Deficiencies per Year
16
12
8
4
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 regarding their health 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
Census: 107
Capacity: 119
Deficiencies: 7
Sep 27, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to complaint NJ167344 and routine recertification requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to reasonable accommodations, self-determination, comprehensive care plans, nutrition/hydration, drug regimen, resident bed safety, and life safety code violations.
Complaint Details
Complaint # NJ167344 triggered the survey. The facility was found not in substantial compliance with multiple regulatory requirements including resident accommodations and care planning.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Reasonable Accommodations Needs/Preferences not met for Resident #69. | SS=D |
| Self-Determination rights not met for 99 of 107 residents regarding food warming and choices. | SS=E |
| Comprehensive Care Plans failed to develop measurable goals and interventions for Resident #105. | SS=D |
| Nutrition/Hydration Status Maintenance failure for Resident #51 regarding snack provision. | SS=D |
| Drug Regimen not free from unnecessary drugs for Resident #105. | SS=D |
| Resident Bed safety issues including bed rails and maintenance for Resident #63. | SS=D |
| Life Safety Code violations related to fire pump testing and fire door inspections. | SS=F |
Report Facts
Survey Census: 107
Total Capacity: 119
Sample Size: 26
Deficiency Severity Counts: 7
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 13
Oct 18, 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 resident call bell accessibility, timely completion and transmission of Minimum Data Set (MDS) assessments, medication administration errors, lack of physician orders for oxygen administration, and failure to notify hospice of significant resident status changes. Life safety code deficiencies included emergency lighting, fire alarm system maintenance, sprinkler system installation, smoke barrier door integrity, HVAC boiler inspections, elevator inspections, and essential electrical system testing.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 6
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to maintain resident call bells accessible and within reach of all residents. | SS=D |
| Facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. | SS=D |
| Facility failed to appropriately remove, clarify, accurately administer, and document resident's physician ordered medications. | SS=D |
| Facility failed to obtain a physician's order for the administration of oxygen for a resident. | SS=D |
| Facility failed to immediately notify the hospice agency about a significant change in a resident's condition and death. | SS=D |
| Facility failed to provide emergency illumination of means of egress that operates automatically. | SS=E |
| Facility failed to provide battery back-up emergency lighting above the emergency generator and fire pump transfer switches. | SS=F |
| Facility failed to provide complete sprinkler coverage in stairwells as required. | SS=F |
| Facility failed to maintain fire alarm system in accordance with NFPA 70 and 72; fire alarm annunciator panel in trouble mode. | SS=F |
| Facility failed to ensure smoke barrier doors fully close to resist passage of smoke, flame, or gases during a fire. | SS=E |
| Facility failed to ensure heating boilers were inspected annually as required. | SS=F |
| Facility failed to ensure elevators conformed with Firefighter's Service Requirements and failed to test and inspect elevators annually. | SS=F |
| Facility failed to certify that the emergency generator transfers power to the building within 10 seconds as required. | SS=F |
Report Facts
Census: 98
Sample Size: 20
Deficiency count: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed findings related to emergency lighting, fire alarm, sprinkler coverage, smoke doors, boiler inspections, elevator inspections, and generator testing. | |
| Regional Plant Operations Director | Interviewed and confirmed findings related to emergency lighting, fire alarm, sprinkler coverage, smoke doors, boiler inspections, elevator inspections, and generator testing. | |
| Licensed Nursing Home Administrator | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Regional Quality Assurance Nurse | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Vice President of Operations | Interviewed regarding medication administration deficiencies, oxygen orders, hospice notification, and life safety code deficiencies. | |
| Registered Nurse MDS Coordinator | Interviewed regarding MDS assessment completion and transmission. | |
| Regional MDS Coordinator | Interviewed regarding MDS submission validation. | |
| Registered Nurse Infection Preventionist | Interviewed regarding medication administration and oxygen order deficiencies. | |
| Consultant Registered Pharmacist | Interviewed regarding medication crushing practices. | |
| Licensed Practical Nurse | Interviewed regarding medication administration and call bell deficiencies. | |
| Certified Nurse Assistant | Interviewed regarding call bell accessibility and oxygen administration. | |
| RN Case Manager | Interviewed regarding hospice notification failures. | |
| Registered Nurse | Interviewed regarding hospice notification failures. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jul 8, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ153575.
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 #: NJ153575. The facility was found compliant based on this complaint survey.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Feb 15, 2022
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ142943) to assess compliance with long term care facility regulations.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B, based on this complaint survey. Additionally, a COVID-19 Focused Infection Control Survey found the facility compliant with infection control regulations and CDC recommended practices.
Complaint Details
Complaint #: NJ142943. The facility was found to be in compliance with the complaint survey requirements.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Jan 12, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ00136968.
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 #: NJ00136968. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 10
Inspection Report
Routine
Census: 96
Deficiencies: 0
Jan 12, 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 CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
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