Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for privacy practices. |
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 1
Apr 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ 184710) to assess compliance with staffing ratios and other regulatory requirements at the facility.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding minimum staffing ratios, specifically failing to meet required CNA staffing levels on multiple day shifts over several weeks. A Plan of Correction was required to address these deficiencies.
Complaint Details
Complaint # NJ 184710 was substantiated with findings of deficient CNA staffing ratios on multiple day shifts during the weeks of 03/02/2025 to 03/08/2025 and 04/13/2025 to 04/26/2025.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 21 day shifts. |
Report Facts
Census: 138
Deficient CNA staffing days: 21
Required CNAs vs Actual CNAs: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Met with Director of Nursing and Staffing Coordinator to address staffing vacancies and corrective actions. | |
| Director of Nursing | Met with Administrator and Staffing Coordinator to address staffing vacancies and corrective actions; responsible for audits and quality assurance. | |
| Staffing Coordinator | Involved in determining staffing vacancies and recruitment efforts. | |
| Human Resource Director | Responsible for exit interviews, recruitment, and quality assurance tracking. |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 2
Dec 5, 2024
Visit Reason
The inspection was conducted based on complaints NJ 177500 and 172217 alleging deficiencies in resident care documentation and staffing ratios at Anchor Care and Rehabilitation Center.
Findings
The facility was found not in substantial compliance with federal and state regulations due to failure to consistently document care provided to residents and failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple day shifts. Documentation deficiencies were noted for 3 of 5 residents reviewed, with numerous days and shifts lacking proper ADL documentation. Staffing deficiencies were documented for multiple weeks with CNA staffing below mandated ratios.
Complaint Details
Complaint # NJ 177500 and 172217. The facility was not in substantial compliance based on these complaints regarding documentation and staffing.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to consistently document care provided to residents in the Resident CNA Documentation Record for 3 of 5 residents reviewed. | SS=E |
| Failure to maintain required minimum staff-to-resident ratios for CNAs on multiple day shifts as mandated by New Jersey state law. | — |
Report Facts
Census: 152
Sample Size: 5
Deficient CNA staffing days: 5
Deficient CNA staffing days: 7
Deficient CNA staffing days: 14
Documentation missing days: 22
Documentation missing days: 23
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 2
Oct 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ00168186) to determine compliance with federal and state regulations regarding the hiring and use of nurse aides and staffing ratios.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on the complaint visit. Deficiencies included the use of a non-certified Temporary Nurse Aide (TNA) working beyond allowed timeframes without proper certification and failure to maintain required minimum direct care staff-to-resident ratios for Certified Nursing Assistants (CNAs) on multiple shifts.
Complaint Details
Complaint # NJ00168186 was substantiated. The facility was found deficient for employing a non-certified Temporary Nurse Aide beyond the allowed period and failing to maintain minimum CNA staffing ratios, potentially affecting all residents.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure that a non-certified Temporary Nurse Aide (TNA) was properly certified and competent before working independently. | SS=D |
| Facility failed to maintain the required minimum direct care staff-to-resident ratio for Certified Nursing Assistants (CNAs) on 5 of 14 day shifts. | — |
Report Facts
Census: 139
Sample Size: 3
Deficient CNA staffing shifts: 5
CNA staffing ratios: 17
CNA staffing counts: 14
CNA staffing counts: 16
CNA staffing counts: 15
CNA staffing counts: 16
CNA staffing counts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| TNA #1 | Temporary Nurse Aide | Non-certified nurse aide working beyond allowed period without CNA certification |
| Assistant Director of Nursing | ADON | Informed TNA #1 about CNA school enrollment requirement |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding supervision of TNA #1 |
| Human Resources Coordinator | HRC | Responsible for tracking staff licenses and certifications |
| Director of Nursing | DON | Interviewed about TNA #1 certification and schedule removal |
| Human Resource Director | Reviewed staffing ratios and hiring procedures | |
| Staffing Coordinator | Monitors staffing ratios and audits CNA certifications |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 1
Sep 29, 2023
Visit Reason
A complaint survey was conducted on behalf of the State of New Jersey Department of Health to assess compliance with regulatory standards.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B but failed to meet mandatory staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts, affecting all residents.
Complaint Details
The complaint survey found the facility deficient in CNA staffing ratios for 12 of 28 day shifts, with specific dates and CNA counts documented showing shortages compared to required minimums.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 12 of 28 day shifts. |
Report Facts
Survey Census: 140
Sample Size: 11
Deficient day shifts: 12
CNA staffing counts: 12
CNA staffing counts: 15
CNA staffing counts: 14
CNA staffing counts: 13
CNA staffing counts: 14
CNA staffing counts: 16
CNA staffing counts: 16
CNA staffing counts: 16
CNA staffing counts: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Met with Director of Nursing and Staffing Coordinator to address staffing vacancies and ensure accuracy of facility needs | |
| Director of Nursing | Met with Administrator and Staffing Coordinator to address staffing vacancies and ensure accuracy of facility needs | |
| Staffing Coordinator | Responsible for monitoring staffing ratios and notifying Director of Nursing and Administrator when ratios are not met | |
| Human Resource Director | Reviews staffing ratios with Administrator and Director of Nursing; completes exit interviews for nursing employees |
Inspection Report
Routine
Census: 141
Deficiencies: 0
Jul 5, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Routine
Census: 143
Deficiencies: 0
Apr 6, 2023
Visit Reason
A COVID-19 Focused Infection 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 14
Inspection Report
Annual Inspection
Census: 139
Capacity: 170
Deficiencies: 4
Mar 17, 2023
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 failure to maintain professional standards of clinical practice for 3 residents, failure to accurately account for controlled medications, improper medication storage, and food safety violations including improper labeling and hand hygiene. The facility was also found deficient in maintaining required minimum direct care staff-to-resident ratios for the day shift.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain professional standards of clinical practice for 3 residents by not monitoring meal intake, not completing assessments before and after administering medications, and not removing an alarm once discontinued. | SS=D |
| Failed to accurately account for and document administration of controlled medications, maintain clean and sanitary medication storage areas, and ensure accountability of narcotic shift count logs. | SS=D |
| Failed to properly handle and store potentially hazardous foods, properly wash hands, and maintain equipment and kitchen areas to prevent microbial growth and cross contamination. | SS=F |
| Failed to maintain required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey. | — |
Report Facts
Census: 139
Total Capacity: 170
Meals without documentation: 272
Missing capsules: 1
Missing nurse signatures: 14
Staffing Deficiency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication administration and narcotic count discrepancy |
| Assistant Director of Nursing | ADON | Interviewed regarding medication assessments and medication storage issues |
| Director of Nursing | DON | Interviewed regarding meal intake documentation and medication administration |
| Nurse Manager | Named in failure to remove alarm bracelet after order discontinued | |
| Food Service Director | FSD | Interviewed regarding kitchen sanitation and hand hygiene |
| Regional Food Service Director | RFSD | Interviewed regarding kitchen sanitation and food labeling |
| Dietary Aide | DA | Observed washing hands improperly in kitchen |
Inspection Report
Life Safety
Census: 138
Capacity: 170
Deficiencies: 0
Mar 9, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted to assess compliance with federal regulations and life safety code requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 for Emergency Preparedness and 42 CFR 483.90(a) Life Safety from Fire, as well as the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Report Facts
Occupied beds: 138
Total licensed capacity: 170
Percentage of building powered by generator: 50
Inspection Report
Original Licensing
Deficiencies: 0
Oct 20, 2022
Visit Reason
The survey was conducted as part of a new construction and renovation project for the newly renovated 1-West Wing of the facility.
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. The renovated areas may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.
Inspection Report
Life Safety
Deficiencies: 0
Oct 20, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 10/20/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 for existing health care occupancies.
Findings
Anchor Care and Rehabilitation Center was found to be in compliance with the Life Safety Code requirements. The survey focused on a newly renovated 1-West Wing consisting of multiple rooms and facilities, and no deficiencies were cited.
Report Facts
Rooms in renovated wing: 14
Smoke zones: 8
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Oct 5, 2022
Visit Reason
The inspection was conducted in response to a complaint (Complaint #NJ150368) alleging misappropriation of a resident's assets and failure to investigate the allegation properly.
Findings
The facility failed to complete and provide an investigation of an allegation of misappropriation of Resident #2's assets through a Durable Power of Attorney (DPOA) assigned by the facility. The resident reported unauthorized sale of personal property and financial exploitation. The facility also failed to follow its policies on Resident Abuse and Resident Rights. No actual harm was cited, and the matter is in litigation.
Complaint Details
Complaint #NJ150368 involved allegations of abuse and misappropriation of Resident #2's assets. The complaint was substantiated as the facility failed to investigate and prevent harm. The matter is in litigation, and no actual harm was cited during the survey.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to investigate allegations of misappropriation of Resident #2's assets and prevent psychosocial harm. | SS=D |
Report Facts
Resident census: 146
Monetary amounts taken: 10500
Monetary amounts taken: 700
Audit frequency: 4
Audit frequency: 3
Audit frequency: 2
Fee amount: 6000
Personal property values: 4000
Personal property values: 3000
Personal property values: 10000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Director | Admissions Director | Mentioned in relation to the misappropriation allegations and Medicaid/DPOA process |
| Social Worker Director | Social Worker Director | Interviewed regarding BIMS score and POA policies |
| Administrator | Administrator | Interviewed about the lawsuit and involvement of Admissions and Business Office |
Inspection Report
Abbreviated Survey
Census: 133
Deficiencies: 0
Sep 15, 2021
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 0
Jul 29, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ142012, NJ140357, NJ135060, and NJ133481.
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 NJ142012, NJ140357, NJ135060, and NJ133481 were investigated and found to be in compliance.
Report Facts
Sample Size: 11
Inspection Report
Annual Inspection
Census: 132
Deficiencies: 8
May 21, 2021
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 physical environment approvals, medication administration errors, respiratory care, drug regimen review irregularities, medication storage, therapeutic diet compliance, food safety, and infection prevention and control practices.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to obtain approvals from the Department of Community Affairs for renovations prior to conducting renovations and re-occupying the areas. | — |
| Facility failed to maintain professional standards of clinical practice by not following manufacturing specifications for administration of delayed release medication and not clarifying physician's orders for two residents. | SS=D |
| Facility failed to maintain necessary respiratory care and services for a resident receiving respiratory care, including improper storage and handling of respiratory equipment and inadequate hand hygiene. | SS=D |
| Facility failed to ensure Consultant Pharmacist reported irregularities and that the facility acted upon pharmacist's recommendations for medication regimen review for two residents. | SS=D |
| Facility failed to properly label, store, and dispose of medications in medication carts, including expired medications and improper dating. | SS=D |
| Facility failed to ensure a resident on fluid restriction received and consumed liquids in the appropriate amount according to physician orders. | SS=E |
| Facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent food borne illness. | SS=D |
| Facility failed to perform hand hygiene appropriately for staff and disinfect equipment used in COVID-19 screening and testing processes according to CDC guidelines. | SS=E |
Report Facts
Census: 132
Sample size: 26
Bread loaves: 35
Medication carts inspected: 7
Medication carts with deficiencies: 4
Staff observed for hand hygiene: 10
Staff observed for disinfecting testing equipment: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration errors and respiratory care deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in respiratory care deficiencies and medication administration errors |
| RN/CN | Registered Nurse/Charge Nurse | Named in medication administration errors and drug regimen review deficiencies |
| PTA | Physical Therapist Assistant | Named in infection control deficiency for failure to perform hand hygiene |
| DON | Director of Nursing | Named in multiple findings including infection control and medication regimen review |
| FSD | Food Service Director | Named in food safety and therapeutic diet deficiencies |
| RD | Registered Dietitian | Named in therapeutic diet deficiency |
| DM | Director of Maintenance | Named in infection control deficiency for failure to disinfect screening equipment |
| OT | Occupational Therapist | Named in infection control deficiency for failure to disinfect screening equipment |
| Receptionist | Named in infection control deficiency for failure to disinfect COVID-19 testing area |
Inspection Report
Life Safety
Deficiencies: 5
May 12, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/12/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety 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 inadequate number of approved exits in corridors, obstructed exit discharge paths, lack of occupant notification devices in the enclosed courtyard, overdue fire alarm system inspection, and deficiencies in sprinkler system maintenance and smoke-resistant ceiling integrity.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure every corridor had two approved exits without passing through intervening rooms. | SS=D |
| Exit discharge path was obstructed by a 12'x12' white tent blocking direct access to the public way. | SS=D |
| Facility failed to provide audible and visible fire alarm notification devices in the enclosed courtyard. | — |
| Fire alarm system inspection was overdue by more than 2 months, failing semi-annual inspection requirements. | SS=E |
| Sprinkler system deficiencies including missing ceiling tiles compromising smoke resistance, sprinkler heads obstructed or iced, and antifreeze system failure. | SS=D |
Report Facts
Date of survey: May 12, 2021
Size of obstructing tent: 144
Number of missing ceiling tiles: 4
Overdue inspection duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Regional Plant Operations Director | Present during observations and interviews related to deficiencies |
Inspection Report
Routine
Census: 139
Deficiencies: 0
Jan 5, 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: 3
Inspection Report
Routine
Census: 142
Deficiencies: 0
Dec 9, 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 recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
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