Inspection Reports for
The Jewish Home for Rehabilitation and Nursing
1151 West Main Street, Freehold, NJ, 07728
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
91% occupied
Based on a May 2023 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 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
Routine
Deficiencies: 2
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning and kitchen sanitation standards at the Jewish Home for Rehabilitation and Nursing.
Findings
The facility failed to update an individual comprehensive care plan for a resident whose tube feeding was discontinued, and failed to maintain kitchen equipment and kitchenettes in a clean and sanitary manner.
Deficiencies (2)
Failed to revise an individual comprehensive care plan for a resident with a discontinued tube feeding order.
Failed to maintain kitchen equipment in a clean and sanitary manner and maintain a clean, sanitary environment in 3 of 3 resident kitchenettes.
Report Facts
Feeding tube caloric intake percentage: 51
Feeding tube discontinued date: Apr 2, 2025
Number of kitchenettes inspected: 3
Number of steam table wells: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding failure to update ICCP for Resident #8. | |
| Registered Dietician (RD) | Interviewed regarding ICCP update for Resident #8 after tube feeding discontinued. | |
| Director of Nursing (DON) | Confirmed ICCP should have been updated promptly upon care changes. | |
| Food Service Director (FSD) | Acknowledged kitchen equipment was not cleaned according to policy. | |
| Housekeeping Director (HKD) | Acknowledged kitchenettes were not cleaned as per facility policy. | |
| Building Service Manager (BSM) | Described maintenance process and delays in cabinet resurfacing. | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged cleaning and sanitation issues in kitchenettes and delays in repairs. | |
| [NAME] | Regional Director of Clinical Services | Present during DON interview confirming ICCP update importance. |
| [NAME] | Regional [NAME] President of Operations | Acknowledged survey concerns during final meeting. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and injury, medication administration errors, inadequate incontinence care, infection prevention and control issues, and medication error rates exceeding acceptable limits.
Complaint Details
The complaint investigation found substantiated failures including late reporting of abuse and injury, medication administration errors, inadequate incontinence care, high medication error rates, and lapses in infection prevention practices.
Findings
The facility failed to timely report allegations of physical abuse and injury of unknown origin for two residents, failed to administer medications as ordered for one resident, failed to provide thorough incontinence care for two residents, had a medication error rate of 20.69% placing three residents at risk, and failed to ensure proper infection prevention practices including glove changes and PPE use during care.
Deficiencies (5)
Failure to timely report suspected abuse and injury of unknown origin for two residents.
Failure to ensure one resident received medications as ordered by the physician.
Failure to provide thorough incontinence care for two residents, risking urinary tract infections.
Medication error rate of 20.69%, exceeding the acceptable rate of less than 5%, risking three residents' medication therapy.
Failure to ensure staff changed gloves when moving from dirty to clean areas during incontinence and catheter care, and failure to wear PPE during care for residents on enhanced barrier precautions.
Report Facts
Medication error rate: 20.69
Medication error rate threshold: 5
Number of residents affected by medication errors: 3
Number of residents reviewed for abuse: 24
Number of residents affected by abuse reporting deficiency: 2
Number of residents affected by incontinence care deficiency: 2
Number of residents affected by infection prevention deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Did not change gloves during suprapubic catheter care and did not perform hand hygiene as expected. |
| Director of Nursing | DON | Provided multiple interviews confirming expectations for timely reporting, medication administration, glove changing, and PPE use. |
| Certified Nursing Assistant 2 | CNA | Observed not changing gloves appropriately during incontinence care. |
| Licensed Practical Nurse 1 | LPN | Omitted zinc medication during medication pass but administered later. |
| Registered Nurse 2 | RN | Prepared medications incorrectly for Resident 8, including omeprazole not given prior to meals. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 2, 2023
Visit Reason
The inspection was conducted based on complaints and observations related to resident grievances, medication administration, respiratory care, pharmaceutical services, and medication error rates.
Complaint Details
Complaint investigations included issues with resident grievance resolution, medication administration observation failures, oxygen administration errors, pharmaceutical service deficiencies, and medication error rates.
Findings
The facility failed to resolve a resident grievance timely, did not properly observe medication administration or assess residents for self-administration, failed to administer oxygen per physician orders, had discrepancies in controlled substance handling and documentation, and had a medication administration error rate of 20% during observed medication passes.
Deficiencies (5)
Failed to resolve a resident's grievance recorded in the Resident Council Minutes in a timely manner.
Failed to observe two residents take medication or assess them for self administration of medication.
Failed to administer oxygen in accordance with physician's orders.
Failed to provide pharmaceutical services in accordance with professional standards including accurate controlled substance documentation and reconciliation.
Medication administration error rate of 20% observed during medication pass.
Report Facts
Medication administration opportunities: 25
Medication administration errors: 5
Medication administration error rate: 20
Medication administration error rate threshold: 5
Resident count in grievance: 1
Residents reviewed for medication observation: 2
Residents reviewed for respiratory care: 2
Medication carts inspected: 9
Residents reviewed for medication management: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration observation and controlled substance handling findings |
| LPN #2 | Licensed Practical Nurse | Named in medication administration observation and medication pass errors |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding grievance, medication, and pharmaceutical service findings |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding grievance findings |
| Regional Director of Risk Management | RDRM | Interviewed regarding grievance and pharmaceutical service findings |
| Registered Nurse | RN | Named in oxygen administration findings |
| Consultant Pharmacist | CP | Interviewed regarding medication observation and pharmaceutical service findings |
| LPN/Unit Manager | LPN/UM | Named in pharmaceutical service findings |
Inspection Report
Routine
Census: 137
Capacity: 150
Deficiencies: 7
Date: May 2, 2023
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.
Complaint Details
Complaint #NJ00160939 was substantiated. The facility failed to observe residents taking medication or assess them for medication administration errors. Medication error rate was found to be 20%, exceeding the allowed 5%.
Findings
The facility was found not in compliance with several standards including grievance resolution, medication administration, respiratory care, pharmacy services, staffing ratios, and infection control. Deficiencies were cited and plans of correction were required.
Deficiencies (7)
Failure to resolve a resident's grievance in a timely manner.
Failure to meet professional standards in medication administration and assessment.
Failure to provide respiratory care including tracheostomy care and suctioning according to professional standards.
Failure to provide pharmaceutical services in accordance with professional standards including drug accountability and medication reconciliation.
Failure to maintain minimum direct care staffing ratios as mandated by the state.
Failure to ensure employees had completed required Mantoux tuberculin skin testing upon hire.
Failure to maintain medication error rates below 5 percent.
Report Facts
Census: 137
Total Capacity: 150
Sample Size: 35
Medication Error Rate: 20
Medication Opportunities Observed: 25
Medication Errors Observed: 5
Staffing Deficiencies: 14
Staffing Deficiencies: 49
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Date: Jun 1, 2022
Visit Reason
The inspection was conducted based on complaints NJ 151308 and 150760 alleging deficiencies in resident records and documentation practices.
Complaint Details
Complaint # NJ 151308, 150760. The facility was found not in substantial compliance based on these complaints regarding incomplete and inaccurate resident medical record documentation.
Findings
The facility was found not in substantial compliance with requirements related to resident-identifiable information and medical record documentation. Specifically, the facility failed to follow its 'Charting Documentation' policy for 2 of 5 sampled residents, with numerous incomplete or missing documentation entries across multiple care tasks.
Deficiencies (1)
Failure to complete documentation of Activities of Daily Living (ADL) tasks for Resident #1 and Resident #4, including incontinence care, skin care, turning and repositioning, eating support, and other nursing tasks.
Report Facts
Census: 128
Sample size: 5
Documentation blanks: 19
Documentation blanks: 21
Documentation blanks: 20
Documentation blanks: 15
Documentation blanks: 15
Documentation blanks: 20
Documentation blanks: 5
Documentation blanks: 43
Documentation blanks: 39
Documentation blanks: 43
Documentation blanks: 20
Documentation blanks: 60
Documentation blanks: 62
Documentation blanks: 62
Documentation blanks: 44
Documentation blanks: 62
Documentation blanks: 24
Documentation blanks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 5/31/2022 regarding responsibility for ensuring documentation completion and acknowledging the impact of blanks in care records. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 2
Date: Sep 13, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146057, NJ145729, and NJ145571 regarding notification of changes in resident condition and quality of care issues.
Complaint Details
Complaint Intake NJ145571 and NJ145729. Resident #2's family was not notified of hospital transfer. Resident #3 experienced delayed treatment and monitoring, resulting in abrupt decline and death. Family complaints included inability to reach facility and concerns about resident condition.
Findings
The facility failed to notify the family/responsible party of a resident's hospital transfer and failed to ensure quality of care for a resident with delayed treatment, including failure to timely report changes in condition to the physician and carry out physician orders. These failures contributed to the abrupt decline and death of Resident #3.
Deficiencies (2)
Failure to notify family/responsible party of Resident #2's hospital transfer.
Failure to ensure quality of care for Resident #3, including delayed treatment, failure to monitor and report changes in condition, and failure to carry out physician orders.
Report Facts
Census: 125
Sample Size: 7
Deficiencies cited: 2
Heart Rate readings: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in failure to notify family of hospital transfer and in quality of care findings |
| LPN #1 | Licensed Practical Nurse | Named in quality of care findings related to Resident #3 |
| RN #1 | Registered Nurse | Named in quality of care findings related to Resident #3 |
| Director of Nursing | DON | Acknowledged failures in notification and quality of care |
| Medical Director | MD | Attending physician involved in Resident #3 care and findings |
| Director of Rehab | DCR | Consulted regarding Resident #3's fluctuating heart rate |
| Certified Nurse Aide #1 | CNA | Reported Resident #3 complaints and condition on day of death |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 2
Date: Jul 9, 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 appropriately administer medication, document medication administration and physician communication for one resident, and failure to ensure a call light was within reach for a resident with a history of falls.
Deficiencies (2)
Failure to appropriately administer medication in accordance with a physician's order, accurately document medication administration, and document communication with the physician for one resident.
Failure to ensure a call light was placed within reach for a resident with a history of falls.
Report Facts
Census: 114
Sample Size: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed administering medication and interviewed regarding medication administration to Resident #96 |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed regarding medication administration and physician communication for Resident #96 |
| CNA #1 | Certified Nursing Aide | Interviewed regarding Resident #96's condition and communication with nurse |
| CNA #2 | Certified Nursing Aide | Interviewed regarding call light placement for Resident #53 |
| Director of Nursing | Director of Nursing | Interviewed regarding call light placement policy and medication administration documentation |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 8, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration and resident safety, including pain medication administration and call light accessibility.
Findings
The facility failed to appropriately administer and document pain medication for one resident, including failure to document communication with the physician and medication administration. Additionally, the facility failed to ensure a call light was within reach for a resident at risk for falls.
Deficiencies (2)
Failure to appropriately administer pain medication, accurately document administration, and document communication with the physician for one resident.
Failure to ensure a call light was placed within reach for a resident with a history of falls.
Report Facts
Residents reviewed for medication deficiency: 24
Residents reviewed for accident hazard deficiency: 2
BIMS score: 3
BIMS score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration deficiency for Resident #96 |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Named in medication administration deficiency and communication with physician for Resident #96 |
| CNA #1 | Certified Nursing Aide | Interviewed regarding Resident #96's pain complaints |
| CNA #2 | Certified Nursing Aide | Interviewed regarding call light placement for Resident #53 |
| DON | Director of Nursing | Confirmed documentation and call light placement deficiencies |
Inspection Report
Life Safety
Deficiencies: 2
Date: Jul 6, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/06/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with emergency lighting requirements due to lack of battery backup emergency light above the emergency generator transfer switch, and hazardous areas were not properly enclosed with self-closing doors in one of three nursing units, with storage of combustible materials in these areas.
Deficiencies (2)
Failed to provide a battery backup emergency light above the emergency generator transfer switch to provide required illumination automatically during power interruption.
Failed to provide hazardous areas with self-closing doors in 1 of 3 nursing units; rooms used for storage of mattresses, night stands, beds, wheelchairs, and resident clothing were not properly enclosed.
Report Facts
Number of nursing units with deficient hazardous area doors: 1
Number of mattresses stored improperly: 5
Number of wooden composite night stands stored improperly: 3
Number of resident room beds with wooden composite parts stored improperly: 3
Number of wheelchairs stored improperly: 19
Number of plastic bags of resident clothing stored improperly: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview confirming lack of emergency light and hazardous area door deficiencies | |
| Regional Representative | Present during observation and interview confirming deficiencies | |
| Administrator | Informed of findings during Life Safety Code survey exit |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Date: Apr 30, 2021
Visit Reason
The inspection was conducted based on a complaint visit (Complaint# NJ 142255) to assess compliance with long term care facility regulations.
Complaint Details
Complaint# NJ 142255. The facility was found not in substantial compliance based on this complaint visit.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to follow professional standards and their own policies in the treatment and prevention of pressure ulcers for one sampled resident. Deficiencies were related to improper wound care practices and hand hygiene by nursing staff.
Deficiencies (1)
Failure to follow professional standards and facility policy in treatment and prevention of pressure ulcers for Resident #1, including improper hand hygiene and wound care technique by nursing staff.
Report Facts
Sample Size: 3
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