Inspection Reports for Arbor Ridge Rehabilitation & Healthcare Center
261 Terhune Dr, Wayne, NJ 07470, NJ, 07470
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Notice
Deficiencies: 0
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 to explain 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 questions about the notice |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 120
Deficiencies: 12
Oct 17, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to complaints NJ178385, NJ178434, and NJ161007 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies related to Medicaid/Medicare coverage notices, freedom from abuse and neglect, comprehensive assessments, psychotropic medication use, food safety, resident records, and life safety code violations.
Complaint Details
The survey was triggered by complaints NJ178385, NJ178434, and NJ161007. The facility was found not in substantial compliance based on these complaints and recertification. Specific substantiation details are embedded in findings related to abuse, neglect, and failure to provide required notices.
Severity Breakdown
Level D: 9
Level F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide skilled nursing facility advance beneficiary notice (SNF ABN) to residents as required. | Level D |
| Failed to protect residents from abuse and neglect, including failure to report alleged violations timely. | Level D |
| Failed to conduct timely comprehensive assessments (MDS) for residents. | Level D |
| Failed to ensure accuracy of assessments and timely completion of significant change assessments. | Level D |
| Failed to ensure residents were free from unnecessary psychotropic medications and proper PRN use. | Level D |
| Failed to label drugs and biologicals properly and store medications securely. | Level D |
| Failed to maintain food procurement, storage, and sanitation standards, risking foodborne illness. | Level D |
| Failed to maintain resident records accurately and confidentially, including documentation of weights and assessments. | Level D |
| Failed to maintain minimum staffing ratios as required by state law. | Level D |
| Failed to ensure exterior handrails and stairway doors met life safety code requirements. | Level F |
| Failed to ensure fire doors were inspected annually and had proper inspection tags. | Level F |
| Failed to ensure smoke barriers were intact and repaired penetrations in smoke barrier walls. | Level F |
Report Facts
Survey Census: 107
Total Capacity: 120
Sample Size: 27
Deficiency Count: 12
Staffing Ratios: 12
Staffing Ratios: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R39 | Resident | Named in abuse and neglect findings and failure to protect from abuse |
| R32 | Resident | Named in abuse and neglect findings and failure to protect from abuse |
| R25 | Resident | Named in psychotropic medication deficiency and medication administration findings |
| Licensed Practical Nurse (LPN) 5 | Licensed Practical Nurse | Named in medication administration and labeling deficiencies |
| Administrator | Facility Administrator | Involved in education and corrective actions for abuse, medication, and safety deficiencies |
| Social Services Director | Social Services Director | Responsible for issuing ABN forms and involved in corrective actions |
| Regional Director of Operations | Regional Director of Operations | Responsible for auditing grievances and abuse allegations |
| Dietitian | Dietitian | Involved in auditing resident charts for weight documentation |
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 0
Feb 16, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 02/16/2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B related to infection control.
Report Facts
Sample Size: 10
Supplemental Residents: 0
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 6
Nov 23, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to expired and discontinued medications in active inventory, failure to identify and report medication interactions, failure to provide appropriate resident furniture and mattress, failure to maintain required staffing ratios, failure to ensure staff COVID-19 vaccination compliance, and failure to meet emergency preparedness plan review requirements.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Expired narcotic medication was administered to Resident #93 for three months and discontinued biologicals were not removed from active inventory for residents #6, #32, and #34. | SS=E |
| Consultant pharmacist failed to identify and report a medication interaction for Resident #26 involving levothyroxine and ferrous sulfate administration timing. | SS=D |
| Facility failed to provide Resident #1 with a chair and a clean, comfortable mattress. | SS=D |
| Facility failed to maintain required minimum direct care staff to resident ratios for 12 of 42 shifts reviewed. | — |
| Facility failed to ensure staff were up to date with COVID-19 vaccinations as required by State and Federal mandates for 4 of 7 staff reviewed. | — |
| Facility failed to meet with municipal and county emergency management officials annually to review and update the emergency evacuation plan. | — |
Report Facts
Census: 106
Staffing Deficiency Count: 12
Staff Vaccination Deficiency Count: 4
Staffing Ratios: 10
Staffing Ratios: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nursing Aide | Named in COVID-19 vaccination deficiency; declined booster |
| Staff #2 | Certified Nursing Aide | Named in COVID-19 vaccination deficiency; no booster received |
| Staff #3 | Hospice Aide | Named in COVID-19 vaccination deficiency; no booster received |
| Staff #4 | X-ray Technician | Named in COVID-19 vaccination deficiency; no booster received |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Confirmed expired medication administration and inventory issues |
| Director of Nursing | DON | Confirmed expired medication issues and vaccination policy |
| Licensed Nursing Home Administrator | LNHA | Confirmed expired medication issues and emergency preparedness deficiencies |
| Regional Director of Operations | RDO | Confirmed vaccination and emergency preparedness deficiencies |
| Regional Clinical Nurse | RN | Confirmed expired medication issues and vaccination deficiencies |
Inspection Report
Life Safety
Deficiencies: 8
Nov 22, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/22/22 and 11/23/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Arbor Ridge Rehabilitation and Healthcare Center.
Findings
The facility was found noncompliant with multiple Life Safety Code requirements including exit door functionality, emergency illumination, hazardous area door enclosures, cooking facility inspections, sprinkler system installation, portable fire extinguisher inspections, smoke barrier integrity, and electrical outlet GFCI protection. Deficiencies were identified in door operation, emergency lighting, fire-rated doors, fire suppression system inspections, sprinkler head installations, fire extinguisher maintenance, smoke barrier penetrations, and electrical safety near water sources.
Severity Breakdown
SS=D: 3
SS=E: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Exit discharge door (Stairwell F) required more than 15 pounds of pressure to open due to rust and poor maintenance. | SS=D |
| Emergency illumination failed to provide automatic lighting along an exit discharge path and keypad area. | SS=E |
| Fire-rated doors to hazardous areas (Stairwell D) were missing or lacked self-closing devices, allowing fire and smoke to enter exit corridors. | SS=E |
| Range-hood fire suppression system was not inspected semi-annually as required. | — |
| Seven sprinkler heads lacked escutcheon caps or deflector plates, and one sprinkler head was hanging down from the ceiling. | SS=E |
| One portable fire extinguisher lacked an annual inspection tag and was manufactured in 2016 without recent inspection. | SS=D |
| Smoke barrier wall had an unsealed penetration with electrical cable and a loosely mounted illuminated exit sign, compromising fire resistance. | SS=D |
| Two electrical outlets near water sources lacked Ground-Fault Circuit Interrupter (GFCI) protection and failed to de-energize during testing. | SS=E |
Report Facts
Exit discharge doors tested: 6
Resident sleeping rooms: 57
Range-hood fire suppression inspections: 3
Sprinkler heads with deficiencies: 7
Portable fire extinguishers inspected: 20
Electrical outlets tested near water: 13
Electrical outlets lacking GFCI: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to door maintenance, fire system inspections, and audits | |
| Regional Director of Plant Operations | Present during observations and confirmed findings | |
| Licensed Nursing Home Administrator | Informed of findings during exit conferences |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Jul 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143843 and NJ144060.
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.
Complaint Details
Complaint numbers NJ143843 and NJ144060 were investigated and the facility was found compliant.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 99
Deficiencies: 0
Jan 5, 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 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.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Dec 4, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00135821 and NJ00133093.
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.
Complaint Details
Complaint # NJ00135821, NJ00133093. The facility was found in compliance based on this complaint survey.
Report Facts
Sample Size: 6
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