Inspection Reports for Rolling Hills Care Center
16 Cratetown Road, NJ, 08833
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Inspection Report
Routine
Census: 59
Capacity: 67
Deficiencies: 8
Feb 7, 2025
Visit Reason
A recertification/LSC survey was conducted from 1/29/25 through 2/7/25 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility was found to be in noncompliance with several regulatory requirements including failure to ensure resident safety related to food consistency, environmental safety concerns, inadequate notification before transfer or discharge, deficient care planning and infection control practices, and life safety code violations. Corrective actions were implemented and accepted by the survey team.
Complaint Details
Complaint numbers NJ 174181 and 174259 were investigated during this survey. The complaints involved issues related to staffing, resident safety, and care practices. The complaints were substantiated as evidenced by the deficiencies cited.
Severity Breakdown
Immediate Jeopardy: 2
Level 3: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure 5 residents were free from risk related to food consistency leading to an Immediate Jeopardy (IJ) situation. | Immediate Jeopardy |
| Failure to maintain a safe, clean, comfortable, and homelike environment with multiple environmental concerns including peeling wallpaper, broken floor tiles, and missing handrail end caps. | Level 3 |
| Failure to provide timely and proper notice before transfer or discharge of residents. | Level 3 |
| Failure to provide care and treatment in accordance with professional standards for residents reviewed for infection and hospitalization. | Level 3 |
| Failure to maintain a safe environment free from accident hazards for 5 residents at risk of harm. | Immediate Jeopardy |
| Failure to maintain kitchen sanitation and food safety protocols, including dishwasher temperature and sanitizer levels. | Level 3 |
| Failure to maintain fire safety code compliance including sprinkler system maintenance and exit access. | Level 3 |
| Failure to maintain adequate staffing levels as required by state regulations. | Level 3 |
Report Facts
Census: 59
Total Capacity: 67
Deficiencies cited: 8
Staffing hours: 174.75
Staffing hours difference: -22.75
Inspection Report
Annual Inspection
Census: 62
Capacity: 67
Deficiencies: 12
Nov 22, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident property protection, comprehensive care plans, quality of care, medication administration, staffing ratios, infection preventionist qualifications, food safety, emergency preparedness, life safety code compliance, and resident activities.
Complaint Details
Complaint # NJ00166500 related to failure to protect resident's personal belongings from loss or theft was substantiated with findings of unlabeled and un-inventoried clothing for Resident #214.
Severity Breakdown
SS=D: 4
SS=G: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to exercise reasonable care for the protection of resident's property from loss or theft by failing to ensure resident's personal belongings were labeled and inventoried. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for residents, including medication use and discharge planning. | SS=D |
| Failed to ensure residents received treatment and care in accordance with professional standards, including timely lab work and medication administration. | SS=G |
| Failed to maintain required staffing ratios for Certified Nursing Aides (CNAs) on day shifts. | — |
| Failed to provide two evening activity programs per week for residents. | — |
| Failed to maintain a three-day minimum emergency food and water supply, including expired items and missing items. | — |
| Failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control prior to assuming the role. | SS=D |
| Failed to maintain a system of record keeping for DEA Form-222 to ensure accurate reconciliation and prompt identification of loss or diversion of controlled substances. | — |
| Failed to maintain fire alarm system in accordance with NFPA 72, including removal of protective cover from smoke detector. | — |
| Failed to ensure corridor doors resist passage of smoke and close properly. | — |
| Failed to maintain emergency water supply sufficient for residents and staff for three days. | — |
| Failed to maintain a safe, clean, comfortable, and homelike environment, including sanitation of kitchen utensils and proper labeling and storage of resident clothing and personal belongings. | SS=D |
Report Facts
CNA staffing deficiency: 13
Resident census: 62
Total licensed beds: 67
Medication administration errors: 4
Medication administration opportunities: 27
Emergency water supply: 201
Expired emergency food items: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #214's family | Contacted and reimbursed for missing clothing items. | |
| Director of Nursing (DON) | Conducts audits of personal belongings inventory and medication administration. | |
| Director of Social Services (DoSS) | Completes audits of grievance forms related to missing items. | |
| Facility Educator | Educates staff on medication administration and personal belongings inventory. | |
| Regional Nurse Consultant (RNC) | Re-educated staff on CNA hiring and infection preventionist training. | |
| Licensed Nursing Home Administrator (LNHA) | Acknowledged staffing deficiencies and emergency preparedness issues. | |
| Staffing Coordinator | Coordinates CNA staffing assignments. | |
| Food Service Director (FSD) | Responsible for emergency food and water supply. | |
| Director of Activities (DoA) | Responsible for scheduling resident activities. | |
| Maintenance Director (MD) | Responsible for fire safety and maintenance of smoke detectors. |
Inspection Report
Routine
Census: 56
Deficiencies: 0
Oct 26, 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 and preparedness for COVID-19.
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
Enforcement
Deficiencies: 1
Jul 23, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as required by new minimum staffing laws.
Findings
The facility failed to meet required staffing ratios for 5 of 15 shifts reviewed, with CNA to resident ratios exceeding the mandated limits on multiple days. The deficient practice had the potential to affect all residents. The facility is actively attempting to hire new CNAs and has implemented corrective actions including bonuses, policy reviews, and increased recruitment efforts.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 5 of 15 shifts reviewed, with CNA to resident ratios exceeding minimum requirements. |
Report Facts
Shifts with staffing ratio deficiencies: 5
Staffing ratio day shift: 1
Staffing ratio day shift: 1
Staffing ratio night shift: 1
Number of Nursing Agency contracts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed by surveyor regarding staffing ratios and hiring efforts | |
| Administrator | Discussed staffing ratio concerns with surveyor | |
| Director of Nursing | Discussed staffing ratio concerns and corrective actions with surveyor; responsible for conducting weekly CNA staffing schedule audits | |
| Managers, Supervisors, Assistant Director of Nursing (ADON) | May assist with resident care depending on daily needs |
Inspection Report
Routine
Census: 47
Deficiencies: 0
Jan 28, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 5
Report
Nov 19, 2025
File
20251119-REPORT-notice_of_privacy_practices.pdf
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