Deficiencies (last 6 years)
Deficiencies (over 6 years)
19.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
275% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
247 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census 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 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
Deficiencies: 2
Date: May 12, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to timely report an allegation of misappropriation involving a resident's missing items and failure to update and implement care plans for residents with changed conditions and smoking history.
Complaint Details
Complaint # NJ00180247 involved failure to report an allegation of misappropriation of four vapes missing from Resident #1's belongings. The investigation revealed no substantiated theft, and the items were found in the soiled utility room. The facility did not report the incident to the NJDOH in a timely manner. Additional complaints NJ00179392, NJ00184406, NJ00184468 were related to care plan deficiencies.
Findings
The facility failed to report an allegation of misappropriation of resident property to the New Jersey Department of Health and failed to update and implement care plan interventions for residents with changed diet consistency and smoking history. The investigation found no physical evidence of theft, and the missing items were recovered. Care plans were not updated post incidents as required.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to develop the complete care plan within 7 days of the comprehensive assessment; and failure to prepare, review, and revise care plans by a team of health professionals.
Report Facts
Missing items: 4
Residents reviewed for care plans: 8
Residents affected: 2
Date of incident: Aug 10, 2024
Date of survey: May 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Signed Investigational Summary and involved in investigation and interviews | |
| Licensed Nursing Home Administrator (LNHA) | Involved in investigation, interviews, and affirmed failure to report incident | |
| Licensed Practical Nurse (LPN #1) | Alleged in misappropriation incident, interviewed, and reassigned from resident's room | |
| Assistant Director of Nursing (ADON) | Interviewed by surveyor and affirmed findings | |
| Social Worker (SW) | Secured missing items and interviewed by surveyor |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to protect residents' health information confidentiality and failure to ensure proper nursing care related to a mist humidifier order.
Complaint Details
Complaint NJ00178065 involved breach of confidentiality related to the Newave Care program. Complaint NJ00176773 involved failure to follow physician's order for mist humidifier by Licensed Registered Nurse #1.
Findings
The facility failed to protect the confidentiality of residents' health information by disclosing PHI to an external medical practice without proper consent, affecting two residents. Additionally, the facility failed to ensure a licensed nurse followed a physician's order for a mist humidifier, with the nurse signing off on the order without performing it.
Deficiencies (2)
Failure to protect the confidentiality of residents' health related information when introducing an external medical practice that involved data collection and disclosure of residents' PHI without proper consent.
Failure to ensure Licensed Registered Nurse followed a physician order for a mist humidifier and signed the order as administered when it was not carried out.
Report Facts
Residents affected: 2
Residents affected: 1
Order Date: Jul 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Registered Nurse | Named in finding for signing off on mist humidifier order without performing it |
| LNHA | Licensed Nursing Home Administrator | Affirmed making order entry for Newave Care program in residents' charts |
| ADON | Assistant Director of Nursing | Interviewed regarding Newave Care program referrals |
Inspection Report
Complaint Investigation
Census: 247
Deficiencies: 3
Date: Oct 24, 2024
Visit Reason
The inspection was conducted based on complaints NJ00178065, NJ00176773, and NJ00176890 to investigate the facility's compliance with privacy, confidentiality, and professional standards of care.
Complaint Details
The complaint investigation was based on complaints NJ00178065, NJ00176773, and NJ00176890. The facility was found not in substantial compliance with privacy and confidentiality requirements and professional standards of care. Specific complaints included unauthorized access and disclosure of residents' protected health information and failure to meet staffing requirements.
Findings
The facility was found not in substantial compliance with federal and state regulations, including failure to protect residents' privacy and confidentiality of medical records, and failure to meet professional standards in care and staffing ratios. Deficient practices were observed in protecting residents' health information and medication administration.
Deficiencies (3)
Failure to protect the confidentiality of residents' health-related information when the facility introduced an external medical practice involving data collection and disclosure of residents' PHI.
Failure to meet professional standards of quality in services provided or arranged by the facility, including medication administration and documentation.
Failure to ensure staffing ratios met the required minimum staff-to-resident ratios as mandated by the State of New Jersey for 3 of 14 day shifts.
Report Facts
Census: 247
Sample Size: 8
Staffing Deficiency Days: 3
Certified Nurse Aides Required: 31
Certified Nurse Aides Present: 30
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 24, 2024
Visit Reason
The inspection was conducted based on complaint NJ#169038 concerning medication administration errors and pain management issues, as well as fall investigations and pain management for residents.
Complaint Details
Complaint NJ#169038 involved medication administration errors, pain management issues, fall investigations, and failure to report injuries.
Findings
The facility failed to follow physician orders for medication parameters for Resident #106 and did not specify a site for a pain medication patch for Resident #316. The facility also failed to conduct proper fall investigations with root cause analysis and implement new non-pharmacological interventions after falls for Resident #227. Additionally, Resident #316 was not timely assessed after a fall, had inadequate pain management, and the injury was not reported to the state health department.
Deficiencies (3)
Failure to follow physician's orders for medication parameters for Resident #106 and failure to specify site for pain medication patch for Resident #316.
Failure to ensure unwitnessed fall investigations included root cause analysis and failure to implement new non-pharmacological interventions after falls for Resident #227.
Failure to timely assess Resident #316 after an unwitnessed fall, inadequate pain management, and failure to report injury to the New Jersey Department of Health.
Report Facts
Residents reviewed for medication with parameters: 38
Residents reviewed for falls: 3
Residents reviewed for accidents: 5
Pain scale: 10
Pain scale: 13
Medication administration dates: 5
Fall dates: 4
Pain medication order delay: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Registered Nurse | Registered Nurse (RN) | Admitted to administering Metoprolol without documenting SBP and pulse on multiple dates. |
| Unnamed Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Explained pain documentation and medication administration responsibilities. |
| Unnamed Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding medication administration, fall investigations, pain management, and facility policies. |
| Unnamed Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Participated in meetings and exit conference regarding findings. |
| Unnamed Unit Manager | Unit Manager (UM1A) | Interviewed regarding fall investigation process and interventions. |
| Unnamed Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding fall investigation process and interventions. |
| Unnamed Director of Rehabilitation | Director of Rehabilitation (DOR) | Interviewed regarding therapy documentation and awareness of resident falls and pain complaints. |
| Unnamed Certified Occupational Therapy Assistant | Certified Occupational Therapy Assistant (COTA) | Interviewed regarding documentation of resident pain complaints and notification of nursing staff. |
| Unnamed Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding pain management and awareness of resident fall. |
| Unnamed Physiatrist | Physiatrist | Interviewed regarding pain management and awareness of resident fall. |
Inspection Report
Routine
Deficiencies: 15
Date: Jul 24, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, staff licensing, resident assessments, medication management, infection control, environment safety, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to serve meals in a dignified manner, incomplete staff license and background verifications, late and inaccurate resident assessments, failure to follow medication orders and specify medication administration details, inadequate fall investigations and interventions, improper respiratory care and oxygen therapy, incomplete physician documentation and visits, failure to post nurse staffing daily, improper medication storage, inadequate infection control practices including hand hygiene and transmission-based precautions, and failure to maintain a safe and sanitary environment.
Deficiencies (15)
Failure to serve meals in a dignified manner for one resident during meal service.
Failure to verify licenses, conduct criminal background checks, and obtain reference checks for new employees.
Failure to complete comprehensive and quarterly Minimum Data Set (MDS) assessments timely for multiple residents.
Failure to accurately code MDS assessments for cognition, hospice care, and pain assessment for several residents.
Failure to follow physician medication orders with parameters and incomplete medication orders for pain management.
Failure to provide accurate discharge summaries including medication reconciliation and post-discharge instructions.
Failure to conduct root cause analysis and implement new non-pharmacological interventions after resident falls.
Failure to provide appropriate respiratory care including oxygen therapy per physician orders and proper storage of oxygen equipment.
Failure to ensure attending physician signs and dates monthly orders and documents monthly visits as required.
Failure to post daily nurse staffing information for licensed nurses, certified nursing aides, and resident census on multiple days.
Failure to store medications securely and appropriately; medication left unattended on top of medication cart.
Failure to maintain proper kitchen sanitation practices including use of expired juice boxes, improper jewelry and hair restraints, and uncovered facial hair.
Failure to follow appropriate hand hygiene practices by housekeeping and nursing staff and failure to provide hand hygiene to residents before meals.
Failure to follow transmission-based precautions including improper use of personal protective equipment by staff and physicians, and failure to isolate residents appropriately.
Failure to maintain a clean, safe, and sanitary environment including loose safety railings in resident toilet room, blood stains on chapel carpet, and chipped paint and discoloration in resident room.
Report Facts
Residents affected: 5
Residents affected: 6
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Days missing nurse staffing posting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN#1 | Registered Nurse | Acknowledged lack of hand hygiene during dining observation |
| CNA#1 | Certified Nursing Aide | Distributed lunch trays without providing hand hygiene |
| HK#1 | Housekeeper | Observed wearing gloves improperly and not performing hand hygiene |
| HK#2 | Housekeeper | Entered isolation room without wearing gown as required |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Acknowledged improper respiratory equipment storage and failure to change nebulizer mask timely |
| DON | Director of Nursing | Acknowledged multiple deficiencies including medication reconciliation, infection control, and fall interventions |
| LNHA | Licensed Nursing Home Administrator | Provided facility policies and acknowledged deficiencies |
| IP/RN | Infection Preventionist/Registered Nurse | Provided infection control policy and acknowledged failures in PPE use and hand hygiene |
Inspection Report
Re-Inspection
Census: 260
Deficiencies: 26
Date: Jul 24, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint # NJ172084 cited failure to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey.
Findings
Deficiencies were cited related to emergency preparedness, resident rights, abuse/neglect policies, comprehensive assessments, medication administration, discharge summaries, quality of care, accident prevention, nurse staffing, medication storage, infection control, environment safety, life safety code violations including fire safety and sprinkler system issues.
Deficiencies (26)
Facility failed to ensure Emergency Preparedness Plan was sent to local emergency management for annual review.
Residents were not served meals in a dignified manner during meal service.
Facility failed to ensure license verification, criminal background checks, and reference checks were completed timely for staff.
Facility failed to complete comprehensive assessments timely for three residents.
Facility failed to complete quarterly assessments timely for two residents.
Facility failed to accurately code Minimum Data Set for three residents.
Facility failed to follow physician's orders for medications with parameters and failed to specify site of application for a medication.
Resident was not provided with an accurate discharge summary including medication reconciliation and post-discharge instructions.
Facility failed to ensure unwitnessed fall investigation included root cause analysis and new non-pharmacological interventions.
Facility failed to ensure oxygen and nebulizer tubing were changed timely and stored properly, and physician orders were followed.
Physician orders were not signed and dated timely and monthly physician visits were not documented for five residents.
Facility failed to post nurse staffing information daily on three days during the survey.
Medications were left unattended on top of medication cart during medication pass observation.
Facility failed to ensure expired juice boxes were discarded and kitchen staff wore appropriate attire including hair restraints and no jewelry.
Facility failed to follow hand hygiene and transmission-based precautions for residents on isolation and during dining observation.
Facility failed to maintain a clean, safe, and sanitary environment in resident room and common areas including chapel and public toilet room.
Exit stairwell access doors failed to maintain 1-1/2 hour fire resistance rating due to doors not latching properly.
Hazardous area room used for combustible storage lacked a fire-rated door to resist smoke.
Kitchen cooking equipment wet chemical fire suppression system nozzles were improperly positioned.
Smoke detection system was missing in a game room open to corridor.
Fire sprinkler system missing ceiling tiles and had openings in ceiling allowing smoke passage.
Portable fire extinguishers were not maintained in operable range or proper working condition.
Corridor doors did not positively latch into frame and resist passage of smoke.
Smoke barrier walls had holes and penetrations allowing smoke passage.
Resident room air conditioner units had clogged and dirty filters.
Facility failed to provide remote annunciator panel for one of two emergency generators to alert staff of system condition.
Report Facts
Deficient CNA staffing days: 13
Deficient CNA staffing days: 14
Deficient CNA staffing days: 12
Resident census: 260
Number of residents reviewed for staffing: 14
Number of exit stairwell doors tested: 29
Number of fire extinguishers inspected: 108
Number of kitchen cooking equipment nozzles misaligned: 4
Number of ceiling tiles missing or damaged: 24
Number of fire sprinkler heads replaced: 4
Number of emergency generators: 2
Number of emergency generator annunciators: 1
Number of residents with clogged AC filters observed: 4
Number of days with missing nurse staffing posting: 3
Number of residents without signed monthly physician orders: 1
Number of residents without documented monthly physician visits: 5
Number of medication carts with unattended meds: 1
Number of expired juice boxes observed: 3
Number of staff observed with improper kitchen attire: 3
Number of residents rooms and common areas with environmental issues: 3
Number of exit stairwell doors with latching issues: 3
Number of hazardous rooms without fire-rated door: 1
Number of kitchen fire suppression nozzles misaligned: 4
Number of rooms open to corridor without smoke detection: 1
Number of missing ceiling tiles or openings in ceiling: 24
Number of fire extinguishers out of operable range: 5
Number of corridor doors not latching properly: 3
Number of smoke barrier wall penetrations: 4
Number of residents room AC units with clogged filters: 4
Number of emergency generator annunciators: 1
Number of residents with isolation signage and PPE bin issues: 2
Number of staff observed not following hand hygiene or PPE protocols: 4
Number of residents sharing room with different isolation status: 2
Number of residents with unrelieved pain and inadequate pain management: 1
Number of residents with inaccurate or incomplete MDS assessments: 3
Number of residents with missing quarterly assessments: 2
Number of residents with inaccurate MDS coding: 3
Number of residents with missing reference checks or license verifications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in medication administration and dining environment findings | |
| Infection Preventionist | Named in infection control and hand hygiene findings | |
| Licensed Nursing Home Administrator | Named in staffing and infection control findings | |
| Staff #1 | Licensed Practical Nurse | Named in license verification and reference check deficiencies |
| Staff #3 | Licensed Practical Nurse | Named in license verification and reference check deficiencies |
| Staff #6 | Named in license verification deficiency | |
| Staff #10 | Named in criminal background check deficiency | |
| Certified Nursing Aide #1 | Named in dining observation and hand hygiene findings | |
| Housekeeper #1 | Named in infection control and hand hygiene findings | |
| Housekeeper #2 | Named in infection control and PPE use findings | |
| Dietary Aide #1 | Named in kitchen attire and food safety findings | |
| Dietary Aide #2 | Named in kitchen attire findings | |
| Dietary Aide #3 | Named in kitchen attire findings | |
| Director of Maintenance | Named in life safety and environment maintenance findings | |
| Regional Administrator | Named in education and compliance monitoring | |
| Licensed Nursing Home Administrator | Named in staffing and compliance monitoring | |
| Staffing Coordinator | Named in staffing deficiencies and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was conducted in response to a complaint regarding a medication error involving Resident #2, who was administered two blood thinners simultaneously due to a transcription error.
Complaint Details
Complaint NJ00174351 involved a medication error where Resident #2 was administered Warfarin in error due to transcription by RN #1. The resident was also on Xarelto, leading to adverse effects including bleeding and hospitalization. The error was substantiated by interviews, record reviews, and facility investigation.
Findings
The facility's Consultant Pharmacist failed to identify and notify the facility of a medication irregularity where Resident #2 was administered both Xarelto and Warfarin (Coumadin) for 18 days, resulting in the resident becoming symptomatic and requiring hospitalization. The error was traced to a transcription mistake by a Registered Nurse who entered a medication order intended for another resident.
Deficiencies (2)
Failure to ensure a licensed pharmacist performed a monthly drug regimen review including medical chart review, resulting in failure to identify medication irregularity involving blood thinners.
Failure to ensure residents are free from significant medication errors, specifically transcription and administration of two incompatible blood thinners to Resident #2.
Report Facts
Doses of Warfarin administered: 18
Residents reviewed for medication regimen: 4
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Transcribed the Warfarin medication order in error into Resident #2's medical record. |
| Consultant Pharmacist | Failed to identify and notify the facility of the medication irregularity during monthly drug regimen review. | |
| Director of Nursing | DON | Conducted investigation on the medication error incident and provided signed Investigation Summary. |
| Nurse Unit Manager | NUM | Documented resident's admission to hospital and clinical status. |
Inspection Report
Complaint Investigation
Census: 264
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted based on complaint NJ00174351 regarding medication errors and staffing issues at Morris View Healthcare Center.
Complaint Details
Complaint NJ00174351 was substantiated. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on the complaint visit related to medication errors and staffing shortages.
Findings
The facility was found not in substantial compliance with federal regulations due to medication transcription and administration errors affecting Resident #2, and failure to maintain required minimum staffing ratios on several day shifts. The medication error involved a resident receiving medication prescribed for another resident, resulting in adverse health effects and hospitalization. Staffing deficiencies were noted on 4 of 14 day shifts with insufficient CNAs.
Deficiencies (3)
Failure to ensure drug regimen review irregularities were reported and acted upon, resulting in medication errors.
Resident #2 was administered a medication prescribed for another resident, causing adverse effects and hospitalization.
Facility failed to maintain required minimum staffing ratios on 4 of 14 day shifts.
Report Facts
Census: 264
Sample Size: 4
Deficiencies cited: 2
Staffing deficiency days: 4
Residents on deficient days: 272
Residents on deficient days: 274
Residents on deficient days: 266
Residents on deficient days: 263
Medication doses administered in error: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Named in medication transcription error involving Resident #2 |
| Licensed Practical Nurse #1 | LPN | Documented progress notes related to Resident #2's adverse reaction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
A Life Safety Code Renovation Survey was conducted by the New Jersey Department of Health on 10/25/2023 to assess compliance with fire safety requirements under 42 CFR 483.90(a) and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility failed to maintain the integrity of two of seven inspected smoke barrier walls, with unsealed penetrations allowing smoke, fumes, and fire to pass through. These deficiencies were identified above corridor ceiling tiles near double smoke doors, involving unsealed wire penetrations.
Deficiencies (1)
Failure to maintain the 1/2 hour fire rated construction of smoke barrier walls due to unsealed penetrations with wires passing through, compromising smoke barrier integrity.
Report Facts
Smoke barrier walls inspected: 7
Smoke barrier walls with deficiencies: 2
Smoke zones in facility: 45
Facility generators: 2
Generator capacity KW: 750
Generator capacity KW: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Maintenance Director | Present during inspection and confirmed findings | |
| Facility Maintenance Director | Present during inspection and confirmed findings | |
| Administrator | Informed of findings during survey exit | |
| Corporate Project Manager | Requested to provide facility layout for inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 12, 2023
Visit Reason
The inspection was conducted based on complaint NJ00161074 and a review of medical record request practices. The visit aimed to investigate the facility's compliance with resident rights to access medical records and to ensure a safe, clean, and homelike environment.
Complaint Details
Complaint # NJ00161074 regarding failure to maintain a safe, clean, and homelike environment on unit 2 D for 3 of 13 resident rooms (Residents #11, #13, and #14).
Findings
The facility failed to provide a discharged resident a requested copy of their medical records, constituting a deficient practice. Additionally, the facility failed to maintain a sanitary and homelike environment on one unit, with observations of soiled recliner chairs, privacy curtains, and resident chairs, which staff acknowledged and planned to address.
Deficiencies (2)
Failed to provide a discharged resident a requested copy of their medical records.
Failed to provide a sanitary and homelike environment on unit 2 D, including soiled recliner chairs and privacy curtains in resident rooms.
Report Facts
Residents affected: 1
Residents affected: 3
Units toured: 6
Resident rooms inspected: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Stated the medical record request process and acknowledged oversight in failing to complete Resident #1's request |
| Registered Nurse/Unit Manager | RN/UM | Acknowledged recliner chair cleanliness issues and directed housekeeping to clean |
| Regional Director of Clinical Compliance | RDCC | Observed and confirmed need for cleaning recliner chair and other soiled items |
| Certified Nursing Assistant #1 | CNA | Stated he would try to clean dirty chairs or call housekeeping |
| Certified Nursing Assistant #2 | CNA | Stated residents' areas should be kept clean |
| Certified Nursing Assistant #3 | CNA | Asked to clean soiled chair on unit 2 D |
| Director of Nursing | DON | Expected staff to call housekeeping or maintenance to clean or replace soiled items |
| Assistant Licensed Nursing Home Administrator | ALNHA | Made environmental rounds daily and entered maintenance requests |
Inspection Report
Complaint Investigation
Census: 249
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted in response to multiple complaints regarding compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities, focusing on staffing ratios, resident rights to access medical records, and facility environment conditions.
Complaint Details
The complaint investigation involved multiple complaint numbers (158624, 160647, 160940, 161074, 162472, 163219, 164434, 165161, 165285, 166991) and focused on staffing deficiencies, failure to provide medical records, and environmental concerns. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on these complaints.
Findings
The facility was found deficient in maintaining required direct care staff-to-resident ratios, failed to provide timely access to medical records for a discharged resident, and did not maintain a sanitary and homelike environment in resident rooms. Several instances of inaccurate reporting of CNA staffing and unclean resident chairs were documented.
Deficiencies (3)
Failure to accurately report and maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Failure to provide a discharged resident a requested copy of their medical records within the required timeframe.
Failure to provide a safe, clean, comfortable, and homelike environment, including unclean and soiled resident chairs in multiple rooms.
Report Facts
Resident census: 249
Sample size: 23
Staffing deficiencies: 70
Deficient CNA staffing days: 3
Deficient CNA staffing days: 6
Deficient CNA staffing days: 10
Deficient CNA staffing days: 14
Deficient CNA staffing days: 29
Deficient CNA staffing days: 8
Inspection Report
Plan of Correction
Census: 248
Capacity: 363
Deficiencies: 1
Date: May 2, 2023
Visit Reason
The inspection was conducted as part of a new construction and renovation project involving interior renovations and the addition of 80 long-term care beds to increase the licensed bed count from 283 to 363 beds.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities, specifically failing to maintain the required minimum direct care staff to resident ratios for 13 out of 42 shifts reviewed. The facility must submit a Plan of Correction to address these deficiencies.
Deficiencies (1)
Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 13 out of 42 shifts reviewed.
Report Facts
Licensed bed count increase: 80
Census: 248
Shifts reviewed: 42
Shifts not meeting staffing requirements: 13
Required CNA staffing: 31
Actual CNA staffing: 12
CNA staffing shortfall: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Provided information to survey team and reeducated Human Resources Director and Staffing Coordinator on staffing regulations. | |
| Human Resources Director | Reeducated on staffing regulations and involved in corrective actions. | |
| Staffing Coordinator | Reeducated on staffing regulations, directed to increase rounding and fill open shifts, involved in corrective actions and monitoring. | |
| Nursing Supervisor | Directed to increase rounding on weekends to confirm staffing ratios. | |
| Administrator | Assisted Staffing Coordinator with recruiting and staffing efforts. |
Inspection Report
Complaint Investigation
Census: 247
Deficiencies: 1
Date: Oct 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on NJ Complaint #100578747 and NJ Complaint #NJ100158747 to determine compliance with staffing requirements and other regulatory standards.
Complaint Details
The complaint investigation was based on NJ Complaint #100578747 and NJ Complaint #NJ100158747. The facility was found deficient in staffing ratios but was in substantial compliance overall based on the complaint visit.
Findings
The facility was found deficient in maintaining the required minimum direct care staff to resident ratios for 5 of 14 nursing day shifts reviewed during a two-week period. Despite the staffing deficiencies, the facility was in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Deficiencies (1)
Failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 5 of 14 nursing day shifts reviewed.
Report Facts
Census: 247
Deficient CNA staffing days: 5
Residents: 241
Residents: 240
CNAs present: 24
CNAs present: 29
CNAs present: 21
CNAs present: 25
CNAs present: 25
CNAs required: 30
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Sep 21, 2022
Visit Reason
The inspection was conducted due to complaints regarding facility cleanliness, grievance process, abuse reporting, resident safety, medication management, care planning, and infection control.
Complaint Details
Complaint investigation related to multiple concerns including facility cleanliness, grievance process, abuse reporting, resident safety, medication management, care planning, and infection control.
Findings
The facility was found deficient in maintaining a clean environment, educating residents on grievance processes, timely reporting and investigating abuse allegations, ensuring resident safety including elopement prevention, accurate assessments and care planning, medication management, respiratory care, and infection control practices.
Deficiencies (13)
Facility failed to maintain a clean and sanitary environment in multiple units including stained floors, missing wall tiles, broken shower heads, and dirty fish tanks.
Facility failed to provide information and educate residents on the grievance process, with residents unaware of how to file grievances.
Facility failed to timely report and investigate multiple abuse allegations and injuries of unknown origin for several residents, including Resident #75's hip fracture and Resident #191's aspiration pneumonia.
Resident #206 eloped from the facility through an unlocked door without supervision, resulting in death. Facility failed to ensure adequate supervision and secure environment to prevent elopement.
Resident #191 was provided thin liquids instead of ordered honey thickened liquids, resulting in aspiration pneumonia and hospitalization.
Facility failed to accurately assess and properly code residents' cognitive status in the Minimum Data Set (MDS) for multiple residents.
Facility failed to implement comprehensive person-centered care plans for communication and behavior for Residents #102 and #150.
Facility failed to accurately transcribe physician's orders for wound care and failed to disinfect wound care surfaces properly.
Facility failed to ensure appropriate hand hygiene by staff during dining and wound care, and failed to disinfect wound care tables according to CDC guidelines.
Facility failed to provide pharmaceutical services ensuring medication availability, accurate administration, and proper storage for multiple residents.
Facility failed to provide safe and appropriate respiratory care including proper oxygen administration and storage of respiratory equipment for multiple residents.
Facility failed to maintain complete and readily accessible medical records, including missing attending physician progress notes for multiple residents.
Facility failed to implement gradual dose reductions and document non-pharmacological interventions for psychoactive medications and failed to document behaviors and PRN medication use appropriately.
Report Facts
Residents reviewed for care plans: 39
Residents reviewed for medication management: 18
Residents reviewed for medication administration: 7
Residents reviewed for respiratory care: 3
Residents reviewed for wound care: 4
Residents reviewed for infection control: 13
Residents reviewed for medical records: 39
Residents reviewed for unnecessary medications: 5
Residents reviewed for behavior monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Interviewed regarding Resident #75's injury investigation and care |
| CNA#2 | Certified Nursing Assistant | Interviewed regarding Resident #75's care and medication incident |
| DON | Director of Nursing | Interviewed multiple times regarding investigations, care plans, and policies |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding investigations, care plans, and facility policies |
| CNO | Chief Nursing Officer | Interviewed regarding behavior monitoring and investigations |
| CP | Consultant Pharmacist | Interviewed regarding medication administration and behavior monitoring |
| LPN#1 | Licensed Practical Nurse | Interviewed regarding medication administration and Resident #121 |
| RN/UM | Registered Nurse/Unit Manager | Interviewed regarding medication administration and Resident #121 |
| CNA#1 | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and dining care |
| IPN | Infection Preventionist Nurse | Interviewed regarding hand hygiene and wound care competencies |
| LPN#2 | Licensed Practical Nurse | Interviewed regarding wound care and medication administration |
| LPN#3 | Licensed Practical Nurse | Interviewed regarding PRN medication administration and documentation |
| RN#1 | Registered Nurse | Interviewed regarding PRN medication administration and Resident #101 |
| RN#2 | Registered Nurse | Interviewed regarding PRN medication administration and Resident #101 |
| RN#3 | Registered Nurse | Interviewed regarding PRN medication administration and Resident #101 |
| LPN#4 | Licensed Practical Nurse | Interviewed regarding PRN medication administration and Resident #101 |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Interviewed regarding Resident #206 elopement and behavior |
| SS | Security Supervisor | Interviewed regarding security and keypad system |
| DA | Dietary Aide | Interviewed regarding Resident #206 behavior and exit |
| PNP | Psychiatric Nurse Practitioner | Interviewed regarding Resident #206 psychiatric care |
| RD | Recreation Director | Interviewed regarding smoking program and resident supervision |
Inspection Report
Complaint Investigation
Census: 252
Deficiencies: 17
Date: Sep 21, 2022
Visit Reason
Complaint investigation triggered by allegations including resident safety, medication administration, infection control, and care planning.
Complaint Details
Complaint numbers #NJ157771, #NJ157773, #NJ157831 triggered the investigation. Immediate Jeopardy was identified for failure to supervise elopement risk and failure to provide appropriate thickened liquids. Other deficiencies were cited in multiple areas including infection control, grievance process, reporting and investigation of abuse, medication management, and staffing.
Findings
The facility was found in Immediate Jeopardy for failure to supervise residents at risk for elopement and to provide appropriate thickened liquids to a resident at risk for aspiration pneumonia. Deficiencies were also cited for environmental cleanliness, grievance process education, reporting of alleged violations, investigation of abuse, accuracy of assessments, care planning, pressure ulcer treatment, accident hazards, respiratory care, medication administration, infection control, and social work staffing.
Deficiencies (17)
Failure to supervise a resident with cognitive impairment at risk for elopement, resulting in Immediate Jeopardy.
Failure to provide appropriate thickened liquids to a resident at risk for aspiration pneumonia, resulting in Immediate Jeopardy.
Facility failed to maintain a clean and sanitary environment, including stained floors and walls, broken shower heads, and leaking ceilings.
Facility failed to educate residents on grievance process and failed to document and resolve grievances timely.
Facility failed to report and investigate alleged violations and abuse in a timely and thorough manner.
Facility failed to accurately complete Minimum Data Set (MDS) cognitive assessments.
Facility failed to update care plans timely to reflect incidents and resident behaviors.
Facility failed to transcribe physician's orders accurately for pressure ulcer treatment.
Facility failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision to prevent elopement.
Facility failed to provide respiratory care consistent with physician orders and infection control standards.
Facility failed to provide pharmaceutical services ensuring medications were available, administered timely and accurately documented.
Facility failed to implement comprehensive care plans reflecting resident communication needs and personal hygiene preferences.
Facility failed to ensure residents were free from unnecessary psychotropic medications and failed to document non-drug interventions and behavior monitoring appropriately.
Facility failed to maintain complete, accurate, and readily accessible medical records including attending physician notes.
Facility failed to maintain required minimum direct care staffing ratios and failed to designate a full-time Infection Preventionist with no other responsibilities.
Facility failed to provide required social work services hours and failed to maintain adequate social work staffing.
Facility failed to ensure proper hand hygiene and infection control practices during dining and wound care treatment observations.
Report Facts
Census: 252
Staffing ratio: 22
Staffing ratio: 27
Staffing ratio: 30
BIMS score: 15
BIMS score: 15
BIMS score: 8
BIMS score: 15
BIMS score: 15
BIMS score: 15
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Medication administration times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and behavior monitoring findings for Resident #101 |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and behavior monitoring findings for Resident #101 |
| RN #1 | Registered Nurse | Named in medication administration and behavior monitoring findings for Resident #101 |
| CNA #1 | Certified Nursing Assistant | Named in infection control hand hygiene and dining observation findings |
| CNA #2 | Certified Nursing Assistant | Named in infection control hand hygiene and dining observation findings |
| IPN | Infection Preventionist Nurse | Named in infection control findings and interview |
| DON | Director of Nursing | Named in multiple findings including infection control, medication administration, grievance process, abuse investigation, and staffing |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including infection control, medication administration, grievance process, abuse investigation, and staffing |
| CP | Consultant Pharmacist | Named in medication administration findings and interview |
| RD | Registered Dietician | Named in diet and thickened liquid findings and interview |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Named in diet and thickened liquid findings and interview |
| CNA3 | Certified Nursing Assistant | Named in diet and thickened liquid findings and interview |
| CNA4 | Certified Nursing Assistant | Named in diet and thickened liquid findings and interview |
| CNA5 | Certified Nursing Assistant | Named in diet and thickened liquid findings and interview |
| PNP | Primary Nurse Practitioner | Named in diet and thickened liquid findings and interview |
| LPN#3 | Licensed Practical Nurse | Named in medication administration findings and interview |
| RN#2 | Registered Nurse | Named in medication administration findings and interview |
Inspection Report
Life Safety
Deficiencies: 10
Date: Sep 21, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 9/14/22 to 9/16/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for an existing health care occupancy.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including failure to conduct daily inspections of construction areas, lack of emergency lighting above generator transfer switches, inadequate fire barriers in hazardous areas, missing fire alarm notification devices in enclosed courtyards, deficiencies in fire alarm system maintenance, corridor doors not resisting smoke passage, smoke barrier doors not closing properly, inadequate bathroom ventilation, missing firefighter service records for elevators, and incomplete testing and documentation of emergency generator transfer times and remote manual stop stations.
Deficiencies (10)
Failed to conduct daily inspection of construction repair, alterations or additions and means of egress in renovation projects.
Failed to provide battery back-up emergency lighting above emergency generator transfer switches.
Failed to provide fire barrier with two-hour fire resistance rating in boiler room and storage room hazardous areas.
Failed to provide fire alarm notification by audible and visible signals in two enclosed courtyards.
Failed to maintain fire alarm system properly; trouble condition on annunciator panels not resolved.
Corridor doors failed to resist passage of smoke; 7 resident room doors had hardware or fitting issues.
Smoke barrier doors failed to close completely or had gaps, rub on floor, or missing astragal.
Residents' bathroom ventilation systems in 8 units were not functioning properly.
Elevators lacked documented monthly firefighter's service inspection records; 2 of 7 elevators were out of service during survey.
Failed to certify emergency generator transfer time within 10 seconds and lacked remote manual stop stations.
Report Facts
Renovation projects with missing daily inspection logs: 2
Transfer switches without battery back-up emergency lighting: 4
Hazardous areas with deficient fire barrier: 2
Enclosed courtyards without fire alarm notification devices: 2
Resident room doors with hardware or latching issues: 7
Smoke barrier doors with closure or gap issues: 4
Residents' bathrooms with non-functioning ventilation: 8
Elevators lacking firefighter service records: 7
Elevators out of service during survey: 2
Generators lacking documented transfer times: 2
Generators: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to multiple findings including failure to conduct daily inspections, emergency lighting, fire alarm maintenance, door inspections, ventilation, elevator service, and generator testing. | |
| Regional Administrator | Present during observations and interviews confirming deficiencies. | |
| Manager Engineer | Responsible for generator testing and repairs. | |
| Boiler Operator | Performed monthly load tests on generators but did not record transfer times. |
Inspection Report
Routine
Census: 259
Deficiencies: 0
Date: Jan 14, 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 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: 220
Deficiencies: 1
Date: Aug 16, 2021
Visit Reason
The inspection was conducted based on a complaint visit to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The facility was found not in substantial compliance based on this complaint visit. The deficiency involved environmental safety issues including blood-like stains on a resident's wall and exposed wires, with staff interviews confirming lapses in cleaning and reporting procedures.
Findings
The facility failed to maintain a safe, clean, and homelike environment for 1 of 3 residents observed, evidenced by stains on the resident's room wall and exposed non-live wires from an old call bell system. Corrective actions were implemented, including sanitizing the room and covering the wires, with audits and staff education planned to prevent recurrence.
Deficiencies (1)
Failure to maintain a safe, clean, and homelike environment due to stains on the wall and exposed wires in a resident's room.
Report Facts
Census: 220
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shabsi Ganzweig | Administrator | Named as responsible for oversight and corrective action monitoring |
Inspection Report
Complaint Investigation
Census: 250
Deficiencies: 1
Date: Jul 29, 2021
Visit Reason
The inspection was conducted based on a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was based on a complaint investigation. The facility was found deficient for incomplete and inaccurate medical records for Resident #1. The deficiency was substantiated by interviews and record reviews.
Findings
The facility was found not in substantial compliance due to failure to ensure that one resident's medical record was complete and accurate, specifically missing documentation of bed mobility, skin observation, personal hygiene, and transfer for Resident #1.
Deficiencies (1)
Failure to ensure Resident #1's medical record was complete and accurate, missing documentation of bed mobility, skin observation, personal hygiene, and transfer.
Report Facts
Census: 250
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shabsi Ganzweig | Administrator | Signed plan of correction and responsible for oversight |
Inspection Report
Abbreviated Survey
Census: 241
Deficiencies: 1
Date: May 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 related to COVID-19.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations due to failure of one staff member to use required Personal Protective Equipment (PPE) when entering a Person Under Investigation (PUI) unit, specifically not wearing a gown as required by CDC guidelines.
Deficiencies (1)
Facility staff failed to use the required Personal Protective Equipment (PPE) identified for donning and doffing in a PUI unit, specifically a Housekeeper was not wearing a gown.
Report Facts
Sample size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper | Observed not wearing required gown PPE in PUI unit | |
| Licensed Practical Nurse (LPN) | Interviewed regarding PPE requirements | |
| Licensed Nursing Home Administrator (LPNH) | Met with surveyors regarding concerns | |
| Director of Nursing (DON) | Provided facility policy and described corrective actions and monitoring plan |
Inspection Report
Abbreviated Survey
Census: 239
Deficiencies: 4
Date: Jan 19, 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 not to be in compliance with infection control regulations, specifically failing to disinfect and sanitize equipment used in the COVID-19 screening process and failing to practice appropriate hand hygiene among staff. Several hand sanitizer dispensers were empty, and staff demonstrated improper hand hygiene techniques.
Deficiencies (4)
Failure to disinfect and sanitize equipment used in the COVID-19 screening process.
Failure to practice appropriate hand hygiene for 2 of 7 staff observed according to CDC guidelines.
Hand sanitizer dispensers in the lobby and reception area were empty and not working.
Staff demonstrated improper hand hygiene techniques, including not wetting hands before applying soap and wiping sink area with used paper towel after handwashing.
Report Facts
Sample size: 5
Hand sanitizer dispensers empty: 3
Staff observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator Assistant | Administrator Assistant | Did not disinfect kiosk after each use and did not question visitor for not performing hand hygiene |
| Department Head of Housekeeping | Department Head of Housekeeping | Observed performing improper hand hygiene technique |
| Certified Nursing Assistant | Certified Nursing Assistant | Observed performing improper hand hygiene technique |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Informed surveyors about kiosk sanitization responsibility and hand sanitizer maintenance |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided feedback on improper hand hygiene techniques observed |
| Director of Nursing | Director of Nursing | Provided facility policies and plans of correction |
| Chief Nursing Officer | Chief Nursing Officer | Participated in meetings regarding findings |
Inspection Report
Routine
Census: 228
Deficiencies: 0
Date: Dec 22, 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: 7
Inspection Report
Complaint Investigation
Census: 232
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00130143, NJ00126648, NJ00129965, NJ00131673, and NJ00140109.
Complaint Details
The survey was triggered by multiple complaints as listed, and the facility was found compliant with no deficiencies cited.
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: 11
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 9, 2020
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided by Morris View Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to develop and update comprehensive care plans for residents, medication transcription errors, improper respiratory care without physician orders, medication errors exceeding acceptable rates, improper labeling and disposal of medications, and failure to follow infection prevention and control protocols including PPE use and hand hygiene.
Deficiencies (6)
Failure to develop a person-centered comprehensive care plan addressing indwelling catheter, psychoactive medications, and weight-bearing status changes for specified residents.
Failure to maintain professional standards by inaccurately transcribing physician's orders for medications for 2 residents.
Failure to provide safe and appropriate respiratory care; administration of nebulizer treatment without physician's order and oxygen administered at incorrect flow rate.
Medication error rate exceeded 5%, with 2 errors observed among 25 medication administrations.
Failure to properly label and dispose of medications in medication carts and refrigerators, including undated opened bottles and expired medications.
Failure to follow infection prevention and control procedures including not donning appropriate PPE for a resident on contact precautions and failure to perform hand hygiene after glove removal during medication pass.
Report Facts
Medication error rate: 8
Medication administrations observed: 25
Residents affected: 3
Residents affected: 5
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Involved in medication administration errors and respiratory care deficiencies |
| Director of Nursing | DON | Provided information on care plan deficiencies and medication order transcription issues |
| Assistant Director of Nursing | ADON | Present during discussions of care plan and medication order issues |
| Licensed Nursing Home Administrator | LNHA | Provided facility policies and participated in survey discussions |
| Regional Nurse | Regional Nurse | Involved in survey discussions regarding care plan and medication order issues |
| Speech Therapist | ST | Entered resident room on contact precautions without proper PPE |
| Unit Manager | UM | Interviewed regarding medication administration and labeling errors |
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