Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
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 details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties and responsibilities regarding 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
Complaint Investigation
Census: 100
Deficiencies: 1
Jun 23, 2025
Visit Reason
The inspection was conducted in response to complaint NJ187234 to investigate staffing ratio compliance at the facility.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, failing to meet minimum CNA staffing requirements on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint NJ187234 was substantiated as the facility failed to meet minimum staffing requirements for CNAs on all 14 day shifts reviewed from 06/08/2025 to 06/21/2025.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 14 of 14-day shifts reviewed, deficient in CNAs for resident care. |
Report Facts
Deficient CNA staffing days: 14
Census on 06/08/25: 106
Census on 06/09/25: 104
Census on 06/10/25: 104
Census on 06/11/25: 103
Census on 06/12/25: 103
Census on 06/13/25: 101
Census on 06/14/25: 99
Census on 06/15/25: 99
Census on 06/16/25: 99
Census on 06/17/25: 99
Census on 06/18/25: 99
Census on 06/19/25: 99
Census on 06/20/25: 99
Census on 06/21/25: 99
Inspection Report
Routine
Census: 105
Deficiencies: 0
Dec 13, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 6
Inspection Report
Follow-Up
Census: 118
Deficiencies: 1
Sep 29, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for long term care facilities and to follow up on previously identified deficiencies related to staffing ratios.
Findings
The facility was found deficient in maintaining the required minimum Certified Nurse Aide (CNA) staffing ratios for day shifts on multiple dates, affecting all residents. A plan of correction was submitted and a revisit on 11/17/2022 confirmed that the deficiency was corrected as of 10/01/2022.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on day shifts. |
Report Facts
Census: 118
Sample Size: 5
Deficient CNA staffing days: 14
CNA staff vs required on 04/24/2022: 11
CNA staff vs required on 04/25/2022: 11
CNA staff vs required on 04/26/2022: 11
CNA staff vs required on 04/27/2022: 13
CNA staff vs required on 04/28/2022: 10
CNA staff vs required on 04/29/2022: 10
CNA staff vs required on 04/30/2022: 9
CNA staff vs required on 08/14/2022: 10
CNA staff vs required on 08/15/2022: 9
CNA staff vs required on 08/16/2022: 10
CNA staff vs required on 08/17/2022: 11
CNA staff vs required on 08/18/2022: 10
CNA staff vs required on 08/19/2022: 10
CNA staff vs required on 08/20/2022: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Educated on NJ minimum staffing mandate and involved in monitoring compliance | |
| Director of Nursing | Educated on NJ minimum staffing mandate and involved in monitoring compliance | |
| Staffing Coordinator | Educated on NJ minimum staffing mandate and involved in monitoring compliance | |
| Human Resources Manager | Responsible for managing recruitment efforts and documentation |
Inspection Report
Routine
Census: 122
Deficiencies: 0
May 17, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 6
COVID+ in house: 26
Inspection Report
Plan of Correction
Census: 104
Deficiencies: 1
Mar 29, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically evaluating staffing ratios as mandated by state law.
Findings
The facility was found deficient in maintaining the required minimum direct care staff to resident ratios for the day shift, failing CNA staffing requirements for 12 of 14 day shifts between 02/27/22 and 03/12/22. The facility submitted a plan of correction to address these deficiencies.
Deficiencies (1)
| Description |
|---|
| Failed to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey, deficient in CNA staffing for 12 of 14 day shifts. |
Report Facts
Residents present: 104
CNA staffing deficiency days: 12
CNA staffing required: 13
CNA staffing actual: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Payroll and Schedule Manager | Interviewed regarding staffing ratios and facility staffing practices | |
| Administrator | Named in plan of correction for re-education and monitoring staffing compliance | |
| Director of Nursing | Named in plan of correction for re-education and monitoring staffing compliance | |
| Staffing Coordinator | Named in plan of correction for re-education and monitoring staffing compliance |
Inspection Report
Life Safety
Deficiencies: 2
Mar 29, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 03/29/2022 to assess compliance with Medicare/Medicaid participation requirements related to fire safety 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 fire safety requirements including failure to ensure illuminated exit signs in nine locations and inadequate fire sprinkler coverage in one resident shower area. Corrective actions included installation of nine illuminated exit signs and two sprinkler heads in the affected shower stalls.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure illuminated exit signs in nine locations to clearly identify exit access paths. | SS=E |
| Failure to provide proper fire sprinkler coverage in one resident shower area as required by NFPA 13. | SS=D |
Report Facts
Number of illuminated exit signs missing: 9
Number of sprinkler heads missing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Present during observations and responsible for contacting vendors for corrective actions. | |
| Administrator | Informed of findings during the Life Safety Code survey exit conference. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
May 7, 2021
Visit Reason
The inspection was conducted based on a complaint visit regarding allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility failed to thoroughly investigate an incident involving one resident (Resident #2) as required by the facility's policy. Documentation showed the resident was found with a tied object causing injury, and the incident was not properly entered or investigated in the Risk Management System as required.
Complaint Details
The visit was complaint-related due to allegations of abuse, neglect, exploitation, or mistreatment. The facility was found not in compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate an incident involving Resident #2 and failure to enter the incident into the Risk Management System as required by facility policy. | SS=D |
Report Facts
Sample size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to investigate and document the incident |
| Administrator | Administrator | Interviewed regarding failure to investigate and document the incident |
| Physical Therapist Assistant | Physical Therapist Assistant (PTA) | Documented initial observation of the resident needing assistance and reported the incident |
| Registered Nurse | Registered Nurse (RN) | Documented findings and stayed with the resident until transfer to hospital |
Inspection Report
Routine
Census: 89
Deficiencies: 0
Dec 22, 2020
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
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