Inspection Reports for Regency Heritage Nursing And Rehabilitation Center
380 Demott Lane, NJ, 08873
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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 questions about the notice |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 1
Apr 28, 2025
Visit Reason
The inspection was conducted based on complaints NJ00185340, NJ00175616, and NJ00183791 to investigate compliance with federal regulations related to resident records and activities of daily living documentation.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to accurately and consistently document Activities of Daily Living (ADLs) for residents. Deficiencies were observed in medical record documentation and staff adherence to documentation policies.
Complaint Details
Complaint investigation based on complaints NJ00185340, NJ00175616, and NJ00183791. The facility was found not in substantial compliance with federal requirements related to resident records and ADL documentation.
Severity Breakdown
Level 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accurately and consistently document all Activities of Daily Living (ADLs) of residents #1, #2, and #3 in the Certified Nursing Assistant Observation Sheet (COS) according to facility policy and procedure. | Level 2 |
Report Facts
Census: 181
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 192
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted in response to Complaint #NJ181913 to investigate allegations related to staffing ratios at Regency Heritage Nursing and Rehabilitation Center.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on all 21 day shifts reviewed. The facility was deficient in CNA staffing for 7 of 7 day shifts during 12/15/2024 to 12/21/2024 and 14 of 14 day shifts from 12/29/2024 to 01/11/2025, with fewer CNAs than required by state law.
Complaint Details
Complaint #NJ181913 was substantiated with findings that the facility did not meet mandatory CNA staffing ratios on all day shifts reviewed during the complaint period.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 21 of 21 day shifts. |
Report Facts
Census: 192
Deficient CNA staffing days: 21
Required CNAs: 23
Actual CNAs: 19
Inspection Report
Complaint Investigation
Census: 195
Capacity: 265
Deficiencies: 4
Apr 26, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to multiple complaints (NJ163525, NJ179143, NJ162866, NJ171841, NJ161011, NJ168161) to assess compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with federal and state regulations, including failure to notify resident representatives of significant changes, incomplete PASARR Level I assessments for residents, and failure to maintain required minimum direct care staff-to-resident ratios. Additionally, fire doors were not inspected annually as required.
Complaint Details
The visit was triggered by multiple complaints (NJ163525, NJ179143, NJ162866, NJ171841, NJ161011, NJ168161). The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify resident's responsible party regarding a new diagnosis and change in condition. | SS=D |
| Failure to ensure accurate PASARR Level I assessments were completed after admission for residents. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law. | — |
| Failure to ensure fire doors were inspected annually by qualified personnel as required by NFPA 101 Life Safety Code. | SS=F |
Report Facts
Survey Census: 195
Total Licensed Capacity: 265
Sample Size: 42
Deficiency Completion Dates: 05/24/2024
CNA Staffing Deficiencies: 7
Required CNA Staffing: 20
Actual CNA Staffing: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in deficiency related to failure to notify resident's responsible party of condition changes. |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for reviewing notification policies and compliance. |
| Admissions Director | Admissions Director | Reinserviced on PASARR accuracy and responsible for reviewing PASARR documentation. |
| Social Service Director | Social Service Director | Reinserviced on PASARR accuracy and responsible for reviewing PASARR documentation. |
| Maintenance Director | Maintenance Director | Created inspection form and responsible for fire door inspections. |
| Administrator/Designee | Administrator/Designee | Responsible for reviewing staffing and ensuring mandatory staffing is maintained. |
Inspection Report
Abbreviated Survey
Census: 170
Deficiencies: 0
Sep 13, 2023
Visit Reason
A Focused Infection Control survey was conducted on behalf of the New Jersey Department of Health.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Census: 168
Deficiencies: 3
Jan 25, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. In addition, a COVID-19 Focused Infection Control Survey was conducted.
Findings
The facility was found deficient in infection control related to respiratory/tracheostomy care and suctioning, and food safety practices including improper handling, storage, and dating of food items. Additionally, the facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement infection control measures for handling and storage of respiratory care equipment for 2 of 4 residents reviewed. | SS=D |
| Failure to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. | SS=E |
| Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 11 of 14 day shifts and 1 of 14 overnight shifts reviewed. | — |
Report Facts
Census: 168
Deficiencies cited: 3
CNA staffing deficiency counts: 11
Overnight staffing deficiency counts: 1
Required CNAs on 12/19/21: 22
Actual CNAs on 12/19/21: 16
Required CNAs on 12/20/21: 22
Actual CNAs on 12/20/21: 18
Required CNAs on 12/21/21: 22
Actual CNAs on 12/21/21: 16
Required CNAs on 12/22/21: 22
Actual CNAs on 12/22/21: 16
Required CNAs on 12/23/21: 22
Actual CNAs on 12/23/21: 19
Required CNAs on 12/24/21: 21
Actual CNAs on 12/24/21: 19
Required CNAs on 12/25/21: 21
Actual CNAs on 12/25/21: 18
Required CNAs on 12/26/21: 21
Actual CNAs on 12/26/21: 17
Required CNAs on 12/29/21: 22
Actual CNAs on 12/29/21: 18
Required CNAs on 12/30/21: 22
Actual CNAs on 12/30/21: 14
Required total staff on 12/31/21 overnight: 13
Actual total staff on 12/31/21 overnight: 12
Required CNAs on 01/01/22: 21
Actual CNAs on 01/01/22: 17
Inspection Report
Life Safety
Deficiencies: 6
Jan 25, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 1/24/2022 and 1/25/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including fire barrier door self-closing mechanisms, fire alarm notification in outdoor resident areas, sprinkler system coverage, smoke barrier maintenance, HVAC ventilation system maintenance, and electrical receptacle GFCI protection. Corrective actions and plans of correction were outlined for each deficiency.
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Fire-rated corridor door leading into the Medical records room had no means to self-close. | SS=D |
| Facility failed to provide fire alarm notification by audible and visible signals for 2 enclosed outdoor resident areas. | SS=E |
| Facility failed to provide proper fire sprinkler coverage in the soiled utility room due to an incorrectly installed escheon cap blocking the sprinkler head. | SS=D |
| Smoke barriers were not maintained as smoke, fire, and poisonous gas resistant in sleeping areas; dining room doors lacked self-closing devices. | SS=D |
| Facility ventilation systems were not properly maintained; 6 of 12 resident bathroom exhaust systems failed to function properly when tested. | SS=E |
| One electrical outlet near a water source lacked GFCI protection and two GFCI outlets failed to function properly when tested. | SS=D |
Report Facts
Deficiencies cited: 6
Facility smoke zones: 22
Medical records room size: 264
Resident bathrooms inspected: 12
Resident bathrooms with exhaust failure: 6
Electrical outlets inspected near water sources: 12
Electrical outlets failing GFCI test: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during observations and confirmed findings related to fire door self-closing devices, fire alarm notification, sprinkler system, smoke barriers, ventilation, and electrical outlets. | |
| Facility Administrator | Informed of all findings during the Life Safety Code survey exit conference. |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 4
Oct 5, 2021
Visit Reason
Complaint investigation based on multiple complaints (NJ 147495, NJ 148044, NJ 148226, NJ 148430) regarding abuse allegations, staffing, infection control, and care issues at Regency Heritage Nursing and Rehabilitation Center.
Findings
The facility was found not in substantial compliance with requirements due to failure to report alleged verbal abuse timely, inadequate investigation of abuse allegations, failure to maintain required minimum direct care staff-to-resident ratios, delayed feeding of a resident, delayed call bell responses, and failure to follow manufacturer cleaning instructions for glucometers leading to infection control concerns.
Complaint Details
Complaint numbers NJ 147495, NJ 148044, NJ 148226, NJ 148430 triggered the investigation. The facility failed to report verbal abuse allegations timely and failed to thoroughly investigate abuse allegations. Staffing shortages and care delays were documented. Infection control lapses were identified in glucometer cleaning practices.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report an alleged verbal abuse violation to the New Jersey Department of Health for 1 of 3 residents reviewed for abuse allegations. | SS=D |
| Failure to thoroughly and timely investigate an allegation of verbal abuse for 1 of 3 residents reviewed for abuse. | SS=D |
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 33 of 35-day shifts and 29 of 35 overnight shifts reviewed; failure to ensure timely feeding for 1 of 13 residents; failure to ensure timely call bell responses for 3 of 13 residents. | SS=E |
| Failure to follow manufacturer's directions for cleaning and disinfecting glucometers for 4 of 4 residents observed, risking infection transmission. | SS=E |
Report Facts
Census: 168
Sample size: 13
Staffing ratios: 33
Staffing ratios: 29
Residents with delayed feeding: 1
Residents with delayed call bell response: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding abuse investigation and staffing | |
| Assistant Director of Nursing (ADON) | Provided investigation summary and interviewed about abuse allegations and infection control | |
| Administrator | Interviewed regarding abuse reporting and staffing | |
| Certified Nurses Aide (CNA #1) | Named in verbal abuse allegation and investigation | |
| Registered Nurse Charge Nurse (RN/CN) | Observed during medication pass and glucometer cleaning | |
| Medication Nurse | Interviewed about glucometer cleaning practices | |
| Director of Social Services (DOSS) | Interviewed regarding abuse investigation and concern forms |
Inspection Report
Complaint Investigation
Census: 183
Deficiencies: 0
Jul 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145122, NJ142811, NJ140596, NJ14701, and NJ140648.
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 NJ145122, NJ142811, NJ140596, NJ14701, and NJ140648 were investigated and found to be in compliance.
Report Facts
Sample Size: 6
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 0
Jan 22, 2021
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: 11
Inspection Report
Abbreviated Survey
Census: 176
Deficiencies: 7
Dec 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations related to appropriate use of PPE during COVID-19 testing and care of newly admitted residents under investigation, sharing of gowns between residents, hand hygiene practices, proper doffing of single-use gowns, posting of transmission-based precaution signs, and access to hand hygiene stations in the COVID-19 positive cohort unit.
Severity Breakdown
SS=E: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to wear full PPE including gown, eye protection, and respirator mask during rapid antigen COVID-19 testing. | SS=E |
| Gowns were shared between residents under investigation for COVID-19 contrary to CDC guidelines. | SS=E |
| Hand hygiene was not performed in accordance with CDC guidelines, including failure to perform hand hygiene after glove removal and before donning new PPE. | SS=E |
| Single-use gowns were doffed improperly, including doffing in hallways rather than inside resident rooms. | SS=E |
| Transmission-based precaution signs were incomplete or missing, lacking instructions for eye protection and respirator use. | SS=E |
| Lack of accessible alcohol-based hand gel in the PPE changing area and along the COVID-19 positive cohort unit hallway. | SS=E |
| Staff did not consistently wear eye protection; some relied on eyeglasses which are not considered adequate eye protection. | SS=E |
Report Facts
Census: 176
Sample size: 5
Completion date for plan of correction: Jan 21, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Observed not wearing gown or eye protection while emptying urine drainage bag; acknowledged forgetting PPE; interviewed about PPE use and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Observed not wearing eye protection during resident care and rapid antigen testing; interviewed about PPE policies and practices |
| LPN #2 | Licensed Practical Nurse | Observed wearing eye protection; interviewed about PPE use |
| CNA #4 | Certified Nursing Aide | Interviewed about lack of alcohol-based hand gel in COVID-19 positive cohort unit PPE changing area |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Interviewed multiple times regarding PPE policies, compliance monitoring, and infection control practices |
Inspection Report
Routine
Census: 174
Deficiencies: 0
Dec 3, 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: 5
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