Inspection Reports for
Foothill Acres Rehabilitation & Nursing Center
39 East Mountain Road, Hillsborough, NJ, 08844
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 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
20
15
10
5
0
Occupancy
Latest occupancy rate
18% occupied
Based on a March 2025 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Deficiencies: 2
Date: Mar 7, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to provide one resident (R68) with the opportunity to review her care plan and medication list during a quarterly care conference, and failure to provide timely incontinence care, placing the resident at risk for skin breakdown and infections.
Complaint Details
The complaint investigation focused on resident R68's care plan involvement and timely incontinence care. The complaint was substantiated with findings that the resident was not adequately involved in care planning and was left in wet briefs for extended periods, missing activities and appointments.
Findings
The facility failed to ensure that resident R68 was involved in her care planning and medication review during the quarterly care conference, resulting in an outdated care plan. Additionally, the facility failed to provide timely incontinence care to R68, causing her to remain in a wet brief for extended periods, increasing risk for skin issues and missed activities.
Deficiencies (2)
Failure to provide resident R68 the opportunity to review and discuss her care plan and medication list during the quarterly care conference, resulting in an outdated care plan.
Failure to provide timely incontinence care to resident R68, resulting in prolonged exposure to wet briefs and increased risk for skin breakdown and infections.
Report Facts
Residents reviewed: 34
Residents reviewed for ADL: 5
BIMS score: 15
Medication duration: 3
Skin redness size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Nurse 3 | Unit Nurse | Interviewed regarding care conference and care plan review for resident R68; acknowledged failure to update care plan. |
| CNA5 | Certified Nursing Assistant | Observed responding to resident R68's call light and providing incontinence care. |
| CNA6 | Certified Nursing Assistant | Observed assisting with resident R68's care and responding to call light. |
| CNA4 | Certified Nursing Assistant | Interviewed regarding resident R68's missed incontinence care and missed doctor's appointment. |
| CNA1 | Certified Nursing Assistant | Observed assisting with resident R68's care. |
| LPN6 | Licensed Practical Nurse | Applied barrier cream and patch to resident R68's skin to prevent further skin breakdown. |
Inspection Report
Routine
Census: 36
Deficiencies: 16
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, resident safety, care planning, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to ensure safe medication self-administration, call bell accessibility, accurate resident assessments, comprehensive care plans, proper insulin administration, timely incontinence care, pain management, bed rail use assessments and consents, secure medication return procedures, proper portion sizes in dining, expired milk storage, dumpster sanitation, infection control practices, and psychotropic medication monitoring.
Deficiencies (16)
Failure to ensure residents self-administer medications safely without proper orders or assessments.
Call bell was not accessible to a resident, placing him at risk of injury or distress.
Inaccurate coding of Minimum Data Set (MDS) assessments for two residents.
Failure to develop comprehensive, measurable care plans for glucose monitoring and behavior management.
Failure to provide resident opportunity to review care plan and medication list during quarterly care conference.
Licensed Practical Nurse failed to prime insulin pen prior to administration, risking incorrect dosing.
Resident did not receive timely incontinence care, resulting in prolonged exposure to wet briefs and skin irritation.
Failure to monitor pain management efficacy and document non-pharmacological interventions for pain.
Failure to assess need, safety, and obtain informed consent for bed rail use for multiple residents.
Medications for return to pharmacy were not kept in a secure location and lacked proper inventory documentation.
Residents in second-floor dining room received inadequate portion sizes inconsistent with menu specifications.
Expired milk cartons were found in the dairy refrigerator prepared for resident use.
Dumpster lids were left open and trash was on the ground in the dumpster area, risking pest infestation.
Licensed Practical Nurse failed to don required PPE and perform hand hygiene during wound care for a resident on Enhanced Barrier Precautions.
Soiled utility room was unsanitary with trash and soiled laundry on the floor.
Failure to monitor psychotropic medication efficacy, lack of stop dates and rationale for PRN antianxiety medications beyond 14 days for multiple residents.
Report Facts
Residents observed: 36
Residents eating in second-floor dining room: 28
Portion size served: 2
Expired milk cartons: 9
Medication counts: 20
Residents sample size: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Failed to don PPE and perform hand hygiene during wound care for resident on Enhanced Barrier Precautions |
| Unit Nurse 3 | Unit Nurse | Reviewed care plans and acknowledged deficiencies in care plan updates and expectations for PPE use |
| Director of Nursing | Director of Nursing | Acknowledged missing assessments for bed rails and lack of psychotropic medication monitoring |
| Dietary Manager | Dietary Manager | Reported portion size issues and expired milk discovery |
| Regional Food Service Director | Regional Food Service Director | Observed expired milk and dumpster sanitation issues |
| Housekeeping Director | Housekeeping Director | Observed and corrected trash and laundry on floor in soiled utility room |
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ176706 at Foothill Acres Rehabilitation & Nursing Center.
Complaint Details
Complaint #NJ176706 was investigated and the facility was found to be in substantial compliance with regulatory requirements.
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.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00171019, NJ00172666, NJ00173080, and NJ00174033.
Complaint Details
The complaint investigation involved multiple complaint numbers and concluded that the facility was in compliance with regulatory requirements.
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.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failure to ensure a resident's use of oxygen therapy was addressed in the comprehensive care plan.
Failure to provide necessary ADL services to maintain good grooming and personal hygiene for a resident.
Failure to ensure respiratory care, including oxygen administration, was provided according to physician orders.
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.
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
Deficiencies: 3
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including respiratory care, activities of daily living (ADLs), and administration of oxygen therapy.
Findings
The facility failed to ensure a resident's use of supplemental oxygen was addressed in the comprehensive care plan and failed to administer oxygen at the ordered rate for one resident. Additionally, the facility failed to provide adequate grooming and personal hygiene care, specifically shaving, for another resident dependent on staff for ADLs.
Deficiencies (3)
Failed to ensure a resident's use of supplemental oxygen was addressed in the comprehensive care plan for 1 resident.
Failed to provide services to a resident unable to carry out activities of daily living, resulting in inadequate grooming and facial hair not being shaved.
Failed to administer oxygen at the rate ordered by the physician for 1 resident.
Report Facts
Residents reviewed for respiratory care: 3
Residents reviewed for ADLs: 1
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding oxygen therapy and physician orders | |
| Licensed Practical Nurse (LPN) #4 | Interviewed regarding oxygen therapy and physician orders | |
| Certified Nurse Aide (CNA) #5 | Interviewed regarding grooming and shaving care for Resident #328 | |
| Licensed Practical Nurse (LPN) #6 | Interviewed regarding grooming and shaving care for Resident #328 | |
| Unit Manager (UM) #7 | Interviewed regarding grooming and shaving care for Resident #328 | |
| Director of Nursing (DON) | Interviewed regarding expectations for ADL care and grooming | |
| Administrator | Interviewed regarding responsibilities for resident grooming and hygiene |
Inspection Report
Routine
Census: 132
Deficiencies: 0
Date: 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
Date: Nov 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ149553, NJ149680, and NJ149859.
Complaint Details
Complaint #: NJ149553, NJ149680, NJ149859. The facility was found to be in compliance 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 and with infection control regulations related to COVID-19.
Report Facts
Sample Size: 9
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: 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.
Complaint Details
Complaint Intake#: NJ146794. The complaint was substantiated as the facility failed to meet minimum staffing ratios on multiple shifts, affecting all residents.
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.
Deficiencies (1)
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
Date: 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
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Foothill Acres Rehabilitation & Nursing Center, summarizing the results of a regulatory survey completed on July 15, 2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Life Safety
Deficiencies: 3
Date: 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.
Deficiencies (3)
Facility failed to provide emergency lighting in the basement electrical room containing emergency generator transfer switches.
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.
Facility failed to certify that the emergency generator transfers power to the building within the required 10 seconds during monthly tests.
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
Date: 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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