Inspection Reports for
Hunterdon Care Center
1 Leisure Court, Flemington, NJ, 08822
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
92% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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 explains 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
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
The inspection was conducted based on complaint #2582599 regarding the facility's failure to ensure a safe discharge for a resident with severe cognitive impairment who was discharged to the community without necessary home nursing care services.
Complaint Details
Complaint #2582599 involved a resident with severe cognitive impairment discharged without necessary home nursing care and therapy services, and without a discharge summary note. The complaint was substantiated with findings of immediate jeopardy and minimal harm deficiencies.
Findings
The facility failed to ensure a safe discharge for Resident #3, who had severe cognitive impairment and was discharged without necessary home nursing and therapy services, placing the resident and others at risk of serious harm. Additionally, the facility failed to complete a discharge summary note at the time of discharge for Resident #3.
Deficiencies (2)
Failure to ensure a safe transfer/discharge meeting the resident's needs and preferences, resulting in immediate jeopardy to resident health or safety.
Failure to provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies, specifically the absence of a discharge summary note.
Report Facts
BIMS score: 5
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed about discharge process; stated she did not complete Resident #3's discharge as per facility policy. |
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #3 would not have been a safe discharge and discussed discharge process. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding familiarity with Resident #3 and discharge process. |
| Director of Social Work | Director of Social Work (DSW) | Interviewed about discharge planning and social work involvement. |
| Director of Rehab | Director of Rehab (DOR) | Interviewed about therapy recommendations for Resident #3. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Hunterdon Care Center LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Mar 19, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident rights, abuse investigations, medication management, infection control, and facility compliance with regulatory requirements.
Complaint Details
Complaint #NJ00172794 involved failure to timely report suspected abuse, failure to conduct thorough investigations, and other related deficiencies.
Findings
The facility was found deficient in honoring resident self-determination and choice, failure to complete employee reference checks, failure to timely report and investigate suspected abuse, inaccurate Minimum Data Set (MDS) coding, incomplete documentation of controlled substance receipt, failure to ensure unnecessary medications were avoided, improper storage of medical equipment, and malfunctioning call bell systems.
Deficiencies (9)
Failed to honor a resident's choice to get out of bed at preferred times and attend preferred activities.
Failed to implement abuse policy ensuring reference checks were completed for 10 of 10 employee files reviewed.
Failed to timely submit facility investigation of suspected abuse to NJDOH within 5 days.
Failed to conduct a thorough investigation for a resident who sustained a significant injury of unknown origin.
Failed to accurately code the Minimum Data Set (MDS) for significant weight loss for one resident.
Failed to provide accurate documentation of receipt of controlled substances on DEA 222 forms.
Failed to ensure resident did not receive unnecessary medication (Flomax) without proper diagnosis documentation or periodic assessment.
Failed to follow appropriate infection control practices for storing medical devices and equipment while not in use (nebulizer equipment found on floor).
Failed to ensure all call bell devices in resident bathrooms and bathing areas were properly functioning.
Report Facts
Employee files missing reference checks: 10
DEA 222 Forms with incomplete receipt documentation: 2
Residents affected by call bell malfunction: 6
Residents reviewed for unnecessary medications: 5
Residents reviewed for MDS coding accuracy: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager #3 | LPN/UM | Named in failure to honor resident preferences and infection control findings. |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding resident preferences and care. |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding resident preferences and care. |
| Licensed Practical Nurse/Unit Manager #1 | LPN/UM | Interviewed regarding resident preferences and care. |
| Activities Director | AD | Interviewed regarding resident activities and preferences. |
| Director of Nursing | DON | Interviewed regarding resident care, investigations, and medication management. |
| Director of Human Resources | DHR | Interviewed regarding employee reference checks. |
| Certified Nurse Aide #5 | CNA | Interviewed regarding discovery of resident injury. |
| Registered Nurse #1 | RN | Interviewed regarding resident injury assessment and investigation. |
| Primary Care Physician | PMD | Interviewed regarding medication use and diagnosis documentation. |
| Director of Maintenance | DOM | Interviewed regarding call bell system malfunctions. |
Inspection Report
Routine
Census: 170
Deficiencies: 10
Date: Mar 19, 2025
Visit Reason
A Recertification Survey was conducted from 03/13/25 to 03/19/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint NJ #s: 170517, 172426, 172794, and 183244 were investigated. Some complaints were substantiated related to resident care and abuse investigations.
Findings
The facility was found to have multiple deficiencies related to resident self-determination, abuse/neglect policies, infection control, medication management, emergency preparedness, life safety code violations, and other regulatory requirements. Deficiencies were cited across various areas including resident rights, staffing, emergency plans, and physical environment.
Deficiencies (10)
Facility failed to honor a resident's choice to get out of bed at the preferred time and attend preferred activities.
Facility failed to implement abuse/neglect policies including ensuring reference checks for employees.
Facility failed to submit timely investigations of alleged abuse to the NJ Department of Health.
Facility failed to conduct thorough investigations of resident abuse allegations.
Facility failed to accurately assess and code resident Minimum Data Set (MDS) assessments.
Facility failed to provide pharmaceutical services in accordance with professional standards including accurate documentation of controlled substances.
Facility failed to maintain an effective infection prevention and control program.
Facility failed to maintain an effective emergency preparedness plan and conduct required drills.
Facility failed to maintain means of egress free of obstructions and maintain fire safety equipment properly.
Facility failed to maintain adequate resident call system functioning.
Report Facts
Census: 170
Sample size: 37
Number of employee files reviewed: 10
Number of residents affected by staffing deficiency: 7
Number of residents affected by call bell deficiency: 6
Number of fire sprinkler inspections reviewed: 3
Number of fire extinguishers deficient: 5
Number of unprotected spray nozzles: 9
Inspection Report
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Hunterdon Care Center LLC, summarizing the results of a regulatory survey completed on 2023-08-10.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 152
Deficiencies: 0
Date: Aug 10, 2023
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.
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
Routine
Census: 163
Deficiencies: 9
Date: Feb 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food safety, hospice coordination, and documentation at Hunterdon Care Center LLC.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, inaccurate resident assessments, incomplete PASARR screenings, inconsistent range of motion exercises, inadequate monitoring of psychotropic medications, improper maintenance of nourishment room refrigerators and ice machines, incomplete wound documentation, failure to maintain hospice documentation, and poor hand hygiene practices during dining service.
Deficiencies (9)
Failed to honor a resident's choice of shower over bed baths.
Failed to ensure resident assessment accurately reflected hospice designation.
Failed to ensure completion of PASARR screening after new mental health diagnoses.
Failed to provide consistent range of motion exercises for a resident.
Failed to monitor efficacy of psychotropic medications for target symptoms.
Failed to maintain nourishment room refrigerators and ice machines to prevent foodborne illness.
Failed to document facial wounds in resident's medical record.
Failed to maintain hospice orders, care plan, and election form for hospice resident.
Failed to ensure proper hand hygiene during dining service, risking transmission of communicable diseases.
Report Facts
Census: 163
Temperature reading: 50
Temperature reading: 42
Temperature reading: 43
Deficiency sample size: 32
Residents affected: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident bathing preferences, PASARR screening, wound documentation, hospice care coordination, and infection control expectations |
| Unit Manager | Unit Manager Registered Nurse | Provided information on resident bathing schedules and restorative nursing program |
| Certified Nursing Assistant 1 | CNA | Interviewed about resident bathing, ROM care, and nourishment room refrigerator temperature logs |
| Certified Nursing Assistant 2 | CNA | Interviewed about resident bathing preferences and shower refusals |
| Certified Nursing Assistant 3 | CNA | Interviewed about ROM care and hand hygiene during dining service |
| Director of Rehabilitation Services | DRS | Interviewed about restorative nursing program and therapy evaluations |
| Social Services Director | SSD | Provided information on PASARR screening for resident |
| MDS Coordinator | MDS Coordinator | Interviewed about resident assessment accuracy |
| Food Service Director | FSD | Interviewed about nourishment room refrigerator and ice machine maintenance |
| Director of Housekeeping | Director of Housekeeping | Interviewed about cleaning responsibilities for ice machines |
| Director of Maintenance | Director of Maintenance | Interviewed about ice machine maintenance and cleaning |
| Hospice Nurse | Hospice Nurse | Interviewed about hospice documentation and care coordination |
| Hospice Aide | Hospice Aide | Interviewed about hospice care plan usage |
| Dayroom Hostess | Dayroom Hostess (DH) | Observed and interviewed regarding feeding residents and hand hygiene practices |
| Licensed Practical Nurse 1 | LPN | Observed during meal service and hand hygiene practices |
| Certified Nursing Assistant 5 | CNA | Observed during meal service and hand hygiene practices |
| Unit Manager 1 | Unit Manager | Observed and interviewed regarding meal service and hand hygiene practices |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed about hand hygiene expectations |
Inspection Report
Routine
Census: 164
Capacity: 185
Deficiencies: 9
Date: Feb 16, 2023
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with federal and state regulations for Hunterdon Care Center.
Findings
The facility was found not to be in substantial compliance with multiple regulatory requirements including resident self-determination, accuracy of assessments, coordination of PASARR and assessments, mobility and prevention of decrease in range of motion, medication management, food safety, resident records, infection prevention and control, and life safety code compliance. Corrective actions were planned or implemented for all cited deficiencies.
Deficiencies (9)
Failure to honor a resident's choice of a shower over bed baths.
Failure to ensure resident assessments accurately reflected resident status.
Failure to coordinate PASARR assessments with pre-admission screening and resident review.
Failure to ensure residents received consistent exercises to prevent decrease in range of motion.
Failure to ensure medication orders were properly monitored and documented.
Failure to maintain proper food safety including refrigerator temperatures and food storage.
Failure to maintain resident records complete, accurate, and confidential.
Failure to establish and maintain an infection prevention and control program.
Failure to maintain means of egress and smoke barrier walls in accordance with Life Safety Code.
Report Facts
Survey Census: 164
Total Capacity: 185
Sample Size: 32
Supplemental Residents: 6
Deficiency Count: 9
Nursing Staff Deficiency: 14
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ148036 and NJ146737.
Complaint Details
Complaint numbers NJ148036 and NJ146737 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: 12
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 1
Date: Jul 8, 2021
Visit Reason
The inspection was conducted based on complaints NJ145681 and NJ146311 to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Complaint Details
Complaint investigation NJ145681 determined the facility failed to document accurately and follow nursing standards for residents with enteral feeding orders. The facility was not in substantial compliance based on this complaint visit.
Findings
The facility was found not in substantial compliance due to failure to consistently document resident status and adhere to nursing practice standards, including failure to follow physician's orders and care plan interventions for residents with enteral feeding orders.
Deficiencies (1)
Failure to consistently document administration of enteral feeding orders and follow physician's orders and care plan interventions for residents with tube feeding.
Report Facts
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Re-educated nurses on accurate documentation of enteral feeding orders and administration |
| Unit Manager | Unit Manager | Interviewed regarding documentation practices and nurse responsibilities |
Inspection Report
Routine
Census: 143
Deficiencies: 0
Date: Jan 25, 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 recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 00141794.
Complaint Details
Complaint #: NJ 00141794. The facility was found compliant based on this complaint visit.
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 visit.
Report Facts
Sample Size: 4
Inspection Report
Routine
Deficiencies: 4
Date: Oct 9, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to comprehensive care planning, wound care management, medication storage, and infection prevention and control in a nursing facility.
Findings
The facility was found deficient in developing comprehensive care plans for residents with dementia and psychotropic medication use, communicating and documenting physician responses to wound care recommendations, removing expired medications from active inventory, and performing proper infection control practices during wound treatment.
Deficiencies (4)
Failure to develop a comprehensive care plan for a resident with dementia and psychotropic medication use.
Failure to communicate and document physician's response to wound consultant recommendations for a resident with pressure ulcers.
Failure to remove expired glucose medication from active inventory in the medication cart.
Failure to perform hand hygiene between glove changes and failure to cleanse a pressure ulcer after it came into contact with bed linens during wound treatment.
Report Facts
Residents reviewed for comprehensive care plans: 30
Residents reviewed with pressure ulcers: 3
Medication carts inspected: 4
Expired glucose gel tubes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #135's assigned Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Acknowledged lack of care plan for dementia and psychotropic medication use |
| Unit Manager (UM) | Unit Manager | Discussed involvement in care planning and wound rounds |
| MDS Coordinator | MDS Coordinator | Unable to provide evidence of care plan initiation for cognition/dementia or psychotropic medication use |
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficiencies in care planning, wound care communication, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Discussed wound care order process and communication failures |
| LPN #1 | Licensed Practical Nurse | Unaware of wound care recommendations and order changes |
| Wound Consultant/Nurse Practitioner | Wound Consultant/Nurse Practitioner (WC/NP) | Provided wound care recommendations and discussed treatment changes |
| Registered Nurse | Registered Nurse (RN) | Responsible for medication cart inspection and acknowledged expired medications |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Responsible for unit inspections but unable to perform due to COVID-19 restrictions |
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