Deficiencies per Year
12
9
6
3
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 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 | NJDHSS Privacy Officer listed as contact for this notice |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
May 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00173227, NJ00185677, and NJ00185653 to assess compliance with long term care facility regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities due to deficiencies in meeting mandatory staffing ratios, specifically CNA staffing shortages during specified periods. The facility leadership acknowledged ongoing staffing challenges and has implemented corrective actions including audits, hiring incentives, and scheduled recruitment efforts.
Complaint Details
Complaint investigation based on complaints NJ00173227, NJ00185677, NJ00185653. The facility was found to be deficient in CNA staffing ratios during the complaint period and prior to survey. The facility was not in substantial compliance with New Jersey licensure standards but no residents were adversely affected by the staffing deficiencies.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met, with CNA staffing deficient on 14 of 14 day shifts from 03/17/2024 to 03/30/2024 and on 10 of 14 day shifts from 04/13/2025 to 04/26/2025. |
Report Facts
Census: 81
Sample Size: 3
Deficient CNA staffing days: 14
Deficient CNA staffing days: 10
Required CNAs: 11
Actual CNAs: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Offered conditional employment to 1 Licensed Practical Nurse and 1 Certified Nursing Assistant pending criminal background checks; involved in staffing audits and corrective actions |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 12
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 timely reporting of alleged violations, pressure ulcer treatment and documentation, nutrition and hydration monitoring, parenteral/IV fluid management, pharmacy services, infection prevention and control, emergency preparedness including subsistence needs, and life safety code compliance including corridor doors and smoke barriers.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment within required timeframes. | SS=D |
| Failure to document pressure ulcer measurements and obtain physician orders for wound treatment upon admission. | SS=E |
| Failure to obtain, record and monitor resident weights on admission, readmission and weekly as per professional standards. | SS=E |
| Failure to obtain physician orders for parenteral/IV fluids and to discontinue IV lines after treatment completion. | SS=D |
| Failure to follow physician orders for medication administration with parameters, resulting in medication given when contraindicated. | SS=D |
| Failure to ensure staff wear appropriate personal protective equipment including eye protection for residents on droplet precautions. | SS=D |
| Failure to designate a qualified full-time Infection Preventionist for the facility. | SS=D |
| Failure to maintain adequate emergency water supply for residents in event of loss of normal water supply. | SS=F |
| Failure to maintain adequate emergency food supply consistent with facility policy and emergency preparedness plan. | SS=F |
| Failure to maintain corridor doors in good repair, including a damaged janitor closet door that negated smoke resistance. | SS=D |
| Failure to maintain smoke barriers with sealed penetrations to resist passage of smoke and fire. | SS=E |
| Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the State of New Jersey. | — |
Report Facts
Census: 86
Total Capacity: 120
Deficient CNA staffing days: 13
Emergency water supply: 132
Emergency water supply updated: 216
Emergency water supply total: 492
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 6
Dec 7, 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 thoroughly investigate an allegation of abuse, failure to ensure preventive measures for pressure ulcers, failure to apply positioning devices as ordered, improper storage of catheter bags, and medication administration errors.
Severity Breakdown
SS=D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to thoroughly investigate an allegation of abuse for 1 of 20 sampled residents. | SS=D |
| Facility failed to ensure preventive measures to prevent/promote healing of pressure ulcers were in place and consistently followed for 1 of 4 residents. | SS=D |
| Facility failed to apply a positioning device as ordered by the physician for 1 of 1 residents reviewed for positioning. | SS=D |
| Facility failed to ensure that the catheter bag was stored in a manner to prevent infection for 1 of 3 residents reviewed for care. | SS=D |
| Facility failed to ensure medication error rates were below 5%, with a 9.38% error rate observed during medication administration. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Census: 99
Medication administration opportunities: 32
Medication administration errors: 3
Medication error rate: 9.38
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) present: 8
Inspection Report
Life Safety
Deficiencies: 1
Dec 7, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/01/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to provide a functioning battery backup emergency light above the emergency generator's transfer switch. The emergency light did not function properly during testing, and the issue was verified by the facility's Maintenance Director. The light was immediately repaired on 12/07/2021.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a functioning battery backup emergency light above the emergency generator's transfer switch. | SS=D |
Report Facts
Date of survey completion: Dec 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Maintenance Director | Verified the emergency light deficiency during inspection |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Aug 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145544, NJ143676, and NJ145982 regarding alleged violations at the facility.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of staff to resident abuse to the New Jersey Department of Health and failure to provide a summary of the final investigation for one resident. The investigation concluded that abuse was unsubstantiated, but the facility did not report the allegation as required.
Complaint Details
Complaint Intake NJ145982 involved failure to report an allegation of staff to resident abuse and failure to provide a summary of the final investigation for Resident #1. The allegation was investigated and found unsubstantiated, but the facility did not report it to the NJDOH as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of staff to resident abuse to the New Jersey Department of Health and failure to provide a summary of the final investigation for one resident. | SS=D |
Report Facts
Census: 105
Sample Size: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Investigated the incident, did not report the allegation or submit a summary of investigation findings |
| CNA #1 | Certified Nurse Aide | Assisted in transferring Resident #1 and provided statements about the transfer |
| CNA #5 | Certified Nurse Aide / Newly licensed Registered Nurse | Assisted in transferring Resident #1 and provided statements about the transfer |
Inspection Report
Routine
Census: 85
Deficiencies: 0
Jan 4, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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