Inspection Reports for Daughters Of Israel Pleasant Valley Home
1155 Pleasant Valley Way, West Orange, NJ, 07052
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
104 residents
Based on a October 2024 inspection.
This facility has shown a decline 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 10, 2025
Visit Reason
The inspection was conducted based on complaint #392826 (187404) regarding the facility's failure to ensure residents' care plans contained post-fall interventions and that fall investigations were thoroughly completed for three residents reviewed for falls.
Complaint Details
Complaint #392826 (187404) focused on failure to update care plans with post-fall interventions and incomplete fall investigations for Residents #1, #2, and #3. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to update or revise care plans to include post-fall interventions for Residents #1, #2, and #3, and did not complete thorough fall investigations with staff statements for Residents #1 and #2. Resident #3 was transferred without following the care plan requiring two staff members for transfers. The facility policies on accident/incident reporting and fall investigations require witness statements and documentation, but these were not consistently followed.
Deficiencies (3)
Failure to ensure residents' current active care plans contained post-fall interventions to prevent additional falls for 3 of 3 residents reviewed.
Fall investigations were not thoroughly completed in accordance with facility policy for 2 of 3 residents reviewed.
Resident #3 was transferred without following the care plan requiring two staff members for transfers.
Report Facts
Fall incidents for Resident #1: 4
Fall incidents for Resident #2: 4
BIMS score for Resident #1: 5
BIMS score for Resident #2: 4
BIMS score for Resident #3: 11
Nursing Fall Risk assessment score for Resident #1: 15
Nursing Fall Risk assessment score for Resident #2: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Witnessed Resident #1 fall on 9/15/25 and described fall investigation procedures |
| Licensed Practical Nurse #2 | LPN | Provided statement about Resident #1 fall on 9/30/25 |
| Licensed Practical Nurse #3 | LPN | Assigned nurse for Resident #2, confirmed cognitive impairment and fall injuries |
| Certified Nursing Aide #1 | CNA | Provided information about Resident #2's cognitive status and fall injuries |
| Certified Nursing Aide #2 | CNA | Assigned aide for Resident #2, reported fall incident and bruising |
| Certified Nursing Aide #3 | CNA | Transferred Resident #3 without assistance of second staff member, unaware of care plan requirement |
| Director of Nursing | DON | Provided accident investigations and confirmed expectations for fall investigations and care plan updates |
| Executive Director | ED / Licensed Nursing Home Administrator | Interviewed regarding fall incident investigations and facility concerns |
| Registered Nurse MDS Coordinator | RNMDSC | Provided CNA documentation history and confirmed care plan details for Resident #3 |
Inspection Report
Routine
Census: 104
Deficiencies: 18
Date: Oct 18, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint numbers NJ 167267 and 177553 were investigated during this survey. Deficiencies were cited related to these complaints.
Findings
The facility was found to have multiple deficiencies including failure to maintain prior State inspection results accessible to residents and families, failure to ensure staff follow physician orders, inadequate care for dependent residents, failure to administer respiratory care properly, lack of annual performance reviews for nursing aides, failure to maintain infection control and quality assurance meetings, and multiple life safety code violations.
Deficiencies (18)
Facility failed to maintain prior year's State of New Jersey inspection results and post the location of those results in an area accessible to residents, families, and the public.
Facility failed to ensure staff follow physician's orders for medication administration and care plans.
Facility failed to ensure residents dependent on staff for ADL care received care in accordance with facility policy.
Facility failed to administer respiratory care and tracheal suctioning according to physician's orders and infection control measures.
Facility failed to ensure Certified Nursing Aides received annual performance reviews as required.
Facility failed to consistently provide pharmaceutical services ensuring reconciliation and accountability of dispensed medications.
Facility failed to ensure required staff attended quarterly Quality Assurance Performance Improvement (QAPI) meetings.
Facility failed to ensure infection control practices were followed including proper hand hygiene and disposal of contaminated items.
Facility failed to maintain minimum direct care staff ratios as mandated by the State of New Jersey.
Facility failed to provide fire alarm notification by audible and visible signals in accordance with NFPA 101 Life Safety Code.
Facility failed to ensure doors in a required means of egress were equipped with a latch or lock.
Facility failed to ensure exit discharge was provided with a hard packed all-weather and level surface.
Facility failed to provide illumination of means of egress continuously or capable of automatic operation.
Facility failed to ensure portable fire extinguishers were installed at proper height and maintained.
Facility failed to ensure smoke barrier doors closed and latched properly.
Facility failed to ensure elevators were inspected and tested annually as required.
Facility failed to ensure electrical systems and emergency generators were maintained and tested.
Facility failed to ensure gas equipment labeling and oxygen storage tanks were properly identified and audited.
Report Facts
Census: 104
Sample Size: 22
Beds: 41
Beds: 56
Beds: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Director | Human Resources Director (HRD) | Interviewed regarding staffing and scheduling |
| Director of Nursing | Director of Nursing (DON) | Interviewed and involved in education and audits |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding Infection Preventionist role |
| Registered Nurse Infection Preventionist | RN Infection Preventionist (RNIP) | Interviewed regarding infection control duties |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 18, 2024
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations regarding nursing home operations, including resident care, medication administration, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to post current inspection results accessibly, improper use of side rails contrary to physician orders, inadequate personal hygiene care for residents, improper oxygen therapy administration and storage, lack of performance reviews for CNAs, discrepancies in narcotic medication accountability, incomplete attendance at Quality Assurance meetings, and failure to follow proper infection control practices during dining services.
Deficiencies (8)
Failed to maintain and post prior year's State inspection results in an area accessible to residents, families, and the public.
Failed to ensure staff followed physician's order for use of side rails for Resident #56 and medication administration protocols for Resident #252.
Failed to provide personal hygiene care in accordance with facility policy for Resident #22, evidenced by long, jagged, and soiled fingernails.
Failed to administer oxygen therapy according to physician's order and failed to ensure respiratory nasal cannula tubing was stored properly for Resident #22.
Failed to ensure Certified Nursing Aides received performance reviews for five CNAs reviewed.
Failed to consistently provide pharmaceutical services ensuring reconciliation and accountability of narcotic medications, with discrepancies noted in medication cart shift-to-shift logs and individual patient controlled drug records.
Failed to assure required staff attendance at quarterly Quality Assurance meetings, specifically the Infection Control Preventionist was absent from all three reviewed meetings.
Failed to ensure infection control practices were followed during dining services, including improper hand hygiene and inappropriate use and disposal of hand wipes.
Report Facts
Residents affected: 6
Residents affected: 21
Residents affected: 9
Residents affected: 1
CNAs reviewed: 5
Medication tablets: 10
Medication tablets: 11
QA meetings reviewed: 3
Residents observed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failure to post inspection results, acknowledged side rail and medication administration issues, discussed narcotic discrepancies, and infection control concerns. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Observed administering medication without following facility policy for vital signs and acknowledged oxygen therapy issues. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Observed failing to provide proper personal hygiene care and improper hand hygiene during dining services. |
| Human Resources Director | Human Resources Director (HRD) | Stated DON was responsible for education, competencies, and performance reviews. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Participated in discussions regarding deficiencies and confirmed infection control education. |
| Activity Coordinator | Activity Coordinator (AC) | Observed performing improper infection control practices during dining services. |
| Activity Director | Activity Director (AD) | Interviewed regarding infection control concerns during dining services. |
| Registered Nurse | Registered Nurse (RN) | Observed narcotic medication cart discrepancies and discussed shift-to-shift reconciliation issues. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 8
Date: Aug 10, 2023
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation revealed multiple deficiencies including resident dignity issues during meals, baseline care plan delays, untimely morning care, medication errors, unsecured medication carts, delayed meal service, unsanitary food storage, and inaccessible call lights.
Findings
Multiple deficiencies were identified including failure to promote resident dignity during meals, failure to provide baseline care plans within 48 hours of admission, failure to provide timely morning care, medication errors exceeding 5%, unlocked medication carts, delayed meal service, unsanitary food storage, and call lights not accessible to residents.
Deficiencies (8)
Failure to promote dignity and independence during meal assistance for three residents, with staff standing while feeding and delayed meal service.
Failure to develop and provide baseline care plan within 48 hours of admission for one resident.
Failure to provide timely morning care for one resident as per care plan.
Medication error rate exceeded 5% with errors noted for two residents.
Medication carts on secured unit left unlocked while unattended, accessible to residents.
Failure to provide meals at regular times; delayed meal service observed.
Food storage bins dirty and opened food items not dated, labeled, or sealed.
Resident call lights not accessible to four residents when in bed.
Report Facts
Survey Census: 93
Sample Size: 24
Medication error rate: 8
Number of residents affected by call light issue: 4
Number of residents affected by unlocked med carts: 2
Number of residents affected by untimely meal service: 3
Number of residents affected by untimely morning care: 1
Number of residents affected by baseline care plan delay: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN6 | Licensed Practical Nurse | Named in medication error findings and training |
| Director of Nursing | Director of Nursing | Provided education on feeding assistance, medication errors, call light placement, and conducted audits |
| Certified Nursing Assistant 1 | CNA | Observed feeding residents while standing |
| Activities Coordinator | Activities Coordinator | Observed feeding resident while standing without prior training |
| Dietary Manager | Dietary Manager | Provided meal service times and commented on meal delays |
| Registered Dietician | Registered Dietician | Commented on meal service delays |
| Director of Building Services | Director of Building Services | Confirmed generator load bank test not completed |
| Certified Nursing Assistant 3 | CNA | Commented on call light placement |
| Licensed Practical Nurse 3 | LPN | Observed leaving medication cart unlocked |
| Licensed Practical Nurse 1 | LPN | Observed leaving medication cart unlocked |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely morning care and assistance with activities of daily living for Resident 40 (R40).
Complaint Details
The complaint investigation focused on Resident 40's care, including missed toileting schedules, delayed shower assistance, and inadequate incontinence care. The complaint was substantiated based on observations, interviews with staff and family, and record reviews.
Findings
The facility failed to provide timely morning care, including toileting and shower assistance, for Resident 40 who required extensive assistance due to cognitive impairment and physical limitations. Documentation and interviews revealed missed toileting schedules and delayed care, contributing to potential harm.
Deficiencies (1)
Failed to provide timely morning care and assistance with activities of daily living for Resident 40.
Report Facts
Residents in sample: 24
Missed toileting documentation days: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA2 | Certified Nurse Aide | Acknowledged delay in getting Resident 40 up and providing morning care on 08/09/23 |
| CNA4 | Certified Nurse Aide | Provided care to Resident 40 and gave shower on 08/09/23; familiar with resident's needs |
| LPN2 | Licensed Practical Nurse | Unaware Resident 40 had not been cared for or had breakfast on 08/10/23 |
| DON | Director of Nursing | Provided information about Resident 40's stroke history and facility layout challenges |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 10, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, food services, and safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during feeding, failure to provide baseline care plans within 48 hours of admission, delayed morning care, medication errors exceeding 5%, unlocked medication carts, delayed meal service, improper food storage and cleanliness, and call lights not accessible to residents in their rooms.
Deficiencies (8)
Failed to promote dignity and independence during feeding; staff were observed standing while feeding residents and one resident waited 29 minutes for lunch while others were served.
Failed to provide a baseline care plan within 48 hours of admission for one resident.
Failed to provide timely morning care for one resident, including delays in showering and toileting schedules.
Medication error rate exceeded 5%, with errors noted in administration timing and dosing for two residents.
Failed to ensure medication carts were locked while unattended on the secured unit, potentially exposing medications to unauthorized access.
Failed to serve meals at regular times; delays in meal service were observed with some residents waiting up to 53 minutes past posted mealtime.
Failed to keep food storage bins clean and failed to ensure opened food was dated, labeled, and sealed properly.
Failed to ensure call lights were within reach of residents in their rooms, including when in bed, creating potential inability to summon assistance.
Report Facts
Medication error rate: 8
Residents affected by dignity deficiency: 3
Residents affected by baseline care plan deficiency: 1
Residents affected by delayed morning care: 1
Residents affected by unlocked medication carts: 2
Residents affected by meal service delays: 3
Residents affected by food storage deficiencies: 91
Residents affected by call light accessibility: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding feeding assistance expectations, medication errors, medication cart security, and call light placement. |
| Certified Nursing Aide 1 | CNA1 | Observed and interviewed regarding feeding residents while standing and lack of chair. |
| Activities Coordinator | AC | Observed feeding resident while standing and interviewed about lack of feeding assistance training. |
| Registered Nurse 2 | RN2 | Interviewed about care plan development and baseline care plan issuance. |
| Social Services Director | SSD | Interviewed about baseline care plan issuance and documentation. |
| Licensed Practical Nurse 6 | LPN6 | Observed medication administration errors and interviewed about medication timing and dosing. |
| Dietary Manager | DM | Interviewed about meal service times, delays, and food supply issues. |
| Registered Dietician | RD | Interviewed about meal service delays. |
| Certified Nursing Assistant 2 | CNA2 | Observed and interviewed about delayed morning care and shower assistance. |
| Certified Nursing Assistant 4 | CNA4 | Interviewed about resident care needs and call light placement. |
| Licensed Practical Nurse 1 | LPN1 | Interviewed about medication cart security. |
| Licensed Practical Nurse 3 | LPN3 | Observed leaving medication cart unlocked and interviewed about it. |
| Licensed Practical Nurse 5 | LPN5 | Observed medication pass and call light accessibility; interviewed about call light checks. |
| Certified Nursing Assistant 3 | CNA3 | Interviewed about call light placement practices. |
Inspection Report
Annual Inspection
Census: 143
Deficiencies: 1
Date: Nov 16, 2021
Visit Reason
The visit was a Recertification Survey to assess compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
The facility was found not in substantial compliance with all standards, specifically failing to maintain mandated direct care staff-to-resident ratios on six out of fourteen day shifts reviewed, potentially affecting all residents.
Deficiencies (1)
Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law on six out of fourteen day shifts reviewed.
Report Facts
Census: 143
Sample Size: 50
Staff-to-resident ratios: 14
Staff-to-resident ratios: 16
Staff-to-resident ratios: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 11/11/2021 regarding staffing challenges and corrective actions. |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 16, 2021
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of physical restraints, care planning, medication storage, food handling, and infection prevention and control in the nursing home.
Findings
The facility was found to have deficiencies related to improper use of physical restraints including side rails, incomplete care plans for residents, improper medication storage by route of administration, unsafe food handling practices with bare hand contact, and inadequate infection control practices including improper cleaning of glucometers and failure to properly don and doff PPE in isolation areas.
Deficiencies (6)
Use of physical restraints including side rails was not consistent with physician orders or consent for multiple residents.
Failure to develop and implement comprehensive care plans reflecting physician orders and resident needs for five residents.
Medications were not stored separately by route of administration in medication carts 2A and 2B.
Facility staff were observed handling ready-to-eat food with bare hands during meal service.
Glucometers were not properly cleaned with germicidal wipes between resident uses; alcohol wipes were used instead.
Staff failed to remove PPE when exiting isolation area and removed resident water pitchers from isolation area, risking contamination.
Report Facts
Residents reviewed for physical restraints: 12
Residents reviewed for care planning: 30
Medication carts observed: 4
Residents affected by food handling issue: 1
Residents affected by infection control issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | CNA | Interviewed regarding side rail use and consent for Resident #89 and #133. |
| Certified Nurse Aide #6 | CNA | Interviewed regarding side rail orders and consent for Resident #89 and #133. |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding side rail use and care plans for Resident #89 and #133. |
| Director of Rehabilitation | DOR | Interviewed regarding therapy screening and siderail assessments. |
| MDS Coordinator | Interviewed regarding siderail assessments and restraint coding. | |
| Director of Nursing | DON | Interviewed regarding siderail consent, care plans, medication storage, and infection control. |
| Assistant Director of Nursing | ADON | Interviewed regarding siderail use, medication storage, and infection control. |
| Registered Nurse #1 | RN | Observed and interviewed regarding medication cart and glucometer cleaning. |
| Registered Nurse #2 | RN | Interviewed regarding food handling and medication storage. |
| Certified Nurse Aide #8 | CNA | Observed and interviewed regarding food handling with bare hands. |
| Certified Nurse Aide #9 | CNA | Observed and interviewed regarding improper PPE use and isolation area breaches. |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding glucometer cleaning and isolation area PPE practices. |
| Administrator | Interviewed regarding expectations for care plans, medication storage, food handling, and infection control. |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 0
Date: Feb 25, 2021
Visit Reason
The inspection was conducted as a complaint visit to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 141
Deficiencies: 0
Date: Feb 10, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Abbreviated Survey
Census: 144
Deficiencies: 1
Date: Dec 29, 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 not to be in compliance with infection control regulations, specifically failing to ensure appropriate hand hygiene practices by staff, which increased the risk of COVID-19 transmission.
Deficiencies (1)
Failure to ensure staff practiced appropriate hand hygiene for 2 of 8 staff in accordance with CDC guidelines to mitigate the spread of COVID-19.
Report Facts
Census: 144
Sample size: 5
Staff non-compliance: 2
Staff COVID-19 positive: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about residents coming out of isolation and staff COVID-19 status | |
| Licensed Nursing Home Administrator (LNHA) | Provided information about facility units and COVID-19 status | |
| Housekeeper (HK) | Observed failing to perform hand hygiene before and after glove use while cleaning resident bathrooms | |
| Certified Nursing Assistant (CNA) | Observed failing to perform hand hygiene between resident contacts and after disposing of bib | |
| Infection Preventionist Nurse (IPN) | Confirmed staff should have performed hand hygiene and stated staff were routinely educated on PPE and hand hygiene | |
| Assistant Administrator | Provided facility handwashing policy and procedure |
Inspection Report
Routine
Census: 158
Deficiencies: 0
Date: Dec 1, 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: 3
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