Deficiencies (last 6 years)
Deficiencies (over 6 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
94% occupied
Based on a October 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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 details the types of information covered, the circumstances under which health information may be used or disclosed, the rights of individuals 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report and investigate an allegation of neglect after a resident fell out of bed and sustained a head injury.
Complaint Details
The complaint involved failure to report and investigate neglect related to a resident fall resulting in injury. The allegation was substantiated as the facility did not report the incident to the State Agency and did not investigate the incident as required.
Findings
The facility failed to timely report suspected abuse and neglect to the State Agency and failed to thoroughly investigate the incident involving Resident #99 who fell out of bed and sustained injuries. Additionally, the facility failed to provide appropriate incontinent care to two residents, which posed risks for infections and skin breakdown.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to thoroughly investigate an allegation of neglect after a resident fell out of bed and sustained a head injury.
Failed to provide appropriate incontinent care to dependent residents, increasing risk of urinary tract infections and skin breakdown.
Report Facts
Residents reviewed for abuse: 3
Residents with improper incontinent care: 2
BIMS score: 3
BIMS score: 6
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated the incident was not reported or investigated and expected reporting and investigation | |
| Licensed Practical Nurse (LPN #1) | Documented finding Resident #99 on the floor after fall | |
| Certified Nurse Aide (CNA #9) | Reported Resident #99 fell out of bed | |
| Certified Nurse Aide (CNA #4) | Observed providing incontinent care to Residents #12 and #87 | |
| Licensed Practical Nurse (LPN #9) | Stated residents should be checked for incontinence every two hours and proper cleaning procedures | |
| Certified Nurse Aide (CNA #11) | Described proper incontinent care wiping procedure | |
| Infection Preventionist | Stated expectations for thorough incontinent care and importance to prevent infections |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state and federal regulations, including resident rights, medication use, personal funds management, code status accuracy, abuse reporting, PASRR screening, care planning, pressure ulcer care, incontinent care, oxygen therapy, and bed rail safety.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity, failure to inform residents or representatives about psychotropic medication risks, failure to provide quarterly personal funds statements, inaccurate and inconsistent resident code status documentation leading to immediate jeopardy, failure to report and investigate abuse allegations, inaccurate PASRR screening, incomplete and untimely care plan updates and meetings, inadequate pressure ulcer prevention and treatment, improper incontinent care, lack of oxygen therapy orders, and failure to assess and document bed rail safety and alternatives.
Deficiencies (12)
Failure to protect resident's right to dignity when staff searched a resident's room without permission.
Failure to ensure residents or representatives were informed of risks and benefits of psychotropic medications.
Failure to provide quarterly personal funds statements to residents.
Failure to ensure accurate and consistent resident code status documentation, resulting in immediate jeopardy.
Failure to timely report suspected abuse and failure to investigate an allegation of neglect after a resident fall.
Failure to complete accurate PASRR Level I screening for mental disorders or intellectual disabilities.
Failure to update care plans timely for new conditions and failure to hold quarterly care plan meetings with residents and families.
Failure to identify and implement interventions to prevent and treat pressure ulcers.
Failure to provide proper incontinent care to dependent residents, risking infection and skin breakdown.
Failure to have physician orders for oxygen therapy for a resident receiving oxygen.
Failure to assess risk and explore alternatives prior to bed rail installation and failure to assess entrapment risk.
Failure to maintain documentation of the facility's ongoing Quality Assessment and Performance Improvement (QAPI) program.
Report Facts
Residents reviewed for code status: 31
Residents reviewed for PASRR screening: 31
Residents reviewed for care planning: 31
Residents reviewed for pressure ulcers: 6
Residents reviewed for incontinent care: 31
Residents reviewed for oxygen therapy: 1
Residents reviewed for bed rails: 31
Residents in facility: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Family Member #2 | Resident #40's guardian | Interviewed regarding resident's code status wishes |
| Family Member #1 | Resident #4's medical Power of Attorney | Interviewed regarding resident's code status wishes |
| Director of Nursing | Interviewed regarding multiple deficiencies including code status, incontinent care, pressure ulcer care, oxygen therapy, and bed rail assessments | |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding failure to ensure staff implemented code status policy |
| Social Services Director | Interviewed regarding PASRR screening and care plan meetings | |
| Maintenance Director | Interviewed regarding bed rail safety checks | |
| Infection Preventionist | Interviewed regarding incontinent care | |
| Medical Director | Interviewed regarding code status discrepancies | |
| Certified Nurse Aide #4 | Observed and interviewed regarding incontinent care | |
| Licensed Practical Nurse #1 | Interviewed regarding oxygen therapy and bed rail assessments |
Inspection Report
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility Complete Care at Chestnut Hill LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Date: Oct 24, 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: 5
Inspection Report
Routine
Census: 100
Deficiencies: 1
Date: Oct 18, 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 and CMS/CDC recommended practices for COVID-19.
Findings
The facility was found to be not in compliance with 42 CFR §483.80 infection control regulations, specifically related to staff vaccination and booster dose compliance. Deficiencies were identified for 8 out of 17 staff members reviewed, with issues in documentation and timely vaccination/booster administration.
Deficiencies (1)
Failure to implement staff vaccination policy ensuring staff were up to date with COVID-19 vaccinations and boosters as required by federal, state, and local regulations.
Report Facts
Staff members reviewed: 17
Staff members deficient: 8
Sample size: 5
Inspection Report
Routine
Deficiencies: 11
Date: Aug 18, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide written information on advance directives, failure to notify physician and family of significant weight loss, inaccurate Minimum Data Set (MDS) coding, incomplete care plans, improper catheter care, failure to maintain accurate medical records, failure to offer pneumococcal vaccinations per CDC guidelines, and failure to routinely inspect beds for safety.
Deficiencies (11)
Failed to ensure written information on advance directives was provided to one resident.
Failed to notify physician and family of significant weight loss for one resident.
Failed to ensure a shared bathroom toilet was secured to prevent accident hazards.
Failed to accurately code the Minimum Data Set (MDS) assessment for one resident.
Failed to develop and implement a complete care plan for a resident with a Foley catheter.
Failed to revise resident care plans to accurately reflect health status for two residents.
Failed to provide justification for continued use of an indwelling Foley catheter and improper catheter bag positioning.
Failed to implement timely care plan interventions and notify physician of significant weight loss for one resident.
Failed to maintain accurate medical record regarding code status for one resident.
Failed to offer pneumococcal vaccinations according to CDC guidelines for two residents.
Failed to routinely inspect beds for safety including side rails, posing potential injury risk.
Report Facts
Residents reviewed for advance directives: 25
Residents affected by advance directive deficiency: 1
Significant weight loss: 40
Significant weight loss percentage: 26
Residents reviewed for MDS accuracy: 25
Residents reviewed for catheter care: 4
Residents reviewed for code status accuracy: 5
Residents reviewed for pneumococcal vaccination: 5
Resident R69 weight loss: 42
Resident R69 weight loss percentage: 27
Resident R27 quarterly MDS assessment date: Jun 2, 2022
Resident R26 quarterly MDS assessment date: Jun 6, 2022
Resident R69 BIMS score: 2
Resident R26 BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings related to advance directives, weight loss notification, care plan accuracy, catheter care, and vaccination compliance |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator (MDSC) | Named in findings related to MDS coding errors and care plan omissions |
| Registered Dietitian | Registered Dietitian (RD) | Named in findings related to weight loss monitoring and nutritional interventions |
| Regional Maintenance Director | Regional Maintenance Director (RMD) | Named in findings related to bed safety and maintenance inspections |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN)4 | Named in catheter care findings |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA)3 | Named in catheter care findings |
Inspection Report
Follow-Up
Census: 107
Deficiencies: 1
Date: Aug 18, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically regarding minimum direct care staff-to-resident ratios.
Findings
The facility was found not in compliance with staffing requirements, failing to maintain the required minimum direct care staff-to-resident ratios on multiple shifts during the review period. A follow-up report dated 10/26/2022 indicates that corrective actions were completed by 09/30/2022.
Deficiencies (1)
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law.
Report Facts
Residents present: 107
CNA staffing deficiency days: 12
Evening shift total staff deficiency days: 5
Overnight shift total staff deficiency days: 1
Required CNAs on 07/31/22 day shift: 13
Actual CNAs on 07/31/22 day shift: 8
Required total staff on 07/31/22 evening shift: 11
Actual total staff on 07/31/22 evening shift: 10
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Jun 8, 2022
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-based and the facility was found to be in compliance.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Jan 13, 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: 13
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00138747.
Complaint Details
Complaint number NJ00138747 was 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: 3
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 11, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to consistently follow medication hold parameters according to physician orders and professional nursing standards, specifically related to administration of Midodrine and Fludrocortisone medications for residents with blood pressure parameters.
Complaint Details
The complaint investigation substantiated that the facility administered medications outside of physician ordered blood pressure parameters and failed to hold medications as required. The investigation included interviews with nursing staff and review of medication administration records showing multiple instances of noncompliance.
Findings
The facility failed to consistently hold medications as ordered for residents with blood pressure parameters, resulting in administration of Midodrine and Fludrocortisone outside of physician-ordered systolic blood pressure limits. This deficient practice was identified for 2 of 23 residents reviewed and included multiple documented instances of medication administration despite blood pressure readings above the hold parameters. Additionally, the facility failed to timely act on pharmacy consultant recommendations regarding these medication errors.
Deficiencies (2)
Failure to consistently follow medication hold parameters for Midodrine and Fludrocortisone according to physician orders and nursing standards.
Failure to act upon pharmacy consultant recommendations in a timely manner regarding medications administered outside physician ordered parameters.
Report Facts
Residents reviewed for medication administration: 23
Residents affected: 2
Times Fludrocortisone administered outside parameters: 26
Times Midodrine administered outside parameters: 26
Pharmacy Consultant recommendations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered Midodrine despite SBP above parameters; interviewed regarding medication administration |
| LPN #2 | Licensed Practical Nurse | Administered Midodrine despite SBP above parameters; interviewed regarding medication administration |
| LPN #3 | Licensed Practical Nurse | Administered Midodrine despite SBP above parameters; unavailable for interview |
| LPN #4 | Licensed Practical Nurse | Nurse assigned to Resident #24; interviewed about medication administration and BP assessment |
| LPN #5 | Licensed Practical Nurse | Responsible for Resident #19; interviewed about medication administration and BP documentation |
| RN | Registered Nurse | Administered medications outside parameters 26 times; interviewed and acknowledged error; previously disciplined |
| DON | Director of Nursing | Interviewed about medication administration expectations and prior discipline of RN |
| UM | Unit Manager | Interviewed about pharmacy recommendations and medication administration follow-up |
| PC | Pharmacy Consultant | Provided medication regimen review and recommendations; interviewed about follow-up process |
| ADON | Assistant Director of Nursing | Interviewed about follow-up on pharmacy consultant recommendations |
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