Inspection Reports for
Barclays Rehabilitation And Healthcare Center
1412 Marlton Pike East, Cherry Hill, NJ, 08034
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
81% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
89% occupied
Based on a November 2024 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, medication administration, respiratory care, and abuse reporting at Barclays Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to inform residents about advance directives, inadequate cleaning and maintenance of resident equipment and environment, failure to timely report and investigate allegations of resident property misappropriation, improper insulin administration timing and documentation, and failure to provide oxygen therapy according to physician orders.
Deficiencies (7)
Failure to inform and offer educational material regarding Advance Directives to residents or their representatives upon admission.
Failure to maintain a resident's wheelchair, wheelchair right armrest, and bathroom in a clean and homelike condition.
Failure to immediately report an allegation of misappropriation of resident property to the New Jersey Department of Health.
Failure to thoroughly and timely investigate an allegation of misappropriation of property reported by a resident.
Failure to provide necessary treatment services consistent with professional standards by not ensuring a resident received blood sugar monitoring and insulin medication according to physician's order.
Failure to provide safe and appropriate respiratory care by administering oxygen at incorrect flow rate and without a timely physician order.
Failure to respond in a timely manner to Consultant Pharmacist's monthly recommendations regarding medication regimen.
Report Facts
Resident affected count: 2
Resident affected count: 1
Resident affected count: 1
Resident affected count: 1
Resident affected count: 1
Consultant Pharmacist reports not timely addressed: 3
Insulin lispro doses missed: 30
Oxygen flow rate: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Acknowledged failure to address advance directives, insulin administration errors, and abuse reporting deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged failure to investigate and report misappropriation of resident property | |
| Chief Nursing Officer (CNO) | Acknowledged failure to provide education on advance directives and insulin administration errors | |
| Licensed Practical Nurse (LPN #1) | Confirmed insulin administration timing errors and blood sugar monitoring issues for Resident #24 | |
| Licensed Practical Nurse (LPN #2) | Confirmed insulin lispro dinner dose was not administered for Resident #24 | |
| Consultant Pharmacist (CP) | Recommended insulin lispro administration timing and identified errors in medication administration | |
| Medical Director (MD) | Acknowledged insulin order confusion and planned to contact resident's physician | |
| Licensed Practical Nurse (LPN) caring for Resident #71 | Acknowledged oxygen flow rate error and need to call physician for order change | |
| MDS Coordinator Registered Nurse (MDSC/RN) | Confirmed oxygen therapy without physician order for Resident #71 |
Inspection Report
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
A project survey was conducted to assess the renovation of the Rehabilitation Gym at Barclays Rehabilitation and Healthcare Center.
Findings
The renovation to the Rehabilitation Gym was found to be in compliance with N.J.A.C 8:39-31.1 and NFPA 101:2012. The identified areas may not be occupied until the New Jersey Certificate of Need and Licensing notifies the facility of approval.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers NJ00176489, NJ00173582, and NJ00174053 to assess compliance with staffing requirements and other regulatory standards.
Complaint Details
The complaint investigation revealed deficiencies in CNA staffing ratios for multiple day shifts during May, August, and November 2024, with the facility failing to meet the minimum required number of CNAs on 37 of 42 day shifts reviewed.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to maintain the required minimum direct care staff-to-resident ratios on multiple day and night shifts during several periods in 2024.
Deficiencies (1)
Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 16 day shifts and 1 night shift.
Report Facts
Census: 96
Sample Size: 5
Deficient CNA staffing days: 37
Required CNAs vs Actual CNAs: Multiple specific daily counts detailed in the report showing actual CNAs below required minimums
Inspection Report
Routine
Deficiencies: 1
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, specifically focusing on the provision of timely incontinence care to dependent residents.
Findings
The facility failed to ensure timely incontinence care for 4 of 6 observed residents, resulting in residents being found wet, malodorous, and with soiled linens. Staff interviews confirmed that incontinence rounds were expected every two hours but were not consistently performed, posing a risk for skin breakdown and infections.
Deficiencies (1)
Failure to provide timely incontinence care to dependent residents, resulting in residents found wet, malodorous, and with soiled linens.
Report Facts
Residents observed for incontinence care: 6
Residents with deficient incontinence care: 4
BIMS score: 11
BIMS score: 3
BIMS score: 14
BIMS score: 14
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Long Term Care Unit Manager | Provided list of incontinent residents and acknowledged issues with incontinence care | |
| Certified Nursing Assistant (CNA#1) | Acknowledged responsibility for incontinence rounds and importance of keeping residents dry | |
| Certified Nursing Assistant (CNA#2) | Acknowledged incontinence rounds schedule and responsibility | |
| Licensed Practical Nurse (LPN#1) | Acknowledged CNAs' responsibility for incontinence care and importance of keeping residents dry | |
| Licensed Practical Nurse (LPN#2) | Acknowledged CNAs' responsibility and importance of clean, dry residents | |
| LPN Unit Manager (LPN/UM) | Acknowledged expectations for incontinence care and prevention of skin issues | |
| Director of Nursing (DON) | Acknowledged CNAs' responsibility and importance of preventing skin breakdown |
Inspection Report
Routine
Deficiencies: 11
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including infection control, resident care, staffing, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, inadequate care planning, improper incontinence care, failure to ensure proper catheter and respiratory care, insufficient RN staffing, improper food handling, inaccurate medical record documentation, failure to follow infection control protocols, and incomplete antibiotic stewardship documentation.
Deficiencies (11)
Failed to maintain a safe, clean, and homelike environment by not cleaning and repairing residents' wheelchairs timely and not providing individual waste receptacles in rooms.
Failed to complete a Significant Change in Status Assessment within 14 days for a resident admitted to hospice services.
Failed to develop a person-centered comprehensive care plan including indwelling urinary catheter care for a resident.
Failed to revise a resident's comprehensive care plan to reflect updated code status (DNR/DNI).
Failed to provide timely incontinence care to dependent residents, resulting in residents found wet and malodorous.
Failed to ensure urinary catheter drainage bag was secured below the bladder and not touching dirty surfaces.
Failed to ensure a Registered Nurse worked 7 days a week for at least 8 consecutive hours a day for 9 of 10 days reviewed.
Failed to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross-contamination.
Failed to safeguard resident-identifiable information and maintain accurate medical records, including failure to follow physician orders regarding blood pressure measurement site.
Failed to ensure infection control practices for residents on transmission-based precautions were followed and failed to perform hand hygiene during meal tray pass.
Failed to accurately utilize an infection assessment tool for residents prescribed antibiotics, including missing or incomplete documentation.
Report Facts
RN staffing days without 8 consecutive hours: 9
Antibiotic treatment days: 5
Antibiotic treatment days: 5
Antibiotic treatment days: 3
Antibiotic treatment days: 5
Antibiotic treatment days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding PPE requirements for COVID-19 isolation and infection control. |
| Housekeeper (HK #1) | Housekeeper | Interviewed and observed not wearing proper PPE in COVID-19 positive room. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding infection control, staffing, and medical record documentation. |
| Certified Nursing Assistant (CNA #2) | Certified Nursing Assistant | Observed and interviewed regarding incontinence care and hand hygiene during meal tray pass. |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Licensed Practical Nurse/Unit Manager | Interviewed regarding catheter care, care plan updates, infection control, and hand hygiene. |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control practices and antibiotic stewardship. |
| Staffing Coordinator | Staffing Coordinator (SC) | Interviewed regarding RN staffing coverage. |
| Certified Nursing Assistant (CNA #1) | Certified Nursing Assistant | Interviewed regarding wheelchair cleaning and incontinence care. |
| Licensed Practical Nurse (LPN #3) | Licensed Practical Nurse | Interviewed regarding AV fistula care and blood pressure documentation. |
| Registered Nurse/Unit Manager (RN/UM) | Registered Nurse/Unit Manager | Interviewed regarding infection control and hand hygiene during meal tray pass. |
Inspection Report
Routine
Census: 92
Capacity: 108
Deficiencies: 14
Date: Feb 23, 2024
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 safe, clean, comfortable environment, comprehensive assessments, care planning, ADL care, infection control, antibiotic stewardship, staffing, food safety, medical record accuracy, and physical environment compliance.
Deficiencies (14)
Facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring timely cleaning and repair of residents' wheelchairs and not providing each resident with their own waste receptacle.
Failed to complete a Significant Change in Status Assessment within 14 days for a resident admitted to services.
Failed to develop a person-centered comprehensive care plan to include a resident's specific condition.
Failed to revise a resident's comprehensive care plan timely after a significant change in condition.
Failed to provide ADL care to dependent residents in a timely manner.
Failed to ensure urinary catheter was not left on the floor or wheelchair and kept below bladder level.
Failed to maintain necessary respiratory care including proper oxygen tubing management.
Failed to ensure a Registered Nurse worked 7 days a week for at least 8 consecutive hours a day for multiple days reviewed.
Failed to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross-contamination.
Failed to maintain medical records that were accurate and consistent for residents, including code status and dialysis documentation.
Failed to follow infection control practices for residents on transmission-based precautions and failed to perform hand hygiene during meal tray pass.
Failed to accurately utilize an antibiotic stewardship program including proper use of assessment tools and documentation.
Failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for day shifts.
Failed to notify the New Jersey Department of Health Certificate of Need and Licensing Division after renovations to the facility were completed to ensure inspection and approval prior to occupancy.
Report Facts
Census: 92
Total Capacity: 108
Deficiencies cited: 14
Staffing ratios: 9
Staffing ratios: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in wheelchair cleaning and meal tray pass hand hygiene findings |
| CNA #2 | Certified Nursing Assistant | Named in wheelchair cleaning and meal tray pass hand hygiene findings |
| LPN #1 | Licensed Practical Nurse | Named in wheelchair cleaning and catheter care findings |
| LPN #2 | Licensed Practical Nurse | Named in catheter care and meal tray pass hand hygiene findings |
| LNHA | Licensed Nursing Home Administrator | Named in staffing and construction approval findings |
Inspection Report
Follow-Up
Census: 94
Deficiencies: 1
Date: Sep 15, 2022
Visit Reason
The inspection was conducted to assess compliance with state-mandated minimum staffing ratios for certified nurse aides (CNAs) in the facility.
Findings
The facility failed to meet the required minimum CNA staffing ratios for 13 of 14-day shifts reviewed, potentially affecting all residents. A follow-up revisit report dated 10/24/2022 confirmed that the previously cited deficiency was corrected.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 13 of 14-day shifts reviewed.
Report Facts
Residents present: 94
CNA staffing deficiency days: 13
CNA staff on 8/21/22: 7
CNA staff on 8/22/22: 9
CNA staff on 8/23/22: 10
CNA staff on 8/24/22: 9
CNA staff on 8/25/22: 10
CNA staff on 8/26/22: 10
CNA staff on 8/28/22: 7
CNA staff on 8/29/22: 10
CNA staff on 8/30/22: 10
CNA staff on 8/31/22: 10
CNA staff on 9/1/22: 9
CNA staff on 9/2/22: 9
CNA staff on 9/3/22: 8
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
The inspection was conducted based on Complaint #NJ 152756 regarding grievances filed by residents, specifically concerning a resident's missing personal property and the facility's failure to follow its grievance policy.
Complaint Details
Complaint #NJ 152756 involved a grievance filed by Resident #3's representative regarding missing personal property. The facility failed to resolve the grievance, did not provide a written decision or resolution to the resident's family or representative, and did not follow its grievance policy.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities due to failure to resolve a grievance related to a resident's missing personal property and failure to follow the grievance policy. The grievance process was not properly followed, and no written grievance decision or resolution was sent to the resident's family or representative.
Deficiencies (1)
Failure to resolve a grievance for a resident's missing personal property and failure to follow the facility's grievance policy.
Report Facts
Census: 93
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Jan 24, 2022
Visit Reason
The inspection was conducted based on a complaint investigation regarding failure to maintain required minimum staff-to-resident ratios and failure to have a Registered Nurse complete admission and readmission assessments for residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to staffing ratios and admission assessment practices.
Findings
The facility failed to meet the mandated minimum direct care staff-to-resident ratios for multiple day and overnight shifts, potentially affecting all residents. Additionally, the facility failed to have a Registered Nurse complete admission and readmission assessments for sampled residents, with Licensed Practical Nurses performing these assessments instead.
Deficiencies (2)
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 13 of 14 day shifts and 4 of 14 overnight shifts reviewed.
Failure to have a Registered Nurse complete admission and readmission assessments for residents sampled.
Report Facts
Residents present: 94
CNA staffing deficiency days: 13
Overnight staffing deficiency days: 4
Required CNAs for day shift: 12
Actual CNAs on day shift: 7
Required total staff for overnight shift: 7
Actual total staff on overnight shift: 5
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 1, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/01/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA Life Safety Code for existing health care occupancies.
Findings
The facility was found to be noncompliant due to failure to provide fire alarm notification by audible and visible signals in 2 of 2 enclosed center courtyards. This deficiency was confirmed by observation and interview with the Maintenance Director during the survey.
Deficiencies (1)
Failure to provide fire alarm notification by audible and visible signals for 2 of 2 enclosed center courtyards.
Report Facts
Number of enclosed courtyards lacking fire alarm notification: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed and confirmed findings regarding fire alarm notification deficiencies. |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 30, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication management, food safety, hospice services, infection control, and facility environment at Barclays Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in maintaining a clean and sanitary environment, medication error follow-up, food safety and storage, hospice documentation and care planning, infection prevention practices, proper waste disposal, and adequate resident room space. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (7)
Failed to maintain a clean and sanitary environment on Unit 1, including dried brown substances on floors and stained furniture.
Failed to monitor and follow-up on Consultant Pharmacist recommendations regarding a medication error involving duplicate Sertraline orders for Resident #20.
Failed to handle potentially hazardous food properly and maintain sanitation in the kitchen, including use of dented cans, expired yogurt, uncovered plastic wrap, and improperly stored frozen foods.
Failed to properly cover garbage dumpsters and recycling dumpsters, exposing waste contents.
Failed to maintain Hospice communication records and initiate care plans for residents receiving Hospice services, specifically Resident #49.
Failed to perform hand hygiene after direct patient contact and before feeding Resident #41, including placing a clothing protector retrieved from the floor on the resident.
Failed to provide minimum required living space of 80 square feet per resident in 12 of 39 double occupancy rooms.
Report Facts
Deficiencies cited: 7
Rooms not meeting space requirements: 12
Dates of observations: Nov 22, 2021
Dates of observations: Nov 23, 2021
Dates of observations: Nov 29, 2021
Medication doses: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error finding related to duplicate Sertraline orders. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication error follow-up and hospice care planning. |
| CNA #1 | Certified Nurse Assistant | Observed failing to perform hand hygiene and placing contaminated clothing protector on resident. |
| Food Service Director | Food Service Director (FSD) | Interviewed and observed during food safety and waste disposal inspections. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding hospice documentation for Resident #49. |
| LPN Unit Manager | Licensed Practical Nurse Unit Manager | Interviewed regarding hospice care planning and documentation responsibilities. |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Provided monthly report identifying medication error for Resident #20. |
Inspection Report
Plan of Correction
Census: 94
Deficiencies: 1
Date: Nov 30, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically regarding mandatory access to care and staffing ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey, with deficiencies noted on 12 of 14 day shifts and 1 of 14 overnight shifts reviewed. Staffing shortages were documented on specific dates in November 2021, affecting resident care.
Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Residents present: 94
Day shifts deficient: 12
Overnight shifts deficient: 1
Required CNAs on day shift: 12
Required total staff on overnight shift: 7
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Aug 31, 2021
Visit Reason
The inspection was conducted in response to complaint NJ143696 to assess compliance with long term care facility regulations.
Complaint Details
Complaint number NJ143696 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jun 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ141782 and NJ139172.
Complaint Details
Complaint numbers NJ141782 and NJ139172 were 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: 6
Inspection Report
Routine
Census: 95
Deficiencies: 0
Date: Feb 4, 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.
Inspection Report
Routine
Census: 90
Deficiencies: 0
Date: Nov 24, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 4
Sample size: 3
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