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
Complaint Investigation
Census: 282
Deficiencies: 0
Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ158722 and NJ168831.
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 NJ158722 and NJ168831 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 3
Inspection Report
Renewal
Deficiencies: 0
May 31, 2024
Visit Reason
The facility requested to add 6 beds to their license.
Findings
The facility was found to be in compliance with the standards in the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Report Facts
Beds requested to add: 6
Inspection Report
Routine
Census: 263
Deficiencies: 0
Jan 15, 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: 5
Inspection Report
Annual Inspection
Census: 262
Deficiencies: 10
Jun 14, 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 including an Immediate Jeopardy (IJ) situation related to resident elopement, failure to timely transmit Minimum Data Set (MDS) assessments, failure to implement comprehensive care plans, medication administration errors, inadequate supervision of residents, failure to follow respiratory and dialysis care standards, medication regimen review irregularities, food safety violations, and infection control breaches.
Severity Breakdown
SS=D: 8
SS=J: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to timely transmit Minimum Data Set (MDS) assessments for 6 residents. | SS=D |
| Failure to carry out comprehensive care plan interventions for Resident #30. | SS=D |
| Failure to follow physician orders for medication administration and documentation for Resident #503. | SS=D |
| Failure to provide adequate supervision leading to resident elopement (Immediate Jeopardy). | SS=J |
| Failure to follow respiratory care orders for Residents #40 and #236. | SS=D |
| Failure to ensure dialysis medication times were adjusted to resident schedule for Resident #503. | SS=D |
| Failure to identify and notify facility of medication irregularities by Consultant Pharmacist for Residents #30 and #503. | SS=D |
| Failure to maintain proper kitchen sanitation, including improper sanitizer concentration, unlabeled canned goods, unlabeled opened breads, unclean blender, and unlabeled food trays. | SS=D |
| Failure to follow infection prevention and control measures including improper use of PPE by staff caring for resident with active infection. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
Report Facts
Census: 262
MDS residents with late transmission: 6
Staffing deficiency days: 10
Staffing deficiency days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA/CBT #1 | Certified Nursing Aide/Certified Behavioral Technician | Named in resident elopement finding for failure to respond to exit door alarm |
| CNA/CBT #2 | Certified Nursing Aide/Certified Behavioral Technician | Named in resident elopement finding for failure to locate resident |
| LPN #1 | Licensed Practical Nurse | Named in resident elopement finding for failure to conduct rounds |
| Director of Nursing | Director of Nursing | Informed of multiple deficiencies including elopement and medication issues |
| Assistant Director of Nursing | Assistant Director of Nursing/Director of Quality | Informed of multiple deficiencies including elopement and medication issues |
| Consultant Pharmacist | Consultant Pharmacist | Failed to identify medication irregularities for Residents #30 and #503 |
Inspection Report
Life Safety
Deficiencies: 4
Jun 14, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/06/2023 and 06/07/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for Christian Health Care Center.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including missing illuminated exit signs in three locations, lack of audible and visible fire alarm notification in three outside enclosed courtyards, inadequate sprinkler coverage in four areas, and one electrical outlet near a water source lacking GFCI protection. Corrective actions were completed by mid-June 2023.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure illuminated exit signs in three locations to clearly identify exit access paths. | SS=E |
| Failed to provide fire alarm notification by audible and visible signals for 3 outside enclosed courtyards. | SS=E |
| Failed to properly install sprinklers in four areas including resident shower room and exterior building overhangs. | SS=E |
| Failed to ensure one of sixteen electrical outlets near water source was equipped with GFCI protection. | SS=D |
Report Facts
Number of missing illuminated exit signs: 3
Number of outside enclosed courtyards lacking fire alarm notification: 3
Number of areas lacking sprinkler coverage: 4
Number of electrical outlets tested near water source: 16
Inspection Report
Original Licensing
Census: 264
Deficiencies: 0
Jun 8, 2023
Visit Reason
The survey was conducted as a new construction and renovation project involving expansion and renovations to the Southgate Unit and its A, B, and C wings, including new resident rooms and support spaces.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code standards for licensure of long term care facilities. The newly renovated areas may not be occupied until formal notification is received from the Certificate of Need and Licensing Division.
Report Facts
Census: 264
Inspection Report
Life Safety
Census: 264
Deficiencies: 0
Jun 8, 2023
Visit Reason
The survey was conducted as a Life Safety Code Survey related to new construction and renovation projects including expansion and renovations of the Southgate Unit and its wings.
Findings
The facility was found to be in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 for Existing Health Care Occupancies.
Report Facts
Census: 264
Inspection Report
Routine
Census: 246
Deficiencies: 0
Sep 13, 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 249
Deficiencies: 1
Oct 18, 2021
Visit Reason
The inspection was conducted as a standard and complaint survey to assess compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law, evident in 4 out of 42 shifts reviewed. The facility submitted a plan of correction detailing staffing challenges and recruitment efforts.
Complaint Details
The visit was complaint-related as indicated by the survey type 'Standard and Complaint Survey'.
Deficiencies (1)
| Description |
|---|
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law on 4 out of 42 shifts reviewed. |
Report Facts
Census: 249
Sample Size: 39
Staff-to-resident ratios: 30
Staff-to-resident ratios: 29
Staff-to-resident ratios: 27.5
Staff-to-resident ratios: 29
New hires: 2
New hires: 2
New hires: 1
New hires: 1
New hires: 1
Additional staff hired: 14
Additional staff hired: 4
Inspection Report
Complaint Investigation
Census: 264
Deficiencies: 1
Jul 20, 2021
Visit Reason
The inspection was conducted based on complaints NJ145115 and NJ143634 regarding the facility's compliance with regulations related to the use of physical restraints on residents.
Findings
The facility was found not in compliance with requirements to ensure residents are free from physical restraints unless medically necessary. Specifically, Resident #9 was found physically restrained with bed linen tied to side rails without medical orders. The facility took corrective actions including removal of restraints, staff suspension, re-education, and ongoing monitoring.
Complaint Details
Complaint #: NJ145115 and NJ143634. The complaint was substantiated as the facility failed to ensure freedom from physical restraints for Resident #9. The CNA responsible was suspended and re-educated. The facility implemented remedial education for all CNA staff and ongoing monitoring.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were free of physical restraints unless medically necessary, specifically Resident #9 was restrained with bed linen tied to side rails. | SS=D |
Report Facts
Census: 264
Sample size: 14
Suspension duration: 5
Training dates count: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Responsible for restraining Resident #9; suspended and re-educated |
| ADON #1 | Assistant Director of Nurses | Responded to incident, involved in investigation and staff training |
| Director of Nurses | Director of Nurses | Interviewed regarding the incident and staff availability |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported information about the resident's restlessness and incident |
| Physical Therapist | Physical Therapist | Observed restraint and alerted staff |
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