Inspection Reports for Homestead Rehabilitation & Health Care Center
129 Morris Turnpike, NJ, 07860
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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 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
Complaint Investigation
Census: 54
Deficiencies: 0
Jul 29, 2024
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Jun 26, 2024
Visit Reason
The inspection was conducted based on complaints NJ #00174902, NJ00174912, and NJ00174921 regarding facility compliance with safety, staffing, and environmental standards.
Findings
The facility was found not in substantial compliance due to failure to maintain safe and comfortable room temperatures across multiple nursing units, failure to meet required staffing ratios on numerous shifts, and failure to timely report HVAC system interruptions to the New Jersey Department of Health. Corrective actions and plans of correction were documented.
Complaint Details
The complaint investigation was substantiated, identifying multiple deficiencies related to environmental safety, staffing shortages, and failure to report critical HVAC system failures.
Severity Breakdown
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain safe and comfortable room temperature levels in 2 of 3 nursing units, with temperatures exceeding the required range of 71 to 81 degrees Fahrenheit. | SS=E |
| Failure to meet required minimum staff-to-resident ratios for certified nursing assistants on 19 of 21 day shifts and deficient total staff on 1 of 21 overnight shifts. | — |
| Failure to notify the New Jersey Department of Health immediately of HVAC system interruption lasting more than three hours. | — |
Report Facts
CNA staffing deficiency: 19
Overnight staffing deficiency: 1
Room temperature: 86.9
Room temperature: 83.5
Room temperature: 84.9
Room temperature: 83.3
Room temperature: 82.4
Inspection Report
Re-Inspection
Census: 61
Capacity: 128
Deficiencies: 29
Mar 12, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to resident rights, professional standards of care, pressure ulcer care, accident hazards, pharmacy services, medication error rates, medication storage, food consistency, kitchen sanitation, infection control, staffing ratios, physician documentation, and multiple life safety code violations including building construction, fire safety, sprinkler system, fire alarm, electrical safety, and HVAC systems.
Complaint Details
Complaint #s: NJ00171520, NJ00170797, NJ00169688, NJ00169710. Complaint investigations were completed during the survey.
Severity Breakdown
SS=F: 8
SS=E: 7
SS=D: 6
SS=G: 1
: 3
Deficiencies (29)
| Description | Severity |
|---|---|
| Failure to maintain resident dignity during feeding assistance; staff were observed standing while feeding residents instead of sitting at eye level. | SS=D |
| Failure to follow professional standards in medication documentation and administration for multiple residents. | SS=D |
| Failure to provide care consistent with professional standards for pressure ulcer prevention and treatment. | SS=D |
| Failure to investigate and prevent falls adequately; care plans not updated appropriately. | SS=G |
| Failure to properly store and maintain oxygen equipment and tubing; oxygen flow rates not consistently checked. | SS=D |
| Failure to maintain medication refrigeration temperature within required range. | SS=D |
| Failure to prepare food in proper consistency for residents on modified diets. | SS=D |
| Failure to maintain proper kitchen sanitation, including labeling, cleaning, and storage of food items. | SS=F |
| Failure to follow infection control practices during medication administration and disposal of sharps containers. | SS=E |
| Infection preventionist did not have required specialized training and qualifications. | SS=F |
| Failure to maintain required minimum direct care staff-to-resident ratios. | — |
| Failure to ensure residents were evaluated by a physician within 48 hours of admission; physician progress notes incomplete or missing. | — |
| Building construction type was Type II unprotected construction with 4 stories, exceeding the maximum allowed 3 stories for this construction type. | SS=F |
| Egress doors had locking devices that could restrict emergency exit; delayed egress doors lacked required signage. | SS=E |
| Exit discharge had a wooden ramp with overgrown vegetation and slippery surface, not providing a firm level walking surface. | SS=E |
| Emergency illumination in day rooms was controlled by wall switches and could be turned off, failing to provide continuous or automatic emergency lighting. | SS=E |
| Fire-rated doors to hazardous areas were missing or not labeled and did not close or latch properly. | SS=E |
| Kitchen exhaust hood grease baffles were improperly installed; fire suppression system inspection was overdue and incomplete. | SS=F |
| Fire alarm system inspections were not performed semi-annually; smoke detector sensitivity testing was not completed as required. | SS=F |
| Sprinkler system did not provide coverage in an interior vestibule; fire pump was not maintained or tested weekly as required. | SS=D |
| Fire extinguishers were missing monthly inspection tags and some had outdated inspection tags. | SS=F |
| Food consistency for residents on mechanical soft diets was not prepared properly; whole fish sticks and whole vegetables served instead of minced or chopped consistency. | SS=D |
| Milk and condiment containers in kitchen refrigerator were not labeled with open or use by dates; ovens were dirty; spice containers were not properly dated; kitchen and dry storage areas were dirty and disorganized; dietary staff did not fully cover hair; walk-in refrigerator and freezer were dirty. | SS=F |
| Hand hygiene breaches observed during medication administration; contaminated saline solution handled without hand hygiene; sharps containers overflowing and not sealed in soiled utility rooms. | SS=E |
| Facility failed to maintain required minimum direct care staff-to-resident ratios for multiple shifts. | — |
| Physicians failed to complete required resident evaluations and progress notes within required timeframes; many notes left in draft status. | — |
| Electrical panels in resident accessible areas were unlocked and unguarded against accidental contact. | SS=E |
| Oxygen cylinders were stored unsecured and unprotected against tipping and damage. | SS=E |
| Plan of Correction for fall incident was incomplete; care plan not updated with appropriate interventions after fall. | SS=D |
Report Facts
Census: 61
Total Capacity: 128
Medication doses observed: 26
Medication errors observed: 3
Medication error rate: 11.54
Deficient CNA staffing shifts: 7
Deficient CNA staffing shifts: 5
Missing fire extinguisher inspections: 3
Fire extinguishers with outdated inspection tags: 1
Fire extinguishers with March inspection only: 12
Missing ceiling tiles: 14
Open electrical panels: 3
Portable oxygen cylinders unsecured: 1
Fire pump inspection overdue: 4
Fire alarm inspections overdue: 10
Fire alarm inspections documented: 2
Fire alarm smoke detector sensitivity testing: 0
Grease baffles improperly installed: 2
Missing or damaged fire doors: 3
Missing or damaged ceiling tiles: 9
Fire extinguishers missing monthly inspection: 3
Fire extinguishers with outdated inspection tags: 1
Fire extinguishers inspected only in March: 12
Milk and condiment containers unlabeled: 4
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 14
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Missing or dirty kitchen equipment: 1
Hand hygiene breaches: 2
Overflowing sharps containers: 2
Physician progress notes missing: 15
Open electrical panels: 3
Deficient CNA staffing shifts: 7
Deficient CNA staffing shifts: 5
Building stories: 4
Missing fire doors: 3
Grease baffles improperly installed: 2
Fire alarm inspections overdue: 10
Fire pump maintenance overdue: 4
Fire extinguishers missing monthly inspection: 3
Fire extinguishers with outdated inspection tags: 1
Food consistency errors: 2
Kitchen sanitation deficiencies: 14
Hand hygiene breaches: 2
Overflowing sharps containers: 2
Physician progress notes missing: 15
Open electrical panels: 3
Unsecured oxygen cylinders: 1
Missing fire doors: 3
Missing or damaged ceiling tiles: 14
Missing or damaged ceiling tiles: 9
Missing or damaged ceiling tiles: 7
Missing or damaged ceiling tiles: 5
Missing or damaged ceiling tiles: 2
Missing or damaged ceiling tiles: 2
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Missing or damaged ceiling tiles: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and hand hygiene deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in wound care treatment and hand hygiene deficiencies |
| RN #1 | Registered Nurse | Named in medication documentation and oxygen equipment deficiencies |
| CNA #1 | Certified Nurse Aide | Named in feeding assistance and diet consistency deficiencies |
| CNA #3 | Certified Nurse Aide | Named in feeding assistance and diet consistency deficiencies |
| Maintenance Staff Member | Named in multiple life safety code deficiencies including fire pump, electrical panels, and building construction | |
| Physician #1 | Named in physician progress notes deficiencies | |
| Physician #2 | Named in physician progress notes deficiencies | |
| DON | Director of Nursing | Named in staffing and physician documentation deficiencies |
| Administrator | Licensed Nursing Home Administrator | Named in physician documentation and fall investigation deficiencies |
| Environmental Service Consultant | Named in multiple life safety code and kitchen sanitation deficiencies | |
| Housekeeping Director | Named in sharps container and kitchen sanitation deficiencies | |
| Dietitian | Named in diet consistency and kitchen sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Feb 27, 2024
Visit Reason
The inspection was conducted based on a complaint survey (Complaint # NJ00168765) to determine compliance with staffing ratio requirements mandated by the state of New Jersey.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to maintain the required minimum certified nursing assistant (CNA) staffing ratios on 28 of 28 day shifts reviewed. The facility submitted a plan of correction addressing CNA staffing shortages and recruitment efforts.
Complaint Details
Complaint # NJ00168765 was substantiated, identifying deficient CNA staffing on all 28 day shifts reviewed during the survey period.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 28 of 28 day shifts. |
Report Facts
CNA staffing deficiency days: 28
Census: 63
Sample size: 4
Required CNAs: 8
Actual CNAs: 4
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Sep 22, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers from 09/20/2023 to 09/22/2023.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staffing ratios for Certified Nursing Assistants (CNAs) on multiple day shifts across several periods in 2023, potentially affecting all residents. The facility submitted a plan of correction including CNA training, recruitment efforts, and monitoring programs.
Complaint Details
Complaint numbers NJ00160554, NJ00166197, NJ00167409, NJ00160905, and NJ00160955 were investigated. The facility was found to be out of compliance with staffing requirements but was in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 60 of 63 day shifts. |
Report Facts
Survey Census: 66
Sample Size: 8
Deficient CNA staffing day shifts: 60
Staffing periods reviewed: 9
Inspection Report
Life Safety
Deficiencies: 0
Sep 22, 2023
Visit Reason
A Life Safety Code Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Health Department from 09/20/23 to 09/22/23.
Findings
The facility was found to be in compliance with the requirements of 42 CFR 483.90. No deficiencies were issued related to complaint NJ00166904.
Complaint Details
Complaint NJ00166904 was investigated and no deficiencies were found.
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 1
May 27, 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 and CDC recommended practices related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations and failed to meet minimum staffing ratios for certified nursing assistants on 14 of 14 day shifts and 2 of 14 evening shifts reviewed, potentially affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts and 2 of 14 evening shifts reviewed. |
Report Facts
Census: 75
Deficiencies cited: 1
Staffing counts: 8
Staffing counts: 9
Staffing counts: 6
Staffing counts: 9
Staffing counts: 6
Staffing counts: 9
Staffing counts: 7
Staffing counts: 4
Staffing counts: 5
Staffing counts: 5
Staffing counts: 5
Staffing counts: 4
Staffing counts: 5
Staffing counts: 5
Staffing counts: 6
Staffing counts: 5
Staffing counts: 6
Inspection Report
Annual Inspection
Census: 76
Capacity: 128
Deficiencies: 16
May 19, 2022
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 privacy violations during blood draws, failure to notify families of hospital transfers, incomplete care plans, improper wound care, incomplete narcotic record keeping, infection control breaches by a phlebotomist, staffing shortages, and multiple life safety code violations including fire door inspections, stairwell markings, emergency lighting, exit signage, sprinkler system maintenance, electrical wiring, HVAC ventilation, elevator testing, fire drills, gas and vacuum system inspections, and generator remote stop station.
Severity Breakdown
SS=D: 6
SS=E: 4
SS=F: 6
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to provide full visual privacy for 2 of 18 residents during blood draws. | SS=D |
| Failed to notify resident families or representatives in writing for facility-initiated hospital transfers for 2 residents. | SS=D |
| Failed to develop a comprehensive care plan for a resident receiving oxygen therapy. | SS=D |
| Failed to provide care consistent with professional standards during wound treatment for a resident. | SS=D |
| Failed to ensure DEA 222 forms were completed with sufficient detail for controlled medications. | SS=D |
| Failed to follow appropriate infection control measures during blood draws by a phlebotomist. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey. | — |
| Failed to inspect fire doors annually as required. | SS=F |
| Failed to provide stair tread marking stripes on stairwells. | SS=F |
| Failed to provide emergency lighting at fire pump house and emergency generator transfer switch room. | SS=F |
| Failed to ensure exit directional signs were installed and illuminated at all times, especially on temporary plastic barriers in COVID-19 wing. | SS=E |
| Failed to maintain sprinkler system; diesel fire pump had non-operational gauges and leaks. | SS=F |
| Failed to maintain electrical wiring; missing outlet cover, frayed wires, and improperly installed cords observed. | SS=E |
| Failed to ensure resident bathroom ventilation systems were functioning in multiple units. | SS=E |
| Failed to perform monthly firefighter emergency operations inspection and test of elevators with documented Phase I recall and floor operation. | SS=F |
| Failed to provide a remote manual stop station for the emergency generator. | SS=F |
Report Facts
CNA staffing: 8
CNA staffing: 6
CNA staffing: 6.5
CNA staffing: 6.75
CNA staffing: 8
CNA staffing: 8
CNA staffing: 8
CNA staffing: 5
CNA staffing: 5.75
CNA staffing: 6
CNA staffing: 8
CNA staffing: 7
CNA staffing: 7
CNA staffing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phlebotomist | Named in infection control and privacy deficiency related to blood draws. | |
| Licensed Practical Nurse #1 | Interviewed regarding privacy during blood draws and care plan updates. | |
| Licensed Practical Nurse #2 | Interviewed regarding privacy concerns and care plan updates. | |
| Social Worker | Interviewed regarding hospital transfer notification process. | |
| Receptionist | Interviewed regarding hospital transfer notification process. | |
| Director of Nursing | Interviewed regarding hospital transfer notification process and narcotic record keeping. | |
| MDS Coordinator | Interviewed regarding care plan updates. | |
| Administrator | Interviewed regarding multiple deficiencies and corrective actions. | |
| Maintenance staff member | Interviewed regarding fire door inspections, emergency lighting, sprinkler system, electrical wiring, ventilation, elevator testing, fire drills, and generator remote stop station. | |
| Regional Plant Operations Director | Interviewed regarding fire door inspections, emergency lighting, sprinkler system, electrical wiring, ventilation, elevator testing, fire drills, and generator remote stop station. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Oct 21, 2021
Visit Reason
The inspection was conducted based on a complaint (#NJ 146772) alleging the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Findings
The facility was found deficient in maintaining the minimum CNA staffing ratios on 14 of 14 day shifts reviewed, with CNAs assigned to more residents than allowed by state law. Interviews with staff confirmed understaffing and the facility acknowledged awareness of the staffing requirements and efforts to meet them.
Complaint Details
Complaint # NJ 146772 regarding failure to maintain minimum CNA staffing ratios was substantiated based on observations, interviews, and staffing reports.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law. |
Report Facts
Residents present: 75
CNA staffing deficiency days: 14
CNA staffing required: 10
CNA staffing actual: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Interviewed staff who reported being assigned 14 residents on the day shift | |
| Staffing Coordinator | Interviewed and stated facility awareness of staffing ratios and efforts to meet requirements | |
| Director of Nursing (DON) | Interviewed and stated facility awareness of staffing ratios |
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 0
Oct 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 73
Deficiencies: 0
Jan 15, 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 related to 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: 15
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