Inspection Reports for Daughters Of Israel Pleasant Valley Home
1155 Pleasant Valley Way, NJ, 07052
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% 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
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
Routine
Census: 104
Deficiencies: 18
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.
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.
Complaint Details
Complaint numbers NJ 167267 and 177553 were investigated during this survey. Deficiencies were cited related to these complaints.
Severity Breakdown
SS=D: 6
SS=F: 11
Deficiencies (18)
| Description | Severity |
|---|---|
| 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. | SS=D |
| Facility failed to ensure staff follow physician's orders for medication administration and care plans. | SS=D |
| Facility failed to ensure residents dependent on staff for ADL care received care in accordance with facility policy. | SS=D |
| Facility failed to administer respiratory care and tracheal suctioning according to physician's orders and infection control measures. | SS=D |
| Facility failed to ensure Certified Nursing Aides received annual performance reviews as required. | SS=F |
| Facility failed to consistently provide pharmaceutical services ensuring reconciliation and accountability of dispensed medications. | SS=D |
| Facility failed to ensure required staff attended quarterly Quality Assurance Performance Improvement (QAPI) meetings. | SS=F |
| Facility failed to ensure infection control practices were followed including proper hand hygiene and disposal of contaminated items. | SS=D |
| Facility failed to maintain minimum direct care staff ratios as mandated by the State of New Jersey. | SS=F |
| Facility failed to provide fire alarm notification by audible and visible signals in accordance with NFPA 101 Life Safety Code. | SS=F |
| Facility failed to ensure doors in a required means of egress were equipped with a latch or lock. | SS=F |
| Facility failed to ensure exit discharge was provided with a hard packed all-weather and level surface. | SS=F |
| Facility failed to provide illumination of means of egress continuously or capable of automatic operation. | SS=F |
| Facility failed to ensure portable fire extinguishers were installed at proper height and maintained. | SS=F |
| Facility failed to ensure smoke barrier doors closed and latched properly. | SS=F |
| Facility failed to ensure elevators were inspected and tested annually as required. | SS=F |
| Facility failed to ensure electrical systems and emergency generators were maintained and tested. | SS=F |
| Facility failed to ensure gas equipment labeling and oxygen storage tanks were properly identified and audited. | SS=F |
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
Complaint Investigation
Census: 93
Deficiencies: 8
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.
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.
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.
Severity Breakdown
SS=E: 4
SS=D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to promote dignity and independence during meal assistance for three residents, with staff standing while feeding and delayed meal service. | SS=E |
| Failure to develop and provide baseline care plan within 48 hours of admission for one resident. | SS=D |
| Failure to provide timely morning care for one resident as per care plan. | SS=D |
| Medication error rate exceeded 5% with errors noted for two residents. | SS=D |
| Medication carts on secured unit left unlocked while unattended, accessible to residents. | SS=D |
| Failure to provide meals at regular times; delayed meal service observed. | SS=E |
| Food storage bins dirty and opened food items not dated, labeled, or sealed. | SS=E |
| Resident call lights not accessible to four residents when in bed. | SS=E |
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
Annual Inspection
Census: 143
Deficiencies: 1
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)
| Description |
|---|
| 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
Complaint Investigation
Census: 141
Deficiencies: 0
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.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 141
Deficiencies: 0
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
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=D |
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
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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