Inspection Reports for
Village Point
Three David Brainerd Drive, Monroe Township, NJ, 08831
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
76% occupied
Based on a December 2023 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 the New Jersey Department of Health and Senior Services, including how personal health information may be used and disclosed, and the rights individuals have regarding their health 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: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to implement residents' care plans, failure to provide scheduled showers, inadequate monitoring and medical care after injury, medication administration issues, and incomplete medical records.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to follow care plans, provide scheduled showers, timely medical care after injury, medication administration, and proper medical record documentation. The investigation substantiated these complaints with findings of minimal harm or potential for harm.
Findings
The facility failed to follow care plans for mechanical lift transfers, ensure showers were provided as scheduled, provide timely medical care and monitoring after a resident's leg injury, administer medications as ordered due to pharmacy delays, and maintain complete and accurate medical records. These failures placed residents at risk for harm and diminished quality of life.
Deficiencies (5)
Failure to implement residents' care plans related to mechanical lift transfers for one resident, resulting in risk of harm due to inappropriate transfers.
Failure to ensure activities of daily living, specifically showers, were provided as scheduled for two residents, risking diminished quality of life.
Failure to provide adequate monitoring and timely medical care after identification of discoloration and swelling to a resident's leg, later identified as a fracture.
Failure to ensure medications were administered as ordered due to pharmacy delays and poor medication ordering practices, affecting one resident.
Failure to maintain complete and accurate medical records for one resident, including lack of documentation of symptoms and progress notes related to a urinary tract infection.
Report Facts
Residents sampled: 24
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 15
Shower frequency: 2
Missed showers: 3
Missed showers: 1
Medication doses missed: 12
Medication doses missed: 2
Antibiotic course: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nurse Aide | Named in finding for failure to use Hoyer lift per care plan and terminated for policy violation |
| HCNA | Hospice Certified Nurse Aide | Named in finding for failure to use two-person Hoyer lift transfer and asked not to return |
| LPN2 | Licensed Practical Nurse | Named in finding for failure to notify physician and document assessment after resident's leg injury |
| DON | Director of Nursing | Provided interviews and information regarding investigations and medication administration issues |
| UM1 | Unit Manager | Interviewed regarding rounds and medication administration issues |
| CNA5 | Certified Nurse Aide | Interviewed regarding shower refusals and protocols |
| RN2 | Registered Nurse | Mentioned in relation to resident 5's UTI complaint and physician notification |
Inspection Report
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Village Point nursing home, summarizing the findings of a regulatory survey completed on December 13, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: Dec 13, 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.
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: 13
Inspection Report
Routine
Deficiencies: 8
Date: Nov 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, nutrition, infection control, food service, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to investigate an injury of unknown origin, significant unplanned weight loss without proper monitoring or intervention, unsanitary kitchen conditions, improper food temperature control, inadequate infection prevention practices including improper storage of respiratory equipment and poor hand hygiene, and lack of full participation in the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (8)
Failure to conduct a thorough investigation for an injury of unknown origin for Resident #87.
Failure to consistently identify, assess, and intervene for significant unplanned weight loss for Resident #23 and Resident #63.
Failure to ensure physician addressed significant weight loss and monitor resident weights for Resident #23.
Failure to serve meals at an appetizing temperature; hot foods below 140°F and cold foods above 41°F.
Failure to maintain kitchen and food storage areas in a clean and sanitary manner, including malfunctioning dish machine, soiled floors, unclean equipment, and improperly stored food.
Failure of QAPI committee to address significant unplanned weight loss and dietary sanitation concerns.
Failure to have Medical Director and Director of Nursing present at one quarterly QAPI meeting.
Failure to adhere to infection prevention and control practices including improper storage of respiratory equipment, failure to perform hand hygiene prior to medication administration and meal service, and lack of staff education on infection control.
Report Facts
Weight loss: 33.4
Weight loss: 8.6
Weight loss: 24.4
Weight loss: 31.2
Weight loss: 7.2
Dish machine wash temperature: 120
Dish machine final rinse temperature: 155
Meal temperature: 121
Meal temperature: 87
Meal temperature: 60
Milk temperature: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #87's injuries and investigation. |
| Registered Nurse Unit Manager | Registered Nurse Unit Manager | Interviewed regarding weight monitoring and respiratory equipment storage. |
| Director of Nursing | Director of Nursing | Interviewed regarding investigation of injuries and weight loss monitoring. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional assessments and weight loss interventions. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding QAPI program and weight loss system failures. |
| Food Service Director | Food Service Director | Interviewed regarding dish machine error and food temperature concerns. |
| Respiratory Therapist | Respiratory Therapist | Interviewed regarding respiratory equipment storage and staff education. |
| Infection Preventionist Registered Nurse | Infection Preventionist Registered Nurse | Interviewed regarding infection control education and respiratory equipment. |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed regarding feeding assistance and meal tray handling. |
| Activity Staff | Activity Staff | Observed and interviewed regarding meal tray handling and hand hygiene. |
| Speech Therapist Director | Speech Therapist Director | Interviewed regarding student infection control education. |
Inspection Report
Annual Inspection
Census: 100
Capacity: 120
Deficiencies: 19
Date: Nov 20, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Deficiencies were cited for this survey.
Findings
Deficiencies were cited related to investigation of alleged abuse, nutrition and hydration status maintenance, food service issues including meal temperature and sanitation, quality assurance and performance improvement program, infection prevention and control, and life safety code violations including egress doors, fire doors, hazardous area enclosures, and electrical safety.
Deficiencies (19)
Facility failed to conduct a thorough investigation for an alleged abuse incident involving Resident #87.
Facility failed to maintain acceptable nutritional status and hydration for Residents #23 and #63, including failure to monitor weight changes and implement dietary interventions.
Facility failed to serve meals at an appetizing temperature and maintain food service sanitation standards.
Facility failed to maintain kitchen and food storage areas in a sanitary manner, including dish machine malfunction and improper hand hygiene by food service staff.
Facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program addressing identified deficiencies and sanitation concerns.
Facility failed to maintain infection prevention and control practices, including improper storage of respiratory equipment, inadequate hand hygiene, and improper handling of resident meal trays.
Facility failed to ensure egress doors were readily accessible and free of impediments, including use of hook-type deadbolt locks on sliding doors.
Facility failed to provide illuminated exit signs to clearly identify exit access routes.
Facility failed to ensure vertical openings between floors were enclosed with 1-hour fire-rated construction.
Facility failed to ensure fire-rated doors to hazardous areas were self-closing, labeled, and separated by smoke resisting partitions.
Facility failed to ensure openings in smoke barrier doors had fire-rated glazing or wired glass panels in steel frames.
Facility failed to ensure GFCI protection for electrical equipment in the physical therapy room.
Facility failed to inspect and test fire door assemblies annually in accordance with NFPA 80.
Facility failed to ensure electrical panels were locked in patient care areas to prevent guarding of live parts.
Facility failed to ensure the Life Safety Code electrical panel was properly identified and labeled.
Facility failed to ensure a remote manual stop station was installed outside the generator enclosure.
Facility failed to prohibit use of extension cords as a substitute for fixed wiring, including use of orange extension cords powering an electric water fountain.
Facility failed to ensure corridor walls were protected against the transfer of smoke, fire and fumes, evidenced by a non-fire rated sliding glass serving hatch.
Facility failed to ensure corridor doors were constructed to resist the passage of smoke, evidenced by gaps in resident room doors and rehabilitation therapy doors.
Report Facts
CNA staffing deficiency: 7
Census: 100
Total licensed capacity: 120
Deficiency completion dates: Various deficiencies have completion dates ranging from 2023-11-21 to 2024-02-29 as per plans of correction
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Food Service Staff | Observed failing hand hygiene and improper dishwashing practices |
| Registered Nurse Unit Manager (RN/UM #1) | Nurse Manager | Interviewed regarding weight monitoring and infection control |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding investigation, weight monitoring, infection control, and QAPI |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Interviewed regarding QAPI and facility operations |
| Registered Dietitian (RD) | Dietitian | Interviewed regarding nutrition assessments and QAPI |
| Respiratory Therapist (RT) | Respiratory Therapist | Interviewed regarding respiratory equipment education |
| Speech Therapist Director (STD) | Speech Therapist Director | Interviewed regarding infection control education for speech therapy student |
| Maintenance Director (MD) | Maintenance Director | Interviewed regarding life safety code deficiencies and corrective actions |
| Regional Plant Operations Director (RPOD) | Regional Plant Operations Director | Interviewed regarding life safety code deficiencies and corrective actions |
| Staffing Coordinator (SC) | Staffing Coordinator | Interviewed regarding staffing levels and recruitment |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding dish machine malfunction and food temperature |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The inspection was conducted based on complaints NJ154907, NJ157736, and NJ168456 to assess compliance with regulatory requirements for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ154907, NJ157736, and NJ168456 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, based on this complaint survey.
Report Facts
Sample Size: 4
Inspection Report
Routine
Deficiencies: 2
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care and food safety practices at the nursing facility.
Findings
The facility was found deficient in following physician orders for PICC line dressing changes for one resident, and in maintaining proper food labeling, dating, storage, and kitchen sanitation standards, which posed potential risks for residents.
Deficiencies (2)
Failure to follow physician order for PICC line dressing change consistent with professional standards for 1 of 23 residents reviewed.
Failure to properly label, date, and store potentially hazardous foods and dry foods, and failure to maintain kitchen equipment and areas to prevent microbial growth and cross contamination.
Report Facts
Residents reviewed: 23
Resident affected: 1
Dates of PICC dressing orders: Nov 3, 2021
Date of PICC dressing observed: Nov 17, 2021
Date survey completed: Dec 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Interviewed regarding PICC line dressing change frequency and orders | |
| Registered Nurse assigned to Resident #139 | Interviewed about PICC line dressing change training and practice | |
| Director of Nursing | Interviewed about PICC line dressing policy awareness and compliance | |
| Administrator | Informed of findings during survey | |
| Dietary Aide | Observed and interviewed regarding food labeling and storage deficiencies | |
| Director of Dietary Services | Interviewed and toured kitchen with surveyor regarding food safety deficiencies |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 4
Date: Dec 3, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to follow physician orders for care plans, improper food procurement and storage practices, and failure to maintain required minimum direct care staff-to-shift ratios. Life safety code deficiencies were also identified regarding emergency lighting.
Deficiencies (4)
Facility failed to follow a physician order for a change consistent with professional standards of clinical practice for Resident #139.
Facility failed to properly label, date, and store potentially hazardous foods and dry foods, and maintain equipment and kitchen areas to prevent microbial growth and cross contamination.
Facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 3 of 14-day shifts reviewed.
Facility failed to provide battery backup emergency lighting above the emergency generator's transfer switches independent of the building's electrical system and emergency generator.
Report Facts
Census: 93
Sample size: 22
Deficiencies cited: 36
Staffing ratios: 11
Staffing ratios: 11
Staffing ratios: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Stated assigned 9 residents on Evergreen Unit |
| Certified Nursing Assistant #2 | CNA | Stated assigned 9 residents on Evergreen Unit |
| Registered Nurse Supervisor | RN Supervisor | Reported census and staffing on Evergreen Unit |
| Staffing Coordinator | Aware of staffing ratios and compliance | |
| Director of Health Services | Aware of staffing ratios | |
| Director of Maintenance | Responsible for emergency lighting corrective action and monitoring |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Aug 11, 2021
Visit Reason
The inspection was conducted in response to complaint #NJ 141362 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint # NJ 141362 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, based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: May 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health due to concerns about compliance with infection control regulations related to COVID-19.
Complaint Details
The survey was complaint-related, triggered by concerns about COVID-19 infection control practices during an outbreak. The facility was found to have multiple failures in infection prevention and control, including improper cohorting, PPE use, and resident isolation.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to maintain infection control standards and procedures to address the risk of COVID-19 transmission. Deficiencies included failure to follow appropriate isolation precautions, improper use of personal protective equipment (PPE), and allowing residents on Transmission-Based Precautions (TBP) to be out of their rooms without proper safeguards.
Deficiencies (1)
Failure to follow appropriate isolation precaution protocols for residents on Transmission-Based Precautions (TBP) units, including improper use of PPE by staff and allowing residents to be out of their rooms without adequate protection.
Report Facts
Census: 98
Sample size: 14
Plan of Correction Completion Date: Jul 9, 2021
Fall risk assessment score: 11
Vaccination rate: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator (AA) | Provided information about the outbreak and infection control practices. | |
| Licensed Practical Nurse (LPN) | Observed and interviewed regarding PPE use and resident care on the TBP unit. | |
| Activities Aide | Observed providing activities while wearing PPE and interviewed about resident presence in common areas. | |
| Certified Nursing Assistant (CNA) | Interviewed about PPE use, resident isolation, and infection control practices. | |
| Occupational Therapist (OT) | Observed not wearing gown and gloves when entering a resident's room on the TBP unit. | |
| Director of Nursing (DON) | Interviewed regarding infection control policies and resident precautions. | |
| Director of Rehabilitation (DOR) | Provided information on cohorting and PPE requirements for residents and staff. | |
| Registered Nurse Supervisor (RNS) | Interviewed about PPE requirements and resident quarantine status. | |
| Housekeeper (HK) | Interviewed about cleaning protocols and PPE use on the TBP unit. |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Date: Apr 7, 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
Routine
Census: 83
Deficiencies: 0
Date: Feb 16, 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 and recommended COVID-19 practices.
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: 8
Inspection Report
Routine
Census: 79
Deficiencies: 0
Date: Dec 21, 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: 5
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
Date: Dec 4, 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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