Inspection Reports for
Pine Acres Rehabilitation And Healthcare
51 Madison Ave, Madison, NJ, 07940
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
83% occupied
Based on a August 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2026
Visit Reason
The inspection was conducted based on Complaint #2707766 to investigate allegations that the facility failed to provide timely incontinence care to dependent residents on the first floor nursing unit.
Complaint Details
Complaint #2707766 was substantiated based on observations, interviews, and record reviews showing failure to provide timely incontinence care to 6 residents on the first floor nursing unit.
Findings
The facility failed to ensure timely incontinence care for 6 of 6 dependent residents observed, resulting in saturated briefs and strong urine odors. Staffing shortages and inadequate CNA-to-resident ratios contributed to the deficient care. The facility's policy requires incontinence care every 2 hours, which was not consistently provided.
Deficiencies (1)
Failure to provide timely incontinence care to dependent residents, resulting in saturated briefs and potential skin breakdown.
Report Facts
Residents affected: 6
CNA-to-patient ratio: 21
Required CNA-to-patient ratio: 14
Resident BIMS scores: 15
Resident BIMS scores: 3
Resident BIMS scores: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Identified residents as incontinent and dependent on staff; confirmed saturated briefs and staffing issues | |
| 7PM-7AM Licensed Practical Nurse (LPN) | Stated CNA should provide incontinence care every 2 hours but had too many residents | |
| 11-7 Certified Nursing Assistant (CNA) | Confirmed inability to provide incontinence care every 2 hours due to 21 residents on assignment | |
| Staffing Coordinator | Unaware of state-mandated CNA-to-resident ratios; confirmed misunderstanding of staffing requirements | |
| Director of Operations | Acknowledged night shift CNA-to-patient ratio was 1:21 instead of required 1:14; confirmed staffing noncompliance | |
| Director of Nursing (DON) | Confirmed incontinence care should be provided every 2 hours and as needed |
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
Routine
Deficiencies: 4
Date: Aug 30, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident assessments, care planning, facility licensing, infection prevention, and hand hygiene practices at Pine Acres Rehabilitation and Healthcare.
Findings
The facility was found deficient in accurately completing resident assessments, developing and implementing comprehensive care plans, notifying CMS of a facility name change, and maintaining infection prevention practices including proper urinary catheter care and hand hygiene. Deficiencies were noted in medication coding, care plan documentation, facility licensing name compliance, and infection control procedures.
Deficiencies (4)
Failure to accurately complete the Minimum Data Set (MDS) assessment for one resident, including omission of antipsychotic medication coding.
Failure to develop and implement a comprehensive, person-centered care plan reflecting residents' needs and refusals for two residents.
Failure to notify CMS and receive authorization for a change in facility name, resulting in noncompliance with Medicare enrollment requirements.
Failure to provide and implement an infection prevention and control program, including improper urinary catheter bag handling and inadequate hand hygiene practices.
Report Facts
Residents reviewed for MDS accuracy: 19
Residents reviewed for care plan deficiencies: 19
BIMS score: 4
BIMS score: 14
BIMS score: 13
BIMS score: 99
Medication administration dates: 3
Facility license expiration date: Aug 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, part-time MDS Coordinator | Interviewed regarding missed coding of antipsychotic medication in MDS | |
| Certified Nurse Assistant #2 | Interviewed about Resident #30's use of left arm due to right arm weakness | |
| Licensed Practical Nurse #3 | Interviewed about Resident #30's refusal to wear right-hand splint | |
| Certified Nurse Assistant #1 | Interviewed about Resident #15's resting hand splint and urinary catheter care | |
| Licensed Practical Nurse #1 | Confirmed physician's order for Resident #15's resting hand splint | |
| Licensed Practical Nurse #2 | Interviewed about proper handling of urinary catheter bag | |
| Infection Preventionist/Registered Nurse | Interviewed regarding infection control practices and hand hygiene | |
| Licensed Nursing Home Administrator | Met with survey team to discuss deficiencies and facility name change issue | |
| Director of Nursing | Met with survey team to discuss deficiencies and facility name change issue |
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
Annual Inspection
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Pine Acres Rehabilitation and Healthcare to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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
Routine
Census: 89
Deficiencies: 3
Date: Aug 22, 2022
Visit Reason
The inspection was conducted to evaluate compliance with sanitation procedures related to food handling, dishwashing, and proper storage of residents' food, as well as to assess the cleanliness of the dumpster area.
Findings
The facility failed to ensure dish machine rinse temperatures met required standards, resulting in inadequate sanitization of dishware, and failed to properly label and date residents' food or monitor freezer temperatures in residents' refrigerators. Additionally, the dumpster area was found to be unsanitary with garbage on the ground over multiple days.
Deficiencies (3)
Dish machine rinse temperature did not meet the minimum required 180°F, reaching only 169-170°F, risking inadequate sanitization of dishware.
Residents' food in refrigerators was not properly labeled or dated, and freezer temperatures were not monitored.
Dumpster area was not maintained in a sanitary manner, with significant garbage on the ground over two days.
Report Facts
Residents at risk: 86
Total residents present: 89
Garbage pieces observed: 30
Dish machine rinse temperature: 169
Dish machine rinse temperature: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director | Verified dish machine rinse temperatures and acknowledged issues with the machine | |
| Administrator | Interviewed regarding notification of dish machine issues and dumpster area maintenance | |
| Dietary Aide | Observed washing dishes and verified dish machine temperature readings | |
| Infection Preventionist | Verified use of disposable and regular dishware due to dishwasher issues | |
| Licensed Practical Nurse 2 | LPN | Verified mold on cheese and food labeling practices |
| Unit Manager 2 | UM | Verified food labeling and expiration practices on third floor |
| Unit Manager 1 | UM | Verified food labeling and expiration practices on first floor |
| Corporate Food Service Director | CFSD | Conducted monthly audits of refrigerators and commented on dumpster area sanitation |
| Housekeeper | Responsible for cleaning refrigerators and dumpster area |
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 |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 24, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with federal regulations regarding resident assessments and clinical care, including the timely completion and transmission of Minimum Data Set (MDS) assessments and the adequacy of nursing care following a resident fall.
Findings
The facility failed to timely complete and transmit required MDS assessments for 4 of 23 residents reviewed, including missing entry and discharge assessments. Additionally, the facility failed to ensure a Registered Nurse assessed a resident after a fall resulting in injury, and the resident did not receive timely evaluation and treatment according to nursing standards and facility policy.
Deficiencies (2)
Failure to complete and transmit Minimum Data Set (MDS) assessments timely for 4 residents, including missing discharge and entry tracking records.
Failure to ensure a Registered Nurse assessed a resident after a fall with injury and to provide evaluation and treatment in accordance with nursing standards and facility fall policy.
Report Facts
Residents reviewed for MDS assessments: 23
Residents with deficient MDS assessments: 4
Date of resident fall: Oct 4, 2019
PRN Tylenol dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Spoke with surveyor regarding untimely MDS assessments | |
| MDS Coordinator | Acknowledged assessments were not submitted timely | |
| Licensed Practical Nurse (LPN #1) | Reported assessing resident post-fall and provided statements about fall incident | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed about fall incident and facility policy | |
| Administrator | Discussed observations and concerns with survey team | |
| Regional Administrator | Discussed observations and concerns with survey team |
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