Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
101 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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 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: 101
Deficiencies: 12
Dec 23, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities, including complaint investigations for complaint numbers NJ 168544 and 178887.
Findings
Deficiencies were cited related to medication administration, skin integrity and pressure ulcer prevention, infection control, emergency preparedness, life safety code violations including emergency lighting, fire drills, sprinkler system maintenance, electrical systems, and exit signage. Plans of correction were submitted with completion dates in early 2025.
Complaint Details
Complaint investigations were completed during the survey for complaint numbers NJ 168544 and 178887. The deficiencies cited included failure in medication administration and infection control. Substantiation status is not explicitly stated.
Severity Breakdown
SS=D: 3
SS=F: 8
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure proper administration of Fluticasone (Flonase) nasal spray according to manufacturer's specifications. | SS=D |
| Failure to maintain infection control standards and procedures for pressure ulcer care treatment. | SS=D |
| Failure to provide emergency lighting along means of egress. | SS=F |
| Failure to conduct functional testing and documentation of emergency lighting system. | SS=F |
| Failure to provide exit signage showing direction of travel to nearest exit. | SS=E |
| Failure to ensure hazardous areas were protected by fire barriers and automatic sprinkler systems. | SS=F |
| Failure to conduct 3-year air leakage test for sprinkler system. | SS=F |
| Failure to conduct and document fire drills with varying activation types. | SS=F |
| Failure to inspect, test, and maintain fire doors annually. | SS=F |
| Failure to ensure electrical outlets near water sources were protected by GFCI. | SS=D |
| Failure to provide safety electrical labels or tags on patient care related electrical equipment. | SS=F |
| Failure to maintain and test emergency and standby power generator diesel fuel quality. | SS=F |
Report Facts
Census: 101
Sample Size: 23
Deficiency Completion Dates: Jan 31, 2025
Deficiency Completion Dates: Feb 15, 2025
Date of Revisit: Feb 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reviewed manufacturer’s specifications and started mandatory inservice for nurses on medication administration. |
| Nurse LPN | Licensed Practical Nurse | Administered Fluticasone (Flonase) nasal spray to Resident #11 and completed medication pass observation/competency. |
| Pharmacy Consultant | Pharmacy Consultant | Included administration of nasal sprays in medication pass competency and conducted monthly observations. |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Feb 8, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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: 8
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 6
Sep 29, 2023
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 accident hazards and supervision, bowel/bladder incontinence care, and pharmacy services including controlled substance documentation. Life safety code deficiencies were also identified including exit signage, electrical outlets without GFCI protection, and unsecured oxygen cylinders.
Severity Breakdown
SS=D: 4
SS=F: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a functioning bathroom door alarm for a resident with a history of falls. | SS=D |
| Failed to maintain proper care of urinary catheters to prevent urinary tract infections for 4 residents. | SS=F |
| Failed to accurately document administration of controlled medication for 1 sampled resident. | SS=D |
| Failed to provide one illuminated exit sign to clearly identify the exit access path to reach an exit discharge door. | SS=D |
| Failed to ensure that 2 of 11 electrical outlets near water sources were equipped with GFCI protection. | SS=D |
| Failed to ensure freestanding compressed oxygen cylinders were properly chained or supported. | SS=E |
Report Facts
Census: 84
Sample size: 20
Deficiency count: 6
Staffing deficiency days: 2
Required CNA staffing: 12
Actual CNA staffing: 10
Required CNA staffing: 11
Actual CNA staffing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in findings related to bathroom door alarm and catheter care |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in findings related to bathroom door alarm, catheter care, and controlled substance documentation |
| Certified Nursing Assistant | CNA | Named in findings related to bathroom door alarm and catheter care |
| Registered Nurse | RN | Named in findings related to catheter care and controlled substance documentation |
| Maintenance Foreman | Maintenance Foreman | Named in findings related to exit signage, electrical outlets, and oxygen cylinder securement |
| Administrator | Administrator | Named in findings related to exit signage, electrical outlets, oxygen cylinder securement, and staffing |
| Assistant Director of Maintenance | Assistant Director of Maintenance/Grounds | Named in findings related to exit signage, electrical outlets, and oxygen cylinder securement |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 8
Jun 14, 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 failure to provide written notification of bed hold policy prior to hospital transfer, failure to follow professional standards in medication administration and physician order adherence, failure to post nurse staffing information, improper labeling and storage of medications, and infection prevention and control program deficiencies.
Severity Breakdown
SS=C: 3
SS=D: 3
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide written notification of the facility's bed hold policy prior to transfer to the hospital for 2 residents. | SS=C |
| Failed to follow professional standards of clinical practice concerning administration of medications and following physician's orders for residents. | SS=E |
| Failed to post nurse staffing information in a prominent place accessible to residents and visitors. | SS=C |
| Failed to properly label, store, and dispose of medications in medication carts, including expired eye drops and unlabeled insulin pen. | SS=D |
| Failed to establish and maintain an infection prevention and control program including proper PPE use and isolation procedures. | SS=E |
| Failed to provide proper fire sprinkler coverage in a closet inside the Social Services Director's office. | SS=D |
| Failed to provide a portable class K-type fire extinguisher in one of eight kitchen cooking areas. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios for day and evening shifts as mandated by the State of New Jersey. | — |
Report Facts
Census: 80
Deficient CNA staffing day shifts: 7
Deficient CNA staffing evening shifts: 1
Expired eye drops: 2
Insulin pen opened date: May 26, 2022
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 2
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 related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to ensure appropriate hand hygiene practices among staff and inadequate knowledge of cleaning chemical contact times for disinfection.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to practice appropriate hand hygiene for 3 of 10 staff observed. | SS=E |
| Failure to ensure workers are knowledgeable of the cleaning chemical used in the workplace and their kill times for disinfection for 3 of 3 staff. | SS=E |
Report Facts
Staff observed for hand hygiene: 10
Staff knowledgeable of cleaning chemicals: 3
Handwashing duration observed: 39
Handwashing duration observed: 13
Handwashing duration observed: 24
Disinfectant contact time stated by Housekeeping Director: 1.5
Disinfectant contact time per product specification: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Informed surveyors about COVID-19 status and hand hygiene policy |
| Registered Nurse/Unit Manager | RN/UM | Observed performing handwashing incorrectly |
| Housekeeper #1 | Housekeeper | Observed not performing hand hygiene between glove use and unable to state proper handwashing duration |
| Licensed Practical Nurse | LPN | Observed performing handwashing incorrectly and unaware of proper technique |
| Rehab Director/Physical Therapist | RD/PT | Unable to state disinfectant contact time |
| Housekeeping Director | HD | Stated disinfectant contact time and reviewed product specifications |
| Director of Nursing | DON | Present during surveyor interviews and aware of concerns |
| Licensed Nursing Home Administrator | LNHA | Present during surveyor interviews and aware of concerns |
Inspection Report
Original Licensing
Capacity: 108
Deficiencies: 1
Nov 30, 2020
Visit Reason
Initial inspection for licensure of a new or renovated long term care facility.
Findings
The facility was found to be not in compliance with requirements for long term care facilities due to the absence of locked narcotic boxes permanently affixed inside medication storage refrigerators in all three observed medication storage rooms. The facility was unoccupied at the time of inspection.
Deficiencies (1)
| Description |
|---|
| Facility failed to have locked narcotic boxes available and permanently affixed in the 3 of 3 medication storage refrigerators. |
Report Facts
Total beds: 108
Resident rooms: 84
Units reviewed: 6
Medication storage refrigerators without narcotic boxes: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Present during observation of medication storage refrigerators and confirmed narcotic boxes had not been installed. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed and confirmed narcotic boxes had not been installed. |
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