Inspection Reports for
United Methodist Communities At Bristol Glen
200 Bristol Glen Drive, Newton, NJ, 07860
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
82% occupied
Based on a May 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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: 2
Date: Aug 26, 2025
Visit Reason
The inspection was conducted based on a complaint (NJ 2565649) regarding the facility's failure to provide a safe environment and follow fall prevention interventions as outlined in individual care plans for two residents.
Complaint Details
Complaint NJ 2565649 was substantiated, finding that the facility failed to follow fall prevention interventions and safe transfer protocols, leading to actual harm to residents.
Findings
The facility failed to ensure safe mechanical lift transfers requiring two staff members, resulting in Resident #2 falling and sustaining a head injury requiring hospitalization. Resident #5 was also involved in an incident where proper transfer assistance was not provided, leading to a fall without injury. Staff involved were re-educated or terminated as appropriate.
Deficiencies (2)
Failure to provide safe mechanical lift transfers with two staff members as required by care plans, resulting in Resident #2's fall and head injury.
Failure to provide proper transfer assistance to Resident #5, resulting in a fall while attempting transfer by one staff member.
Report Facts
Length of hospital stay: 8
BIMS score: 1
BIMS score: 13
Date of MDS assessment: Jul 31, 2025
Date of MDS assessment: Jul 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Attempted mechanical lift transfer alone resulting in resident fall; terminated. |
| CNA #2 | Certified Nursing Assistant | Attempted transfer alone resulting in resident fall; re-educated on transfer protocols. |
| Director of Nursing | Director of Nursing | Notified of incident, suspended CNA #1, participated in investigation and interviews. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Confirmed mechanical lift policy requiring two staff members; involved in interviews. |
Inspection Report
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 10
Date: 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.
Complaint Details
Complaint #: NJ172491, NJ172492. Complaint investigations were 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.
Deficiencies (10)
Failure to consistently follow standards of clinical practice including following physician's orders for wound care and neurological assessments for residents #1 and #14.
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.
One of two exit access stairwell doors failed to positively latch, compromising the 1-1/2 hour fire rated construction.
Sprinkler system deficiencies including a protective cap on a sprinkler head, ceiling tile openings allowing smoke passage, and missing sprinkler escutcheon fitting.
Failure to conduct annual inspection of six of fifteen portable fire extinguishers.
Penetrations in smoke and fire barriers were not sealed to restrict transfer of smoke and fire.
Elevator #4 was last inspected over one year ago and monthly firefighter service function was not performed or recorded.
One of six electrical outlets near water sources lacked Ground-Fault Circuit Interrupter (GFCI) protection.
Emergency generator failed to document power transfer time within 10 seconds during monthly testing.
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
Routine
Deficiencies: 3
Date: May 22, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in nursing care, specifically regarding adherence to physician orders, neuro-check completion after falls, and clarity of respiratory care orders.
Findings
The facility failed to consistently follow physician orders for wound treatment for one resident, did not complete required neuro-checks after a resident's fall, and had unclear oxygen therapy orders for another resident. These deficiencies were observed through record reviews, observations, and interviews.
Deficiencies (3)
Failure to follow a physician's order as written for wound treatment for Resident #1.
Failure to complete neuro-checks after a fall for Resident #14.
Failure to clarify oxygen therapy order with a specific rate for Resident #16.
Report Facts
Resident #1 BIMS score: 12
Resident #14 BIMS score: 3
Resident #16 BIMS score: 13
Physician order date for wound treatment: May 17, 2024
Fall incident date: Mar 5, 2024
Oxygen flow rate range: 2-4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Observed performing wound treatment and acknowledged not following physician order |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding oxygen therapy order for Resident #16 |
| Registered Nurse/Nurse Mentor #1 | Registered Nurse/Nurse Mentor | Interviewed regarding oxygen order clarity |
| Registered Nurse #2 | Registered Nurse | Assigned nurse for Resident #14 at time of fall, interviewed about neuro-check documentation |
| Licensed Nursing Home Administrator | Administrator | Informed about concerns regarding wound treatment and neuro-check documentation |
| Director of Nursing | Director of Nursing | Interviewed and provided neuro-check documentation and policy information |
| Executive Director | Executive Director | Informed about concerns during survey team meeting |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Informed about concerns during survey team meeting |
| Respiratory Therapist | Respiratory Therapist | Interviewed regarding oxygen order clarity |
Inspection Report
Annual Inspection
Census: 35
Capacity: 60
Deficiencies: 7
Date: 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.
Deficiencies (7)
Failed to issue required Medicare Beneficiary Protection Notification to 3 residents.
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.
Delayed egress doors exceeded the maximum 15-second release time, releasing in 30 seconds without required signage.
Emergency lighting not provided at emergency generator transfer switch and fire pump transfer switch locations.
Corridor doors failed to resist passage of smoke and did not latch properly, compromising smoke compartment integrity.
No remote manual stop station provided for the facility's emergency generator.
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
Routine
Deficiencies: 2
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to assess compliance with Medicare Beneficiary Protection Notification requirements and to evaluate food safety and sanitation practices in the facility.
Findings
The facility failed to issue required Medicare Beneficiary Protection Notifications to three residents, resulting in potential minimal harm. Additionally, the facility failed to store potentially hazardous foods properly and maintain kitchen sanitation, posing a risk for foodborne illness.
Deficiencies (2)
Failed to issue required Medicare Beneficiary Protection Notification forms to 3 residents.
Failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Report Facts
Residents affected: 3
Undated food items: 32
Use-by dates exceeded: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (LNHA) | Discussed missing notification forms and was informed of concerns | |
| Director of Nursing (DON) | Informed of concerns regarding notification forms and kitchen sanitation | |
| Social Worker (SW) | Interviewed about beneficiary notifications and confirmed forms were not given | |
| Chef Manager | Present during kitchen inspection | |
| Operations Manager (OM) | Present during kitchen inspection and discussions |
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (1)
Failure to ensure the Ansul wet chemical fire suppression system for cooking equipment was inspected in accordance with NFPA 96.
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
Date: 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
Date: 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.
Complaint Details
Federal Allegation Survey (C#NJ00141974) conducted to investigate compliance with infection control conditions.
Findings
The facility was found to be in compliance with the infection control requirements, including a Federal COVID-19 Focused Infection Control survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with federal guidelines regarding the completion and transmission of Minimum Data Set (MDS) assessments for residents.
Findings
The facility failed to complete and transmit MDS assessments timely for 2 of 16 residents reviewed, specifically Resident #1 and Resident #2, resulting in a deficiency related to resident assessment data submission.
Deficiencies (1)
Failure to complete and transmit Minimum Data Set (MDS) assessments within the federally mandated timeframe for Resident #1 and Resident #2.
Report Facts
Residents reviewed for assessment: 16
Residents with deficient MDS transmission: 2
Assessment Reference Date for Resident #1: Oct 11, 2019
Assessment Reference Date for Resident #2: Oct 17, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Spoke with surveyor regarding MDS transmission concerns | |
| MDS Coordinator | Agreed that assessments were not submitted timely |
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