Inspection Reports for
Mcauley Hall Health Care Cente
1633 Highway 22, Watchung, NJ, 07069
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
92% occupied
Based on a March 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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 personal health information may be used and disclosed, and the rights individuals have concerning their health information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, legal duties of the department, and contact information for privacy concerns.
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
Routine
Deficiencies: 2
Date: Aug 12, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration standards and food safety regulations at McAuley Hall Health Care Center.
Findings
The facility was found deficient in ensuring proper medication administration for a resident with hypertension, specifically failing to document parameters for holding medication. Additionally, the facility failed to maintain food safety standards, including improper storage of hazardous foods and unsanitary kitchen conditions.
Deficiencies (2)
Failure to ensure a high blood pressure medication was administered according to physician's order and professional standards, with missing documentation of vital sign parameters for holding medication.
Failure to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner to prevent food borne illness.
Report Facts
Medications prepared: 9
Cook top burners soiled: 3
Cook top burners total: 12
Dry storage room temperature: 87.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Observed preparing medications and failing to document parameters for holding medication | |
| Licensed Nursing Home Administrator (LNHA) | Discussed medication administration concerns with survey team | |
| Director of Nursing (DON) | Discussed medication administration and food safety concerns with survey team | |
| Food Services Director (FSD) | Present during food safety observations and provided statements about food storage and cleanliness | |
| Maintenance Director (MD) | Present during dry storage room temperature observation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 13, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to timely report an allegation of abuse/neglect and failure to maintain safe, clean, and homelike conditions in certain facility areas including patios, laundry, and kitchenettes.
Complaint Details
Complaint NJ169416 involved failure to timely report an abuse allegation for Resident #57. The abuse event occurred on 11/25/23 and was reported late on 11/28/23. The CNA involved was terminated. Complaint NJ154270 involved environmental deficiencies including unsafe patio conditions, unsanitary laundry area, and unclean kitchenettes.
Findings
The facility failed to report an allegation of abuse within the required timeframe for one resident and failed to maintain safe and sanitary conditions in the residents' patio, laundry area, and one of three kitchenettes. Deficiencies included ripped screens, paint deterioration, dirty laundry vents and floors, and unsanitary kitchen equipment and surfaces.
Deficiencies (4)
Failure to timely report suspected abuse/neglect to the New Jersey Department of Health for one resident.
Failure to maintain the residents' patio in a safe and homelike condition, including ripped screens and paint deterioration.
Failure to maintain the laundry area in a safe and sanitary condition, including grayish substances on ceiling vents, brownish discoloration on ceiling tiles and floors, and lack of cleaning accountability logs.
Failure to maintain a safe and sanitary environment in one of three kitchenettes, including dirty refrigerator door gasket, brown sediment in ice machine vent, cracked refrigerator drawer with debris, unclean coffee pot, and unsanitary trash can and shelving.
Report Facts
Residents reviewed for incident/event: 3
Residents affected: 1
Residents affected: 2
Date of abuse event: Nov 25, 2023
Date abuse reported: Nov 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Involved in investigation and interview regarding abuse reporting | |
| Licensed Nursing Home Administrator | Interviewed regarding abuse reporting timeframe and facility policies | |
| Housekeeping Director | Provided information about laundry area conditions and cleaning practices | |
| Director of Maintenance | Provided maintenance schedule and information about facility repairs | |
| Food Service Director | Interviewed regarding kitchen stocking and cleaning responsibilities | |
| Licensed Practical Nurse | Interviewed regarding notification procedures for kitchen issues |
Inspection Report
Routine
Census: 68
Deficiencies: 17
Date: Mar 13, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to issue required Medicare Beneficiary Protection Notifications, incomplete license verification for newly hired staff, delayed reporting of abuse allegations, failure to provide written notifications for hospital transfers and bed hold policies, inaccurate resident assessments, incomplete PASARR screenings, infection control deficiencies, inadequate pressure ulcer care, lack of dialysis access site monitoring, incomplete medical records, poor coordination with hospice care, incomplete attendance at Quality Assurance meetings, environmental safety and sanitation issues, inaccurate nurse staffing reports, and missing mandatory staff training on QAPI and behavioral health.
Deficiencies (17)
Failed to issue required Medicare Beneficiary Protection Notification to residents.
Failed to verify licensed staff credentials prior to hire for two newly hired staff.
Failed to timely report suspected abuse to proper authorities.
Failed to provide written notification of hospital transfer reason and bed hold policy to residents and representatives.
Failed to accurately code Minimum Data Set (MDS) for resident, including restraint coding.
Failed to complete and update PASARR screening for psychiatric diagnoses.
Failed to obtain physician order for droplet precaution and post required sign for infection control.
Failed to maintain infection control practices and follow physician orders during pressure ulcer treatment.
Failed to provide appropriate dialysis access site care and monitoring with no care plan or physician order.
Failed to maintain accurate and complete medical records accessible for review.
Failed to ensure consistent coordination and communication between facility staff and hospice staff.
Failed to ensure Infection Preventionist, Director of Nursing, Medical Director or designee attended quarterly Quality Assurance meetings.
Failed to maintain safe, clean, and homelike environment including ripped screens, paint deterioration, laundry area water damage, and unsanitary kitchenettes.
Failed to post accurate and complete 24-hour nurse staffing reports including census and RN presence.
Failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training for Certified Nurse Assistants.
Failed to provide mandatory behavioral health training for Certified Nurse Assistants.
Failed to maintain system of record keeping for DEA Form-222 and lacked policy for narcotic medication ordering and tracking.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 68
Residents affected: 1
Residents affected: 68
Staff affected: 5
Staff affected: 5
Inspection Report
Complaint Investigation
Census: 68
Capacity: 74
Deficiencies: 22
Date: Mar 12, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaints NJ#154270, NJ#169416, NJ#170377, NJ#170461.
Complaint Details
Complaint numbers NJ#154270, NJ#169416, NJ#170377, NJ#170461 triggered the recertification survey.
Findings
Deficiencies were cited related to Medicaid/Medicare coverage notices, abuse/neglect policies, reporting of alleged violations, notice requirements before transfer/discharge, bed hold policy, accuracy of assessments, PASARR screening, services meeting professional standards, treatment of pressure ulcers, dialysis care, posted nurse staffing information, pharmacy services, resident records, hospice services, quality assurance committee participation, safe and sanitary environment, QAPI training, behavioral health training, universal transfer form use, exit signage, fire alarm system maintenance, subdivision of building spaces including smoke barriers and doors, and electrical system safety.
Deficiencies (22)
Facility failed to issue required Medicare Beneficiary Protection Notification for two residents.
Facility failed to implement abuse/neglect policies including license verification upon hire for nursing staff.
Facility failed to report an alleged violation to the NJ Department of Health within required timeframe for one resident.
Facility failed to provide written notice of transfer/discharge to resident, representative, and Ombudsman for two residents.
Facility failed to provide written notice of bed hold policy to resident or representative prior to transfer for two residents.
Facility failed to accurately code Minimum Data Set for one resident.
Facility failed to obtain physician order and post required signage for transmission-based precautions for one resident.
Facility failed to maintain infection control practices during wound treatment, follow physician and wound care recommendations, and document wound status for one resident.
Facility failed to ensure appropriate dialysis care and care plan for one resident.
Facility failed to post accurate nurse staffing information including census and licensed nurse presence.
Facility failed to maintain system of record keeping for DEA Form-222 and lacked policy for narcotic medication ordering.
Facility failed to maintain a copy of the New Jersey Universal Transfer Form as part of the medical record for two residents.
Facility failed to maintain illuminated exit sign to clearly identify exit access path to an exit discharge door.
Facility failed to ensure smoke detection sensitivity testing was performed every alternate year for smoke detectors.
Facility failed to perform six-year maintenance on seven portable fire extinguishers.
Facility failed to maintain integrity of smoke barrier partitions for three smoke barrier walls.
Facility failed to maintain smoke barrier doors to resist transfer of smoke when completely closed for fire and smoke protection.
Facility failed to ensure one electrical outlet located within 6 feet of a sink was equipped with Ground-Fault Circuit Interrupter protection.
Facility failed to maintain complete and readily accessible medical records for one resident.
Facility failed to ensure consistent coordination and communication between hospice staff and facility staff for one resident.
Facility failed to ensure facility staff attended mandatory QAPI training for five CNAs.
Facility failed to ensure facility staff attended mandatory behavioral health training for five CNAs.
Report Facts
Census: 68
Total Capacity: 74
Deficiency counts: 22
Staffing ratios: 7
Staffing ratios: 8
Fire extinguishers: 7
Fire extinguishers: 33
Inspection Report
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of McAuley Hall Health Care Center.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The inspection was a standard annual survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample size: 20
Inspection Report
Routine
Census: 53
Deficiencies: 0
Date: Dec 9, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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