Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Census: 83
Capacity: 113
Deficiencies: 9
Oct 29, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations for complaint numbers NJ#171778, #172937, and #177383.
Findings
The facility was found to have multiple deficiencies including failure to ensure accurate comprehensive assessments after significant changes, failure to meet professional standards in care plans and medication administration, insufficient nursing staff, inadequate infection control practices, and fire safety code violations. Deficiencies were cited in areas such as assessment accuracy, medication administration, quality of care, infection prevention, resident rights, staffing, and life safety code compliance.
Complaint Details
The survey included investigations of complaints NJ#171778, #172937, and #177383. Findings included failure to provide adequate care, failure to follow physician orders, failure to maintain staffing ratios, and failure to ensure resident rights. The facility was found to have repeat deficiencies related to these complaints.
Severity Breakdown
Level 3: 3
Level 4: 4
Level 5: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure comprehensive assessment after significant change in resident condition. | Level 3 |
| Failure to accurately code Minimum Data Set (MDS) assessments for residents. | Level 4 |
| Failure to follow physician orders and medication administration standards. | Level 4 |
| Failure to maintain sufficient nursing staff to meet resident needs. | Level 5 |
| Failure to provide quality care including honoring resident requests and proper medication administration. | Level 4 |
| Failure to maintain accurate and complete resident medical records. | Level 3 |
| Failure to provide adequate infection prevention and control measures including hand hygiene and PPE use. | Level 5 |
| Failure to conduct required fire drills quarterly per shift. | Level 3 |
| Failure to maintain sprinkler system and smoke barriers in accordance with fire safety codes. | Level 4 |
Report Facts
Sample size: 20
Number of residents present: 83
Total licensed beds: 113
Staffing ratios: 7
Medication orders reviewed: 6
Fire drills: 0
Residents affected: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication administration and interviewed regarding findings for Resident #61 and others |
| Director of Nursing | Director of Nursing | Provided in-service education and conducted audits related to medication administration and staffing |
| Environmental Services Director | Environmental Services Director | Conducted monthly pressure gauge inspections and fire drill audits |
| Licensed Nursing Home Administrator | LNHA | Provided education and was aware of staffing deficiencies |
| Infection Preventionist | Infection Preventionist | Conducted audits and provided in-service education on infection control |
| Housekeeper | Housekeeper | Provided in-service education on infection prevention and PPE use |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Apr 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ00172714) to determine compliance with federal and state regulations regarding staffing ratios in the facility.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and total staff on 1 of 14 overnight shifts during the review period.
Complaint Details
Complaint #: NJ00172714. The facility was found to be deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts. The facility was found to be in substantial compliance overall based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 14 of 14 day shifts. |
Report Facts
Census: 79
Deficient day shifts: 14
Deficient overnight shifts: 1
Staffing ratios required: 8
Staffing ratios required: 10
Staffing ratios required: 14
Staffing counts example: 8
Staffing counts example: 10
Staffing counts example: 5
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Jan 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ00170331 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to consistently document resident care in medical records, specifically regarding resident-identifiable information and documentation of care provided or refused. Additionally, staffing ratios were deficient for Certified Nurse Aides (CNAs) on multiple day shifts.
Complaint Details
Complaint #NJ00170331 was substantiated based on findings of deficient documentation and staffing issues.
Severity Breakdown
Level B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain complete, accurate, and accessible medical records for residents, including documentation of care provided or refused. | Level B |
| Failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides on 12 of 14 day shifts reviewed. | — |
Report Facts
Census: 80
Sample Size: 3
Deficient CNA staffing shifts: 12
CNA staffing counts: 7
CNA staffing counts: 8
CNA staffing counts: 8
CNA staffing counts: 9
CNA staffing counts: 8
CNA staffing counts: 8
CNA staffing counts: 6
CNA staffing counts: 7
CNA staffing counts: 6
CNA staffing counts: 9
CNA staffing counts: 8
CNA staffing counts: 9
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Oct 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ00168378.
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 # NJ00168378 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jul 21, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00153300 and NJ00152395.
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 # NJ00153300, NJ00152395. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jun 27, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139610 and NJ144423.
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 #: NJ139610, NJ144423. The facility was found compliant based on the complaint survey.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 1
Jun 7, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in infection prevention and control practices, specifically failing to follow appropriate hand hygiene practices during medication administration by one nurse to two residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow appropriate hand hygiene practices for 1 of 2 nurses who administered medication to 2 of 5 residents. | SS=D |
Report Facts
Sample Size: 20
Inspection Report
Life Safety
Deficiencies: 1
Jun 7, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19 for existing health care occupancies.
Findings
The facility was found to be in noncompliance due to failure to ensure that exit discharge paths were provided with two sources of lighting. Specifically, one of two exit discharges in the building's basement had only a single-bulb light fixture without a secondary light source, posing a safety risk if the single bulb failed.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Exit discharge paths were not provided with two sources of lighting; one basement exit had only a single-bulb light fixture. | SS=D |
Report Facts
Number of exit discharge paths with lighting deficiency: 1
Number of smoke zones in facility: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified the lighting deficiency during observation and was involved in corrective actions. |
Inspection Report
Routine
Census: 53
Deficiencies: 0
Dec 16, 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.
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.
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