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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health 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
Complaint Investigation
Census: 220
Deficiencies: 0
Jan 16, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation based on Complaint #: NJ00181778.
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 #: NJ00181778; the facility was found in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 236
Deficiencies: 2
Feb 5, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00170177 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to document notification to the resident's Responsible Representative regarding medication changes for one resident and failed to consistently document Activities of Daily Living (ADL) care for two residents according to facility policy and protocol.
Complaint Details
Complaint #NJ00170177 was substantiated with findings that the facility was not in substantial compliance with regulations related to resident records and documentation.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document notification to the Responsible Representative of medication changes for Resident #2. | SS=D |
| Failure to consistently document Activities of Daily Living (ADL) care provided or refused for Residents #2 and #3. | SS=D |
Report Facts
Sample Size: 3
Deficiency Correction Completion Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant | Documented progress notes for Resident #2 | |
| Licensed Practical Nursing/Unit Manager (LPN/UM) | Provided statements regarding documentation and notification practices | |
| Certified Nursing Assistant (CNA) | Provided statements about ADL documentation practices | |
| Director of Nursing (DON) | Interviewed regarding documentation expectations and notification procedures |
Inspection Report
Complaint Investigation
Census: 223
Deficiencies: 13
Dec 20, 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 failure to notify resident representatives of changes in condition, failure to maintain a safe, clean, comfortable environment, inaccurate assessments, medication administration errors, failure to follow pain management protocols, pharmacy service deficiencies, improper medication storage and labeling, food safety violations, infection control lapses, failure to meet staffing ratios, and failure to provide required resident activities.
Complaint Details
Complaint numbers NJ00158413, NJ00159043, NJ00159091, NJ00157069, NJ00156915, NJ00155925, NJ00156539, NJ00159631 triggered the complaint investigation and recertification survey.
Severity Breakdown
SS=D: 7
SS=E: 4
SS=F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to notify resident representative of change in condition for 1 of 35 residents. | SS=D |
| Failure to maintain a safe, clean, comfortable and homelike environment including timely laundering of clothing and repair of damaged walls. | SS=D |
| Failure to accurately complete Minimum Data Set (MDS) assessments for 4 of 29 residents. | SS=D |
| Failure to consistently follow professional standards for medication administration and monthly medication summaries for 1 of 5 residents and 1 of 3 nurses observed. | SS=D |
| Failure to ensure physician orders for respiratory care including tracheostomy care and suctioning for 1 resident. | SS=D |
| Failure to ensure pain management regimen was followed in accordance with physician orders for 2 of 3 residents reviewed. | SS=D |
| Failure to ensure accountability of narcotic shift count logs and medication administration in accordance with medication cautionary statements for 2 of 6 residents and 2 of 3 nurses observed. | SS=F |
| Failure to properly store medications and label opened multidose medications in 4 medication carts and 1 medication storage room. | SS=E |
| Failure to serve hot foods at acceptable temperatures during lunch meal service. | SS=E |
| Failure to properly handle and store potentially hazardous foods, maintain equipment and kitchen areas to prevent microbial growth and cross contamination, and maintain infection control practices during food service. | SS=E |
| Failure to establish and maintain an infection prevention and control program including proper hand hygiene and equipment disinfection during medication administration. | SS=E |
| Failure to train designated staff and facility staff within required timeframes for LGBTQI+ and HIV+ program and failure to maintain required minimum direct care staff-to-resident ratios. | — |
| Failure to provide two evening activity programs per week as required. | SS=E |
Report Facts
Resident census: 223
Deficiency counts: 12
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
Food temperature: 85
Food temperature: 127
Food temperature: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration and infection control |
| Food Service Director | Food Service Director | Interviewed regarding food temperature and food safety deficiencies |
| Vice President of Dining Services | Vice President of Dining Services | Interviewed regarding food temperature and emergency food supply deficiencies |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication administration deficiencies |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding multiple deficiencies and training |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing deficiencies |
| Dietary Aide #1 | Dietary Aide | Observed and interviewed regarding food safety deficiencies |
| Dietary Aide #2 | Dietary Aide | Observed and interviewed regarding food safety deficiencies |
| Licensed Practical Nurse/Unit Manager | Licensed Practical Nurse/Unit Manager | Interviewed regarding medication administration and infection control deficiencies |
| Infection Preventionist Registered Nurse | Infection Preventionist Registered Nurse | Interviewed regarding infection control deficiencies |
| Acting Director of Activities | Acting Director of Activities | Interviewed regarding resident activities deficiencies |
Inspection Report
Life Safety
Census: 223
Capacity: 240
Deficiencies: 9
Dec 15, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/15/2023 and 12/18/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with several Life Safety Code requirements including illumination of means of egress, sprinkler system installation, portable fire extinguisher maintenance, corridor door smoke resistance, smoke barrier door functionality, HVAC ventilation in bathrooms, laundry chute door latching, electrical outlet GFCI protection, and emergency generator testing and documentation.
Severity Breakdown
SS=D: 5
SS=E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure continuous illumination for 1 of 4 designated exit discharge doors. | SS=D |
| Failed to properly install sprinklers in multiple locations due to missing ceiling tiles. | SS=D |
| Failed to perform monthly visual inspection for 7 of 31 portable fire extinguishers and 4 of 31 extinguishers were installed at incorrect heights. | SS=E |
| Failed to ensure 4 of 36 corridor doors resisted passage of smoke due to missing door knobs, excessive gaps, or improper latching. | SS=D |
| Failed to maintain smoke barrier doors to resist transfer of smoke when completely closed for 2 of 10 sets of corridor smoke barrier doors. | SS=E |
| Failed to maintain proper ventilation in 4 of 9 resident bathrooms and 1 of 2 staff bathrooms lacked exhaust ventilation. | SS=E |
| Failed to ensure 4 of 4 laundry chute access doors closed and positively latched to maintain one-hour fire protection rating. | SS=E |
| Failed to ensure 1 of 12 electrical outlets within 6 feet of a water source had required GFCI protection. | SS=D |
| Failed to exercise emergency generator under load every 20-40 days for 30 minutes and document transfer time within 10 seconds. | SS=D |
Report Facts
Certified beds: 240
Census: 223
Portable fire extinguishers inspected: 31
Corridor doors inspected: 36
Smoke barrier doors tested: 10
Resident bathrooms inspected: 9
Staff bathrooms inspected: 2
Laundry chute doors tested: 4
Electrical outlets tested: 12
Generator monthly load tests documented: 8
Generator transfer time: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Provided facility layout, confirmed findings, and participated in inspections | |
| Regional Plant Operations Director | Participated in inspections and confirmed findings |
Inspection Report
Abbreviated Survey
Census: 222
Deficiencies: 0
Sep 29, 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: 6
Inspection Report
Complaint Investigation
Census: 230
Deficiencies: 2
Aug 1, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ165964 to investigate allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of abuse involving Resident #2 to the New Jersey Department of Health and to properly investigate the incident. The facility also failed to implement its Incident and Accident Report and Investigation policy. The deficient practice involved 3 of 4 residents reviewed.
Complaint Details
Complaint #NJ165964 was substantiated as the facility failed to report and investigate an alleged abuse incident involving Resident #2. The incident involved inappropriate touching and loud, sexually inappropriate comments by Resident #3. The Director of Nursing and Administrator acknowledged the failure to report to NJDOH. The facility policy was reviewed and found not properly implemented.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse involving Resident #2 to the NJDOH and failure to investigate the incident thoroughly. | SS=D |
| Failure to implement the Incident and Accident Report and Investigation policy. | SS=D |
Report Facts
Census: 230
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 1
Jun 16, 2022
Visit Reason
The inspection was conducted based on multiple complaints (NJ 153072, 154593, 155483, 155484) regarding the facility's compliance with regulations for long term care facilities.
Findings
The facility failed to maintain a clean, sanitary, and homelike environment in good repair, particularly on the 4th and 5th floors, elevators, and a Day Room. Observations included dust buildup, loose chair rails with exposed nails, jagged door edges, and dirty elevator walls and floors. Residents reported dissatisfaction with cleanliness despite housekeeping efforts.
Complaint Details
Complaint numbers NJ 153072, 154593, 155483, 155484. The facility was found not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment including dust buildup, loose chair rails with exposed nails, jagged door edges, and dirty elevator walls and floors. | SS=B |
Report Facts
Census: 194
Sample Size: 5
Housekeeper to rooms ratio: 1
Plan of Correction Completion Date: Jul 12, 2022
Post-Certification Revisit Date: Jul 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding room readiness and staffing | |
| Housekeeping Director (HKD) | Interviewed regarding housekeeping staffing and cleaning practices | |
| Housekeeper assigned to 4th floor | Interviewed about cleaning practices in room 414 |
Inspection Report
Annual Inspection
Census: 187
Capacity: 240
Deficiencies: 15
Jan 31, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to advance directives documentation, medication administration, food temperature and safety, infection control practices, staffing ratios, and life safety code violations including emergency lighting, fire alarm system maintenance, sprinkler system issues, corridor door latching, smoke barrier doors, HVAC ventilation, electrical equipment safety, and oxygen cylinder storage.
Severity Breakdown
SS=D: 6
SS=E: 6
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure that an updated advance directive was accurately maintained within a resident's medical record. | SS=D |
| Failed to administer medication in accordance with physician's orders and professional standards. | SS=D |
| Failed to serve hot and cold foods at acceptable temperatures for residents. | SS=D |
| Failed to properly handle and store potentially hazardous foods, maintain equipment and kitchen areas to prevent microbial growth and cross contamination, and maintain adequate infection control practices during food service. | SS=F |
| Failed to ensure infection control practices were implemented including proper use of PPE and hand hygiene. | SS=D |
| Failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 7 of 14-day shifts reviewed. | — |
| Failed to provide automatic emergency illumination that would operate automatically along the means of egress. | SS=D |
| Failed to provide operational battery backup emergency light above the emergency generator's transfer switches. | SS=D |
| Failed to maintain sprinkler system and ceiling tiles in accordance with NFPA standards. | SS=E |
| Failed to ensure corridor doors resist passage of smoke and latch properly. | SS=E |
| Failed to maintain smoke barrier doors to resist transfer of smoke when completely closed. | SS=E |
| Failed to ensure resident bathroom ventilation systems were adequately maintained. | SS=D |
| Used extension cords beyond temporary installation as a substitute for adequate wiring, creating electrical fire and shock hazards. | SS=E |
| Failed to secure oxygen cylinders to prevent tipping, rupture, and damage. | SS=E |
| Failed to maintain power strips and extension cords in accordance with safety standards. | SS=E |
Report Facts
Census: 187
Total Capacity: 240
Deficient CNA staffing shifts: 7
Required CNA staffing: 24
Actual CNA staffing: 19
Number of resident rooms with door latch issues: 8
Number of smoke barrier doors with issues: 2
Number of resident bathrooms with ventilation issues: 3
Number of unsecured oxygen cylinders: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding advance directive discrepancies and medication administration | |
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and infection control practices | |
| Assistant Maintenance Staff Member | Verified emergency lighting, fire alarm, sprinkler system, door latching, ventilation, and electrical equipment deficiencies | |
| Regional Plant Operations Director | Verified emergency lighting, fire alarm, sprinkler system, door latching, ventilation, and electrical equipment deficiencies | |
| Food Service Director | Interviewed and observed regarding food safety, temperature, and infection control deficiencies | |
| Registered Nurse Unit Manager | Interviewed regarding infection control signage and procedures | |
| Licensed Practical Nurse (LPN) | Observed failing to doff gown and gloves properly during infection control survey |
Inspection Report
Life Safety
Census: 187
Capacity: 240
Deficiencies: 9
Jan 24, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be in noncompliance with several life safety code requirements including emergency illumination, emergency lighting, fire alarm system maintenance, sprinkler system maintenance, corridor door latching, smoke barrier door functionality, HVAC ventilation in resident bathrooms, electrical equipment safety, and oxygen cylinder storage.
Severity Breakdown
SS=D: 3
SS=E: 5
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide automatic emergency illumination along means of egress, including no emergency lighting at the lock or beyond the gate to the public way. | SS=D |
| Failed to provide operational battery backup emergency light above emergency generator's transfer switches. | SS=D |
| Fire alarm system was in trouble mode due to a heat detector needing replacement. | SS=F |
| Failed to maintain sprinkler system ceiling as smoke resistant and fire rated; missing and damaged ceiling tiles observed in multiple areas. | SS=E |
| Corridor doors to resident rooms failed to close and latch properly, compromising smoke resistance. | SS=E |
| Smoke barrier doors failed to close properly due to mechanical issues and obstruction by wheelchair. | SS=E |
| Resident bathroom ventilation systems for 3 of 29 units were not functioning. | SS=D |
| Use of extension cords beyond temporary installation as substitute for adequate wiring in resident rooms and kitchen. | SS=E |
| Oxygen cylinders were found unsecured and freestanding, risking tipping and damage. | SS=E |
Report Facts
Certified beds: 240
Census: 187
Deficiencies cited: 9
Resident rooms with door latching issues: 8
Resident bathrooms with ventilation issues: 3
Oxygen cylinders unsecured: 3
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 0
Aug 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ142750 and NJ145609.
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 NJ142750 and NJ145609 were investigated and found to be without deficiencies.
Report Facts
Sample Size: 12
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 1
Jan 20, 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 related to COVID-19.
Findings
The facility failed to ensure staff properly donned and doffed personal protective equipment (PPE) on units housing persons under investigation for COVID-19 and failed to prevent cross contamination of a common area identified as non-contaminated (clean). Multiple staff were observed wearing contaminated gowns in hallways and not following proper PPE protocols, including improper handling of medication carts and resident transfers through clean areas.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff properly donned and doffed PPE on COVID-19 units and prevent cross contamination in clean areas. | SS=E |
Report Facts
Sample size: 8
Completion date: Feb 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Observed wearing contaminated isolation gown in hallways and improper PPE use |
| Licensed Practical Nurse #1 | LPN | Admitted to wearing contaminated isolation gown in hallway |
| Certified Nursing Assistant #2 | CNA | Observed wearing same contaminated gown between rooms without gloves |
| Certified Nursing Assistant #3 | CNA | Observed wearing same contaminated gown between rooms and improper glove use |
| Activity Aide | Activity Aide | Observed wearing contaminated gown in hallway and improper PPE use |
| Director of Nursing | DON | Interviewed regarding PPE policies and confirmed staff should not wear contaminated gowns in hallways |
| Assistant Director of Nursing Infection Preventionist | ADON/IP | Observed and commented on improper PPE use by staff |
| Registered Nurse Unit Manager | RN/UM | Observed staff PPE use and confirmed policies |
| Licensed Practical Nurse #2 | LPN | Interviewed about PPE policies on unit |
| Licensed Practical Nurse #4 | LPN | Interviewed about PPE policies on unit |
| Licensed Practical Nurse Unit Manager #2 | LPN UM | Interviewed about PPE policies on unit |
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