Inspection Report
Annual Inspection
Census: 104
Deficiencies: 12
Dec 13, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to reasonable accommodations, professional standards of care, medication administration, incontinent care, life safety code violations including exit signage, hazardous area enclosures, cooking facilities, sprinkler system maintenance, fire extinguisher placement, HVAC maintenance, essential electrical system maintenance, and electrical equipment testing and maintenance.
Complaint Details
Complaint # NJ175927 was investigated during this survey. Deficiencies were cited related to reasonable accommodations, medication administration, and care provision.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to maintain call bell within reach of residents. | SS=D |
| Facility failed to ensure blood pressure apparatus was used according to manufacturer's specifications and antibiotic treatment was administered as ordered. | SS=D |
| Facility failed to provide care for dependent resident's incontinent needs timely. | SS=D |
| Facility failed to ensure medication administration without error rate less than 5%. | SS=D |
| Exit signage missing 'NO Exit' sign on stairwell door likely to be mistaken for an exit. | SS=E |
| Hazardous areas not properly enclosed with self-closing or automatic-closing doors. | SS=F |
| Failed to perform monthly inspections of kitchen range-hood fire suppression system wet chemical cylinder. | SS=F |
| Sprinkler system heads missing escutcheon plates and ceiling tiles missing or displaced near sprinkler heads. | SS=F |
| Class K portable fire extinguisher lacked instructional placard. | SS=F |
| HVAC exhaust fans in resident bathrooms not operational. | SS=E |
| Essential electrical system lacked remote manual stop station for generator. | SS=F |
| Electrical equipment testing and maintenance program for patient care related electrical equipment was not established or documented. | SS=F |
Report Facts
Census: 104
Sample Size: 24
Medication administration error rate: 7.6
Number of residents affected by call bell deficiency: 2
Number of residents affected by medication administration deficiency: 2
Number of residents affected by incontinent care deficiency: 1
Number of sprinkler heads missing escutcheon plates: 2
Number of bathrooms with non-operational exhaust fans: 3
Inspection Report
Complaint Investigation
Census: 106
Capacity: 118
Deficiencies: 10
Sep 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to failure to electronically transmit Minimum Data Set (MDS) assessments timely, pharmaceutical services documentation errors, food safety violations, staffing shortages, and multiple life safety code violations including fire safety and electrical system maintenance.
Complaint Details
Complaint investigations were conducted for multiple complaint numbers including NJ00164324, NJ00159354, NJ00155340, NJ00160076, NJ00163192, NJ00160703, NJ00164427, and NJ00163988. Staffing shortages were substantiated with documented deficiencies in CNA staffing ratios over multiple weeks. Other complaints related to MDS transmission, medication administration, food safety, and life safety code violations were also substantiated.
Severity Breakdown
SS=D: 3
SS=F: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to electronically transmit Minimum Data Set (MDS) assessments within 14 days for multiple residents. | SS=D |
| Failure to accurately document administration of physician ordered medications in the electronic medication administration record (EMAR) for multiple residents. | SS=D |
| Failure to store potentially hazardous foods properly, sanitize and air-dry kitchen pans, and maintain kitchen equipment in a sanitary manner. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Means of egress obstructed by storage rooms accessed from within stairway enclosures. | SS=F |
| Failure to complete smoke detection sensitivity testing every alternate year as required. | SS=F |
| Sprinkler head missing under HVAC unit larger than 4 feet wide. | SS=F |
| Failure to inspect and test fire doors annually with proper documentation. | SS=F |
| Failure to conduct annual electrical outlet testing. | SS=F |
| Failure to complete three-year load bank test on emergency generator. | SS=F |
Report Facts
Census: 106
Total Capacity: 118
Sample Size: 25
Deficiency Count: 10
Staffing Deficiencies: 7
Staffing Deficiencies: 7
Staffing Deficiencies: 7
Staffing Deficiencies: 12
Staffing Deficiencies: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 2, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as required by state law.
Findings
The facility was found not in compliance with mandatory staffing ratios for 4 of 14 day shifts and 3 of 14 overnight shifts reviewed, with staffing ratios exceeding the minimum required. No negative outcomes were observed. The facility submitted a plan of correction to address staffing deficiencies and improve recruitment and retention.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 4 of 14 day and 3 of 14 overnight shifts checked out of 42 total shifts reviewed. |
Report Facts
Shifts reviewed: 42
Day shifts with staffing deficiencies: 4
Overnight shifts with staffing deficiencies: 3
Staffing ratio: 15.33
Staffing ratio: 11.88
Staffing ratio: 15.83
Staffing ratio: 8.55
Staffing ratio: 13.43
CNA hourly rate: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed staffing ratio concerns with surveyor | |
| Director of Nursing | Discussed staffing ratio concerns with surveyor |
Inspection Report
Life Safety
Capacity: 120
Deficiencies: 4
Dec 2, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/02/2021 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be noncompliant with several life safety code requirements including emergency lighting, sprinkler system installation, HVAC ventilation in resident bathrooms, and generator testing. Specific deficiencies included lack of emergency lighting independent of the building electrical system, incomplete sprinkler coverage in a nursing storage closet, non-functioning bathroom ventilation fans, and failure to certify generator transfer time within 10 seconds.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system and emergency generator. | SS=D |
| Did not provide complete sprinkler coverage in a nursing storage closet approximately 3' x 3' in size near the nurse station and resident room. | SS=D |
| Resident bathroom ventilation systems in multiple units were not functioning, failing to provide adequate ventilation as required. | SS=E |
| Failed to certify that the emergency generator transfers power to the building within the required 10-second time frame during monthly load tests. | SS=D |
Report Facts
Certified beds: 120
Monthly generator load tests missing transfer time data: 12
Size of nursing storage closet without sprinkler coverage: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified deficiencies related to emergency lighting, sprinkler coverage, ventilation, and generator testing. | |
| Administrator | Notified of deficiencies at the Life Safety Code exit conference on 12/02/21. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 28, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number 129497.
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 #129497 was investigated with a sample size of 3, and the facility was found compliant.
Report Facts
Sample Size: 3
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS 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.
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 and privacy policies. |
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