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Complaint Investigation

Trenton Gardens Rehabilitation And Nursing Center

October 14, 2025 · Trenton, NJ · 512 Union Street
Citations 2
Beds 215
Provider ID 315324
Healthcare Facility
Trenton Gardens Rehabilitation And Nursing Center
Trenton, NJ  ·  View full profile →
Inspection Summary

TRENTON GARDENS REHABILITATION AND NURSING CENTER in TRENTON, NJ — inspection on October 14, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

The surveyor was unable to verify the RP, and the DON was informed that the immediacy continued. An acceptable Removal Plan (RP) was received on 10/12/2025 at 5:52 P.M., indicating the action the facility will take to prevent serious harm from occurring or recurring.

The facility implemented a corrective action plan to remediate the deficient practice to include: the NS immediately removed the cigarette from Resident #2; Resident #2 was searched, and a pack of cigarettes and a pint of vodka was confiscated and destroyed; and Resident #2 was placed on 1:1 assignment until their discharge from the facility on 09/26/2025. On 09/16/2025, the NS educated Resident #2 and Resident #3 that smoking was prohibited in a resident room. On 10/08/2025, nurse leaders began educating all residents who smoked on the facility's smoking policy and the dangers of smoking near oxygen, and their rooms and equipment were searched by the ADON for violation of the smoking policy. On 10/10/2025, the nurse leaders and Consultant Registered Nurse (RN) re-educated all staff on the smoking policy and the dangers of smoking near oxygen.

The surveyor verified the implementation of the RP on-site during the continuation of the survey on 10/14/2025 2:23 P.M. N.J.A.C. 8:39-27.1(a), 31.6(e)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Trenton Gardens Rehabilitation and Nursing Center

512 Union Street Trenton, NJ 08611

SUMMARY STATEMENT OF DEFICIENCIES

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Complaint #2620207Based on interviews and review of other pertinent facility documentation on 10/07/2025 and 10/14/2025, it was determined that the facility failed to: a.) ensure that the facility-wide assessment (FA) evaluated its resident population and b.) identified the resources needed to provide the necessary care and services required for residents admitted with a history or current use of, tobacco or drug and alcohol abuse.

This deficient practice had the potential to affect all residents and was evidenced by the following:Refer to F689A review of the facility's Facility Assessment provided by the Director of Nursing (DON), indicated that the assessment was completed on 05/03/2025. A further review of the facility's FA did not include any documentation that addressed the resident population that was admitted to the facility with a history or current use of, tobacco or drug and alcohol abuse.During a joint interview with the DON, the Consultant DON, and the Consultant Administrator on 10/14/2025 at 2:14 P.M., the DON stated that the FA was a snapshot of residents that included all departments involved in their care and a breakdown of demographics involving staffing and their care needs.

The DON stated that it was more than just the physical needs required by the residents, but detailed needs that each resident would require.

The DON further stated that the facility currently had 41 smokers. In the presence of the surveyor, the DON reviewed the FA and confirmed it did not identify smoking/smokers as a category population that they served.

The DON stated that an issue was identified involving a smoker that affected all residents, and that the facility planned to update the FA accordingly. NJAC 8:39-5.1(a)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TRENTON, NJ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from TRENTON GARDENS REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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