Deficiencies per Year
20
15
10
5
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
Annual Inspection
Census: 128
Capacity: 180
Deficiencies: 18
Sep 19, 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).
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in notification of changes, investigation of alleged violations, PASARR screening, food accommodations, staffing ratios, emergency preparedness, life safety code compliance including building construction, emergency lighting, hazardous areas, fire alarm system, sprinkler system, corridor doors, smoke barriers, elevator firefighter service, smoking regulations, electrical receptacles, essential electrical systems, and gas equipment storage.
Complaint Details
Complaint survey included review of staffing and investigation of alleged abuse incidents. The facility was found deficient in staffing ratios and failed to conduct thorough investigations of abuse allegations.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 12
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to notify resident's representative of significant change in condition. | SS=D |
| Failed to conduct thorough investigation of alleged abuse incident. | SS=D |
| Failed to ensure accurate Preadmission Screening and Resident Review (PASARR) for sampled residents. | SS=D |
| Failed to provide food accommodating resident allergies and preferences. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios. | — |
| Emergency preparedness communication plan not updated and contained inaccurate contact information. | SS=F |
| Ceiling tiles missing at covered parking area below floors two through five. | SS=F |
| Emergency lighting system not tested monthly for 18 months prior to survey. | SS=F |
| Unsealed penetrations and doors not latching in hazardous areas and soiled linen rooms. | SS=F |
| Fire alarm system deficiencies not corrected including pull station, heat detector, and smoke detector. | SS=F |
| Sprinkler system relief valve leaking and not repaired. | SS=F |
| Corridor doors failed to latch and close properly. | SS=F |
| Unsealed gaps and penetrations in smoke barriers. | SS=F |
| Elevator monthly firefighter service operation not documented. | SS=F |
| Smoking area lacked metal containers with self-closing lids for cigarette butts disposal. | SS=E |
| Power receptacles lacked required grounding poles and had multiple bad GFCIs. | SS=F |
| Generator alarms for low water temperature and call powerhouse not addressed timely. | SS=F |
| Oxygen storage room lacked required caution signage. | SS=F |
Report Facts
Census: 128
Total Capacity: 180
Sample Size: 37
Deficiency counts: 17
Staffing ratios: 1
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
May 23, 2024
Visit Reason
The inspection was conducted in response to a complaint (NJ00171421) to determine compliance with federal and state regulations for long term care facilities.
Findings
The facility was found to be out of compliance with New Jersey Administrative Code standards due to failure to meet required minimum staffing ratios on 2 of 14 day shifts during the survey period. The facility must submit a plan of correction to address these deficiencies.
Complaint Details
Complaint #: NJ00171421. The facility was found non-compliant based on the complaint survey but was in compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities. Staffing deficiencies were identified related to CNA staffing ratios on specific days.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 2 of 14 day shifts. |
Report Facts
Census: 135
Deficient CNA staffing days: 2
CNA staffing on 05/05/24: 16
CNA staffing on 05/12/24: 15
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
Apr 24, 2024
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with staffing ratio requirements mandated by the state of New Jersey for long term care facilities.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staff-to-resident ratios on multiple day shifts and one overnight shift. The facility submitted a plan of correction to address staffing deficiencies.
Complaint Details
The complaint investigation found the facility deficient in CNA staffing on 6 of 28 day shifts during the review periods from 04/30/2023 to 05/13/2023 and 04/07/2024 to 04/20/2024, and deficient in total staff on 1 overnight shift. Specific dates with deficiencies include 04/30/23, 05/07/23, 05/13/23, 04/07/24, 04/14/24, and 04/20/24. The facility was required to submit a Plan of Correction.
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 6 of 28 day shifts. |
Report Facts
Deficient CNA staffing day shifts: 6
Deficient total staff overnight shifts: 1
Census: 135
Staffing ratios required: 8
Staffing ratios required: 10
Staffing ratios required: 14
CNA staffing on 04/30/23: 11
CNA staffing on 05/07/23: 15
CNA staffing on 05/13/23: 15
CNA staffing on 04/07/24: 15
CNA staffing on 04/14/24: 15
Total staff on 04/20/24 overnight shift: 9
Inspection Report
Routine
Census: 129
Deficiencies: 11
Sep 19, 2022
Visit Reason
The inspection was a standard survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance with certain regulatory requirements, including reasonable accommodations for resident call bells, safe and homelike environment during meal service, and proper encoding and transmitting of resident assessments. Deficiencies were cited in multiple areas including resident care, environment, and documentation.
Severity Breakdown
Level D: 9
Level F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to maintain resident call bells accessible and within reach of all residents. | Level D |
| Facility failed to provide a safe, clean, comfortable, and homelike environment during meal service. | Level D |
| Facility failed to complete and transmit Minimum Data Set (MDS) assessments in accordance with federal guidelines. | Level D |
| Facility failed to develop and implement a comprehensive person-centered care plan for residents. | Level D |
| Facility failed to follow professional standards of practice related to medication administration and documentation. | Level D |
| Facility failed to ensure free of accident hazards and provide adequate supervision to prevent accidents. | Level D |
| Facility failed to provide hospice services in accordance with regulatory requirements. | Level D |
| Facility failed to maintain adequate staffing ratios for certified nurse aides. | Level D |
| Facility failed to maintain life safety code compliance including means of egress, fire door assemblies, sprinkler system maintenance, and emergency lighting. | Level F |
| Facility failed to maintain electrical systems and emergency power systems in accordance with NFPA standards. | Level F |
| Facility failed to maintain proper storage and handling of gas equipment and cylinders. | Level F |
Report Facts
Census: 129
Sample Size: 31
Deficiencies cited: 12
Audit frequency: 5
Audit frequency: 10
Audit frequency: 6
Audit frequency: 4
Audit frequency: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) / Unit Manager (UM) | RN/UM | Interviewed regarding resident call bell placement and care plan issues. |
| Certified Nursing Assistant (CNA) | CNA | Interviewed about resident call bell placement and care. |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Informed of findings and involved in policy review and corrective actions. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plans, medication administration, and policy compliance. |
| Assistant Director of Nursing/Inservice Designee | Assistant Director of Nursing | Responsible for inservice training related to call bell use, meal service, and medication administration. |
| Regional MDS Coordinator | MDS Coordinator | Responsible for MDS transmission and training. |
| Registered Dietitian (RD) | Dietitian | Interviewed about resident care plans and nutritional assessments. |
| Licensed Practical Nurse (LPN) | LPN | Interviewed regarding medication administration and documentation. |
| Registered Nurse (RN) #1 | RN | Interviewed about resident care and medication administration. |
| Registered Nurse (RN) #2 | RN | Interviewed about medication labeling and administration. |
| Registered Nurse (RN) #3 | RN | Interviewed about resident care and physician orders. |
| Registered Nurse Charge Nurse (RNCN) | Charge Nurse | Interviewed about medication inventory and control. |
| Consultant Pharmacist (CRPh) | Pharmacist | Interviewed about medication inventory and control. |
| Provider Pharmacy | Pharmacy | Provided medication administration records and inventory. |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Mar 31, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00152441, NJ00152829, and NJ00152949 regarding the facility's compliance with professional standards of care.
Findings
The facility failed to follow professional standards and their Physician Notification Policy for one resident by not completing a stat order and failing to notify the physician. The Director of Nursing acknowledged the failure to complete the order and notify the physician as required.
Complaint Details
The complaint investigation found that the facility did not follow acceptable professional standards of practice on documentation and physician notification for one of eight residents reviewed. The deficiency was substantiated based on interviews, record review, and facility policy review.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow the Physician Notification Policy and complete a stat order for one resident, resulting in lack of physician notification. | SS=D |
Report Facts
Sample Size: 8
Census: 120
QA Audit Frequency: 5
QA Audit Duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding the facility's policy and acknowledged failure to notify physician and complete stat order | |
| Unit Manager (UM #2) | Documented physician order for stat and interviewed about notification procedures |
Inspection Report
Routine
Census: 128
Deficiencies: 0
Jan 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.
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: 135
Deficiencies: 1
Sep 23, 2021
Visit Reason
The inspection was conducted as a complaint survey based on grievance allegations regarding the facility's failure to promptly resolve a resident's grievance about a missing mini refrigerator.
Findings
The facility failed to ensure that a resident's grievance regarding a missing mini refrigerator was promptly resolved. The grievance process was not timely, although corrective actions were later implemented including policy revision, staff inservice, and monitoring procedures.
Complaint Details
Complaint #: NJ00146243. The facility failed to promptly resolve a grievance filed by a resident's responsible party regarding a missing mini refrigerator. The grievance was documented but not resolved in a timely manner despite repeated notifications to facility staff and administration.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure prompt resolution of resident grievances as required by 42 CFR Part 483, Subpart B. | SS=D |
Report Facts
Census: 135
Sample Size: 6
Inspection Report
Routine
Census: 151
Deficiencies: 0
Sep 3, 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 had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
May 18, 2021
Visit Reason
The inspection was conducted as a complaint survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Dec 14, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00130929 and NJ00140205.
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 NJ00130929 and NJ00140205 were investigated and found to be in compliance.
Report Facts
Sample Size: 4
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