Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, and 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: 6
Date: Feb 25, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication storage, kitchen sanitation, facility assessment, quality assurance, infection control, and emergency preparedness.
Findings
The facility was found deficient in multiple areas including improper storage of controlled drugs, expired emergency medical supplies, unsanitary kitchen conditions, inadequate hand hygiene practices, incomplete facility assessment regarding resident population and staff competencies, ineffective Quality Assurance and Performance Improvement (QAPI) program lacking staff and family input, and failure to implement proper infection prevention and control measures during meal service.
Deficiencies (6)
Failure to ensure controlled drugs were stored in a permanently affixed compartment and emergency crash cart contained expired supplies.
Failure to maintain kitchen environment and equipment in a sanitary manner and ensure proper hand hygiene by staff.
Failure to conduct and document a facility-wide assessment addressing resident population specifics and staff competencies.
Failure to implement an effective QAPI program ensuring monitoring of medication carts, emergency carts, narcotic storage, and staff competencies.
Failure to set up an ongoing quality assessment and assurance group that incorporates feedback from all departments and direct care staff.
Failure to provide and implement an infection prevention and control program, including proper hand hygiene during meal service.
Report Facts
Expired suction catheter kits: 4
Expired suction tubing kits: 4
Expired non-rebreather oxygen masks: 2
Expired bag valve mask: 1
Resident rooms accessible for instant use: 14
Resident rooms with air conditioner not maintained: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Present during inspection of emergency crash cart and medication storage | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding emergency cart inspection process and checklist | |
| Director of Nursing (DON) | Interviewed regarding narcotic storage, facility assessment, QAPI program, and emergency cart inspections | |
| Licensed Practical Nurse (LPN) | Observed during medication storage inspection and meal delivery without hand hygiene | |
| Executive Chef (EC) | Participated in kitchen inspection and acknowledged unsanitary conditions | |
| Director of Dining (DD) | Participated in kitchen inspection and observed improper hand hygiene | |
| Dining Manager (DM) | Participated in kitchen inspection | |
| Registered Nurse Infection Preventionist (RN/IP) | Responsible for QAPI program and infection prevention; acknowledged deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged ultimate responsibility for QAPI program | |
| Certified Nursing Aide (CNA) | Observed during meal delivery without hand hygiene and interviewed about QAPI knowledge |
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on July 11, 2023.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations standards for Licensure of Assisted Living Residences and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 3
Inspection Report
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Medford Leas nursing home, summarizing the results of a regulatory survey completed on July 11, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Deficiencies: 2
Date: Jan 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to timely completion and transmission of Minimum Data Set (MDS) assessments and the inclusion of pertinent information on baseline care plans for residents.
Findings
The facility failed to complete and transmit MDS assessments in a timely manner for 2 of 12 residents reviewed and failed to include diagnosis and treatment of Clostridium difficile on the baseline care plan for 1 of 8 residents reviewed. Interviews with staff revealed misunderstandings and process failures related to these deficiencies.
Deficiencies (2)
Failure to complete and transmit Minimum Data Set (MDS) assessments in a timely manner for 2 residents.
Failure to include diagnosis and treatment of Clostridium difficile on baseline care plan for 1 resident.
Report Facts
Residents reviewed for MDS assessments: 12
Residents with untimely MDS assessments: 2
Residents reviewed for baseline care plans: 8
Residents with missing C-diff care plan: 1
Vancomycin dosage: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS Supervisor absence and MDS process oversight | |
| MDS Supervisor | Responsible for MDS process; missed submitting assessments | |
| Administrator | Interviewed regarding expectations for timely MDS transmission and baseline care plans | |
| Unit Manager #1 | Interviewed regarding baseline care plan initiation for C-diff resident |
Inspection Report
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of the nursing home facility Medford Leas.
Findings
No health deficiencies were found during the inspection.
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