Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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, 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: 98
Deficiencies: 4
Nov 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers (NJ177860, NJ178708, NJ179130, NJ179216) to assess compliance with federal and state regulations for long-term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to comprehensive care plans, professional standards of care, foot care, and laboratory services. Deficiencies were identified in developing and implementing person-centered care plans, ensuring timely nursing assessments, foot care services, and prompt notification of abnormal lab results.
Complaint Details
The complaint investigation was based on complaint numbers NJ177860, NJ178708, NJ179130, and NJ179216. The facility was found not in substantial compliance with federal and state regulations related to care planning, clinical standards, foot care, and lab reporting. Deficiencies were substantiated as evidenced by interviews, medical record reviews, and observations.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for residents. | SS=D |
| Failure to meet professional standards of quality in services provided or arranged by the facility. | SS=D |
| Failure to provide proper foot care and treatment to maintain mobility and good foot health. | SS=D |
| Failure to promptly notify the ordering physician of laboratory results that fall outside clinical reference ranges. | SS=D |
Report Facts
Census: 98
Sample Size: 8
Deficient CNA staffing shifts: 6
CNA staffing counts: 9
CNA staffing counts: 10
CNA staffing counts: 11
Required CNA staffing: 12
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Sep 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ177309) to determine compliance with staffing requirements and other regulatory standards.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, failing to meet minimum staffing requirements on 12 of 14 day shifts and 2 of 14 overnight shifts reviewed. The deficiency had the potential to affect all residents.
Complaint Details
Complaint #: NJ177309. The facility was substantiated to be deficient in staffing ratios based on interviews and document review. The deficiency had the potential to affect all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 12 of 14-day shifts and deficient in total staff for residents on 2 of 14 overnight shifts reviewed. |
Report Facts
Census: 97
Sample Size: 3
Staffing Deficiencies: 12
Staffing Deficiencies: 2
Required CNAs on Day Shift: 12
Actual CNAs on Day Shift: 6
Required Total Staff on Overnight Shift: 7
Actual Total Staff on Overnight Shift: 6
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 9
Mar 13, 2024
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 maintaining a safe, clean, and homelike environment, professional standards in care plans, accident prevention, infection control, medication labeling and storage, food safety, resident record accuracy, and staffing ratios.
Complaint Details
Complaint NJ #: 168629. The complaint involved issues with staffing, infection control, medication management, and resident care.
Severity Breakdown
SS=E: 4
SS=D: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to maintain a comfortable and homelike environment in resident rooms with damaged furniture, walls, and blinds. | SS=E |
| Facility failed to follow professional standards by not obtaining diagnosis for antibiotic use for Resident #184. | SS=D |
| Facility failed to obtain physician order and update care plan after resident #334 had an accident. | SS=D |
| Resident #67's Foley catheter drainage bag was touching the floor and not kept below bladder level. | SS=D |
| Facility failed to label and properly dispose of IV medications for Resident #184. | SS=D |
| Facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent contamination. | SS=E |
| Facility failed to maintain complete and accurate medical records for Resident #334. | SS=D |
| Facility failed to follow infection control practices and hand hygiene during meal tray pass. | SS=E |
| Facility failed to maintain required minimum direct care staff to resident ratio as mandated by New Jersey staffing regulations. | — |
Report Facts
Census: 85
Staffing deficiency counts: 6
Staffing deficiency counts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding antibiotic order and staffing | |
| Infection Preventionist | Interviewed regarding infection control and hand hygiene observations | |
| Staff Nurse | Observed during meal tray pass with deficient hand hygiene | |
| Dietary Director | Interviewed regarding food safety and kitchen sanitation | |
| Staffing Coordinator | Interviewed regarding staffing ratios and corrective actions |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 5
Dec 8, 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 consistently monitor fluid restriction orders, failure to clarify conflicting physician medication orders, failure to apply prescribed heel protectors, incomplete posting of nurse staffing information, failure to timely act on pharmacist consultant recommendations, and unsafe food handling and sanitation practices.
Severity Breakdown
SS=D: 2
SS=B: 1
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to consistently monitor fluid restriction instructions and clarify conflicting physician medication orders. | SS=D |
| Failure to follow active physician's order to apply heel protectors while in bed for residents at risk for pressure ulcers. | SS=D |
| Failure to post Resident Care Staffing Report on one nursing unit and incomplete posting on another unit. | SS=B |
| Failure to act on pharmacist consultant recommendations in a timely manner for medication review. | SS=E |
| Failure to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner to prevent foodborne illness. | SS=E |
Report Facts
Census: 66
Sample size: 20
Dates with incomplete staffing reports: 24
Expired health shakes discarded: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to fluid restriction monitoring, medication order clarification, pharmacist consultant recommendations, and nurse staffing report completion |
| Unit Manager | Unit Manager | Named in relation to fluid restriction monitoring, medication order clarification, and nurse staffing report completion |
| Licensed Practical Nurse | Licensed Practical Nurse | Named in relation to medication order clarification and pharmacist consultant recommendations |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in relation to observations of resident care and application of heel protectors |
| Food Service Director | Food Service Director | Named in relation to food safety and sanitation deficiencies |
Inspection Report
Routine
Census: 63
Deficiencies: 0
Aug 25, 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 CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 64
Deficiencies: 0
Mar 18, 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: 55
Deficiencies: 0
Jan 22, 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: 5
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Nov 27, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ00141338, NJ00141384, NJ00141371, and NJ00141375.
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 numbers NJ00141338, NJ00141384, NJ00141371, and NJ00141375 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
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