Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
104% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
106 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 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 questions about the notice |
Inspection Report
Routine
Census: 106
Deficiencies: 15
Date: Aug 5, 2025
Visit Reason
Routine inspection of Forest Hills Center for Rehabilitation and Healing to assess compliance with regulatory requirements including residents' rights, environment, care, medication administration, infection control, staffing, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, maintain a clean and safe environment, provide timely incontinence care, ensure safe medication administration, maintain proper infection control practices, provide adequate staffing, and ensure dietary preferences and food temperatures met standards. Several specific deficiencies were documented with minimal harm potential.
Deficiencies (15)
Failure to treat residents with respect and dignity; staff and contractors entered resident rooms without knocking or announcing themselves.
Failure to maintain a clean, sanitary, and homelike environment including unclean vents, missing tiles, soiled privacy curtains, and inadequate linen supply.
Failure to provide timely incontinence care for dependent residents; saturated briefs observed.
Failure to provide a safe smoking environment; no ashtrays or fire extinguishers in designated smoking area.
Failure to secure urinary drainage bag in a privacy bag for infection control and dignity.
Failure to ensure residents with significant weight changes were addressed timely by the dietitian and weekly weights were documented as ordered.
Failure to store oxygen nasal cannula tubing in plastic bags when not in use to prevent infection.
Insufficient nursing staff to meet resident needs; CNA to resident ratio exceeded regulatory limits on multiple shifts.
Failure to administer medications according to physician orders and manufacturer instructions, including incorrect eye drop administration and crushing medications that should not be crushed.
Failure to properly dispose of medications; medication tablets were initially disposed in trash instead of drug disposal system.
Failure to provide food at safe and appetizing temperatures; residents reported receiving cold food due to delays and elevator issues.
Failure to consistently implement and follow residents' dietary preferences; multiple residents' trays missing ordered items.
Failure to maintain proper kitchen sanitation including uncovered opened food items without use-by labels, dirty equipment, and improper food temperature measurement.
Failure to keep dumpster and surrounding area free of garbage and debris.
Failure to follow proper hand hygiene practices by staff including inadequate handwashing technique and failure to change gloves between tasks.
Report Facts
Facility census: 106
Medication administration opportunities: 25
Medication administration errors: 6
Medication administration error rate: 24
CNA to resident ratio: 15
Weight: 86.7
Weight: 86
Weight: 84.7
Weight: 84.2
Weight: 84
Weight: 102.2
Towels: 180
Washcloths: 120
Missing CNAs: 1
Missing CNAs: 1
Missing CNAs: 4
Missing CNAs: 1
Missing CNAs: 1
Missing CNAs: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Involved in medication administration errors and improper medication disposal |
| RN #1 | Registered Nurse | Administered medications crushed that should not be crushed |
| Director of Maintenance and Housekeeping | Interviewed regarding cleanliness and maintenance issues | |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding multiple deficiencies and facility policies |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding deficiencies and facility policies |
| Infection Preventionist | IP/RN | Interviewed regarding infection control practices |
| Director of Housekeeping/Maintenance | DHK | Interviewed regarding linen supply and smoking area |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding linen shortages and hand hygiene |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding linen shortages and food temperature complaints |
| Regional Registered Dietitian | RD | Interviewed regarding nutritional assessments and weight documentation |
| Staffing Coordinator | Interviewed regarding CNA staffing levels | |
| Consultant Pharmacist | CP | Interviewed regarding medication crushing and regimen review |
| Food Service Director | FSD | Interviewed regarding kitchen sanitation and food service issues |
| Assistant Director of Nursing | ADON | Interviewed regarding incontinence care policy and hand hygiene education |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Observed and interviewed regarding incontinence care and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted based on a complaint to determine if the facility provided timely incontinence care to dependent residents on the 4th-floor Nursing Unit.
Complaint Details
The complaint investigation found that incontinence care was not provided in a timely manner to 3 of 4 residents observed on the 4th-floor Nursing Unit. The Assistant Director of Nursing and Acting DON confirmed that best practice is to provide incontinence care every 2-3 hours, but staff interviews revealed uncertainty about the facility policy. The CNAs responsible were unavailable for interviews.
Findings
The facility failed to ensure timely incontinence care for 3 of 4 residents observed, with saturated briefs and soiled bedding noted. Interviews revealed uncertainty among staff about the facility's incontinence care policy, though best practice was acknowledged as care every two hours.
Deficiencies (1)
Failure to provide timely incontinence care to dependent residents, resulting in saturated briefs and soiled bedding for residents #47, #63, and #64.
Report Facts
Residents observed for incontinence care: 4
Residents with deficient incontinence care: 3
BIMS scores: 9
BIMS scores: 0
BIMS scores: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | Accompanied surveyor during observations and confirmed saturated briefs and soiled bedding | |
| Assistant Director of Nursing | Interviewed about facility policy on incontinence care and confirmed best practice | |
| MDS Coordinator/Acting Director of Nursing | Discussed observations and confirmed incontinence care should be provided every 2-3 hours |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, nutritional status, diet consistency, dialysis care, physician order signatures, medication administration, and resident record keeping.
Findings
The facility was found deficient in multiple areas including failure to timely transmit Minimum Data Set assessments, incomplete care plans for oxygen and BIPAP use, failure to assess significant weight changes, improper preparation and serving of pureed diets, failure to adjust medication administration times for dialysis patients, lack of physician signatures on monthly orders, failure to act on consultant pharmacist recommendations, and inadequate documentation of resident status when on pass.
Deficiencies (8)
Failure to electronically transmit Minimum Data Set (MDS) assessments within required 14 days for 5 of 22 residents.
Failure to develop a comprehensive care plan for oxygen and BIPAP use for Resident #12.
Failure to assess significant weight loss for 2 of 3 residents reviewed for nutritional status (Residents #73 and #58).
Failure to provide prescribed pureed diet consistency; pureed mashed potatoes served with chunks instead of smooth pureed food for 4 residents, resulting in immediate jeopardy.
Failure to adjust medication administration times to accommodate dialysis schedule and document accurately for Resident #22.
Failure to ensure physicians signed and dated monthly physician orders for 20 of 22 residents reviewed.
Failure to act timely on Consultant Pharmacist recommendations regarding medication administration times for Resident #22.
Failure to accurately document resident status when resident left facility on pass (Resident #154).
Report Facts
Residents reviewed for MDS transmission: 22
Residents reviewed for care plan: 22
Residents reviewed for nutritional status: 3
Residents affected by pureed diet deficiency: 4
Residents reviewed for dialysis medication timing: 1
Residents reviewed for physician order signatures: 22
Residents reviewed for consultant pharmacist follow-up: 21
Residents reviewed for documentation of pass status: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan, medication timing, physician order signatures, and resident documentation |
| Registered Nurse/MDS Coordinator | RN/MDS Coordinator | Interviewed regarding MDS transmission delays |
| Licensed Practical Nurse | LPN | Interviewed regarding care plan responsibilities and medication administration |
| Certified Nursing Assistant | CNA | Interviewed regarding feeding residents and weight measurements |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication timing recommendations |
| Dietary Director | Director of Dietary | Interviewed regarding pureed diet preparation and meal ticket discrepancies |
| Speech Language Pathologist | Speech Language Pathologist | Interviewed regarding risks of improper pureed diet consistency |
| Social Services Director | Social Services Director | Interviewed regarding resident pass and documentation |
Inspection Report
Annual Inspection
Census: 108
Capacity: 120
Deficiencies: 20
Date: Dec 12, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities, including complaint investigations.
Complaint Details
Complaint numbers NJ00168941, NJ00164363, NJ00165457 were investigated during this survey. Immediate Jeopardy was identified related to food consistency on 12/4/23 and removed on 12/5/23.
Findings
Deficiencies were cited related to food consistency posing aspiration risk, late resident assessment transmissions, failure to develop comprehensive care plans, failure to assess weight changes, failure to provide proper supervision and diet consistency, dialysis medication timing issues, unsigned physician orders, inaccurate resident records, staffing shortages, and multiple life safety code violations including fire door latching, fire alarm testing, sprinkler system maintenance, electrical safety, elevator inspections, and oxygen cylinder storage.
Deficiencies (20)
Facility served pureed mashed potatoes with chunks instead of smooth consistency, risking aspiration and choking.
Failed to electronically transmit Minimum Data Set (MDS) assessments within 14 days for 5 of 22 residents.
Failed to develop and implement a comprehensive person-centered care plan for a resident.
Failed to assess weight changes for 2 of 3 residents reviewed, not contributing to harm.
Failed to provide adequate supervision and proper diet consistency for residents on pureed diets.
Failed to adjust medication administration times to accommodate dialysis schedules for one resident.
Failed to ensure physicians signed and dated monthly orders for multiple residents.
Failed to accurately document resident disposition after leaving facility on pass.
Failed to ensure 13 of 15 stairwell exit doors latched properly to maintain 1.5 hour fire resistance rating.
Failed to maintain fire barrier with 1-hour fire resistance rating due to missing fire-rated material on steel beams in 4 areas.
Failed to inspect and maintain fire alarm system semi-annually and conduct smoke detector sensitivity testing.
Failed to maintain sprinkler system including missing quarterly inspections, pipe corrosion, and needed repairs.
Failed to ensure electrical equipment near water had ground-fault circuit interrupter (GFCI) outlets.
Failed to ensure annual elevator inspections were current; last inspection over 3 years overdue.
Failed to ensure fire doors were inspected annually by qualified personnel.
Blocked access to electrical panels with water bottles, preventing quick disconnection of power.
Failed to functionally test non-hospital grade electrical receptacles annually for grounding, polarity, and blade tension.
Failed to ensure emergency generator annunciator panel was located in an area with 24-hour surveillance.
Failed to install remote manual stop station for diesel generator and certify generator transfer time within 10 seconds.
Failed to properly store portable oxygen cylinders to prevent tipping, rupture, and damage.
Report Facts
Census: 108
Total Capacity: 120
Sample Size: 28
Deficient CNA staffing shifts: 6
Deficient CNA staffing shifts total: 14
Residents with unsigned physician orders: 20
Oxygen cylinders improperly stored: 14
Fire door sets failing latch: 13
Elevators overdue inspection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Named in multiple fire safety and maintenance deficiencies and corrective actions. |
| Director of Nursing | Director of Nursing | Named in medication timing, physician orders, and documentation deficiencies. |
| Administrator | Facility Administrator | Named in oversight and corrective action discussions. |
| Registered Nurse/MDS Coordinator | RN/MDS Coordinator | Named in MDS transmission deficiency. |
| Certified Nursing Assistant #1 | CNA | Named in diet consistency and supervision deficiencies. |
| Certified Nursing Assistant #2 | CNA | Named in diet consistency and supervision deficiencies. |
| Certified Nursing Assistant #3 | CNA | Named in diet consistency and supervision deficiencies. |
| Director of Dietary | Dietary Director | Named in diet consistency deficiency and corrective actions. |
| Speech Language Pathologist | SLP | Named in diet consistency and aspiration risk findings. |
| Licensed Practical Nurse | LPN | Named in care plan and weight assessment deficiencies. |
| Registered Dietitian | RD | Named in weight assessment deficiencies. |
| Licensed Practical Nurse assigned to Resident #12 | LPN | Named in care plan deficiency. |
| Food Service Worker | FSW | Named in food preparation deficiency. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ165490 and NJ168677.
Complaint Details
Complaint numbers NJ165490 and NJ168677 were investigated and found to be without deficiencies.
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: 4
Inspection Report
Deficiencies: 2
Date: May 10, 2023
Visit Reason
The inspection was conducted to investigate the facility's compliance with reporting and documentation requirements, including timely reporting of suspected abuse and consistent documentation of Activities of Daily Living (ADL) care provided to residents.
Findings
The facility failed to immediately investigate and report an injury of unknown origin to the New Jersey Department of Health for one resident. Additionally, the facility staff failed to consistently document ADL care provided to two residents according to facility policy and protocol.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or injury of unknown origin to proper authorities.
Failure to consistently document Activities of Daily Living (ADL) care provided to residents according to facility policy and protocol.
Report Facts
Residents reviewed for incidents and accidents: 3
Residents reviewed for documentation: 4
Dates with missing ADL documentation for Resident #1: 34
Dates with missing ADL documentation for Resident #2: Multiple shifts in April and May 2023 (exact count not specified)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to investigate and report injury |
| RN #2 | Registered Nurse | Documented transfer of resident to hospital |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to report injury and documentation issues |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding failure to report injury and documentation issues |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding ADL documentation expectations |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding ADL documentation practices |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: May 10, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ 162381, NJ 161269, and NJ 157892 to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
The complaint investigation involved three complaint numbers (NJ 162381, NJ 161269, NJ 157892). The facility failed to report and investigate an injury of unknown origin for Resident #3 and failed to properly document ADL care for Residents #1 and #2. The deficiencies were substantiated as evidenced by interviews, record reviews, and policy assessments.
Findings
The facility was found not in compliance due to failure to immediately investigate and report an injury of unknown origin for one resident, and failure to consistently document Activities of Daily Living (ADL) status and care provided for two residents. Deficiencies involved inadequate reporting of alleged violations and incomplete medical record documentation.
Deficiencies (2)
Failure to immediately investigate and report an injury of unknown origin for Resident #3 as required by facility policy and state law.
Failure to consistently document Activities of Daily Living (ADL) status and care provided to residents #1 and #2 according to facility policy and protocol.
Report Facts
Census: 94
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in the deficiency for failure to investigate and report injury of unknown origin for Resident #3. |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to investigate and report injury; involved in corrective action and policy review. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding failure to report injury; involved in corrective action and policy review. |
| LPN #1 | Licensed Practical Nurse | Interviewed about documentation expectations for ADL care. |
| CNA #1 | Certified Nursing Assistant | Interviewed about documentation responsibilities and use of Point of Care system. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00154021, NJ00154481, NJ00157397, and NJ00157417.
Complaint Details
The survey was complaint-driven with multiple complaint numbers cited. The facility was found compliant with no deficiencies noted.
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
Routine
Deficiencies: 4
Date: Jul 27, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, physician order documentation, medical record maintenance, infection prevention and control practices, and proper pronouncement of deceased residents in the nursing facility.
Findings
The facility failed to ensure that a Registered Nurse assessed and pronounced a deceased resident, physicians did not sign and date monthly orders for several residents, medical records lacked complete physician progress notes, and infection control practices regarding PPE use on the observation unit were not properly followed.
Deficiencies (4)
Failure to ensure that a Registered Nurse assessed and pronounced a deceased resident in accordance with nursing standards; death was pronounced by a Licensed Practical Nurse instead.
Physicians failed to sign and date monthly physician's orders for 4 of 18 residents reviewed and failed to accurately assess and evaluate one resident.
Failure to maintain complete, accurate, and readily accessible medical records, specifically missing physician progress notes for one resident.
Failure to practice appropriate use of personal protective equipment (PPE) in accordance with CDC guidelines on the observation unit, including not wearing gowns when required.
Report Facts
Residents reviewed: 18
Residents reviewed: 23
Residents reviewed: 21
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged that an RN or physician should have assessed the deceased resident; discussed physician order signing requirements |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Completed Incident/Accident Report for Resident #61 fall |
| Physician | Physician | Failed to sign monthly orders and omitted documentation of resident's injury |
| Licensed Practical Nurse | Licensed Practical Nurse | Pronounced deceased resident's death and prepared medications without proper PPE |
| Housekeeper | Housekeeper | Observed not wearing gowns as required on observation unit |
| Occupational Therapist | Occupational Therapist | Observed not wearing gown as required on observation unit |
| Infection Preventionist | Infection Preventionist Registered Nurse | Provided CDC training certificate and acknowledged misinterpretation of PPE guidelines |
| Administrator | Administrator | Discussed CDC directive on gown use and facility policy |
Inspection Report
Renewal
Census: 73
Deficiencies: 1
Date: Jul 27, 2021
Visit Reason
The survey was conducted as a re-certification survey to assess compliance with New Jersey staffing requirements and licensure standards for long term care facilities.
Findings
The facility was found not in compliance with the New Jersey minimum direct care staff-to-resident ratios on several dates, particularly on weekend shifts and the 7:00 AM - 3:00 PM shift. The facility had deficient CNA staffing levels below the state-mandated minimum ratios but was actively recruiting and implementing corrective actions to address staffing shortages.
Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 71
CNA staffing ratio: 8.88
CNA staffing ratio: 6.45
CNA staffing ratio: 8.88
Census: 73
CNA staffing ratio: 8.11
CNA staffing ratio: 6.64
CNA staffing ratio: 9.13
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Jul 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146068 and NJ141741.
Complaint Details
Complaint numbers NJ146068 and NJ141741 were investigated and found to be unsubstantiated as the facility was in compliance.
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: 7
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Dec 14, 2020
Visit Reason
The inspection was conducted based on complaints #NJ00133486 and #NJ00134349.
Complaint Details
Complaint #NJ00133486 and #NJ00134349 were investigated and the facility was found compliant.
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: 6
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