Inspection Reports for Fellowship Village
8000 Fellowship Rd, Basking Ridge, NJ 07920, United States, NJ, 07920
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
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 explains 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 named as contact person for privacy practices |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 67
Deficiencies: 6
Nov 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint NJ #: 174415, 173702, to assess compliance with federal and state regulations including emergency preparedness and life safety code requirements.
Findings
The facility was found to be in compliance with long term care requirements but was not in compliance with emergency preparedness communication plan requirements and life safety code standards, including fire alarm system activation, sprinkler system maintenance, smoke barrier penetrations, and generator inspection documentation. Plans of correction were submitted and a post-certification revisit was scheduled.
Complaint Details
Complaint NJ #: 174415, 173702 triggered the survey conducted from 10/30/24 to 11/4/24. The complaint was substantiated with findings related to emergency preparedness and life safety code deficiencies.
Deficiencies (6)
| Description |
|---|
| Failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State, and Local laws. |
| Failed to provide a manual means to activate the fire alarm system in the path of egress as required by NFPA 101 Life Safety Code. |
| Failed to ensure the fire alarm system was tested and maintained in accordance with NFPA 101 requirements. |
| Failed to maintain documentation of sprinkler system inspections and tests as required by NFPA 25. |
| Failed to ensure smoke barriers were protected by a system or material capable of restricting smoke transfer, with unsealed penetrations noted. |
| Failed to maintain generator inspection and testing records as required by NFPA 110. |
Report Facts
Census: 58
Total Capacity: 67
Deficiency Completion Dates: 6
Sample Records Reviewed: 18
Inspection Report
Annual Inspection
Census: 59
Capacity: 67
Deficiencies: 7
Jul 20, 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 pharmacy services and medication administration, staffing ratios for certified nurse aides, fire safety including building rehabilitation and fire alarm system maintenance. The facility failed to ensure medication was administered according to physician orders and acceptable standards, and failed to maintain required minimum direct care staff ratios. Fire safety deficiencies included inadequate separation of licensed wings and issues with corridor doors and fire alarm system maintenance.
Severity Breakdown
SS=D: 1
SS=F: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure medication was administered according to physician orders and acceptable standards, evidenced by medication observation pass for Resident #46. | SS=D |
| Facility failed to maintain required minimum direct care staff ratios for CNAs during multiple 14-day shifts. | — |
| Facility failed to ensure separation from different licensed wings on each floor with a 3/4-hour fire rated door as required by NFPA 80 and NFPA 101. | SS=F |
| Facility failed to ensure fire alarm system was maintained and operational according to NFPA 70 and NFPA 72. | SS=F |
| Facility failed to ensure corridor doors resist passage of smoke and properly defend occupants, with compromised gaskets on 46 of 50 resident rooms. | SS=F |
| Facility failed to ensure hot water storage tanks were properly maintained, with active leaks and risk of catastrophic failure. | SS=F |
| Facility failed to ensure heating device safety features to prevent ignition of combustible materials. | SS=F |
Report Facts
Census: 59
Total Capacity: 67
Medication Observation Sample: 7
CNA Staffing Ratios: 6
Deficiency Completion Dates: Aug 4, 2023
Deficiency Completion Dates: Aug 15, 2023
Deficiency Completion Dates: Aug 11, 2023
Deficiency Completion Dates: Sep 1, 2023
Deficiency Completion Dates: Sep 5, 2023
Deficiency Completion Dates: Sep 18, 2023
Inspection Report
Original Licensing
Census: 43
Capacity: 67
Deficiencies: 2
May 20, 2022
Visit Reason
Initial inspection or licensure of new and/or renovated long term care facilities including Phase III renovation of Household 101 area and increase in licensed beds from 54 to 67.
Findings
No F-tag deficiencies were noted during the inspection. However, a Life Safety Code Survey found noncompliance with exit discharge walking surface and sprinkler system installation in the newly renovated areas, requiring corrective actions before occupancy.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide one of three exit discharges with a stable, hard packed walking surface to reach a public way in case of emergency. | SS=E |
| Failed to provide proper fire sprinkler coverage to all areas of the newly renovated section, specifically missing sprinkler coverage under a 20 feet by 6 feet porch overhang. | SS=E |
Report Facts
Licensed beds increase: 13
Current census: 43
Exit discharge walking surface length: 97
Porch dimensions without sprinkler coverage: 120
Porch dimensions with sprinkler coverage: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Health and Medical Services | Present during survey and informed of deficiencies. | |
| Director of Building Projects | Present during survey and informed of deficiencies. | |
| Vice-President of Construction | Responsible for inspection and corrective actions per plan of correction. | |
| Senior Director of Plant Operations | Responsible for inspection and corrective actions per plan of correction. | |
| Administrator | Responsible for inspection and corrective actions per plan of correction. |
Inspection Report
Life Safety
Census: 43
Capacity: 67
Deficiencies: 2
May 20, 2022
Visit Reason
Inspection of the Phase III, Household 101 area of Renovation of existing building including various resident and common areas, to increase licensed beds from 54 to 67. A Life Safety Code Survey was conducted to assess compliance with fire safety regulations.
Findings
The facility was found noncompliant with Life Safety Code requirements due to failure to provide a stable, hard packed walking surface at one exit discharge and inadequate fire sprinkler coverage in a newly renovated section, specifically under a porch overhang. These deficiencies posed fire hazards.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide 1 of 3 exit discharges with a stable, hard packed walking surface to reach a public way in case of fire or emergency. | SS=E |
| Failed to provide proper fire sprinkler coverage to all areas of a newly renovated section, including a 20 feet by 6 feet porch overhang without sprinkler coverage. | SS=E |
Report Facts
Licensed beds increase: 13
Current census: 43
Exit discharge walking surface length: 97
Porch overhang dimensions without sprinkler coverage: 20
Porch overhang depth without sprinkler coverage: 6
Porch overhang dimensions with sprinkler coverage: 8
Porch overhang depth with sprinkler coverage: 6
Number of resident rooms inspected in Household 101: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Health and Medical Services | Present during survey and informed of deficiencies. | |
| Director of Building Projects | Present during survey and informed of deficiencies. | |
| Vice-President of Construction | Responsible for inspection and corrective actions in plan of correction. | |
| Senior Director of Plant Operations | Responsible for inspection and corrective actions in plan of correction. | |
| Administrator | Responsible for inspection and corrective actions in plan of correction. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Jul 22, 2021
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 improper labeling, storage, and disposal of medications in 2 of 2 medication room refrigerators inspected. The facility failed to remove expired medications and did not follow manufacturer and policy guidelines for medication storage and disposal.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly label, store and dispose of medications for 2 of 2 medication room refrigerators inspected. | SS=D |
Report Facts
Census: 42
Sample size: 12
Deficiency correction completion date: Jul 27, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding expired eye drops in medication refrigerator |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding expired vial and pen in medication refrigerator |
| Director of Nursing | Director of Nursing | Met with surveyor on 6/14/21; provided facility policies |
| Licensed Nursing Home Administrator | Administrator | Met with surveyor on 6/14/21 |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Jun 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ136161 and NJ142747.
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
Complaint numbers NJ136161 and NJ142747 were investigated and found to be in compliance.
Report Facts
Sample Size: 8
Inspection Report
Original Licensing
Deficiencies: 0
Mar 23, 2021
Visit Reason
Inspection for licensure of new or renovated long term care facilities.
Findings
No deficiencies were noted during the inspection of Area 303. The area was deep cleaned, repainted, and repaired where applicable to be used for resident rooms. The area may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.
Inspection Report
Routine
Census: 38
Deficiencies: 0
Dec 4, 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
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