Inspection Reports for
Waterfront Rehabilitation And Healthcare Center
633 State Route 28, Raritan, NJ, 08869
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
91% occupied
Based on a April 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy 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 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, individuals' rights to access and control their information, and the department's legal duties and responsibilities regarding privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer listed as contact for privacy practices |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00185469 to determine compliance with long term care facility regulations.
Complaint Details
Complaint #NJ00185469 triggered the visit. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on the complaint visit. Staffing deficiencies were documented for CNA coverage on 14 day shifts during the complaint period. Documentation deficiencies were identified for one resident's medical record.
Findings
The facility was found not in substantial compliance with federal and state requirements, including failure to properly document resident records and failure to meet minimum staffing ratios for Certified Nursing Assistants (CNAs) during the complaint period.
Deficiencies (2)
Failure to consistently document resident records according to facility policy and regulatory requirements, evidenced by incomplete documentation for Resident #4.
Failure to maintain required minimum staffing ratios for CNAs during 14 day shifts in the complaint period from 04/06/2025 to 04/19/2025.
Report Facts
Census: 128
Sample Size: 5
Staffing Deficiencies: 14
CNA Staffing Counts: 13
CNA Staffing Counts: 14
CNA Staffing Counts: 12
CNA Staffing Counts: 13
CNA Staffing Counts: 13
CNA Staffing Counts: 13
CNA Staffing Counts: 12
CNA Staffing Counts: 13
CNA Staffing Counts: 13
CNA Staffing Counts: 13
Inspection Report
Routine
Census: 126
Capacity: 138
Deficiencies: 19
Date: Apr 11, 2022
Visit Reason
An Emergency Preparedness Comparative Federal Monitoring Survey was conducted by CMS on April 11, 2022 following a New Jersey Department of Health survey on March 22, 2022 to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code.
Findings
The facility was found not in compliance with multiple federal requirements including emergency preparedness program updates, emergency plan risk assessment, fire safety including egress door signage and operation, emergency illumination, exit signage, hazardous area enclosures, cooking facility protections, fire alarm system installation, sprinkler system installation and maintenance, fire extinguisher maintenance, corridor construction, fire drills, electrical system reliability, emergency generator annunciator maintenance, and medical gas equipment training.
Deficiencies (19)
Failed to establish and maintain a comprehensive Emergency Preparedness Program updated at least annually.
Failed to develop and maintain emergency preparedness plan including risk assessment and strategies for emergency events.
Failed to develop, implement and update emergency preparedness policies addressing the facility's role under a 1135 Waiver.
Failed to provide signs at exits with delayed egress locking devices indicating operation procedure and ensure doors open with less than 15 pounds of force.
Failed to provide emergency illumination that operates automatically along means of egress.
Failed to properly identify doors that are not exits with 'No Exit' signs and provide directional exit signs.
Failed to provide fire barriers with one-hour fire resistance rating and maintain self-closing devices on doors to hazardous areas.
Failed to provide and maintain range hood and grease baffles in cooking facilities.
Failed to install supervised smoke detection in areas including skylight above corridor ceiling.
Failed to properly install sprinklers including missing escutcheon fittings, corroded sprinklers, gaps around sprinkler piping, and lack of coverage under skylight.
Failed to maintain sprinkler system ensuring ceiling level was smoke resisting and fire stopped penetrations.
Failed to provide required instructional placards near Class K fire extinguisher and maintain monthly inspection records.
Failed to ensure corridor walls resist passage of smoke due to transfer grille discharging air into corridor.
Failed to provide smoke barrier doors without gaps preventing 20-minute fire resistance.
Failed to conduct fire drills under varying conditions, locations, and simulation of emergency fire conditions.
Failed to demonstrate reliability of natural gas fuel supply for emergency generator.
Failed to maintain remote annunciator for emergency generator.
Failed to inspect, test and maintain automatic transfer switch for emergency power source.
Failed to ensure personnel responsible for medical gases are trained on risks, safety, usage, and emergency shut off valve location.
Report Facts
Certified beds: 138
Census: 126
Residents affected: 60
Residents affected: 40
Residents affected: 30
Residents affected: 20
Inspection Report
Life Safety
Deficiencies: 5
Date: Mar 21, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 03/21/2022 and 03/22/2022 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code for Existing Health Care Occupancies.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting backup, fire barriers in hazardous areas, fire alarm system notification in an enclosed courtyard, integrity of smoke barrier partitions, and generator maintenance and testing. Corrective actions and plans of correction were provided for each deficiency.
Deficiencies (5)
Failed to provide a battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system and emergency generator.
Failed to provide fire barriers with a one-hour fire resistance rating to hazardous areas such as the boiler room, with missing ceiling tiles and unsealed penetrations.
Failed to provide fire alarm notification by audible and visible signals for 1 of 1 enclosed courtyard.
Failed to maintain the integrity of smoke barrier partitions for six of eight smoke barrier walls with penetrations ranging from 3/8 inch to 10 inches allowing potential passage of smoke, fumes, and fire.
Failed to certify that the emergency generator transfers power to the building within 10 seconds and failed to exercise the emergency electrical generator 12 times each year for monthly load tests as required.
Report Facts
Deficiencies cited: 5
Smoke barrier penetrations: 6
Generator load tests: 12
Generator exercise duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Conducted emergency light function test, fire barrier repairs, generator testing, and was educated on compliance requirements | |
| Administrator | Participated in inspections, informed of findings, and educated staff on compliance |
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 9
Date: Mar 10, 2022
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 comprehensive assessments and timing, encoding/transmitting resident assessments, development and implementation of comprehensive care plans, meeting professional standards for services, treatment and services to prevent and heal pressure ulcers, food procurement and safety, infection prevention and control, COVID-19 vaccination of facility staff, and mandatory access to care staffing ratios.
Deficiencies (9)
Failed to complete comprehensive Minimum Data Set assessments in a timely manner for 3 of 16 residents reviewed.
Failed to electronically transmit Minimum Data Set assessments within 14 days of completion for 13 of 16 residents reviewed and 2 of 28 residents reviewed.
Failed to develop a comprehensive care plan for the use of therapy for 1 of 2 residents reviewed.
Failed to obtain physician orders to provide supplementation for 2 of 2 residents reviewed.
Failed to implement physician's order for treatment to prevent worsening of pressure ulcers for 1 of 1 resident reviewed.
Failed to properly label and date food products stored in walk-in refrigerator/freezer and failed to ensure kitchen staff wore hair restraint that fully covered hair during food preparation.
Failed to maintain appropriate infection control practices including cleaning of equipment and proper use of personal protective equipment (PPE) for residents on droplet and contact precautions.
Failed to ensure mitigation measures were followed to prevent potential spread of COVID-19 by partially vaccinated and unvaccinated staff.
Failed to maintain required minimum direct care staff-to-resident ratios for 13 of 14 day shifts and 1 of 14 evening shifts reviewed.
Report Facts
Census: 126
Staffing deficiency counts: 13
Staffing deficiency counts: 1
Residents reviewed for MDS late submission: 16
Residents reviewed for MDS transmission: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Administrator | Named in relation to staffing and MDS coordination issues |
| Regional MDS Coordinator | MDS Coordinator | Named in relation to MDS assessment and transmission delays |
| MDS Consultant | Consultant | Named in relation to MDS assessment and transmission delays |
| Director of Nursing | DON | Named in relation to staffing, care plan, and infection control findings |
| Assistant Director of Nursing | ADON | Named in relation to care plan and infection control findings |
| Director of Environmental Services | DEVS | Named in relation to cleaning and infection control findings |
| Licensed Practical Nurse | LPN | Named in relation to COVID-19 vaccination and PPE use |
| Certified Nursing Assistant | CNA | Named in relation to COVID-19 vaccination and PPE use |
| Business Office Manager | BOM | Named in relation to PPE use observation |
| Interim Infection Preventionist | IIP | Named in relation to infection control and COVID-19 vaccination findings |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Nov 12, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints #NJ149011 and #NJ148886.
Complaint Details
Complaint #NJ149011 and #NJ148886 were investigated and the facility was found compliant.
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: 6
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Date: Aug 9, 2021
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jan 19, 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: 11
Inspection Report
Routine
Census: 110
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.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Dec 1, 2020
Visit Reason
The inspection was conducted in response to complaints NJ 141299 and NJ 141433 regarding alleged verbal abuse at the facility.
Complaint Details
Complaint # NJ 141299, NJ 141433 involved an allegation of verbal abuse by staff toward Resident #2. The allegation was not reported to the New Jersey Department of Health as required. The facility investigated and ruled out abuse based on staff interviews and ongoing investigation.
Findings
The facility failed to report an allegation of verbal abuse involving Resident #2 to the New Jersey Department of Health and did not follow their abuse policy. The investigation found no substantiating evidence of abuse, but the reporting failure was confirmed.
Deficiencies (1)
Failure to report an allegation of verbal abuse to the New Jersey Department of Health and failure to follow facility abuse policy.
Report Facts
Census: 110
Sample size: 3
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