Inspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a pattern of deficiencies primarily related to staffing shortages, medication administration, resident care choices, and life safety code compliance, including fire safety and emergency preparedness. Several complaint investigations substantiated issues with staffing ratios and resident care, including an immediate jeopardy finding in June 2023 that was later resolved. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history suggests some improvement over time, with recent surveys showing no deficiencies after prior citations in multiple areas.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
147 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health 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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 147
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
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: 20
Inspection Report
Renewal
Census: 130
Deficiencies: 17
Date: Nov 19, 2024
Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Complaint Details
Complaint numbers NJ177864 and NJ168254 were investigated during this survey. The complaint investigations were completed and deficiencies were cited accordingly.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' call devices were accessible, failure to provide resident bathing choice, failure to be free from physical restraints, failure to complete required background checks for new hires, medication administration errors, and deficiencies in life safety code compliance such as self-closing doors and fire alarm systems.
Deficiencies (17)
Facility failed to ensure the resident's call device was readily accessible.
Facility failed to ensure residents' bathing choice was provided.
Facility failed to ensure residents were free from physical restraints without physician orders.
Facility failed to complete criminal background checks and reference checks for newly hired staff prior to employment.
Facility failed to ensure medication was administered according to physician's orders.
Facility failed to maintain complete and accessible medical records for residents.
Facility failed to ensure exit doors with self-closing devices were kept in closed position.
Facility failed to ensure exit signs had continuous illumination and were served by emergency lighting system.
Facility failed to maintain sprinkler system and conduct required monthly fire pump tests.
Facility failed to conduct monthly visual inspections of portable fire extinguishers.
Facility failed to conduct fire drills with required frequency and documentation.
Facility failed to maintain smoke detection sensitivity testing on smoke detectors.
Facility failed to maintain ventilation systems in resident bathrooms.
Facility failed to maintain sprinkler system and fire alarm system in accordance with NFPA standards.
Facility failed to maintain electrical equipment testing and maintenance.
Facility failed to maintain corridor doors and fire rated corridor walls to resist passage of smoke.
Facility failed to store compressed oxygen cylinders properly to prevent tipping and rupture.
Report Facts
Census: 130
Sample Size: 25
Deficiencies cited: 19
Completion Date: Dec 9, 2024
Completion Date: Dec 6, 2024
Completion Date: Dec 10, 2024
Completion Date: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident showers and restraint use. |
| Registered Nurse #1 | Registered Nurse | File reviewed for background checks and reference checks. |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | File reviewed for background checks and reference checks. |
| Director of Nursing (DON) | Director of Nursing | Oversaw re-education of nursing staff on policies and procedures. |
| Maintenance Director | Maintenance Director | Conducted inspection of self-closing doors and fire safety equipment. |
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
Date: Jul 12, 2024
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ172636, NJ175486, NJ175522, NJ175524, NJ175526) to assess compliance with federal and state regulations for long-term care facilities.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The facility was found deficient in meeting minimum staffing ratios, which was substantiated by review of staffing reports and documentation.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to maintain minimum direct care staff-to-resident ratios on 14 of 28 day shifts, potentially affecting all residents. The facility submitted a plan of correction addressing staffing shortages and recruitment efforts.
Deficiencies (1)
Failure to ensure minimum direct care staff-to-resident ratios as mandated by New Jersey law on 14 of 28 day shifts.
Report Facts
Census: 135
Deficient day shifts: 14
CNA staffing shortages: 5
CNA staffing shortages: 9
CNAs hired: 6
Staffing correction completion date: Plan of correction completion date August 12, 2024.
Inspection Report
Routine
Capacity: 73
Deficiencies: 10
Date: Jul 17, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/05/2023 through 07/07/2023 to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found noncompliant with several Life Safety Code requirements including egress door accessibility, illumination of means of egress, exit signage, cooking facilities inspection, sprinkler system installation and maintenance, portable fire extinguisher inspection and installation, HVAC ventilation maintenance, electrical system testing, and emergency generator safety features.
Deficiencies (10)
Failed to provide 1 of 10 designated exit discharge doors readily accessible and free of obstructions or impediments to full instant use in case of fire or other emergencies.
Failed to ensure continuous illumination for 2 of 9 designated exit discharges so that failure of any single lighting unit did not result in illumination level less than 0.2 ft-candle.
Failed to ensure illuminated exit signs in six locations to clearly identify the exit access path to reach an exit discharge door.
Failed to inspect the range-hood fire suppression system semi-annually as required by NFPA 96.
Failed to properly install sprinklers and provide fire sprinkler coverage to all areas of the facility as required.
Failed to comply with inspection and testing requirements for sprinkler system; missed quarterly inspections resulting in 12 months gap.
Failed to perform monthly examination for 2 of 28 portable fire extinguishers, inspect 1 of 28 annually, and install 11 of 28 extinguishers within required height.
Failed to ensure proper maintenance of 4 of 9 resident bathroom exhaust ventilation systems.
Failed to ensure annual electrical outlet testing was conducted on the electrical system.
Failed to install a remote manual stop station for the emergency generator as required.
Report Facts
Designated exit discharge doors: 10
Designated exit discharge doors with illumination issues: 2
Exit signs missing illumination: 6
Range-hood fire suppression inspections missed: 1
Resident sleeping rooms: 73
Portable fire extinguishers inspected: 28
Portable fire extinguishers with installation height issues: 11
Resident bathroom exhaust systems tested: 9
Resident bathroom exhaust systems not functioning: 4
Electrical outlet testing missed year: 2022
Emergency generator inspection date: Jul 5, 2023
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 5
Date: Jun 26, 2023
Visit Reason
Complaint survey conducted on 6/15/23, 6/20/23, and 6/26/23 to investigate multiple complaints regarding resident care and facility compliance.
Complaint Details
Complaint numbers NJ160552, NJ164625, NJ164644, NJ164690, NJ164724 triggered the investigation. Immediate jeopardy was identified related to resident care failures and was removed after corrective actions were implemented.
Findings
The facility was found not in substantial compliance with federal requirements due to immediate jeopardy situations related to failure to notify physicians of changes in resident condition, failure to provide adequate care and oversight, neglect, and failure to maintain minimum staffing ratios. Deficiencies included failure to communicate care needs, failure to monitor residents properly, and medication administration issues.
Deficiencies (5)
Failure to notify the primary care physician and related practitioners of significant changes in resident condition, resulting in immediate jeopardy.
Failure to provide care free from abuse and neglect, including leaving a resident unattended during a medical emergency.
Failure to provide services meeting professional standards, including failure to notify appropriate staff and follow policies during resident condition changes.
Failure to label and store drugs and biologicals properly, including leaving medications at the bedside and signing medication records without administration.
Failure to maintain minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Report Facts
Census: 114
Sample Size: 6
Deficient CNA staffing shifts: 5
Required CNA staffing: 14
Actual CNA staffing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to failure to notify physician, leaving resident unattended, and failure to follow job duties |
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications at bedside and signing MAR without administration |
| Director of Nursing | Director of Nursing (DON) | Responsible for monitoring LPN #1 and overseeing quality assurance |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 1
Date: Mar 25, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ153425, NJ153428, NJ151815, and NJ151607) to determine compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities.
Complaint Details
Complaint numbers NJ153425, NJ153428, NJ151815, and NJ151607 were investigated. The facility was found deficient in staffing ratios, which had the potential to affect all residents. The complaint was substantiated based on interviews, document review, and NJDOH memo dated 01/28/2021.
Findings
The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for certified nursing assistants and total staff on multiple shifts during the review periods from January 16-29, 2022 and March 6-19, 2022. Staffing shortages were confirmed through document review and interviews, with the Administrator acknowledging the shortages and efforts to recruit and incentivize staff.
Deficiencies (1)
Failure to ensure staffing ratios were met for 29 out of 56 shifts reviewed, including CNA staffing shortages on 14 of 14 day shifts and total staff shortages on some overnight and evening shifts.
Report Facts
Census: 127
Shifts with staffing deficiencies: 29
Day shifts deficient in CNA staffing: 14
Overnight shifts deficient in total staff: 1
Required CNAs on 01/16/2022 day shift: 15
Actual CNAs on 01/16/2022 day shift: 12
Required total staff on 01/17/2022 overnight shift: 9
Actual total staff on 01/17/2022 overnight shift: 8
Required CNAs on 03/06/2022 day shift: 16
Actual CNAs on 03/06/2022 day shift: 11
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 4
Date: Dec 3, 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 respiratory/tracheostomy care, dialysis care, and pharmacy services including medication administration and controlled substances management. Additionally, the facility was found deficient in maintaining required minimum direct care staff-to-resident ratios.
Deficiencies (4)
Facility failed to ensure therapy was administered in accordance with physician's orders for respiratory care.
Facility failed to observe, monitor, assess and document care of a hemodialysis resident's access site.
Facility failed to maintain controlled medications in a manner that would decrease the possibility of loss or diversion; discrepancies found in narcotic counts and documentation.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state regulations.
Report Facts
Census: 120
Sample Size: 28
Deficiencies cited: 4
Staffing Deficiencies: 14
Staffing Deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Mentioned in relation to respiratory therapy deficiency and medication administration | |
| Director of Nursing (DON) | Involved in addressing respiratory therapy and dialysis care deficiencies and staffing issues | |
| Licensed Nursing Home Administrator (LNHA) | Involved in addressing respiratory therapy deficiency | |
| Registered Nurse (RN) | Mentioned in relation to medication cart and narcotic count deficiencies | |
| Administrator | Discussed staffing ratio concerns with surveyor |
Inspection Report
Life Safety
Census: 121
Capacity: 159
Deficiencies: 5
Date: Dec 3, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/03/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety code standards.
Findings
The facility was found to be in noncompliance with several life safety code requirements including emergency lighting, sprinkler system installation and maintenance, fire pump testing, generator transfer time certification, and improper use of power strips. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (5)
Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of building electrical system.
Incomplete sprinkler coverage in multiple stairwells under the first accessible landing.
Failed to perform monthly electric fire pump churn test as required.
Failed to certify generator transfer time within required 10 seconds during monthly tests.
Use of multi-outlet power strip for high draw electrical appliances in patient care vicinity.
Report Facts
Certified beds: 159
Census: 121
Deficiencies cited: 5
Completion dates: Dec 4, 2021
Completion dates: Mar 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified deficiencies and participated in interviews regarding emergency lighting, sprinkler coverage, fire pump testing, generator transfer time, and electrical equipment. |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145280, NJ145251, and NJ144172.
Complaint Details
Complaint numbers NJ145280, NJ145251, and NJ144172 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jan 15, 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: 9
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00135882.
Complaint Details
Complaint #: NJ00135882. The facility was found compliant based on this complaint survey.
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.
Report Facts
Sample Size: 6
Inspection Report
Routine
Census: 107
Deficiencies: 0
Date: Nov 17, 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 and recommended practices for 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
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