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 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.
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
Routine
Census: 114
Deficiencies: 0
Dec 9, 2024
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: 3
Inspection Report
Annual Inspection
Census: 114
Capacity: 137
Deficiencies: 13
Aug 21, 2024
Visit Reason
A Recertification/LSC survey was conducted from 8/5/24 through 8/21/24 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies including failure to prevent abuse, failure to notify family of changes, failure to maintain accurate medication and controlled substance records, failure to provide adequate staffing, failure to ensure proper infection control, and life safety code violations. Immediate Jeopardy situations related to abuse allegations were identified and removed after corrective actions. The facility was found not in compliance with several federal and state regulations.
Severity Breakdown
Immediate Jeopardy: 1
Severity Level E: 4
Severity Level D: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to prevent abuse and neglect of residents, including allowing accused staff to continue working without thorough investigation. | Immediate Jeopardy |
| Failure to notify resident's family after a significant change in condition. | Severity Level D |
| Failure to ensure privacy for residents with urinary catheters by not using privacy bags. | Severity Level D |
| Failure to maintain accurate narcotic count logs with missing nurse signatures. | Severity Level D |
| Failure to provide nourishing bedtime snacks to all residents when there is more than 14 hours between dinner and breakfast. | Severity Level E |
| Failure to properly store and label respiratory equipment and include care plans for respiratory needs. | Severity Level D |
| Failure to perform hand hygiene when exiting rooms under enhanced barrier precautions, risking infection spread. | Severity Level D |
| Failure to maintain required minimum direct care staff-to-resident ratios on 2 of 42 shifts reviewed. | Severity Level D |
| Failure to provide emergency illumination that operates automatically along means of egress in two dining/activity rooms. | Severity Level E |
| Failure to provide required instructional signage above Class K portable fire extinguisher in kitchen. | Severity Level D |
| Resident room corridor doors stuck in frames, preventing proper closing and smoke resistance. | Severity Level D |
| Electrical panels in resident accessible areas were unlocked and not guarded against accidental contact. | Severity Level E |
| Failure to certify generator transfer time within 10 seconds and lack of remote manual stop station for generator. | Severity Level E |
Report Facts
Residents present: 114
Licensed capacity: 137
Deficiency counts: 13
Missing narcotic count signatures: 6
Staffing ratio shortfalls: 2
Residents affected by corridor door issues: 30
Residents affected by emergency illumination issues: 40
Open electrical panels: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in abuse allegation and investigation |
| CNA #1 | Certified Nursing Aide | Named in abuse allegation and investigation |
| Employee #4 | Employee file missing criminal background check | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication storage and infection control |
| CNA #2 | Certified Nursing Aide | Interviewed regarding infection control procedures |
| UM/RN #1 | Unit Manager/Registered Nurse | Interviewed regarding clothing protectors |
| UM/RN #2 | Unit Manager/Registered Nurse | Interviewed regarding clothing protectors |
| UM/RN #3 | Unit Manager/Registered Nurse | Interviewed regarding smoking policy and resident care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding smoking policy and resident care |
| Director of Maintenance | Named in corrective actions for multiple facility maintenance issues | |
| Administrator | Named in corrective actions and interviews |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Mar 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ00171710 regarding failure to report an alleged abuse incident within the required timeframe.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to timely report an alleged abuse incident involving Resident #1 to the New Jersey Department of Health and failure to follow the facility's Abuse Policy. The investigation revealed delays in reporting and notification procedures.
Complaint Details
Complaint #: NJ00171710. The complaint involved an allegation that a staff member entered Resident #1's room and committed abuse. The facility failed to report the incident within the required timeframe to the NJDOH and did not follow the facility's Abuse Policy. The resident was interviewed and preventive measures were initiated. The facility nursing administration and staff were educated on reporting requirements. The incident was eventually reported late due to staff vacation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged abuse within the required timeframe to the New Jersey Department of Health and failure to follow the facility's Abuse Policy. | SS=D |
Report Facts
Census: 115
Sample Size: 4
Completion Date: Mar 30, 2024
Inspection Report
Routine
Census: 102
Deficiencies: 0
Dec 7, 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: 5
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 5
Dec 12, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to bedrails, pharmacy services, drug storage, food procurement and sanitation, and COVID-19 staff vaccination compliance. The facility failed to ensure informed consent and proper assessment for bedrails, accurate documentation of controlled medication administration, proper labeling and storage of medications, safe food handling and sanitation, and up-to-date COVID-19 vaccinations for staff.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure informed consent and proper assessment for bedrails prior to installation. | SS=D |
| Failure to accurately document administration of controlled medication for an unsampled resident. | SS=D |
| Failure to maintain refrigerator temperature log and properly label and date medications. | SS=D |
| Failure to handle potentially hazardous foods safely and maintain kitchen equipment to prevent microbial growth. | SS=D |
| Failure to ensure staff were up to date with all COVID-19 vaccinations as eligible and develop facility COVID-19 vaccination policies in accordance with State requirements. | — |
Report Facts
Census: 98
Staff reviewed for COVID-19 vaccination status: 18
Staff not up to date with COVID-19 booster: 9
Medication carts audited monthly: 5
Medication rooms audited monthly: 3
Cutting boards replaced every: 6
Inspection Report
Routine
Census: 90
Deficiencies: 0
Oct 27, 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 was found to be in compliance with 42 CFR 483.80 infection control regulations as it relates to the implementation of CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Jun 5, 2021
Visit Reason
The inspection was conducted based on complaint intake NJ136645 and NJ143632 to investigate the facility's compliance with notification requirements related to changes in resident condition.
Findings
The facility failed to notify the physician and responsible party of a pressure wound for a resident, as required by regulations. Interviews and record reviews confirmed lack of documentation of notification despite the resident's condition changes. The Director of Nursing and staff were reeducated on notification procedures.
Complaint Details
Complaint intake NJ136645 and NJ143632 triggered the survey. The complaint was substantiated based on failure to notify physician and responsible party of resident's pressure wound.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify physician and responsible party of a pressure wound for a resident. | SS=D |
Report Facts
Census: 89
Sample Size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Signed physician's verbal order and involved in treatment documentation |
| Director of Nursing | DON | Interviewed regarding notification failures and reeducation of staff |
| Medical Director | MD | Interviewed about resident orders and notification |
| Nurse Practitioner | NP | Interviewed regarding resident care and wound treatment |
Inspection Report
Routine
Census: 91
Deficiencies: 0
Jan 26, 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 COVID-19 practices.
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
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