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
Annual Inspection
Census: 154
Capacity: 179
Deficiencies: 7
Apr 23, 2024
Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited including Immediate Jeopardy for failure to provide adequate supervision to prevent resident elopement, medication preparation errors, failure to follow physician orders, infection control lapses, inadequate staffing, and sprinkler system inspection deficiencies.
Complaint Details
Multiple complaints (NJ165064, NJ167260, NJ167255, NJ170551, NJ167044, NJ169248) were investigated during the survey. The Immediate Jeopardy was related to resident elopement and inadequate supervision.
Severity Breakdown
SS=J: 1
SS=D: 4
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent resident elopement resulting in Immediate Jeopardy. | SS=J |
| Failure to adhere to professional nursing standards including improper medication preparation and administration. | SS=D |
| Failure to maintain infection control practices including hand hygiene and wound care. | SS=D |
| Failure to maintain proper kitchen sanitation and food storage practices. | SS=D |
| Failure to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Failure to ensure five-year internal obstruction inspection of the automatic sprinkler system was conducted. | SS=F |
| Failure to ensure physician monthly progress notes were completed for residents. | SS=D |
Report Facts
Census: 154
Total Capacity: 179
Deficiencies cited: 7
Staffing ratios: 9
Staffing ratios: 7
Staffing ratios: 9
Staffing ratios: 11
Staffing ratios: 6
Staffing ratios: 16
Staffing ratios: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication preparation and administration deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in hand hygiene deficiency |
| LPN #4 | Licensed Practical Nurse | Named in hand hygiene deficiency |
| LPN #5 | Licensed Practical Nurse | Named in resident elopement investigation |
| Physician #1 | Primary Physician | Named in failure to document monthly progress notes |
| Director of Nursing | Director of Nursing | Named in multiple corrective action plans and staff education |
| Maintenance Director | Maintenance Director | Named in sprinkler system inspection deficiency |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 1
Jun 16, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers between 06/13/2023 and 06/16/2023.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code staffing requirements due to failure to meet minimum staff-to-resident ratios on numerous day, evening, and overnight shifts across multiple weeks. The deficiencies had the potential to affect all residents. The facility submitted a plan of correction and was found to be in substantial compliance at the time of the complaint visit.
Complaint Details
Complaint numbers NJ00157832, NJ00160960, NJ00160774, NJ00153648, NJ00163667, and NJ00154349 were investigated. The facility was found deficient in staffing ratios but was in substantial compliance overall. The deficiencies had the potential to affect all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 68 of 70 day shifts, 5 of 70 evening shifts, and 11 of 70 overnight shifts, violating minimum staffing requirements for CNAs and direct care staff. |
Report Facts
Survey Census: 133
Sample Size: 8
Staffing Deficiency Counts: 68
Staffing Deficiency Counts: 5
Staffing Deficiency Counts: 11
Inspection Report
Routine
Census: 111
Capacity: 180
Deficiencies: 16
Feb 23, 2022
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 safe environment, comprehensive assessments, medication administration, behavior monitoring, infection control, staffing, and life safety code compliance.
Severity Breakdown
SS=D: 8
SS=E: 5
SS=F: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe, clean, comfortable environment; observed torn and soiled resident equipment. | SS=D |
| Failed to complete timely comprehensive and quarterly Minimum Data Set (MDS) assessments for multiple residents. | SS=D |
| Failed to follow professional standards for medication administration including crushing non-crushable meds, inaccurate documentation, and improper disposal. | SS=E |
| Failed to provide personal grooming care to a dependent resident. | SS=D |
| Failed to follow physician orders for administration of medication and failed to monitor for side effects. | SS=D |
| Failed to post oxygen therapy signage and properly store oxygen equipment. | SS=D |
| Failed to consistently document and monitor behaviors for residents on psychotropic medications. | SS=E |
| Expired biological drugs and supplies found in crash cart. | SS=D |
| Improper hand hygiene and improper use of N95 masks by staff. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios for day, evening, and night shifts. | — |
| Failed to provide emergency lighting above generator transfer switches. | SS=E |
| Fire alarm system in trouble mode; monthly firefighter service test not performed. | SS=F |
| Failed to maintain sprinkler system; fire pump not tested under emergency power annually. | SS=F |
| Packaged Terminal Air Conditioner (PTAC) units had clogged, dirty, or missing filters. | SS=E |
| Elevators not inspected and tested monthly as required. | SS=F |
| Generator transfer time not certified within 10 seconds; no remote manual stop station for generator. | SS=E |
Report Facts
Deficiencies cited: 16
Residents present: 111
Total licensed beds: 180
Staffing ratios: 14
Staffing ratios: 8
Staffing ratios: 11
Staffing ratios: 10
Staffing ratios: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Failed to administer medication but signed MAR; did not clarify order. |
| LPN #1 | Licensed Practical Nurse | Crushed non-crushable medication; improper medication disposal. |
| LPN #2 | Licensed Practical Nurse | Administered crushed medication; educated after survey. |
| DON | Director of Nursing | Acknowledged delays in medication clarification and monitoring; provided policies and education. |
| ADON | Assistant Director of Nursing | Conducted audits and in-services on medication administration and infection control. |
| Regional Plant Operations Director | Maintenance Director | Observed fire alarm trouble and generator issues; coordinated repairs. |
| CNA | Certified Nursing Assistant | Improper use of masks; educated after observation. |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 3
Jan 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ149385 and NJ144738, focusing on COVID-19 infection control and food safety practices.
Findings
The facility was found not in compliance with infection control regulations and failed to ensure sanitary food preparation, distribution, and serving practices. Specific deficiencies included improper cleaning of utensils when the dishwasher was broken, failure to perform hand hygiene between tasks and glove changes, and inadequate sanitization of food preparation surfaces.
Complaint Details
The visit was complaint-related with complaints NJ149385 and NJ144738. The facility was found not in compliance with infection control regulations and food safety requirements during the complaint survey.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Dietary staff failed to utilize the three compartment sink to wash and disinfect food preparation and serving utensils when the dishwasher was broken. | SS=F |
| Dietary staff failed to perform hand hygiene between tasks and glove changes. | SS=F |
| Dietary staff cleaned food preparation surfaces with plain water instead of sanitizing solution. | SS=F |
Report Facts
Sample Size: 6
Date Survey Completed: Jan 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Observed failing to perform hand hygiene and improper cleaning of food preparation surfaces. | |
| Dietary Aide #1 | Observed not properly washing and disinfecting utensils when dishwasher was broken. | |
| Food Service Director | FSD | Provided interviews and described training and corrective actions related to food safety and sanitation. |
| Nursing Home Administrator | NHA | Provided interviews and documentation regarding incident and corrective actions. |
| Director of Nursing | DON | Provided interview regarding ongoing hand hygiene training. |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 8
Apr 8, 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 failure to follow professional standards in care plans, failure to provide appropriate services for limited mobility residents, failure to maintain nutritional status and hydration, improper medication labeling and storage, failure to ensure food safety and proper food temperatures, incomplete medical records, and inadequate infection prevention and control practices.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 1
SS=B: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to follow a Dietician's recommendation for nutrition and to set appropriate weight on equipment for residents. | SS=D |
| Failed to provide appropriate services to residents with limited mobility. | SS=D |
| Failed to verify, monitor, and document resident weights after significant weight changes and modify nutritional interventions accordingly. | SS=D |
| Failed to properly label and dispose of medications and maintain medication storage according to regulations. | SS=D |
| Failed to ensure safe and appetizing temperatures of cold food and drink served to residents. | SS=E |
| Failed to maintain proper kitchen sanitation practices and properly label, date, and store potentially hazardous foods. | SS=F |
| Failed to maintain complete, accurate, and readily accessible medical records including missing monthly physician progress notes. | SS=B |
| Failed to follow transmission-based precautions, infection control practices during wound treatment, proper PPE disposal, hand hygiene, posting of TBP signs, and PPE use by transport personnel on the PUI unit. | SS=E |
Report Facts
Census: 114
Sample size: 23
Weight changes: 14
Weight changes: 7
Dishwasher temperature: 160
Dishwasher temperature: 180
Dishwasher temperature: 170
Dishwasher temperature: 174
Cold food temperature: 42
Cold food temperature: 48
Cold food temperature: 52
Cold food temperature: 53
Cold food temperature: 54
Cold food temperature: 57
Cold food temperature: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse/Unit Manager | Informed surveyor about resident infection and isolation status | |
| Licensed Practical Nurse #1 | Observed during wound treatment, failed to perform hand hygiene and PPE use properly | |
| Certified Nursing Aide #1 | Observed during wound treatment, failed to perform hand hygiene properly | |
| Director of Nursing | Acknowledged infection control deficiencies and corrective actions | |
| Assistant Director of Nursing | Acknowledged infection control deficiencies and corrective actions | |
| Food Service Director | Responsible for food safety, sanitation, and temperature monitoring | |
| Food Service Supervisor | Responsible for food safety, sanitation, and temperature monitoring | |
| Licensed Nursing Home Administrator | Participated in interviews and acknowledged deficiencies |
Inspection Report
Life Safety
Deficiencies: 2
Apr 8, 2021
Visit Reason
The inspection was conducted to assess compliance with Life Safety Code requirements, specifically focusing on emergency preparedness, cooking facilities, and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance with minimum Life Safety Code requirements due to improperly positioned exhaust hood grease baffles in the kitchen and failure to maintain and provide records for monthly testing of the electronic fire pump. Corrective actions were initiated during the survey.
Severity Breakdown
SS=D: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Two of six exhaust hood grease baffles were improperly positioned, creating air gaps that could allow grease and fire to enter the exhaust hood system. | SS=D |
| Failure to comply with maintenance and testing requirements for the automatic sprinkler system's electronic fire pump, with no records of monthly testing for the prior 12 months. | SS=C |
Report Facts
Exhaust hood grease baffles: 6
Air gap: 1.5
Air gap: 0.5
Months without fire pump test records: 12
Weekly fire pump checks: 4
Monthly fire pump checks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged grease baffle deficiency, performed corrective actions, and responsible for ongoing monitoring and reporting | |
| Food Service Manager | Acknowledged grease baffle deficiency | |
| Facility Administrator | Verbally informed of findings during Life Safety Code survey exit conference |
Inspection Report
Abbreviated Survey
Census: 108
Deficiencies: 3
Jan 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 related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, including failure to provide disinfectant wipes for equipment, inadequate hand hygiene practices by staff, and improper infection control procedures during meal tray service to residents in isolation.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide disinfectant wipes and sanitize equipment used in the COVID-19 screening process. | SS=E |
| Inappropriate hand hygiene practices observed in 8 of 14 staff members, including improper handwashing technique and failure to follow hand hygiene protocols. | SS=E |
| Failure to follow appropriate infection control procedures while serving meal trays to residents in isolation, including not changing gloves between residents and not performing hand hygiene. | SS=E |
Report Facts
Staff observed for hand hygiene: 14
Staff deficient in hand hygiene: 8
Census: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Observed performing improper hand hygiene |
| Assistant Director of Maintenance | Assistant Director of Maintenance | Observed performing improper hand hygiene |
| Housekeeper | Housekeeper | Observed performing improper hand hygiene |
| Certified Nursing Assistant / Staffing Coordinator | Certified Nursing Assistant / Staffing Coordinator | Observed performing improper hand hygiene and improper glove use during meal service |
| Dietary Aide | Dietary Aide | Observed performing improper hand hygiene |
| Kitchen Aide | Kitchen Aide | Observed performing improper hand hygiene |
| Dietary Supervisor | Dietary Supervisor | Observed performing improper hand hygiene |
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