Deficiencies (last 4 years)
Deficiencies (over 4 years)
17.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
242% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
133 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 133
Deficiencies: 13
Mar 17, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to accuracy of assessments, pain management, dialysis, drug regimen review, administration, governing body oversight, and life safety code violations including means of egress, fire alarm system, and sprinkler system maintenance. The facility failed to accurately code the Minimum Data Set for one resident and failed to ensure proper pain management and dialysis medication administration. Several life safety code deficiencies were noted including issues with fire alarm notification, smoke detectors, and exit door hardware.
Complaint Details
Complaint numbers NJ 163118, 168060, 168580, 172135, 176208, 178873, 179238, 179547, 182434, 183981 were investigated during this survey. Deficiencies were cited based on these complaints.
Severity Breakdown
Level A: 1
Level D: 4
Level E: 1
Level F: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set (MDS) for 1 of 5 residents. | Level D |
| Facility failed to ensure pain management was provided consistent with professional standards for 1 of 3 residents. | Level D |
| Facility failed to adjust medication administration times to accommodate dialysis schedule for 1 of 2 residents. | Level E |
| Facility failed to ensure drug regimen review was conducted monthly by a licensed pharmacist for 1 of 5 residents. | Level D |
| Facility failed to ensure a licensed nursing home administrator was actively involved in daily oversight and policy implementation. | Level F |
| Facility failed to maintain required minimum direct care staff-to-resident ratios for 14 of 14 shifts reviewed. | Level A |
| Facility failed to ensure horizontal-sliding doors were installed in accordance with NFPA 101 standards. | Level F |
| Facility failed to ensure fire alarm notification was audible and visible in enclosed courtyards. | Level F |
| Facility failed to ensure battery-powered smoke detectors were maintained and replaced as required. | Level F |
| Facility failed to ensure fire alarm pull stations were installed at required heights. | Level F |
| Facility failed to ensure Class K fire extinguishers were provided with required instructional placards. | Level F |
| Facility failed to ensure emergency exit doors were equipped with approved hardware and locking devices. | Level F |
| Facility failed to ensure fire alarm system was maintained and tested in accordance with NFPA standards. | Level F |
Report Facts
Census: 133
Sample size: 26
Deficiencies cited: 13
Staffing shifts deficient: 14
Certified beds: 227
Resident census: 206
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report abuse allegations, inadequate care related to mobility and skin integrity, improper pain management, unsafe food temperatures, and infection control breaches.
Findings
The facility failed to timely report abuse allegations within the required two-hour timeframe, failed to ensure consistent use of heel booties to prevent skin breakdown, did not properly assess and document PRN pain medication administration, served hot food at unsafe temperatures, and failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions.
Complaint Details
The complaint investigation was triggered by allegations of abuse against Certified Nursing Assistants involving Residents #61 and #241, including failure to timely report the abuse, and concerns about care practices related to mobility, pain management, food safety, and infection control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse to the New Jersey Department of Health within two hours for allegations against CNAs for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure heel booties were consistently applied to prevent skin breakdown for a resident with limited mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to appropriately assess, monitor, and document PRN pain medications for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure hot foods were served at safe and appetizing temperatures, with observed food temperatures below the required 140°F. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure staff wore appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions during high-contact care activities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
BIMS score: 0
BIMS score: 15
Food temperature: 116
Food temperature: 127
Food temperature: 123.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Made abuse allegation regarding CNA and Resident #61 |
| Licensed Nursing Home Administrator #2 | LNHA | Completed Reportable Event Record and delayed abuse reporting |
| Assistant Director of Nursing | ADON | Interviewed during investigation and provided statement about Resident #241 incident |
| Director of Nursing | DON | Provided investigation information and reported abuse event to NJDOH |
| Certified Nursing Assistant #2 | CNA | Assigned CNA for Resident #241, interviewed about yelling incident |
| Certified Nursing Assistant #3 | CNA | Interviewed about yelling incident with Resident #241 |
| Regional Clinical Supervisor | RCS | Interviewed resident and surveyor regarding abuse investigation |
| Licensed Practical Nurse #1 | LPN | Resident #241's assigned nurse, interviewed about pain medication documentation |
| Food Service District Manager | FSDM | Interviewed about food temperature issues |
| Assistant Food Service Director | AFSD | Responsible for overseeing food temperatures |
| Unit Manager | UM | Observed not wearing gown during incontinence care for Resident #95 on Enhanced Barrier Precautions |
| Infection Preventionist | IP | Interviewed about PPE requirements for residents on Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report allegations of abuse against Certified Nursing Assistants for two residents and failure to ensure safe and appetizing food temperatures.
Findings
The facility failed to report allegations of abuse within the required two-hour timeframe for two residents and failed to ensure hot foods were served at safe and appetizing temperatures, as evidenced by food temperature measurements below the required standards.
Complaint Details
Complaint NJ00174720 involved failure to timely report abuse allegations against CNAs for Residents #61 and #241. The facility delayed reporting an allegation from 12/19/23 until 12/20/23, exceeding the two-hour reporting requirement. Complaint NJ166824 involved failure to ensure hot foods were served at safe temperatures, confirmed by food temperature checks on 3/6/25.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Food temperature: 116
Food temperature: 127
Food temperature: 123.5
Brief Interview for Mental Status (BIMS) score: 0
Brief Interview for Mental Status (BIMS) score: 1
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Made accusation of abuse regarding CNA#1 and Resident #61 |
| Licensed Nursing Home Administrator (LNHA) #2 | Licensed Nursing Home Administrator | Completed Reportable Event Record/Report and delayed abuse reporting |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Provided typed statement regarding Resident #241 incident and was involved in investigation |
| Director of Nursing (DON) | Director of Nursing | Provided investigation information and reported event to NJDOH |
| Regional Clinical Supervisor (RCS) | Regional Clinical Supervisor | Interviewed resident and participated in investigation |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Stated he was the abuse officer and described abuse reporting procedures |
| Food Service District Manager (FSDM) | Food Service District Manager | Interviewed regarding food temperature issues and food service oversight |
| Assistant Food Service Director (AFSD) | Assistant Food Service Director | Provided lunch meal food temperature log and responsible for food temperature oversight |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident rights to written notice before room transfers, timely notification before discharge, proper respiratory care, pain management, and the use of bed rails.
Findings
The facility failed to provide written notice to residents before room transfers, failed to provide 30-day discharge notices to residents being transferred to other facilities, failed to provide proper tracheostomy care including cleaning around the stoma, failed to identify and manage pain for a resident, and failed to ensure interventions were attempted prior to the use of side rails on a resident's bed.
Complaint Details
Complaints NJ00182358, NJ00169293, NJ00167278, NJ0161406, NJ00169314, NJ00172868 were investigated related to resident rights, discharge notification, respiratory care, pain management, and bed rail use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide written notice to two residents prior to room transfers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide 30-day notice of discharge and notify Ombudsman for two residents discharged to another facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide proper tracheostomy care including cleaning the skin around the stoma and outer cannula for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify and manage pain for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure interventions were attempted prior to the use of side rails on one resident's bed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for room transfers: 34
Residents reviewed for discharge: 3
Residents reviewed for tracheostomy care: 7
Residents reviewed for pain management: 34
Residents reviewed for side rails: 3
BIMS score for R5: 9
BIMS score for R30: 14
BIMS score for R14: 15
BIMS score for R15: Did not complete BIMS due to not being understood.
BIMS score for R23: 0
BIMS score for R33: 0
BIMS score for R34: 10
BIMS score for R17: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Performed tracheostomy care without cleaning skin around stoma; stated she should have cleaned. |
| LPN4 | Licensed Practical Nurse | Performed tracheostomy care without cleaning skin around stoma; stated she should have cleaned; administered pain medication to R34. |
| RN2 | Unit Manager for Tracheostomy Unit | Stated tracheostomy care requires cleaning all parts to prevent infection. |
| ADON | Assistant Director of Nursing | Described training on tracheostomy care including cleaning around stoma. |
| DON | Director of Nursing | Described expectations for tracheostomy care and pain management communication. |
| Social Services Director | Social Services Director | Confirmed no written room transfer notice for R5 or R30. |
| Regional Clinical Nurse | Regional Clinical Nurse | Unaware of facility policy at time of room transfers for R5 and R30. |
| Social Worker | Social Worker | Informed residents and families about discharge; stated no 30-day notice was provided. |
| RSS | Regional Social Services | Described discharge process and lack of 30-day notice for R14 and R15. |
| Family Member F5 | Reported no choice or 30-day notice for R14's transfer. | |
| Family Member F6 | Reported no choice or written notice for R15's transfer. | |
| LPN1 | Licensed Practical Nurse | Confirmed R17 uses side rails during care. |
| Director of Rehabilitation | Director of Rehabilitation | Stated therapy does not determine use of side rails; nursing decision. |
Inspection Report
Routine
Census: 194
Capacity: 227
Deficiencies: 10
Feb 13, 2023
Visit Reason
Routine inspection to assess compliance with fire safety, building rehabilitation, electrical systems, and other life safety code requirements.
Findings
The facility was found deficient in multiple areas including fire door ratings, egress door accessibility, emergency illumination, hazardous area enclosures, fire alarm system maintenance, electrical system compliance, oxygen cylinder storage, and gas equipment storage. Corrective actions were planned or implemented for all deficiencies.
Severity Breakdown
SS=E: 6
SS=F: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure separation from an addition was provided with a 90 minute fire rated door; current door was 45 minute rated. | SS=E |
| Exit doors in the means of egress were not readily accessible and free of obstructions due to locking latch issues. | SS=E |
| Failed to provide emergency illumination that would operate automatically along the means of egress. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing, labeled, and separated by smoke resisting partitions. | SS=E |
| Fire alarm system was in trouble mode and maintenance/testing records were incomplete. | SS=F |
| Failed to provide documentation that the Essential Electrical System (EES) was a Type I system with required branches and transfer switches. | SS=F |
| Electrical panels were not locked or guarded against accidental contact in resident accessible areas. | SS=F |
| Failed to provide a remote manual stop station for the generator located outside the facility. | SS=F |
| Failed to ensure patient care-related electrical equipment (PCREE) was maintained and tested properly; equipment intake and exhaust were blocked in resident rooms. | SS=E |
| Failed to segregate or properly label full and empty oxygen cylinders in storage. | SS=E |
Report Facts
Certified beds: 227
Census: 194
Deficiencies cited: 10
Oxygen cylinders: 15
Overhang dimensions: 15
Overhang dimensions: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed multiple findings related to fire safety, electrical systems, and maintenance | |
| Maintenance Director from sister facility | Present during observations and interviews confirming findings |
Inspection Report
Complaint Investigation
Census: 192
Capacity: 227
Deficiencies: 12
Feb 13, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and had multiple deficiencies related to resident rights, abuse prevention, medication administration, infection control, staffing ratios, and life safety code violations. Immediate Jeopardy was identified for failure to address new resident behavior and failure to protect residents from abuse and neglect.
Complaint Details
Complaint investigations were conducted for multiple complaint numbers including NJ00160907, NJ00160796, NJ00160615, NJ00160518, and NJ00158684. The complaints involved failure to address resident behavior, abuse and neglect, staffing deficiencies, and infection control issues. Some complaints were substantiated as evidenced by the deficiencies cited.
Severity Breakdown
Level 1: 2
Level 2: 10
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to address new behavior displayed by residents, resulting in Immediate Jeopardy. | Level 1 |
| Failure to maintain minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | Level 2 |
| Failure to provide care and services in a dignified and respectful manner, including failure to prevent staff from using cell phones in resident care areas. | Level 2 |
| Failure to prevent abuse and neglect, including failure to intervene in resident-to-resident altercations. | Level 1 |
| Failure to implement and maintain an effective emergency preparedness program including all-hazard assessment and subsistence needs. | Level 2 |
| Failure to maintain emergency power systems and emergency generator testing and maintenance. | Level 2 |
| Failure to maintain infection prevention and control program, including improper use of personal protective equipment and mask wearing. | Level 2 |
| Failure to properly store and manage medications, including expired medications and medication errors resulting in a medication error rate of 6.9%. | Level 2 |
| Failure to maintain fire safety code compliance including fire door ratings, fire alarm system maintenance, and emergency egress door locking arrangements. | Level 2 |
| Failure to maintain electrical systems including emergency power system and electrical panels. | Level 2 |
| Failure to maintain adequate illumination of means of egress and emergency lighting. | Level 2 |
| Failure to maintain safe storage of oxygen cylinders and related equipment. | Level 2 |
Report Facts
Census: 192
Total Capacity: 227
Sample Size: 41
Medication Error Rate: 6.9
Staffing Deficiencies: 14
Deficiency Counts: 12
Deficiency Counts: 9
Deficiency Counts: 4
Deficiency Counts: 11
Deficiency Counts: 100
Deficiency Counts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Asher Jacobs | LNHA, Administrator | Named in infection control deficiency related to PPE use and mask wearing. |
| Connie Opoku | RN, Director of Nursing | Named in infection control deficiency and medication administration findings. |
| Dr Joseph Schulman | Medical Director | Named in infection control deficiency and medication administration findings. |
| Gibril Sandy | RN, ADON/ Nurse Educator | Named in infection control deficiency related to PPE use. |
| Shanique Williams | LPN, Infection Preventionist | Named in infection control deficiency related to PPE use. |
| Rachel Thomas | Housekeeping Supervisor | Named in infection control deficiency related to PPE use. |
| Regina Chatman | Unit Manager | Named in infection control deficiency related to PPE use. |
| Sylvan Staples | Unit Manager | Named in infection control deficiency related to PPE use. |
| Jonathan Gutierrez | Unit Manager | Named in infection control deficiency related to PPE use. |
| Monina Abella | RN Supervisor | Named in infection control deficiency related to PPE use. |
| Ernest Kumi | RN Supervisor | Named in infection control deficiency related to PPE use. |
| Audrey Williams | CNA – Staffing Coordinator | Named in infection control deficiency related to PPE use. |
| William Roberts | Porter | Named in infection control deficiency related to PPE use. |
| Tamika Parrot | CNA | Named in infection control deficiency related to PPE use. |
| Sherley Cantave | RN Supervisor | Named in infection control deficiency related to PPE use. |
| Ruby Codjoe | RN Supervisor | Named in infection control deficiency related to PPE use. |
| Bentzy Davidowitz | Regional Director of Operations | Named in infection control deficiency related to PPE use. |
| Bal Grewal | VP of clinical services | Named in infection control deficiency related to PPE use. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Feb 13, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide dignified care, failure to protect residents from abuse, and other concerns including medication errors and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide care in a dignified manner, failure to protect residents from abuse resulting in immediate jeopardy, failure to implement proper respiratory care, medication management errors including expired medications and medication administration errors, and failure to follow infection prevention and control protocols.
Complaint Details
Complaint # NJ00158684 related to dignified care; Complaint # NJ00160796 and # NJ00160907 related to abuse and immediate jeopardy; Complaint NJ# 00160615, 00160518 related to infection control.
Severity Breakdown
Level 1: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide care and services in a dignified and respectful manner, including staff speaking on cell phones in resident care areas. | Level 1 |
| Failure to protect residents from abuse, including failure to address new aggressive behavior leading to an assault causing serious injury and death of a resident. | Level 1 |
| Failure to implement infection control measures for handling and storage of respiratory equipment, including use of expired sodium chloride in tracheostomy care. | Level 1 |
| Failure to ensure pharmaceutical services met standards, including unlabeled medications, expired medications in active inventory, and improper medication storage. | Level 1 |
| Failure to ensure medication error rates were below 5%, with observed medication administration errors including incorrect timing of medications. | Level 1 |
| Failure to follow infection prevention and control program requirements, including improper mask use by staff. | Level 1 |
Report Facts
Medication error rate: 6.9
Medication cart inspection date: 2023
Immediate Jeopardy notification time: 12.23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Regularly assigned nurse to Resident #190, involved in behavior documentation. |
| LPN #2 | Licensed Practical Nurse | Found Resident #98 injured after assault, provided statements about incident. |
| CNA #1 | Certified Nursing Assistant | Worked with Residents #190 and #98, reported no prior aggression. |
| CNA #2 | Certified Nursing Assistant | Assigned to Residents #190 and #98 on night of assault, described resident behaviors. |
| RN/UM | Registered Nurse/Unit Manager | Provided information about behavior monitoring and resident conditions. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and administration concerns. |
| Licensed Nursing Home Administrator | LNHA | Notified of Immediate Jeopardy and involved in corrective action plans. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 6, 2023
Visit Reason
The inspection was conducted based on multiple complaints alleging failure to provide dignified care, failure to prevent resident abuse, and failure to implement infection prevention and control measures.
Findings
The facility failed to provide care in a dignified and respectful manner, evidenced by staff using cell phones in resident care areas. The facility also failed to address new aggressive behavior by a resident that resulted in an assault causing serious injury and death of another resident. Additionally, the facility failed to ensure staff properly wore personal protective equipment to prevent infection spread.
Complaint Details
Complaint # NJ00158684 involved failure to provide dignified care. Complaints # NJ00160796 and # NJ00160907 involved failure to protect residents from abuse, including an assault by Resident #190 on Resident #98 resulting in serious injury and death. Complaint NJ# 00160615 and 00160518 involved failure to implement infection prevention and control measures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise rights, evidenced by staff speaking on cell phones in resident care areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from abuse, including failure to address new aggressive behavior leading to an assault causing serious injury and death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide and implement an infection prevention and control program, evidenced by staff not properly wearing masks. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 2
Staff assignment: 14
Staff assignment: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding cell phone policy and immediate jeopardy notification. |
| Director of Nursing | DON | Interviewed regarding cell phone concerns and immediate jeopardy notification. |
| Licensed Practical Nurse #1 | LPN | Regularly assigned nurse to Resident #190; provided information on resident behavior and assault incident. |
| Certified Nursing Assistant #1 | CNA | Provided information on resident behavior and interactions. |
| Certified Nursing Assistant #2 | CNA | Witnessed events on the night of the assault and provided details about resident behavior. |
| Registered Nurse/Unit Manager | RN/UM | Provided information on resident behavior monitoring and unit conditions. |
| Director of the Memory Care Unit | DMCU | Provided information on resident behavior and unit practices. |
| Licensed Practical Nurse #2 | LPN | Found Resident #98 injured after assault and provided details about the incident. |
| Infection Preventionist | Interviewed regarding facility infection control policies. | |
| Social Worker | SW | Observed not properly wearing mask in resident areas. |
| Account Manager | AM | Observed staff not properly wearing masks during kitchen tour. |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 0
Nov 23, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00159457.
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 # NJ00159457 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 9
Inspection Report
Complaint Investigation
Census: 199
Deficiencies: 2
Oct 14, 2022
Visit Reason
The inspection was conducted based on Complaint #NJ00151323 to investigate compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found non-compliant for failing to consistently implement the comprehensive care plan interventions for Resident #2, specifically regarding bed mobility and transfer requiring two staff. Additionally, the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey state law during the weeks of 9/25/22 to 10/8/22.
Complaint Details
Complaint #NJ00151323 triggered the survey. The complaint involved failure to implement care plan interventions and inadequate staffing ratios. The complaint was substantiated based on interviews, record reviews, and staffing data.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for Resident #2, including measurable objectives and timeframes, resulting in inconsistent implementation of care plan interventions for bed mobility and transfer requiring two staff. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law for 14 of 14 day shifts reviewed. | — |
Report Facts
Census: 199
Sample Size: 4
Deficiency cited: 1
Day shifts with deficient CNA staffing: 14
Staffing ratios required: 1
CNA staffing counts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding care provided to Resident #2 and documentation of assistance. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing and care plan compliance; acknowledged staffing shortages and care plan implementation issues. |
| Regional Director of Nursing | Regional Director of Nursing | Interviewed with DON regarding staffing and care plan compliance. |
| Schedule Manager | Schedule Manager and CNA | Interviewed about staffing challenges and efforts to cover shifts. |
Inspection Report
Routine
Census: 179
Deficiencies: 2
Apr 22, 2022
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 and CMS/CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure proper handwashing technique by a Certified Nursing Assistant and failing to provide influenza and pneumococcal immunization education and opportunities to residents. Corrective actions and staff reeducation were implemented.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure handwashing was performed according to facility policy and CDC standards by a Certified Nursing Assistant. | SS=D |
| Failure to provide information and opportunity to receive influenza and pneumococcal vaccines to residents, including documentation of education and refusal. | SS=D |
Report Facts
Sample size: 5
Census: 179
Completion date for handwashing deficiency: May 17, 2022
Completion date for immunization deficiency: May 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in handwashing technique deficiency |
| Director of Nursing | Director of Nursing | Responsible for ensuring facility compliance and monitoring corrective actions |
Document
Deficiencies: 0
Nov 12, 2021
Visit Reason
This document provides instructions for classifying and extracting key data elements from state facility inspection reports and related regulatory documents.
Findings
The document outlines the classification categories, extraction rules, and required data fields for analyzing inspection reports and related documents.
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Jul 7, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers listed in the report.
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
The survey was conducted in response to complaints NJ145703, NJ145585, NJ145292, NJ144995, NJ143541, NJ142530, NJ145391, and NJ142210. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 8
Inspection Report
Original Licensing
Deficiencies: 0
Jun 22, 2021
Visit Reason
Initial inspection for licensure of new and/or renovated long term care facilities, specifically for the addition of five ventilator beds.
Findings
No deficiencies were noted during the inspection of the facility adding five ventilator beds. The new areas may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.
Report Facts
Ventilator beds added: 5
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 1
May 6, 2021
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 deficient in food safety requirements, specifically failing to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to properly handle and store potentially hazardous foods to prevent foodborne illnesses and maintain equipment and kitchen areas to prevent microbial growth and cross-contamination. | SS=F |
Report Facts
Census: 120
Sample Size: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Account Manager | Present during kitchen tour and acknowledged food safety issues | |
| District Manager | Interviewed regarding food storage and labeling policies | |
| Food Services Director | Food Services Director | Responsible for conducting weekly audits and staff in-service |
| Assistant Food Services Director | Assistant Food Services Director | Responsible for conducting weekly audits and staff in-service |
Inspection Report
Annual Inspection
Deficiencies: 3
May 6, 2021
Visit Reason
A Life Safety Code Survey was conducted as a Standard Recertification Survey to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with life safety code requirements including failure to ensure six illuminated exit signs were posted, doors to hazardous areas were not self-closing or maintaining fire rated assembly, and lack of automatic fire sprinkler coverage in certain areas. Corrective actions were initiated immediately and ongoing monitoring and audits were planned.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure six illuminated exit signs were posted to clearly identify exit access paths. | SS=E |
| Failure to ensure doors to hazardous areas were self-closing and maintained fire rated assembly. | SS=D |
| Failure to provide automatic fire sprinkler protection to all areas in accordance with NFPA 13. | SS=D |
Report Facts
Number of unilluminated exit signs: 6
Invoice amount: 1028
Sprinkler head relocation date: May 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and responsible for corrective actions and staff in-service |
Inspection Report
Routine
Deficiencies: 7
May 6, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with food handling, storage, and kitchen sanitation standards to prevent foodborne illnesses and cross-contamination.
Findings
The facility failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen areas to prevent microbial growth and cross-contamination, and ensure food items were appropriately dated and stored. Multiple instances of undated food items, improper storage, and equipment issues were observed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Foot pedal at handwashing station did not open trash can lid. | Level of Harm - Minimal harm or potential for actual harm |
| Personal staff lunches stored in reach-in fridge where they should not be. | Level of Harm - Minimal harm or potential for actual harm |
| Containers of pudding and cheese slices in walk-in fridge had no prepared or use-by dates. | Level of Harm - Minimal harm or potential for actual harm |
| Opened boxes of turkey bacon and beef sandwich steaks in freezer had internal plastic bags opened exposing meat to air. | Level of Harm - Minimal harm or potential for actual harm |
| Multiple-sized serving pans and lids were nested with moisture between them on drying rack. | Level of Harm - Minimal harm or potential for actual harm |
| Opened plastic bag of corn mix in Dry Food Room was expired and removed. | Level of Harm - Minimal harm or potential for actual harm |
| Opened bags of hot dog rolls, cinnamon bread, and wheat bread had no received by or open dates and were discarded. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight of turkey bacon box: 5.44
Weight of beef sandwich steaks box: 10.5
Count of hot dog rolls: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Account Manager | Present during kitchen observations and acknowledged deficiencies | |
| District Manager | Interviewed regarding food dating and disposal policies |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Jan 5, 2021
Visit Reason
The inspection was conducted based on complaints NJ140105, NJ140832, and NJ139137 to determine compliance with regulatory requirements.
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 NJ140105, NJ140832, and NJ139137 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 11
Inspection Report
Routine
Census: 124
Deficiencies: 0
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 and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
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