Deficiencies per Year
20
15
10
5
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 explains the types of information covered, the circumstances under which health information may be used or disclosed, the rights of individuals 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
Routine
Census: 85
Capacity: 128
Deficiencies: 7
Jan 7, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483 for Long-Term Care Facilities, including complaint investigations for complaint numbers NJ 170228 and 175455. The survey included observations, interviews, and record reviews from 12/30/2024 to 1/7/2025.
Findings
Deficiencies were cited in multiple areas including resident rights, exercise of rights, accuracy of assessments, respiratory care, pharmacy services, infection control, life safety code compliance, and emergency preparedness. Corrective actions and plans of correction were provided for all cited deficiencies.
Complaint Details
The survey included complaint investigations for complaint numbers NJ 170228 and 175455. The complaints involved issues such as resident dignity during meal service, accuracy of assessments, respiratory care, and medication errors. The complaints were substantiated as deficiencies were cited.
Severity Breakdown
Level D: 4
Level E: 1
Level F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain the dignity of residents during meal service by Certified Nursing Aides (CNAs) not being seated while assisting residents and improper handling of meal trays. | Level D |
| Failure to ensure accurate documentation and review of residents' advance directives and assessments, including Minimum Data Set (MDS) coding accuracy. | Level D |
| Failure to provide respiratory care and tracheostomy suctioning consistent with professional standards for one resident. | Level D |
| Failure to provide pharmaceutical services including accurate documentation and reconciliation of controlled substances. | Level E |
| Failure to maintain sanitation and food safety requirements in the kitchen and food storage areas. | Level F |
| Failure to maintain infection prevention and control program including proper use of Personal Protective Equipment (PPE) and hand hygiene. | Level F |
| Failure to comply with life safety code requirements including maintaining smoke barrier doors and conducting required fire drills. | Level D |
Report Facts
Census: 85
Total Capacity: 128
Deficiency Count: 7
Medication Error Rate: 15.38
Fire Drill Frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in corrective actions and education related to resident rights and meal service deficiencies |
| Registered Nurse (RN) MDS Coordinator | RN MDS Coordinator | Named in corrective actions related to Minimum Data Set (MDS) accuracy |
| Social Service Director | Director of Social Services | Named in corrective actions related to advance directives and resident rights |
| Environmental Service Director | Environmental Service Director | Named in corrective actions related to infection control and environmental safety |
| Pharmacist | Pharmacist | Named in corrective actions related to pharmacy services and medication administration |
| Assistant Director of Social Services | Assistant Director of Social Services | Named in corrective actions related to advance directives and resident rights |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 2
Nov 19, 2024
Visit Reason
The inspection was conducted based on complaints NJ00179638, NJ00176252, and NJ00175455 to investigate compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to ensure a resident's safety related to accident hazards and medication administration. Additionally, the facility failed to meet required staffing ratios as mandated by the State of New Jersey.
Complaint Details
Complaint investigation based on complaints NJ00179638, NJ00176252, and NJ00175455. The facility was found not in substantial compliance. The complaint regarding accident hazards was substantiated based on interviews, record reviews, and facility document review. The complaint related to staffing ratios was substantiated based on facility document review.
Severity Breakdown
G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the resident environment remains free of accident hazards and that residents receive adequate supervision and assistance devices to prevent accidents. | G |
| Facility failed to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple day shifts. | — |
Report Facts
Census: 78
Staffing Deficiencies: 5
CNA staffing counts: 6
CNA staffing counts: 9
CNA staffing counts: 9
CNA staffing counts: 8
CNA staffing counts: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration deficiency and investigation |
| Director of Nursing | Contacted NJ Executive Order authorities and conducted audits related to deficient practice | |
| RN #2 | Registered Nurse | Observed during surveyor tour and medication cart checks |
| Licensed Practical Nurse #2 | LPN | Observed administering medication during survey |
| Resident #1 | Resident involved in medication administration incident | |
| Resident #1's attending physician | Physician | Provided orders immediately after incident |
Inspection Report
Annual Inspection
Census: 92
Capacity: 128
Deficiencies: 11
Oct 13, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had multiple deficiencies related to abuse reporting, comprehensive care planning, pressure ulcer prevention, respiratory care, dialysis, food safety, staffing, life safety code violations, and fire safety systems.
Severity Breakdown
Level D: 6
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse to the New Jersey Department of Health within 24 hours. | Level D |
| Failure to develop and implement comprehensive, person-centered care plans for residents. | Level D |
| Failure to provide treatment and services to prevent pressure ulcers and promote healing. | Level D |
| Failure to obtain physician's orders and ensure respiratory care for residents requiring tracheostomy care and suctioning. | Level D |
| Failure to obtain physician's orders and provide dialysis care consistent with professional standards. | Level D |
| Failure to properly store, label, and discard food items to prevent foodborne illness. | Level D |
| Failure to maintain required minimum direct care staffing ratios as mandated by the State of New Jersey. | — |
| Life Safety Code violations including failure of vertical openings enclosure, fire alarm system testing and maintenance, and fire extinguisher inspections. | — |
| Failure to maintain smoke barriers and corridor doors to resist passage of smoke. | — |
| Failure to maintain ventilation systems and exhaust systems in resident bathrooms. | — |
| Failure to maintain electrical systems including emergency generator testing and maintenance. | — |
Report Facts
Census: 92
Total Capacity: 128
Deficiencies cited: 6
Fire extinguishers inspected: 19
Resident rooms: 64
Resident shower rooms: 33
Resident rooms on 3rd floor: 33
Resident rooms on 2nd floor: 31
Resident rooms on 1st floor: 31
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Jul 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ00165718) to determine compliance with regulatory requirements related to staffing ratios at the facility.
Findings
The facility was found not in compliance with New Jersey staffing regulations, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and 3 of 14 evening shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint # NJ00165718. The facility was found deficient in CNA staffing ratios during the complaint survey. The deficiency was substantiated as the facility failed to meet minimum staffing requirements.
Deficiencies (1)
| Description |
|---|
| Failure 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 3 of 14 evening shifts reviewed. |
Report Facts
Census: 98
Day shifts deficient in CNA staffing: 14
Evening shifts deficient in CNA staffing: 3
Required CNAs on day shift: 12
Actual CNAs on day shifts: 5
Required CNAs on evening shift: 7
Actual CNAs on evening shifts: 5
Inspection Report
Routine
Census: 97
Deficiencies: 0
Jun 24, 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: 33
Inspection Report
Re-Inspection
Census: 94
Capacity: 128
Deficiencies: 17
Aug 3, 2022
Visit Reason
Reinspection survey conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, following prior deficiencies.
Findings
Multiple deficiencies were cited including failure to notify residents in writing of room changes, failure to report and investigate alleged abuse, failure to develop appropriate care plans for resident-to-resident abuse, failure to follow physician orders and update code status, failure to follow resident care plans leading to accidents, failure to document catheter care and urine output, failure to ensure timely physician visits, failure to maintain required staffing ratios, failure to obtain certificate of occupancy for renovated areas, and multiple life safety code violations including obstructed egress doors, hazardous storage areas without self-closing doors, fire alarm and sprinkler system maintenance issues, elevator firefighter service testing deficiencies, ventilation system failures, and generator transfer time certification.
Severity Breakdown
SS=E: 8
SS=F: 5
SS=D: 3
SS=G: 1
: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to notify residents in writing of room changes and failed to have a formal policy for room change notification and consent. | SS=E |
| Facility failed to report an incident of resident-to-resident abuse to the New Jersey Department of Health and failed to thoroughly investigate the incident. | SS=D |
| Facility failed to develop and implement an appropriate comprehensive care plan for a resident with known resident-to-resident abuse. | SS=D |
| Facility failed to follow physician orders for medication and failed to assess and update resident code status upon admission. | SS=E |
| Facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall and injury. | SS=G |
| Facility failed to ensure catheter care and urine output documentation every shift per physician orders. | SS=D |
| Facility failed to ensure timely physician face-to-face visits and documentation at least every 30 days for a resident. | SS=E |
| Facility failed to maintain required minimum direct care staffing ratios as mandated by New Jersey for multiple day and night shifts. | SS=E |
| Facility failed to have a full-time Infection Preventionist with no other job duties and with required infection control education and certification. | — |
| Facility allowed occupancy of renovated resident rooms without obtaining certificate of occupancy or notifying the New Jersey Department of Health. | — |
| Facility failed to provide exit doors in the means of egress readily accessible and free of obstructions; a sliding door had a lockset that could restrict emergency egress. | SS=F |
| Facility failed to maintain self-closing devices on doors to hazardous storage areas. | SS=E |
| Facility failed to maintain fire alarm system in accordance with NFPA 70 and 72; fire alarm annunciator panel showed trouble condition with unresolved ground fault. | SS=F |
| Facility failed to maintain sprinkler system ceilings as smoke resistant and fire rated; multiple oversized ceiling tile openings were observed allowing passage of smoke and heat. | SS=F |
| Facility failed to maintain bathroom ventilation systems in 4 resident rooms. | SS=E |
| Facility failed to ensure firefighter's service on elevators was operated monthly with written record for both elevators. | SS=F |
| Facility failed to certify generator transfer time within 10 seconds and failed to provide a remote manual stop station for the generator. | SS=F |
Report Facts
Resident census: 94
Total licensed beds: 128
Resident room doors with latch issues: 3
Resident bathrooms with ventilation failure: 4
Elevators: 2
Elevator monthly firefighter service tests missing: 8
Days with staffing below minimum ratio: 28
Days with staffing below minimum ratio: 6
Resident falls: 4
Generator transfer time: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in resident fall and accident incident |
| RN/Supervisor #1 | Registered Nurse/Supervisor | Interviewed regarding abuse investigation |
| RN/Supervisor #2 | Registered Nurse/Supervisor | Interviewed regarding abuse investigation |
| LPN #1 | Licensed Practical Nurse | Named in abuse investigation |
| DON | Director of Nursing | Interviewed about infection control and staffing |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Interviewed about infection control role and education |
| Physician | Primary Care Physician | Interviewed about resident visits and documentation |
| Maintenance Director | Maintenance Director | Interviewed about facility maintenance issues |
| Regional Plant Operations Director | Regional Plant Operations Director | Interviewed about facility maintenance issues |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Nov 24, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Apr 5, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Dec 19, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00133380, NJ00136941, and NJ00140446.
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 NJ00133380, NJ00136941, and NJ00140446 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 8
Inspection Report
Routine
Census: 85
Deficiencies: 0
Dec 15, 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: 5
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