Inspection Reports for
Rolling Hills Care Center
16 Cratetown Road, Lebanon, NJ, 08833
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
88% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health 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
Routine
Census: 59
Capacity: 67
Deficiencies: 8
Date: 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.
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.
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.
Deficiencies (8)
Failure to ensure 5 residents were free from risk related to food consistency leading to an Immediate Jeopardy (IJ) situation.
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.
Failure to provide timely and proper notice before transfer or discharge of residents.
Failure to provide care and treatment in accordance with professional standards for residents reviewed for infection and hospitalization.
Failure to maintain a safe environment free from accident hazards for 5 residents at risk of harm.
Failure to maintain kitchen sanitation and food safety protocols, including dishwasher temperature and sanitizer levels.
Failure to maintain fire safety code compliance including sprinkler system maintenance and exit access.
Failure to maintain adequate staffing levels as required by state regulations.
Report Facts
Census: 59
Total Capacity: 67
Deficiencies cited: 8
Staffing hours: 174.75
Staffing hours difference: -22.75
Inspection Report
Routine
Deficiencies: 10
Date: Feb 7, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with state and federal regulations related to resident care, safety, environment, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, failure to notify the State Long-Term Care Ombudsman of resident hospitalization, failure to provide timely notification of bed hold policy, failure to monitor and document IV catheter dressing changes, failure to schedule resident appointments, failure to provide pureed diet consistent with physician orders, failure to obtain re-weights after significant weight loss, failure to maintain kitchen sanitation and dish machine temperatures, failure to perform proper hand hygiene and infection control practices, and failure to maintain a safe and sanitary emergency food storage room.
Deficiencies (10)
Failed to maintain a safe and homelike environment with peeling wallpaper, broken floor tiles, missing handrail end caps, and lack of maintenance policies.
Failed to notify the State Long-Term Care Ombudsman of a resident hospitalization.
Failed to provide written notification of the facility's bed hold policy to resident or representative.
Failed to accurately monitor and document dressing changes for a midline IV catheter and ensure care met professional standards.
Failed to schedule a urology follow-up appointment as ordered for a resident with recurrent UTIs.
Failed to ensure residents on pureed diets received food consistent with prescribed texture, serving pastina and couscous instead of smooth pureed food.
Failed to obtain a re-weight after significant weight loss and notify dietician or physician.
Failed to maintain proper kitchen sanitation and dish machine temperatures, and staff failed to wear hair nets.
Failed to perform proper hand hygiene when donning and doffing gloves and failed to initiate enhanced barrier precautions for a resident with a PICC line.
Failed to maintain a safe and sanitary emergency food storage room with leaks and contamination near food supplies.
Report Facts
Weight loss percentage: 10.5
Dishwasher temperature: 136
Dishwasher temperature: 145
Dishwasher temperature: 146
Dishwasher rinse temperature: 94
Dishwasher rinse temperature: 95
Chemical sanitizer concentration: 10
Pureed spaghetti portion: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EVS #1 | Environmental Services Staff | Observed failing to perform hand hygiene when donning and doffing gloves. |
| Director of Maintenance | Interviewed regarding environmental maintenance and food storage room leaks. | |
| Licensed Nursing Home Administrator | Acknowledged findings related to environment, infection control, and food storage. | |
| Director of Nursing | Interviewed regarding infection control practices and IV dressing changes. | |
| Registered Nurse #1 | RN | Interviewed regarding IV dressing change practices. |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding pureed diet consistency. |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding pureed diet and weight monitoring. |
| Food Service Director | FSD | Interviewed regarding kitchen sanitation and dish machine issues. |
| Regional Food Service Director | RFSD | Interviewed regarding kitchen sanitation and dish machine issues. |
| Infection Preventionist | IP | Interviewed regarding infection control and hand hygiene education. |
| Director of Social Services | DSS | Interviewed regarding notification to Ombudsman and bed hold notices. |
| Medical Director | MD | Interviewed regarding urology appointment and pureed diet consistency. |
| Staffing Coordinator | SC | Interviewed regarding scheduling resident appointments. |
| Director of Rehabilitation | DOR | Interviewed regarding pureed diet consistency. |
| Registered Dietician | RD | Interviewed regarding pureed diet consistency and weight monitoring. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 67
Deficiencies: 12
Date: Nov 22, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
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.
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.
Deficiencies (12)
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.
Failed to develop and implement a comprehensive person-centered care plan for residents, including medication use and discharge planning.
Failed to ensure residents received treatment and care in accordance with professional standards, including timely lab work and medication administration.
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.
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.
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
Complaint Investigation
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
The inspection was conducted based on complaints regarding missing resident belongings and failure to follow physician orders for laboratory tests at Rolling Hills Care Center.
Complaint Details
Complaint # NJ00166500 involved missing personal belongings of Resident #214. Complaint # NJ00154003 involved failure to follow physician's order and notify physician regarding missed serum CBC for Resident #215.
Findings
The facility failed to ensure proper labeling and inventory of resident clothing for Resident #214, resulting in missing personal items without proper grievance investigation. Additionally, the facility failed to follow a physician's order for a timely serum CBC test for Resident #215 and did not notify the physician of the missed lab, resulting in a critical low hemoglobin level being discovered late.
Deficiencies (2)
Failed to exercise reasonable care for the protection of resident's property by not labeling and inventorying clothing for Resident #214.
Failed to follow physician's order for serum CBC on time and failed to notify physician of missed lab for Resident #215.
Report Facts
Residents reviewed for closed records: 5
Residents reviewed for quality of care: 16
BIMS score: 6
BIMS score: 15
Critical low hemoglobin level: 5.4
Physician order date: Jan 31, 2022
Lab drawn date: Feb 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding process for resident clothing and missing items | |
| Director of Nursing (DON) | Interviewed regarding resident clothing process and missing items complaint | |
| Director of Social Services (DoSS) | Interviewed regarding grievance process and missing items | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding missing items complaint and grievance process | |
| Housekeeping Manager (HM) | Interviewed regarding laundry and labeling of resident clothing | |
| Assistant Director of Nursing (ADON) | Interviewed regarding laboratory requisition process and missed lab | |
| Licensed Practical Nurse (LPN) | Wrote progress notes about Resident #215's nosebleed and lab orders |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 67
Deficiencies: 10
Date: Nov 22, 2023
Visit Reason
Complaint investigation related to missing resident belongings, care planning, pressure ulcer care, respiratory care, medication errors, infection preventionist training, emergency water supply, and nurse aide training compliance.
Complaint Details
Complaint # NJ00166500 regarding missing resident belongings and multiple care and compliance issues.
Findings
The facility was found deficient in multiple areas including failure to protect resident property, incomplete care plans for smoking and psychotropic medication use, inadequate pressure ulcer care and documentation, improper respiratory care, medication administration errors, lack of proper infection preventionist training prior to role assumption, insufficient emergency water supply, and failure to verify nurse aide training and competency before independent assignments.
Deficiencies (10)
Failed to ensure resident's personal belongings were labeled and inventoried, resulting in missing clothing for Resident #214.
Failed to develop a comprehensive care plan addressing smoking and psychotropic medication use for Resident #24.
Failed to document incident report and investigation for facility-acquired pressure ulcers and failed to accurately code MDS for Resident #214; also failed to timely assess and treat pressure ulcer for Resident #3.
Failed to maintain necessary respiratory care and services for Resident #38 receiving continuous oxygen.
Failed to verify nurse aide was enrolled and actively taking CNA training classes and validated completion of Module 1 before independent resident assignment.
Failed to maintain a system of record keeping for DEA Form-222, resulting in missing forms and inability to track controlled substances properly.
Medication administration errors observed with a 7.41% error rate including administering incorrect eye drops and bowel regimen medications.
Failed to handle potentially hazardous foods and maintain sanitation in the kitchen, including unclean utensils, improper bread date labeling, and expired emergency water supply.
Infection Preventionist did not have required specialized training prior to assuming the role.
Failed to maintain designated emergency water supply for residents and staff in accordance with emergency disaster plan; water supply was expired and insufficient.
Report Facts
Residents affected by missing belongings: 1
Residents sampled for care plan deficiency: 16
Residents reviewed for pressure ulcers: 2
Medication administration opportunities observed: 27
Medication administration errors observed: 2
Medication error rate: 7.41
Resident census: 62
Total licensed capacity: 67
Emergency water supply: 81
Required emergency water supply: 201
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Interviewed regarding missing resident clothing process | |
| Director of Nursing (DON) | Interviewed regarding multiple deficiencies including care plans, pressure ulcer care, medication errors, and emergency water supply | |
| Director of Social Services (DoSS) | Interviewed regarding grievance process for missing items | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding multiple deficiencies including grievance process, nurse aide training, emergency water supply, and DEA form management | |
| Housekeeping Manager (HM) | Interviewed regarding laundry and resident clothing labeling | |
| Infection Preventionist (IP) | Interviewed regarding pressure ulcer care and infection prevention training | |
| Licensed Practical Nurse (LPN) | Observed medication administration with errors | |
| Food Service Director (FSD) | Interviewed regarding kitchen sanitation and emergency water supply | |
| Nurse Aide (NA) | Interviewed regarding CNA training and resident assignment | |
| Regional Nurse Consultant (RNC) | Present during multiple interviews and exit conference | |
| Assistant Director of Nursing (ADON) | Present during exit conference | |
| [NAME] President of Skilled Nursing Division (VPoSND) | Present during exit conference |
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: 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
Date: 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)
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
Deficiencies: 5
Date: Jul 23, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident privacy during medication administration and phlebotomy, care plan implementation, medication administration documentation, respiratory care, and pharmaceutical services.
Findings
The facility was found deficient in providing full visual privacy during medication administration and phlebotomy for several residents, inconsistent implementation of care plan interventions for pressure ulcer prevention, failure to sign medication and treatment administration records, improper oxygen administration and tubing management, and discrepancies in controlled medication inventory and documentation.
Deficiencies (5)
Failure to provide full visual privacy during medication administration and phlebotomy services for 4 of 14 residents.
Failure to consistently implement care plan interventions to provide pressure reduction for a resident at high risk of pressure ulcers.
Failure to sign for medications in the Electronic Medication Administration Record and treatments in the Electronic Treatment Administration Record for 2 of 14 residents.
Failure to administer oxygen in accordance with physician's orders and improper management of oxygen tubing for 2 residents.
Failure to ensure accurate inventory and documentation of controlled medications in the automatic medication dispensing system.
Report Facts
Residents affected: 4
Residents reviewed: 14
Residents reviewed: 17
Oxygen flow rates: 2.5
Oxygen flow rates: 3
Oxygen flow rates: 4
Medication discrepancies: 2
Missing nurse signatures: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Licensed Practical Nurse | LPN | Observed failing to provide privacy during medication administration and unable to recall medication dispensing discrepancy |
| Unnamed Certified Nursing Assistant | CNA | Observed changing oxygen settings without authorization |
| Unnamed Director of Nursing | DON | Interviewed regarding privacy concerns, oxygen administration, and medication discrepancies |
| Unnamed Licensed Nursing Home Administrator | LNHA | Interviewed regarding privacy concerns and medication administration policies |
| Unnamed Assistant Director of Nursing | ADON | Interviewed about controlled medication discrepancies and staffing issues |
| Unnamed Registered Nurse | RN | Interviewed regarding oxygen administration and medication administration practices |
Inspection Report
Routine
Census: 47
Deficiencies: 0
Date: 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
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