Deficiencies per Year
8
6
4
2
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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 1
Mar 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ00184368 to assess compliance with staffing requirements and other regulatory standards.
Findings
The facility was found to be in substantial compliance with federal long-term care requirements but was not in compliance with New Jersey state staffing regulations, failing to meet minimum certified nurse aide staffing ratios on 14 of 14 day shifts reviewed.
Complaint Details
Complaint #: NJ00184368. The facility was found to be deficient in CNA staffing for residents on 14 of 14 day shifts. The complaint was substantiated as the facility failed to meet minimum staffing ratios as required by New Jersey law.
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: 176
Deficient CNA staffing days: 14
Required CNAs per day shift: 21
Actual CNAs per day shift: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Involved in reviewing daily staffing and implementing corrective actions. | |
| Director of Nursing | Involved in reviewing daily staffing, re-education, and monitoring corrective actions. |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 1
Apr 16, 2024
Visit Reason
The inspection was conducted in response to complaint NJ00172629 to investigate compliance with staffing ratios and other regulatory requirements.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on 14 of 14 day shifts and deficient in total staff on 3 of 14 overnight shifts. Despite staffing deficiencies, no residents were negatively affected.
Complaint Details
Complaint #: NJ00172629. The facility was not in compliance with the standards in the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities. The facility must submit a Plan of Correction including completion dates. No residents were negatively affected by the CNA staffing deficiency.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 14 of 14 day shifts and deficient in total staff for residents for 3 of 14 overnight shifts. |
Report Facts
CNA staffing deficiency days: 14
Overnight staffing deficiency days: 3
Census during staffing review: 160
Required CNAs on day shift: 20
Actual CNAs on day shift: 13
Required total staff on overnight shift: 12
Actual total staff on overnight shift: 9
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 3
Jan 26, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health from 01/24/24 through 01/26/24, triggered by multiple complaint numbers related to alleged abuse and staffing concerns.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on failure to timely report and thoroughly investigate injuries of unknown origin for residents, and failure to maintain required minimum staffing ratios for certified nurse aides (CNAs) on multiple day and night shifts.
Complaint Details
The complaint investigation involved multiple complaint numbers alleging abuse and staffing deficiencies. The facility failed to timely report injuries of unknown origin and failed to thoroughly investigate such incidents for residents R1 and R4. Staffing deficiencies were documented across multiple weeks with inadequate CNA staffing ratios on day and night shifts.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure an injury of unknown origin was reported to appropriate entities in a timely manner for one resident. | SS=D |
| Failure to conduct thorough investigations related to injuries of unknown origin for two residents. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 33 of 35 day shifts and 13 of 35 overnight shifts. | — |
Report Facts
Survey Census: 167
Sample Size: 21
Deficient CNA staffing days: 33
Deficient CNA staffing nights: 13
Staffing ratios required: 8
Staffing ratios required: 10
Staffing ratios required: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to report and investigate injuries; stated expectation for immediate reporting and thorough investigation. | |
| Administrator | Interviewed regarding failure to report and investigate injuries; stated expectation for immediate reporting and thorough investigation. | |
| Infection Preventionist/Wound Care Nurse | Interviewed and familiar with residents involved; confirmed lack of reporting and investigation. |
Inspection Report
Routine
Census: 169
Deficiencies: 0
Jan 17, 2024
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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 177
Capacity: 181
Deficiencies: 8
Jan 18, 2023
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care (LTC) Facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had several deficiencies related to resident care, grievance procedures, comprehensive care plans, nursing services, infection control, food safety, and life safety code violations.
Severity Breakdown
F 553: 1
F 585: 1
F 656: 1
F 726: 1
F 755: 1
F 812: 1
F 880: 1
K 311: 1
K 321: 1
K 324: 1
K 351: 1
K 363: 1
K 541: 1
K 911: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure resident participation in care planning and implementation. | F 553 |
| Failure to establish and implement a grievance policy and procedure. | F 585 |
| Failure to develop and implement comprehensive care plans for residents. | F 656 |
| Failure to provide sufficient nursing services and ensure nurse competency. | F 726 |
| Failure to provide pharmacy services ensuring accurate medication records and removal of expired medications. | F 755 |
| Failure to maintain food safety and sanitation standards. | F 812 |
| Failure to maintain infection prevention and control program. | F 880 |
| Failure to maintain life safety code compliance including fire safety and sprinkler system issues. | K 311, K 321, K 324, K 351, K 363, K 541, K 911 |
Report Facts
Census: 177
Total Capacity: 181
Deficiency Count: 14
Inspection Report
Routine
Census: 161
Deficiencies: 0
May 19, 2022
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Routine
Census: 160
Deficiencies: 0
Jan 14, 2022
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: 184
Deficiencies: 0
Aug 19, 2021
Visit Reason
The inspection was conducted in response to a complaint identified as NJ 146463.
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 visit.
Complaint Details
Complaint#: NJ 146463. The facility was found compliant based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 189
Deficiencies: 2
Jan 26, 2021
Visit Reason
The inspection was a standard survey conducted to assess 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 complete treatments according to physician orders and failure to obtain physician orders and maintain safe cleaning and storage of respiratory equipment. Deficiencies were observed in treatment administration and respiratory care practices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete a treatment in accordance with the physician's order. | SS=D |
| Failure to obtain a physician's order for respiratory equipment use and failure to maintain safe cleaning and storage of respiratory equipment. | SS=D |
Report Facts
Sample Size: 38
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed performing treatment incorrectly and unable to explain physician order | |
| Unit Manager/Registered Nurse (UM/RN) | Interviewed about physician's order for treatment | |
| RN Facility Educator | Responsible for re-educating nursing staff on treatment administration and respiratory care | |
| Director of Nursing (DON) | Involved in review and oversight of corrective actions | |
| Registered Nurse Unit Manager (RNUM) | Confirmed cleaning responsibilities for respiratory equipment | |
| Licensed Practical Nurse (LPN #3 and LPN #4) | Discussed lack of physician orders for oxygen therapy and respiratory equipment |
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