Deficiencies per Year
20
15
10
5
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 | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 15
Oct 17, 2023
Visit Reason
A complaint investigation and recertification survey were conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by multiple complaints.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including failure to prevent recurrence of dislodged hemodialysis catheter leading to resident death, failure to develop person-centered care plans timely, inadequate reporting of alleged violations, insufficient nursing staff, medication administration errors, inadequate ADL care, pressure ulcer prevention and treatment failures, and food safety violations.
Complaint Details
Complaint numbers NJ #157522, NJ# 3157946, NJ #159449, NJ #162733, NJ #161469, NJ #162687, NJ #163369, NJ #165118 triggered the complaint investigation. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 9
SS=E: 3
SS=F: 1
SS=J: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to develop and implement interventions to prevent recurrence of dislodged hemodialysis catheter after resident pulled it out requiring emergency transport and subsequent death. | SS=D |
| Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment immediately and complete investigations. | SS=D |
| Failure to develop person-centered baseline care plans within 48 hours of admission/readmission for residents with specific care needs. | SS=D |
| Failure to revise comprehensive person-centered care plans after significant change in resident condition for multiple residents. | SS=D |
| Failure to follow professional standards in medication administration including leaving medications unattended and pre-pouring medications. | SS=D |
| Failure to provide necessary personal hygiene and incontinence care to dependent residents. | SS=E |
| Failure to ensure preventive measures and treatments for pressure ulcers were in place and consistently followed. | SS=E |
| Failure to provide appropriate treatment and services to increase or prevent decrease in range of motion and mobility. | SS=D |
| Failure to provide adequate supervision and assistance devices to prevent accidents, including failure to investigate and report an incident involving a resident pulling out a hemodialysis catheter. | SS=J |
| Failure to provide appropriate treatment and services to prevent urinary tract infections and restore continence for residents with urinary incontinence. | SS=D |
| Failure to provide sufficient nursing staff to meet resident care needs and maintain required staff-to-resident ratios. | SS=E |
| Failure to label and date multi-use medication vials upon opening in medication carts. | SS=D |
| Failure to maintain food safety including proper dish machine temperatures, labeling and dating of food items, sanitary kitchen environment, and proper hair restraints. | SS=F |
| Failure to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that addresses staffing and other quality indicators. | SS=E |
| Failure to provide effective training and competency evaluation for staff providing care to residents with special care needs including hemodialysis. | SS=D |
Report Facts
Census: 95
Deficient CNA staffing day shifts: 39
Deficient CNA staffing day shifts: 11
Deficient CNA staffing day shifts: 20
Deficient CNA staffing day shifts: 6
Deficient CNA staffing day shifts: 4
Deficient CNA staffing day shifts: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple interviews regarding failure to investigate and report incidents, and staff education | |
| Licensed Nursing Home Administrator | Named in interviews regarding staffing, incident reporting, and facility compliance | |
| Licensed Practical Nurse #1 | Named in incident documentation and interviews regarding resident care and incident reporting | |
| Licensed Practical Nurse #2 | Named in incident documentation regarding resident care | |
| Registered Nurse Unit Manager | Named in interviews regarding resident care and incident reporting | |
| Certified Nursing Assistant #1 | Named in interviews regarding resident monitoring and care | |
| Certified Nursing Assistant #2 | Named in interviews regarding resident monitoring and care | |
| Food Service Director | Named in kitchen inspection and food safety interviews | |
| Registered Nurse Infection Preventionist | Named in interviews regarding infection control and care plan communication | |
| Registered Nurse Supervisor | Named in medication administration observation and interviews | |
| Physical Therapy Director | Named in interview regarding restorative nursing program |
Inspection Report
Life Safety
Census: 85
Capacity: 138
Deficiencies: 3
Oct 17, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of 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 fire safety requirements including issues with smoke detectors (an activated alarm in room 219 not properly signaling, missing smoke detectors in a resident lounge), and deficiencies related to the solid fuel-burning fireplace (battery-operated carbon monoxide detectors not electrically supervised and glass doors left open).
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Smoke detector in room 219 was in alarm but not properly signaling on the main fire alarm panel. | SS=F |
| Smoke detection was not installed in rooms open to the corridor, specifically in the resident lounge. | SS=F |
| Carbon monoxide detectors were battery operated and not electrically supervised; glass doors on the solid fuel-burning fireplace were open with solid fuel burning. | SS=F |
Report Facts
Occupied beds: 85
Total licensed capacity: 138
Deficiency completion date: Nov 30, 2023
Deficiency completion date: Jan 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed smoke detector alarm and carbon monoxide detector issues; involved in corrective actions |
Inspection Report
Routine
Census: 111
Capacity: 138
Deficiencies: 18
Jun 2, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Multiple deficiencies were cited including failure to develop and implement comprehensive person-centered care plans for residents on transmission-based precautions, failure to follow physician orders for daily weights, improper catheter care, failure to monitor psychotropic medication use, improper medication labeling and storage, poor kitchen sanitation and food safety practices, inadequate infection prevention and control practices including PPE use and COVID-19 screening, failure to properly perform COVID-19 testing, staffing shortages, and multiple life safety code violations including fire door inspections, stairwell markings, corridor door smoke resistance, elevator firefighter service testing, electrical safety, and gas equipment storage.
Severity Breakdown
SS=E: 5
SS=F: 8
SS=D: 4
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to develop and implement a comprehensive person-centered care plan for residents on transmission-based precautions. | SS=E |
| Failed to follow a physician's order for daily weight monitoring for a resident. | SS=D |
| Failed to provide appropriate catheter care to prevent urinary tract infections. | SS=D |
| Failed to ensure consultant pharmacist reported irregularities in drug regimen and follow-up. | SS=D |
| Failed to properly label, store, and dispose of medications in medication carts and refrigerators. | SS=D |
| Failed to maintain proper kitchen sanitation and food safety practices including storage and handling of food items. | SS=F |
| Failed to properly dispose and maintain waste in dumpster areas. | SS=E |
| Failed to ensure staff wore appropriate PPE, performed hand hygiene, and conducted COVID-19 screening and monitoring for staff and residents. | SS=F |
| Failed to appropriately perform COVID-19 rapid antigen testing according to manufacturer's instructions. | SS=D |
| Failed to meet staffing ratios and did not have a full-time designated Infection Preventionist without other responsibilities. | — |
| Failed to inspect fire doors annually in accordance with regulatory requirements. | SS=F |
| Failed to provide stair tread marking stripes on stairwells. | SS=F |
| Resident room corridor doors did not resist passage of smoke due to gaps at the top of doors. | SS=E |
| Failed to perform monthly firefighter emergency operations inspection and testing for elevators. | SS=F |
| Failed to provide remote manual stop station for emergency generator. | SS=F |
| Used extension cords beyond temporary installation as a substitute for fixed wiring. | SS=E |
| Failed to prohibit combustible storage within 5 feet of oxygen cylinders exceeding 300 cubic feet. | SS=F |
| Failed to properly design and protect liquid oxygen storage and transfilling room from sources of ignition. | SS=F |
Report Facts
CNA staffing deficiency: 11
Resident census: 111
Facility capacity: 138
Number of residents reviewed for care plans: 13
Number of residents with deficient care plans: 6
Number of residents reviewed for medication regimen: 5
Number of residents reviewed for catheter care: 3
Number of residents reviewed for COVID-19 screening: 4
Number of residents reviewed for COVID-19 testing: 3
Number of fire doors inspected: 9
Number of stairwells observed: 3
Number of resident room doors with smoke passage gaps: 10
Number of elevators: 2
Number of extension cords observed: 1
Number of oxygen cylinders stored improperly: 14
Number of light switches observed as ignition sources: 2
Number of light fixtures observed as ignition sources: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding care plan, PPE use, and COVID-19 screening. |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and hand hygiene. |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and hand hygiene. |
| CNA #3 | Certified Nursing Assistant | Observed in COVID-19 positive unit without proper PPE. |
| Dietary Cook | Observed wearing improper PPE. | |
| Maintenance Staff | Observed not performing hand hygiene before entering isolation room. | |
| Director of Nursing | DON | Interviewed regarding infection control and staffing. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding infection control and staffing. |
| Registered Nurse Educator | RNE | Interviewed regarding fit testing and infection control education. |
| Licensed Practical Nurse #2 | LPN | Observed with beard and improper N95 fit. |
| Certified Nursing Assistant #4 | CNA | Observed wearing eye shield improperly. |
| Licensed Practical Nurse #3 | LPN | Observed improper handling of blood glucose testing equipment. |
| Porter | Observed improper handling of clean linens. | |
| Laundry Aide | Interviewed regarding laundry cleaning and PPE storage. | |
| Housekeeper #1 | Interviewed regarding PPE storage and laundry area. | |
| Regional Plant Operations Director | Interviewed regarding fire door inspections and oxygen storage. | |
| Maintenance Director | Interviewed regarding fire door inspections, elevator testing, generator, and oxygen storage. |
Inspection Report
Life Safety
Census: 111
Capacity: 138
Deficiencies: 8
Jun 2, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 6/1/22 and 6/2/22 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including failure to perform annual fire door inspections, lack of stair tread marking stripes, corridor doors not resisting smoke passage, missing firefighter elevator operation inspection records, absence of a remote manual stop station for the emergency generator, improper use of extension cords, combustible storage near oxygen cylinders, and unsafe storage and trans filling of liquid oxygen.
Severity Breakdown
SS=F: 6
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to inspect fire doors annually as required. | SS=F |
| Failed to provide stair tread marking stripes on stairwells. | SS=F |
| Corridor doors did not resist passage of smoke due to gaps at door moulding. | SS=E |
| No evidence of monthly firefighter elevator emergency operations inspection and testing. | SS=F |
| Emergency generator lacked a remote manual stop station. | SS=F |
| Extension cords used beyond temporary installation and overloaded power strips observed. | SS=E |
| Combustible storage within 5 feet of oxygen cylinders exceeding 300 cubic feet. | SS=F |
| Sources of ignition (light switches and non-explosion proof light fixture) present in liquid oxygen storage and trans filling rooms. | SS=F |
Report Facts
Certified beds: 138
Census: 111
Fire doors observed: 9
Resident room doors observed: 45
Resident room doors deficient: 10
Elevators: 2
Oxygen cylinders: 14
Combustible packages: 14
Light switches: 2
Light fixtures: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Involved in observations and interviews related to fire door inspections, stairwell markings, corridor doors, elevator inspections, generator issues, extension cord use, oxygen storage, and liquid oxygen room safety. | |
| Regional Plant Operations Director | Involved in observations and interviews related to fire door inspections, stairwell markings, corridor doors, elevator inspections, generator issues, extension cord use, oxygen storage, and liquid oxygen room safety. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 5
Dec 22, 2021
Visit Reason
Complaint survey conducted based on complaints NJ150341, NJ149826, and NJ149047 to investigate compliance with long term care facility regulations including medication administration, notification of changes, catheter use, psychotropic medication use, and staffing ratios.
Findings
The facility was found not in compliance with multiple regulatory requirements including failure to notify families of medication changes, failure to hold medications when residents' vital signs were outside physician parameters, lack of medical justification and care plans for catheter use, failure to obtain consents and monitor behaviors for psychotropic medications, and failure to meet minimum staffing ratios on multiple days.
Complaint Details
Complaint Intake #NJ150341, NJ149826, and NJ149047. The survey was triggered by complaints alleging failures in medication notification, medication administration, catheter use, psychotropic medication management, and staffing shortages.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to notify resident family of medication changes and obtain consent for medications. | SS=D |
| Failure to hold medications when resident's vital signs were outside physician ordered parameters. | SS=D |
| Failure to have physician orders, care plan, and assessment justifying indwelling catheter use. | SS=D |
| Failure to obtain consents for psychotropic medications and failure to monitor and document behavior tracking. | SS=E |
| Failure to meet minimum staffing ratios for certified nurse aides on 13 of 14 day shifts reviewed. | — |
Report Facts
Census: 125
Sample Size: 9
Staffing ratios: 11
Staffing ratios: 15
Staffing ratios: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration, notification, catheter use, psychotropic medication management, and staffing. | |
| Nursing Home Administrator | Interviewed regarding staffing challenges and regulatory compliance. | |
| Licensed Practical Nurse #1 | Interviewed regarding medication notification, holding medications, catheter orders, and psychotropic medication consents. | |
| Licensed Practical Nurse #2 | Interviewed regarding medication notification, holding medications, catheter orders, and psychotropic medication consents. | |
| Licensed Practical Nurse #3 | Interviewed regarding medication notification, holding medications, catheter orders, and psychotropic medication consents. | |
| Licensed Practical Nurse #4 | Interviewed regarding medication notification, holding medications, catheter orders, and psychotropic medication consents. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Sep 30, 2021
Visit Reason
The inspection was conducted based on a complaint visit regarding failure to report an allegation of mistreatment and abuse for one resident, and failure to meet professional standards in skin care assessment and treatment for another resident.
Findings
The facility failed to notify administration and report an allegation of abuse for one resident, and failed to properly assess, document, and treat a resident's skin condition in accordance with physician orders and professional nursing standards. Additionally, the facility failed to maintain the required minimum direct care staff to resident ratios for the day shift on multiple occasions.
Complaint Details
The complaint investigation revealed that the facility failed to report an allegation of abuse involving one resident to the New Jersey Department of Health within required timeframes. The allegation was investigated and found unsubstantiated. The facility also failed to properly assess and treat another resident's skin condition, and failed to maintain required staffing ratios.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify administration and report an allegation of mistreatment and abuse for one resident. | SS=D |
| Failure to appropriately assess, document, and treat a resident's skin condition, including failure to follow physician's orders for treatment. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. | — |
Report Facts
Census: 105
Deficient CNA staffing days: 22
CNA to resident ratios: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Wrote progress note regarding resident complaint but failed to report allegation to administration. | |
| Director of Nursing (DON) | Interviewed regarding complaint reporting and skin care deficiencies; confirmed staffing issues. | |
| Director of Rehab (DOR) | Interviewed regarding resident's condition and therapy. | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding resident care and complaint reporting. | |
| Director of Social Work (DSW) | Interviewed regarding resident and family communication. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding skin care assessment and treatment. |
Inspection Report
Abbreviated Survey
Census: 122
Deficiencies: 1
Aug 17, 2021
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 infection control.
Findings
The facility failed to ensure proper infection control practices related to hand hygiene and donning/doffing of personal protective equipment (PPE) in accordance with CDC guidance. Observations revealed staff, including housekeeping and nursing personnel, did not consistently perform hand hygiene or change gloves appropriately when caring for residents under transmission-based precautions.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow proper handwashing and PPE donning/doffing procedures in accordance with CDC guidance, observed in 2 of 2 nursing units. | SS=E |
Report Facts
Census: 122
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Provided information about facility cohorting and infection control zones during entrance conference | |
| Director of Nursing | DON | Participated in entrance conference and infection control audit |
| Housekeeper | HK | Observed failing to perform hand hygiene and proper glove changes while cleaning PUI resident rooms |
| Assistant Director of Nursing | ADON | Observed housekeeping practices and provided infection control guidance during survey |
| Registered Nurse/Infection Preventionist | RN/IP | Interviewed regarding proper PPE use and hand hygiene |
| Director of Environmental Services | DES | Interviewed about housekeeping training and cleaning procedures |
| Certified Nursing Aide | CNA | Observed and interviewed regarding handwashing technique |
| Physical Therapist | PT | Observed exiting PUI resident room with gloves on without hand hygiene |
Inspection Report
Routine
Census: 124
Deficiencies: 0
Feb 5, 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.
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
Abbreviated Survey
Census: 97
Deficiencies: 0
Dec 21, 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 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: 6
Inspection Report
Routine
Census: 76
Deficiencies: 0
Dec 1, 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 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.
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