Deficiencies per Year
16
12
8
4
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 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: 50
Deficiencies: 0
Dec 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ180268.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and in compliance with New Jersey Administrative Code standards for licensure of long term care facilities.
Complaint Details
Complaint NJ180268 was investigated and the facility was found to be in substantial compliance with regulatory requirements.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 50
Capacity: 64
Deficiencies: 15
Sep 6, 2024
Visit Reason
Complaint investigation survey conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, based on complaints NJ 168306, 173740, 176087.
Findings
The facility was found not in substantial compliance with requirements, citing deficiencies related to resident dignity and rights, food safety and sanitation, staffing ratios, fire safety including fire drills, fire barriers, hazardous area protections, fire alarm system installation and maintenance, portable fire extinguisher inspections, electrical system maintenance, and patient care related electrical equipment testing.
Complaint Details
Complaint investigation based on complaints NJ 168306, 173740, 176087. Facility found not in substantial compliance with 42 CFR Part 483, Subpart B.
Severity Breakdown
SS=F: 13
SS=D: 1
SS=C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to treat residents with respect and dignity by not providing privacy bags for urinary catheter drainage bags for 2 residents. | SS=D |
| Failed to properly label, date, and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross contamination. | SS=F |
| Failed to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. | SS=F |
| Failed to conduct required fire drills on weekends annually. | SS=F |
| Failed to ensure fire barrier walls had proper 2-hour fire resistance rating and fire barrier doors had identification plates. | SS=F |
| Failed to ensure hazardous areas were protected with self-closing doors. | SS=F |
| Failed to ensure kitchen range-hood fire suppression system was inspected semi-annually and required instructional signage was present on Class K fire extinguisher. | SS=F |
| Failed to install supervised smoke/heat detection in the Long-Term Care main entrance foyer enclosure. | SS=F |
| Failed to ensure semi-annual fire alarm system inspections, testing, maintenance, and sensitivity testing of smoke detectors were conducted. | SS=F |
| Failed to inspect portable fire extinguishers in 30 day intervals. | SS=C |
| Failed to ensure penetrations through smoke/fire barriers were protected by materials restricting smoke transfer and maintaining fire rating. | SS=F |
| Failed to ensure smoke barrier doors closed to their frame to resist passage of smoke when released from hold-open devices. | SS=F |
| Failed to ensure annual inspection of fire doors by qualified individuals. | SS=F |
| Failed to exercise emergency generator under full load 12 times per year on 20 to 40 day intervals, conduct continuous load test every 36 months, conduct annual load bank test, and ensure generator assumed building load within 10 seconds. | SS=F |
| Failed to establish policies and protocols for inspection, testing, and maintenance intervals for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Census: 50
Total Capacity: 64
Staffing Deficiency: 2
Fire Drills: 0
Food Safety Inspection Date: Dec 12, 2023
Fire Extinguisher Inspection Interval: 47
Generator Load Test Interval: 51
Generator Load Test Failures: 4
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 11
Jun 21, 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 care plan revisions, medication administration and documentation, pharmacy services, food safety, staffing ratios, and life safety code compliance including fire safety and electrical systems.
Severity Breakdown
SS=D: 9
SS=E: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to revise a resident's comprehensive care plan to include the location of a elopement alarm. | SS=D |
| Failed to check a resident's wander guard for function and placement as ordered. | SS=D |
| Failed to maintain accurate accountability and reconciliation for controlled medications and maintain integrity of emergency medication boxes. | SS=D |
| Failed to properly store and dispose of controlled medications; medication dropped on inventory record was returned to pill bottle. | SS=D |
| Failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, including unlabeled food items and improper food labeling dates. | SS=F |
| Failed to maintain required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey. | — |
| Fire-rated doors to hazardous areas were not properly separated by smoke resisting partitions; commercial laundry door did not close fully. | SS=D |
| Failed to properly install sprinklers; missing sprinkler escheon caps and missing ceiling tiles in electrical room. | SS=D |
| Portable fire extinguishers were not installed within required height for 7 of 14 extinguishers observed. | SS=D |
| Failed to ensure 2 of 7 electrical outlets next to water sources were equipped with Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Failed to exercise emergency generator 12 times per year for at least 30 minutes and document transfer time within 10 seconds; lacked remote manual stop station for emergency generator. | SS=E |
Report Facts
Census: 53
Staffing ratios: 5
Staffing ratios: 5
Fire extinguisher height: 5.33
Fire extinguisher height: 6.21
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Jun 20, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Census: 46
Sample size: 5
Sample size: 5
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 5
Apr 14, 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 failure to issue proper Skilled Nursing Facility Advance Beneficiary Notices, failure to initiate care plans for residents on certain medications, improper medication administration including crushing and opening medications without physician orders, failure to document oxygen administration and care plans, and inaccurate narcotic medication ordering and receiving documentation.
Severity Breakdown
SS=C: 1
SS=E: 1
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to issue proper Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 3 residents discharged from Medicare Part A with benefit days remaining. | SS=C |
| Failed to initiate a comprehensive care plan for residents receiving certain medications (e.g., anticoagulants) for 5 of 17 residents reviewed. | SS=E |
| Nurse failed to properly administer correct dose of medication and obtain physician order to crush and open medication for one resident. | SS=D |
| Failed to obtain physician order for oxygen administration, document oxygen administration and care plan for one resident. | SS=D |
| Failed to ensure accurate ordering and receiving of narcotic medications; DEA 222 forms lacked required details for 6 of 7 forms reviewed. | SS=D |
Report Facts
Residents reviewed for care plan deficiency: 17
Residents reviewed for SNFABN deficiency: 3
DEA 222 forms with deficiencies: 6
Medication cups observed: 2
Inspection Report
Life Safety
Deficiencies: 3
Apr 12, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically focusing on emergency preparedness, cooking facilities, and HVAC systems.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements. Deficiencies included improperly positioned exhaust hood grease baffles in the kitchen and inadequate maintenance of the resident bathroom ventilation system and PTAC unit filters.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Two of 24 exhaust hood grease baffles over the main cooking area had gaps, failing to protect against grease and fire entering the exhaust hood system as per NFPA 96. | SS=D |
| Resident bathroom ventilation system for 32 of 37 units was not adequately maintained, with broken belts and non-functioning exhaust vents. | SS=D |
| Five PTAC units had clogged and dirty filters, compromising air conditioning function. | SS=D |
Report Facts
Exhaust hood grease baffles: 2
Resident bathroom ventilation units: 32
PTAC units with clogged filters: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Facility Administrator | Present during observations and interviews related to deficiencies | |
| Dietary Director | Present during observations and interviews related to kitchen exhaust hood deficiency |
Inspection Report
Routine
Census: 47
Deficiencies: 0
Mar 10, 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: 8
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