Deficiencies per Year
8
6
4
2
0
High
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 explains 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: 37
Capacity: 56
Deficiencies: 7
Mar 14, 2025
Visit Reason
A Recertification Survey was conducted from 3/7 to 3/12/2025 to determine compliance with 42 CFR Part 483 for Long-Term Care Facilities, including complaint investigations. Additionally, an Emergency Preparedness Survey and a Life Safety Code Survey were conducted on 3/13 and 3/14/2025.
Findings
Deficiencies were cited related to personal privacy/confidentiality of records, pharmacy services including narcotic medication inspection and disposal, infection prevention and control, emergency lighting, HVAC, fire drills, and electrical systems. Corrective actions and plans of correction were provided and completed by early April 2025.
Complaint Details
Complaint numbers NJ 164566, 165341, 182642 were investigated during the survey. The complaint investigation was substantiated as deficiencies were cited related to privacy and pharmaceutical services.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide physical privacy during treatment for Resident #21. | SS=D |
| Failure to provide pharmaceutical services in accordance with regulations, including narcotic medication inspection and record keeping. | SS=E |
| Failure to establish and maintain an infection prevention and control program. | SS=D |
| Emergency lighting did not have battery backup emergency light above the interior emergency generator transfer switch. | SS=F |
| Facility failed to ensure ventilation complied with NFPA 101:2012 Edition. | SS=E |
| Fire drills with varying activation types and specific simulation of emergency fire conditions were not conducted as required. | SS=F |
| Electrical systems failed to ensure emergency power supply was exercised and documented properly. | SS=F |
Report Facts
Census: 37
Total Capacity: 56
Sample Size: 15
Deficiency Count: 7
Dates of Survey: 2025-03-07 to 2025-03-12
Dates of Emergency Preparedness Survey: 2025-03-13 to 2025-03-14
Inspection Report
Annual Inspection
Census: 43
Capacity: 56
Deficiencies: 6
Jan 27, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to respiratory care, pharmacy services, medication administration errors, food safety, infection prevention and control, and staffing ratios. The facility failed to maintain oxygen supplies properly, ensure accurate pharmaceutical services, prevent medication errors, maintain sanitary food preparation, and enforce infection control PPE protocols. Staffing ratios did not meet state requirements on one day shift.
Severity Breakdown
SS=D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain oxygen supplies consistent with infection control protocols for Resident #26. | SS=D |
| Failed to provide pharmaceutical services in accordance with professional standards, including expired narcotics in inventory, medication reconciliation errors, and improper medication disposal. | SS=D |
| Medication administration error for Resident #245 with duplicate medication doses administered. | SS=D |
| Failed to sanitize and air dry steam table pans properly, maintain kitchen environment and equipment in sanitary manner, and remove dented cans from use. | SS=D |
| Failed to properly wear personal protective equipment (PPE) when entering a resident's room on droplet precautions. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Census: 43
Total Capacity: 56
Sample Size: 14
Deficiency Count: 6
Staffing Deficiency: 1
Residents: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to oxygen tubing deficiency and medication errors |
| Licensed Practical Nurse | LPN | Named in medication administration error for Resident #245 |
| Certified Nursing Assistant | CNA | Named in infection control PPE deficiency |
| General Manager | General Manager | Named in food safety deficiencies and corrective actions |
| Licensed Nursing Home Administrator | LNHA | Involved in medication administration and pharmacy service interviews |
Inspection Report
Annual Inspection
Census: 23
Deficiencies: 4
Feb 25, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to Medicaid/Medicare coverage and liability notice, abuse/neglect policies and investigations, pressure ulcer prevention and treatment, and safe transfer procedures using mechanical lifts.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=G: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide written notification to Medicaid-eligible resident of potential liability charges for services not covered when coverage changed. | SS=D |
| Facility failed to thoroughly investigate and initiate investigation of facility-acquired pressure ulcer and possible neglect. | SS=E |
| Facility failed to prevent an avoidable facility-acquired pressure ulcer, re-assess risk upon development, appropriately assess and treat the pressure ulcer, ensure staff knowledge of presence of pressure ulcer, update care plan, and ensure use of physician-ordered offloading devices. | SS=G |
| Facility failed to ensure resident was transferred using two-person assist with mechanical lift in accordance with facility policy to prevent accidents and injuries. | SS=D |
Report Facts
Census: 23
Weight loss percentage: 3.47
Weight loss percentage: 0.65
Care plan review date: Feb 23, 2021
Incident report sign-off date: Feb 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Involved in Medicaid liability notification and resident education | |
| Director of Nursing | Involved in abuse/neglect investigation and oversight | |
| Licensed Nursing Home Administrator | Provided information on resident insurance and investigation status | |
| Licensed Practical Nurse | Performed wound treatment and provided nursing care | |
| Certified Nursing Aide | Provided direct care and assisted with transfers | |
| Registered Dietician | Provided nutritional assessment and recommendations | |
| Wound Care Consultant/Medical Doctor | Provided wound assessment and treatment recommendations | |
| Nurse Practitioner | Provided medical progress notes and nutritional assessment | |
| Executive Director/Licensed Nursing Home Administrator | Oversight of investigations and facility operations |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Dec 22, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00139536 and NJ00133095.
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 NJ00139536 and NJ00133095 were investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 7
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