Inspection Reports for Bartley Healthcare Nursing and Rehabilitation Center
NJ
Back to Facility Profile
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and 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: 198
Deficiencies: 0
Sep 10, 2024
Visit Reason
The inspection was conducted in response to a complaint (Complaint #: NJ00176465) to assess compliance with regulatory requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and the New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities based on this complaint visit.
Complaint Details
Complaint #: NJ00176465. The facility was in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 204
Deficiencies: 13
Apr 30, 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 medication administration timing, activities of daily living including shower provision, food safety and storage, resident record accuracy, infection prevention practices, and life safety code violations including exit signage, hazardous area enclosures, sprinkler system installation, corridor door smoke resistance, smoke barrier integrity, electrical safety, and emergency generator controls.
Severity Breakdown
SS=D: 8
SS=E: 2
SS=F: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to administer medications within scheduled time parameters for two residents. | SS=D |
| Facility failed to ensure a resident received showers as scheduled. | SS=D |
| Facility failed to store potentially hazardous foods properly, maintain kitchen equipment sanitary, and maintain cold food temperatures during meal service. | SS=D |
| Facility failed to maintain complete and accurate resident medical records for one resident. | SS=D |
| Facility failed to ensure appropriate storage and cleaning of respiratory equipment after nebulizer treatments for one resident. | SS=D |
| Facility failed to maintain resident environment and equipment in a safe, sanitary, and homelike manner including unsecured doorknob backplates and detached PTAC unit covers. | SS=D |
| Facility failed to provide seven illuminated exit signs to clearly identify exit access paths. | SS=F |
| Facility failed to ensure fire-rated doors to hazardous areas were separated by smoke resisting partitions; one corridor door lacked self-closing mechanism. | SS=E |
| Facility failed to install sprinklers to all areas in accordance with NFPA 101 requirements; one outside overhang lacked sprinkler coverage. | SS=D |
| Facility failed to ensure corridor doors resisted passage of smoke; two corridor doors had excessive gaps allowing smoke passage. | SS=D |
| Facility failed to maintain integrity of smoke barrier partitions; multiple penetrations with unsealed wires were observed. | SS=E |
| Facility failed to ensure two electrical outlets near sinks were equipped with required ground-fault circuit interrupter (GFCI) protection. | SS=D |
| Facility failed to ensure remote manual stop stations were installed for two emergency generators. | SS=F |
Report Facts
Resident census: 204
Medication administration time delay: 82
Medication administration time delay: 99
Shower schedule missed: 1
Food temperature: 43
Food temperature: 44
Food temperature: 51
Food temperature: 49
Smoke barrier penetration size: 1.5
Smoke barrier penetration size: 3
Door gap: 0.625
Door gap: 0.375
Sprinkler overhang size: 5
GFCI outlet distance from sink: 12
GFCI outlet distance from sink: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Involved in medication administration deficiency and re-education | |
| Director of Nursing | Provided counseling and re-education on weekly skin assessments and medication administration | |
| Pharmacy Consultant | Provided re-education on medication administration timing | |
| Staff Development Coordinator | Provided re-education on medication administration and shower policy | |
| Certified Nursing Assistant (CNA #1) | Involved in shower provision deficiency | |
| Certified Nursing Assistant (CNA #2) | Provided information on shower assignments | |
| Food Service Director | Involved in food safety deficiencies and corrective actions | |
| Administrator | Provided in-service and oversight for life safety code deficiencies | |
| Maintenance Director | Performed repairs and inspections related to life safety code deficiencies |
Inspection Report
Complaint Investigation
Census: 203
Deficiencies: 1
Sep 12, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ162053 regarding the facility's failure to follow policies and procedures for a facility-initiated discharge of a resident who was involved in an incident with another resident and was sent to the hospital for evaluation.
Findings
The facility failed to permit a resident to return after hospitalization due to concerns about managing the resident's behaviors and medication. The resident was discharged immediately without a 30-day notice, and the facility cited safety concerns for other residents and discomfort with managing the resident's medication. The investigation found the incident was isolated, and the facility did not document attempts to meet the resident's needs or physician documentation supporting the discharge.
Complaint Details
Complaint #NJ162053 was substantiated. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit regarding improper discharge and readmission procedures.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow policies and procedures for facility-initiated discharge, including not permitting a resident to return after hospitalization and immediate discharge without proper notice. | SS=D |
Report Facts
Census: 203
Sample size: 3
Bed hold period: 10
Therapeutic leave bed hold: 24
Inspection Report
Routine
Census: 192
Deficiencies: 1
May 16, 2023
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by the New Jersey Department of Health on 05/16/2023 to assess compliance with infection control regulations, specifically related to influenza and pneumococcal immunizations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B due to failure to ensure that residents were properly educated and offered influenza and pneumococcal vaccines. Two of six residents reviewed were not provided education or properly offered vaccines, potentially leaving them unprotected from life-threatening illnesses.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that two residents were educated and offered influenza and pneumococcal vaccines as required by policy and regulations. | SS=D |
Report Facts
Survey Census: 192
Sample Size: 10
Completion Date for Plan of Correction: Jun 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Provided education to residents #3 and #4 on 05/16/23 and provided documentation related to immunization education and consent |
Inspection Report
Routine
Census: 182
Deficiencies: 0
Nov 1, 2022
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.
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: 5
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 1
Jul 17, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ151532, NJ153738, NJ154486, and NJ156095.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 standards due to failure to meet mandatory nurse staffing ratios. Deficiencies in certified nursing assistant (CNA) staffing were identified on multiple day shifts across several weeks, potentially affecting all residents.
Complaint Details
Complaint investigation based on complaint numbers NJ151532, NJ153738, NJ154486, and NJ156095. The facility was found deficient in CNA staffing ratios on multiple day shifts over several weeks, with potential impact on all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met, specifically deficient CNA staffing on multiple day shifts during the weeks of 03/27/2022 - 04/02/2022, 04/03/2022 - 04/09/2022, 05/15/2022 - 05/21/2022, and 05/22/2022 - 05/28/2022. |
Report Facts
Census: 159
Deficient CNA staffing days: 6
Deficient CNA staffing days: 4
Deficient CNA staffing days: 7
Deficient CNA staffing days: 7
Required CNAs: 20
Actual CNAs: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator acknowledged staffing challenges and efforts to improve staffing ratios. |
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 1
Dec 20, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey staffing ratio requirements following concerns about minimum direct care staff-to-shift ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-shift ratios for 9 of 14-day shifts reviewed, as mandated by New Jersey law. The facility submitted a plan of correction including re-training staffing coordinators, increasing CNA rates, and implementing ongoing monitoring and recruitment strategies.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 9 of 14-day shifts reviewed. |
Report Facts
Deficient shifts: 9
Census: 59
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
CNA counts: 13
CNA counts: 12
CNA counts: 14
CNA counts: 13
CNA counts: 11
CNA counts: 14
CNA counts: 15
CNA counts: 15
CNA counts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Aware of staffing ratios and staffing issues as stated during interview on 12/13/21 | |
| Staffing Coordinator | Re-serviced on staffing ratios on December 9, 2021; aware of staffing ratios during interview on 12/13/21 | |
| Licensed Practical Nurse/Unit Manager | Provided census and staffing information during interview on 12/13/21 | |
| CNA #1 | Certified Nurse Aide | Assigned 12 residents during interview on 12/08/21 |
| CNA #2 | Certified Nurse Aide | Assigned 11 residents during interview on 12/09/21 |
| CNA #3 | Certified Nurse Aide | Assigned 14 residents during interview on 12/09/21 |
Inspection Report
Life Safety
Census: 122
Capacity: 234
Deficiencies: 2
Dec 20, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with emergency lighting requirements and fire alarm notification for enclosed courtyards. Specifically, emergency lighting independent of the building's electrical system was missing above the emergency generator's transfer switch, and audible and visible fire alarm signals were absent in three enclosed courtyards.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency lighting above the emergency generator's transfer switch independent of the building's electrical system and emergency generator. | SS=D |
| Failed to provide fire alarm notification by audible and visible signals for 3 enclosed courtyards (Aspen, Birch, Cedar). | SS=E |
Report Facts
Certified beds: 234
Census: 122
Waivers utilized: 1135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings related to emergency lighting and fire alarm system | |
| Administrator | Verified findings and was notified of deficiencies at exit conference |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Jun 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ142524.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ142524; the facility was found in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Mar 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ 144008.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #NJ 144008 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 126
Deficiencies: 0
Dec 22, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 234
Deficiencies: 0
Dec 9, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ120835 and NJ132007.
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 NJ120835 and NJ132007 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 119
Deficiencies: 0
Dec 2, 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.
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.
Loading inspection reports...
