Inspection Reports for Preferred Care at Cumberland
154 Sunny Slope Dr, Bridgeton, NJ 08302, NJ
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Notice
Deficiencies: 0
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 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Aug 19, 2024
Visit Reason
The inspection was conducted in response to Complaint Number NJ175824 to investigate allegations related to documentation deficiencies in resident care records.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to consistently document Activities of Daily Living (ADL) status for Resident #2, with multiple days of missing documentation across all shifts. The facility's policy and job descriptions require timely and accurate documentation, which was not met.
Complaint Details
Complaint Number NJ175824 triggered the investigation. The complaint was substantiated as the facility failed to document ADL care properly for Resident #2, with multiple days of missing documentation noted.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to consistently document Activities of Daily Living (ADL) status and follow Certified Nursing Aide job description and facility policy for documentation in medical records for Resident #2. | SS=D |
Report Facts
Census: 131
Days with missing documentation: 11
Days with missing documentation: 17
Days with missing documentation: 23
Sample size: 3
Inspection Report
Renewal
Census: 124
Deficiencies: 10
Feb 23, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and life safety code survey.
Findings
The facility was found to be in substantial compliance with emergency preparedness but had deficiencies in maintaining a safe, clean, and homelike environment, pressure ulcer treatment, respiratory care, nursing staffing, pharmacy services, food temperature control, infection prevention and control, and life safety code requirements including fire alarm system and sprinkler installation.
Complaint Details
Complaint numbers NJ 001052177, NJ 00150683, NJ00150837, NJ 00151536, NJ00152223, NJ00153534, NJ00159116 were investigated as part of this survey.
Severity Breakdown
Level D: 8
Level E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean environment in shower rooms. | Level D |
| Facility failed to provide necessary treatment and services to promote healing of pressure ulcers. | Level D |
| Facility failed to ensure there was a Physician's Order for respiratory care for one resident. | Level D |
| Facility failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week for 2 of 14 days reviewed. | Level D |
| Facility failed to follow appropriate standards of practice for pharmacy services including medication storage and labeling. | Level D |
| Facility failed to ensure food temperatures were maintained at safe levels. | Level D |
| Facility failed to implement infection control practices including use of PPE and isolation precautions. | Level D |
| Facility failed to ensure corridors had firmly secured handrails. | Level D |
| Facility failed to maintain fire alarm system sensitivity and sprinkler system coverage. | Level E |
| Facility failed to maintain electrical outlets and ensure emergency generator monthly load testing. | Level E |
Report Facts
Census: 124
Sample size: 30
Number of shower rooms inspected: 3
Residents reviewed for pressure ulcer treatment: 4
Residents reviewed for respiratory care: 1
Days reviewed for RN coverage: 14
Medication rooms inspected: 2
Medication carts inspected: 3
Food temperature surveys: 10
Smoke zones: 11
Resident sleeping rooms: 91
Electrical outlets tested: 12
Emergency generator load tests missing: 7
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 1
Sep 1, 2023
Visit Reason
The inspection was conducted based on complaint NJ166796 to investigate staffing ratio compliance at the facility.
Findings
The facility was found to be in substantial compliance with federal requirements but not in compliance with New Jersey state staffing ratio requirements, failing to meet minimum CNA staffing ratios on 10 of 14 day shifts reviewed.
Complaint Details
Complaint NJ166796 was substantiated as the facility failed to meet minimum CNA staffing ratios on multiple day shifts. No care concerns were reported related to the staffing deficiencies.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 10 of 14 day shifts. |
Report Facts
Census: 138
Deficient day shifts: 10
Required CNAs per day shift: 17
Actual CNAs on 08/13/23: 10
Actual CNAs on 08/14/23: 12
Actual CNAs on 08/15/23: 14
Actual CNAs on 08/16/23: 16
Actual CNAs on 08/17/23: 16
Actual CNAs on 08/18/23: 16
Actual CNAs on 08/19/23: 11
Actual CNAs on 08/20/23: 9
Actual CNAs on 08/22/23: 15
Actual CNAs on 08/26/23: 13
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Dec 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ149917, NJ149500, and NJ148351.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and infection control regulations related to COVID-19.
Complaint Details
The complaint survey found the facility in compliance with all applicable regulations.
Report Facts
Sample Size: 4
Inspection Report
Plan of Correction
Census: 137
Deficiencies: 1
Nov 12, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically regarding mandatory access to care and staffing ratios.
Findings
The facility failed to maintain the required minimum direct care staff to resident ratios for the day shift on 3 of 14 days reviewed, as mandated by the State of New Jersey. The facility submitted a plan of correction to address staffing shortages, including increased hiring, use of agency staff, and monitoring by the Director of Nursing.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. |
Report Facts
Residents on day shift: 137
Certified Nurse Aides (CNAs) present: 17
Required CNAs: 18
Certified Nurse Aides (CNAs) present: 16
Residents on day shift: 134
Required CNAs: 17
Certified Nurse Aides (CNAs) present: 16
Residents on day shift: 130
Required CNAs: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for weekly meetings to determine staffing needs and monthly audits of staffing patterns |
| Administrator | Interviewed by surveyor regarding staffing ratios and corrective actions |
Inspection Report
Life Safety
Deficiencies: 3
Nov 12, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/10/2021 and 11/12/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with several life safety code requirements including inadequate illumination of means of egress, failure to maintain self-closing devices on fire-rated doors to hazardous areas, and lack of audible and visible fire alarm notification devices in two outside enclosed courtyards. Corrective actions were implemented promptly by the maintenance director.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure continuous lighting with two lamps at exit discharge areas; some areas had only a single bulb or no lighting. | SS=D |
| Failed to provide and maintain self-closing devices and hardware on fire rated doors to hazardous areas, specifically the Medical Records room door. | SS=D |
| Failed to provide notification by audible and visible signals (horn/strobe) for two outside enclosed courtyards inspected. | SS=D |
Report Facts
Number of smoke zones: 11
Number of fire rated doors inspected: 1
Number of outside enclosed courtyards lacking fire alarm notification devices: 2
Number of banker boxes observed: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during observations and interviews related to deficiencies; acknowledged findings. | |
| Administrator | Notified of deficiencies at Life Safety Code exit conference on 11/12/2021. |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Aug 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145171 and NJ142626.
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.
Complaint Details
Complaint numbers NJ145171 and NJ142626 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 14
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 0
May 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ139345, NJ140291, and NJ140555.
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.
Complaint Details
Complaint numbers NJ139345, NJ140291, and NJ140555 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 4
Jan 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health due to concerns about infection control practices related to COVID-19.
Findings
The facility failed to implement appropriate infection control practices, including improper use of Personal Protective Equipment (PPE) such as not changing gowns between residents on the PUI unit and staff wearing surgical masks instead of N95 masks despite CDC and NJDOH guidance. This posed a serious and immediate threat to residents. The facility was found to have corrected the immediate jeopardy by the date of the onsite removal plan verification survey.
Complaint Details
The visit was complaint-related due to concerns about infection control practices during the COVID-19 pandemic, including PPE use and hand hygiene. The immediate jeopardy was identified on 1/21/2021 and removed by 1/25/2021.
Severity Breakdown
Immediate Jeopardy: 1
Level F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to wear isolation gowns properly and change soiled gowns between residents on the PUI unit, exposing residents to COVID-19. | Immediate Jeopardy |
| Failure to provide hand hygiene to residents before meals. | Level F |
| Staff wearing surgical masks instead of required N95 masks on PUI units, including staff with respiratory issues allowed to wear surgical masks without formal policy or training. | Level F |
| Staff exiting COVID-19 positive unit while still wearing isolation gowns. | Level F |
Report Facts
Census: 142
COVID-19 positive residents: 25
Staff out on quarantine: 9
Staff observed with deficient PPE use: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed wearing same gown between residents and failing to provide hand hygiene to residents before meals. |
| CNA #2 | Certified Nursing Assistant | Observed wearing same gown between residents, wearing surgical mask instead of N95, and failing to provide hand hygiene. |
| LPN/UM #1 | Licensed Practical Nurse Unit Manager | Observed wearing surgical mask instead of N95 and did not provide hand hygiene to residents. |
| LPN #1 | Licensed Practical Nurse | Observed wearing surgical mask instead of N95 and did not provide hand hygiene to resident. |
| CNA #3 | Agency Certified Nursing Assistant | Observed wearing surgical mask instead of N95 due to discomfort. |
| Housekeeper | Housekeeper | Observed wearing surgical mask instead of N95 while cleaning PUI rooms. |
| CNA #4 | Certified Nursing Assistant | Observed exiting COVID-19 positive unit wearing isolation gown. |
| LPN #3 | Licensed Practical Nurse | Observed exiting COVID-19 positive unit wearing two isolation gowns. |
| DON | Director of Nursing | Provided statements regarding PPE policies and staff mask use. |
| LNHA | Licensed Nursing Home Administrator | Provided statements regarding PPE policies and staff mask use. |
| IP | Infection Preventionist | Provided statements regarding PPE policies and staff mask use. |
| AD | Activities Director | Reported providing hand hygiene to residents but did not do so during survey observation. |
Inspection Report
Routine
Census: 134
Deficiencies: 0
Dec 11, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 145
Deficiencies: 0
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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 2
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