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: 108
Deficiencies: 0
Jun 16, 2025
Visit Reason
The inspection was conducted in response to Complaint #186678 to assess compliance with New Jersey Administrative Code standards for licensure of long-term care facilities.
Findings
The facility was found to be in compliance with the standards in the New Jersey Administrative Code, Chapter 8:39, for licensure of long-term care facilities.
Complaint Details
Complaint #186678 was investigated and the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00185855.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #: NJ00185855. The facility was found to be in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers NJ184184 and NJ184689.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ184184 and NJ184689 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ00178219 and NJ00182485.
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 NJ00178219 and NJ00182485 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Dec 19, 2024
Visit Reason
The inspection was conducted in response to complaints NJ00179135 and NJ00181553.
Findings
The facility was found to be in compliance with the standards in the New Jersey Administrative code, 8:39, standards for licensure of Long Term Care Facilities.
Complaint Details
Complaint numbers NJ00179135 and NJ00181553 were investigated and found to be unsubstantiated as the facility was in compliance with applicable standards.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 113
Deficiencies: 10
Oct 3, 2024
Visit Reason
A Recertification/LSC survey was conducted at Majestic Center for Rehabilitation and Sub-Acute Care from 9/26/24 through 10/3/24 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility was found to be in noncompliance with several regulatory requirements including an Immediate Jeopardy (IJ) situation related to emergency equipment availability and staff training for Resident #313, deficiencies in Medicaid/Medicare coverage notices, abuse/neglect policies, comprehensive care plans, medication administration, nursing staff credential verification, life safety code violations including fire safety and sprinkler system maintenance, and medication dispensing system discrepancies. Corrective actions and re-education plans were implemented with completion dates mostly by 10/20/2024.
Complaint Details
Complaint investigation included multiple NJ complaint numbers: 163766, 165891, 167106, 168173, 168717, 169228, 169862, 169297, 171864, 171947, and 173833. The Immediate Jeopardy was identified during this complaint-related survey.
Severity Breakdown
Immediate Jeopardy: 2
Severity D: 6
Severity E: 1
Severity F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Immediate Jeopardy identified for failure to ensure emergency equipment was available and staff trained for Resident #313. | Immediate Jeopardy |
| Failure to issue required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 residents. | Severity D |
| Failure to develop and implement abuse/neglect policies and procedures including employee rights and retaliation prevention. | Severity D |
| Failure to verify nursing staff licenses and references prior to employment. | Severity D |
| Failure to develop and implement comprehensive care plans for residents. | Severity D |
| Failure to administer medications according to physician's orders and nursing standards. | Severity D |
| Failure to maintain adequate emergency equipment and supplies for Resident #313, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Failure to maintain adequate fire safety including exit doors, sprinkler systems, and fire barrier doors. | Severity F |
| Failure to maintain medication dispensing system accountability and documentation. | Severity D |
| Failure to maintain adequate pharmacy services and medication storage. | Severity E |
Report Facts
Census: 113
Sample size: 24
Deficiency counts: 10
Completion dates: Oct 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Cared for Resident #313 but did not have education for taking care of the resident. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Observed administering medications improperly and was re-educated on medication administration. |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Stated facility was not prepared to take care of a patient and did not receive education regarding care. |
| Employee #3 | Certified Nursing Assistant | Certification was not verified prior to employment. |
| Employee #8 | Certified Nursing Assistant | Certification was not verified prior to employment. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Did not have a reference check on file. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Did not have a reference check on file. |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Did not have a license verification printout in the employee file. |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Did not have a reference check on file. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Did not have an active license verified. |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Sep 4, 2024
Visit Reason
The inspection was conducted in response to complaint NJ 00176554 to investigate compliance with staffing requirements and other regulatory standards.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on 3 of 14-day shifts. No residents were affected by the deficient practice, and a plan of correction was submitted.
Complaint Details
Complaint #: NJ 00176554. The complaint investigation found the facility deficient in staffing ratios but no residents were affected. The facility must submit a plan of correction and ensure implementation to avoid enforcement action.
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 3 of 14-day shifts. |
Report Facts
Census: 110
Deficient shifts: 3
Required CNAs: 14
Actual CNAs on 08/18/24: 13
Actual CNAs on 08/24/24: 13
Actual CNAs on 08/25/24: 12
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 4
Jul 19, 2023
Visit Reason
The visit was conducted due to a complaint regarding malfunctioning air conditioning systems during a heat emergency, with concerns about resident safety and facility compliance with regulations.
Findings
The facility failed to maintain adequate room temperatures during a heat emergency, did not properly monitor or document temperatures, failed to notify the Department of Health timely, and did not adequately protect residents at risk, resulting in an immediate jeopardy situation. Resident #1 was hospitalized due to heat-related illness. The facility also failed to maintain properly stocked emergency code carts and had expired emergency equipment.
Complaint Details
Complaint #165731 regarding malfunctioning air conditioning and heat emergency conditions leading to resident harm and regulatory noncompliance.
Severity Breakdown
Immediate Jeopardy: 2
Level F: 1
Level L: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain adequate room temperatures during a heat emergency, resulting in resident harm and hospitalization. | Immediate Jeopardy |
| Failure to identify and monitor high-risk residents during the heat emergency and failure to provide adequate cooling measures. | Immediate Jeopardy |
| Failure to store medications and biologicals at proper temperatures; medication room temperature was excessively high and medications were discarded. | Level F |
| Failure to administer the facility in a manner that ensures effective emergency heat plan implementation and resident safety. | Level L |
Report Facts
Resident census: 114
Temperature readings: 92
Temperature readings: 88
Temperature readings: 86
Temperature readings: 81
Number of fans purchased: 30
Number of portable air conditioners purchased: 10
Number of hydration stations placed: 1
Number of residents at risk: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged air conditioning issues and lack of Licensed Nursing Home Administrator (LNHA) on site | |
| Regional Licensed Nursing Home Administrator | Provided updates on corrective actions and HVAC repairs | |
| Director of Nursing | Acknowledged lack of temperature monitoring and delayed reporting to Department of Health | |
| Maintenance Director | Responsible for HVAC maintenance and temperature monitoring; acknowledged lack of logs | |
| Licensed Practical Nurse (LPN #3) | Reported no additional monitoring or vital signs required during heat emergency | |
| Nurse Practitioner | Assessed Resident #1 and initiated hospital transfer |
Inspection Report
Routine
Deficiencies: 0
Mar 16, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 3/16/2023 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.
Inspection Report
Life Safety
Capacity: 64
Deficiencies: 8
Mar 9, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 03/08/2023 and 03/09/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to have multiple deficiencies including emergency lighting failures, fire-rated door issues, hazardous area door closures, sprinkler system installation problems, portable fire extinguisher inspection lapses, ventilation system failures in resident bathrooms, missing GFCI protection on electrical outlets near water sources, and lack of a remote emergency stop button for the emergency generator.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency light above emergency generator transfer switch and a functioning battery backup light above the emergency generator. | SS=D |
| One of eleven exit access stairwell doors failed to maintain 1-1/2 hour fire rated construction due to door not latching properly. | SS=D |
| Fire-rated doors to hazardous areas were not self-closing and not separated by smoke resisting partitions. | SS=E |
| Failed to properly install sprinklers including missing sprinkler protection in emergency generator room and elevator hoist-way, and missing escheon caps on multiple sprinklers. | SS=F |
| Failed to perform monthly inspections and maintenance on portable fire extinguishers; some extinguishers were not properly charged or tested. | SS=E |
| Failed to maintain and provide proper ventilation in three of seven resident bathrooms; one bathroom lacked any exhaust system. | SS=D |
| Two of eleven electrical outlets near water sources lacked required GFCI protection. | SS=E |
| Emergency generator lacked a remote manual stop (Emergency Stop) button. | SS=E |
Report Facts
Resident sleeping rooms: 64
Portable fire extinguishers inspected: 25
Electrical outlets tested: 11
Exit access stairwell doors tested: 11
Resident bathrooms inspected for ventilation: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lead Maintenance Director of Support | Named in multiple findings related to emergency lighting, fire doors, sprinkler system, ventilation, and electrical issues | |
| Maintenance Director | Named in multiple findings related to emergency lighting, fire doors, sprinkler system, ventilation, and electrical issues |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Sep 21, 2022
Visit Reason
The inspection was conducted in response to a complaint identified as NJ157940.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
Complaint NJ157940 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 111
Deficiencies: 0
Aug 17, 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 size: 5
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Sep 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144796, NJ145043, NJ145408, NJ145791, and NJ146803 to determine 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 meet minimum staffing ratios for 15 of 42 shifts reviewed, potentially affecting all residents. The Director of Nursing stated staffing was based on resident acuity and that the facility met staffing ratios, despite documented deficiencies.
Complaint Details
Complaint Intake NJ144796 and others; substantiation status not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 15 of 42 shifts reviewed, violating minimum staffing requirements effective 02/01/2021. |
Report Facts
Census: 103
Staffing ratios: 9
Staffing ratios: 12
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 9
Staffing ratios: 11
Staffing ratios: 9
Staffing ratios: 10
Staffing ratios: 9
Staffing ratios: 6
Staffing ratios: 11
Staffing ratios: 10
Staffing ratios: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated staffing was based on resident acuity and that the facility met staffing ratios |
Inspection Report
Routine
Census: 112
Deficiencies: 0
Aug 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 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
Routine
Census: 104
Deficiencies: 0
Feb 12, 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.
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
Annual Inspection
Census: 95
Deficiencies: 2
Dec 23, 2020
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Additionally, a COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations.
Findings
Deficiencies were cited related to failure to complete required Minimum Data Set (MDS) discharge assessments for 5 of 6 residents reviewed, and failure to ensure proper positioning and accurate administration of enteral feeding for one resident, which posed risks for complications.
Severity Breakdown
SS=B: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to complete the required Minimum Data Assessment (MDS) upon a resident's discharge for 5 of 6 residents reviewed. | SS=B |
| Facility failed to ensure proper positioning of a resident while receiving enteral feeding and failed to ensure accurate administration of the feeding according to Physician's Orders for 1 resident. | SS=D |
Report Facts
Sample size: 38
Residents with omitted discharge MDS: 5
Residents reviewed for MDS discharge assessment: 6
Date of survey: Dec 23, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding missing discharge MDS assessments and corrective actions | |
| Corporate Nurse | Interviewed regarding expectations for MDS Coordinator | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Observed resident positioning and confirmed proper head of bed elevation during enteral feeding | |
| LPN #1 | Licensed Practical Nurse | Provided care to Resident #60 and interviewed about resident positioning and feeding |
| LPN #2 | Licensed Practical Nurse | Acknowledged medication administration records and feeding orders |
| Certified Nursing Aide (CNA) | Provided care to Resident #60 and observed resident positioning | |
| Registered Dietician (RD) | Interviewed regarding feeding orders and resident tolerance | |
| Director of Nursing (DON) | Interviewed regarding resident care and feeding deficiencies |
Inspection Report
Life Safety
Deficiencies: 2
Dec 23, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically focusing on the inspection and testing of gas and vacuum piped systems and the proper storage of gas cylinders.
Findings
The facility was found not in substantial compliance with the Life Safety Code due to failure to annually inspect and test the piped-in medical gas system since April 30, 2018, and failure to properly secure compressed gas cylinders to prevent tipping and rupture.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to annually inspect and test the piped-in medical gas system as required by NFPA 99. | SS=F |
| Failure to store cylinders of compressed gas in a manner that protects against tipping and rupture. | SS=D |
Report Facts
Months since last inspection: 31
Number of portable tanks improperly stored: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Administrator | Present during inspection and interview regarding gas system inspection and storage. | |
| Facility Administrator | Present during inspection and interview regarding gas system inspection and storage. | |
| Maintenance Director | Maintenance Director | Interviewed about the piped-in medical gas system inspection and responsible for maintaining inspections. |
| Corporate Regional Manager | CRM | Observed improper storage of compressed gas tanks and stated tanks should be secured. |
| Director of Maintenance | Director of Maintenance | Observed improper storage of compressed gas tanks. |
Loading inspection reports...
