Inspection Reports for New Community Extended Care Facility
266 S Orange Ave, NJ, 07103
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Dec 5, 2023
Visit Reason
The inspection was conducted based on complaint NJ#169394 to determine compliance with regulatory staffing requirements.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to maintain the minimum direct care staff to resident ratios on 6 of 14 day shifts reviewed. No residents were directly affected by the deficient practice, but it had the potential to affect all residents.
Complaint Details
Complaint NJ#169394 was investigated and substantiated with findings of deficient staffing ratios. The facility was required to submit a Plan of Correction.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey on 6 of 14 day shifts reviewed. |
Report Facts
Census: 86
Sample Size: 3
Deficient Day Shifts: 6
Staffing Ratios Required: 11
Staffing Ratios Actual: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Involved in review and corrective action planning for staffing deficiencies. | |
| Director of Nursing | Involved in review and corrective action planning for staffing deficiencies. | |
| Director of Human Resources | Involved in review and corrective action planning for staffing deficiencies. | |
| Chief Financial Officer | Involved in review and corrective action planning for staffing deficiencies. | |
| Chief Executive Officer | Involved in review and corrective action planning for staffing deficiencies. |
Inspection Report
Routine
Census: 99
Capacity: 99
Deficiencies: 20
Jan 11, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to have multiple deficiencies related to comprehensive care planning, cardio-pulmonary resuscitation equipment maintenance, pharmacy services, food safety, infection control, life safety code compliance, and emergency preparedness. Corrective actions and systemic changes were planned or implemented to address these deficiencies.
Severity Breakdown
SS=D: 18
SS=F: 4
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility failed to initiate a comprehensive care plan for 2 of 20 residents reviewed for care planning. | SS=D |
| Facility failed to maintain current equipment for immediate response to potential life-threatening cardiac emergencies. | SS=D |
| Facility failed to administer medication according to manufacturer's cautionary specifications for 1 of 5 residents observed. | SS=D |
| Facility failed to sanitize and maintain kitchen environment and equipment in a sanitary manner to prevent microbial growth and foodborne illness. | SS=D |
| Facility failed to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases and infections. | SS=D |
| Facility failed to maintain fire safety requirements including fire doors, fire alarm system, sprinkler system, emergency generator testing, and exit door locking arrangements. | SS=D |
| Facility failed to maintain required minimum staffing ratios as mandated by the state of New Jersey. | — |
| Facility failed to maintain smoking areas with metal containers with self-closing cover devices as required. | SS=D |
| Facility failed to maintain emergency generator testing and transfer switch inspections. | SS=D |
| Facility failed to maintain fire pump testing and inspection. | SS=D |
| Facility failed to maintain fire door inspections and repairs. | SS=D |
| Facility failed to maintain sprinkler system inspection and testing. | SS=F |
| Facility failed to maintain fire alarm system inspection and testing. | SS=F |
| Facility failed to maintain exit discharge doors unlocked and accessible. | SS=D |
| Facility failed to maintain door closers and latching on fire doors. | SS=D |
| Facility failed to maintain fire alarm system testing and maintenance. | SS=F |
| Facility failed to maintain sprinkler system testing and maintenance. | SS=F |
| Facility failed to maintain emergency generator testing and maintenance. | SS=D |
| Facility failed to maintain fire door inspections and repairs. | SS=D |
| Facility failed to maintain smoking area safety requirements. | SS=D |
Report Facts
Census: 99
Total Capacity: 99
Sample Size: 22
Deficiencies cited: 22
Staffing ratios: 7
Staffing ratios: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings related to care planning, medication administration, and corrective actions. |
| Administrator | Administrator | Named in multiple findings related to care planning, medication administration, fire safety, and corrective actions. |
| Director of Environmental Services | Director of Environmental Services | Named in findings related to fire safety, maintenance, and corrective actions. |
| Chief Operations Officer | Chief Operations Officer | Named in findings related to fire safety and corrective actions. |
| Food Service Director | Food Service Director | Named in findings related to food safety and corrective actions. |
| Assistant Food Service Director | Assistant Food Service Director | Named in findings related to food safety and corrective actions. |
| Food Service Manager | Food Service Manager | Named in findings related to food safety and corrective actions. |
| Maintenance Supervisor | Maintenance Supervisor | Named in findings related to fire safety and corrective actions. |
| Licensed Practical Nurse | Licensed Practical Nurse | Named in medication administration deficiency. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Named in staffing ratio findings. |
Inspection Report
Routine
Census: 104
Deficiencies: 2
Dec 21, 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 and CMS/CDC recommended practices for COVID-19.
Findings
The facility was found not to be in compliance with New Jersey staffing regulations, failing to maintain required minimum direct care staff-to-shift ratios for 14 of 14 day shifts reviewed and not employing a full-time Consultant Infection Preventionist as mandated. Corrective actions and systemic changes were planned and partially implemented.
Deficiencies (2)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-shift ratios for 14 of 14 day shifts reviewed. |
| Failure to ensure the Consultant Infection Preventionist worked full-time as mandated by the State of New Jersey. |
Report Facts
CNA staffing counts: 7
CNA staffing counts: 11
CNA staffing counts: 9
CNA staffing counts: 10
CNA staffing counts: 9
CNA staffing counts: 8
CNA staffing counts: 7
CIP hours worked: 7
CIP hours worked: 15
CIP hours worked: 14.5
CIP hours worked: 4
CIP hours worked: 11.75
CIP hours worked: 13.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to staffing deficiencies and corrective actions | |
| Administrator | Named in relation to staffing deficiencies and corrective actions | |
| Human Resource Director | Named in relation to staffing deficiencies and corrective actions | |
| Chief Operating Officer | Named in relation to staffing deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 2
Jul 6, 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 CMS and CDC recommended practices for COVID-19. Additionally, the facility was investigated for compliance with New Jersey staffing requirements and infection preventionist staffing.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to maintain minimum direct care staff-to-resident ratios for multiple shifts and failing to employ a full-time infection preventionist as mandated. No residents were directly affected by these deficiencies. The facility implemented corrective actions including staffing policy revisions, increased salaries, recruitment efforts, and ongoing monitoring.
Complaint Details
The visit was complaint-related focusing on staffing and infection preventionist compliance. The deficiencies were substantiated with no residents directly affected.
Deficiencies (2)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
| Failed to ensure that the Infection Preventionist assigned to oversee the infection control program had no other responsibilities and was employed full-time as required by state regulations. |
Report Facts
Census: 107
Shifts out of compliance: 15
CNA staffing shortfalls: 13
Salary increase: 1
Sign-on bonus: 1000
RN salary increase: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed staffing ratios and participated in corrective action meetings. | |
| Administrator | Participated in staffing review and corrective action meetings. | |
| Human Resource Director | Reviewed staffing and recruitment efforts and participated in corrective action meetings. | |
| Chief Operating Officer | Participated in corrective action meetings regarding staffing and recruitment. | |
| Chief Executive Officer | Participated in corrective action meetings regarding staffing and recruitment. |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Nov 5, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ148123 and NJ148071 regarding the facility's compliance with staffing ratios mandated by New Jersey State Law.
Findings
The facility failed to maintain the required direct care staff-to-resident ratios for 14 out of 42 shifts reviewed, which had the potential to affect all residents. The facility was not in substantial compliance with New Jersey Administrative Code 8:39 standards for licensure of long-term care facilities.
Complaint Details
Complaint #: NJ148123 and #NJ148071. The complaint was substantiated as the facility did not meet minimum staffing requirements as per NJDOH memo dated 01/28/2021.
Deficiencies (1)
| Description |
|---|
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law for 14 out of 42 shifts reviewed. |
Report Facts
Shifts not meeting staffing ratios: 14
Census: 100
Required CNAs on day shift: 13
Actual CNAs on day shift: 7
Date of correction completion: Nov 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Administrator | Interviewed regarding staffing ratios and recruitment efforts. |
| Director of Nursing | Director of Nursing | Reviewed staffing ratios and involved in recruitment and corrective actions. |
| Director of Human Resources | Director of Human Resources | Reviewed staffing ratios and involved in recruitment and corrective actions. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to long term care at the facility.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for the long term care complaints visit.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00135284.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint number NJ00135284 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
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