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, individuals' rights to access and control their information, and 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
Complaint Investigation
Census: 64
Deficiencies: 0
Aug 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00176097.
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 visit.
Complaint Details
Complaint #NJ00176097 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ172933.
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 visit. Additionally, the facility was in compliance with New Jersey Administrative Code, Chapter 8:39, standards for licensure of long term care facilities.
Complaint Details
Complaint #: NJ172933; the facility was found to be in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Census: 64
Capacity: 100
Deficiencies: 12
Mar 27, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities, including complaint investigations.
Findings
Deficiencies were cited in multiple areas including comprehensive assessments, encoding/transmitting resident assessments, accuracy of assessments, professional standards of care, pressure ulcer prevention, range of motion, nutrition/hydration, respiratory care, pharmacy services, resident records, payroll based journal submission, influenza and pneumococcal immunizations, and multiple life safety code violations related to building construction, fire safety, sprinkler systems, fire alarm systems, portable fire extinguishers, HVAC ventilation, electrical systems, and door maintenance.
Complaint Details
Complaint numbers NJ 167761, NJ 170615, NJ 171733 were investigated during this survey.
Severity Breakdown
SS=E: 8
SS=D: 5
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to complete and submit electronically the Minimum Data Set (MDS) within 14 days of completion for multiple residents. | SS=E |
| Failure to accurately code the Minimum Data Set (MDS) for multiple residents. | SS=E |
| Failure to assess and provide care for a resident at risk for falls according to professional standards. | SS=D |
| Failure to provide care to prevent pressure ulcers and to treat existing pressure ulcers according to professional standards. | SS=E |
| Failure to implement restorative nursing interventions and revise care plans timely for residents using splints or assistive devices. | SS=E |
| Failure to maintain acceptable nutritional and hydration status and to follow interdisciplinary recommendations for residents with significant weight loss. | SS=D |
| Failure to provide respiratory care and physician orders consistent with professional standards for a resident with tracheostomy care needs. | SS=E |
| Failure to submit Payroll Based Journal (PBJ) staffing data to CMS for Fiscal Year Quarter 1 2024. | SS=F |
| Failure to offer pneumococcal immunization to a resident and document consent and administration properly. | SS=D |
| Life Safety Code violations including building construction type exceeding allowed height for wood-frame structures, inadequate number of exits, vertical openings not enclosed with 1-hour fire rated construction, missing sprinkler coverage in stairwell landing, failure to maintain portable fire extinguishers, failure to conduct hydrostatic testing of kitchen range hood fire suppression system, failure to conduct smoke detector sensitivity testing, failure to maintain fire alarm system, failure to provide ventilation in resident bathrooms, and failure to provide GFCI protection for electrical outlets near water sources. | — |
| Failure to maintain electrical outlets near water sources with required Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Failure to maintain fire-rated doors with properly functioning latching systems. | SS=E |
Report Facts
Census: 64
Total Capacity: 100
Deficiencies cited: 26
Fire extinguisher maintenance interval: 6
Fire extinguisher maintenance interval: 1
Smoke detector sensitivity testing interval: 2
Hydrostatic testing interval: 12
GFCI outlet distance: 6
Resident rooms inspected: 45
Resident bathrooms inspected: 13
Electrical outlets tested: 9
Electrical outlets failed GFCI test: 5
Fire alarm systems inspected: 1
Fire alarm sensitivity testing missing: 1
Exit access doors tested: 9
Exit access doors failed latching test: 1
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 15
Sep 15, 2023
Visit Reason
A complaint investigation and recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to environmental concerns including failure to maintain a safe, clean, comfortable, and homelike environment; failure to maintain and clean resident equipment properly; failure to complete and transmit resident assessments timely and accurately; failure to clarify medication orders; failure to post nurse staffing information daily; failure to properly label and store medications and biologicals; failure to maintain food safety standards; and failure to follow infection prevention and control practices including hand hygiene. Life Safety Code deficiencies were also cited related to building construction, exits, hazardous area enclosures, and fire door maintenance.
Complaint Details
Complaint NJ #: 163930; 166007. The complaint involved multiple issues including environmental concerns, infection control, staffing, and medication management.
Severity Breakdown
SS=E: 5
SS=F: 4
SS=D: 2
SS=B: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility failed to maintain resident living environment in a clean, comfortable, homelike manner with stained curtains, chipped molding, holes in walls, and improper bed placement. | SS=E |
| Facility failed to clean and maintain resident equipment properly, including soiled respiratory equipment. | SS=E |
| Facility failed to complete and transmit discharge Minimum Data Set (MDS) for a discharged resident. | SS=B |
| Facility failed to accurately code a resident's MDS related to antipsychotic medication use. | SS=E |
| Facility failed to clarify physician's order for medication dosage on electronic Medication Administration Record (eMAR). | SS=E |
| Facility failed to post nurse staffing information daily and timely in a prominent location. | SS=B |
| Facility failed to properly label, date, and store biologicals and discard medications after expiration. | SS=D |
| Facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross contamination. | SS=E |
| Facility failed to follow appropriate infection control practices and hand hygiene during meal service. | SS=D |
| Facility failed to maintain required minimum direct care staff to resident ratio as mandated by the State of New Jersey. | — |
| Facility failed to comply with building construction requirements for wood-frame structures exceeding allowed height. | SS=F |
| Facility failed to provide two acceptable exits from each floor or fire section of the building. | SS=F |
| Facility failed to ensure vertical openings between floors were enclosed with 1-hour fire-rated construction. | SS=F |
| Facility failed to ensure fire-rated doors to hazardous areas were labeled in accordance with NFPA 101. | SS=E |
| Facility failed to inspect all fire-rated door assemblies for proper operation as required by NFPA 101 and NFPA 80. | SS=F |
Report Facts
Census: 68
Total Capacity: 100
Deficiencies cited: 15
Staffing ratio: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to findings on fire safety, door maintenance, and labeling of fire-rated doors | |
| Administrator in Training | Named in relation to fire safety code survey and building construction findings | |
| Licensed Nursing Home Administrator | Named in relation to staffing and medication order findings | |
| Director of Nursing | Named in relation to infection control, staffing, and medication order findings | |
| Housekeeping Director | Named in relation to environmental cleanliness and housekeeping practices | |
| Registered Nurse | Named in relation to resident equipment cleaning and infection control | |
| Licensed Practical Nurse/Infection Preventionist | Named in relation to infection control and resident equipment cleaning | |
| Recreation Aide | Named in relation to infection control and hand hygiene during meal service | |
| Staffing Coordinator | Named in relation to nurse staffing posting and staffing ratio compliance |
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 0
Jun 14, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Apr 19, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00161489 and NJ00162174.
Findings
The facility failed to obtain physician-ordered medications in a timely manner for two residents, R1 and R8, which posed potential harm. Documentation was lacking regarding medication administration and notifications to medical staff. The facility did not follow proper procedures for medication availability and notification.
Complaint Details
Complaint survey based on complaints NJ00161489 and NJ00162174. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain physician ordered medications in a timely manner for two residents, resulting in potential harm. | SS=D |
Report Facts
Survey Census: 69
Sample Size: 9
Correction Completion Date: Apr 25, 2023
Post-Certification Revisit Date: May 16, 2023
Time delay for medication administration: 15
Time delay for medication administration: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding medication administration procedures and delays |
| LPN3 | Licensed Practical Nurse | Interviewed regarding notification of medication issues for resident R1 |
| Director of Nursing | Director of Nursing (DON) | Reviewed records, confirmed deficiencies, and described expectations for medication administration and notification |
| Medical Director | Medical Director | Provided expectations for medication availability and timely administration |
| Infectious Diseases Physician | Facility Infectious Diseases Physician | Stated R8 should have received medication within six hours of return due to pharmacological properties |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Dec 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ158481.
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 visit.
Complaint Details
Complaint #NJ158481; the facility was found in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Follow-Up
Deficiencies: 4
Jun 16, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities, focusing on staffing ratios, infection control, employee health screenings, and emergency preparedness.
Findings
The facility was found deficient in maintaining minimum direct care staff-to-resident ratios, ensuring timely physical examinations and two-step Mantoux tuberculosis testing for new employees, and properly inviting emergency management officials to evacuation drills. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (4)
| Description |
|---|
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
| Failed to ensure new employees received physical examinations within required time frames. |
| Failed to ensure employees had two-step Mantoux tuberculosis skin testing completed upon hire. |
| Failed to invite Local, County, and State emergency management officials to emergency drills at least 10 working days in advance. |
Report Facts
Deficient CNA staffing day shifts: 5
Residents on day shifts requiring CNAs: 9
Employee files reviewed: 5
Employees without timely physicals: 2
Employees without two-step Mantoux testing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Did not have physical examination completed upon hire; physical done previously at another facility. | |
| Employee #5 | Did not have physical examination completed upon hire; physical done previously at another facility. | |
| Employee #1 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. | |
| Employee #2 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. | |
| Employee #4 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. |
Inspection Report
Life Safety
Census: 69
Capacity: 100
Deficiencies: 16
Jun 16, 2022
Visit Reason
The facility underwent a Life Safety Code Survey conducted by the New Jersey Department of Health on 6/13/22 and 6/14/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including emergency preparedness plan review, building construction type, means of egress, fire door inspections, egress door locking mechanisms, number of exits, discharge from exits, illumination of means of egress, vertical openings enclosure, hazardous area door closures, fire alarm system testing and maintenance, sprinkler system installation and maintenance, corridor door smoke resistance, elevator inspections, electrical system reliability, and gas cylinder storage.
Severity Breakdown
SS=F: 10
SS=E: 6
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to fully review and sign the Emergency Preparedness Plan annually. | SS=F |
| Annex section building exceeded the 1-story height requirement for wood-frame structures. | SS=F |
| Failed to inspect fire doors annually; no documentation for last 12 months. | SS=F |
| Exit doors in means of egress were obstructed or locked improperly, including hook-type deadbolt and non-functioning delayed egress features. | SS=E |
| Failed to provide two acceptable exits from each floor or fire section; stairways were winding and second exit was through a dining room leading to a fire escape. | SS=F |
| Exit discharge landing was uneven, creating a tripping hazard. | SS=E |
| Corridor lighting could be shut off manually, disabling emergency illumination unless power was lost. | SS=F |
| Vertical openings between floors were not enclosed with 1-hour fire-rated construction. | SS=F |
| Failed to provide self-closing devices on doors to hazardous areas. | SS=E |
| Fire alarm system inspections were not conducted semiannually; smoke detectors over 10 years old; manual pull stations failed to report to panel. | SS=F |
| Fire sprinkler system did not provide coverage to a closet outside the conference room. | SS=E |
| Sprinkler system ceiling penetrations were not properly sealed; missing sprinkler head finish cap and open ceiling around pipes and wiring. | SS=E |
| Corridor doors failed to resist passage of smoke due to improper latching, holes, or obstructions preventing closure. | SS=E |
| Elevator annual inspection was overdue by almost 4 months. | SS=F |
| Failed to certify generator transfer time within 10 seconds and lacked a remote manual stop station. | SS=E |
| Portable oxygen cylinders were not secured properly in storage, posing tipping and damage risks. | SS=E |
Report Facts
Certified beds: 100
Census: 69
Fire doors not inspected: 9
Delayed egress doors with issues: 2
Corridor doors with deficiencies: 4
Elevator devices: 2
Portable oxygen cylinders unsecured: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present during interviews and informed of findings at exit conferences. | |
| Regional Operations Director | Present during interviews and informed of findings at exit conferences. | |
| Maintenance Director | Interviewed regarding deficiencies, responsible for corrective actions and audits. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Nov 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint Intake #NJ143545 and NJ145559, triggered by allegations related to quality of care and staffing ratios at the facility.
Findings
The facility was found not in compliance with quality of care standards due to improper application of briefs for one resident and failure to meet minimum staffing ratios for three of 14 shifts reviewed. The deficient practices had the potential to affect all residents.
Complaint Details
Complaint Intake #NJ143545 and NJ145559. The complaint investigation found substantiated deficiencies related to quality of care and staffing shortages.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to properly apply briefs for one resident, resulting in improper care. | SS=D |
| Facility failed to ensure staffing ratios were met for three of 14 shifts reviewed. | — |
Report Facts
Census: 60
Sample Size: 8
Staffing Deficiencies: 3
Staff to Resident Ratios: 6
Staff to Resident Ratios: 7
Staff to Resident Ratios: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding improper briefing of resident and staff re-education |
| Administrator | Administrator | Interviewed regarding briefing practices and staffing issues |
| CNA #2 | Certified Nurse Aide | Re-educated and suspended for improper use of briefs on resident |
| CNA #3 | Certified Nurse Aide | Observed providing care and interviewed about briefing practices |
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