Deficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Notice
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 6
Date: Oct 29, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to notify physician and resident representative about a resident's fall, failure to maintain a safe and homelike environment, inadequate investigation of abuse allegations, improper incontinence care, failure to honor dietary preferences, and failure to ensure safety from accident hazards.
Complaint Details
The complaint investigation involved multiple complaints (#423030, #2622045, #2620240) regarding failure to notify physician and resident representative about a fall, failure to maintain a safe environment, inadequate abuse investigations, improper incontinence care, failure to honor dietary preferences, and failure to investigate a reported fall. Substantiation was found for all complaints with deficiencies identified affecting multiple residents.
Findings
The facility was found deficient in multiple areas including failure to notify appropriate parties of a resident's fall, inadequate investigation of abuse allegations, unsafe and unclean environment conditions, improper incontinence care practices, failure to honor resident dietary preferences, and failure to comprehensively investigate a reported fall. Several residents were affected by these deficiencies, with issues ranging from minimal harm to potential for actual harm.
Deficiencies (6)
Failure to notify the physician and resident representative about a resident's reported fall and failure to initiate fall investigation protocol.
Failure to maintain a safe, clean, comfortable, and homelike environment including broken window blinds, damaged door frames, torn carpet, and loose ceiling tiles.
Failure to conduct a thorough investigation and maintain documentation for allegations of abuse for two residents.
Failure to provide proper incontinence care to a resident, including use of two incontinent briefs without documented resident preference.
Failure to ensure a resident's dietary preferences were honored, including not providing ordered pancakes and inadequate communication about substitutions.
Failure to comprehensively investigate a resident reported fall to ensure resident safety according to facility policy.
Report Facts
Facility Reported Event (FRE) investigations: 1
Resident BIMS score: 6
Resident BIMS score: 15
Resident BIMS score: 8
Resident BIMS score: 15
Resident BIMS score: 15
Investigation lookback period: 72
Occupational Therapy frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed and involved in discussions regarding deficiencies and investigations. | |
| Director of Nursing (DON) | Interviewed and involved in discussions regarding deficiencies and investigations. | |
| Registered Nurse (RN) Supervisor | Interviewed regarding fall and injury reporting protocols. | |
| Licensed Practical Nurse (LPN) | Assigned to Resident #1 on 4/30/25; failed to report fall and initiate investigation. | |
| Certified Occupational Therapist Assistant (COTA) | Reported resident's fall to LPN and confirmed resident's complaint of pain. | |
| Certified Nursing Assistant (CNA) | Assigned to Resident #1 and Resident #5; involved in care and reporting. | |
| Registered Nurse (RN) #1 | Wrote progress note regarding Resident #1's bruise report. | |
| Licensed Practical Nurse (LPN) #2 | Documented scratch mark on Resident #2 and involved in abuse investigation. | |
| Certified Nursing Assistant (CNA) #2 and #3 | Suspended pending investigation for alleged abuse. |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with federal and state regulations regarding resident assessments, care planning, medication administration, dietary services, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including late submission of Minimum Data Set (MDS) assessments, inaccurate MDS coding, failure to initiate baseline care plans for fall risk residents, incomplete care plans for oxygen use, failure to record urinary catheter output, delayed physician progress note documentation, improper medication administration, inconsistent dietary preference implementation, failure to provide evening snacks, and poor kitchen sanitation practices.
Deficiencies (10)
Facility failed to complete and transmit Minimum Data Set (MDS) assessments within required timeframes for 9 residents.
Facility failed to accurately code MDS assessments for 2 residents.
Facility failed to initiate baseline care plans within 48 hours for residents at fall risk.
Facility failed to develop and implement a comprehensive care plan for continuous oxygen use for 1 resident.
Facility failed to record urinary catheter output every shift as ordered and physician failed to accurately document wound assessment for 2 residents.
Facility failed to ensure physician progress notes were written, signed, and dated on the date of service for 3 residents.
Facility failed to follow physician orders for blood pressure medication administration, administering medication when parameters indicated to hold.
Facility failed to consistently implement and follow residents' dietary preferences for 4 residents during meal observations.
Facility failed to provide and document nourishing evening snacks when there was more than a 14-hour span between dinner and breakfast for 6 residents.
Facility failed to maintain proper kitchen sanitation practices including staff wearing inappropriate jewelry, unclean equipment, missing lids on food containers, dusty fans, and dented canned goods.
Report Facts
Residents with late MDS submission: 9
Residents with inaccurate MDS coding: 2
Residents with missing baseline care plans for fall risk: 2
Residents with missing oxygen care plan: 1
Residents with missing urinary catheter output recording: 2
Residents with delayed physician progress notes: 3
Residents with medication administered against hold parameters: 1
Residents with dietary preference issues: 4
Residents without documented evening snacks: 6
Dietary staff wearing earrings: 3
Dented canned goods observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding late MDS submissions and coding errors | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyor regarding multiple deficiencies | |
| Director of Nursing (DON) | Met with surveyor regarding multiple deficiencies | |
| Licensed Practical Nurse (LPN#1) | Acknowledged medication administration errors for Resident #22 | |
| Food Service Director (FSD) | Interviewed regarding dietary preference and snack deficiencies | |
| Regional Food Service Director (RFSD) | Provided facility policies and observed kitchen sanitation issues | |
| Physician (MD) | Interviewed regarding delayed progress notes and wound assessment |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 24, 2025
Visit Reason
The inspection was conducted based on complaint NJ00180085 regarding failure to develop and implement a comprehensive person-centered care plan including continuous oxygen use for Resident #158, and a review of medication administration practices for Resident #22.
Complaint Details
Complaint #NJ00180085 involved failure to develop a care plan for continuous oxygen use for Resident #158 and failure to follow physician orders for blood pressure medication for Resident #22. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to develop and implement a care plan for continuous oxygen use for Resident #158 and failed to follow physician orders for blood pressure medication administration for Resident #22, administering medication despite orders to hold under certain vital sign parameters.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan including continuous oxygen use for Resident #158.
Failed to follow physician orders for administration of blood pressure medication for Resident #22, administering medication when systolic blood pressure was below 120 and heart rate was below 60.
Report Facts
Residents reviewed for care plans: 22
Residents reviewed for blood pressure management: 1
Number of times medication was administered against hold parameters: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Medication Nurse | Acknowledged that Resident #22's Nifedipine was administered multiple times against physician's hold parameters. |
| Director of Nursing | Director of Nursing | Confirmed Resident #158 did not have an oxygen care plan in place. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Provided facility policies and participated in interviews regarding deficiencies. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication administration, pressure ulcer care, medication storage, and food safety practices in the nursing facility.
Findings
The facility was found deficient in accurately completing resident assessments, following physician's orders for medication and device use, providing appropriate pressure ulcer care, removing expired and discontinued medications timely, and maintaining proper kitchen sanitation practices.
Deficiencies (5)
Failure to accurately complete the Minimum Data Set (MDS) for residents, including incorrect language coding and medication administration documentation.
Failure to accurately follow physician's orders, including not obtaining orders for specialized devices and not documenting daily weights as ordered.
Failure to provide effective pressure ulcer prevention and care, including delayed identification and treatment of a progressing pressure ulcer and missing weekly skin assessments and Braden Scale evaluations.
Failure to ensure expired, unidentified, and discontinued medications were removed from medication carts in a timely manner.
Failure to disinfect food thermometer prior to taking food temperatures during lunch service.
Report Facts
Residents reviewed for MDS completion: 18
Residents reviewed for physician's orders: 18
Residents reviewed for pressure ulcers: 5
Medication carts inspected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Performed skin assessment and documented pressure ulcer for Resident #3 |
| RN #2 | Registered Nurse | Assessed pressure ulcer and discussed missing documentation for Resident #3 |
| LPN2 | Licensed Practical Nurse | Administered medication to Resident #48 and interviewed regarding medication parameters |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding deficiencies and facility policies |
| Licensed Nursing Home Administrator | Administrator | Met with surveyors to discuss concerns |
| Certified Nurse's Assistant | CNA | Provided care to Resident #8 and interviewed about device use and skin checks |
| Food Service Director | FSD | Interviewed regarding food thermometer sanitation |
| Chef | Chef | Observed not disinfecting food thermometer prior to use |
Inspection Report
Routine
Census: 9
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with the New Jersey Administrative Code, Chapter 8:43, Standards For Licensure of Residential Health Care Facilities.
Findings
The facility was found to be in substantial compliance with all applicable standards during the inspection.
Report Facts
Sample size: 2
Inspection Report
Routine
Deficiencies: 4
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, food safety and diet management, infection prevention and control, and COVID-19 related protocols at the nursing facility.
Findings
The facility was found deficient in maintaining professional nursing standards by not following a physician's oxygen order for a resident, failing to serve food and drink at safe temperatures, not ensuring a resident on a fluid-restricted diet received appropriate fluid amounts, and lapses in infection prevention and control practices including improper PPE use, hand hygiene, chemical disinfectant use, and social distancing.
Deficiencies (4)
Failure to follow a physician's order for oxygen administration for Resident #8.
Failure to ensure food and drink were served at safe and appetizing temperatures.
Failure to ensure a resident on a fluid-restricted diet received and consumed liquids in the appropriate amount.
Failure to provide and implement an effective infection prevention and control program, including proper PPE use, hand hygiene, chemical disinfectant use, and social distancing.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 15
Fluid restriction: 1000
Fluid restriction per meal: 240
Fluid restriction per shift: 90
Food temperature: 62.1
Food temperature: 96.8
Food temperature: 100
Food temperature: 116.7
Food temperature: 98.9
Food temperature: 48.8
Food temperature: 158.1
Food temperature: 64.7
Tray line temperature: 170.7
Tray line temperature: 134
Table measurement: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Informed surveyor about new admit residents and infection control procedures |
| Licensed Practical Nurse #2 | LPN | Acknowledged fluid restriction order and resident fluid consumption |
| Physical Therapist Assistant | PTA | Observed not wearing eye protection entering isolation room |
| Director of Nursing | DON | Infection Preventionist Nurse, provided policies and instructions on PPE and infection control |
| Food Service Director | FSD | Interviewed regarding food temperature logs and tray preparation |
| Registered Dietitian | RD | Interviewed regarding fluid restriction and food temperature issues |
| Housekeeper | HK | Observed not performing handwashing and improper disinfectant use |
| Registered Nurse/Supervisor | RN/S | Instructed housekeeper on handwashing and provided infection control information |
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