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 regarding their health 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
Census: 152
Capacity: 162
Deficiencies: 10
Dec 23, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations for complaint numbers NJ 169201, 169245, and 170494.
Findings
Deficiencies were cited related to failure to make survey results readily accessible to residents and visitors, unsafe and unsanitary environment conditions, food safety violations, and multiple life safety code violations including fire door labeling, means of egress, and fire door inspections. The facility was found to be in substantial compliance with emergency preparedness but had multiple deficiencies in other areas.
Complaint Details
The survey included complaint investigations for complaint numbers NJ 169201, 169245, and 170494. The complaints were substantiated as deficiencies were cited related to survey result accessibility and environmental concerns.
Severity Breakdown
SS-D: 2
SS-E: 3
SS-F: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to make survey results readily accessible to residents and visitors. | SS-D |
| Facility failed to maintain a clean, safe, and sanitary environment for 2 of 3 units' floors. | SS-E |
| Facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. | SS-D |
| Facility failed to provide two-hour fire resistance-rated elements and assemblies in accordance with NFPA 101. | SS-F |
| Facility failed to provide guards at exit ramps in accordance with NFPA 101 Life Safety Code. | SS-E |
| Facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments. | SS-E |
| Facility failed to provide required instructional signage for K-type fire extinguishers. | SS-F |
| Facility failed to ensure fire doors were inspected annually by a qualified person. | SS-F |
| Facility failed to ensure smoke control systems were maintained in a safe operating condition. | SS-F |
| Facility failed to provide electrical policy for patient care related electrical equipment and maintain required testing and maintenance documentation. | SS-F |
Report Facts
Census: 152
Total Capacity: 162
Number of Deficiencies: 10
Completion Dates: Various completion dates for plans of correction range from 01/15/2025 to 03/01/2026.
Inspection Report
Complaint Investigation
Census: 150
Capacity: 162
Deficiencies: 7
Sep 28, 2023
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health due to complaints and recertification requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to safe environment, freedom from abuse, comprehensive care planning, accident hazards, nutrition/hydration, and life safety code violations. Several complaints were substantiated with deficiencies.
Complaint Details
Multiple complaints were investigated with some substantiated deficiencies at tags F584 and F600 related to safe environment and freedom from abuse. Several complaints were unsubstantiated with no citations.
Severity Breakdown
Level D: 2
Level E: 2
Level F: 1
Level G: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide a clean and sanitary environment for residents, including room disrepair and stained linens. | Level D |
| Facility failed to protect residents from abuse and neglect, including failure to follow incident reporting protocols. | Level G |
| Facility failed to develop and implement comprehensive person-centered care plans for residents. | Level G |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents and falls. | Level D |
| Facility failed to maintain nutrition and hydration status, including failure to provide prescribed nutrition interventions and proper food service. | Level E |
| Facility failed to maintain fire alarm system and smoke barriers in accordance with NFPA codes. | Level F |
| Facility failed to ensure oxygen cylinders were stored safely and separated from combustible materials. | Level E |
Report Facts
Survey Dates: 2023-09-25 to 2023-09-28
Sample Size: 30
Supplemental Residents: 0
Occupied Beds: 148
Total Licensed Capacity: 162
Residents Reviewed: 33
Residents Reviewed for Falls: 33
Residents Reviewed for Nutrition: 33
Residents Reviewed for Abuse: 7
Residents Reviewed for Oxygen Storage: 53
Residents Potentially Affected by Fire Alarm Deficiency: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 12 | Licensed Practical Nurse | Named in abuse incident report failure to follow protocol |
| Certified Nurse Aide 4 | Certified Nurse Aide | Interviewed regarding resident interactions and abuse allegations |
| Registered Nurse 18 | Registered Nurse | Interviewed regarding resident interactions and abuse allegations |
| Unit Manager 20 | Unit Manager | Interviewed regarding resident interactions and abuse allegations |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incident and falls protocol |
| Food Service Director | Food Service Director | Interviewed regarding food service and nutrition deficiencies |
| Dietitian | Registered Dietitian | Interviewed regarding nutrition and meal service |
| Maintenance Director | Maintenance Director | Interviewed regarding fire alarm and oxygen storage deficiencies |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 4
Aug 18, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ00166465 to investigate compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to documentation of Activities of Daily Living (ADL) care, respiratory/tracheostomy care and suctioning, and resident records including lifesaving measures documentation. Deficiencies were identified in CNA staffing ratios and physician orders for oxygen therapy.
Complaint Details
Complaint #NJ00166465 was substantiated based on observations, interviews, and record reviews indicating multiple deficiencies in care and documentation.
Severity Breakdown
Level D: 1
Level B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to consistently document Activities of Daily Living (ADL) care for dependent residents. | Level D |
| Failure to obtain physician's order for respiratory care including tracheostomy and suctioning and failure to follow facility policy. | Level B |
| Failure to document lifesaving measures in resident medical records and maintain confidentiality and completeness of medical records. | Level B |
| Failure to maintain required minimum direct staff-to-resident ratios for Certified Nursing Assistants (CNA) on 5 of 14 day shifts. | — |
Report Facts
Census: 148
Sample Size: 5
Deficient CNA staffing shifts: 5
CNA staffing required: 18
CNA staffing actual: 15
Date of revisit: Sep 27, 2023
Inspection Report
Routine
Deficiencies: 0
Mar 21, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 3/21/2023 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.
Inspection Report
Annual Inspection
Census: 143
Deficiencies: 9
Jul 26, 2022
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 resident rights, nutrition and dietary services, accident hazards, infection control, dialysis orders, food safety and sanitation, garbage disposal, and antibiotic stewardship.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were assisted to eat meals in a timely manner and dining experience promoted dignity and respect for 5 of 32 residents. | SS=D |
| Facility failed to ensure consistent dietician assessments and obtain physician orders for dietary supplements for 2 residents. | SS=D |
| Resident was found in possession of prohibited smoking supplies. | SS=D |
| Resident's urinary catheter was not maintained properly; catheter bag was on floor and not covered. | SS=D |
| Facility failed to maintain a current physician order for dialysis for 1 resident. | SS=D |
| Facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner in the kitchen and resident pantry. | SS=E |
| Facility failed to keep garbage compactor doors closed and loading dock area free of debris and cigarette butts. | SS=D |
| Staff failed to wear appropriate personal protective equipment (gowns) in a resident's room under contact precautions. | SS=D |
| Facility failed to implement antibiotic stewardship protocols to prevent unnecessary antibiotic use for 1 resident. | SS=D |
Report Facts
Census: 143
Sample size: 36
Number of residents reviewed for dining: 32
Number of residents reviewed for nutrition: 2
Number of residents reviewed for accident hazards: 1
Number of residents reviewed for catheter care: 1
Number of residents reviewed for dialysis: 1
Number of residents reviewed for infection control: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Food Service Director | Interviewed about meal tray delivery and food service procedures | |
| Licensed Nursing Home Administrator | Interviewed about dining room seating and feeding assistance | |
| Registered Dietician | Interviewed about nutrition assessments and dietary supplement orders | |
| Licensed Practical Nurse #3 | Interviewed about resident dietary supplement orders | |
| Licensed Nurse/Unit Manager #1 | Interviewed about dietary supplement orders and feeding assistance | |
| Certified Nursing Assistants (CNAs) | Named in relation to feeding assistance and PPE deficiencies | |
| Licensed Practical Nurse/Unit Manager #1 | Interviewed about resident possession of smoking supplies | |
| Director of Nursing | Interviewed about infection control, dietary supplement orders, and PPE compliance | |
| Infection Preventionist | Provided education and audit plans for infection control and PPE compliance | |
| Certified Nursing Assistant #1 | Interviewed about failure to wear gown during care |
Inspection Report
Life Safety
Deficiencies: 6
Jul 25, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/25 and 07/26/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Preferred Care at Absecon.
Findings
The facility was found to have multiple life safety deficiencies including failure of stairwell doors to maintain fire resistance rating, hazardous area doors not self-closing, improperly installed portable fire extinguishers, corridor doors not resisting smoke passage, breaches in smoke barrier walls, and malfunctioning bathroom exhaust ventilation systems.
Severity Breakdown
SS=E: 3
SS=F: 2
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Two of sixteen exit stairwell doors failed to positive latch into their frames, compromising the two-hour fire rated construction. | SS=E |
| Fire-rated doors to hazardous areas were not self-closing and lacked proper separation by smoke-resisting partitions, specifically the medical records room door. | SS=E |
| Twelve of forty-three portable fire extinguishers were installed below the required height, violating NFPA 10 installation standards. | SS=F |
| One corridor door to a resident room did not close properly, leaving a one-inch gap allowing passage of smoke and fire. | SS=D |
| Two of seven smoke barrier walls had penetrations with unsealed holes allowing smoke, fumes, and fire to pass through. | SS=E |
| Four of fifteen resident bathroom exhaust systems were not functioning properly, failing to provide required mechanical ventilation. | SS=F |
Report Facts
Fire rated stairwell doors tested: 16
Portable fire extinguishers inspected: 43
Resident rooms inspected for bathroom exhaust: 15
Smoke barrier walls inspected: 7
Resident room doors inspected: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during observations and confirmed findings |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
Oct 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on complaints NJ149124, NJ149391, and NJ149474.
Findings
The facility was found to be in substantial compliance with 42 CFR §483.80 infection control regulations related to COVID-19 and the requirements of 42 CFR Part 483, Subpart B for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ149124, NJ149391, and NJ149474 were investigated. The facility was found to be in substantial compliance with infection control requirements.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Aug 3, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144042, NJ143936, NJ142696, and NJ134968.
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 NJ144042, NJ143936, NJ142696, and NJ134968 were investigated and found to be in compliance.
Report Facts
Sample Size: 9
Inspection Report
Routine
Census: 123
Deficiencies: 0
Feb 17, 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: 8
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 2
Jan 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ136404, NJ139598, NJ140308, NJ138537) to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant with infection prevention and control requirements, specifically failing to ensure staff changed gloves during incontinent care for one resident and failing to prohibit indoor visitation during Phase 0 of reopening amid a COVID-19 outbreak. The facility was in Phase 0 with active COVID-19 cases and did not follow NJDOH directives regarding visitation restrictions.
Complaint Details
The visit was complaint-driven based on four complaint numbers. The facility was found not in compliance with infection control and visitation policies during the COVID-19 pandemic, with substantiated deficiencies related to glove use and visitation restrictions.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff changed gloves while providing incontinent care for Resident #3, including not washing hands before or after care. | SS=E |
| Failure to prohibit indoor visitation during Phase 0 of reopening for Resident #6, contrary to NJDOH Executive Directive No. 02-026-1. | SS=E |
Report Facts
Census: 134
Sample Size: 6
COVID-19 positive residents: 5
Total residents with COVID-19: 14
Glove change re-education completion date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in deficiency for failing to change gloves and wash hands during incontinent care |
| Unit Manager #1 | Unit Manager | Observed providing care with CNA #1 |
| DON | Director of Nursing | Interviewed regarding visitation policies and COVID-19 status |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control and visitation policies |
| Administrator | Facility Administrator | Involved in visitation policy discussion and corrective actions |
Inspection Report
Routine
Census: 134
Deficiencies: 0
Jan 20, 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: 5
Inspection Report
Routine
Census: 95
Deficiencies: 0
Dec 9, 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.
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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