Inspection Reports for United Methodist Communities At Bristol Glen
200 Bristol Glen Drive, NJ, 07860
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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 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
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 10
May 22, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to failure to follow physician orders for wound care and neurological assessments, failure to maintain minimum staffing ratios, and multiple life safety code violations including exit signage, fire door latching, sprinkler system maintenance, fire extinguisher inspections, smoke barrier penetrations, elevator inspections, electrical safety, and emergency generator testing.
Complaint Details
Complaint #: NJ172491, NJ172492. Complaint investigations were completed during this survey.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to consistently follow standards of clinical practice including following physician's orders for wound care and neurological assessments for residents #1 and #14. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Exit and directional signs were not provided or marked by approved, readily visible signs where exit or way to reach exit was not readily apparent. | SS=D |
| One of two exit access stairwell doors failed to positively latch, compromising the 1-1/2 hour fire rated construction. | SS=D |
| Sprinkler system deficiencies including a protective cap on a sprinkler head, ceiling tile openings allowing smoke passage, and missing sprinkler escutcheon fitting. | SS=E |
| Failure to conduct annual inspection of six of fifteen portable fire extinguishers. | SS=E |
| Penetrations in smoke and fire barriers were not sealed to restrict transfer of smoke and fire. | SS=F |
| Elevator #4 was last inspected over one year ago and monthly firefighter service function was not performed or recorded. | SS=D |
| One of six electrical outlets near water sources lacked Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Emergency generator failed to document power transfer time within 10 seconds during monthly testing. | SS=F |
Report Facts
Census: 49
Total Capacity: 60
Deficiencies cited: 10
Staffing Deficiency Days: 2
Fire Extinguishers without annual inspection: 6
Elevator inspection overdue: 1
Fire barrier penetrations: 7
Electrical outlets lacking GFCI: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Named in medication and wound care deficiency related to Resident #1 | |
| Registered Nurse #2 | Named in neurological assessment deficiency related to Resident #14 | |
| Licensed Practical Nurse #1 | Interviewed regarding oxygen order deficiency for Resident #16 | |
| Registered Nurse/Nurse Mentor #1 | Interviewed regarding oxygen order deficiency for Resident #16 | |
| Director of Nursing | Responsible for oversight of neurological assessment audits and oxygen order reviews | |
| Corporate Director of Clinical Services | Interviewed regarding staffing deficiencies | |
| Licensed Nursing Home Administrator | Interviewed regarding staffing deficiencies | |
| Plant Operations Director | Interviewed regarding fire extinguisher inspections and sprinkler system deficiencies | |
| Building Services Director | Responsible for monitoring fire door latching, sprinkler heads, fire extinguisher inspections, elevator inspections, and generator testing |
Inspection Report
Annual Inspection
Census: 35
Capacity: 60
Deficiencies: 7
Mar 17, 2022
Visit Reason
Annual standard survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including Medicaid/Medicare notification, staffing ratios, food safety, life safety code, emergency lighting, corridor door compliance, and electrical system maintenance. Deficiencies were cited and plans of correction were submitted.
Severity Breakdown
SS=B: 1
SS=D: 1
SS=E: 3
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to issue required Medicare Beneficiary Protection Notification to 3 residents. | SS=B |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | — |
| Failed to store potentially hazardous foods properly and maintain kitchen sanitation to prevent food borne illness. | SS=D |
| Delayed egress doors exceeded the maximum 15-second release time, releasing in 30 seconds without required signage. | SS=F |
| Emergency lighting not provided at emergency generator transfer switch and fire pump transfer switch locations. | SS=E |
| Corridor doors failed to resist passage of smoke and did not latch properly, compromising smoke compartment integrity. | SS=E |
| No remote manual stop station provided for the facility's emergency generator. | SS=E |
Report Facts
Census: 35
Total Capacity: 60
Deficiencies cited: 7
Delayed egress door release time: 30
Pump switch emergency lighting: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and observed during life safety and emergency lighting deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Interviewed regarding staffing and notified of deficiencies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staffing and notified of deficiencies |
| Social Worker | Interviewed regarding Medicare Beneficiary Protection Notification forms |
Inspection Report
Original Licensing
Deficiencies: 0
Jan 21, 2022
Visit Reason
Initial inspection for licensure of new and/or renovated long term care facilities, specifically for Phase two and Phase three renovation project areas.
Findings
No deficiencies were noted during the inspection of the renovated sections including resident rooms, living room, dining room, pantry/kitchen area, and bathing spas. The inspected areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Life Safety
Census: 30
Capacity: 60
Deficiencies: 1
Jan 21, 2022
Visit Reason
Inspection of Phase two and Phase three renovation project in a section of the Long Term Care building, including resident rooms, living room, dining room pantry/kitchen area, and bathing spas, focusing on Life Safety Code compliance.
Findings
The facility was found to be in noncompliance with Life Safety Code requirements, specifically failing to ensure that the Ansul wet chemical fire suppression system for cooking equipment was inspected in accordance with NFPA 96. The deficiency was corrected by a vendor inspection on 2022-01-31, with no residents affected as the kitchen/pantry was not yet in use.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the Ansul wet chemical fire suppression system for cooking equipment was inspected in accordance with NFPA 96. | SS=D |
Report Facts
Licensed Beds: 60
Census: 30
Deficiency correction completion date: Feb 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Contacted regarding inspection reports and findings | |
| Maintenance Director | Confirmed findings during observations | |
| Director of Building Services/Designee | Responsible for monthly visual inspections and maintaining annual fire inspection log for Ansul fire suppression systems | |
| Administrator of the Long Term Care | Informed of findings during Life Safety Code survey exit |
Inspection Report
Routine
Census: 37
Deficiencies: 0
Sep 9, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 11, 2021
Visit Reason
This was a Center for Medicare/Medicaid Services (CMS) authorized Federal Allegation Survey conducted to determine compliance with Conditions of Participation for Hospitals, specifically 42 CFR Part 482.42 Infection Control.
Findings
The facility was found to be in compliance with the infection control requirements, including a Federal COVID-19 Focused Infection Control survey.
Complaint Details
Federal Allegation Survey (C#NJ00141974) conducted to investigate compliance with infection control conditions.
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