Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Follow-Up
Census: 152
Deficiencies: 1
Apr 28, 2025
Visit Reason
The visit was a project survey conducted on 04/28/2025 for occupancy approval of 38 additional beds in the renovated part of the main building, followed by a project revisit survey on 05/27/2025 to verify the plan of correction for compliance.
Findings
The initial survey found the facility failed to provide a sanitary environment by not properly disposing of garbage and refuse, with dumpsters uncovered and surrounding areas littered. The follow-up survey found the deficiency was not corrected as dumpsters remained uncovered, but corrective actions were underway including ordering covers and improving waste management practices.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide a sanitary environment by failing to keep dumpsters and surrounding area free of garbage and debris. |
Report Facts
Additional beds for occupancy approval: 38
Residents affected: 152
Residents affected: 144
Dumpsters uncovered: 2
Dumpsters uncovered: 4
Inspection Report
Routine
Census: 142
Capacity: 183
Deficiencies: 9
Apr 4, 2025
Visit Reason
A Recertification Survey was conducted from 3/31/25 through 4/4/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to notify resident representatives in writing for emergency transfers, incomplete and untimely Minimum Data Set (MDS) assessments, medication administration errors, food safety violations, life safety code violations including means of egress and sprinkler system maintenance, and staffing deficiencies. The facility was found not in compliance with several federal and state regulations.
Deficiencies (9)
| Description |
|---|
| Failure to notify resident's representative in writing for emergency transfer or discharge. |
| Failure to complete and transmit Minimum Data Set (MDS) assessments timely for multiple residents. |
| Medication administration errors including failure to follow physician orders and documentation errors. |
| Food safety violations including improper kitchen sanitation and employee hygiene. |
| Life Safety Code violations including obstructed exits, missing stair markings, and sprinkler system deficiencies. |
| Failure to maintain minimum staffing levels as required by state regulations. |
| Smoking policy violations including unapproved smoking areas and improper ashtray containers. |
| Electrical receptacle issues including lack of Ground-Fault Circuit Interrupter (GFCI) protection in wet locations. |
| Gas equipment storage deficiencies including unsecured oxygen tanks. |
Report Facts
Census: 142
Total Capacity: 183
Sample Size: 24
Deficiencies cited: 9
Staffing hours: 370
Staffing hours difference: -2
Residents affected by exit obstruction: 15
Residents affected by stair handrail issues: 15
Residents affected by sprinkler system deficiencies: 142
Residents affected by electrical outlet issues: 12
Residents affected by gas equipment storage issues: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication administration deficiency observation. |
| Director of Nursing | Director of Nursing | Responsible for oversight of medication administration and staffing deficiencies. |
| Regional Director of Business Development | Regional Director of Business Development | Involved in policy review and corrective actions related to resident transfers. |
| Maintenance Director | Maintenance Director | Responsible for oversight of life safety code corrections and sprinkler system maintenance. |
| Food Service Director | Food Service Director | Responsible for food safety audits and corrective actions. |
| Administrator | Administrator | Responsible for staffing and quality assurance oversight. |
| Regional MDS Coordinator | Regional MDS Coordinator | Involved in MDS assessment completion and staff re-education. |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Jan 18, 2023
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to accurately assess and encode a resident (Resident #2) in the Minimum Data Set (MDS) assessments, specifically in Section M related to skin conditions and coding accuracy. The inaccuracy was confirmed through observation, interviews, and record reviews.
Complaint Details
The complaint survey found the facility was not in compliance with accuracy of assessments requirements. The deficiency was substantiated based on observation, interview, and record review of Resident #2's MDS assessments.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accurately assess and encode a resident in the Minimum Data Set (MDS) assessments for skin conditions. | SS=D |
Report Facts
Sample Size: 5
Census: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #1) | Interviewed and confirmed coding error on Resident #2's MDS | |
| Regional MDS Coordinator (RMDSC) | Interviewed and confirmed inaccurate coding on Resident #2's MDS | |
| Administrator and Director of Nursing (DON) | Interviewed regarding importance of accurate MDS coding |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 1
May 12, 2022
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 CDC recommended practices for COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure that all staff and visitors were properly screened for COVID-19 signs and symptoms according to facility policy and CDC guidelines. Seven of fifteen employees and seven of twenty visitors were not fully screened prior to entry.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure all staff and visitors entering the building were screened for COVID-19 signs and symptoms in accordance with facility policy and CDC guidelines. | SS=E |
Report Facts
Employees not fully screened: 7
Visitors not fully screened: 7
Census: 112
COVID-19 outbreak start date: May 3, 2022
Last positive COVID-19 test date: May 4, 2022
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Mar 29, 2022
Visit Reason
The inspection was conducted as a complaint survey to determine 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
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Nov 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146183 and NJ146187.
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 #: NJ146183 and NJ146187; the survey was complaint-based and the facility was found compliant.
Report Facts
Sample Size: 11
Inspection Report
Routine
Census: 106
Deficiencies: 4
Jun 10, 2021
Visit Reason
Routine standard survey conducted on 6/10/21 to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies noted in resident privacy during medication administration and physical examination, accident hazards and supervision, pharmacy services including narcotic inventory discrepancies, and infection prevention and control practices.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide full visual privacy during medication administration and physical examination for 2 residents. | SS=D |
| Failed to provide a safe environment to prevent a fall during repositioning and care of a resident. | SS=D |
| Failed to ensure accurate inventory and reconciliation of controlled narcotic medications in the backup narcotic cabinet. | SS=D |
| Failed to follow appropriate infection prevention and control measures, including improper use of PPE and N95 masks for residents on droplet precautions. | SS=D |
Report Facts
Sample Size: 25
Residents present: 106
Deficiencies cited: 4
Narcotic tablet discrepancy: 1
Fall incident date: Jun 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Involved in re-education and monitoring of privacy and infection control deficiencies. | |
| Registered Nurse Unit Manager | Interviewed regarding fall incident and narcotic inventory. | |
| Infection Preventionist | Interviewed regarding infection control deficiencies and PPE use. | |
| Administrator | Discussed concerns related to privacy, fall, narcotic inventory, and infection control. | |
| Physician | Observed not wearing required N95 mask during examination of resident on droplet precautions. | |
| Laundry Aide | Observed not wearing required N95 mask when entering resident room on droplet precautions. |
Inspection Report
Life Safety
Deficiencies: 4
Jun 10, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/04/21 and 06/08/21 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including smokeproof enclosures, fire alarm system maintenance, corridor wall construction, and corridor door integrity. Deficiencies included a faulty door in an exit enclosure, fire alarm panel trouble condition, missing doors and partitions in corridor walls, and doors with missing hardware or improper latching.
Severity Breakdown
SS=D: 1
SS=C: 1
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Smokeproof enclosure door separating mechanical room from rear exit vestibule was ajar and failed to latch due to faulty hardware and bent doorframe creating a 2-inch gap. | SS=D |
| Fire alarm display panel was in 'trouble' mode with a lit yellow indicator and intermittent audible beep due to suspected smoke detection device issue. | SS=C |
| Corridor walls were breached with 5 of 31 doors missing and glass partitions missing, compromising protection against smoke, fire, and fumes. | SS=E |
| 20 of 31 corridor doors had 2-2.5 inch diameter openings due to missing door hardware and lacked latching hardware to ensure secure closure. | SS=E |
Report Facts
Number of exit enclosures: 5
Number of smoke zones: 12
Number of missing corridor doors: 5
Number of corridor doors with missing hardware: 20
Number of door knobs ordered: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in relation to deficiencies and corrective actions for door repairs, fire alarm system, and corridor audits | |
| Maintenance Director | Observed deficiencies and confirmed findings during survey |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Dec 17, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00135562, NJ00139782, and NJ00140237.
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 NJ00135562, NJ00139782, and NJ00140237 were investigated and found to be in compliance.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 106
Deficiencies: 0
Dec 3, 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: 6
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