Inspection Reports for
Royal Suites Health Care & Rehabilitation
214 West Jimmie Leeds Road, Galloway Township, NJ, 08205
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
88% occupied
Based on a December 2024 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 as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by the New Jersey Department of Health and Senior Services and its components, and to describe 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, legal duties of the department, and contact information for privacy concerns.
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
Deficiencies: 2
Date: May 23, 2025
Visit Reason
The inspection was conducted based on complaints regarding inadequate incontinence care and pressure ulcer management at Royal Suites Health Care & Rehabilitation.
Complaint Details
Complaint #NJ183027 involved failure to provide appropriate pressure ulcer care and prevention for Resident #288, including missed wound treatments, incomplete skin assessments, and inconsistent implementation of pressure-relieving interventions.
Findings
The facility failed to provide appropriate incontinence care to residents needing assistance with toileting hygiene and failed to consistently follow physician orders and implement pressure ulcer prevention and treatment protocols for a resident with a facility-acquired pressure ulcer. Documentation and care plan updates were also deficient.
Deficiencies (2)
Failure to ensure appropriate incontinence care for residents needing assistance with toileting hygiene, evidenced by saturated briefs, malodorous urine odor, and lack of timely changing.
Failure to consistently follow physician orders for treatment of facility-acquired pressure ulcer, implement pressure-relieving interventions, and complete weekly skin assessments.
Report Facts
Residents assigned per CNA: 12
Pressure ulcer size: 1
Dates of missed wound treatments: 2
Dates of missed air mattress checks: 8
Dates of missed skin assessments: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated CNAs check residents every 2 hours but do not document checks; stated blank in administration record means order not done. |
| Licensed Practical Nurse/ Unit Manager #2 | LPN/UM | Observed saturated incontinence brief and malodorous urine odor for Resident #68. |
| Licensed Practical Nurse/ Unit Manager #1 | LPN/UM | Observed Resident #23 wet without incontinence brief and confirmed wet pants. |
| Certified Nursing Assistant #1 | CNA | Assigned to Resident #68 and Resident #23; reported workload and care details. |
| Certified Nursing Assistant #2 | CNA | Confirmed CNA assignments and resident changing frequency. |
| Licensed Nursing Home Administrator | LNHA | Stated facility did not have a policy for activities of daily living (ADLs). |
Inspection Report
Routine
Deficiencies: 7
Date: May 23, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including inadequate incontinence care for residents, inconsistent pressure ulcer care, failure to provide ordered urinary catheter care, medication administration errors including controlled substances and high-risk medications, unsafe food handling practices, and lapses in infection prevention and control practices such as failure to sanitize shared equipment and improper use of protective barriers.
Deficiencies (7)
Failure to provide appropriate incontinence care to residents needing assistance with toileting hygiene.
Failure to consistently follow physician orders for treatment of facility-acquired pressure ulcer and ensure pressure-relieving interventions and weekly skin assessments.
Failure to consistently provide urinary catheter care as ordered for a resident with a suprapubic catheter.
Failure to accurately document administration of controlled medications for a resident.
Failure to ensure blood work and administration of high-risk medications were done as ordered for a resident.
Failure to handle potentially hazardous foods and maintain sanitation to prevent foodborne illness, including improper drying and storage of dishes and pans.
Failure to implement infection prevention and control practices including sanitizing shared equipment between residents, wearing protective gowns during high-contact care for residents on Enhanced Barrier Precautions, and placing residents with indwelling catheters on appropriate precautions.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) #2 | Observed during incontinence care and medication administration; failed to sanitize BP cuff and did not wear gown during Enhanced Barrier Precautions | |
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding care of Resident #68 and Resident #23 | |
| Director of Nursing (DON) | Interviewed regarding documentation practices, infection control, and medication errors | |
| Licensed Practical Nurse (LPN) | Observed during medication cart inspection and medication administration | |
| Registered Nurse/Infection Preventionist (RN/IP) | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers from 12/18/24 through 12/19/24.
Complaint Details
Complaint numbers NJ00169683, NJ00172246, NJ00173972, NJ00177724, and NJ00179480 were investigated. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long-term care facilities based on this complaint visit.
Report Facts
Sample Size: 16
Inspection Report
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Royal Suites Health Care & Rehabilitation.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 162
Deficiencies: 0
Date: Sep 5, 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 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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Routine
Deficiencies: 9
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, dining services, respiratory care, staffing, food safety, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to transport residents with dignity, inconsistent meal service timing, improper respiratory equipment care, inadequate staffing levels, unsafe food handling and storage, incomplete quality assurance documentation, and failure to enforce infection control PPE protocols for visitors and contractors.
Deficiencies (9)
Residents were pulled backwards in Geri chairs during transport, which is not appropriate and compromises dignity.
Residents were not served meals at the same time while seated at the same table, compromising dignity during dining.
Food was served on trays without removing food from trays to promote a homelike environment.
Nebulizer mask and tubing were not properly stored or covered, exposing equipment to contamination.
Nasal cannula tubing was not replaced weekly or stored properly as per facility policy.
Facility failed to maintain adequate nursing staff levels to meet resident needs, resulting in missed showers, delayed care, and unmet resident needs.
Food safety violations including uncovered food, expired items, dented cans, unclean nourishment room freezer, and improper labeling of resident food.
Quality Assessment and Performance Improvement (QAPI) program failed to properly document and implement corrective actions related to weight measurement discrepancies.
Visitors and contracted lab technicians entered COVID-19 isolation rooms without required PPE, violating infection control protocols.
Report Facts
Residents affected: 34
Residents affected: 17
Residents affected: 161
Certified Nurse Aides (CNAs) staffing: 7
Certified Nurse Aides (CNAs) staffing: 13
Certified Nurse Aides (CNAs) staffing: 15
Certified Nurse Aides (CNAs) staffing: 14
Certified Nurse Aides (CNAs) staffing: 16
Certified Nurse Aides (CNAs) staffing: 18
Certified Nurse Aides (CNAs) staffing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM/LPN #1 | Unit Manager Licensed Practical Nurse | Named in findings related to improper resident transport and dining service |
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding resident transport, staffing, infection control, and QAPI |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in interviews regarding respiratory care and infection control |
| CNA #5 | Certified Nursing Assistant | Named in staffing and resident care interviews |
| CNA #3 | Certified Nursing Assistant | Named in staffing interviews |
| Staffing Director | Staffing Director | Named in staffing interviews |
| Food Service Director | Food Service Director | Named in food safety observations |
| Unit Manager/Licensed Practical Nurse #2 | Unit Manager Licensed Practical Nurse | Named in infection control observation |
| Infection Preventionist | Infection Preventionist | Named in infection control interview |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Named in staffing interview |
Inspection Report
Routine
Census: 161
Deficiencies: 10
Date: Mar 8, 2023
Visit Reason
Routine inspection of Royal Suites Health Care & Rehabilitation to assess compliance with New Jersey Administrative Code and federal regulations related to staffing, infection control, emergency preparedness, resident rights, food safety, respiratory care, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain required minimum direct care staff ratios, inadequate influenza vaccination records for employees, failure to conduct required emergency preparedness drills, failure to ensure resident dignity during transport and meal service, improper food handling and storage, insufficient nursing staff to meet resident needs, failure to properly maintain respiratory equipment, and deficiencies in infection prevention and control practices. The facility also failed to fully implement and document quality assurance and performance improvement activities.
Deficiencies (10)
Failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey.
Failed to maintain a record of influenza vaccinations for all facility employees, per diem and contract employees as required.
Failed to conduct required emergency preparedness drills including community-based or facility-based exercises twice annually.
Failed to ensure residents were transported in a dignified manner and meals were served at the same time to residents seated at the same table.
Failed to create a homelike environment during dining by not removing food from serving trays.
Failed to provide necessary respiratory care equipment maintenance including replacing and properly storing respiratory equipment.
Failed to provide sufficient nursing staff to ensure resident care needs were met including assistance with activities of daily living and showers.
Failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness.
Failed to ensure visitors and contracted agents adhered to infection prevention and control practices including proper use of personal protective equipment (PPE).
Failed to utilize the Quality Assessment and Performance Improvement (QAPI) program effectively to measure and improve compliance with obtaining resident weights as ordered.
Report Facts
Residents present: 161
Staffing ratios: 7
Staffing ratios: 13
Staffing ratios: 5
Staffing ratios: 10
Staffing ratios: 13
Staffing ratios: 8
Staffing ratios: 15
Staffing ratios: 10
Staffing ratios: 14
Staffing ratios: 12
Staffing ratios: 8
Staffing ratios: 16
Staffing ratios: 12
Staffing ratios: 9
Staffing ratios: 7
Staffing ratios: 8
Staffing ratios: 14
Staffing ratios: 8
Staffing ratios: 14
Staffing ratios: 16
Staffing ratios: 7
Staffing ratios: 11
Staffing ratios: 16
Staffing ratios: 7
Staffing ratios: 18
Staffing ratios: 15
Staffing ratios: 9
Staffing ratios: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM/LPN #1 | Unit Manager Licensed Practical Nurse | Named in resident transport and meal service dignity findings and re-educated on resident rights and communication process. |
| Resident #18 | Resident | Assessed by Registered Nurse for adverse effects related to lying in urine and feces. |
| Resident #41 | Resident | Assessed by Registered Nurse for adverse effects related to not being able to get assistance to get out of bed. |
| Resident #43 | Resident | Assessed by Registered Nurse for adverse effects related to staffing issues. |
| Resident #13 | Resident | Assessed by Assistant Director of Nursing for psychosocial effects related to transport dignity. |
| Resident #82 | Resident | Assessed by Assistant Director of Nursing for psychosocial effects related to meal service timing. |
| Resident #145 | Resident | Had respiratory equipment replaced and care plan reviewed. |
| Resident #36 | Resident | Had respiratory equipment replaced and care plan reviewed. |
| DON | Director of Nursing | Acknowledged staffing shortages and discussed QAPI and infection control practices. |
| ADON | Assistant Director of Nursing | Re-educated staff on resident rights, respiratory equipment care, and infection control. |
| FSD | Food Service Director | Re-educated on food safety, labeling, and infection control. |
| IP | Infection Preventionist | Re-educated staff and conducted infection control rounds. |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding staffing and care issues. |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding staffing and care issues. |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding staffing and care issues. |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding staffing and care issues. |
| UM/LPN #2 | Unit Manager Licensed Practical Nurse | Interviewed regarding staffing and care issues. |
| Staffing Director | Interviewed regarding staffing shortages. | |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding admissions and staffing. |
Inspection Report
Routine
Census: 157
Capacity: 186
Deficiencies: 7
Date: Mar 8, 2023
Visit Reason
Routine inspection of Royal Suites Health Care & Rehabilitation to assess compliance with fire safety, building, and equipment regulations.
Findings
The facility was found deficient in multiple areas including emergency lighting, cooking facilities inspection, smoke barrier doors, HVAC bathroom ventilation, elevator emergency communication, fire drills, and electrical receptacle testing. Corrective actions were implemented and verified during a revisit.
Deficiencies (7)
Failed to provide battery back-up emergency lighting above transfer switches independent of building electrical system.
Failed to ensure monthly inspection tags for kitchen ansul systems were completed and logged.
Smoke barrier doors did not completely close, allowing approximately 1/4" gap that could permit smoke and gases to pass.
Resident bathroom ventilation systems were not adequately maintained and failed to operate properly in 8 of 50 rooms.
Failed to maintain elevator emergency communication telephone for 1 of 2 passenger elevators.
Fire drills lacked varying activation types and simulation of specific emergency fire conditions for 11 of 13 drills.
Failed to functionally test electrical receptacles in residents' rooms annually for grounding, polarity, and blade tension for 47 of 75 rooms.
Report Facts
Certified beds: 186
Census: 157
Deficiencies cited: 7
Resident rooms with ventilation issues: 8
Resident rooms with untested electrical receptacles: 47
Fire drills lacking varied simulation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director | Present during emergency lighting deficiency observation. | |
| Maintenance Director | Named in multiple findings including emergency lighting, kitchen inspections, smoke doors, HVAC, elevator, fire drills, and electrical systems. | |
| Regional Plant Operations Director | Present during kitchen ansul system and electrical receptacle inspections. | |
| Administrator | Informed of all findings and responsible for education and corrective action oversight. | |
| Director of Maintenance | Conducted audits and corrective actions for smoke barrier doors, ventilation, elevator, fire drills, and electrical receptacles. |
Inspection Report
Abbreviated Survey
Census: 154
Deficiencies: 2
Date: Dec 14, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 12/14/2022 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, failing to thoroughly screen all staff and visitors for COVID-19 symptoms and not utilizing acceptable hand hygiene practices. Deficiencies included failure to screen surveyors upon entry, incomplete staff screening logs, and improper hand washing technique by staff.
Deficiencies (2)
Failure to thoroughly screen all staff and visitors for COVID-19 signs and symptoms in accordance with facility policies and CDC guidelines.
Failure to utilize acceptable infection control practices for hand hygiene, including improper hand washing technique by staff.
Report Facts
Census: 154
Sample size: 5
COVID-19 cases: 31
Direct care staff worked: 53
Staff screened: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist | Failed to screen surveyors for COVID-19 symptoms upon entry | |
| Certified Nursing Assistant | Demonstrated improper hand washing technique and felt intimidated during survey | |
| Assistant Director of Nursing | Provided reeducation on hand hygiene and visitor screening | |
| Infection Preventionist | Conducted interviews, provided training, and monitored hand hygiene compliance | |
| Administrator | Reported inability to sync electronic screening tablet data |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Date: Nov 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ147478.
Complaint Details
Complaint number NJ147478 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 134
Deficiencies: 0
Date: Sep 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 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: 5
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 1
Date: Sep 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ146131, NJ146501, NJ146510, NJ146367, and NJ147261 to investigate compliance with long-term care facility regulations.
Complaint Details
Complaint numbers NJ146131, NJ146501, NJ146510, NJ146367, and NJ147261 were investigated. The facility was found not in substantial compliance with staffing requirements, with substantiation implied by the findings.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities due to failure to maintain mandatory nurse staffing ratios as required by state law, affecting staffing levels on 14 out of 42 shifts reviewed with potential impact on all residents.
Deficiencies (1)
Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law for 14 out of 42 shifts reviewed.
Report Facts
Census: 134
Sample Size: 16
Shifts with staffing deficiencies: 14
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
Staffing counts: 16
Staffing counts: 17
Staffing counts: 18
Staffing counts: 15
Staffing counts: 15
Staffing counts: 14
Staffing counts: 14
Staffing counts: 12
Staffing counts: 9
Staffing counts: 16
Staffing counts: 15
Staffing counts: 16
Staffing counts: 15
Staffing counts: 15
Staffing counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Stated awareness of the staffing mandate on 09/19/2021 at 3:33 PM. | |
| Director of Nursing (DON)/Assistant Director of Nursing (ADON) | Reviewed staffing regulations and implemented daily reviews of census and staffing ratios. | |
| Staffing Coordinator | Re-educated on new minimum staffing requirements. |
Inspection Report
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The inspection was conducted as a standard annual survey combined with a COVID-19 Focused Infection Control Survey in conjunction with the recertification survey.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and in compliance with infection control regulations related to COVID-19 as recommended by CMS and CDC.
Report Facts
Sample size: 29
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 127
Deficiencies: 0
Date: Nov 25, 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: 3
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