Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
182 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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 explains 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
Complaint Investigation
Census: 182
Deficiencies: 7
Jan 9, 2025
Visit Reason
A Recertification and Complaint Survey was conducted due to multiple complaint numbers listed. The survey was to assess compliance with 42 CFR 483 subpart B for long term care facilities.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to notify residents and representatives of changes in condition, drug regimen review irregularities, unsafe environmental conditions, and life safety code violations related to fire safety and maintenance.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed (NJ163566, NJ166367, NJ167186, NJ168560, NJ169565, NJ173055, NJ178204, NJ178367, NJ178833, NJ179065, NJ180762, and NJ180949). The facility was found not to be in substantial compliance based on the recertification and complaint visit.
Severity Breakdown
SS=D: 3
SS=F: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to notify residents and representatives of changes in condition. | SS=D |
| Drug regimen review irregularities and failure to act on pharmacist recommendations. | SS=D |
| Unsafe environmental conditions including damaged walls, peeling paint, and unsafe maintenance issues in resident rooms. | SS=D |
| Failure to maintain fire resistance rating of vertical openings and sprinkler system deficiencies. | SS=F |
| Failure to maintain and inspect portable fire extinguishers. | SS=F |
| Failure to ensure corridor doors close and latch properly. | SS=F |
| Failure to maintain corridor doors closed and latched to resist passage of smoke. | SS=F |
Report Facts
Survey Census: 182
Sample Size: 43
Number of beds occupied: 56
Number of beds occupied: 129
Number of residents affected: 8
Number of residents affected: 35
Number of residents affected: 45
Number of residents affected: 30
Number of residents affected: 75
Number of residents affected: 129
Inspection Report
Complaint Investigation
Census: 191
Deficiencies: 0
May 13, 2024
Visit Reason
The inspection was conducted as a complaint survey triggered by multiple complaint numbers listed in the report.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey. A COVID-19 Focused Infection Control Survey was also conducted, and the facility was found to be in compliance with infection control regulations.
Complaint Details
The survey was based on multiple complaints (NJ00166435, NJ00166436, NJ00166522, NJ00166599, NJ00166600, NJ00167442, NJ00167641, NJ00168057, NJ00170017, NJ00173439). The facility was found to be in compliance and no deficiencies were cited.
Report Facts
Sample Size: 13
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 1
Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00147498, NJ00146405, and NJ00149099 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to maintain complete and accurate medical records for Resident #3, specifically related to documentation of care and medication administration. The facility policy requires complete and accurate charting, but the LPN failed to document medication administration in the resident's medical record.
Complaint Details
The complaint investigation was based on complaints NJ00147498, NJ00146405, and NJ00149099. The facility was found not in compliance with requirements related to resident medical records and documentation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #3's medical record was complete and accurate according to facility policies, including missing documentation of medication administration by nursing staff. | SS=D |
Report Facts
Census: 138
Sample Size: 6
PRN pain medication documentation audit sample: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Primary nurse for Resident #3 who failed to document medication administration | |
| Director of Nursing (DON) | Provided statements regarding documentation expectations and conducted re-inservice on clinical charting and documentation |
Inspection Report
Annual Inspection
Census: 203
Capacity: 73
Deficiencies: 8
Dec 21, 2022
Visit Reason
Standard annual survey to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with federal requirements, with deficiencies cited related to Minimum Data Set (MDS) submissions, accuracy of assessments, professional standards in care, respiratory care, pharmacy services, food safety, infection control, and life safety code violations including fire safety and electrical systems.
Severity Breakdown
SS=E: 3
SS=D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to complete and transmit Minimum Data Set (MDS) assessments timely for 21 of 38 residents. | SS=E |
| Failure to accurately complete MDS assessments for 1 of 38 residents (#207). | SS=D |
| Failure to maintain professional nursing standards including labeling and dating enteral feeding containers and following physician orders for Resident #41. | SS=D |
| Failure to maintain necessary respiratory care and services for Resident #126 according to standards of practice. | SS=D |
| Failure to provide pharmacy services with accurate documentation and removal of expired medications. | SS=D |
| Failure to maintain proper kitchen sanitation and food labeling practices. | SS=D |
| Failure to establish and maintain an infection prevention and control program including proper PPE use, hand hygiene, and linen storage. | SS=D |
| Life Safety Code deficiencies including penetrations in fire rated walls, improper exit discharge surfaces, fire alarm system testing and maintenance deficiencies, sprinkler system installation and maintenance issues, portable fire extinguisher maintenance, HVAC boiler inspection deficiencies, electrical system deficiencies including GFCI outlets and essential electrical system failures. | — |
Report Facts
Residents with late MDS submissions: 21
Sample size: 38
Certified beds: 73
Census: 203
Fire extinguisher count: 26
Electrical outlets tested: 10
Generator load test transfer time: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator #1 | Registered Nurse/MDS Coordinator | Interviewed regarding late MDS submissions and transmission procedures. |
| RN/MDS Coordinator #2 | Registered Nurse/MDS Coordinator | Interviewed regarding MDS transmission delays. |
| Director of Nursing | Director of Nursing | Responsible for auditing MDS transmission reports and infection control audits. |
| Licensed Practical Nurse (LPN#1) | Licensed Practical Nurse | Interviewed regarding medication administration and labeling. |
| Unit Manager/Registered Nurse (UM/RN) | Unit Manager/Registered Nurse | Interviewed regarding respiratory care and mask storage. |
| Executive Licensed Nursing Home Administrator (LNHA) | Administrator | Interviewed regarding infection control concerns and late MDS transmissions. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Performed inventory count of controlled substances and interviewed about medication removal procedures. |
| Maintenance Director | Maintenance Director | Interviewed regarding fire safety, electrical, and sprinkler system deficiencies. |
| Assistant Regional Maintenance (ARM) | Assistant Regional Maintenance | Assisted with facility tours and confirmed fire safety and electrical findings. |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding kitchen sanitation and food labeling. |
| Regional Quality Assurance RN | Regional Quality Assurance Registered Nurse | Participated in infection control interviews and audits. |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 1
Jul 7, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ145575, NJ141557, NJ144168, NJ143791, NJ145020, NJ144966) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to provide written notice of a facility-initiated discharge to the resident, resident representative, and the Ombudsman for one resident. The resident was transferred to a hospital and the facility decided not to permit the resident to return but failed to send the required discharge notices.
Complaint Details
Complaint Intake NJ144168 found that the facility failed to provide written notice of a facility-initiated discharge for one resident who was transferred to a hospital and not permitted to return. The facility only sent an emergency transfer notice but did not send a discharge notice as required. The resident did not return to the facility.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written notice of a facility-initiated discharge to the resident, resident representative, and the Ombudsman. | SS=D |
Report Facts
Census: 139
Sample Size: 10
Inspection Report
Routine
Census: 189
Deficiencies: 0
Mar 23, 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: 8
Inspection Report
Original Licensing
Capacity: 178
Deficiencies: 0
Jan 21, 2021
Visit Reason
Initial inspection for licensure of new or renovated long term care facilities, including transfer of 178 beds from another facility and room conversions.
Findings
No deficiencies were noted during the inspection. Multiple rooms were converted from semi-private to private and from 3-bedded to 2-bedded rooms. Only cosmetic work was noted.
Report Facts
Total licensed beds: 178
Inspection Report
Routine
Census: 50
Deficiencies: 0
Nov 24, 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 and preparedness for 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 to prepare for COVID-19.
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