Deficiencies per Year
16
12
8
4
0
Moderate
Unclassified
Census Over Time
Census
Capacity
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: 102
Capacity: 120
Deficiencies: 9
Mar 7, 2025
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH) from 03/03/25 to 03/06/25, including multiple complaint investigations identified by complaint numbers NJ173146, NJ171780, NJ182018, NJ178131, NJ172789, NJ183135, NJ170938, NJ167184, NJ175067.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long-term care facilities based on deficiencies in resident care planning, grievance resolution, mobility, respiratory care, infection control, meal service, and life safety code compliance. Multiple deficiencies were cited with severity levels ranging from SS=D (substantial compliance not met) to SS=E (immediate jeopardy not indicated).
Complaint Details
The visit was complaint-related with multiple complaint numbers listed. The facility was found deficient in several areas including care planning, grievance resolution, staffing, infection control, and life safety. The complaints were substantiated as evidenced by the cited deficiencies.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure interdisciplinary team determined appropriate care for resident R27, leading to potential infection risk due to lack of assessment. | SS=D |
| Facility failed to provide resolution to grievances for one of nine residents reviewed, affecting outcome of concerns and grievances. | SS=D |
| Facility failed to develop and implement a comprehensive care plan for one resident, potentially not receiving necessary care. | SS=D |
| Facility failed to ensure appropriate treatment and documentation for resident with limited range of motion, potentially leading to further decline. | SS=D |
| Facility failed to obtain physician's order prior to administration of respiratory care for three residents, risking improper care. | SS=D |
| Facility failed to ensure meal service was timely and consistent with resident preferences, potentially affecting resident routines. | SS=E |
| Facility failed to maintain infection prevention and control program, including proper storage of medications and infection control protocols. | SS=E |
| Facility failed to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Facility failed to ensure fire safety compliance including proper signage and maintenance of fire doors. | SS=F |
Report Facts
Survey Census: 102
Total Capacity: 120
Sample Size: 27
Deficiency Counts: 8
Staffing Deficiencies: 12
Staffing Deficiencies: 7
Required Staffing Hours: 278.75
Staffing Hours Difference: -30.75
Inspection Report
Routine
Census: 106
Deficiencies: 13
Feb 14, 2023
Visit Reason
Routine state survey and recertification inspection of North Cape Center to assess compliance with licensure and Medicare/Medicaid participation requirements.
Findings
The facility was found deficient in multiple areas including staffing ratios, influenza vaccination record keeping for contracted employees, Mantoux testing for new employees, dining environment, transfer/discharge notification to Ombudsman, accuracy of assessments and care plans, accident hazard supervision, annual CNA performance reviews, pharmacy record keeping, food safety and sanitation, infection prevention and control practices including PPE use, antibiotic stewardship, and COVID-19 vaccination tracking for contracted staff.
Deficiencies (13)
| Description |
|---|
| Failed to maintain required minimum direct care staff to resident ratios and failed to maintain influenza vaccination records for contracted employees. |
| Failed to ensure new employees received the required two-step Mantoux tuberculin skin test. |
| Failed to create a homelike dining environment by serving meals on trays and not posting menus in dining rooms. |
| Failed to notify the State Long-Term Care Ombudsman in writing of resident transfers/discharges in a timely manner. |
| Failed to ensure accurate Minimum Data Set (MDS) assessments and coding for residents receiving bolus tube feedings. |
| Failed to develop and implement a person-centered comprehensive care plan addressing intravenous medication use for infection. |
| Failed to ensure residents who smoke do not possess smoking materials unsupervised and failed to enforce facility smoking policy. |
| Failed to maintain accurate DEA 222 forms for controlled substances including documenting date and quantity received. |
| Failed to maintain food safety and sanitation including proper storage, labeling, dating, temperature monitoring, and drying of kitchenware. |
| Failed to ensure staff properly wore personal protective equipment (PPE), specifically masks and eye protection, in accordance with infection control policies. |
| Failed to adequately monitor antibiotic use by administering medication without a duration or stop date. |
| Failed to accurately track and document COVID-19 vaccination status of contracted staff/vendors. |
| Failed to complete annual performance reviews for certified nurse aides (CNAs) for 5 of 5 reviewed employees. |
Report Facts
Census: 106
Staffing Deficiencies: 14
Staffing Deficiencies: 1
Staffing Deficiencies: 1
CNA files reviewed: 5
DEA 222 forms reviewed: 3
Food items expired: 8
Pans stacked wet: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Licensed Nursing Home Administrator | Interviewed regarding staffing, Ombudsman notification, and PPE compliance. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, Mantoux testing, care plans, PPE compliance, and COVID-19 vaccination tracking. |
| Infection Preventionist | Infection Prevention Nurse | Interviewed regarding vaccination record keeping, PPE compliance, and antibiotic stewardship. |
| Certified Nurse Aide #1 | CNA | Interviewed regarding dining service practices. |
| Certified Nurse Aide #2 | CNA | Interviewed regarding dining service practices. |
| Certified Nurse Aide #3 | CNA | Interviewed regarding supervision of residents with smoking materials. |
| Unit Manager/Licensed Practical Nurse #1 | Unit Manager/LPN | Interviewed regarding care plan responsibilities and smoking materials policy. |
| Clinical Reimbursement Coordinator | CRC | Interviewed regarding MDS coding and care plan development. |
| Business Office Manager | Business Office Manager | Responsible for discharge notification tracking and reporting. |
| Account Manager | Dietary Account Manager | Interviewed regarding food storage and sanitation deficiencies. |
| Campus Human Resources Manager | HR Manager | Interviewed regarding CNA annual performance evaluations. |
Inspection Report
Life Safety
Deficiencies: 4
Feb 6, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 2/06/2023 and 2/07/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with several Life Safety Code requirements including failure to provide 7 illuminated exit signs, improper mounting height of 4 portable fire extinguishers, failure to conduct annual electrical receptacle testing in resident rooms for 2022, and failure to perform 30-minute load tests on two emergency generators as required.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide 7 illuminated exit signs to clearly identify the exit access path to reach an exit discharge door. | SS=E |
| Failed to install portable fire extinguishers within the required height for 4 of 14 fire extinguishers, mounted higher than 5 feet above the floor. | SS=D |
| Failed to test electrical receptacles in resident rooms every 12 months in accordance with NFPA 99; no evidence of 2022 electrical inspection. | SS=E |
| Failed to exercise 2 emergency generators for at least 30 minutes in 20 to 40-day intervals; load tests were only 25 minutes. | SS=E |
Report Facts
Deficiencies cited: 4
Number of portable fire extinguishers inspected: 14
Emergency generators: 2
Load test duration: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and responsible for corrective actions including installation of exit signs and fire extinguisher mounting | |
| Administrator | Informed of Life Safety Code deficiencies at survey exit | |
| Property Manager | Confirmed findings related to electrical inspections and emergency generator load tests | |
| Maintenance Assistant | Learning to conduct generator load tests; responsible for future compliance |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Nov 20, 2021
Visit Reason
Complaint Survey and Focused Infection Control survey conducted due to complaints NJ150129, NJ149266, and NJ147745.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities, specifically failing to meet minimum staffing ratios for Certified Nursing Assistants (CNAs) and total staff on multiple shifts between August and November 2021. Staffing shortages potentially affected all residents.
Complaint Details
Complaint numbers NJ150129, NJ149266, and NJ147745 triggered the survey. The facility was found deficient in staffing ratios as substantiated by review of staffing reports and interviews.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios met minimum requirements for CNAs and total staff on day, evening, and overnight shifts from 08/01/2021 to 11/13/2021. |
Report Facts
Census: 73
Deficient shifts: 30
Deficient shifts: 8
Deficient shifts: 10
Deficient shifts: 49
Deficient shifts: 3
Deficient shifts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Nursing Home Administrator | Acknowledged facility did not staff in accordance with NJDOH memo and explained staffing challenges. |
| Staffing Coordinator | Staffing Coordinator | Re-educated on NJ minimum staffing mandate and responsible for auditing daily staffing sheets. |
| Director of Nursing | Director of Nursing | Re-educated on NJ minimum staffing mandate and involved in staffing efforts. |
Inspection Report
Routine
Census: 76
Deficiencies: 0
Mar 31, 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 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: 6
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 1
Feb 24, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to implement physician orders for 3 of 21 residents reviewed, resulting in missing or delayed physician orders for treatments and medications. The facility provided education to staff and implemented audits to ensure timely transcription of orders.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement physician orders for 3 of 21 residents reviewed. | SS=E |
Report Facts
Census: 90
Sample size: 21
Deficiency count: 1
Plan of Correction Completion Date: Mar 18, 2021
Post-certification revisit date: Apr 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Confirmed absence of physician orders for a resident | |
| Unit Manager | Provided information about order transcription and audits | |
| Administrator | Confirmed typographical errors and lack of physician orders; confirmed staff education | |
| Certified Nursing Assistant (CNA) | Provided statement about resident care without physician order |
Inspection Report
Life Safety
Deficiencies: 0
Feb 24, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and met the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 73
Deficiencies: 0
Dec 7, 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: 3
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