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 details 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.
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
Annual Inspection
Census: 108
Capacity: 120
Deficiencies: 20
Dec 12, 2023
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 related to food consistency posing aspiration risk, late resident assessment transmissions, failure to develop comprehensive care plans, failure to assess weight changes, failure to provide proper supervision and diet consistency, dialysis medication timing issues, unsigned physician orders, inaccurate resident records, staffing shortages, and multiple life safety code violations including fire door latching, fire alarm testing, sprinkler system maintenance, electrical safety, elevator inspections, and oxygen cylinder storage.
Complaint Details
Complaint numbers NJ00168941, NJ00164363, NJ00165457 were investigated during this survey. Immediate Jeopardy was identified related to food consistency on 12/4/23 and removed on 12/5/23.
Severity Breakdown
Immediate Jeopardy: 1
Level D: 2
Level E: 5
Level F: 9
Level K: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility served pureed mashed potatoes with chunks instead of smooth consistency, risking aspiration and choking. | Immediate Jeopardy |
| Failed to electronically transmit Minimum Data Set (MDS) assessments within 14 days for 5 of 22 residents. | Level D |
| Failed to develop and implement a comprehensive person-centered care plan for a resident. | Level D |
| Failed to assess weight changes for 2 of 3 residents reviewed, not contributing to harm. | Level E |
| Failed to provide adequate supervision and proper diet consistency for residents on pureed diets. | Level K |
| Failed to adjust medication administration times to accommodate dialysis schedules for one resident. | Level E |
| Failed to ensure physicians signed and dated monthly orders for multiple residents. | Level F |
| Failed to accurately document resident disposition after leaving facility on pass. | Level D |
| Failed to ensure 13 of 15 stairwell exit doors latched properly to maintain 1.5 hour fire resistance rating. | Level F |
| Failed to maintain fire barrier with 1-hour fire resistance rating due to missing fire-rated material on steel beams in 4 areas. | Level E |
| Failed to inspect and maintain fire alarm system semi-annually and conduct smoke detector sensitivity testing. | Level F |
| Failed to maintain sprinkler system including missing quarterly inspections, pipe corrosion, and needed repairs. | Level F |
| Failed to ensure electrical equipment near water had ground-fault circuit interrupter (GFCI) outlets. | Level E |
| Failed to ensure annual elevator inspections were current; last inspection over 3 years overdue. | Level F |
| Failed to ensure fire doors were inspected annually by qualified personnel. | Level F |
| Blocked access to electrical panels with water bottles, preventing quick disconnection of power. | Level E |
| Failed to functionally test non-hospital grade electrical receptacles annually for grounding, polarity, and blade tension. | Level F |
| Failed to ensure emergency generator annunciator panel was located in an area with 24-hour surveillance. | Level F |
| Failed to install remote manual stop station for diesel generator and certify generator transfer time within 10 seconds. | Level F |
| Failed to properly store portable oxygen cylinders to prevent tipping, rupture, and damage. | Level F |
Report Facts
Census: 108
Total Capacity: 120
Sample Size: 28
Deficient CNA staffing shifts: 6
Deficient CNA staffing shifts total: 14
Residents with unsigned physician orders: 20
Oxygen cylinders improperly stored: 14
Fire door sets failing latch: 13
Elevators overdue inspection: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Named in multiple fire safety and maintenance deficiencies and corrective actions. |
| Director of Nursing | Director of Nursing | Named in medication timing, physician orders, and documentation deficiencies. |
| Administrator | Facility Administrator | Named in oversight and corrective action discussions. |
| Registered Nurse/MDS Coordinator | RN/MDS Coordinator | Named in MDS transmission deficiency. |
| Certified Nursing Assistant #1 | CNA | Named in diet consistency and supervision deficiencies. |
| Certified Nursing Assistant #2 | CNA | Named in diet consistency and supervision deficiencies. |
| Certified Nursing Assistant #3 | CNA | Named in diet consistency and supervision deficiencies. |
| Director of Dietary | Dietary Director | Named in diet consistency deficiency and corrective actions. |
| Speech Language Pathologist | SLP | Named in diet consistency and aspiration risk findings. |
| Licensed Practical Nurse | LPN | Named in care plan and weight assessment deficiencies. |
| Registered Dietitian | RD | Named in weight assessment deficiencies. |
| Licensed Practical Nurse assigned to Resident #12 | LPN | Named in care plan deficiency. |
| Food Service Worker | FSW | Named in food preparation deficiency. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Nov 6, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ165490 and NJ168677.
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 NJ165490 and NJ168677 were investigated and found to be without deficiencies.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
May 10, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ 162381, NJ 161269, and NJ 157892 to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to immediately investigate and report an injury of unknown origin for one resident, and failure to consistently document Activities of Daily Living (ADL) status and care provided for two residents. Deficiencies involved inadequate reporting of alleged violations and incomplete medical record documentation.
Complaint Details
The complaint investigation involved three complaint numbers (NJ 162381, NJ 161269, NJ 157892). The facility failed to report and investigate an injury of unknown origin for Resident #3 and failed to properly document ADL care for Residents #1 and #2. The deficiencies were substantiated as evidenced by interviews, record reviews, and policy assessments.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately investigate and report an injury of unknown origin for Resident #3 as required by facility policy and state law. | SS=D |
| Failure to consistently document Activities of Daily Living (ADL) status and care provided to residents #1 and #2 according to facility policy and protocol. | SS=D |
Report Facts
Census: 94
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in the deficiency for failure to investigate and report injury of unknown origin for Resident #3. |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to investigate and report injury; involved in corrective action and policy review. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding failure to report injury; involved in corrective action and policy review. |
| LPN #1 | Licensed Practical Nurse | Interviewed about documentation expectations for ADL care. |
| CNA #1 | Certified Nursing Assistant | Interviewed about documentation responsibilities and use of Point of Care system. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Aug 25, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00154021, NJ00154481, NJ00157397, and NJ00157417.
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
The survey was complaint-driven with multiple complaint numbers cited. The facility was found compliant with no deficiencies noted.
Report Facts
Sample Size: 5
Inspection Report
Renewal
Census: 73
Deficiencies: 1
Jul 27, 2021
Visit Reason
The survey was conducted as a re-certification survey to assess compliance with New Jersey staffing requirements and licensure standards for long term care facilities.
Findings
The facility was found not in compliance with the New Jersey minimum direct care staff-to-resident ratios on several dates, particularly on weekend shifts and the 7:00 AM - 3:00 PM shift. The facility had deficient CNA staffing levels below the state-mandated minimum ratios but was actively recruiting and implementing corrective actions to address staffing shortages.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Census: 71
CNA staffing ratio: 8.88
CNA staffing ratio: 6.45
CNA staffing ratio: 8.88
Census: 73
CNA staffing ratio: 8.11
CNA staffing ratio: 6.64
CNA staffing ratio: 9.13
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Jul 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146068 and NJ141741.
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 NJ146068 and NJ141741 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Dec 14, 2020
Visit Reason
The inspection was conducted based on complaints #NJ00133486 and #NJ00134349.
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 #NJ00133486 and #NJ00134349 were investigated and the facility was found compliant.
Report Facts
Sample size: 6
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