Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
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 health 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
Complaint Investigation
Census: 161
Deficiencies: 1
Dec 20, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ181445) to investigate compliance with staffing requirements and other regulatory standards at the facility.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding minimum staffing requirements, failing to meet required CNA staffing ratios on 4 of 14 days reviewed. The facility was required to submit a Plan of Correction to address these deficiencies.
Complaint Details
Complaint NJ181445 was substantiated with findings of deficient CNA staffing ratios on multiple days, potentially affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 4 of 14-day shifts reviewed, specifically CNA staffing shortages. |
Report Facts
Census: 161
Days with deficient CNA staffing: 4
CNA staffing shortfalls: 1
Inspection Report
Annual Inspection
Census: 110
Capacity: 161
Deficiencies: 15
Sep 29, 2023
Visit Reason
A Recertification and Complaint investigation was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Jersey.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this recertification and complaint survey. Deficiencies were identified in areas including safe environment, freedom from abuse and neglect, reporting of alleged violations, accuracy of assessments, comprehensive care plans, food safety, licensure compliance, infection prevention and control, and life safety code compliance.
Complaint Details
The complaint investigation was related to resident-to-resident abuse and misappropriation of resident property. The facility failed to ensure two residents were free from abuse and failed to submit a timely final investigation report for misappropriation of property.
Severity Breakdown
SS=D: 5
SS=F: 5
SS=E: 3
SS=C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to provide a clean, comfortable, homelike environment; water marks and damaged walls in resident rooms; cracked handrails posing injury risk. | SS=D |
| Failed to ensure two residents were free from resident-to-resident abuse. | SS=D |
| Failed to send a final investigation report within 5 days to the Department of Health for misappropriation of resident property. | SS=D |
| Failed to ensure accuracy of Minimum Data Set (MDS) assessment for one resident, missing behavioral symptoms. | SS=D |
| Failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for two residents. | SS=D |
| Failed to keep kitchen equipment and food storage areas clean and properly labeled with use-by dates. | SS=F |
| Failed to ensure facility name change was timely submitted and reflected in licensing documentation. | SS=C |
| Failed to follow enhanced barrier precautions during medication pass, including gown use and equipment decontamination. | SS=D |
| Exit discharge ramp blocked by weeds, obstructing means of egress. | SS=E |
| Hazardous areas not properly enclosed with fire barriers; doors not latching; unsealed pipe penetrations in rated walls. | SS=E |
| Range hood fire protection system had loose caulk and unsealed gaps not grease tight. | SS=D |
| Interior wall finishes with peeling wallpaper and wood paneling of unknown flame spread rating. | SS=E |
| Sprinkler system had excessive corrosion buildup on sprinkler heads and fire pump, and lint buildup on sprinkler head. | SS=F |
| Smoke barriers had multiple unsealed gaps and penetrations allowing smoke transfer. | SS=F |
| Emergency Power Supply lacked a remote manual stop station to prevent inadvertent operation. | SS=F |
Report Facts
Survey Census: 110
Total Capacity: 161
Sample Size: 28
Deficiency Counts: 15
Staffing Deficiencies: 4
Date of Survey: 2023-09-26 to 2023-09-29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in infection control deficiency related to failure to follow enhanced barrier precautions |
| Maintenance Director | Named in multiple deficiencies related to maintenance issues including exit obstructions, fire safety, sprinkler system, and smoke barriers | |
| Director of Nursing | DON | Named in complaint investigation and infection control deficiency |
| Administrator | Named in licensure and facility name change deficiency |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 7
May 31, 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 rights, accuracy of assessments, accident hazards, provision of social services, pharmacy services, medication errors, and medication administration. Specific issues included failure to obtain vaccination consent, inaccurate MDS coding, inadequate supervision for residents, lack of social services for a cognitively impaired resident, expired medications in stock, incomplete DEA forms, and medication administration errors.
Severity Breakdown
SS=E: 5
SS=D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to obtain consents from a resident representative prior to administering the COVID-19 vaccination for 1 of 6 residents reviewed for immunizations. | SS=E |
| Facility failed to accurately code a resident's Minimum Data Set (MDS) related to tobacco use. | SS=D |
| Facility failed to follow resident's care plan to consistently assess residents to determine the level of supervision needed while smoking. | SS=E |
| Facility failed to provide medically-related social services for a resident with cognitive impairment. | SS=E |
| Facility failed to detect and remove expired medication in medication storage and ensure accurate completion of DEA Form-222. | SS=E |
| Facility failed to maintain medication error rate below 5%, with errors observed in medication administration to residents. | SS=D |
| Facility failed to ensure residents were free of significant medication errors, including inaccurate transcription and administration of psychotropic medication. | SS=E |
Report Facts
Census: 90
Sample Size: 21
Medication Opportunities: 27
Medication Errors: 2
Medication Error Rate: 7
Expired Medication Count: 4
DEA Form-222 Incomplete: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Provided information about Resident #34's communication abilities | |
| Licensed Practical Nurse/Unit Manager #2 (LPN/UM) | Provided information about Resident #34's condition and vaccination consent | |
| Social Worker (SW) | Discussed decision-making for residents without family or guardians and vaccination consent issues | |
| Director of Nursing (DON) | Provided information about decision-making for residents without representatives and medication errors | |
| Registered Nurse/Unit Manager (RN/UM) | Acknowledged expired medications in stock and described medication administration process | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Observed medication administration errors for Residents #3 and #82 |
Inspection Report
Life Safety
Deficiencies: 4
May 31, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/27/22 and 05/31/22 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including failure to ensure illuminated exit signage in five locations, inadequate sprinkler coverage in one of four resident shower rooms, failure to maintain smoke barrier doors properly, and one electrical outlet lacking proper GFCI protection.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure illuminated exit signs in five locations to clearly identify exit access paths. | SS=E |
| Failure to provide proper fire sprinkler coverage in one of four resident shower rooms. | SS=E |
| Failure to maintain smoke barrier doors to resist transfer of smoke due to warped door plate causing a gap. | SS=E |
| Failure to ensure one electrical outlet next to a water source was equipped with proper working Ground-Fault Circuit Interrupter (GFCI) protection. | SS=E |
Report Facts
Exit signs not illuminated: 5
Resident shower rooms observed: 4
Smoke barrier doors tested: 6
Electrical outlets inspected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance and Environmental Services Director (MESD) | Present during observations and confirmed findings related to exit signage, sprinkler coverage, smoke barrier doors, and electrical outlet deficiencies. | |
| Regional Administrator (RA) | Present during electrical outlet inspection. | |
| Director of Maintenance (DOM) | Present during electrical outlet inspection. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Feb 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 142921.
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 142921 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
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