiencies were identified in emergency lighting at exit discharge doors, battery backup emergency lighting in generator areas, self-closing fire-rated doors, monthly inspection documentation of fire extinguishers, and fire-rated laundry chute doors and latches.

The facility was found deficient in multiple areas including failure to inform residents and their representatives about advance directives, failure to implement and update care plans for residents with falls and infections, failure to administer and document medication properly, failure to provide adaptive eating equipment, failure to maintain kitchen sanitation and food storage, and failure to track and document COVID-19 vaccination status for all staff including contracted hires.

The facility failed to maintain a clean and sanitary environment on two of four nursing units, with multiple areas showing damage such as torn carpets, cracked floor tiles, exposed substrates, loose molding, broken window blinds, and unrepaired walls. Staff responsible for maintenance had not documented or completed necessary repairs despite awareness of the issues.