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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 93
Deficiencies: 7
Feb 5, 2024
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 notice requirements before transfer/discharge, encoding/transmitting resident assessments, posted nurse staffing information, labeling and storage of drugs and biologicals, fire alarm system installation and testing, smoke detection, and electrical system maintenance.
Severity Breakdown
SS=B: 2
SS=D: 2
SS=E: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to notify the Ombudsman’s Office about discharges within 30 days of a resident being discharged. | SS=B |
| Facility failed to transmit the Minimum Data Set (MDS) assessments in a timely manner and in accordance with CMS RAI manual. | SS=B |
| Facility failed to accurately post nurse staffing information including total number and actual hours worked for licensed and unlicensed staff responsible for resident care. | SS=D |
| Facility failed to properly label, store, and dispose of medications in 1 of 5 medication carts inspected. | SS=D |
| Facility failed to ensure two of 165 photoelectric smoke detectors were greater than 36 inches from ceiling air diffusers. | SS=E |
| Facility failed to complete a smoke detector sensitivity test for all 165 photoelectric smoke detectors. | SS=E |
| Facility failed to ensure load bank testing was completed for 3 generators as required. | SS=F |
Report Facts
Census: 93
Deficiencies cited: 7
Medication carts inspected: 5
Photoelectric smoke detectors: 165
Generators: 3
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Dec 21, 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 staffing requirements.
Findings
The facility was found to be in compliance with COVID-19 infection control regulations but was not in compliance with the State of New Jersey minimum staffing requirements for certified nurse aides (CNAs) on multiple day shifts from 12/9/22 through 12/15/22, being short by one CNA on those shifts.
Complaint Details
The visit was complaint-related due to failure to maintain minimum staffing ratios. The deficiency was substantiated based on interviews, documentation review, and staffing reports.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, specifically being one CNA short on several day shifts between 12/9/22 and 12/15/22. |
Report Facts
Census: 91
Deficiency counts: 7
CNA staffing shortfall: 1
New CNAs hired: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed by surveyor regarding staffing and nurse staffing task | |
| Quality Coordinator | Designated on January 17, 2023 to manage and adjust CNA staffing, reports to DON and Administrator |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Mar 24, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #NJ00152257 regarding allegations of abuse at the facility.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of abuse involving one resident. The complaint involved a nurse verbally abusing and being rough with Resident #2, but the allegation was not reported to the Administrator or Director of Nursing and was not investigated or reported to the New Jersey Department of Health as required.
Complaint Details
Complaint #NJ00152257 involved an allegation by Resident #2's representative that a nurse was verbally abusive and rough towards Resident #2. The complaint was not reported to the Administrator or Director of Nursing, resulting in no investigation or reporting to the NJ Department of Health. The resident was discharged on 8/27/2021.
Deficiencies (1)
| Description |
|---|
| Failure to report an allegation of abuse to the Administrator and follow facility policy on 'Prohibition of Resident Abuse and Neglect' for one resident. |
Report Facts
Census: 85
Sample Size: 3
Inspection Report
Routine
Census: 80
Deficiencies: 3
Dec 3, 2021
Visit Reason
A Federal Comparative survey was conducted from 11/29/2021 to 12/03/2021 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found to not be in substantial compliance with requirements related to nurse staffing information posting, labeling and storage of drugs and biologicals, and food safety requirements including sanitation and proper dish machine operation.
Severity Breakdown
Level C: 1
Level D: 1
Level F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to post nurse staffing information daily in a clear and readable format accessible to residents and visitors. | Level C |
| Failure to properly label and store drugs and biologicals, including expired medications and loose pills found in medication storage areas. | Level D |
| Failure to procure, store, prepare, and serve food in accordance with professional food safety standards, including issues with dish machine final rinse temperature and kitchen sanitation. | Level F |
Report Facts
Census: 80
Sample Size: 19
Deficiencies cited: 3
Expiration dates: 4
Final rinse temperature: 160
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 1
Oct 28, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey state staffing requirements for nursing homes, specifically to evaluate whether the facility maintained the required minimum direct care staff-to-resident ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios for 4 of 42 shifts reviewed, as evidenced by staffing reports showing insufficient certified nursing assistants on several days. The facility acknowledged staffing challenges and described multiple interventions to recruit and retain staff.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 4 of 42 shifts reviewed. |
Report Facts
Shifts with staffing deficiencies: 4
Residents during staffing review: 84
Certified Nursing Assistants (CNAs): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Acknowledged awareness of staffing ratio law and compliance status during survey. | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyors to discuss staffing ratio concerns and acknowledged awareness of staffing requirements. | |
| Director of Nursing (DON) | Monitors staff needs and met with surveyors to discuss staffing ratio concerns. |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
May 12, 2021
Visit Reason
The inspection visit was conducted in response to complaint NJ 140520 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint NJ 140520 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 80
Deficiencies: 0
Mar 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: 8
Inspection Report
Routine
Census: 82
Deficiencies: 0
Jan 21, 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: 5
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 1
Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to practice appropriate hand hygiene for 4 of 12 staff members observed, contrary to CDC guidelines to mitigate the spread of COVID-19.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to practice appropriate hand hygiene by 4 of 12 staff, including improper handwashing technique and use of the same paper towel to dry hands and turn off faucet. | SS=E |
Report Facts
Staff observed with deficient hand hygiene: 4
Total staff observed for hand hygiene: 12
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist | Occupational Therapist (OT) | Observed applying soap without wetting hands first |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA #1) | Observed improper use of paper towel during hand hygiene |
| Certified Nursing Assistant #2 | Certified Nursing Assistant (CNA #2) | Observed applying soap without wetting hands and washing for only 7 seconds |
| Registered Nurse | Registered Nurse (RN) | Observed washing hands for 12 seconds and using same paper towel to dry hands and turn off faucet |
| Infection Preventionist Nurse | Infection Preventionist Nurse (IPN) | Reported all staff were educated on hand hygiene and competencies |
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