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 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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 285
Capacity: 290
Deficiencies: 4
Jan 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00181697, NJ00181722, and NJ00182050. The visit included a COVID-19 focused infection control survey and review of facility compliance with safety and medication administration regulations.
Findings
The facility was found not in substantial compliance with long term care requirements, with deficiencies related to ensuring a safe environment for residents, medication administration errors, and inadequate staffing levels. Immediate Jeopardy was identified and later removed after corrective actions. The facility failed to secure residents from unsafe areas and did not consistently document care and medication administration.
Complaint Details
Complaint investigation based on complaints NJ00181697, NJ00181722, and NJ00182050. Immediate Jeopardy was identified related to Resident #2's safety but was removed after corrective action. The facility was found deficient in staffing and medication administration practices.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure a safe environment for Resident #2, posing serious and immediate risk to health and safety. | Immediate Jeopardy |
| Medication administration errors identified for 2 of 3 residents reviewed, including failure to administer medications timely and notify physicians. | — |
| Facility deficient in CNA staffing for residents on multiple day shifts, affecting care delivery. | — |
| Failure to maintain resident medical records accurately and confidentially. | — |
Report Facts
Census: 285
Total Capacity: 290
Sample Size: 11
Sample Size: 9
Deficiencies cited: 4
Staffing Deficiency Days: 14
Staffing Deficiency Days: 11
Inspection Report
Routine
Census: 277
Capacity: 276
Deficiencies: 10
Oct 17, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH). The facility was found not to be in substantial compliance with 42 CFR 483 subpart B during this recertification and complaint visit.
Findings
The facility was found not in substantial compliance with resident rights, privacy and confidentiality, abuse and neglect protections, safe environment, infection control, and other regulatory requirements. Multiple deficiencies were identified related to resident dignity, privacy breaches, abuse investigations, staffing, medication administration, food safety, and fire safety.
Complaint Details
The survey was a Recertification and Complaint Survey. Complaints #NJ136113, NJ166137, NJ168809, NJ170019, NJ172459, NJ175436, NJ176328, NJ176501, NJ176722, NJ177353, NJ177725, and NJ178658 were investigated. Multiple substantiated findings of abuse, neglect, and failure to protect residents were identified.
Deficiencies (10)
| Description |
|---|
| Resident R265 was assessed by the facility and found to have sustained a determination of abuse from CNA 15 standing over them while toileting them with their meal. |
| Residents R75 and R110 were assessed by the facility and found not ensuring privacy when personal care was being provided. |
| Residents R140, R142, R66, R262, R76 and R128 were assessed by the facility for abuse and neglect and found to have delayed reporting and failure to protect residents. |
| Residents R262 and R76 were assessed for abuse and neglect with delayed reporting and failure to protect residents. |
| The facility failed to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
| Resident R157 was assessed and found not receiving proper pain management prior to assessment. |
| The facility failed to ensure medications were administered accurately and timely to residents R110 and R157. |
| Food safety deficiencies including failure to maintain proper food temperatures and palatability. |
| The facility failed to ensure fire extinguishing system was tested semi-annually and sprinkler system was maintained and inspected. |
| The facility failed to ensure stairway doors were equipped with panic hardware and fire alarm system was properly maintained. |
Report Facts
Survey Census: 277
Sample Size: 45
Total Licensed Capacity: 276
Deficiency Counts: 10
Inspection Report
Complaint Investigation
Census: 271
Deficiencies: 1
Sep 24, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ 00176328) to determine compliance with staffing requirements and other regulatory standards.
Findings
The facility was found not in compliance with New Jersey staffing regulations, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on multiple day shifts during the review period. The facility submitted a plan of correction and recognized staffing shortages on several shifts.
Complaint Details
Complaint #: NJ 00176328. The facility was found deficient in CNA staffing for residents on 11 of 14-day shifts during 06/23/2024 to 07/06/2024 and on 7 of 14-day shifts plus 1 of 14 evening shifts during 09/08/2024 to 09/21/2024. The complaint investigation concluded the facility failed to meet minimum staffing requirements as per New Jersey statutes.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 3 of 14-day shifts. |
Report Facts
Census: 271
Deficient CNA staffing days: 11
Deficient CNA staffing days: 7
Deficient total staff evening shifts: 1
Deficient CNA to total staff evening shifts: 1
Inspection Report
Routine
Census: 264
Deficiencies: 0
Jul 5, 2024
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 CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 260
Deficiencies: 0
Oct 24, 2023
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.
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 to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 263
Deficiencies: 2
Oct 17, 2023
Visit Reason
The inspection was conducted based on complaints NJ00163659 and NJ00164821 to determine compliance with federal and state regulations regarding resident records and staffing ratios.
Findings
The facility was found not in compliance with requirements for maintaining resident-identifiable information and medical records documentation. Additionally, the facility failed to maintain required minimum staffing ratios for Certified Nurse Aides (CNAs) during multiple shifts over several periods.
Complaint Details
Complaint numbers NJ00163659 and NJ00164821 triggered the investigation. The complaint was substantiated as the facility failed to consistently implement policies on charting and documentation for residents and failed to maintain required CNA staffing ratios on multiple shifts.
Severity Breakdown
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain resident-identifiable information and medical records according to 42 CFR Part 483, Subpart B. | SS=B |
| Failure to ensure staffing ratios met minimum requirements as mandated by New Jersey Administrative Code 8:39-5.1(a). | — |
Report Facts
Census: 263
Sample Size: 4
Deficient CNA staffing shifts: 13
Deficient CNA staffing shifts: 6
Deficient CNA staffing shifts: 7
CNA staffing counts: 29
CNA staffing counts: 31
CNA staffing counts: 30
CNA staffing counts: 32
CNA staffing counts: 31
CNA staffing counts: 27
CNA staffing counts: 27
CNA staffing counts: 30
CNA staffing counts: 29
CNA staffing counts: 32
CNA staffing counts: 31
CNA staffing counts: 33
CNA staffing counts: 32
CNA staffing counts: 33
CNA staffing counts: 28
CNA staffing counts: 32
CNA staffing counts: 32
CNA staffing counts: 31
CNA staffing counts: 30
CNA staffing counts: 31
Inspection Report
Complaint Investigation
Census: 263
Deficiencies: 0
Sep 7, 2023
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #NJ00162567.
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 #NJ00162567 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 272
Deficiencies: 2
May 23, 2023
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ00164286) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to ensure that emergency exit doors were unobstructed on Units 7, 8, and 9, with wheelchairs and patient lifts blocking the exits, posing a fire hazard. Additionally, the facility failed to maintain required minimum staff-to-resident ratios for 6 of 21 day shifts reviewed.
Complaint Details
Complaint #: NJ00164286. The complaint survey found the facility not in compliance with accident hazard and supervision requirements, specifically regarding blocked emergency exits. The complaint also included staffing deficiencies.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Emergency exit doors were obstructed by wheelchairs and patient lifts on Units 7, 8, and 9. | SS=E |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 6 of 21 day shifts reviewed. | — |
Report Facts
Census: 272
Sample Size: 4
Deficient CNA staffing days: 6
Residents: 269
Required CNAs: 34
Actual CNAs: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Mentioned in relation to observations of blocked emergency exits and responsibility for environmental rounds. | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed about emergency exit procedures and equipment blocking exits. | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about emergency exit clearance on Unit 7. | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about emergency exit clearance on Unit 8. | |
| Assistant Director of Nursing (ADON #1) | Responsible for safety checks on Units 7, 8, and 9, including ensuring emergency exits were unobstructed. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding expectations for emergency exit door clearance. | |
| Staffing Coordinator | Educated on proper staffing levels as part of plan of correction. | |
| Administrator | Responsible for plan of correction regarding staffing. |
Inspection Report
Routine
Census: 260
Deficiencies: 2
Dec 2, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities, focusing on staffing ratios and resident activities.
Findings
The facility was found non-compliant with minimum direct care staff-to-resident ratios as mandated by New Jersey state law, failing to meet required CNA staffing levels on all 14 day shifts reviewed. Additionally, the facility failed to provide residents with two evening activity programs per week on two resident units for four consecutive months.
Deficiencies (2)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. |
| Failure to provide residents two evening activity programs per week on Units 1 and 2 for four months. |
Report Facts
Residents: 260
Certified Nurse Aides (CNAs) required: 33
Certified Nurse Aides (CNAs) present: 21
Day shifts reviewed: 14
Months without two evening activities: 4
Resident units affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Recreation Aide | Interviewed and stated no staff worked past 5:00 PM | |
| Recreation Director | Acknowledged lack of evening activities on Units 1 and 2 due to staffing | |
| Licensed Nursing Home Administrator | Surveyor expressed concerns regarding lack of evening activities | |
| Director of Nursing | Surveyor expressed concerns regarding lack of evening activities |
Inspection Report
Complaint Investigation
Census: 255
Deficiencies: 3
Oct 18, 2022
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ00158740) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found non-compliant due to medication administration errors involving unauthorized staff administering medications to residents and failure to follow physician orders and facility policies on medication administration for two residents. Additionally, the facility failed to maintain appropriate food temperatures during service, risking food safety hazards.
Complaint Details
Complaint #: NJ00158740. The complaint investigation found deficiencies related to medication administration by unauthorized staff and medication errors, as well as food safety violations.
Severity Breakdown
SS=D: 2
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure that all staff administering medications were authorized according to professional standards and facility policy for 1 of 6 residents (Resident #6). | SS=D |
| Failed to follow physician orders and facility policy on administering medications for 1 of 6 residents (Resident #1), resulting in medication errors. | SS=D |
| Failed to ensure hot food and cold beverages were served within appropriate temperature ranges to reduce or prevent food safety hazards for 4 of 5 units and 5 test trays. | SS=F |
Report Facts
Census: 255
Sample Size: 6
Test trays: 5
Meal delivery delay: 6
Elevator outage duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in medication administration deficiency for handing medications to unauthorized CNA. |
| CNA #1 | Certified Nursing Assistant | Named in medication administration deficiency for administering medications without authorization. |
| ADON #2 | Assistant Director of Nursing | Interviewed regarding medication administration incident and education provided. |
| RN #1 | Registered Nurse | Interviewed regarding medication error involving Resident #1. |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding awareness of medication error. |
| FSD | Food Service Director | Interviewed regarding food temperature deficiencies and corrective actions. |
| DA #1 | Dietary Aid | Observed transporting meal delivery cart during food temperature testing. |
| DA #2 | Dietary Aid | Interviewed regarding use of disposable plates and utensils due to shortages. |
| DA #3 | Dietary Aid | Interviewed regarding use of disposable plates and utensils due to shortages. |
| DA #4 | Dietary Aid | Interviewed regarding use of disposable plates and utensils due to shortages. |
| DM | Director of Maintenance | Interviewed regarding kitchen elevator outage affecting meal transport. |
Inspection Report
Complaint Investigation
Census: 263
Deficiencies: 2
Jun 15, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ00148396, NJ00148644, NJ00148865, NJ00148892) alleging abuse and failure to report incidents properly.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, due to failure to report alleged abuse incidents to the New Jersey Department of Health, inadequate investigation and reporting procedures, and failure to consistently document care and assistance provided to residents.
Complaint Details
The complaint investigation revealed that the facility failed to report an allegation of abuse involving Resident #1 to the New Jersey Department of Health as required. Interviews and record reviews confirmed the incident was not reported, and the facility did not follow its Abuse Prevention Program policy. Additional complaints involved failure to document care for Residents #2 and #3 as per facility policy.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report a resident allegation of abuse to the New Jersey Department of Health within required timeframes. | SS=D |
| Failure to consistently implement policy on charting and documentation for residents, including incomplete documentation of assistance with activities of daily living. | SS=D |
Report Facts
Census: 263
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed the abuse incident and reported it to ADON #1 |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding failure to report abuse incident to NJDOH |
| ADON #2 | Assistant Director of Nursing | Conducted Concern Investigation and interviewed during survey |
| UM #1 | Unit Manager | Interviewed about documentation practices |
| CNA #1 | Certified Nursing Assistant | Interviewed about documentation of care provided to residents |
Inspection Report
Complaint Investigation
Census: 240
Deficiencies: 0
Aug 31, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00147402 and 00147432.
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 numbers NJ00147402 and 00147432 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 241
Deficiencies: 0
Aug 23, 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.
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
Complaint Investigation
Census: 248
Deficiencies: 0
Jul 17, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145805, NJ145406, NJ142060, NJ141800, and NJ141400.
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 numbers NJ145805, NJ145406, NJ142060, NJ141800, and NJ141400 were investigated and found to be in compliance.
Report Facts
Sample size: 12
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Dec 14, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00140084 and NJ00139874.
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 numbers NJ00140084 and NJ00139874 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 6
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