Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
85% occupied
Based on a May 2023 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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection prevention, and control practices at the nursing home.
Findings
The facility was found deficient in proper catheter care and storage, medication administration errors exceeding 5%, and inadequate infection prevention practices including hand hygiene and glove use during meal delivery and specimen collection.
Deficiencies (3)
Failure to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections.
Failure to ensure that all medications were administered without error of 5% or more, resulting in a medication administration error rate of 7.41%.
Failure to ensure staff performed appropriate hand hygiene during meal delivery and removed soiled gloves upon exiting resident rooms to prevent infection spread.
Report Facts
Medication administration error rate: 7.41
Number of medications administered in error: 2
Number of medications administered during observation: 9
Number of medications administered during observation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Provided Resident #32's indwelling catheter care; did not indicate drainage port disinfection |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Assigned to unit; provided information on catheter care and medication administration errors |
| Registered Nurse Supervisor (RN/SON) | Registered Nurse Supervisor | Provided information on catheter bag storage and staff education |
| Consultant Pharmacist (CP) | Consultant Pharmacist | Interviewed regarding medication administration policies and observations |
| Assistant Nursing Home Administrator (ANHA) | Assistant Nursing Home Administrator | Interviewed regarding infection prevention and medication administration observations |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed regarding medication administration observations and infection control practices |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Observed delivering meals without proper hand hygiene |
| Certified Nursing Assistant (CNA) #4 | Certified Nursing Assistant | Observed delivering meals without proper hand hygiene |
| Contracted Laboratory Technician (LT) | Laboratory Technician | Observed leaving resident room with soiled gloves on |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 17, 2023
Visit Reason
The inspection was conducted based on complaint #NJ00163437 to investigate concerns regarding the facility's failure to ensure physician's orders and documentation for discharge and diet consistency were properly followed and documented.
Complaint Details
Complaint #NJ00163437 involved allegations that the facility failed to have physician's orders and documentation for discharge and failed to follow diet orders for nectar thick consistency. The complaint was substantiated based on record reviews, observations, and interviews.
Findings
The facility failed to ensure a physician's order and documentation regarding discharge for one resident (Resident #117) and failed to follow a physician's order for a nectar thick diet consistency for another resident (Resident #1). Additionally, the facility did not document a proper discharge summary for Resident #117 until after surveyor inquiry.
Deficiencies (3)
Failure to ensure a physician's order and documentation regarding discharge for Resident #117.
Failure to follow physician's order for nectar thick diet consistency during medication pass for Resident #1.
Failure to document a discharge summary including recapitulation of stay and final status for Resident #117.
Report Facts
Closed medical records reviewed for discharge: 3
Residents reviewed for diet order compliance: 5
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding the process of resident discharge and physician orders. |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed during medication pass for Resident #1 regarding nectar thickened liquid preparation. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding discharge process, physician orders, and diet order compliance. |
| Licensed Nursing Home Administrator | LNHA | Notified of findings and confirmed absence of physician's discharge order and discharge summary. |
| Director of Admissions and Marketing/Assistant Administrator | DoAM/AA | Notified of findings and provided late clinical physician order and late entry medical progress note. |
| Rehabilitation Director | RD | Interviewed regarding Resident #1's diet upgrade and speech therapy recommendations. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 17, 2023
Visit Reason
The inspection was conducted based on complaint #NJ00163437, involving concerns about discharge documentation, medication administration, respiratory care, pharmaceutical services, and food safety at the nursing facility.
Complaint Details
Complaint #NJ00163437 involved issues with discharge documentation, medication administration errors, respiratory care deficiencies, pharmaceutical service lapses, and food safety concerns.
Findings
The facility failed to ensure physician orders and documentation for discharge, failed to follow physician diet orders during medication administration, lacked proper respiratory care and equipment maintenance, had pharmaceutical service deficiencies including expired and unlabeled medications, and failed to maintain sanitary food storage and labeling practices.
Deficiencies (7)
Failure to ensure physician's order and documentation regarding discharge for Resident #117.
Failure to follow physician's order for nectar thick consistency diet during medication pass for Resident #1.
Failure to document a discharge summary including recapitulation of stay and final resident status for Resident #117.
Failure to provide necessary respiratory care and services for residents on oxygen treatment, including lack of care plan, tubing change orders, and proper equipment maintenance for Residents #10, #31, and #120.
Failure to provide pharmaceutical services meeting professional standards, including expired medications in back-up supply, discontinued medications not removed, unlabeled medications, and improper medication storage.
Failure to ensure licensed pharmacist performs monthly drug regimen review and follow up on recommendations, including failure to act on Consultant Pharmacist's recommendations for Residents #118 and #120.
Failure to properly label and date opened bulk dry food items and maintain kitchen environment and equipment in a sanitary manner to prevent contamination and potential foodborne illness.
Report Facts
Expired medication count: 2
Medication quantity: 2
Medication quantity: 30
Milk crates: 6
Milk crates: 4
Milk gallon: 1
Bulk food weight: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication pass observation and failure to follow nectar thickened liquid order for Resident #1. |
| DON | Director of Nursing | Interviewed regarding discharge process, medication errors, respiratory care, and pharmaceutical service deficiencies. |
| LNHA | Licensed Nursing Home Administrator | Notified of deficiencies and involved in follow-up interviews and discussions. |
| DoAM/AA | Director of Admissions and Marketing/Assistant Administrator | Present during surveyor notifications and discussions of findings. |
| RN/UM | Registered Nurse/Unit Manager | Involved in medication room inspection and acknowledged expired medication presence. |
| CP | Consultant Pharmacist | Involved in medication regimen review and acknowledged missed irregularities. |
| GM/FS | General Manager/Food Service | Interviewed regarding food storage and sanitation deficiencies. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding suction machine equipment and oxygen tubing care. |
| RN/S | Registered Nurse/Supervisor | Interviewed regarding follow-up on Consultant Pharmacist recommendations. |
Inspection Report
Routine
Census: 70
Capacity: 82
Deficiencies: 11
Date: May 17, 2023
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 professional standards of care, discharge documentation, medication administration, respiratory care, pharmacy services, drug regimen review, food safety, staffing ratios, and life safety code compliance including emergency lighting and fire alarm system.
Deficiencies (11)
Failed to ensure physician's order and documentation for discharge and diet order were followed.
Failed to document a discharge summary including recapitulation of stay and final resident status.
Failed to maintain necessary respiratory care and suctioning services according to standards for three residents.
Failed to provide pharmaceutical services ensuring expired medications removed, proper labeling, and accurate inventory.
Failed to follow up and act upon consultant pharmacist recommendations and identify medication irregularities.
Failed to properly label and date opened bulk dry food items and maintain sanitary kitchen environment.
Failed to maintain required minimum direct care staff to resident ratios on one day shift.
Failed to provide emergency lighting at emergency generator transfer switches.
Failed to locate manual fire alarm box within 60 inches of rear exit door.
Failed to inspect fire doors annually by qualified individual with documentation.
Failed to complete three-year load bank test on emergency generators.
Report Facts
Census: 70
Total Capacity: 82
Deficient CNA staffing: 1
Expired medication count: 2
Medication cart unlabeled items: 3
Medication cart unlabeled tablets: 23
Milk crates: 6
Bulk sugar and flour bags: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding discharge process and medication administration | |
| Director of Nursing (DON) | Interviewed regarding discharge orders, medication administration, and pharmacy issues | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding discharge documentation and pharmacy follow-up | |
| Staff Development Coordinator | Conducted re-inservices on medication administration and respiratory care | |
| General Manager/Food Service | Interviewed regarding kitchen sanitation and food storage | |
| Maintenance Director | Confirmed emergency lighting and fire door inspection deficiencies | |
| Consultant Pharmacist | Interviewed regarding medication regimen review and irregularities |
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: Jun 18, 2021
Visit Reason
The inspection was conducted as a complaint survey based on allegations of abuse, neglect, and failure to report and investigate injuries of unknown origin involving Resident #1.
Complaint Details
Complaint Intake NJ135858 and NJ144937 involved allegations that the facility failed to report and investigate an injury of unknown origin and failed to provide timely emergency care to Resident #1. The complaint was substantiated based on record review, interviews, and policy review.
Findings
The facility failed to report an injury of unknown source to the state agency and failed to investigate the injury properly for Resident #1. Additionally, the facility failed to ensure timely emergency medical services were requested when Resident #1 exhibited symptoms of a medical emergency. Corrective actions included staff terminations, policy revisions, staff re-education, and implementation of new reporting and investigation forms.
Deficiencies (3)
Failure to report an injury of unknown source to the state agency within required timeframes.
Failure to investigate an injury of unknown origin thoroughly and prevent further potential abuse or neglect.
Failure to ensure nursing staff requested emergency medical services timely when Resident #1 exhibited symptoms of a medical emergency.
Report Facts
Census: 89
Sample Size: 5
Deficiencies cited: 3
Date of survey completed: Jun 18, 2021
Date of plan of correction completion: Jul 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Nurse | Terminated due to error in nursing judgment regarding timing and urgency of calling 911 for Resident #1. |
| Director of Nursing | Director of Nursing | Reviewed Resident #1's medical record and verified failure to report and investigate injury; involved in corrective action implementation. |
| Nursing Home Administrator | Administrator | New administrator hired July 2020; previous administrator responsible for failure to report injury no longer employed. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 23, 2021
Visit Reason
Annual inspection survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 0
Date: Apr 23, 2021
Visit Reason
The visit was a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample size: 18
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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