Inspection Reports for Pine Acres Rehabilitation And Healthcare
51 Madison Ave, Madison, NJ, 07940
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a pattern of deficiencies related mainly to staffing ratios, infection prevention and control, care planning, and life safety code compliance. Complaint investigations conducted during the August 30, 2024 survey were completed without enforcement actions listed in the available reports. Prior reports noted issues with food sanitation and fire safety features, as well as some infection control concerns during the COVID-19 pandemic. The facility appears to have addressed many prior deficiencies, as reflected by the clean most recent inspection.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
85 residents
Based on a August 2024 inspection.
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 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 the notice |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 10
Date: Aug 30, 2024
Visit Reason
A recertification survey was conducted from 08/26/2024 through 08/30/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Complaint Details
Complaint investigation was part of the survey with complaint numbers NJ173552, NJ173390, NJ170602, NJ166036, NJ163429. The complaint investigations were completed during the survey.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had deficiencies related to accuracy of assessments, comprehensive care plans, licensure, infection prevention and control, staffing, and life safety code violations. Corrective actions and plans of correction were provided for all cited deficiencies.
Deficiencies (10)
Failure to accurately complete the Minimum Data Set (MDS) for residents.
Failure to develop and implement comprehensive person-centered care plans for residents.
Failure to notify CMS and receive authorization for a change in facility name.
Failure to establish and maintain an infection prevention and control program.
Failure to maintain required minimum direct care staff-to-resident ratios.
Failure to post written evacuation diagrams in each resident care unit and department.
Failure to ensure doors in exit passageways are self-closing and latching.
Failure to provide illumination of means of egress continuously or capable of automatic operation.
Failure to maintain fire alarm pull stations at required heights and locations.
Failure to maintain portable fire extinguishers properly installed and inspected.
Report Facts
Census: 85
Sample Size: 20
Survey Dates: 08/26/2024 through 08/30/2024
Deficiency Completion Dates: Most corrections planned for completion by 09/22/2024
Staffing Ratios: 8
Staffing Ratios: 10
Staffing Ratios: 14
Inspection Report
Routine
Census: 77
Deficiencies: 0
Date: Sep 25, 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.
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: 5
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 3
Date: Aug 26, 2022
Visit Reason
A Recertification Survey was conducted to assess the facility's compliance with regulatory standards including food safety, sanitation, staffing, and environmental conditions.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B due to deficiencies in food procurement and sanitation, improper labeling and temperature monitoring of residents' food, unsanitary dumpster area conditions, and failure to maintain required minimum direct care staff-to-resident ratios.
Deficiencies (3)
Failed to ensure staff followed sanitation procedures for sanitizing dishware through the dishwasher and failed to label and date residents' food and monitor freezer temperatures for residents' refrigerators.
Failed to ensure the dumpster area was maintained in a sanitary manner with garbage on the ground creating potential for pest harborage.
Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Survey Census: 89
Dishwasher rinse temperature: 170
Number of residents at risk: 86
Garbage pieces: 30
Deficient CNA staffing days: 14
Required CNAs: 11
Actual CNAs: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director | Educated on proper dish machine policies and procedures; involved in dishwasher temperature findings | |
| Dietary Aide | Observed washing dishes with inadequate rinse temperature | |
| Administrator | Notified of dishwasher issues and dumpster area cleanliness; responsible for staffing oversight | |
| Corporate Food Service Director | Reported dishwasher issues and dumpster area sanitation concerns | |
| Licensed Practical Nurse 2 | LPN | Verified mold on cheese and discussed food labeling and temperature monitoring |
| Unit Manager 2 | Verified food labeling issues and food storage policies | |
| Housekeeper | Responsible for cleaning refrigerators and dumpster area | |
| Staffing Coordinator | Educated on required minimum direct care staff-to-resident ratios |
Inspection Report
Life Safety
Deficiencies: 3
Date: Aug 26, 2022
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with 42 CFR 483.90.
Findings
The facility was found not in compliance with life safety code requirements, including deficiencies related to stairway exit door fire rating, fire alarm pull station locations, and enclosure of laundry chutes. Corrective actions were planned and later verified as completed.
Deficiencies (3)
One of six stairway exit doors lacked a fire rating identification tag and did not meet NFPA 101 (2012 edition) requirements, affecting 49 residents in three smoke compartments on three floors.
Fire alarm pull stations were not located within five feet of the exit on three of nine exits, potentially affecting 45 residents on three floors.
One laundry chute lacked a full enclosure, including a door that closed with alarm activation or self-closed and latched, potentially affecting all 87 residents.
Report Facts
Residents affected: 49
Residents affected: 45
Residents affected: 87
Deficiency correction completion date: Stairway exit door corrected on 08/29/2022
Deficiency correction completion date: Fire alarm pull station corrected on 09/01/2022
Deficiency correction completion date: Laundry chute enclosure corrected on 09/23/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Facilities Director | Interviewed regarding stairway door fire rating and fire alarm pull station locations |
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 1
Date: Jan 21, 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 COVID-19 recommended practices.
Findings
The facility was found to be in compliance with infection control regulations related to COVID-19 in one part of the report, but another section found noncompliance with New Jersey Administrative Code infection control standards, specifically failing to maintain required minimum direct care staff to resident ratios for 10 out of 42 shifts reviewed.
Deficiencies (1)
Failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 10 out of 42 shifts reviewed.
Report Facts
Census: 83
Shifts with staffing deficiencies: 10
Staffing ratios required: 1
Staffing ratios required: 1
Staffing ratios required: 1
CNA staffing on deficient days: 7
CNA staffing on deficient days: 8
CNA staffing on deficient days: 9
CNA staffing on deficient days: 10
Residents on deficient days: 80
Residents on deficient days: 82
Residents on deficient days: 83
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Aug 17, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00145204.
Complaint Details
Complaint #: NJ00145204. The facility was found compliant based on this complaint survey.
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: 3
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 28, 2021
Visit Reason
Initial inspection for licensure of new or renovated long term care facilities, specifically regarding construction and renovations to the front entrance including a new access ramp and modification to the front lobby.
Findings
The facility complies with the building requirements for long term care facilities related to the inspected construction and renovations. The building may not be occupied until formal notification by the licensing program is received.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #NJ00138262.
Complaint Details
Complaint #NJ00138262 was investigated and the facility was found compliant.
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: 4
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 3
Date: Nov 20, 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 and CMS/CDC recommended practices for COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to provide disinfectant wipes and sanitize screening equipment, ensure proper PPE use for staff, and properly dispose of COVID-19 testing swabs. Observations included unmonitored employee screening, improper cleaning of thermo scan and computer, staff not wearing required gowns in PUI rooms, and improper disposal of contaminated swabs.
Deficiencies (3)
Failure to provide disinfectant wipes and sanitize equipment used in COVID-19 screening process.
Failure to ensure proper use of personal protective equipment (PPE) for 1 of 2 staff.
Improper disposal of used COVID-19 testing swab and kit not in accordance with CDC guidelines.
Report Facts
Census: 83
Date of Compliance: 2020
Staff Surveillance: 10
Surveillance Frequency: 3
Screening Monitoring: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Infection Preventionist Nurse | Performed nasopharyngeal swab collection and improperly disposed of contaminated swabs |
| Certified Nursing Aide | Reported self-screening process and improper cleaning of screening equipment | |
| Occupational Therapist Assistant | Observed providing care in PUI room without wearing isolation gown | |
| Licensed Nursing Home Administrator | Interviewed regarding COVID-19 positive cases and facility procedures | |
| Assistant Director of Nursing | Interviewed and acknowledged PPE deficiencies |
Viewing
Loading inspection reports...
