Inspection Reports for Gardens At Monroe Healthcare And Rehabilitation, T
189 Applegarth Road, Monroe Township, NJ, 08831
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a mixed record, with the April 9, 2025, routine survey citing deficiencies related to resident assessments, pharmacy services, infection control, and life safety code compliance. Prior reports noted issues with life safety code requirements, such as fire safety equipment and door mechanisms, as well as staffing documentation and construction approvals. Complaint investigations conducted in 2021 were unsubstantiated, indicating no confirmed violations from those complaints. The facility’s record shows some improvement in infection control compliance over time, though recent deficiencies suggest ongoing challenges in care documentation and safety standards.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
75% occupied
Based on a April 2025 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 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: 102
Capacity: 136
Deficiencies: 5
Date: Apr 9, 2025
Visit Reason
The inspection was a standard survey conducted from 04/03/2025 to 04/09/2025 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including accuracy of resident assessments, professional standards for care plans, pharmacy services, infection control, and life safety code violations. Deficiencies were identified in coding discharge locations, RN assessments, medication administration, infection prevention, and fire safety.
Deficiencies (5)
Failure to accurately code a resident's Minimum Data Set (MDS) discharge location.
Failure to ensure Registered Nurse (RN) documented resident assessments after incidents.
Failure to provide pharmaceutical services in accordance with professional standards, including medication administration errors and documentation issues.
Failure to establish and maintain an infection prevention and control program, including improper use of PPE and mask wearing.
Life Safety Code deficiencies including failure to maintain integrity of smoke barrier partitions and improper function of bathroom exhaust systems.
Report Facts
Census: 102
Total licensed beds: 136
Sample size: 24
Deficiency corrections completion date: May 16, 2025
Date of revisit: May 22, 2025
Inspection Report
Routine
Census: 90
Deficiencies: 0
Date: Jul 26, 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 the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample residents: 5
Inspection Report
Routine
Census: 66
Deficiencies: 0
Date: Jan 25, 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 the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139415 and NJ134377.
Complaint Details
Complaint numbers NJ139415 and NJ134377 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: 4
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 2
Date: May 11, 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 failure to verify multi-state registry status for a newly hired Certified Nursing Aide with Reciprocity qualification and failure to notify the New Jersey Department of Health and other authorities for inspection and approval of newly constructed areas prior to occupancy.
Deficiencies (2)
Facility failed to attempt to verify multi-state registry information for a newly hired Certified Nursing Aide with Reciprocity qualification status.
Facility failed to notify the New Jersey Department of Health, Certificate of Need and Licensing Division (CN&L) and/or Department of Community Affairs (DCA) for inspection and approval of newly constructed area prior to occupancy.
Report Facts
Sample size: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding verification of Certified Nursing Aide registry status and background checks. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding construction completion and notification to regulatory authorities. |
Inspection Report
Life Safety
Deficiencies: 4
Date: May 10, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 5/10/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 EXISTING Health Care Occupancies.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including exit discharge door locking mechanisms not functioning properly, lack of fire sprinkler protection in an employee bathroom, inadequate maintenance and accessibility of portable fire extinguishers, and smoke barrier doors with excessive gaps allowing smoke transfer.
Deficiencies (4)
Exit discharge doors on Nassau and Princeton units did not open within 15 seconds due to improper locking mechanisms not meeting delayed egress locking requirements.
Failure to provide automatic fire sprinkler protection in the employee bathroom on the Princeton unit.
Failure to perform and document monthly visual inspections of fire extinguishers, one extinguisher blocked and another with pressure needle in the red discharge zone.
Smoke barrier doors on Nassau unit had gaps greater than 3/4 inch from floor to bottom of door, compromising smoke resistance.
Report Facts
Exit discharge doors tested: 10
Fire extinguishers observed: 20
Fire extinguishers with deficiencies: 2
Smoke barrier doors with excessive gap: 3
Gap measurements: 1.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during building tour and exit door testing | |
| Licensed Nursing Home Administrator | Notified of deficiencies during inspection | |
| Assistant Administrator | Present during smoke barrier door observations |
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Mar 30, 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.
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: 7
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
Date: Nov 17, 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 and recommended practices for COVID-19.
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: 3
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