Inspection Reports for Garden Terrace Nursing Home
361 Main Street, Chatham, NJ, 07928
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed some issues, including infection control problems, staffing shortages, incomplete care plans, medication errors, and failure to conduct required evacuation drills with proper notification. Inspectors cited infection control practices and emergency preparedness as recurring themes, with deficiencies related to gown use, hand hygiene, PPE use, and evacuation drills. A complaint investigation in February 2025 substantiated infection control and emergency preparedness deficiencies, while other complaints were not noted. The inspection history suggests some improvement over time, culminating in a clean report at the latest inspection.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30 residents
Based on a August 2021 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, 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 department's legal duties and responsibilities regarding privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's compliance with infection control and emergency preparedness standards.
Complaint Details
The complaint investigation found deficient infection control practices and failure to conduct required evacuation drills with proper notification to emergency management officials.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards, specifically failing to adhere to infection control practices including lack of proper gown use by nurses during treatments and inadequate signage for isolation precautions. Additionally, the facility failed to conduct an evacuation drill with proper notification to emergency management officials within the past 12 months.
Deficiencies (2)
Failure to adhere to infection control practices to prevent or reduce the spread of infection, including improper gown use by Registered Nurses during treatments and lack of signage for isolation precautions.
Failure to conduct at least one evacuation drill in the last 12 months with proper notification to State, county, and municipal emergency management officials.
Report Facts
Date survey completed: Feb 21, 2025
Date of revisit: Mar 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Named in infection control deficiency for not wearing gown during treatment | |
| Registered Nurse (RN) #2 | Named in infection control deficiency for not wearing gown during treatment | |
| Infection Preventionist (IP) | Interviewed regarding infection control practices and facility confusion about PPE use | |
| Administrator | Interviewed regarding emergency preparedness and evacuation drill deficiencies |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 6
Date: Aug 27, 2021
Visit Reason
Annual survey to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Findings
The facility was found non-compliant with staffing ratios on night shifts, failure to develop comprehensive care plans for residents, improper dietary services including incorrect diet consistency and transcription errors, inadequate infection control practices during treatment, incomplete employee health examinations within required timeframes, and inaccurate medication administration.
Deficiencies (6)
Failed to maintain required minimum direct care staff to resident ratios for night shift as mandated by New Jersey law.
Failed to develop person-centered comprehensive care plans for residents #1 and #5.
Failed to ensure resident received diet according to physician's order and failed to transcribe order to monthly physician's order for Resident #5.
Failed to ensure proper infection control practices during treatment observation for Resident #1, including improper glove use and hand hygiene.
Failed to ensure 3 of 4 recently hired employees received required physical examination within 30 days after nursing assessment.
Failed to accurately administer medication to Resident #3; administered whole tablet instead of prescribed half tablet.
Report Facts
Night shifts reviewed: 14
Night shifts with staffing deficiency: 3
Census: 30
Sample size: 10
New employees reviewed: 4
Employees non-compliant with physical exam timing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged staffing deficiencies and care plan issues; involved in infection control observation. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Acknowledged staffing deficiencies and involved in hiring process. |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed improperly administering medication and infection control deficiencies. |
| Certified Nursing Aide #1 | Certified Nursing Aide | New employee file reviewed for physical exam compliance. |
| Certified Nursing Aide #2 | Certified Nursing Aide | New employee file reviewed for physical exam compliance. |
| Certified Nursing Aide #3 | Certified Nursing Aide | New employee file reviewed for physical exam compliance. |
| Licensed Nursing Home Administrator/Social Worker | Licensed Nursing Home Administrator/Social Worker | Responsible for hiring process and acknowledged physical exam timing issues. |
Inspection Report
Abbreviated Survey
Census: 23
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 and CDC recommended practices related to COVID-19.
Findings
The facility was found not in compliance with infection control standards, specifically failing to ensure proper hand hygiene, proper use and storage of personal protective equipment (PPE), and adequate staff in-service training on PPE use and hand hygiene.
Deficiencies (3)
Failure to perform proper hand hygiene including wetting hands before applying soap and using clean towels to dry hands and close faucet.
Staff did not properly utilize personal protective equipment (PPE), including failure to wear masks outside the kitchen and improper storage of masks.
Staff were not properly in-serviced on the proper donning and doffing of PPE.
Report Facts
Sample size: 5
Hand Hygiene Competency date: Oct 7, 2020
Hand Hygiene Competency date: Oct 13, 2020
Inservice date: Aug 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper | Housekeeper | Observed performing improper hand hygiene and interviewed regarding hand hygiene practices |
| Chef | Kitchen Staff | Observed not wearing mask outside kitchen, storing mask improperly, and not in-serviced on PPE use |
| Director of Nursing | Director of Nursing (DON)/LNHA | Interviewed regarding proper hand hygiene and PPE use, confirmed deficiencies and in-service status |
| Dietary Aide | Dietary Aide (DA) | Interviewed regarding hand hygiene technique, had documented missed steps in hand hygiene competency |
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