Inspection Reports for Continuing Care At Lantern Hill
537 Mountain Avenue, NJ, 07974
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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 details 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: 38
Deficiencies: 8
Sep 12, 2024
Visit Reason
A recertification survey was conducted from 09/09/2024 through 09/12/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Findings
The facility was found to have multiple deficiencies including failure to develop and implement comprehensive person-centered care plans, failure to maintain nursing professional standards of clinical practices, failure to maintain proper kitchen sanitation practices, and failure to comply with life safety code requirements. Deficient practices had the potential to affect all residents but no residents were directly affected. Corrective actions and plans of correction were submitted and some deficiencies were corrected by the revisit date.
Complaint Details
Complaint # NJ174676 was investigated during the survey. Deficiencies related to complaint allegations were cited.
Severity Breakdown
Level F: 7
Level D: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for residents. | Level F |
| Failure to maintain nursing professional standards of clinical practices related to pain management and medication use. | Level D |
| Failure to maintain proper kitchen sanitation practices to prevent foodborne illness. | Level F |
| Failure to ensure exit discharge pathways were clear and properly marked in accordance with NFPA 101. | Level F |
| Failure to ensure quarterly Uniform Fire Safety Code inspections were conducted and documented. | Level F |
| Failure to ensure fire door assemblies were inspected and tested annually. | Level F |
| Failure to ensure sprinkler system gauges were replaced or recalibrated every 5 years. | Level F |
| Failure to ensure portable fire extinguishers were properly installed and maintained. | Level F |
Report Facts
Census: 38
Sample Size: 15
Deficiencies cited: 8
Audit percentage: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to care plan audits, education, and corrective actions |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding care plans and resident information |
| General Services Director | General Services Director (GSD) | Named in relation to fire safety and maintenance deficiencies |
Inspection Report
Routine
Census: 37
Deficiencies: 0
Jan 25, 2024
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 recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 40
Capacity: 40
Deficiencies: 4
Aug 18, 2023
Visit Reason
A Recertification and complaint survey was conducted to assess compliance with regulatory standards including complaint intakes and recertification requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B with no deficiencies related to complaint intakes. However, deficiencies were noted in staffing ratios, emergency lighting, fire extinguisher maintenance, and smoke barrier integrity.
Complaint Details
No deficiencies were issued related to Complaint Intakes NJ162192, NJ163620, NJ163741, NJ164118, NJ164483, NJ164624, and NJ165562.
Severity Breakdown
SS=F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff-to-shift ratios for day shifts as mandated by New Jersey state law. | — |
| Emergency lighting was not provided at the emergency generator transfer switch as required by NFPA 110. | SS=F |
| Stored-pressure fire extinguishers lacked six-year internal examination and verification of service collar as required by NFPA 10. | SS=F |
| Penetrations in smoke barrier walls were not sealed, compromising smoke barrier continuity as required by NFPA 101. | SS=F |
Report Facts
Survey Census: 40
Sample Size: 12
Deficient CNA staffing day shifts: 5
Deficient CNA staffing day shifts count: 5
Occupied Beds: 37
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 0
Oct 19, 2021
Visit Reason
The visit was a recertification survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this recertification survey.
Report Facts
Sample size: 22
Inspection Report
Life Safety
Deficiencies: 3
Oct 19, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with fire safety requirements including failure to conduct required quarterly fire drills on all shifts, failure to annually inspect and test all fire-rated door assemblies, and failure to maintain and test the essential emergency power generator as required by NFPA standards. These deficiencies could potentially affect all 36 residents, staff, and visitors.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure required fire drills were conducted each quarter for each shift and under varying conditions; staff were not adequately trained and prepared for fire emergencies. | SS=F |
| Failed to annually inspect and test all fire-rated door assemblies in accordance with NFPA 80 standards. | SS=F |
| Failed to maintain and test the essential emergency power generator in accordance with NFPA 110, including missed weekly inspections and lack of documentation for monthly load testing. | SS=F |
Report Facts
Residents potentially affected: 36
Missed fire drills: 2
Weekly generator inspections completed: 7
Required monthly generator load tests: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Associate Executive Director | Acknowledged missing fire drills and lack of awareness of required annual fire door inspections. | |
| Senior Facility Manager | Acknowledged missing fire drills and generator inspections; received re-education on fire drills, door inspections, and generator maintenance; responsible for reviewing documentation and reporting to Administrator. | |
| Security Supervisor | Conducted in-service fire safety training for 1st and 3rd shifts on 11/11/21. |
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 0
Jan 11, 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 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: 9
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