Deficiencies per Year
24
18
12
6
0
Moderate
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: 108
Deficiencies: 2
Aug 12, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00174172 to investigate allegations of failure to report abuse, neglect, exploitation, or mistreatment and failure to revise residents' care plans appropriately.
Findings
The facility was found not in substantial compliance due to failure to report alleged violations involving abuse and neglect for two sampled residents and failure to revise care plans timely for two residents after incidents. Corrective actions and education were planned and implemented.
Complaint Details
Complaint #NJ00174172 was substantiated as the facility failed to report alleged violations and failed to revise care plans for residents #2 and #4 as required by regulation and facility policy.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the New Jersey Department of Health and follow facility policy for 2 of 5 sampled residents. | SS=D |
| Failure to ensure residents' care plans were revised timely after incidents for 2 of 5 residents reviewed. | SS=D |
Report Facts
Census: 108
Sample Size: 5
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in relation to incident reports and care plan revision deficiencies. |
| LPN #1 | Licensed Practical Nurse | Named in relation to incident reports and failure to report. |
| LPN #2 | Licensed Practical Nurse | Named in relation to incident reports. |
| LPN #3 | Licensed Practical Nurse | Named in relation to incident reports. |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Jul 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00175467 to determine compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. However, a deficiency was identified related to failure to maintain required minimum staff-to-resident ratios on 13 of 14 day shifts.
Complaint Details
Complaint # NJ00175467. The facility was found to be in substantial compliance 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 13 of 14 day shifts. |
Report Facts
Census: 102
Deficiency days: 13
CNA staffing counts: 7
CNA staffing counts: 12
CNA staffing counts: 8
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 11
CNA staffing counts: 8
CNA staffing counts: 6
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 12
CNA staffing counts: 12
CNA staffing counts: 10
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 23
Jan 12, 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 resident rights, personal privacy, accuracy and timeliness of resident assessments, medication administration, infection control, staffing ratios, and life safety code compliance.
Complaint Details
Complaint numbers NJ00167793, NJ00167387, NJ00166908, NJ00166506, NJ00164636, NJ00164205, NJ00162689, NJ00162265, NJ00160759 were investigated during this recertification survey.
Severity Breakdown
SS=D: 18
SS=E: 7
Deficiencies (23)
| Description | Severity |
|---|---|
| Facility failed to maintain resident rights during mealtime assistance, including staff standing and use of personal electronic devices. | SS=D |
| Facility failed to maintain confidentiality of resident information on Electronic Health Records system. | SS=D |
| Facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessment timely for Resident #84. | SS=D |
| Facility failed to accurately code Minimum Data Set (MDS) assessments for Residents #105 and #47. | SS=D |
| Facility failed to accurately document and clarify medication administration for Residents #39, #43, and #21. | SS=D |
| Facility failed to follow physician orders related to oxygen administration for Resident #15. | SS=D |
| Facility failed to ensure monthly physician orders were signed by attending physicians for Residents #76, #51, #47, and #27. | SS=D |
| Facility failed to ensure responsible physician conducted face-to-face visits and wrote progress notes at least every 60 days for Resident #76. | SS=D |
| Facility failed to ensure expired and discontinued medications were removed from active inventory and emergency kit was missing. | SS=D |
| Facility failed to clarify medication dosage for newly admitted Resident #21 during initial medication review. | SS=D |
| Facility failed to maintain proper kitchen sanitation including expired food and improper staff attire. | SS=D |
| Facility failed to comply with minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | SS=D |
| Facility failed to maintain complete and readily accessible medical records for Resident #42, missing physician progress notes. | SS=D |
| Facility failed to provide 1 of 9 designated exit discharge doors with readily accessible and unobstructed exit signage. | SS=E |
| Facility failed to provide continuous lighting with two lamps for 3 of 9 exit discharge doors. | SS=E |
| Facility failed to ensure fire-rated doors to hazardous areas were separated by smoke resisting partitions. | SS=E |
| Facility failed to provide smoke detectors in rooms open to exit access corridors. | SS=E |
| Facility failed to properly install sprinklers in resident rooms #139 and #127. | SS=D |
| Facility failed to perform monthly visual inspection of 3 of 24 portable fire extinguishers and maintain inspection records. | SS=D |
| Facility failed to ensure 6 of 32 corridor doors resisted passage of smoke due to gaps, propped doors, and hold open devices. | SS=E |
| Facility failed to ensure fire rated corridor double doors fully functioned and lacked annual inspection documentation. | SS=E |
| Facility failed to install a permanent emergency generator and provide electrical wiring in accordance with National Electrical Code. | SS=E |
| Facility failed to prohibit use of extension cords and power strips beyond temporary installation in nursing office. | SS=D |
Report Facts
Census: 94
Deficiency counts: 25
Staffing ratios: 12
Staffing ratios: 8
Fire extinguisher count: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Conducted rounds and audits related to meal assistance, medication administration, and infection control | |
| Regional Maintenance Director | Responsible for corrective actions related to fire safety, emergency generator, and facility maintenance | |
| Licensed Practical Nurse (LPN2) | Observed removing discontinued medications from medication cart | |
| Pharmacist | Conducted medication reviews and audits | |
| Surveyor | Conducted observations and interviews during inspection |
Inspection Report
Routine
Census: 103
Deficiencies: 0
Jul 7, 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 CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 10
COVID-19 positive in house: 9
Inspection Report
Routine
Census: 102
Deficiencies: 0
May 10, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 6
COVID+ in house: 20
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Oct 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 142736.
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 number NJ 142736 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Plan of Correction
Census: 92
Deficiencies: 1
Sep 20, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically regarding staffing ratios.
Findings
The facility was found not in compliance with the minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey, failing to meet the required CNA to resident ratio on 13 out of 14 day shifts.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. |
Report Facts
Residents on day shift: 91
Certified Nurse Aides (CNAs): 7
Certified Nurse Aides (CNAs): 11
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 9
Residents on day shift: 96
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 10
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 10
Residents on day shift: 95
Certified Nurse Aides (CNAs): 8
Certified Nurse Aides (CNAs): 8
Residents on day shift: 92
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 11
Certified Nurse Aides (CNAs): 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed by surveyor and confirmed facility awareness of staffing shortages | |
| Director of Nursing or designee | Responsible for monitoring staffing ratios daily and documenting weekly reviews |
Inspection Report
Life Safety
Deficiencies: 1
Sep 20, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to provide mechanical ventilation in 1 of 7 resident bathrooms inspected, specifically the Occupational Therapy resident's bathroom, which lacked an exhaust system and a window. No residents were affected, and corrective actions included installation of an exhaust fan and ongoing monthly inspections.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide ventilation for 1 of 7 resident bathrooms inspected, specifically no exhaust system in the Occupational Therapy resident's bathroom. | SS=D |
Report Facts
Resident bathrooms inspected: 7
Deficient bathrooms: 1
Exhaust fan installation date: Sep 28, 2021
Monthly inspection duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during inspection and confirmed lack of exhaust system | |
| Licensed Nursing Home Administrator | Notified of the finding during Life Safety Code exit |
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Jan 28, 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: 91
Deficiencies: 0
Jan 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00134852, NJ00137543, NJ00136349, and NJ00138835.
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
The survey was complaint-driven with four complaint numbers referenced. The facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 11
Inspection Report
Routine
Census: 91
Deficiencies: 0
Jan 8, 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 and recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
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