Inspection Reports for Embassy Manor At Edison Nursing and Rehabilitation
NJ, 08817
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
Moderate
Unclassified
Census Over Time
Census
Capacity
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 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 the notice |
Inspection Report
Routine
Census: 225
Capacity: 225
Deficiencies: 6
May 12, 2025
Visit Reason
A Recertification Survey was conducted at Embassy Manor at Edison Nursing and Rehabilitation to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
During the survey, findings constituting Immediate Jeopardy (IJ) were identified under 42 CFR 483.1(a)(1) F 600, F 609, and F 610, related to failure to ensure residents were free from abuse and neglect. The facility implemented a corrective action plan and removal plans were accepted. Additional deficiencies were cited related to resident rights, abuse prevention, care planning, medication administration, pain management, and life safety code compliance.
Complaint Details
Complaint #NJ187096 was investigated, revealing abuse and neglect issues involving specific residents and staff. The complaint was substantiated with findings of abuse and failure to report and investigate incidents properly.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from abuse and neglect, constituting Immediate Jeopardy. | Immediate Jeopardy |
| Failure to protect resident rights and ensure dignity and respect. | — |
| Failure to develop and implement comprehensive care plans. | — |
| Failure to administer medications as ordered and ensure medication safety. | — |
| Failure to ensure adequate pain management for residents. | — |
| Failure to maintain life safety code compliance including fire safety systems and egress. | — |
Report Facts
Census: 225
Total Capacity: 225
Deficiency Count: 6
Immediate Jeopardy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Registered Nurse | Named in abuse and neglect findings related to failure to protect residents and report incidents |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Named in abuse findings involving mistreatment of residents |
| Director of Nursing | Director of Nursing | Responsible for oversight of abuse prevention and quality assurance activities |
Inspection Report
Complaint Investigation
Census: 229
Deficiencies: 2
Jul 25, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging noncompliance with professional standards and staffing requirements at the facility.
Findings
The facility was found not in substantial compliance due to failure to administer medications properly for one resident and failure to maintain required staffing ratios on multiple shifts, potentially affecting all residents.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ155941, NJ157437, NJ157714, NJ160740, NJ166295, NJ167271, NJ169912, NJ172972, NJ174687, NJ174875, NJ175723). The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer medications according to acceptable nursing standards for 1 of 3 residents, including leaving medications unattended at bedside. | SS=D |
| Failure to maintain required minimum direct care staffing ratios for 6 of 14 day shifts reviewed. | — |
Report Facts
CNA staffing deficiency: 6
Census: 229
Sample size: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration deficiency for failing to ensure resident took medications before leaving room. |
Inspection Report
Complaint Investigation
Census: 238
Deficiencies: 1
Sep 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ148950, NJ149606, and NJ150494 regarding compliance with New Jersey Administrative Code standards for licensure of long term care facilities.
Findings
The facility was found not in compliance with mandatory staffing ratios as required by New Jersey law, with deficiencies in Certified Nurse Aide (CNA) staffing on multiple day shifts during two complaint periods in 2021 and 2023. Management implemented corrective actions including staff in-services, recruitment efforts, and monitoring procedures to address staffing shortages.
Complaint Details
The complaint investigation involved three complaint numbers NJ148950, NJ149606, and NJ150494. The facility was found deficient in CNA staffing for residents on 13 of 14 day shifts from 11/28/2021 to 12/04/2021 and on 12 of 14 day shifts from 09/10/2023 to 09/23/2023. The facility took corrective actions including calling staff to cover shifts, offering overtime, contracting staffing agencies, conducting staff in-services, and implementing monitoring and reporting procedures.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 25 of 28 day shifts reviewed. |
Report Facts
Census: 238
Sample Size: 5
Deficient CNA staffing days: 13
Deficient CNA staffing days: 12
Required CNAs: 25
Actual CNAs: 16
Required CNAs: 30
Actual CNAs: 25
Inspection Report
Annual Inspection
Census: 210
Deficiencies: 10
Mar 10, 2023
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 and dignity, safe and clean environment, comprehensive care planning, medication administration, respiratory care, dialysis, food safety, infection prevention and control, and staffing ratios.
Severity Breakdown
SS=E: 6
SS=D: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide privacy and promote dignity during care for 3 residents and during dining in 1 dining room. | SS=E |
| Failed to ensure a resident's mattress was maintained in a clean, sanitary, and homelike manner. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for a resident. | SS=D |
| Failed to revise and update care plans in a timely manner for residents who fell. | SS=D |
| Failed to accurately transcribe and follow physician's orders for medications and monitoring. | SS=E |
| Failed to ensure respiratory care was provided consistent with physician orders and professional standards. | SS=D |
| Failed to ensure dialysis medication times were adjusted to accommodate resident's schedule. | SS=E |
| Failed to procure, store, prepare, distribute and serve food in accordance with professional standards for food service safety. | SS=E |
| Failed to establish and maintain an infection prevention and control program including hand hygiene compliance. | SS=E |
| Failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 14 of 14 day shifts reviewed. | — |
Report Facts
CNA staffing deficiency: 14
Census: 210
Medication administration times: 9
Weight monitoring frequency: 4
Staffing ratios: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse Unit Manager | Named in care plan and medication administration findings |
| DON | Director of Nursing | Named in multiple findings including infection control and medication administration |
| ADON | Assistant Director of Nursing | Named in infection control and care plan findings |
| IP | Infection Preventionist | Named in infection control findings |
| RNUM #1 | Registered Nurse Unit Manager | Named in medication administration and respiratory care findings |
| Dietary Aide #2 | Dietary Aide | Named in food safety findings for improper hair restraint |
| LPN #4 | Licensed Practical Nurse | Named in respiratory care findings |
| LPN #3 | Licensed Practical Nurse | Named in medication scheduling findings |
Inspection Report
Life Safety
Census: 204
Capacity: 204
Deficiencies: 9
Feb 28, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 02/28/23 to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress obstructions, lack of illumination at exit discharge, emergency lighting deficiencies, hazardous area enclosures without self-closing doors, missing smoke detection in certain areas, sprinkler coverage missing under stair landings, smoking regulation enforcement issues, and storage in the generator transfer switch room.
Severity Breakdown
SS=E: 5
SS=F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Exit discharge serving second and third floor dining areas was obstructed and rusted shut, impeding egress. | SS=E |
| Illumination of means of egress, including exit discharge, was lacking at one stairway exit discharge. | SS=E |
| Emergency lighting was not provided for the generator transfer switch room. | SS=F |
| Hazardous areas lacked self-closing doors and had openings allowing smoke passage on two floors. | SS=E |
| Fire alarm system failed to complete smoke detection sensitivity test for all 88 ionization smoke detectors in past two years. | SS=F |
| Two spaces open to corridors lacked hardwired smoke detection systems. | SS=E |
| Sprinkler coverage was missing under six of six staircase landings. | SS=F |
| Smoking area lacked ashtrays and metal self-closing containers for cigarette disposal. | SS=E |
| Generator transfer switch room contained storage blocking walking path, violating NFPA 110 standards. | SS=F |
Report Facts
Residents potentially affected: 204
Residents potentially affected: 12
Residents potentially affected: 7
Residents potentially affected: 24
Ionization smoke detectors: 88
Staircase landings lacking sprinkler coverage: 6
Smokers observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings including means of egress obstruction, emergency lighting, hazardous area enclosures, fire alarm testing, sprinkler system, smoking regulation enforcement, and transfer switch room storage | |
| Regional Operations Director | Interviewed regarding means of egress obstruction, illumination, smoke detection, and smoking area observations | |
| Administrator | Involved in in-services and corrective action plans for multiple deficiencies |
Inspection Report
Routine
Census: 213
Deficiencies: 0
Dec 29, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 12/29/2022 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: 193
Deficiencies: 0
Jan 11, 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 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: 5
Inspection Report
Complaint Investigation
Census: 177
Deficiencies: 0
Jun 27, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144369, NJ144330, NJ141667, and NJ141513.
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
The survey was complaint-driven with multiple complaint numbers cited. The facility was found compliant with no deficiencies noted.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Census: 178
Deficiencies: 4
Feb 26, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to improper use of physical restraints without proper assessment and consent, failure to timely address consultant pharmacist recommendations for medication irregularities, failure to ensure residents were free from unnecessary psychotropic medications, and failure to properly don PPE on COVID-19 and PUI units to prevent infection spread.
Severity Breakdown
SS=E: 1
SS=D: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to identify, assess, and obtain consent for use of physical restraints on residents #131 and #330. | SS=E |
| Failure to address consultant pharmacist recommendations timely for resident #73's medication regimen. | SS=D |
| Failure to ensure resident #17 was free from unnecessary psychotropic medications and proper monitoring. | SS=D |
| Failure to don appropriate PPE including gowns and gloves on COVID-19 and PUI units by multiple staff members. | SS=F |
Report Facts
Census: 178
Sample size: 35
Completion date for plan of correction: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in restraint use deficiency related to Resident #330 |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding restraint use for Resident #131 |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding improper PPE use on PUI unit |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed regarding improper PPE use on PUI unit |
| CNA #3 | Certified Nursing Assistant | Observed and interviewed regarding improper PPE use on PUI unit |
| DON | Director of Nursing | Interviewed regarding restraint use, medication management, and PPE compliance |
| IP Nurse | Infection Prevention Nurse | Interviewed regarding PPE policies and compliance |
| Housekeeping Director | Housekeeping Director | Observed without proper eye protection on COVID unit |
| Social Work Secretary | Social Work Secretary | Observed without gown and gloves on quarantine room |
Inspection Report
Life Safety
Deficiencies: 1
Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 requirements, specifically focusing on elevator safety and emergency communication systems.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements due to failure to maintain emergency communication telephones in all three elevators, which did not function during testing. A plan of correction was implemented and verified during a follow-up revisit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain elevator emergency communication telephones in elevators #1, #2, and #3, which did not function when tested. | SS=D |
Report Facts
Elevators tested: 3
Date of deficiency correction: Apr 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Conducted testing of elevator emergency communication telephones and acknowledged deficiencies | |
| Regional Director | Present during testing and acknowledged deficiencies |
Inspection Report
Routine
Census: 175
Deficiencies: 0
Dec 18, 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.
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: 183
Deficiencies: 0
Nov 27, 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: 4
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