Deficiencies per Year
12
9
6
3
0
Severe
Moderate
Low
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 explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 120
Capacity: 179
Deficiencies: 12
Apr 15, 2025
Visit Reason
Routine inspection survey conducted on 04/15/2025 to assess compliance with federal and state regulations for Spring Creek Healthcare Center, including complaint investigations and life safety code survey.
Findings
The facility was found not in substantial compliance with multiple deficiencies cited related to resident rights, safe environment, comprehensive care plans, respiratory care, food safety, staffing, life safety code, and emergency preparedness. Deficiencies were identified in resident dignity, facility maintenance, care planning, medication administration, food storage, staffing ratios, and fire safety measures.
Complaint Details
Complaint numbers NJ 169458, 173993, 176442, 178844, 178871, 181815, 183719, 184224 were investigated during the survey.
Severity Breakdown
Level D: 5
Level F: 7
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to maintain dignity of a resident during transport in a wheelchair. | Level D |
| Failure to maintain a clean, safe, and sanitary environment in multiple units. | Level D |
| Failure to develop and implement comprehensive care plans for residents. | Level D |
| Failure to provide respiratory care including tracheostomy and suctioning consistent with professional standards. | Level D |
| Failure to procure, store, prepare, and serve food in accordance with professional food safety standards. | Level F |
| Failure to maintain minimum staffing requirements for Certified Nurse Aides (CNAs) on multiple shifts. | — |
| Failure to ensure automatic closing of roll down doors in smoke compartments. | Level F |
| Failure to provide emergency illumination along means of egress. | Level F |
| Failure to maintain battery backup emergency lighting above emergency generator transfer switch. | Level F |
| Failure to maintain corridor doors to resist passage of smoke. | Level F |
| Failure to conduct required monthly testing and documentation for elevator fire recall systems. | Level F |
| Failure to maintain smoking regulations including metal containers with self-closing covers and smoking area maintenance. | Level F |
Report Facts
CNA staffing deficiency counts: 6
Resident census: 120
Licensed bed capacity: 179
Deficiency correction completion dates: Multiple deficiencies have correction completion dates of 06/10/2025 or 06/12/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Named in education and corrective actions related to resident dignity, medication documentation, and infection control. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and educated regarding resident care and medication documentation. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed food storage and disposal practices in pantry. |
| Unit Manager Licensed Practical Nurse #1 | Unit Manager Licensed Practical Nurse | Observed pantry conditions and repairs. |
| Unit Manager Licensed Practical Nurse #2 | Unit Manager Licensed Practical Nurse | Observed pantry conditions and repairs. |
| Director of Nursing | Director of Nursing | Responsible for education on anticoagulation protocol and medication documentation. |
| Administrator/Designee | Administrator/Designee | Responsible for education and corrective actions related to fire safety deficiencies. |
Inspection Report
Census: 112
Deficiencies: 1
Aug 2, 2024
Visit Reason
A survey was conducted for the renovation project for the first floor 100 Unit resident wing with shower room and nursing station, room 200 on the second floor, and room 300 on the third floor.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to provide full visual privacy to residents caused by gaps in cubicle curtains in 14 shared resident rooms and one common shower room. Privacy curtains were missing or improperly installed, potentially affecting all residents in the renovated unit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide full visual privacy to residents through gaps in cubicle curtains in shared resident rooms and in shower rooms. | SS=D |
Report Facts
Resident rooms with privacy curtain gaps: 14
Common shower rooms without privacy curtains: 1
Inspection Report
Original Licensing
Census: 114
Deficiencies: 0
Jan 3, 2024
Visit Reason
Initial inspection for licensure of renovated long term care facilities.
Findings
No deficiencies were noted during the inspection of the Dining Room installation of new lighting, Lobby area, Admissions Office and renovated Therapy Gym. The noted areas may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 2
Oct 18, 2023
Visit Reason
The inspection was conducted based on multiple complaints regarding the facility's compliance with regulations, including a complaint about improper denial of readmission to a resident after hospitalization and failure to maintain required staffing ratios.
Findings
The facility was found not in substantial compliance due to failure to permit a resident to return after hospitalization despite the resident's wish and lack of proper discharge documentation, and failure to maintain minimum direct care staff to resident ratios as required by state law.
Complaint Details
Complaint numbers NJ#168144, NJ#168251, NJ#165464, NJ#164728 triggered the complaint investigation. The facility was found not in substantial compliance based on these complaints, including issues with resident discharge and staffing.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow policies for facility-initiated discharge by not permitting Resident #3 to return after hospitalization despite the resident's wish and lack of 30-day discharge notice. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios for 14 of 14 day shifts and multiple overnight shifts reviewed. | — |
Report Facts
Census: 117
Deficiencies cited: 2
Staffing deficiencies: 14
Staffing deficiencies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Completed incident report on Resident #3's altercation. |
| Director of Nursing | DON | Interviewed regarding Resident #3's incident and behavior monitoring. |
| Licensed Nursing Home Administrator | LNHA | Provided information on discharge and readmission decisions for Resident #3. |
| Medical Director | MD | Advised facility not to readmit Resident #3 due to safety concerns. |
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 8
Apr 6, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Multiple deficiencies were cited related to residents' rights to communication, accuracy of assessments, professional standards of care, pharmacy services, medication errors, food safety, staffing ratios, and life safety code violations. Corrective actions and plans of correction were outlined for each deficiency.
Severity Breakdown
Level D: 5
Level F: 1
Level E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide daily delivery of mail including Saturdays, affecting residents' right to communication. | Level D |
| Failure to accurately complete the Minimum Data Set (MDS) for residents, including incorrect tobacco use coding. | Level D |
| Failure to maintain professional standards of clinical practice, including documentation of transfer after a fall. | Level D |
| Failure to provide pharmaceutical services in accordance with professional standards, including expired narcotic medications in emergency supply. | Level D |
| Medication errors exceeding 5% error rate, including errors in medication administration for residents. | Level D |
| Failure to procure, store, prepare, and serve food in a sanitary manner, including improper food storage and inadequate handwashing. | Level F |
| Failure to maintain required minimum direct care staff-to-resident ratios for Certified Nursing Assistants (CNAs). | — |
| Life Safety Code violations including failure to maintain fire barriers, exit discharge accessibility, fire alarm system inspection, sprinkler system installation, and fire extinguisher maintenance. | Level E |
Report Facts
Census: 109
Medication administration error rate: 7.14
Certified Nursing Assistants staffing deficiency: 13
Certified Nursing Assistants staffing deficiency: 10
Medication errors observed: 2
Medication opportunities observed: 28
Expired medications observed: 5
Fire extinguishers maintained: 1
Fire extinguishers not maintained: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged incorrect MDS coding for Resident #54 and involved in medication error findings. | |
| Licensed Practical Nurse #1 | LPN | Assessed resident and documented monitoring after fall incident. |
| Licensed Practical Nurse #2 | LPN | Reported resident injury and involved in medication administration observations. |
| Assistant Director of Nursing | ADON | Participated in narcotic medication inspection and medication administration error findings. |
| Staff Nurse | Observed making medication administration errors for residents #1 and #2. | |
| Food Service Director | Responsible for food safety corrective actions and staff re-education. | |
| Maintenance Director | Involved in fire safety corrective actions and staff re-education. | |
| Corporate Compliance Officer | CCO | Participated in life safety code survey and fire safety findings. |
| Director of Maintenance | DOM | Participated in life safety code survey and fire safety findings. |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 3
Nov 4, 2022
Visit Reason
The inspection was conducted based on a complaint visit (Complaint#: NJ00159057) to investigate allegations related to failure to notify physicians about residents' changes in condition and failure to accurately document resident status and assessments.
Findings
The facility was found not in substantial compliance with federal regulations due to nursing staff failing to notify the physician about changes in condition for two residents and failing to accurately document resident status and assessments in medical records. Additionally, the facility failed to report certain serious incidents to the New Jersey Department of Health in a timely manner.
Complaint Details
Complaint#: NJ00159057. The complaint investigation found that nursing staff failed to notify the physician about changes in condition for Residents #2 and #3 and failed to accurately document resident status and assessments. The facility also failed to report serious incidents to the New Jersey Department of Health timely.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the physician about changes in condition for 2 residents. | SS=D |
| Failure to accurately document resident status and assessments in medical records for 2 residents. | SS=D |
| Failure to notify the Department of Health immediately of reportable events involving residents. | — |
Report Facts
Census: 110
Sample Size: 4
Dates of corrective action completion: Dec 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to failure to notify physician and failure to document assessments. |
| ADON | Assistant Director of Nursing | Interviewed regarding failure to notify physician and documentation issues. |
| LNHA | Licensed Nursing Home Administrator | Instructed staff to place residents in rooms and was interviewed about notification failures. |
| DON | Director of Nursing | Interviewed about expectations for nurse notification and documentation. |
| Administrator | Reported on corrective actions related to reportable events for residents #2 and #3. |
Document
Deficiencies: 0
Jul 6, 2022
Visit Reason
Document is a PDF portfolio placeholder page advising to open in specific software.
Findings
No inspection or regulatory content present; only instructions for viewing the PDF portfolio.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Sep 13, 2021
Visit Reason
The inspection was conducted in response to complaints NJ146312 and NJ146293 to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
Complaints NJ146312 and NJ146293 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 8
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 4
Apr 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Onsite Recertification survey were conducted to assess compliance with infection control regulations and quality of care standards.
Findings
The facility was found not in substantial compliance with infection control regulations, with two Immediate Jeopardy findings related to infection control and quality of care. The facility failed to properly isolate residents exposed to COVID-19 and failed to recognize and manage risks for a resident with repeated episodes of significant health changes. Additionally, a resident sustained burns from hot beverages due to lack of temperature control and monitoring. The facility also failed to properly isolate and monitor residents under observation for COVID-19 exposure, posing a serious threat to other residents.
Severity Breakdown
Immediate Jeopardy: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement mitigation strategies to prevent COVID-19 transmission by not properly isolating residents exposed as Persons Under Investigation (PUI). | Immediate Jeopardy |
| Failure to recognize and assess risk factors for Resident #101 leading to repeated episodes of serious health changes and inadequate communication with methadone clinic. | Immediate Jeopardy |
| Resident #85 sustained burns from hot beverages served at unsafe temperatures; facility failed to investigate root cause and implement staff training and monitoring. | — |
| Failure to follow isolation precaution protocols for residents on Transmission-Based Precautions (TBP) and Persons Under Investigation (PUI), resulting in exposure risk to other residents. | Immediate Jeopardy |
Report Facts
Census: 118
Sample size: 30
Temperature of coffee urn: 190
Temperature of coffee urn: 160
BIMS score: 11
BIMS score: 15
BIMS score: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Named in relation to infection control and quality of care findings and staff training | |
| Licensed Nursing Home Administrator (LNHA) | Named in relation to infection control findings, resident non-compliance, and policy decisions | |
| Infection Preventionist | Named in relation to infection control program and staff education | |
| Medical Director | Named in relation to quality of care and infection control findings | |
| Recreation Aide | Named in relation to serving hot beverages and related incident | |
| Food Service Director | Named in relation to hot beverage temperature monitoring | |
| Certified Nursing Assistant (CNA) | Named in relation to resident care and infection control observations | |
| Licensed Practical Nurse (LPN) | Named in relation to resident care and infection control observations |
Inspection Report
Life Safety
Deficiencies: 3
Mar 15, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically focusing on means of egress, discharge from exits, and fire alarm system maintenance.
Findings
The facility was found not in substantial compliance with the Life Safety Code due to an exit door that failed to open immediately because of rust, deteriorated concrete slabs on an exit discharge path creating tripping hazards, and a fire alarm system monitor indicating a trouble mode due to a secondary phone line fault.
Severity Breakdown
SS=D: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Exit door on the floor near a resident room failed to open immediately due to metal rust obstructing the door and doorframe. | SS=D |
| Exit discharge path had deteriorated concrete slabs with voids causing unsafe walking surfaces. | SS=D |
| Fire alarm system monitor indicated trouble mode due to a fault in the secondary phone line, potentially affecting emergency communication. | SS=C |
Report Facts
Exit doors tested: 8
Concrete slab void size: 6
Survey date: Mar 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Physical Plant Manager | Present during observations and interviews regarding exit door failure, exit discharge path condition, and fire alarm system trouble. | |
| Corporate Maintenance Director | Conducted in-service training for maintenance staff on exit door checks. | |
| Maintenance Director | Monitors fire alarm mechanism daily and reviews findings at Quality Assurance meetings. | |
| Administrator | Informed verbally of findings during Life Safety Code Survey exit conference. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jan 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00133964, NJ00135146, NJ00135223, and NJ00136974.
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 NJ00133964, NJ00135146, NJ00135223, and NJ00136974 were investigated and found to be in compliance.
Report Facts
Sample Size: 15
Inspection Report
Plan of Correction
Census: 111
Deficiencies: 1
Jan 15, 2021
Visit Reason
The inspection was conducted to assess compliance with COVID-19 screening and monitoring requirements during Phase 0 of reopening, specifically to evaluate if residents were properly monitored for signs and symptoms of COVID-19 as per NJDOH Executive Directive No. 20-026-1.
Findings
The facility failed to ensure that residents were monitored for signs and symptoms of COVID-19, affecting 3 of 3 residents reviewed and potentially impacting 107 of 111 residents. Residents #10, #17, and #18 had no evidence of proper screening or monitoring documented. The facility implemented corrective actions including in-servicing nurses and monitoring resident charts for compliance.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents were monitored for signs/symptoms of COVID-19 during Phase 0 reopening. |
Report Facts
Residents potentially affected: 107
Total residents in facility: 111
Residents reviewed for screening: 3
Resident charts monitored: 10
Resident charts monitored: 5
Resident charts monitored: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Interviewed regarding facility's surveillance plan and in-serviced by Corporate Consultant | |
| Licensed Practical Nurse #1 | Provided information on resident screening frequency | |
| Licensed Practical Nurse #2 | Provided information on resident screening and monitoring | |
| Director of Nurses | In-serviced nurses on screening policy and procedure | |
| Assistant Director of Nurses | In-serviced nurses and responsible for monitoring resident charts | |
| Corporate Consultant | Infection Preventionist (IP) | In-serviced LPNs on proper screening and monitoring procedures |
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