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
Complaint Investigation
Census: 101
Capacity: 110
Deficiencies: 11
Feb 13, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, based on complaints NJ165086, NJ175960, and NJ179408.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents were served meals in a manner that promotes respect and dignity, failure to report alleged violations timely, failure to develop and implement comprehensive care plans, failure to maintain food palatability, failure to maintain infection control practices, and failure to conduct required inspections and maintenance of fire safety and emergency equipment.
Complaint Details
Complaint investigation for allegations NJ165086, NJ175960, and NJ179408. The complaint was substantiated with findings including failure to serve meals with dignity, failure to report alleged violations timely, and medication administration errors.
Severity Breakdown
Level D: 6
Level E: 4
Level F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure residents were served meals in a manner that promotes respect and dignity. | Level D |
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment timely. | Level D |
| Failure to develop and implement individualized comprehensive care plans for residents. | Level E |
| Failure to maintain acceptable nutritional status and hydration for residents. | Level D |
| Failure to provide pharmaceutical services including accurate medication administration and documentation. | Level E |
| Failure to maintain mandatory physical environment standards including fire safety and emergency preparedness. | Level D |
| Failure to maintain food palatability and proper food storage and handling. | Level F |
| Failure to maintain infection prevention and control practices including hand hygiene and equipment sanitation. | Level E |
| Failure to maintain accurate narcotic count and medication storage security. | Level E |
| Failure to maintain emergency power generator and lighting in accordance with regulations. | Level D |
| Failure to maintain battery powered emergency lighting and conduct required inspections. | Level D |
Report Facts
Census: 101
Total Capacity: 110
Deficiencies cited: 11
Survey Date: 2025-02-07 to 2025-02-13
Plan of Correction Completion Date: Mar 28, 2025
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Sep 17, 2024
Visit Reason
The inspection was conducted based on complaint NJ00176485 to investigate staffing ratio compliance at the facility.
Findings
The facility was found not in substantial compliance with staffing requirements, failing to meet minimum staff-to-resident ratios on 1 of 14 evening shifts and 1 of 14 day shifts during specified periods. No residents were found to be affected by the deficient practice.
Complaint Details
Complaint #: NJ00176485. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 1 of 14 evening shifts and 1 of 14 day shifts. |
Report Facts
Census: 102
Deficient shifts: 1
Deficient shifts: 1
Staffing requirement: 11
Staffing actual: 10
Staffing requirement: 13
Staffing actual: 12
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 8
Feb 9, 2023
Visit Reason
The inspection was a recertification survey to assess compliance with federal and state regulations for long-term care facilities, including life safety code requirements and staffing ratios.
Findings
The facility was found not in substantial compliance with several regulatory requirements including accuracy of assessments, coordination of PASARR and assessments, comprehensive care plans, foot care, menus and nutritional adequacy, staffing ratios, and life safety code compliance. Deficiencies were cited across multiple areas with corrective actions planned and completion dates set for March 21, 2023.
Severity Breakdown
Level D: 5
Level E: 1
Level F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Accuracy of Assessments - The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's status. | Level D |
| Coordination of PASARR and Assessments - The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASRR) was conducted for a resident. | Level D |
| Develop/Implement Comprehensive Care Plan - The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for a resident. | Level D |
| Foot Care - The facility failed to provide care and services to prevent complications for a resident. | Level D |
| Menus Meet Resident Needs/Preparation - The facility failed to follow the planned menu and serve foods in the amount indicated on the diet spreadsheet for 2 meals observed. | Level E |
| Mandatory Access to Care - The facility failed to ensure staffing ratios met minimum requirements for nursing homes. | Level D |
| Maintenance, Inspection & Testing - Doors - The facility failed to inspect all fire-rated doors as required by NFPA 80. | Level F |
| Electrical Systems - Essential Electric System Maintenance and Testing - The facility failed to conduct annual diesel fuel quality analysis test for the emergency generator. | Level F |
Report Facts
Census: 99
Sample Size: 20
Staffing Ratios: 12
Staffing Ratios: 12
Staffing Ratios: 11
Staffing Ratios: 11
Deficiencies cited: 8
Inspection Report
Routine
Census: 101
Deficiencies: 0
Dec 22, 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 and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Aug 26, 2021
Visit Reason
The inspection was conducted based on complaints NJ147082 and NJ146321 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities, focusing on accident hazards, supervision, and devices to prevent accidents.
Findings
The facility failed to ensure the resident environment was free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 was found on the floor after a failed intervention, resulting in hospitalization. The facility's policies and staff actions were inadequate to prevent the incident and ensure resident safety.
Complaint Details
Complaint investigation based on complaints NJ147082 and NJ146321. The complaint was substantiated as the facility failed to prevent accidents and ensure adequate supervision for Resident #1, leading to injury and hospitalization.
Severity Breakdown
SS = G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, resulting in Resident #1's fall and injury. | SS = G |
Report Facts
Census: 86
Sample Size: 11
Completion Date: Oct 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Made aware that Resident #1 had been found on the floor and was involved in the incident |
| Certified Nurse Aide (CNA) #1 | Certified Nurse Aide | Provided care to Resident #1 and was involved in the incident; observed resident in bed and left room without calling for help |
| Aide (HA) #1 | Home Health Aide | Last to provide care to Resident #1 before the fall incident |
| Certified Nurse Aide (CNA) #2 | Certified Nurse Aide | Interviewed and recalled Resident #1 always in bed and not present on day of incident |
| Certified Nurse Aide (CNA) #3 | Certified Nurse Aide | Reported that aides informed her about needing help with resident care |
Inspection Report
Routine
Census: 86
Deficiencies: 0
Aug 17, 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 and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Sample size: 12
Inspection Report
Routine
Census: 78
Deficiencies: 0
Mar 31, 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 and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 1
Feb 11, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in infection prevention and control practices, specifically failing to disinfect reusable blood pressure cuffs between resident uses, which could lead to the spread of infection.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to disinfect reusable blood pressure cuff between each resident use to minimize potential spread of infection. | SS=D |
Report Facts
Sample size: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to disinfect blood pressure cuff between resident uses | |
| Charge Nurse | Interviewed and stated vital signs machine should be wiped down before and after each room |
Inspection Report
Life Safety
Deficiencies: 0
Feb 11, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
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