Deficiencies per Year
16
12
8
4
0
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 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: 88
Deficiencies: 1
Feb 18, 2025
Visit Reason
The inspection was conducted based on complaints NJ00183397 and NJ00182308 to investigate compliance with staffing requirements and other regulatory standards.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, failing to meet minimum staff-to-resident ratios on 2 of 14 day shifts. No residents were affected, but all had potential to be affected.
Complaint Details
Complaint investigation based on NJ00183397 and NJ00182308. The facility was found substantially compliant with federal requirements but deficient in state staffing ratios. No residents were affected; all had potential to be affected.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 2 of 14 day shifts. |
Report Facts
Census: 88
Deficient CNA staffing days: 2
Required CNAs on deficient days: 12
Actual CNAs on deficient days: 11
Residents on 02/05/25: 93
Residents on 02/06/25: 94
Inspection Report
Census: 84
Deficiencies: 0
Nov 22, 2024
Visit Reason
A project survey was conducted for the renovation of multiple rooms and areas at Fallsview Nursing and Rehabilitation Center.
Findings
The facility was found to be in compliance with N.J.A.C 8:39; however, the facility may not occupy the renovated areas until the New Jersey Certificate of Need and Licensing approval is obtained.
Inspection Report
Recertification
Census: 90
Deficiencies: 6
Oct 2, 2024
Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Findings
The facility was found to have multiple deficiencies including failure to accurately reflect resident status in assessments, failure to develop and implement comprehensive person-centered care plans, failure to administer medications according to physician orders, failure to maintain proper medication storage and labeling, failure to maintain proper staffing ratios, and failure to comply with life safety code requirements.
Complaint Details
Complaint investigation was conducted for complaint numbers NJ175578, NJ170736, NJ166580. The facility was found not in compliance with staffing requirements and other deficiencies related to care and safety.
Severity Breakdown
Level 2: 5
Level 3: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to accurately reflect the resident status in the Minimum Data Set (MDS) for one resident. | Level 2 |
| Facility failed to develop and implement a comprehensive person-centered care plan for one resident. | Level 2 |
| Facility failed to administer medications according to physician orders for one resident. | Level 2 |
| Facility failed to ensure proper medication storage and labeling, including expired medications and improper refrigeration. | Level 2 |
| Facility failed to maintain required minimum direct care staffing ratios as mandated by the state. | Level 3 |
| Facility failed to comply with Life Safety Code requirements including sprinkler system maintenance, corridor doors, elevator maintenance, and fire drills. | Level 2 |
Report Facts
Census: 90
Sample Size: 20
Deficiencies cited: 6
Staffing ratios: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed administering medications incorrectly to Resident #61 |
| Director of Nursing | Director of Nursing | In-serviced nursing staff regarding medication administration and care plans |
| Administrator | Administrator | In-serviced nursing staff regarding oxygen settings, medication administration, fire drills, and other deficiencies |
Inspection Report
Re-Inspection
Census: 90
Capacity: 117
Deficiencies: 14
Jul 28, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Deficiencies were cited for this survey.
Findings
Deficiencies were cited related to Minimum Data Set transmission timeliness, pressure ulcer treatment and hand hygiene, medication pass competencies, pharmacy services, drug regimen review, medication errors, staffing ratios, infection control, building construction, fire alarm and sprinkler system maintenance, smoke barrier doors, and electrical system reliability.
Complaint Details
Complaint # NJ00164623 triggered the survey and was related to medication errors and other deficiencies.
Severity Breakdown
SS=C: 1
SS=D: 3
SS=E: 4
SS=F: 3
SS=H: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to transmit Minimum Data Set (MDS) assessments in a timely manner for Resident #7. | SS=C |
| Facility failed to ensure physician's order was followed and proper hand hygiene during treatment observation for Resident #31. | SS=D |
| Facility failed to ensure Licensed Practical Nurses and one RN had Medication Pass Observation competencies. | SS=D |
| Facility failed to ensure accurate medication receipt, administration, and reconciliation for Residents #390, #78, and #47. | SS=E |
| Facility failed to ensure drug regimen review identified irregularities and that appropriate actions were taken for Residents #390 and #78. | SS=D |
| Facility failed to ensure Resident #31 did not receive unnecessary medication without appropriate indication and clinical rationale. | — |
| Facility failed to maintain required minimum direct care staff to resident ratios for the day shift from 7/02/23 through 7/15/23. | — |
| Facility failed to perform required two-step Mantoux tuberculin skin test for newly hired employees Staff #1 and #7. | — |
| Facility building construction did not comply with NFPA 101:2012 for woodframe structures; Evergreen and Magnolia sections were 2-story woodframe exceeding 1-story height requirement. | SS=F |
| Facility failed to ensure smoke detection sensitivity testing was completed and failed to provide updated fire alarm system inspection report per NFPA 70 & 72. | SS=F |
| Facility failed to provide complete sprinkler coverage for exterior combustible overhangs attached to Type-V (000) construction building. | SS=F |
| Facility failed to provide smoke barrier wall doors that completely closed to resist passage of smoke, flame, or gases during a fire. | SS=E |
| Facility failed to demonstrate reliability regarding fuel supply for natural gas generators as required by NFPA 99 and NFPA 110. | SS=E |
| Facility failed to ensure Resident #390 was free of significant medication errors; resident received more than prescribed dose of medication resulting in adverse effects. | SS=H |
Report Facts
Census: 90
Total Capacity: 117
Medication Errors: 3
Staffing Ratios: 7
Staffing Ratios: 5
Fire Alarm Inspection Interval: 7
Overhang Dimensions: 5
Overhang Dimensions: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and competency deficiency |
| LPN #2 | Licensed Practical Nurse | Named in medication error and competency deficiency |
| LPN #3 | Licensed Practical Nurse | Named in medication error and competency deficiency |
| RN #1 | Registered Nurse | Named in medication error and competency deficiency |
| Director of Nursing | Director of Nursing | Named in relation to oversight of medication errors and staffing |
| Staff #1 | New Hire Employee | Named in missing tuberculosis screening |
| Staff #7 | New Hire Employee | Named in missing tuberculosis screening |
| Staffing Coordinator | Staffing Coordinator | Named in staffing ratio interview |
| Director of Human Resources | Director of Human Resources | Named in employee health file interview |
| Regional Chief Nurse Officer | Regional Chief Nurse Officer | Named in staffing ratio interview |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Named in staffing ratio and employee health file interview |
| Surveyor | State Surveyor | Conducted interviews and observations |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
May 3, 2023
Visit Reason
The inspection was conducted based on a complaint survey to determine compliance with state and federal regulations regarding staffing ratios and resident record documentation.
Findings
The facility was found deficient in maintaining the required minimum direct care staff to resident ratios for the day shift, failing CNA staffing requirements on multiple days. Additionally, the facility failed to consistently document Activities of Daily Living (ADL) care provided to residents in the medical records, with missing documentation for two residents over multiple shifts.
Complaint Details
The complaint survey found substantiated deficiencies related to staffing ratios and medical record documentation for residents.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. | — |
| Failure to consistently document Activities of Daily Living (ADL) care provided to residents according to facility policy and protocol for 2 of 4 residents reviewed. | SS=D |
Report Facts
Census: 86
Deficient CNA staffing days: 5
Required CNA staffing: 10
Actual CNA staffing: 8
Actual CNA staffing: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing and use of agency staff |
| Certified Nursing Assistant #1 | CNA | Interviewed about ADL documentation practices |
| Licensed Practical Nurse #1 | LPN | Interviewed about CNA documentation and supervisory responsibilities |
| Unit Manager Licensed Practical Nurse #2 | UM/LPN | Interviewed about ADL care provision and documentation oversight |
| Director of Nursing | DON | Interviewed about CNA documentation expectations and oversight |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Mar 10, 2022
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Jun 1, 2021
Visit Reason
The inspection was a standard annual survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample size: 18
Inspection Report
Routine
Census: 61
Deficiencies: 0
May 13, 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 and recommended practices for COVID-19.
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: 5
Inspection Report
Routine
Census: 57
Deficiencies: 0
Jan 28, 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: 7
Inspection Report
Routine
Census: 49
Deficiencies: 0
Dec 7, 2020
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 the CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Nov 30, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00140524.
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 # NJ00140524 was investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 4
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