Deficiencies per Year
20
15
10
5
0
Moderate
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 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, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 129
Deficiencies: 4
Jan 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ178902, covering the period from 1/15/25 to 1/23/25.
Findings
The facility was found to be in substantial compliance with federal long-term care requirements but was not in compliance with New Jersey state licensure standards. Deficiencies included failure to maintain minimum direct care staff to resident ratios for one day shift, and failure to ensure newly hired employees completed required health histories and physical examinations within mandated timeframes. Additionally, life safety code deficiencies were noted related to sprinkler system spare heads and emergency generator monthly load testing.
Complaint Details
Complaint #: NJ178902 triggered the survey conducted from 1/15/25 to 1/23/25. The complaint investigation found staffing and employee health record deficiencies.
Severity Breakdown
Severity F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratio for 1 of 14 day shifts (1/6/25) with 11 CNAs for 98 residents instead of required 12 CNAs. | — |
| Failed to ensure newly hired employees completed health history and received physical examination by physician, advanced practice nurse, or licensed physician assistant within two weeks prior to employment or within 30 days if RN assessment was done; identified in 5 of 10 employee files reviewed. | — |
| Failed to ensure at least six spare quick response sprinkler heads were present in the sprinkler cabinet as required by NFPA 13 standard. | Severity F |
| Failed to ensure monthly load tests were conducted on the emergency generator in accordance with NFPA 110 standards; no documented evidence of monthly load testing. | Severity F |
Report Facts
Census: 103
Total Capacity: 129
Deficient CNA staffing: 1
Newly hired employee files reviewed: 10
Non-compliant employee files: 5
Spare sprinkler heads required: 6
Residents potentially affected: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Administrator/Designee | Responsible for conducting staffing audits and monitoring new hire physicals |
| Director of Nursing | DON | Interviewed regarding staffing policies and minimum staffing requirements |
| Director of Human Resources/Scheduling Coordinator | DHR/SC | Interviewed regarding staffing policies and employee file compliance |
| Licensed Practical Nurse/Infection Preventionist | LPN/IP | Responsible for ensuring newly hired employees had physicals completed |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Jun 11, 2024
Visit Reason
The inspection was conducted based on complaints NJ001547, NJ00173115, and NJ00172367 regarding the facility's compliance with long term care regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to maintain complete medical records including the New Jersey Universal Transfer Form for a resident sent to the hospital. Additionally, the facility failed to meet required staffing ratios for Certified Nurse Aides on multiple shifts.
Complaint Details
Complaint numbers NJ001547, NJ00173115, and NJ00172367 triggered the visit. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain complete medical records including the New Jersey Universal Transfer Form for a resident sent to the hospital. | SS=D |
| Failure to ensure staffing ratios were met for Certified Nurse Aides on 11 of 14 day shifts and 4 of 14 night shifts. | — |
Report Facts
Census: 110
Sample Size: 5
Staffing Deficiencies: 11
Staffing Deficiencies: 4
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) required: 8
Inspection Report
Complaint Investigation
Census: 105
Capacity: 101
Deficiencies: 10
Oct 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints received regarding resident care and facility compliance with regulations.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for residents, inadequate care planning and implementation, improper notification of room changes, unsafe environment conditions, insufficient staff training and supervision, and failure to maintain accurate and complete medical and administrative records.
Complaint Details
The visit was complaint-related based on complaints NJ00160546, NJ00163908, NJ00156816, and NJ00158985. The investigation included review of resident records, interviews, and environmental observations. The complaints involved issues of resident care, abuse/neglect allegations, and facility compliance.
Deficiencies (10)
| Description |
|---|
| Failure to provide reasonable accommodations and specialized call bell according to resident's limitations and preferences. |
| Failure to notify resident and family of room/roommate changes in a timely and documented manner. |
| Unsafe environment due to presence of construction materials and adhesive in dining area without proper controls. |
| Failure to ensure all newly hired staff had verified licenses prior to hire. |
| Failure to thoroughly investigate and document allegations of abuse and neglect. |
| Failure to provide timely and adequate care planning and interventions for residents at risk, including pressure ulcers and specialized care needs. |
| Failure to maintain accurate and complete medical records, including physician visits, assessments, and care plans. |
| Failure to maintain adequate staffing levels and provide required staff training and competency evaluations. |
| Failure to maintain a safe, clean, and sanitary environment, including food service and infection control practices. |
| Failure to provide required immunizations and document refusals or contraindications. |
Report Facts
Census: 105
Total Capacity: 101
Sample Size: 21
Closed Records: 3
Additional Records: 20
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 2
Jan 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ157128, NJ157438, NJ16028, and NJ160661 to determine compliance with regulatory standards.
Findings
The facility was found not in substantial compliance with professional standards of care, specifically failing to follow clinical practice standards and document treatments for 2 of 17 residents reviewed. Additionally, the facility failed to meet required staffing ratios for certified nurse aides on multiple shifts.
Complaint Details
Complaint investigation based on complaint numbers NJ157128, NJ157438, NJ16028, and NJ160661. The facility was found not in substantial compliance with professional standards and staffing requirements.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice and document treatments as ordered by the physician for 2 of 17 residents. | SS=D |
| Failure to ensure staffing ratios were met to maintain required minimum staff-to-resident ratios for certified nurse aides on 14 of 35 day shifts and 2 of 35 overnight shifts. | — |
Report Facts
Census: 124
Sample size: 17
Staffing deficiency: 14
Staffing deficiency: 2
Certified Nurse Aides (CNAs) required: 13
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) actual: 11
Certified Nurse Aides (CNAs) actual: 12
Total staff required overnight: 8
Total staff actual overnight: 4
Total staff actual overnight: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Stated facility policies and practices during interviews related to treatment administration and documentation. | |
| Unit Manager/Registered Nurse (RN) | Interviewed regarding treatment administration record documentation. |
Inspection Report
Routine
Census: 103
Deficiencies: 0
Jul 28, 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.
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: 5
Inspection Report
Re-Inspection
Census: 99
Capacity: 130
Deficiencies: 18
Jul 1, 2022
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 multiple areas including accuracy of assessments, medication administration, nutrition/hydration status, respiratory care, psychotropic drug use, food safety, infection control, staffing ratios, and life safety code compliance. Corrective actions were implemented and verified during the revisit.
Severity Breakdown
Level 3: 17
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to ensure accuracy of resident assessments and coding. | Level 3 |
| Medications were not administered according to physician orders and improper labeling of medications. | Level 3 |
| Failure to maintain proper nutrition and hydration status for residents. | Level 3 |
| Respiratory care deficiencies including improper tracheostomy care and suctioning. | Level 3 |
| Psychotropic drugs prescribed without proper documentation and monitoring. | Level 3 |
| Expired and improperly stored medications found in medication carts and refrigerators. | Level 3 |
| Failure to prepare and serve therapeutic diets consistent with physician orders. | Level 3 |
| Kitchen sanitation deficiencies including improper storage and cleaning. | Level 3 |
| Infection prevention and control deficiencies including improper PPE use. | Level 3 |
| Failure to maintain minimum direct care staffing ratios as required by state law. | Level 3 |
| Life safety code violations including blocked means of egress, malfunctioning fire doors, delayed egress locks, and improper locking mechanisms. | Level 3 |
| Smoke detectors in resident rooms lacked a preventative maintenance program and battery replacement. | Level 3 |
| Sprinkler system deficiencies including improper installation and maintenance of exterior sprinklers. | Level 3 |
| Corridor doors failed to resist passage of smoke due to improper latching and gaps. | Level 3 |
| Hazardous areas not properly enclosed or maintained, including basement storage and sprinkler shutoff valve room. | Level 3 |
| HVAC ventilation systems in resident bathrooms were not functioning. | Level 3 |
| Electrical equipment with exposed wiring found in resident room. | Level 3 |
| Gas equipment cylinders not properly secured and protected from damage. | Level 3 |
Report Facts
Residents present: 99
Licensed capacity: 130
Deficiency counts: 17
Staffing ratios: 11
Staffing ratios: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Named in medication administration and labeling deficiencies | |
| Licensed Practical Nurse (LPN #4) | Named in respiratory care and PPE donning/doffing deficiencies | |
| Director of Nursing | Named in multiple corrective actions and education | |
| Maintenance Director | Named in life safety and facility maintenance corrective actions | |
| Administrator | Named in multiple corrective actions and education | |
| Staff member (unnamed) | Named in electrical equipment exposed wiring finding |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Sep 3, 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: 5
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jun 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139868, NJ140564, and NJ143693.
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 NJ139868, NJ140564, and NJ143693 were investigated and found to be in compliance.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
May 20, 2021
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to the facility.
Findings
The facility was found to be in substantial 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 complaint-based and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
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