Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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: 185
Capacity: 185
Deficiencies: 2
Jan 26, 2024
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH) to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. However, a deficiency was cited for failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law.
Deficiencies (2)
| Description |
|---|
| Facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey, specifically deficient in CNA staffing on 1 of 14 day shifts reviewed. |
| Facility failed to ensure supplemental oxygen was prohibited from entering and using beauty shop hair dryers in accordance with NFPA 99, potentially affecting 15 residents using oxygen. |
Report Facts
Survey Census: 185
Sample Size: 46
Deficient CNA staffing count: 1
CNA staffing numbers: 22
Required CNA staffing: 23
Facility capacity: 185
Residents potentially affected by oxygen deficiency: 15
Inspection Report
Original Licensing
Capacity: 120
Deficiencies: 2
Nov 10, 2022
Visit Reason
The inspection was conducted as an initial survey and new construction project involving a 10 add-a-bed plus a six bed transfer to total 16 additional beds; new subacute unit and rehabilitation facility.
Findings
The facility was found to be in substantial compliance with long term care facility requirements for the project survey, but was not in compliance with New Jersey Administrative Code standards for licensure and Life Safety Code requirements. Deficiencies included missing evacuation diagrams on resident care units and missing Class K fire extinguishers in kitchens, as well as failure to perform semi-annual inspections of kitchen fire suppression systems.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure evacuation diagrams including evacuation procedures and locations of fire exits, alarm boxes, and fire extinguishers were posted conspicuously on all resident care units on the first and second floors of the newly constructed building. | — |
| Failure to inspect one of two kitchen range-hood fire suppression systems semi-annually and failure to ensure both kitchens were equipped with Class K fire extinguishers as required. | SS=E |
Report Facts
Total licensed capacity: 120
Additional beds: 16
Deficiency correction completion date: Nov 22, 2022
Deficiency correction completion date: Nov 17, 2022
Inspection Report
Abbreviated Survey
Census: 168
Deficiencies: 0
Jun 1, 2022
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 residents: 5
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 0
Oct 26, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ136979 and NJ141669.
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 NJ136979 and NJ141669 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Census: 165
Deficiencies: 5
Aug 5, 2021
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 nursing program according to resident preference, failure to meet professional standards in care plans, failure to follow incident/accident report interventions, and failure to maintain kitchen sanitation to prevent food borne illness. A Life Safety Code deficiency was also cited for emergency lighting.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident received a nursing program in accordance with his/her preference. | SS=D |
| Services provided or arranged by the facility did not meet professional standards of quality. | SS=D |
| Facility failed to follow Incident/Accident Report Final Disposition Interventions for alert with regards to incidents for 1 of 4 residents. | SS=D |
| Facility failed to maintain kitchen sanitation in a manner to prevent the spread of food borne illness. | SS=D |
| Facility failed to provide a battery backup emergency light above the generator transfer switch to provide automatic illumination in the event of electrical power interruption. | SS=D |
Report Facts
Census: 165
Sample Size: 33
Deficiency Completion Date: Dates of completion for deficiencies range from 08/27/2021 to 09/15/2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in discussion of nursing program deficiency and plan of correction | |
| Licensed Practical Nurse (LPN) | Manages the Restorative Nursing Program and interviewed during survey | |
| Registered Nurse/Unit Manager (RN/UM) | Provided information about Resident #267 during incident/accident report deficiency | |
| Food Service Director (FSD) | Involved in kitchen sanitation deficiency and plan of correction | |
| Director of Maintenance (DOM) | Involved in emergency lighting deficiency and plan of correction |
Inspection Report
Routine
Census: 137
Deficiencies: 0
Dec 15, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Nov 27, 2020
Visit Reason
The inspection visit was conducted based on complaints received regarding the facility.
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 complaints visit.
Complaint Details
The visit was complaint-related and the facility was found to be in compliance.
Inspection Report
Abbreviated Survey
Census: 144
Deficiencies: 4
Nov 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to concerns about infection control practices related to COVID-19, including improper use of PPE, hand hygiene, handling of soiled isolation gowns, and social distancing.
Findings
The facility was found not in compliance with infection control regulations, failing to implement CMS and CDC recommended practices to prevent COVID-19 spread. Immediate Jeopardy was identified due to improper use of isolation gowns and other infection control deficiencies. Multiple staff and residents tested positive for COVID-19, and several residents were hospitalized.
Severity Breakdown
Immediate Jeopardy: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure proper use of Personal Protective Equipment (PPE), including isolation gowns. | Immediate Jeopardy |
| Failure to ensure proper handwashing and hand hygiene among staff. | Immediate Jeopardy |
| Improper handling and disposal of soiled isolation gowns by housekeeping staff. | Immediate Jeopardy |
| Failure to ensure social distancing among residents in common areas. | Immediate Jeopardy |
Report Facts
Residents positive for COVID-19: 24
Staff positive for COVID-19: 14
Residents hospitalized related to COVID-19: 4
Sample size: 16
Employees tested for COVID-19: 177
Employees tested for COVID-19: 172
Employees tested for COVID-19: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Observed reusing isolation gown for entire shift and improper infection control practices. | |
| LPN #1 | Observed improper handwashing and PPE use; disciplined and in-serviced. | |
| Housekeeper #1 | Observed improper handling of soiled isolation gowns and lack of hand hygiene; disciplined and in-serviced. | |
| Housekeeper #2 | Failed competency check on PPE donning and doffing; employment terminated. | |
| CNA #3 | Observed supervising residents improperly on social distancing; disciplined and in-serviced. | |
| CNA #4 | Observed improper handwashing; disciplined and in-serviced. | |
| CNA #5 | Observed improper handwashing; disciplined and in-serviced. | |
| CNA #6 | Observed improper handwashing; disciplined and in-serviced. | |
| Director of Nursing | DON | Provided immediate removal plan and oversaw infection control corrective actions. |
| Administrator | Notified of Immediate Jeopardy and involved in corrective action plans. | |
| Housekeeping Director | HD | Oversaw housekeeping staff training and corrective actions related to infection control. |
| Assistant Director of Nursing | ADON | Reinserviced staff on hand hygiene and infection control practices. |
Loading inspection reports...
