Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
80% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census 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 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, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 129
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ178902, covering the period from 1/15/25 to 1/23/25.
Complaint Details
Complaint #: NJ178902 triggered the survey conducted from 1/15/25 to 1/23/25. The complaint investigation found staffing and employee health record deficiencies.
Findings
The facility was found to be in substantial compliance with federal long-term care requirements but was not in compliance with New Jersey state licensure standards. Deficiencies included failure to maintain minimum direct care staff to resident ratios for one day shift, and failure to ensure newly hired employees completed required health histories and physical examinations within mandated timeframes. Additionally, life safety code deficiencies were noted related to sprinkler system spare heads and emergency generator monthly load testing.
Deficiencies (4)
Failed to maintain required minimum direct care staff to resident ratio for 1 of 14 day shifts (1/6/25) with 11 CNAs for 98 residents instead of required 12 CNAs.
Failed to ensure newly hired employees completed health history and received physical examination by physician, advanced practice nurse, or licensed physician assistant within two weeks prior to employment or within 30 days if RN assessment was done; identified in 5 of 10 employee files reviewed.
Failed to ensure at least six spare quick response sprinkler heads were present in the sprinkler cabinet as required by NFPA 13 standard.
Failed to ensure monthly load tests were conducted on the emergency generator in accordance with NFPA 110 standards; no documented evidence of monthly load testing.
Report Facts
Census: 103
Total Capacity: 129
Deficient CNA staffing: 1
Newly hired employee files reviewed: 10
Non-compliant employee files: 5
Spare sprinkler heads required: 6
Residents potentially affected: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Administrator/Designee | Responsible for conducting staffing audits and monitoring new hire physicals |
| Director of Nursing | DON | Interviewed regarding staffing policies and minimum staffing requirements |
| Director of Human Resources/Scheduling Coordinator | DHR/SC | Interviewed regarding staffing policies and employee file compliance |
| Licensed Practical Nurse/Infection Preventionist | LPN/IP | Responsible for ensuring newly hired employees had physicals completed |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
Annual inspection survey completed to assess compliance with health and safety regulations at Country Arch Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Date: Jun 11, 2024
Visit Reason
The inspection was conducted based on complaints NJ001547, NJ00173115, and NJ00172367 regarding the facility's compliance with long term care regulations.
Complaint Details
Complaint numbers NJ001547, NJ00173115, and NJ00172367 triggered the visit. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to maintain complete medical records including the New Jersey Universal Transfer Form for a resident sent to the hospital. Additionally, the facility failed to meet required staffing ratios for Certified Nurse Aides on multiple shifts.
Deficiencies (2)
Failure to maintain complete medical records including the New Jersey Universal Transfer Form for a resident sent to the hospital.
Failure to ensure staffing ratios were met for Certified Nurse Aides on 11 of 14 day shifts and 4 of 14 night shifts.
Report Facts
Census: 110
Sample Size: 5
Staffing Deficiencies: 11
Staffing Deficiencies: 4
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) required: 8
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted based on Complaint# NJ00172367 to investigate the facility's failure to maintain a complete Medical Record containing the New Jersey Universal Transfer Form (NJUTF) for a resident transferred to the hospital.
Complaint Details
Complaint# NJ00172367 was substantiated based on interviews, record review, and documentation review on 06/12/24, confirming the missing NJUTF for Resident #3's hospital transfer on 03/21/2024.
Findings
The facility failed to maintain the required NJUTF for Resident #3's hospital transfer on 03/21/2024, as confirmed by record reviews and interviews with the Director of Nursing.
Deficiencies (1)
Failure to maintain a complete Medical Record containing the New Jersey Universal Transfer Form (NJUTF) for a resident transferred to the hospital.
Report Facts
Blood Pressure: 136
Pulse: 78
Respiration: 19
Pulse Oximeter: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding missing NJUTF for Resident #3 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Country Arch Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 105
Capacity: 101
Deficiencies: 10
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints received regarding resident care and facility compliance with regulations.
Complaint Details
The visit was complaint-related based on complaints NJ00160546, NJ00163908, NJ00156816, and NJ00158985. The investigation included review of resident records, interviews, and environmental observations. The complaints involved issues of resident care, abuse/neglect allegations, and facility compliance.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for residents, inadequate care planning and implementation, improper notification of room changes, unsafe environment conditions, insufficient staff training and supervision, and failure to maintain accurate and complete medical and administrative records.
Deficiencies (10)
Failure to provide reasonable accommodations and specialized call bell according to resident's limitations and preferences.
Failure to notify resident and family of room/roommate changes in a timely and documented manner.
Unsafe environment due to presence of construction materials and adhesive in dining area without proper controls.
Failure to ensure all newly hired staff had verified licenses prior to hire.
Failure to thoroughly investigate and document allegations of abuse and neglect.
Failure to provide timely and adequate care planning and interventions for residents at risk, including pressure ulcers and specialized care needs.
Failure to maintain accurate and complete medical records, including physician visits, assessments, and care plans.
Failure to maintain adequate staffing levels and provide required staff training and competency evaluations.
Failure to maintain a safe, clean, and sanitary environment, including food service and infection control practices.
Failure to provide required immunizations and document refusals or contraindications.
Report Facts
Census: 105
Total Capacity: 101
Sample Size: 21
Closed Records: 3
Additional Records: 20
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding incomplete investigations of resident incidents and failure to provide accurate assessments and dental care services for residents.
Complaint Details
Complaints NJ00158985 and NJ00156816 were investigated. The facility was found to have incomplete investigations of incidents and failure to provide accurate assessments and dental care services.
Findings
The facility failed to thoroughly investigate incidents involving residents, including incomplete investigations and missing witness statements for multiple unwitnessed falls and injuries. Additionally, the facility failed to accurately code Minimum Data Set (MDS) assessments for several residents and did not provide mandatory annual dental care services for some residents.
Deficiencies (3)
Facility failed to thoroughly investigate incidents including unwitnessed falls and injuries for residents #27 and #208.
Facility failed to accurately code the Minimum Data Set (MDS) for residents #26, #208, and #209.
Facility failed to provide mandatory annual dental care services for residents #26 and #209.
Report Facts
Number of residents reviewed for accident investigation: 6
Number of residents reviewed for MDS accuracy: 21
Number of residents with inaccurate MDS coding: 3
Number of residents reviewed for dental care services: 21
Number of residents with failed dental care services: 2
Inspection Report
Routine
Census: 105
Deficiencies: 16
Date: Oct 19, 2023
Visit Reason
Routine inspection of Country Arch Care Center to assess compliance with healthcare regulations including resident care, staffing, infection control, and facility management.
Findings
The inspection identified multiple deficiencies including failure to accommodate resident needs, inadequate notification of roommate changes, unsafe storage of construction materials, incomplete license verifications, incomplete incident investigations, failure to provide timely transfer notifications, inaccurate resident assessments, inadequate pressure ulcer care, insufficient physician visits and documentation, staffing shortages, incomplete infection preventionist role, improper infection control practices, failure to provide pneumococcal vaccinations, and inadequate nurse aide training and competency documentation.
Deficiencies (16)
Failed to provide a physically impaired resident a specialized call bell according to the resident's limitation and preference.
Failed to notify in advance and in writing of a resident's new roommate change for a cognitively impaired resident.
Failed to provide residents with a clean, safe, comfortable, and homelike environment; construction materials stored in dining area.
Failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire for three newly hired staff.
Failed to thoroughly investigate incidents/accidents including missing witness statements and incomplete documentation.
Failed to provide written notification of emergency transfer to resident representative and Ombudsman for one resident.
Failed to accurately code Minimum Data Set (MDS) assessments for three residents.
Failed to maintain infection control practices during pressure ulcer treatment and ensure timely care planning and interventions for pressure ulcers.
Failed to implement and document new interventions after each fall to prevent additional falls for one resident.
Failed to ensure tracheostomy care was provided according to clinical standards including proper hand hygiene, disinfection, and orders for inner cannula size.
Failed to ensure accurate documentation in Nurse Staffing Report, meet minimum staffing requirements, ensure timely physician visits and notes, provide mandated nurse aide training, and ensure QAPI meetings included required members.
Failed to store foods properly to prevent foodborne illness and maintain clean storage for food and cooking utensils.
Failed to ensure resident dietary preferences were consistently identified and implemented.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failed to identify residents in need of pneumococcal vaccine, offer vaccine, and follow facility vaccination policy.
Failed to ensure nurse aides received mandated 12-hours annual competency training.
Report Facts
CNA staffing deficiency: 14
Total staff deficiency: 3
Resident census: 105
Resident count on 100 wing 7-3 shift: 46
Resident count on 100 wing 7-3 shift: 47
CNA assignment: 10
CNA assignment: 9
CNA assignment: 9
CNA assignment: 9
CNA assignment: 10
CNA assignment: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN#1 | Licensed Practical Nurse | Named in wound treatment and infection control findings |
| LPN#2 | Licensed Practical Nurse | Named in wound care and infection prevention education |
| CNA#1 | Certified Nursing Assistant | Named in staffing and resident care findings |
| CNA#2 | Certified Nursing Assistant | Named in staffing and resident care findings |
| DON | Director of Nursing | Named in multiple findings including staffing, infection control, and physician visit documentation |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including staffing, infection control, and QAPI meetings |
| MD | Medical Director | Named in findings related to physician visits, QAPI meetings, and vaccination oversight |
| AiT/RN/IPN | Administrator in Training/Registered Nurse/Infection Preventionist Nurse | Named in infection preventionist role and facility administration |
| HRD | Human Resources Director | Named in staffing and employee file review |
| VPoCS | President of Clinical Services | Named in multiple findings and interviews |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with medication storage and labeling regulations, infection prevention and control practices, and proper handling of linens in the facility.
Findings
The facility failed to ensure medication and treatment carts were locked when unattended, staff did not consistently wear appropriate PPE during transmission-based precautions, and linens were improperly handled and transported, increasing the risk of infection transmission.
Deficiencies (2)
Failed to ensure medication and treatment carts were locked when unattended to limit access to authorized personnel.
Failed to ensure staff wore appropriate PPE when transmission-based precautions were required, removed PPE prior to exiting rooms, and handled linens properly to prevent infection transmission.
Report Facts
Medication carts unlocked: 1
Treatment carts unlocked: 1
Residents in wheelchairs near unlocked carts: 5
Residents affected by infection control deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Observed leaving medication and treatment carts unlocked and not acknowledging unlocked carts |
| Registered Nurse #5 | RN | Responsible for medication and treatment carts left unlocked while cleaning expired medications |
| Administrator | Stated facility lacked policy on medication storage and linen handling; referenced State Operations Manual and CDC guidance | |
| Director of Nursing | DON | Stated staff should lock carts when unattended and remove gloves before leaving rooms; described yellow zone TBP procedures |
| Occupational Therapist #2 | OT | Observed not wearing full PPE as required for transmission-based precautions |
| Licensed Practical Nurse #1 | LPN | Admitted to not wearing required PPE when entering isolation room |
| Certified Nursing Assistant #4 | CNA | Observed improper handling of linens and failure to remove gloves between rooms |
| Infection Preventionist | IP | Provided guidance on PPE and infection control policies |
| Housekeeping and Laundry Supervisor | Stated linens dropped on floor should be placed in soiled linen bin |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 2
Date: Jan 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ157128, NJ157438, NJ16028, and NJ160661 to determine compliance with regulatory standards.
Complaint Details
Complaint investigation based on complaint numbers NJ157128, NJ157438, NJ16028, and NJ160661. The facility was found not in substantial compliance with professional standards and staffing requirements.
Findings
The facility was found not in substantial compliance with professional standards of care, specifically failing to follow clinical practice standards and document treatments for 2 of 17 residents reviewed. Additionally, the facility failed to meet required staffing ratios for certified nurse aides on multiple shifts.
Deficiencies (2)
Failure to follow standards of clinical practice and document treatments as ordered by the physician for 2 of 17 residents.
Failure to ensure staffing ratios were met to maintain required minimum staff-to-resident ratios for certified nurse aides on 14 of 35 day shifts and 2 of 35 overnight shifts.
Report Facts
Census: 124
Sample size: 17
Staffing deficiency: 14
Staffing deficiency: 2
Certified Nurse Aides (CNAs) required: 13
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) actual: 11
Certified Nurse Aides (CNAs) actual: 12
Total staff required overnight: 8
Total staff actual overnight: 4
Total staff actual overnight: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Stated facility policies and practices during interviews related to treatment administration and documentation. | |
| Unit Manager/Registered Nurse (RN) | Interviewed regarding treatment administration record documentation. |
Inspection Report
Routine
Census: 103
Deficiencies: 0
Date: Jul 28, 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
Re-Inspection
Census: 99
Capacity: 130
Deficiencies: 18
Date: Jul 1, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, medication administration, nutrition/hydration status, respiratory care, psychotropic drug use, food safety, infection control, staffing ratios, and life safety code compliance. Corrective actions were implemented and verified during the revisit.
Deficiencies (18)
Failure to ensure accuracy of resident assessments and coding.
Medications were not administered according to physician orders and improper labeling of medications.
Failure to maintain proper nutrition and hydration status for residents.
Respiratory care deficiencies including improper tracheostomy care and suctioning.
Psychotropic drugs prescribed without proper documentation and monitoring.
Expired and improperly stored medications found in medication carts and refrigerators.
Failure to prepare and serve therapeutic diets consistent with physician orders.
Kitchen sanitation deficiencies including improper storage and cleaning.
Infection prevention and control deficiencies including improper PPE use.
Failure to maintain minimum direct care staffing ratios as required by state law.
Life safety code violations including blocked means of egress, malfunctioning fire doors, delayed egress locks, and improper locking mechanisms.
Smoke detectors in resident rooms lacked a preventative maintenance program and battery replacement.
Sprinkler system deficiencies including improper installation and maintenance of exterior sprinklers.
Corridor doors failed to resist passage of smoke due to improper latching and gaps.
Hazardous areas not properly enclosed or maintained, including basement storage and sprinkler shutoff valve room.
HVAC ventilation systems in resident bathrooms were not functioning.
Electrical equipment with exposed wiring found in resident room.
Gas equipment cylinders not properly secured and protected from damage.
Report Facts
Residents present: 99
Licensed capacity: 130
Deficiency counts: 17
Staffing ratios: 11
Staffing ratios: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Named in medication administration and labeling deficiencies | |
| Licensed Practical Nurse (LPN #4) | Named in respiratory care and PPE donning/doffing deficiencies | |
| Director of Nursing | Named in multiple corrective actions and education | |
| Maintenance Director | Named in life safety and facility maintenance corrective actions | |
| Administrator | Named in multiple corrective actions and education | |
| Staff member (unnamed) | Named in electrical equipment exposed wiring finding |
Inspection Report
Routine
Deficiencies: 11
Date: Jul 1, 2022
Visit Reason
Routine inspection of Country Arch Care Center to assess compliance with healthcare regulations including resident care, medication administration, nutrition, respiratory care, infection control, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, medication administration errors, failure to follow physician orders for adaptive devices, inadequate urinary catheter care, failure to identify and address significant weight loss, improper respiratory care and tracheostomy management, improper labeling and storage of medications, failure to discontinue psychotropic medications timely, failure to provide prescribed therapeutic diets, poor kitchen sanitation, and improper use of personal protective equipment.
Deficiencies (11)
Facility failed to accurately code a resident's Minimum Data Set (MDS) assessment for Resident #67.
Medications were not administered according to physician orders for Resident #16; Intravenous Fluid (IVF) medication was not labeled properly for Resident #57.
Facility failed to follow physician orders for adaptive devices for Residents #2 and #87.
Facility failed to provide appropriate urinary catheter care for Resident #57, including missing documentation of urinary output and care plan.
Facility failed to identify and address clinically significant weight loss timely for Residents #77 and #80, including failure to obtain and assess weights, implement nutrition interventions, and monitor meal consumption.
Facility failed to provide safe and appropriate respiratory care for Residents #22 and #338, and failed to provide tracheostomy care according to standards for Resident #76.
Facility failed to properly label, store, and dispose of medications in medication carts and refrigerators.
Facility failed to provide documented clinical rationale for continuation of PRN psychotropic medications beyond 14 days for Resident #67.
Facility failed to ensure foods were provided and prepared consistent with physician prescribed mechanically altered diets for Residents #72 and #58.
Facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment.
Facility failed to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted infection prevention and control guidelines.
Report Facts
Resident weight: 118
Resident weight: 124.5
Resident weight: 120
Resident weight: 125.9
Resident weight: 130
Resident weight: 129
Resident weight: 131
Resident weight: 171.1
Resident weight: 173.2
Resident weight: 178.2
Resident weight: 176.4
Resident weight: 182.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #67 behaviors and medication administration |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding Resident #67 behaviors and medication administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding Resident #67 behaviors and medication administration |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed performing tracheostomy care for Resident #76 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, nutrition, respiratory care, and infection control |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding multiple deficiencies and facility policies |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutrition care and kitchen sanitation |
| Speech Language Pathologist | Speech Language Pathologist | Interviewed regarding therapeutic diets and meal preparation |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE donning and doffing |
| Medical Doctor | Medical Doctor | Interviewed regarding PRN psychotropic medication orders for Resident #67 |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding PRN psychotropic medication orders for Resident #67 |
| Director of Social Work | Director of Social Work | Observed removing PPE incorrectly |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Date: Sep 3, 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
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jun 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139868, NJ140564, and NJ143693.
Complaint Details
Complaint numbers NJ139868, NJ140564, and NJ143693 were investigated and found to be 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: 8
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Date: May 20, 2021
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility.
Complaint Details
The survey was complaint-based 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, for long term care facilities based on this complaint survey.
Report Facts
Sample Size: 3
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