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
Re-Inspection
Census: 31
Deficiencies: 18
Sep 6, 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 reasonable accommodations, abuse/neglect policies, pressure ulcer care, incontinence care, respiratory care, nurse staffing information, drug regimen review, laboratory services, infection prevention and control, life safety code compliance including egress doors, exit signage, cooking facilities, fire alarm and sprinkler system maintenance, smoke compartment integrity, and fire door inspections.
Severity Breakdown
SS=D: 9
SS=F: 7
Deficiencies (18)
| Description | Severity |
|---|---|
| Facility failed to ensure resident's call light was readily accessible within reach. | SS=D |
| Facility failed to ensure reference checks were completed for newly hired staff prior to employment. | SS=D |
| Facility failed to provide care consistent with professional standards for residents with pressure ulcers, including risk assessment and documentation. | SS=D |
| Facility failed to provide appropriate storage and care of urinary drainage bags for a resident. | SS=D |
| Facility failed to ensure respiratory care equipment was changed as per physician orders and suctioning care was provided according to standards. | SS=D |
| Facility failed to post nurse staffing information daily for two of four days during the survey. | SS=D |
| Facility failed to identify irregularities in medication administration related to PRN pain medications for one resident. | SS=D |
| Facility failed to ensure timely laboratory services and follow-up on lab recommendations for one resident. | SS=D |
| Facility failed to ensure newly hired employees completed required two-step Mantoux tuberculin skin test upon hire. | — |
| Facility failed to ensure doors in required means of egress were not equipped with latches or locks requiring a tool or key from the egress side. | SS=F |
| Facility failed to ensure doors permitted to be held open self-close upon loss of power to the hold open device. | SS=F |
| Facility failed to ensure exit signage was visible and directional indicators were properly located. | SS=F |
| Facility failed to ensure cooking equipment was protected and maintained in accordance with NFPA standards, including grease buildup on spray nozzles. | SS=F |
| Facility failed to follow appropriate hand hygiene, use of PPE, and disinfect equipment practices for staff and failed to prevent potential spread of infection in laundry areas. | SS=D |
| Facility failed to ensure semi-annual fire alarm system inspections, testing and maintenance were conducted timely. | SS=F |
| Facility failed to ensure quarterly fire sprinkler system inspection, testing and maintenance was conducted timely. | SS=F |
| Facility failed to ensure fire door assemblies were inspected and tested annually. | SS=F |
| Facility failed to ensure smoke barriers were continuous through all concealed spaces. | SS=F |
Report Facts
Census: 31
Sample size: 12
PRN medication administration discrepancies: 45
PRN medication administration discrepancies: 20
PRN medication administration discrepancies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Certified Nursing Aide | Failed to complete required two-step Mantoux tuberculin skin test upon hire |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Unaware of proper care and storage of urinary drainage bags |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Unaware of proper care and storage of urinary drainage bags |
Inspection Report
Annual Inspection
Census: 32
Capacity: 35
Deficiencies: 7
Aug 18, 2023
Visit Reason
A Recertification Survey was conducted on behalf of the New Jersey Department of Health from 08/14/23 through 08/17/23 to assess compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with requirements including failure to ensure 8 continuous hours of RN coverage daily, medication availability issues, and multiple life safety code deficiencies related to building construction, fire safety systems, smoke barriers, and emergency power systems.
Severity Breakdown
Level F: 6
Level D: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a Registered Nurse (RN) was on duty for eight continuous hours per day, seven days a week. | Level F |
| Medication was not consistently available for one resident due to lack of availability in the facility. | Level D |
| Failed to provide a Life Safety Floor Plan identifying smoke barriers and construction type. | Level F |
| Interior wall finishes did not have a flame spread rating in accordance with NFPA 101. | Level F |
| Smoke detection was not installed at the main fire alarm control panel in an area not continuously occupied. | Level F |
| Failed to ensure smoke barriers formed at least two smoke compartments with proper sealing and door mechanisms. | Level F |
| Emergency Power Supply (EPS) lacked a remote manual stop station to prevent inadvertent operation. | Level F |
Report Facts
Survey Dates: 08/14/23 through 08/17/23
Survey Census: 32
Total Licensed Capacity: 35
Dates with no RN coverage for 8 continuous hours on weekends: 9
Sample Size: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN staffing and medication availability deficiencies |
| Asst Nursing Secretary | Assistant Nursing Secretary | Responsible for nursing staffing schedules and RN monitoring |
| Human Resources Director | Human Resources Director | Reviewed staffing policies and maintains RN monitoring logs |
| Inservice Coordinator | Inservice Coordinator | Inserviced nursing staff on medication ordering and fire safety procedures |
| Maintenance Director | Maintenance Director | Responsible for updating floor plans, fire safety compliance, and emergency power system corrections |
| Assistant Maintenance Director | Assistant Maintenance Director | Confirmed lack of smoke detection at fire alarm control panel |
Inspection Report
Follow-Up
Census: 33
Deficiencies: 1
Nov 15, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey's minimum direct care staff-to-resident ratios as mandated by state law, following concerns about staffing levels on specific day shifts.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios on 2 of 14 day shifts reviewed, specifically on 10/31/21 and 11/02/21 where the number of CNAs was below the required minimum. The facility acknowledged staffing challenges and implemented a plan of correction including monitoring schedules, in-service training, and active recruitment of CNAs.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios on 2 of 14 day shifts reviewed. |
Report Facts
Residents on day shift: 33
Certified Nurse Aides (CNAs) present: 4
Residents on day shift: 34
Certified Nurse Aides (CNAs) present: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Director | In charge of staffing and monitoring compliance with minimum staffing requirements | |
| Assistant Nursing Secretary | Assists with staffing and monitoring compliance | |
| Director of Nursing | Informed of staffing concerns and responsible for reviewing nursing schedules weekly | |
| Assistant Administrator | Made aware of staffing concerns | |
| Administrator | Made aware of staffing concerns |
Inspection Report
Routine
Census: 35
Deficiencies: 0
Nov 23, 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: 3
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