Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
74% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: 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
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the elopement of a severely cognitively impaired resident (Resident #2) who wandered away from the facility on 10/29/2025.
Complaint Details
The complaint investigation substantiated that Resident #2 eloped from the facility on 10/29/2025 due to inadequate supervision. The Immediate Jeopardy began at approximately 4:45 p.m. when the resident was last seen by staff. The facility was notified on 11/12/2025 and submitted a removal plan on 11/13/2025. The resident was found by police about three miles away and returned safely but was later hospitalized due to agitation.
Findings
The facility failed to provide adequate supervision to Resident #2, who eloped from the facility, posing an immediate jeopardy to resident health and safety. The resident was found by police approximately three miles away and returned safely but exhibited increased agitation and was hospitalized. The facility implemented a removal plan and corrective actions to prevent recurrence.
Deficiencies (1)
Failure to provide adequate supervision to a severely cognitively impaired resident with a known history of wandering behaviors who eloped from the facility.
Report Facts
Resident reviewed for elopement: 5
Resident affected: 1
Wandering Risk Scale: 9
BIMS score: 4
Elopement date: Oct 29, 2025
Removal Plan submission date: Nov 13, 2025
Elopement drills frequency: 4
Monitoring frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Last observed Resident #2 at approximately 4:45 p.m. on 10/29/2025 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Assigned to Resident #2, initiated search when resident was missing |
| Licensed Practical Nurse #1 | Unit Manager | Provided information on staff monitoring practices for wandering residents |
| Director of Nursing | Director of Nursing | Provided information on wandering risk assessments and care plans |
| Licensed Nursing Home Administrator | Administrator | Provided clarification on wandering versus elopement risk and care plans |
| Facility Educator | Facility Educator/Director of Nursing | Conducted re-education and training on elopement prevention and supervision |
| Director of Maintenance | Director of Maintenance | Conducted audits and managed keypad codes for facility security |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 178
Deficiencies: 8
Date: Jan 9, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations NJ168504, NJ175432, and NJ176408.
Complaint Details
The survey was triggered by complaints NJ168504, NJ175432, and NJ176408. The complaints involved issues such as staffing deficiencies, abuse/neglect policies, medication errors, and infection control. The complaints were substantiated as evidenced by cited deficiencies.
Findings
Deficiencies were cited related to safe environment, abuse/neglect policies, staffing, medication errors, infection control, nutrition, life safety, and fire safety. The facility failed to maintain required staffing ratios, ensure proper medication administration, and maintain fire safety systems. Corrective actions and audits were implemented for all cited deficiencies.
Deficiencies (8)
Facility failed to maintain a safe, clean, comfortable, and homelike environment; residents observed with dirty overbed tables and wheelchairs.
Facility failed to develop and implement abuse/neglect policies and procedures, including reporting and investigation.
Facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey.
Facility failed to ensure medication error rates were below 5%, with errors observed in medication administration.
Facility failed to maintain menus and nutritional adequacy in accordance with nationally accredited standards.
Facility failed to maintain infection prevention and control program including proper use of PPE and staff training.
Facility failed to maintain means of egress free of obstructions and maintain sprinkler system in accordance with NFPA standards.
Facility failed to maintain electrical systems and conduct required testing and maintenance.
Report Facts
Census: 131
Total Capacity: 178
Staffing Ratios: 10
Medication Error Rate: 7.4
Weight Loss Audit: 5
Deficiencies Cited: 8
Inspection Report
Routine
Deficiencies: 9
Date: Jan 9, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a sanitary environment, failure to report and investigate an injury of unknown origin timely, medication administration errors including borrowing medication from another resident, failure to prevent significant resident weight loss, failure to ensure menus were reviewed and residents received physician-ordered fortified foods, failure to notify CMS of a facility name change, failure to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, and failure to dedicate the Infection Preventionist solely to infection control duties.
Deficiencies (9)
Facility failed to maintain residents' environment and living areas in a sanitary and homelike manner, evidenced by dried brown substances on wheelchairs, recliners, and overbed tables.
Facility failed to report and initiate an investigation for an injury of unknown origin in accordance with abuse and neglect policy until surveyor inquiry for one resident.
Facility failed to follow acceptable professional standards by borrowing a medication (Lidocaine 4% patch) from another resident's supply.
Facility failed to ensure medication error rates were below 5%, with a 7.4% error rate observed during medication administration.
Facility failed to prevent significant unintended weight loss in a resident, failed to implement timely interventions, and failed to provide culturally appropriate meals and fortified foods as ordered.
Facility failed to ensure menus were reviewed and approved by a Registered Dietitian for nutritional adequacy and failed to provide residents with care planned and physician ordered fortified foods.
Facility failed to notify CMS and receive authorization for a change in the facility's name in accordance with federal regulations.
Facility failed to ensure staff wore appropriate personal protective equipment for residents on Enhanced Barrier Precautions, including failure to wear gowns during high-contact care activities.
Facility failed to designate a qualified Infection Preventionist dedicated solely to the infection prevention and control program, with the IP also serving as acting Unit Manager.
Report Facts
Medication administration opportunities: 27
Medication administration errors: 2
Medication administration error rate: 7.4
Resident weight loss: 31.5
Resident weight loss: 14
Resident weight loss: 15
Resident weight loss: 6.5
Resident weight loss: 4
Resident weight loss: 16.5
Resident weight: 139
Resident weight: 107.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN#1 | Registered Nurse | Named in medication error finding for administering wrong strength Lidocaine patch and borrowing medication |
| CNA#1 | Certified Nursing Assistant | Named in abuse investigation for failure to report injury of unknown origin |
| CNA#2 | Certified Nursing Assistant | Named in abuse investigation for failure to report injury of unknown origin |
| UM/IP/LPN | Acting Unit Manager/Infection Preventionist/Licensed Practical Nurse | Named in abuse investigation and infection control findings |
| DON | Director of Nursing | Named in abuse investigation and medication error findings |
| ADON | Assistant Director of Nursing | Named in staff education and medication error findings |
| CP | Consultant Pharmacist | Named in medication error findings |
| FSD | Food Service Director | Named in menu and nutrition findings |
| LNHA | Licensed Nursing Home Administrator | Named in facility name change and administrative findings |
| Regional LNHA | Regional Licensed Nursing Home Administrator | Named in facility name change and administrative findings |
| VP of corporate clinical | Vice President of Corporate Clinical | Named in infection preventionist staffing findings |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 29, 2023
Visit Reason
The inspection was conducted based on multiple complaints regarding facility conditions, resident care, and pest control issues.
Complaint Details
The investigation was complaint-driven with multiple complaint numbers cited: NJ #165453, 159439, 156933, 164687, 163618, 157073.
Findings
The facility was found deficient in maintaining a clean, comfortable, and homelike environment, providing appropriate incontinence care, timely treatment for residents, proper pressure ulcer care, and maintaining an effective pest control program. Specific issues included environmental disrepair, double brief application to a resident, delayed Doppler study for suspected DVT, inadequate pressure ulcer documentation and treatment, incorrect air mattress settings, and persistent pest infestations.
Deficiencies (5)
Failed to maintain a clean, comfortable, homelike environment with issues such as bent cardboard on air conditioning units, bugs in resident rooms, crooked pictures, holes and scratches in walls, and peeling moldings.
Failed to provide dependent residents with routine and appropriate incontinence care, specifically by applying double briefs to Resident #71.
Failed to provide timely treatment and care for Resident #252, including a delay of three days in performing a Doppler study after physician's order for suspected DVT.
Failed to accurately document body check assessments, obtain timely physician orders based on wound care consultant recommendations, and ensure air mattress was set according to resident's weight for Residents #49 and #255.
Failed to maintain an effective pest control program, evidenced by presence of live and dead insects, resident complaints, and documented pest sightings over several months.
Report Facts
Dead bug carcasses: 30
Double briefs: 2
Doppler study delay: 3
Air mattress weight setting: 350
Pest sightings: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed regarding holes in walls and incontinence care for Resident #71. |
| Director of Nursing | DON | Interviewed regarding incontinence policy, delayed Doppler study, wound care, and air mattress settings. |
| Housekeeping Director | HD | Interviewed regarding cleanliness responsibilities and pest control. |
| Maintenance Director | MD | Interviewed regarding maintenance issues and pest control program. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding facility commitment to environment and policies. |
| Certified Nursing Assistant | CNA | Interviewed regarding incontinence care and pest sightings. |
| Vice President of Clinical Services | VPCS | Interviewed regarding staff discipline and air mattress settings. |
Inspection Report
Routine
Census: 148
Capacity: 178
Deficiencies: 8
Date: Sep 29, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey was a standard survey conducted on 09/29/2023.
Complaint Details
The survey included complaint investigations for multiple complaint numbers including NJ#: 165453, 159439, 156933, 164687, 157073, 164539. The complaints involved issues such as staffing deficiencies, quality of care, pest control, and environmental conditions. Some complaints were substantiated as evidenced by cited deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable, homelike environment; failure to develop and implement comprehensive person-centered care plans; failure to provide timely treatment and care; failure to maintain effective pest control; failure to maintain fire alarm and sprinkler systems; failure to maintain smoke barriers; and failure to maintain ongoing communication and documentation related to resident care. Deficiencies were corrected by the facility with plans of correction dated 10/19/2023.
Deficiencies (8)
Facility failed to maintain a clean, comfortable, homelike environment for residents, evidenced by issues such as broken window coverings, bug infestations, damaged walls, and peeling paint.
Facility failed to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
Facility failed to provide timely treatment and care, including failure to complete incident/accident reports and follow physician orders.
Facility failed to maintain effective pest control program, evidenced by presence of insects and rodents in multiple units.
Facility failed to maintain fire alarm system in accordance with NFPA 101 Life Safety Code, including malfunctioning smoke detector and pull stations.
Facility failed to maintain sprinkler system and conduct required testing and maintenance.
Facility failed to maintain smoke barriers, including unsealed gaps and penetrations.
Facility failed to maintain ongoing communication and documentation related to resident care, including medication administration and care plan updates.
Report Facts
Census: 148
Total Capacity: 178
Deficiency counts: 8
Staffing counts: 12
Resident sample size: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | Licensed Practical Nurse Unit Manager (LPN/UM) | Interviewed regarding holes in walls and resident care documentation. |
| Housekeeping Director | Housekeeping Director (HD) | Interviewed regarding housekeeping responsibilities and pest control. |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding maintenance work and pest control. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding facility commitment to resident comfort and incident report creation. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident reports, care plans, and staff education. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and observations of bugs. |
| Vice President of Clinical Services | Vice President of Clinical Services (VPCS) | Interviewed regarding staff education and resident care. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Sep 29, 2023
Visit Reason
The inspection was conducted based on multiple complaints regarding facility conditions, resident care, and pest control issues.
Complaint Details
The investigation was complaint-driven with complaints NJ #165453, 159439, 156933, 164687, 163618, 157073, 164539, and 165453 related to facility environment, resident care, pest control, and other issues.
Findings
The facility was found deficient in maintaining a clean, comfortable, and homelike environment, developing and implementing comprehensive care plans, completing incident reports, providing appropriate incontinence care, timely treatment and care for residents, pressure ulcer care, dialysis communication, and maintaining an effective pest control program.
Deficiencies (8)
Failed to maintain a clean, comfortable, homelike environment with issues such as bugs, peeling walls, and damaged fixtures.
Failed to develop and implement a comprehensive person-centered care plan for a resident's preference to wear a urinary leg bag during the day.
Failed to complete an incident report after a resident sustained an injury.
Failed to provide dependent residents with routine and appropriate incontinence care, specifically by applying double briefs.
Failed to provide timely treatment and care for a resident with a suspected deep vein thrombosis (DVT), including delayed doppler study.
Failed to accurately document body check assessments, obtain timely physician orders based on wound care consultant recommendations, and ensure air mattress was set according to resident's weight.
Failed to maintain ongoing complete communication notes between the facility and dialysis center, including documentation of bruit and thrill assessments.
Failed to maintain an effective pest control program, with ongoing presence of bugs and roaches in multiple units despite pest control efforts.
Report Facts
Residents reviewed for urinary leg bag care plan: 29
Residents reviewed for skin issues: 3
Residents observed for incontinence care: 6
Residents reviewed for quality of care: 32
Residents reviewed for pressure ulcers: 4
Residents reviewed for dialysis care: 1
Dead bugs observed: 30
Air mattress weight setting: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | LPN/UM | Interviewed regarding care plan documentation, air mattress settings, and pest control observations. |
| Licensed Practical Nurse | LPN | Interviewed regarding urinary leg bag care and dialysis communication. |
| Certified Nursing Assistant | CNA | Interviewed regarding urinary leg bag application, incontinence care, and pest observations. |
| Director of Nursing | DON | Interviewed regarding incident report policies, pressure ulcer care, air mattress settings, and dialysis communication. |
| Housekeeping Director | HD | Interviewed regarding pest control program and staff responsibilities. |
| Maintenance Director | MD | Interviewed regarding pest control program and facility maintenance. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding facility environment, air mattress guidelines, and dialysis communication. |
| Registered Nurse | RN | Interviewed regarding dialysis care and incident report procedures. |
| [NAME] President of Clinical Services | VPCS | Interviewed regarding incontinence care discipline, air mattress settings, and dialysis communication. |
| Assistant Director of Nursing | ADON | Interviewed regarding DVT suspected care and doppler study timeliness. |
Inspection Report
Follow-Up
Census: 145
Deficiencies: 6
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities and to follow up on previously cited deficiencies.
Findings
The facility was found deficient in maintaining required minimum direct care staff to resident ratios on 2 of 14-day shifts. Life safety code deficiencies were identified including lack of emergency lighting backup, missing illuminated exit signs, incomplete sprinkler coverage, smoke barrier door deficiencies, and malfunctioning bathroom exhaust systems. Corrective actions were implemented and verified in a follow-up revisit.
Deficiencies (6)
Failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 2 of 14-day shifts.
Failed to provide battery backup emergency lighting above the emergency generator's transfer switch.
Failed to ensure illuminated exit signs in four locations to clearly identify exit access paths.
Failed to ensure complete coverage by supervised automatic fire sprinkler system in all areas of the building.
Failed to maintain smoke barrier doors to resist transfer of smoke when completely closed; one door was warped leaving a gap.
Failed to ensure proper maintenance and function of ventilation systems for 3 of 11 resident bathroom exhaust systems.
Report Facts
Deficient staffing shifts: 2
Residents present: 145
Required CNAs on deficient days: 19
Actual CNAs on deficient days: 18
Deficient exit signs: 4
Sprinkler coverage gaps: 3
Malfunctioning bathroom exhausts: 3
Smoke barrier doors tested: 7
Smoke barrier doors deficient: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing requirements and compliance |
| Corporate Facility's Maintenance | CFM | Participated in building inspections and confirmed deficiencies |
| Maintenance Assistant | MA | Participated in building inspections and confirmed deficiencies |
| Maintenance Director | Responsible for auditing corrective actions for lighting, sprinkler, smoke doors, and ventilation |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations related to resident rights, care planning, environment, and food safety at Gateway Care Center.
Findings
The facility was found deficient in multiple areas including failure to provide privacy during care, call bells not within reach, lack of accessible survey results, unsanitary environment, failure to update care plans after significant changes, failure to implement care plans for mobility and positioning, failure to apply ordered splints, and unsafe food handling and storage practices.
Deficiencies (9)
Failed to provide privacy for a resident during hygienic care by not using the privacy curtain, exposing the resident.
Failed to ensure the resident's call bell was in reach and able to be used for 3 residents.
Failed to maintain the most recent State inspection results in a place readily accessible to residents, families, and the public.
Failed to maintain the facility in a clean and sanitary environment with multiple stains and soiled items observed on floors and furniture.
Failed to review and revise a care plan to reflect changes to a resident's activities of daily living status after a significant decline.
Failed to implement resident-directed care consistent with the care plan by not providing bilateral heel boots and not using a Hoyer lift for transfers as ordered.
Failed to apply a splint as ordered by a physician to prevent/reduce contracture for a resident.
Failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including uncovered food contact surfaces, unlabeled and expired foods, and contaminated ice machine.
Failed to perform hand hygiene prior to donning gloves during food preparation.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Observed failing to use privacy curtain and assisted resident transfer without Hoyer lift | |
| Director of Nursing | Director of Nursing | Provided expectations on privacy and confirmed responsibility for heel boots |
| Certified Nursing Assistant #4 | Reported resident extensive assist needs with ADLs | |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged care plan should be updated after significant change |
| Regional Director of Nursing | Regional Director of Nursing | Confirmed heel booties and heel protector devices are the same |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Clarified resident used Hoyer lift and confirmed care plan inclusion |
| Rehabilitation Director | Rehabilitation Director | Explained splint order process and care plan updates |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Unaware of hand splint order due to missing eTAR documentation |
| Maintenance Worker #1 | Observed contaminated ice machine drip plate | |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Observed food safety violations and ice machine contamination |
| Cook | Did not perform hand hygiene prior to donning gloves |
Inspection Report
Routine
Census: 131
Deficiencies: 0
Date: Sep 29, 2021
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Date: Aug 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146753, NJ146369, and NJ146203.
Complaint Details
Complaint numbers NJ146753, NJ146369, and NJ146203 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Date: May 12, 2021
Visit Reason
The inspection was conducted based on complaint #NJ: 140095 to assess compliance with regulatory requirements.
Complaint Details
Complaint #NJ: 140095 was investigated and found to be unsubstantiated as the facility was in compliance.
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 visit.
Report Facts
Sample Size: 4
Inspection Report
Routine
Census: 112
Deficiencies: 0
Date: Dec 2, 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.
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