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, 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
Routine
Census: 110
Capacity: 114
Deficiencies: 14
May 2, 2025
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/family group participation, comprehensive assessment after significant change, accuracy of assessments, frequency of meals and snacks at bedtime, facility assessment, infection prevention and control, mandatory access to care staffing ratios, life safety code violations including means of egress, stairways and smokeproof enclosures, illumination of means of egress, portable fire extinguishers, corridor doors, smoking regulations, and electrical equipment testing and maintenance.
Severity Breakdown
SS = D: 5
SS = F: 7
SS = E: 1
: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Resident/Family Group and Response | SS = D |
| Comprehensive Assessment After Significant Change | SS = D |
| Accuracy of Assessments | SS = D |
| Frequency of Meals/Snacks at Bedtime | SS = F |
| Facility Assessment | SS = D |
| Infection Prevention & Control | SS = D |
| Mandatory Access to Care - Staffing Ratios | — |
| Means of Egress - General | SS = F |
| Stairways and Smokeproof Enclosures | SS = E |
| Illumination of Means of Egress | SS = F |
| Portable Fire Extinguishers | SS = F |
| Corridor - Doors | SS = F |
| Smoking Regulations | SS = F |
| Electrical Equipment Testing and Maintenance | SS = F |
Report Facts
Census: 110
Total Capacity: 114
Deficient CNA staffing days: 5
Residents: 104
CNAs: 12
Residents: 109
CNAs: 13
Residents: 109
CNAs: 13
Residents: 108
CNAs: 12
Residents: 109
CNAs: 13
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Mar 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00176679 to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to resident records confidentiality and medical record maintenance, as well as inadequate staffing levels of Certified Nursing Assistants (CNAs) during the 14-day review period. Deficiencies were identified that could potentially affect all residents.
Complaint Details
Complaint #NJ00176679 was investigated with survey dates 02/27/2025 and 03/11/2025. The facility was found not in substantial compliance with requirements based on this complaint visit.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain an accurate and complete medical record in accordance with accepted professional standards and practice, including updating residents' Comprehensive Care Plans and interventions. | Level 2 |
| Inadequate number of Certified Nursing Assistants due to call offs and staff not showing up to work, resulting in deficient CNA staffing for 14 of 14 day shifts reviewed. | Level 2 |
Report Facts
Census: 98
Sample Size: 3
Deficient CNA staffing days: 14
CNA staffing counts: 12
Completion date for plan of correction: Apr 16, 2025
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Oct 4, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00170862 and NJ00172003 regarding staffing ratios and compliance with state regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to meet required minimum staff-to-resident ratios for Certified Nursing Assistants (CNAs) on multiple day and overnight shifts. The facility was deficient in CNA staffing on 16 day shifts and 1 overnight shift during the review period.
Complaint Details
Complaint #: NJ00170862, NJ00172003. The facility was found deficient in CNA staffing on multiple shifts during the periods 02/25/2024 to 03/09/2024 and 09/15/2024 to 09/28/2024, affecting all residents due to short staffing as required by NJ DOH.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 16 day shifts and 1 overnight shift. |
Report Facts
Census: 97
Deficient day shifts: 16
Deficient overnight shifts: 1
Sample size: 5
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
May 1, 2024
Visit Reason
The inspection was conducted in response to complaint NJ172275 to investigate staffing ratio compliance at the facility.
Findings
The facility was found to be out of compliance with New Jersey staffing requirements, failing to meet the minimum Certified Nursing Assistant (CNA) staffing ratios on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint #: NJ172275. The facility failed to ensure staffing ratios were met for 14 of 14 day shifts reviewed, potentially affecting all residents. The complaint was substantiated with detailed findings of CNA shortages on specific dates in April 2024.
Deficiencies (1)
| Description |
|---|
| Inadequate number of Certified Nursing Assistants for 14 of 14 day shifts reviewed, failing to meet required staffing ratios. |
Report Facts
Census: 109
Deficient shifts: 14
Required CNAs: 13
Actual CNAs: 9
Inspection Report
Routine
Census: 107
Capacity: 114
Deficiencies: 15
Oct 16, 2023
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 maintaining a safe, clean, comfortable environment, PASARR coordination, professional standards of care, pressure ulcer prevention, dialysis documentation, nurse staffing, food safety, and life safety code compliance.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=B: 1
SS=F: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean, comfortable, homelike environment including cleanliness of resident rooms and common areas. | SS=D |
| Facility failed to conduct a new PASARR Level I assessment after a resident was newly diagnosed with a mental disorder. | SS=D |
| Facility failed to obtain a physician's order and re-apply treatment after removal of a wound vac for a resident. | SS=D |
| Facility failed to provide care to maintain grooming needs of a dependent resident. | SS=D |
| Facility failed to honor a resident's preference for no CPR as directed on POLST form. | SS=D |
| Facility failed to ensure air mattress weight setting was accurate according to resident's weight. | SS=D |
| Facility failed to document dialysis communication notes completely and post dialysis weights as per standards. | SS=E |
| Facility failed to post current nurse staffing information daily with complete data including CNAs. | SS=B |
| Facility failed to maintain equipment and kitchen areas to prevent microbial growth and cross contamination; failed to maintain infection control during food service. | SS=E |
| Facility failed to ensure corridor width on second floor was at least 44 inches as required by Life Safety Code. | SS=F |
| Facility failed to ensure fire rated stairway exit doors were equipped with approved fire exit hardware. | SS=F |
| Facility failed to ensure smoke detector sensitivity testing was completed every alternate year. | SS=F |
| Facility failed to ensure corridor doors closed and latched properly to resist passage of smoke. | SS=E |
| Facility failed to ensure fire doors were inspected annually by qualified personnel and maintained inspection records. | SS=F |
| Facility failed to ensure three-year load bank test was completed on emergency generator. | SS=F |
Report Facts
Census: 107
Total Capacity: 114
Deficiencies cited: 15
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
Inspection date: Oct 16, 2023
Plan of correction completion date: Nov 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | LPN/UM | Interviewed regarding wound vac care and dialysis documentation |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including wound care, dialysis, staffing, and POLST compliance |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing and facility operations |
| Housekeeping Director | HD | Interviewed regarding cleanliness and maintenance issues |
| Maintenance Director | MD | Interviewed regarding life safety code deficiencies and maintenance |
| Food Services Director | FSD | Interviewed regarding kitchen sanitation and food safety |
| Scheduler | Scheduler | Interviewed regarding nurse staffing posting |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 3
Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00163579 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance with professional standards of care, specifically regarding medication administration and infection control practices. Deficiencies included failure to properly manage and document medication administration and inadequate infection prevention and control measures.
Complaint Details
Complaint #NJ00163579 was investigated. The facility was found not in substantial compliance with professional standards of care and infection control requirements. The complaint was substantiated based on observations, interviews, and documentation review.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide care and services according to acceptable standards of clinical nursing practice, including removal and disposal of medicated gel from a resident's room and failure to sign and date treatment records. | SS=D |
| Failure to establish and maintain an infection prevention and control program that prevents the development and transmission of communicable diseases and infections. | SS=D |
| Failure to ensure staffing ratios met required minimum staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Census: 96
Sample Size: 4
Date Survey Completed: Jun 6, 2023
Date of Compliance: Jul 15, 2023
Staffing Deficiency Days: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed failing to properly manage medication administration and infection control practices for Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and infection control deficiencies |
| Licensed Practical Nurse/Unit Manager | Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding medication administration and infection control deficiencies |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 1
May 10, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey staffing regulations, specifically to verify if the facility maintained the required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey.
Findings
The facility was found deficient in maintaining the required minimum CNA staffing ratios for 13 of 14 day shifts during the weeks of 04/03/22 to 04/16/22, with staffing levels consistently below the mandated one CNA per eight residents ratio. The facility submitted a plan of correction including audits, recruitment efforts, and monitoring to address the staffing deficiencies.
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 for 13 of 14 day shifts. |
Report Facts
Residents present: 74
Day shifts with deficient CNA staffing: 13
Required CNA to resident ratio: 8
CNA staffing on 04/03/22: 9
Inspection Report
Life Safety
Census: 74
Capacity: 114
Deficiencies: 6
May 10, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 5/10/22 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 conduct annual fire door inspections, inadequate corridor widths in non-resident areas, lack of tamper alarms on sprinkler system valves, missing smoke dampers on vents, absence of a remote manual stop station for the emergency generator, and improper storage of oxygen cylinders.
Severity Breakdown
SS=F: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to inspect fire doors annually; no documentation for 10 of 10 fire doors. | SS=F |
| Exit corridors in non-resident areas measured less than the required 44 inches wide in three locations. | SS=F |
| Fire sprinkler system water supply valves were not provided with tamper alarms. | SS=F |
| Open transfer grill in Physical Therapy room closet lacked smoke dampers to prevent smoke transfer. | SS=F |
| Exterior diesel generator lacked a remote manual stop station. | SS=F |
| Oxygen cylinders were not secured properly to prevent tipping, rupture, and damage (7 of 46 cylinders). | SS=E |
Report Facts
Certified beds: 114
Census: 74
Fire doors inspected: 10
Corridor widths measured: 3
Oxygen cylinders unsecured: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings including fire door inspection, corridor width measurement, sprinkler system tamper alarms, smoke damper sealing, generator remote stop station, and oxygen cylinder storage. | |
| Regional Operations Director | Present during observations and interviews related to multiple deficiencies. | |
| Administrator | Informed of all findings at the Life Safety Code exit conference. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Sep 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ 147076) to determine compliance with federal regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to provide treatment and follow facility policy for pressure ulcer care for Resident #3. Documentation and physician orders for wound treatment were incomplete or missing, and treatment administration was not properly recorded.
Complaint Details
Complaint # NJ 147076 was substantiated based on findings that the facility failed to provide necessary treatment and documentation for pressure ulcers on Resident #3.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide treatment to existing pressure ulcers and failure to follow facility policy for wound care for Resident #3. | SS=D |
Report Facts
Census: 75
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Interviewed regarding documentation practices for medication/treatment administration | |
| Director of Nursing | Interviewed regarding documentation and treatment protocols for wound care |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jun 25, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ139306, NJ138950, NJ142888, NJ139399, and NJ142035.
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 NJ139306, NJ138950, NJ142888, NJ139399, and NJ142035 were investigated and found to be in compliance.
Report Facts
Sample Size: 8
Inspection Report
Original Licensing
Deficiencies: 0
Mar 25, 2021
Visit Reason
Initial inspection for licensure of new or renovated long term care facilities.
Findings
No deficiencies were noted during the inspection of the new kitchen and plumbing. The building may not be occupied until formal notification by the licensing program is received.
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