Inspection Reports for
Emerson Health Care Center
100 Kinderkamack Road, Emerson, NJ, 07630
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 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
12
9
6
3
0
Occupancy
Latest occupancy rate
84% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS regarding their medical information, including how it may be used, disclosed, and the rights individuals have concerning their health information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individual rights to access and amend information, and 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
Census: 130
Deficiencies: 0
Date: May 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00185634.
Complaint Details
Complaint #NJ00185634 was investigated and the facility was found to be in substantial compliance; no deficiencies were cited.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and in compliance with New Jersey Administrative Code Chapter 8:39 standards for licensure of long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
The inspection was conducted as an annual survey of Emerson Health Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 130
Deficiencies: 8
Date: Mar 5, 2025
Visit Reason
Routine standard survey conducted on 03/05/2025 to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities, but was not in compliance with New Jersey Administrative Code staffing requirements and had deficiencies related to life safety code including egress doors, hazardous areas, fire alarm system, maintenance and testing of fire doors, electrical systems, and emergency power systems.
Deficiencies (8)
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Access-controlled egress door keypad installed at 60 inches above floor, exceeding the 40-inch regulatory standard.
Hazardous areas not properly separated by smoke resisting partitions and doors as required by NFPA 101.
Cooking facilities lacked protective devices such as timer, keyed switch, or switch to deactivate cook-top or range independent of staff action.
Fire alarm pull stations not installed at required heights between 42 and 48 inches above floor.
Fire doors not inspected and tested annually as required by NFPA 80 standards.
Electrical panels in resident accessible areas were unlocked and not secured against unauthorized access.
Emergency backup generator battery was a lead acid battery and monthly recording of electrolyte specific gravity was not conducted.
Report Facts
Census: 130
Sample size: 29
Date of survey: Mar 5, 2025
Correction completion dates: Mar 7, 2025
Correction completion dates: Mar 31, 2025
Correction completion dates: May 15, 2025
Correction completion dates: Mar 12, 2025
Correction completion dates: Mar 14, 2025
Correction completion dates: Mar 11, 2025
Inspection Report
Routine
Deficiencies: 2
Date: Feb 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and respiratory care standards, including the development and implementation of comprehensive, person-centered care plans for residents with specific medical needs such as diabetes and continuous oxygen use.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents with diabetes and those receiving continuous oxygen therapy. Additionally, respiratory equipment was not properly dated to ensure timely changes. These deficiencies were identified for specific residents and discussed with facility leadership.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan for a resident with Type 2 Diabetes Mellitus who was on insulin medication.
Failure to ensure respiratory equipment was dated properly and failure to develop a comprehensive care plan for a resident receiving continuous oxygen therapy.
Report Facts
Residents affected: 1
Residents affected: 4
Oxygen flow rate: 4
Date of oxygen tubing observed dated: Jan 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding care plan completion and diabetes care plan absence | |
| Licensed Nursing Home Administrator (LNHA) | Discussed care plan concerns with surveyor | |
| Assistant Licensed Nursing Home Administrator (Assistant LNHA) | Discussed care plan concerns with surveyor | |
| Director of Nursing (DON) | Confirmed diabetes care plan should be present and discussed care plan concerns | |
| Infection Preventionist (IP) | Participated in meetings discussing care plan concerns | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding oxygen tubing dating and care plan responsibility | |
| Assistant Director of Nursing (ADON) | Participated in meeting on 2/13/23 with survey team |
Inspection Report
Routine
Census: 128
Capacity: 131
Deficiencies: 5
Date: Feb 13, 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 the development and implementation of comprehensive care plans and respiratory/tracheostomy care and suctioning. The facility was found not in compliance with staffing requirements and life safety code related to means of egress and fire safety.
Deficiencies (5)
Facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of diabetes mellitus.
Facility failed to ensure respiratory care, including tracheostomy care and suctioning, was provided consistent with professional standards and comprehensive care plans.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Facility failed to ensure means of egress was continuously maintained free of all obstructions and impediments to full instant use in case of fire or emergency.
Facility failed to ensure all 14 locked exit doors released upon activation of fire alarm, smoke detection, and sprinkler system in accordance with NFPA 101 Life Safety Code.
Report Facts
Sample Size: 28
Resident Census: 128
Total Capacity: 131
Deficiencies cited: 5
Staffing Deficiencies: 12
Staffing Deficiencies: 14
Exit Locks: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Met with survey team regarding care plan and staffing deficiencies |
| Assistant Licensed Nursing Home Administrator | Assistant LNHA | Met with survey team regarding care plan and staffing deficiencies |
| Director of Nursing | DON | Met with survey team and involved in care plan and respiratory care findings |
| Infection Preventionist | IP | Met with survey team regarding care plan and infection prevention |
| Registered Nurse/Unit Manager | RN/UM | Interviewed regarding admission care plans and respiratory care |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed regarding respiratory care and care plan revisions |
| Maintenance Director | Interviewed regarding fire safety and exit door deficiencies |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
The inspection was conducted in response to complaint NJ150958 to investigate allegations regarding compliance with staffing requirements at Emerson Health Care Center.
Complaint Details
Complaint NJ150958 was investigated. The facility was found non-compliant with staffing requirements and required to submit a plan of correction with a completion date. The deficiency was substantiated.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing standards, failing to maintain the required minimum direct care staff to resident ratios, specifically deficient in certified nurse aide (CNA) staffing on 13 of 14 day shifts during the period from 12/19/2021 to 01/01/2022.
Deficiencies (1)
Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey, specifically deficient CNA staffing on 13 of 14 day shifts from 12/19/2021 to 01/01/2022.
Report Facts
Deficient CNA staffing days: 13
Resident census: 125
Required CNAs: 16
Actual CNAs: 13
Correction completion date: Corrective action completion date set for 2022-07-22
Inspection Report
Routine
Census: 133
Deficiencies: 0
Date: Jun 2, 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 132
Deficiencies: 0
Date: Dec 21, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Deficiencies: 3
Date: Mar 16, 2021
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in nursing care, medical record maintenance, infection prevention and control, and proper use of medical equipment such as air mattresses.
Findings
The facility was found deficient in setting the appropriate weight on an air mattress for pressure ulcer care, maintaining complete and accurate medical records for a hospice resident, and ensuring proper removal and disposal of personal protective equipment (PPE) by staff. These deficiencies were associated with minimal harm or potential for actual harm affecting a few residents or staff.
Deficiencies (3)
Failure to set the appropriate weight in an air mattress used to promote wound healing for 1 of 3 residents reviewed for pressure ulcers.
Failure to maintain complete, accurate, and readily accessible medical records for 1 of 24 residents reviewed, including missing hospice nurse virtual visit notes.
Failure to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted guidelines for infection prevention and control for 1 of 4 staff members observed.
Report Facts
Residents reviewed for pressure ulcer: 3
Residents reviewed for medical records: 24
Staff observed for PPE donning and doffing: 4
Air mattress weight setting: 180
Air mattress weight setting corrected to: 80
Air mattress cycle setting incorrect: 25
Air mattress cycle setting corrected to: 20
Morphine dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Informed surveyor about air mattress settings and medical record deficiencies; responsible for checking air mattress and filing hospice notes | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyors to discuss findings and concerns | |
| Director of Nursing (DON) | Acknowledged staff education needs and re-educated housekeeper on PPE removal | |
| Assistant Administrator (AA) | Participated in meetings with surveyors regarding deficiencies | |
| Infection Preventionist Nurse (IPN) | Participated in meetings with surveyors regarding infection control deficiencies | |
| Assistant Director of Nursing (ADON) | Participated in meetings with surveyors | |
| Housekeeper | Observed improperly removing and disposing PPE | |
| Licensed Practical Nurse (LPN) | Regular nurse for Resident #9, responsible for air mattress weight changes |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 3
Date: Mar 16, 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 conducted in conjunction.
Findings
Deficiencies were cited related to failure to meet professional standards in wound care, incomplete and inaccessible resident medical records, and improper infection prevention and control practices including PPE removal.
Deficiencies (3)
Failure to set appropriate equipment settings to promote wound healing for residents according to professional standards.
Failure to maintain complete, accurate, and readily accessible medical records for residents.
Failure to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted infection prevention and control guidelines.
Report Facts
Census: 120
Sample size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed and observed regarding wound care equipment settings and medical record documentation | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyors to discuss observations and concerns | |
| Director of Nursing (DON) | Met with surveyors and acknowledged deficiencies; involved in re-education and monitoring | |
| Infection Preventionist Nurse (IPN) | Met with surveyors to discuss infection control concerns | |
| Housekeeping Aide | Observed improperly removing PPE; re-educated on proper procedures | |
| Housekeeping Supervisor | Responsible for in-service training and monitoring housekeeping staff on infection control practices |
Inspection Report
Routine
Census: 118
Deficiencies: 0
Date: Feb 9, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ140629.
Complaint Details
Complaint #: NJ140629. The facility was found compliant based on this complaint survey.
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: 5
Inspection Report
Abbreviated Survey
Census: 123
Deficiencies: 3
Date: Jan 11, 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 not in compliance with infection control regulations, specifically failing to properly sanitize testing tables, practice appropriate hand hygiene among staff, and follow environmental infection control in the laundry area, contrary to CDC guidelines.
Deficiencies (3)
Failure to sanitize and properly use disinfecting wipes on tables used for COVID-19 testing of visitors and staff.
Inappropriate hand hygiene practices observed in 2 of 8 staff members.
Failure to follow environmental infection control in the laundry area, including presence of food and books on clean laundry folding table and inadequate handwashing by laundry aide.
Report Facts
Sample size: 5
Positive COVID-19 staff cases: 2
Handwashing duration observed: 13
Handwashing monitoring: 5
Handwashing monitoring duration: 90
Table air drying time: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist Nurse | IPN | Responsible for COVID-19 testing and found not sanitizing tables properly and not performing hand hygiene between glove changes |
| Director of Nursing | DON | Directed corrective actions and monitoring related to infection control deficiencies |
| Laundry Aide | Observed folding clean clothes with food and books on table and inadequate handwashing | |
| Licensed Nursing Home Administrator | LNHA | Informed surveyors about positive COVID-19 staff and involved in corrective action discussions |
| Supervisor of Laundry | SL | Observed Laundry Aide's handwashing and cleanliness of laundry area |
Inspection Report
Routine
Census: 115
Deficiencies: 0
Date: 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: 9
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