Inspection Reports for Foothill Acres Rehabilitation & Nursing Center
39 East Mountain Road, NJ, 08844
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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 NJDHSS's legal duties and responsibilities.
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: 155
Deficiencies: 0
Sep 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ176706 at Foothill Acres Rehabilitation & Nursing Center.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B for long term care facilities and in compliance with the New Jersey Administrative Code, Chapter 8:39 standards for licensure of long term care facilities.
Complaint Details
Complaint #NJ176706 was investigated and the facility was found to be in substantial compliance with regulatory requirements.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00171019, NJ00172666, NJ00173080, and NJ00174033.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Complaint Details
The complaint investigation involved multiple complaint numbers and concluded that the facility was in compliance with regulatory requirements.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 5
Feb 23, 2023
Visit Reason
Recertification survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including comprehensive care planning, ADL care, respiratory care, staffing ratios, and life safety code compliance. Deficiencies were cited related to failure to address oxygen therapy in care plans, inadequate grooming and hygiene assistance, improper administration of respiratory care, insufficient CNA staffing, and failure to inspect all fire-rated doors annually.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a resident's use of oxygen therapy was addressed in the comprehensive care plan. | SS=D |
| Failure to provide necessary ADL services to maintain good grooming and personal hygiene for a resident. | SS=D |
| Failure to ensure respiratory care, including oxygen administration, was provided according to physician orders. | SS=D |
| Failure to meet mandatory staffing ratios for certified nursing assistants on multiple day shifts. | — |
| Failure to inspect all fire-rated doors annually as required by NFPA 101 Life Safety Code and NFPA 80 standards. | SS=F |
Report Facts
Census: 119
Sample Size: 24
Deficient CNA staffing day shifts: 3
Required CNA staffing: 16
Actual CNA staffing: 15
Required CNA staffing: 15
Actual CNA staffing: 14
Required CNA staffing: 16
Actual CNA staffing: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding oxygen therapy administration and care plan compliance. |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding oxygen therapy and care plan inclusion. |
| Certified Nurse Aide #5 | CNA | Interviewed regarding grooming and shaving care for Resident #328. |
| Licensed Practical Nurse #6 | LPN | Interviewed regarding ADL care and shaving for Resident #328. |
| Unit Manager #7 | Unit Manager | Interviewed regarding monitoring of ADL care and shaving for Resident #328. |
| Director of Nursing | DON | Interviewed regarding ADL care, grooming, and respiratory care compliance. |
| Administrator | Administrator | Interviewed regarding staffing ratios, ADL care, and facility compliance expectations. |
| Maintenance Director | Maintenance Director | Interviewed regarding failure to perform annual inspection of fire-rated doors. |
Inspection Report
Routine
Census: 132
Deficiencies: 0
Dec 5, 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: 6
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Nov 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ149553, NJ149680, and NJ149859.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and with infection control regulations related to COVID-19.
Complaint Details
Complaint #: NJ149553, NJ149680, NJ149859. The facility was found to be in compliance based on this complaint survey.
Report Facts
Sample Size: 9
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Oct 17, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ147763 and NJ146794 regarding compliance with staffing ratios and other regulatory standards.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:39, specifically failing to meet minimum staffing ratios for 10 of 42 shifts reviewed, potentially affecting all residents. The facility submitted a plan of correction outlining recruitment and retention efforts to address staffing shortages.
Complaint Details
Complaint Intake#: NJ146794. The complaint was substantiated as the facility failed to meet minimum staffing ratios on multiple shifts, affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 10 of 42 shifts reviewed, violating mandatory access to care requirements. |
Report Facts
Census: 121
Shifts reviewed: 42
Shifts not meeting staffing ratios: 10
Staff to resident ratios: 12
Staff to resident ratios: 13
Staff to resident ratios: 15
Staff to resident ratios: 14
Staff to resident ratios: 21
Staff to resident ratios: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 10/16/2021 regarding staffing ratio compliance and recruitment efforts. |
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 0
Jul 15, 2021
Visit Reason
The inspection was conducted as a standard annual survey 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 for long term care facilities.
Report Facts
Sample size: 27
Inspection Report
Life Safety
Deficiencies: 3
Jul 13, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/12/21 and 07/13/21 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting in the mechanical/electric room, failure of room doors to close and latch properly to confine fire and smoke, and lack of documented certification that the emergency generator transfers power within 10 seconds. Corrective actions were planned and completed for these deficiencies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide emergency lighting in the basement electrical room containing emergency generator transfer switches. | SS=D |
| Facility failed to ensure that room doors close and latch properly to confine fire and smoke, specifically in unoccupied resident room 427 used for storage. | SS=D |
| Facility failed to certify that the emergency generator transfers power to the building within the required 10 seconds during monthly tests. | SS=D |
Report Facts
Deficiencies cited: 3
Date of survey: Jul 13, 2021
Completion dates: Aug 5, 2021
Completion dates: Jul 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies; verified emergency lighting deficiency and confirmed lack of generator transfer time documentation. | |
| Administrator | Informed of findings during Life Safety Code survey exit conference. |
Inspection Report
Routine
Census: 107
Deficiencies: 0
Dec 14, 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: 11
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