Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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
Census: 247
Deficiencies: 3
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.
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.
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.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| 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. | SS=E |
| Failure to meet professional standards of quality in services provided or arranged by the facility, including medication administration and documentation. | SS=D |
| 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
Re-Inspection
Census: 260
Deficiencies: 26
Jul 24, 2024
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 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.
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.
Severity Breakdown
SS=D: 18
SS=E: 6
SS=F: 5
Deficiencies (26)
| Description | Severity |
|---|---|
| Facility failed to ensure Emergency Preparedness Plan was sent to local emergency management for annual review. | SS=D |
| Residents were not served meals in a dignified manner during meal service. | SS=D |
| 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. | SS=D |
| Facility failed to complete quarterly assessments timely for two residents. | SS=D |
| Facility failed to accurately code Minimum Data Set for three residents. | SS=D |
| Facility failed to follow physician's orders for medications with parameters and failed to specify site of application for a medication. | SS=D |
| Resident was not provided with an accurate discharge summary including medication reconciliation and post-discharge instructions. | SS=D |
| Facility failed to ensure unwitnessed fall investigation included root cause analysis and new non-pharmacological interventions. | SS=D |
| Facility failed to ensure oxygen and nebulizer tubing were changed timely and stored properly, and physician orders were followed. | SS=D |
| Physician orders were not signed and dated timely and monthly physician visits were not documented for five residents. | SS=E |
| Facility failed to post nurse staffing information daily on three days during the survey. | SS=D |
| Medications were left unattended on top of medication cart during medication pass observation. | SS=D |
| Facility failed to ensure expired juice boxes were discarded and kitchen staff wore appropriate attire including hair restraints and no jewelry. | SS=D |
| Facility failed to follow hand hygiene and transmission-based precautions for residents on isolation and during dining observation. | SS=E |
| Facility failed to maintain a clean, safe, and sanitary environment in resident room and common areas including chapel and public toilet room. | SS=E |
| Exit stairwell access doors failed to maintain 1-1/2 hour fire resistance rating due to doors not latching properly. | SS=E |
| Hazardous area room used for combustible storage lacked a fire-rated door to resist smoke. | SS=F |
| Kitchen cooking equipment wet chemical fire suppression system nozzles were improperly positioned. | SS=E |
| Smoke detection system was missing in a game room open to corridor. | SS=F |
| Fire sprinkler system missing ceiling tiles and had openings in ceiling allowing smoke passage. | SS=E |
| Portable fire extinguishers were not maintained in operable range or proper working condition. | SS=F |
| Corridor doors did not positively latch into frame and resist passage of smoke. | SS=F |
| Smoke barrier walls had holes and penetrations allowing smoke passage. | SS=F |
| Resident room air conditioner units had clogged and dirty filters. | SS=E |
| Facility failed to provide remote annunciator panel for one of two emergency generators to alert staff of system condition. | SS=E |
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
Census: 264
Deficiencies: 3
Jun 6, 2024
Visit Reason
The inspection was conducted based on complaint NJ00174351 regarding medication errors and staffing issues at Morris View Healthcare Center.
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.
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.
Severity Breakdown
G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure drug regimen review irregularities were reported and acted upon, resulting in medication errors. | G |
| Resident #2 was administered a medication prescribed for another resident, causing adverse effects and hospitalization. | G |
| 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
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=D |
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
Census: 249
Deficiencies: 3
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.
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.
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.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| 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. | SS=D |
| Failure to provide a safe, clean, comfortable, and homelike environment, including unclean and soiled resident chairs in multiple rooms. | SS=D |
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
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)
| Description |
|---|
| 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
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
Census: 252
Deficiencies: 17
Sep 21, 2022
Visit Reason
Complaint investigation triggered by allegations including resident safety, medication administration, infection control, and care planning.
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.
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.
Severity Breakdown
J: 3
E: 5
D: 8
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to supervise a resident with cognitive impairment at risk for elopement, resulting in Immediate Jeopardy. | J |
| Failure to provide appropriate thickened liquids to a resident at risk for aspiration pneumonia, resulting in Immediate Jeopardy. | J |
| Facility failed to maintain a clean and sanitary environment, including stained floors and walls, broken shower heads, and leaking ceilings. | D |
| Facility failed to educate residents on grievance process and failed to document and resolve grievances timely. | D |
| Facility failed to report and investigate alleged violations and abuse in a timely and thorough manner. | E |
| Facility failed to accurately complete Minimum Data Set (MDS) cognitive assessments. | D |
| Facility failed to update care plans timely to reflect incidents and resident behaviors. | D |
| Facility failed to transcribe physician's orders accurately for pressure ulcer treatment. | D |
| Facility failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision to prevent elopement. | J |
| Facility failed to provide respiratory care consistent with physician orders and infection control standards. | E |
| Facility failed to provide pharmaceutical services ensuring medications were available, administered timely and accurately documented. | E |
| Facility failed to implement comprehensive care plans reflecting resident communication needs and personal hygiene preferences. | D |
| Facility failed to ensure residents were free from unnecessary psychotropic medications and failed to document non-drug interventions and behavior monitoring appropriately. | E |
| Facility failed to maintain complete, accurate, and readily accessible medical records including attending physician notes. | D |
| Facility failed to maintain required minimum direct care staffing ratios and failed to designate a full-time Infection Preventionist with no other responsibilities. | J |
| Facility failed to provide required social work services hours and failed to maintain adequate social work staffing. | D |
| Facility failed to ensure proper hand hygiene and infection control practices during dining and wound care treatment observations. | D |
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
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.
Severity Breakdown
SS=F: 7
SS=E: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct daily inspection of construction repair, alterations or additions and means of egress in renovation projects. | SS=F |
| Failed to provide battery back-up emergency lighting above emergency generator transfer switches. | SS=F |
| Failed to provide fire barrier with two-hour fire resistance rating in boiler room and storage room hazardous areas. | SS=E |
| Failed to provide fire alarm notification by audible and visible signals in two enclosed courtyards. | SS=F |
| Failed to maintain fire alarm system properly; trouble condition on annunciator panels not resolved. | SS=F |
| Corridor doors failed to resist passage of smoke; 7 resident room doors had hardware or fitting issues. | SS=E |
| Smoke barrier doors failed to close completely or had gaps, rub on floor, or missing astragal. | SS=F |
| Residents' bathroom ventilation systems in 8 units were not functioning properly. | SS=E |
| Elevators lacked documented monthly firefighter's service inspection records; 2 of 7 elevators were out of service during survey. | SS=F |
| Failed to certify emergency generator transfer time within 10 seconds and lacked remote manual stop stations. | SS=F |
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
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
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, and homelike environment due to stains on the wall and exposed wires in a resident's room. | SS=D |
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
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1's medical record was complete and accurate, missing documentation of bed mobility, skin observation, personal hygiene, and transfer. | SS=D |
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
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=D |
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
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.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to disinfect and sanitize equipment used in the COVID-19 screening process. | SS=D |
| Failure to practice appropriate hand hygiene for 2 of 7 staff observed according to CDC guidelines. | SS=D |
| Hand sanitizer dispensers in the lobby and reception area were empty and not working. | SS=D |
| Staff demonstrated improper hand hygiene techniques, including not wetting hands before applying soap and wiping sink area with used paper towel after handwashing. | SS=D |
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
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
Dec 7, 2020
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00130143, NJ00126648, NJ00129965, NJ00131673, and NJ00140109.
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
The survey was triggered by multiple complaints as listed, and the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 11
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