Deficiencies per Year
16
12
8
4
0
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 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
Routine
Census: 105
Capacity: 120
Deficiencies: 13
Oct 8, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a Life Safety Code Survey.
Findings
Deficiencies were identified related to resident mobility and wheelchair use, medication administration timing and documentation, pharmacy services, staffing ratios, fire safety including sprinkler and alarm systems, and emergency preparedness. Corrective actions and plans of correction were documented with completion dates.
Complaint Details
Complaint investigation was part of the survey with complaint numbers NJ 164726, 166672, 168050, 169735, 170064, 170351, 170683, 171427. The complaints involved issues such as medication administration, staffing, and care practices. Substantiation status is not explicitly stated.
Severity Breakdown
SS=D: 4
SS=F: 8
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to consistently follow a physician’s order for the application of a wheelchair for a resident, including documentation and accountability for placement of the device. | SS=D |
| Facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate a resident’s scheduled dialysis. | SS=D |
| Facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring medications were administered in a timely manner as ordered by a physician. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state for nursing aides. | — |
| Facility failed to separate hazardous areas from other parts of the facility in accordance with NFPA 101 Life Safety Code, including unsealed pipe penetrations in the storage room ceiling. | SS=F |
| Facility failed to maintain kitchen range hood system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. | SS=F |
| Facility failed to maintain sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. | SS=F |
| Facility failed to maintain portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers. | SS=F |
| Facility failed to maintain fire alarm system in accordance with NFPA 72 National Fire Alarm Code. | SS=F |
| Facility failed to maintain smoke detection in certain areas, including the receptionist area and a storage room. | SS=F |
| Facility failed to maintain smoke barrier doors in accordance with NFPA 101 Life Safety Code. | SS=F |
| Facility failed to maintain fire extinguishers with required six-year internal examination. | SS=F |
| Facility failed to ensure medication error rates were less than 5 percent as required. | SS=D |
Report Facts
Census: 105
Total Capacity: 120
Medication Error Rate: 6.45
Staffing Ratios: 12
Staffing Ratios: 13
Fire Safety: 52
Fire Extinguishers: 105
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Aug 21, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B related to infection control.
Report Facts
Sample Size: 8
Inspection Report
Annual Inspection
Census: 101
Deficiencies: 10
May 18, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
The facility was found to be out of compliance with several regulatory requirements including notice requirements before transfer/discharge, bed hold policy, accuracy of assessments, food and drink consistency, infection prevention and control, and life safety code requirements. Deficiencies were cited and plans of correction were submitted.
Complaint Details
Complaint investigation was conducted for complaint numbers NJ00161440, NJ00152258, NJ00160158, NJ00161126, NJ00160281. The complaint investigations were completed during the survey.
Severity Breakdown
Level D: 9
Level F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8) | Level D |
| Notice of Bed Hold Policy Before/Upon Transfer CFR(s): 483.15(d)(1)(2) | Level D |
| Accuracy of Assessments CFR(s): 483.20(g) | Level D |
| Food in Form to Meet Individual Needs CFR(s): 483.60(d)(3) | Level D |
| Food Procurement, Store, Prepare, Serve - Sanitary CFR(s): 483.60(i)(1)(2) | Level D |
| Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) | Level D |
| Maintenance, Inspection & Testing - Doors CFR(s): NFPA 101 | Level D |
| Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 | Level D |
| Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 | Level D |
| Illumination of Means of Egress CFR(s): NFPA 101 | Level F |
Report Facts
Census: 101
Sample Size: 24
Deficiencies cited: 10
Beds: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Nursing | Regional Director of Nursing (RDON) | Interviewed regarding notification to resident representatives for emergency transfers and bed hold policies |
| Director of Nursing | Director of Nursing (DON) | Completed audits and in-serviced staff on policies related to transfer/discharge and bed hold notices |
| MDS Coordinator | MDS Coordinator | Interviewed regarding assessments and coding of resident data |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and feeding |
| Dietary Director | Dietary Director | Observed and corrected food service and sanitation deficiencies |
| Maintenance Director | Maintenance Director | Responsible for fire safety, electrical systems, and emergency lighting compliance |
| Housekeeping Director | Housekeeping Director (HKD) | Responsible for linen handling and sanitation compliance |
Inspection Report
Routine
Census: 78
Deficiencies: 0
Dec 8, 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
Complaint Investigation
Census: 70
Deficiencies: 0
Sep 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00146779.
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 #: NJ00146779. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 2
Apr 19, 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 failure to provide written notification of potential liability charges for services not covered to Medicaid beneficiaries upon discharge from Medicare Part A, and failure to timely inform resident representatives of a staff member's confirmed COVID-19 diagnosis.
Severity Breakdown
SS=B: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide written notification to beneficiaries of potential liability charges for services not covered when discharged from Medicare Part A services with benefit days remaining for 2 of 3 residents reviewed. | SS=B |
| Facility failed to ensure resident representatives were informed by 5 PM the next calendar day following a staff member's confirmed COVID-19 diagnosis. | SS=C |
Report Facts
Sample size: 27
Deficiencies cited: 2
Inspection Report
Life Safety
Deficiencies: 4
Apr 12, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 04/12/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with life safety requirements due to obstructed emergency egress paths, locked exit gates with dual padlocks limiting immediate access, unsuitable exit pathways with trip hazards, and lack of directional exit signage for the courtyard area.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Emergency egress from the outdoor courtyard was obstructed by dining tables and chairs blocking the exit path. | SS=D |
| The courtyard exit gate was locked with two padlocks accessible only from outside, delaying emergency egress. | SS=D |
| The exit path beyond the gate consisted of loose gravel, dead vegetation, and a garden hose creating trip hazards, making it unsuitable for evacuation. | SS=D |
| The facility failed to provide directional exit signage for the courtyard exit gate and adjacent dining room exit. | SS=D |
Report Facts
Number of padlocks on courtyard exit gate: 2
Length of exit path beyond gate: 8
Width of cleared exit path: 2
Date of survey completion: Apr 19, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding exit obstructions, locked gates, and signage; confirmed findings and corrective actions. | |
| Administrator | Informed verbally of findings during Life Safety Code exit conference. |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Jan 20, 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
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