Abingdon Care & Rehabilitation Center

Inspectors wroteComplaints: 2706516, 2743086 Based on interview and review of facility documentation, it was determined that the facility failed to employ a full-time Social Worker (SW) from August 2024 until 02/12/2026. This deficient practice had the potential to affect all residents and was evidenced by the following:On 02/11/2026 at 10:05 AM, a survey entrance conference was conducted with the Licensed Nursing Home Administrator (LNHA) who stated that the facility did not have a full-time Social Worker (SW) and the facility's part-time SW left approximately two weeks prior. On 02/12/2026 at 9:34 AM, an interview was conducted with the Human Resources Director (HRD) who stated the facility had no full-time SW for the last five months. The HRD stated after the full-time SW left, a part-time or per diem (as needed) SW worked up to 30 hours per week but they left two weeks ago. [...]

Inspectors wroteComplaints: 2706516, 2743086 Based on interviews, review of the medical records, and review of other pertinent facility documentation on 02/11/2026 and 02/12/2026, it was determined that the facility failed to provide for the medically related social service needs for residents who required assistance with obtaining needed services from outside entities; or who should have received emotional support after an allegation of staff to resident abuse. This deficient practice was identified for 3 of 3 residents (Resident #3, Resident #4, and Resident #5) reviewed and was evidenced by the following:A review of the Resident Council Minutes dated 11/26/20205 revealed that residents inquired about when the facility would have a Social Worker (SW). [...]

Inspectors wroteComplaint #: 2723631 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 02/11/2026, it was determined that the facility failed to update the care plan (CP) with clear focus, goals, and interventions for a resident (Resident #3) involved in a staff to resident abuse allegation. This deficient practice was identified for 1 of 4 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; muscle weakness; need for assistance with personal care; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. [...]

Inspectors wroteComplaint #NJ184191/394091Based on, interviews, and record review, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 7 residents (Resident #5). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the four week cycle menus for nutritional adequacy in accordance with nationally accredited standards and the facility provided Diet Manual, b.) residents consistently received the standard serving of the main entrée/protein (16 out of 56 lunch and dinner meals were inadequate) or an alternate item (2 out of 9 were inadequate) for high biological value protein (proteins of high biological value, also known as complete proteins, are those that contain all the essential amino acids in the appropriate proportions that the body needs to carry out its functions optimally), c.) alternate menu items were available as posted, and d.) that a resident (Resident #54) consistently received breakfast [...]

Inspectors wroteBased on interviews, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 7 alert and oriented residents (Resident's #4, #22, #53, #58, #70, and #81) during the resident council meeting and was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). At the end of the initial tour, the surveyor requested a copy of residents who received labeled snacks, as well as a list of snacks that were sent to the units in the evening to be distributed after dinner. The FSD stated, we really don't send HS (evening) snacks, there was no list. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor toured the kitchen with the Food Service Director (FSD). The following was observed: 1. Inside the ice machine there was a reddish like substance on the bottom of the white baffle (a flow-directing panel that restrained ice), as well as both sides of the interior walls of the ice machine near screws. The FSD took a clean towel and wiped both areas. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to have a system in place to ensure that facility garbage receptacles were covered, and all garbage was contained and removed timely to prevent a buildup of refuse, and that the receptacles including a trash compactor and the surrounding areas were maintained in a clean manner to prevent the accumulation of debris. The deficient practice was evidenced as follows: On 4/14/25 at 9:00 AM, the survey team arrived at the facility. From the parking lot, the surveyor was able to view the dumpster area, in the presence of the survey team. There were two oversized uncovered dumpsters overflowing with waste/debris and had black garbage bags around and between the two dumpsters, as well as debris on the ground. [...]

Inspectors wroteRepeat Deficiency Based on observation and interview it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (Noble and [NAME]) and was evidenced by the following: 1. On 04/14/25 at 10:27 AM, during initial tour of the Noble unit, the surveyor noted dark scuff marks in the hallway outside room [ROOM NUMBER]. Inside room [ROOM NUMBER], the surveyor observed the heater unit with a dark brown/reddish substance noted on the fins of the heater and brownish/blackish marks on the body of the heater unit. At 10:40 AM, the surveyor noted multiple cracked floor tiles in room [ROOM NUMBER]. At 10:49 AM, the surveyor observed the heater in room [ROOM NUMBER] with brown/black substances in fins of unit and on body of heater unit. [...]

Inspectors wroteBased on observation, interview, record review, and facility documentation it was determined that the facility failed to: a.) maintain receipt, accountability, reconciliation, secure storage and removal from active inventory of controlled drugs, (Lorazepam (Ativan) (benzodiazepine Schedule IV), Fentanyl Patches (opioid Schedule II), Methadone(opioid Schedule II), Hydrocodone/Acetaminophen (opioid/analgesic Schedule II), and Morphine Sulfate (opioid Schedule II), for three (3) residents, (unsampled Residents #201, #203, #204) that were discharged [DATE], 5/7/24 and 9/6/24 respectively, until surveyor inquiry, stored in one (1) of two (2) medication rooms, b.) maintain accurate accountability, reconciliation and removal from active inventory upon discontinuation for controlled drugs, (Diazepam gel (benzodiazepine Schedule IV) and Nayzilam (Diazepam nasal spray), stored in the medication [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 12/7/24 to 4/16/25. This deficient practice was evidenced by the following: On 4/15/25 at10:17 AM, the surveyor met with seven residents for a resident council meeting. During that meetin, 6 out of the 7 alert and oriented residents voiced concerns that the facility did not have a full-time social worker. The residents explained for the last 2 or 3 months there was a social worker that worked only Saturdays/Sundays for about 5 hours. On 4/15/25 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated there was a new social worker starting this week. He confirmed the current social worker (SW#2) usually comes in a few hours on Saturday's and Sundays. He verified the last SW's (SW#1) last day was 12/6/24. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was evidenced by the following: On 4/14/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or at either nursing unit. The receptionist was present at the front desk. On 4/15/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or on the Noble nursing unit. The receptionist was present at the front desk. On 04/16/25 at 9:44 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/15/25 for the 7-3 shift. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for two out of four Quality Assurance and Performance Improvement (QAPI) meetings reviewed and was evidenced by the following: 04/23/25 11:33 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated QAPI meetings were held at least quarterly and as needed, he added we also meet monthly. He stated the required members were the administrator (LNHA), the director of nursing (DON), the medical director and other staff were required to attend the meetings at least quarterly. The LNHA stated also will be including a certified nursing assistant in the meetings. [...]

Inspectors wroteRepeat Deficiency Based on observation, record review, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not placing a resident with open wounds on Enhanced Barrier Precautions (EBP- a gown and gloves be worn when performing high contact care), for one of two residents (Resident #45) reviewed for pressure ulcers. The deficient practice was evidenced by the following: On 4/16/25 at 9:33 AM, during a wound treatment observation, the surveyor observed the Certified Nurse Aide (CNA) holding Resident #45 on their right side with their sacral and right heel wound exposed. The CNA was wearing gloves. The surveyor then observed the Licensed Practical Nurse (LPN) cleanse the sacral wound and apply the treatment and dressing. The LPN was wearing gloves. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the kitchen was free of pests. The deficient practiced was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During this tour, he stated that he used a [name redacted] electronic communication system as well as verbal communication with the Director of Environmental Services (DES) when there was a maintenance concern in the kitchen. The surveyor observed an open drain on the floor next to a grease trap. The surveyor observed many flies in this area, coming from the drain, in the air and on the wall. The FSD acknowledged this and stated they were drain flies, and that the grease trap needed to be cleaned. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a) a resident assessment was completed to rule out injury, and the physician was immediately notified when staff witnessed a resident who banged finger hard on a door frame and yelled ouch. This resulted in a delay in treatment for one and a half hours, and the resident experienced pain and was subsequently diagnosed with a fracture of the third finger left hand, and b) appropriate incontinence care and related services were provided for two residents dependent on staff for care. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure the surety bond contained sufficient funds to protect the residents' trust funds. This deficient practice had the potential to affect all residents who resided in the facility that had Personal Needs Account (PNA) funds and was evidenced by the following: On 10/19/23 a 12:45 PM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a three-page document labeled Checking Account Statement, Statement Type: Bank, Trust Account [number redacted]. The document was dated 07/25/23 through 10/18/23. The document revealed a beginning balance $144,211.45, on 07/25/23, and a balance of $129,340.81 on 10/18/23. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents dependent on staff assistance for care, by failing to provide: a) nail care, b) assistance with dressing, c) personal hygiene care, and d) provide incontinence care, including prior to delivering a meal tray. This deficient practice was identified for 5 of 21 residents reviewed for ADLs (Resident #7, #13, #14, #41, and #73) on 2 of 2 resident care units (Noble and [NAME]). This deficient practice was evidenced by the following: a. On 10/18/23 at 9:40 AM, Surveyor #1 toured the [NAME] unit and observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were competent and appropriate care was provided for the hemodialysis (the filtration of waste when the kidneys are no longer able to do so) access sites, and staff were trained to differentiate between an AV (Arteriovenous) Fistula (an abnormal connection between an artery and a vein), and a Permacath (tunneled hemodialysis catheter) a flexible tube used for dialysis treatment, and b.) ensure that staff were trained to properly assess, and document care of the hemodialysis access sites which includes the auscultation/palpation of the AV fistula for Bruit (an abnormal sound generated by turbulent arterial blood flow) and Thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, [...]

Inspectors wroteComplaint # NJ 00162113 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to (a) provide assistance dressing, provide personal hygiene and incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs), b) provide nail care for a resident who was dependent on staff for ADLs, and c) respond to call lights in a timely manner. This deficient practice was identified for 5 of 21 residents (Resident #13, #14, #41, #73 and #7 ) on 2 of 2 nursing units. This deficient practice was evidenced by the following: Refer to 684G and 677F. Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure: a) a Medication Regimen Review (MRR) of each resident was performed at least once a month by a licensed pharmacist, and b) provide documentation that the recommendations were acted upon in a timely matter. This deficient practice was observed for 2 of 2 nursing units with a census of 101, for August 2023 and September 2023, and was evidenced by the following: During an interview with the surveyor on 10/25/23 at 9:22 AM, the Registered Nurse Unit Manager (RN UM) stated that MRR were completed monthly, but the facility had changed pharmacy consultants and not sure how the reporting was being done at present. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that garbage was regularly removed from the facility in a manner to prevent the potential spread of infection and vermin infestation. The deficient practice was evidenced by the following: On 10/18/23 at 8:53 AM, during the initial approach from the parking area/rear of the building, the surveyor observed a large pile of garbage bags that covered approximately one- half of the loading dock. The garbage bags were piled up against the back wall of the loading dock and adjacent to a chain link fence cage that appeared to have oxygen cylinders inside with a sign affixed Danger, No Smoking, No Open Flames to the outside of the cage and above a pile of the garbage bags. The garbage bags that were piled up against the back wall obstructed a sign Notice all cardboard needs to be . [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to follow facility policy to limit the spread of potential infection by ensuring: a.) hand hygiene at the lunch meal service, b.) hand hygiene and clean procedure during the care of a feeding tube dressing, c.) the demonstration of a hemodialysis access assessment, and d.) the Clean Dressing Change Policy was followed for 1 of 1 resident (Resident #14) observed during a wound care treatment observation. This deficient practice was identified for 3 residents (Resident #358, #90, and #14) on 2 of 2 nursing units and was evidenced by the following: a.) On 10/19/23 at 11:48 AM, Surveyor #1 observed the [NAME] unit staff passed out the lunch meal trays. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain resident common areas, resident rooms and equipment in a clean, sanitary and safe functional manner as evidenced by the following: During the initial tour of the Noble unit on 10/18/23 at 10:14 AM, the surveyor observed in room [ROOM NUMBER] the air conditioner unit with blue tape and card board around the bottom of the unit. On 10/18/23 at 10:30 AM, the surveyor toured the [NAME] unit day room and observed an unsampled resident (UR #1) ambulating independently and was looking out of a window that was above an air conditioning unit, and another unsampled resident (UR #2) was sitting at a table watching the television. Upon entering the day room, the surveyor observed a row of wooden cabinets that appeared visibly soiled on the exterior, and the cabinet door appeared to be loose on its hinges. [...]

Inspectors wroteBased on interview, record review and review of pertinent documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) two incidents for one resident (08/20/23 & 09/23/23) for injuries that resulted in fractures. The deficient practice was identified for 1 of 2 (Resident #52) residents reviewed for reportable events and was evidenced by the following: On 10/23/23 at 12:24 PM, the facility provided incident reports for Resident #52. The documents revealed Resident #52 had a fracture of the distal phalanx (bone) of the third finger to the left hand (middle finger of the left hand) which occurred on 08/20/23. Resident #52 also had an incident dated 09/23/23, which resulted in a right nasal bone fracture, minimally displaced nasal septum fracture, and nondisplaced left nasal bone fracture (3 bones in the nose). [...]

Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to complete and document a thorough investigation and follow the facility Abuse Policy for a.) two incidents that resulted in two different fractures for one resident who resided on a secure unit with a diagnosis of Dementia, and b.) failed to conduct an investigation for a resident who was observed self-injecting with an unknown substance. This deficient practice occurred for 2 residents (Resident #52 and Resident #356) reviewed for accidents and incidents and was evidenced by the following: a.) On 10/18/23 at 9:47 AM, Surveyor #1 observed Resident #52 seated in a chair next to the bed. The Resident was alert but unable to answer questions asked due to the resident being confused. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure a.) a resident who was dependent on supplemental oxygen via a tracheostomy was provided with respiratory services to maintain their oxygenation status according to the physician's order and the facility's policy, b) that a resident received oxygen as ordered by the physician, and c) oxygen related treatments were provided in a manner to prevent the spread of infection. This deficient practice was identified for 2 of 2 residents reviewed for respiratory services, Resident #14 and #92 and was evidenced by the following: 1.) On 10/18/23 at 09:10 AM, the surveyor observed Resident #14 in bed. The resident was non verbal. The resident had a tracheostomy (a surgical opening in the anterior neck providing an alternate airway for breathing), and was connected to an oxygen concentrator. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the meals were served at a palatable temperature for 2 of 2 Residents reviewed for food (Resident #23 & Resident #87). The deficient practice was evidenced by the following: On 10/18/23 11:29 AM, the surveyor observed Resident #87 awake and alert sitting in bed. The surveyor asked about the food at the facility and Resident #87 stated the food is horrible and it is cold. On 10/18/23 at 11:40 AM, the surveyor observed Resident #23 awake and alert sitting in wheelchair inside the resident's room. When asked about the meals, Resident #23 stated the food *****, the food is always cold. On 10/20/23 at 8:27 AM, the surveyor observed the meal cart brought to the second floor by the dietary staff. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure that a process was in place for explaining the arbitration agreement to a resident prior to having the resident sign the agreement. This deficient practice occurred for 1 of 2 residents reviewed for arbitration agreements (Resident #16) and was evidenced by the following: On [DATE] at 12:19 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility utilized arbitration agreements which were part of the admission agreement and would provide a list of residents who have signed the agreement. The LNHA stated the admission Diretor was responsible for having the residents sign the agreements. On [DATE] at 11:30 AM, the surveyor received the list of facility arbitration agreements which include resident #16. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to provide education and assess staff competencies for staff who provided care for residents who received dialysis [a type of treatment used to clean the blood when kidneys do not function properly] as identified as residents with skilled needs per the Facility Assessment. The deficient practice was evidenced by the following: On 10/19/23 at 10:55 AM, the surveyor observed Resident #90 lying in bed awake, watching television with snacks on his/her bedside table. Resident #90 stated that he/she had been going to hemodialysis for a while. The resident stated that he/she used to have a catheter in his/her chest, while pointing to his/her right side of chest and neck area, but now had a fistula in his/her right arm, pointing to his/her right upper arm. [...]

Inspectors wroteComplaint # NJ 162113 Based on interview, and record review it was determined that the facility failed to ensure that resident temperatures were documented per physician order for 1 of 1 closed record (Resident #356) reviewed for physician orders. The deficient practice was evidenced by the following: On 10/20/23 at 10:31 AM, a review of the closed medical record for Resident # 356 revealed a Physician Order dated 02/18/23 for Blood pressure (BP) monitoring every shift, HR [heart rate], RR [respiratory rate], Temp [Temperature], SPO2 [Pulse Oximetry], Pain every shift for BP monitoring. The Electronic Medical Record (EMR) documentation of Temp was reviewed from 02/18/23 through 03/04/23 when resident was transferred to the hospital and indicated the following: Date: Time: Temp: [...]

Inspectors wroteBased on observation, interview, and review of facility documents it was determined that the facility failed to properly label and date medications in 2 of 4 medication carts inspected. The deficient practice was evidenced by the following: 1. On 10/19/23 at 11:00 AM, the surveyor inspected the low side of the Noble Unit medication cart on the 2nd floor with the Licensed Practical Nurse (LPN#1) who was assigned to the cart. Inside of the medication cart the surveyor observed following: -1 bottle of Nitroglycerin tablet (medication used to treat angina) with an expiration date of 07/23 -1 multi dose vial of insulin opened but not dated, a pack of Oxycodone 5/325 milligrams( mg) (medication to treat pain) with an expiration date of 09/23 -5 multi dose vials of Insulin that had an open date and no expiration date -1 multi doses vial of Aspart Insulin opened 09/07/23 last used 10/19/23. 2. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain the resident nurse call system to operate as designed with visual and audible signals at the nursing station for 1 of 21 residents ( Resident #15) on 1 of 2 units (Noble). This deficient practice was evidenced by the following: On [DATE] at 10:59 AM, the surveyor observed when Resident#15's call bell was illuminated, there was no audible or visual signal emitting from the resident call system console located at the Noble Unit nurse's station. At 11:06 AM, the surveyor observed the call light outside Resident #15's room was not illuminated (turned off). On [DATE] at 11:40 AM, the surveyor observed that the nurse call light outside Resident #15's room was illuminated. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to document assessments of the resident's condition by monitoring for complications after dialysis treatments were received at a certified dialysis center for 1 of 2 residents (Resident #61) reviewed for dialysis documentation. This deficient practice was evidenced by the following: On 8/24/21 at 11:20 AM, the surveyor observed Resident #61 seated in a wheelchair with oxygen infusing at 3 liters/minute via nasal cannula. The resident stated they went out of the facility for dialysis treatments on Monday, Wednesday, and Friday. Resident #61 informed the surveyor that the hemodialysis access site (Arteriovenous shunt/fistula) was not assessed by the facility nurse before leaving or after returning to the facility after dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident # 79. This deficient practice was evidenced by the following: On 8/25/21 at 11:08 AM, during the initial tour, Resident #79 was observed in bed, with eyes closed. A review of Resident #79's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to, Parkinson's Disease, Type II Diabetes Mellitus, Hypertension and Schizo-Affective Disorder. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care management dated 7/15/21, indicated a Brief Interview for Mental Status scored at 15, which indicated that the resident was cognitively intact. [...]