Inspection Reports for Chatham Hills Subacute Care Center
415 Southern Blvd, NJ, 07928
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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 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 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
Routine
Census: 79
Deficiencies: 0
Jul 26, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in/not in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 76
Capacity: 108
Deficiencies: 17
May 31, 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 resident rights, communication, activities of daily living care, pharmacy services, food safety, waste management, infection control, life safety code violations including egress doors, emergency lighting, cooking facilities, fire alarm and sprinkler system maintenance, corridor doors, and smoke barrier integrity.
Severity Breakdown
SS=D: 4
SS=E: 3
Deficiencies (17)
| Description | Severity |
|---|---|
| Residents were not served meals in a dignified manner during meal service, with inconsistent timing and delivery. | SS=D |
| Facility failed to provide daily mail delivery including Saturdays to residents. | SS=D |
| Residents dependent on assistance for activities of daily living were not consistently provided care as needed. | SS=D |
| Pharmacy services failed to clarify duplicate orders and obtain medication timely for residents. | SS=D |
| Facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. | SS=E |
| Facility failed to provide a sanitary environment by not keeping garbage container area free of debris and trash. | SS=D |
| Staff failed to wear appropriate personal protective equipment for residents on enhanced barrier precautions. | SS=E |
| Facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. | — |
| Delayed egress locking devices failed to release after 15 seconds when pressure was applied on two exit doors. | — |
| Emergency lighting at exit discharge was inadequate with only one bulb instead of two. | — |
| Kitchen hood system had an unsealed hole between grease filter dividers. | — |
| Fire alarm system lacked a pull station at the front lobby exit and missing documentation of smoke detector sensitivity testing. | — |
| Sprinkler system lacked documentation of weekly inspections of gauges and had a missing escutcheon plate. | — |
| Corridor doors failed to close and latch properly due to contact with floor, preventing full closure. | — |
| Penetrations in smoke barriers were unsealed allowing potential smoke transfer. | — |
| Smoke doors had large gaps due to malfunctioning door coordinators, allowing passage of smoke. | — |
| Smoke barrier doors failed to resist passage of smoke due to large gaps between doors. | — |
Report Facts
CNA staffing deficiency days: 47
Residents present: 76
Total licensed capacity: 108
Deficiency count: 16
Inspection Report
Routine
Census: 88
Deficiencies: 0
Dec 10, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Apr 27, 2023
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #NJ00163449 regarding failure to comply with emergency response procedures for a resident without a physician order for cardiopulmonary resuscitation (CPR).
Findings
The facility failed to immediately initiate and activate their emergency response system when Resident #1, who lacked a physician order for CPR, was found unresponsive in bed. This failure placed residents at risk and was determined to be an Immediate Jeopardy past noncompliance. The facility subsequently corrected the deficiency and implemented staff education and policy reviews.
Complaint Details
Complaint #NJ00163449 involved allegations that the facility failed to initiate emergency procedures for Resident #1 who was found unresponsive without a physician order for CPR. The complaint was substantiated with findings of Immediate Jeopardy past noncompliance.
Severity Breakdown
SS=J: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately initiate and activate emergency response system including calling 911 and notifying staff when Resident #1 was found unresponsive without a physician order for CPR. | SS=J |
| Failure to provide services to prevent neglect of Resident #1 who was found unresponsive without a physician order for CPR. | SS=G |
Report Facts
Census: 90
Sample Size: 6
Date of Survey Completion: Apr 27, 2023
Date of Revisit: Jun 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to initiate emergency response and failure to notify physician properly |
| LPN #2 | Licensed Practical Nurse | Involved in notification and calling 911 during emergency |
| CNA #1 | Certified Nursing Assistant | Notified nurse about Resident #1's condition and provided witness statement |
| RN/NS | Registered Nurse/Nursing Supervisor | Involved in emergency response and education |
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Dec 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Document
Deficiencies: 0
Mar 24, 2022
Visit Reason
This document does not contain an inspection or regulatory visit reason; it is an instructional prompt for opening the PDF.
Findings
No inspection findings or content are present in this document.
Inspection Report
Life Safety
Census: 94
Capacity: 108
Deficiencies: 5
Mar 22, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 3/22/22 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting, corridor door smoke resistance, HVAC maintenance, essential electrical system testing, and gas cylinder storage. Deficiencies were observed in emergency lighting above the generator transfer switch, warped resident room doors, dirty PTAC filters, lack of generator transfer time certification, improper location of generator manual stop station, and unsecured oxygen cylinders.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide operational battery backup emergency light above the emergency generator's transfer switch. | SS=D |
| Corridor doors to resident rooms were warped and did not fully close and latch to resist passage of smoke. | SS=F |
| Packaged Terminal Air Conditioner (PTAC) units had clogged and dirty filters in 13 of 50 units observed. | SS=E |
| Failed to certify generator transfer time within required 10 seconds and manual stop station for generator was not installed remote of the generator. | SS=F |
| Oxygen cylinders were not secured against tipping, rupture, and damage; 7 of 24 cylinders were free standing. | SS=F |
Report Facts
Certified beds: 108
Census: 94
PTAC units with clogged filters: 13
Resident rooms with warped doors: 9
Oxygen cylinders unsecured: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified multiple deficiencies including emergency lighting, corridor doors, PTAC units, generator testing, and oxygen cylinder storage. |
Document
Deficiencies: 0
Feb 21, 2022
Visit Reason
This document does not contain any inspection or regulatory information; it is an instructional prompt for opening the PDF portfolio.
Findings
No inspection findings or regulatory content are present in this document.
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation due to the facility's failure to comply with requirements for notifying the Office of the State Long-Term Care Ombudsman regarding resident transfers and discharges.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to send timely notices of transfer or discharge to the Office of the State Long-Term Care Ombudsman for Resident #6 and other emergency transfers from November 2021 to January 2022.
Complaint Details
The complaint investigation found that the facility did not send notifications to the Office of the State Long-Term Care Ombudsman for emergency transfers from November 2021 through January 2022, including Resident #6's emergency discharge.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to send a copy of the monthly notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for 1 of 6 residents reviewed for emergency transfer. | SS=C |
Report Facts
Census: 102
Sample Size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding failure to send notifications to the Office of the State Long-Term Care Ombudsman | |
| Director of Nursing | Interviewed regarding policy and corrective actions related to transfer or discharge notices |
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Aug 20, 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 residents: 6
Inspection Report
Routine
Census: 91
Deficiencies: 0
Apr 26, 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.
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
Routine
Census: 82
Deficiencies: 0
Dec 7, 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.
Report Facts
Sample size: 10
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Dec 5, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00136592 and NJ00132634.
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 NJ00136592 and NJ00132634 were investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 5
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