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, the circumstances under which health information may be used or disclosed, and the legal duties and rights of individuals regarding their health information privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Routine
Census: 83
Deficiencies: 0
Aug 23, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 8
Feb 29, 2024
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
Deficiencies were cited related to accuracy of resident assessments, failure to meet professional nursing standards including medication administration and documentation, failure to maintain accurate resident records, and life safety code violations including sprinkler system installation and maintenance, HVAC safety, and gas equipment storage and handling.
Complaint Details
Complaint numbers NJ 155949, 158851, 162976, 163790, 164500, 166683, 168298, 170251, 170584, 171165 were investigated during this survey.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to code the Minimum Data Set (MDS) accurately for 1 of 21 residents reviewed. | SS=D |
| Facility failed to maintain professional standards of nursing practice for not following physician orders and documenting medication administration for 3 of 21 residents reviewed. | SS=E |
| Facility failed to accurately document resident progress and changes in condition for 1 of 21 residents reviewed. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
| Facility failed to provide automatic fire sprinkler protection to all areas of the facility. | SS=D |
| Facility failed to inspect and test private fire hydrant in accordance with NFPA 25 and NFPA 101. | SS=F |
| Facility failed to provide protective wire mesh on Direct-Vent Gas Fireplace and failed to provide hard-wired carbon monoxide detection. | SS=D |
| Facility failed to transport a cylinder of compressed oxygen in a manner that would protect it against tipping and rupture. | SS=D |
Report Facts
Census: 87
Sample Size: 21
Deficiency Completion Dates: May 1, 2024
Deficiency Completion Dates: Apr 30, 2024
Staffing Deficiencies: 31
Inspection Report
Life Safety
Capacity: 87
Deficiencies: 5
Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and life safety code requirements, including sprinkler system installation, maintenance, gas equipment storage, and direct-vent gas fireplace safety.
Findings
The facility was found deficient in multiple areas including failure to provide automatic fire sprinkler protection in all areas, failure to inspect and test the private fire hydrant, lack of protective mesh and proper carbon monoxide detection on a direct-vent gas fireplace, improper transport of compressed oxygen cylinders, and deficiencies in gas equipment storage. All deficiencies had the potential to affect all 87 residents.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide automatic fire sprinkler protection to all areas of the facility, specifically the delivery/receiving area roof overhang. | SS=D |
| Failed to inspect and test the facility's private fire hydrant in accordance with NFPA 25. | SS=F |
| Failed to provide protective wire mesh on Direct-Vent Gas Fireplace and lacked required hard-wired carbon monoxide detector interconnected to fire alarm system. | SS=D |
| Failed to transport a cylinder of compressed oxygen in a manner that would protect it against tipping and rupture. | SS=D |
| Gas equipment cylinder and container storage did not meet NFPA requirements. | SS=D |
Report Facts
Total residents potentially affected: 87
Deficiency completion dates: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews confirming deficiencies related to sprinkler system, fire hydrant inspection, gas fireplace, and oxygen cylinder transport. | |
| Regional Plant Operations Director | Present during observations and interviews confirming deficiencies related to sprinkler system and fire hydrant inspection. | |
| Certified Nursing Assistant | Observed transporting oxygen cylinder improperly. | |
| Director of Nursing | Provided inservice education to staff on proper oxygen cylinder handling. |
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 0
Dec 20, 2023
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: 7
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
May 23, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on a complaint survey to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19.
Findings
The facility failed to ensure that all staff and visitors entering the building were screened for COVID-19 signs and symptoms according to facility policy and CDC guidelines. Specifically, 3 of 10 employees and 6 of 10 visitors reviewed did not complete required screening or temperature checks prior to entry, violating infection prevention and control program requirements.
Complaint Details
The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey related to COVID-19 infection control screening failures.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure all staff and visitors were screened for COVID-19 signs and symptoms in accordance with facility policy and CDC guidelines. | SS=E |
Report Facts
Census: 73
Employees not properly screened: 3
Visitors not properly screened: 6
Visitors without temperature recorded: 7
Employees without temperature recorded: 3
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 4
Nov 22, 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 staffing ratios, failure to clarify physician orders for fluid consistency, improper labeling and dating of feeding bottles, inadequate treatment of pressure ulcers, and improper labeling and storage of medications.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. | — |
| Failed to clarify a physician order regarding fluid consistency for 1 resident and failed to label and date feeding bottles for 1 resident. | SS=D |
| Failed to provide treatment consistent with professional standards for an existing pressure ulcer and failed to implement facility policy concerning dressing technique for 1 resident. | SS=D |
| Failed to properly label, store, and dispose of medications in two medication refrigerators inspected, including opened vials not dated and expired medication found. | SS=D |
Report Facts
Census: 87
Staffing Deficiency Days: 10
Staffing Deficiency Evenings: 1
Sample Size: 21
Sample Size: 1
Sample Size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Resident #23's medication nurse who failed to clarify physician order |
| RN #1 | Registered Nurse | Responsible nurse for Resident #69 who acknowledged unlabeled feeding bottles |
| RN/UM | Registered Nurse/Unit Manager | Acknowledged unlabeled feeding bottles and proper labeling requirements |
| RN #2 | Registered Nurse | Admitted to forgetting to label feeding bottle due to being busy |
| LPN #2 | Licensed Practical Nurse | Admitted to forgetting to label feeding bottle despite knowing policy |
| DON | Director of Nursing | Acknowledged staffing issues and discussed policy on clarifying orders and treatment procedures |
| LNHA | Licensed Nursing Home Administrator | Discussed resident non-compliance and facility policies |
| IPN | Infection Preventionist Nurse | Observed during pressure ulcer treatment and acknowledged procedural lapses |
Inspection Report
Life Safety
Census: 90
Capacity: 116
Deficiencies: 1
Nov 22, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with fire safety regulations and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with NFPA 96 regarding cooking facilities. Specifically, combustible items were stored on an operating electric training stove in the Physical Therapy room, posing a fire hazard.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Cooking equipment was not protected in accordance with NFPA 96; combustible items were stored on an operating electric training stove in the Physical Therapy room. | SS=D |
Report Facts
Certified beds: 116
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview regarding cooking equipment deficiency | |
| Regional Plant Operations Director | Present during observation and interview regarding cooking equipment deficiency |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145901 and NJ143954.
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 numbers NJ145901 and NJ143954 were investigated and found to be in compliance.
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 65
Deficiencies: 0
Dec 28, 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.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Dec 11, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00136925, NJ00136775, and NJ00136447.
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 numbers NJ00136925, NJ00136775, and NJ00136447 were investigated and found to be in compliance.
Report Facts
Sample size: 4
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