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 outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
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: 181
Deficiencies: 1
Jan 25, 2023
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint intake numbers related to allegations of abuse, neglect, and failure to report injuries of unknown origin.
Findings
The facility was found not in compliance with federal regulations for failing to report an injury of unknown origin involving Resident #3 to the state agency within the required timeframe. The investigation revealed the resident had fractures of unknown cause that were not reported promptly, violating reporting requirements.
Complaint Details
The complaint investigation involved multiple complaint intake numbers (NJ152448, NJ152897, NJ153708, NJ154069, NJ157542). The facility failed to report an injury of unknown origin for Resident #3, which was substantiated by the investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin to the required entities for Resident #3 within the required timeframe. | SS=D |
Report Facts
Census: 181
Sample Size: 16
Completion Date for Plan of Correction: Feb 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to report injury and corrective actions |
| Administrator | Administrator | Interviewed regarding injury cause and reporting requirements |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 0
Jul 27, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00156375.
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 # NJ00156375 was investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 166
Capacity: 215
Deficiencies: 20
Feb 9, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to residents' rights during medication administration, facility cleanliness and maintenance, ADL care, physician order signatures, medication labeling and storage, staffing shortages, infection control practices, life safety code violations including fire safety, electrical and HVAC maintenance, and elevator safety.
Severity Breakdown
SS=D: 14
SS=E: 3
SS=F: 3
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to maintain residents' rights during medication administration by crushing medication and administering without resident knowledge. | SS=D |
| Failed to maintain a clean and sanitary environment including dirty ceiling vents, broken PTAC units, stained ceiling tiles, and damaged walls. | SS=E |
| Failed to provide nail care for dependent residents, resulting in overgrown nails and lack of grooming documentation. | SS=D |
| Failed to ensure physicians signed and dated monthly physician orders for multiple residents. | SS=F |
| Failed to store insulin vials according to manufacturer specifications and failed to properly label insulin. | SS=D |
| Failed to maintain sufficient nursing staff to meet residents' ADL needs, resulting in inadequate care and unmet preferences. | SS=D |
| Failed to follow effective infection control practices during medication administration, including improper sanitization and hand hygiene. | SS=D |
| Failed to maintain PTAC units in safe and optimal condition with clogged and dirty filters. | SS=E |
| Failed to ensure wooden handrails were installed, secured, and splinter free in all required locations. | SS=E |
| Basement area had only one exit, failing to provide two approved exits as required. | SS=F |
| Failed to provide automatic emergency illumination at the smoking courtyard egress gate. | SS=D |
| Failed to provide emergency lighting above emergency generator transfer switches. | SS=D |
| Failed to maintain self-closing devices on doors to hazardous areas, including combustible storage room door without self-closing device. | SS=D |
| Failed to maintain elevator emergency communication telephones in working order; vendor contract expired and phones not answered. | SS=F |
| Electrical panel face plate not properly secured, exposing live wires. | SS=D |
| Failed to maintain sprinkler system including missing ceiling tiles and lack of quarterly inspection documentation. | SS=D |
| Failed to ensure corridor doors resist passage of smoke and properly latch. | SS=D |
| Smoke barrier door blocked from closing by linen cart. | SS=D |
| Resident bathroom ventilation systems not functioning in two resident rooms. | SS=D |
| Extension cords used as permanent wiring in resident room. | SS=D |
Report Facts
Deficiencies cited: 20
Census: 166
Total Capacity: 215
Staffing ratios: 20
Staffing ratios: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in infection control deficiency related to medication pass. |
| Licensed Practical Nurse #2 | LPN | Named in infection control deficiency related to medication pass. |
| Director of Nursing | DON | Involved in discussions and corrective actions for multiple deficiencies. |
| Maintenance Director | Maintenance Director | Named in multiple deficiencies related to facility maintenance and safety. |
| Certified Nursing Assistant #1 | CNA | Named in nail care deficiency. |
| Certified Nursing Assistant #2 | CNA | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #1 | LPN/UM | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #2 | LPN/UM | Named in nail care deficiency. |
| Licensed Practical Nurse/Unit Manager #3 | LPN/UM | Named in physician order deficiency. |
Inspection Report
Life Safety
Census: 166
Capacity: 215
Deficiencies: 12
Feb 1, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health from 02/01/2022 to 02/03/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to have multiple life safety deficiencies including inadequate number of exits in the basement, lack of emergency illumination, failure to maintain self-closing doors on hazardous areas, fire alarm system deficiencies, sprinkler system maintenance issues, corridor doors not latching properly, smoke barrier doors blocked, HVAC ventilation failures in resident bathrooms, elevator emergency communication failures, exposed electrical panel wiring, and improper use of extension cords.
Severity Breakdown
SS=F: 4
SS=D: 8
Deficiencies (12)
| Description | Severity |
|---|---|
| Basement area provided with only one exit, failing to provide two acceptable exits from each floor. | SS=F |
| Failed to provide automatic emergency illumination at the smoking courtyard egress/discharge gate. | SS=D |
| Failed to provide operational battery backup emergency light above the emergency generator's transfer switches. | SS=D |
| Failed to provide and maintain self-closing devices and hardware on doors to hazardous areas. | SS=D |
| Failed to provide and maintain supervised smoke/heat detection in operating condition; one smoke detector taped over. | SS=D |
| Failed to maintain sprinkler system; missing ceiling tiles and incomplete quarterly inspections. | SS=F |
| Corridor doors failed to resist passage of smoke; doors did not latch properly in 4 resident rooms and storage area. | SS=D |
| Smoke barrier door blocked from fully closing by a linen cart. | SS=D |
| Resident bathroom ventilation systems for 2 units not functioning properly. | SS=D |
| Failed to maintain elevator emergency communication for 3 passenger elevators; vendor contract expired. | SS=F |
| Electrical panel face plate not properly positioned exposing live wires. | SS=D |
| Use of household grade extension cord in resident room as substitute for fixed wiring. | SS=D |
Report Facts
Certified beds: 215
Census: 166
Deficiency count: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including basement exits, emergency lighting, fire alarm, sprinkler system, corridor doors, smoke barrier doors, ventilation, elevator communication, and electrical panel issues. | |
| Administrator | Notified of all deficiencies at Life Safety Code exit conference on 02/03/2022. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Jun 29, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ142857, NJ139231, and NJ136076.
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 NJ142857, NJ139231, and NJ136076 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 17
Inspection Report
Routine
Census: 137
Deficiencies: 0
Mar 16, 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: 7
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 1
Jan 26, 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, specifically failing to ensure that staff adhered to proper hand hygiene practices. One Respiratory Therapist was observed not washing or sanitizing hands before donning gloves and after glove removal, posing a risk for infection transmission.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff performed handwashing as per facility policy to prevent spread of infection while rendering care to residents. | SS=D |
Report Facts
Sample size: 20
Audit frequency: 25
Audit duration: 2
Audit duration: 4
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Respiratory Therapist | Observed failing to perform proper hand hygiene before and after glove use | |
| Director of Nursing/Infection Preventionist | Provided 1:1 education and handwashing competency training to Respiratory Therapist and re-educated all staff on hand hygiene policy |
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