Deficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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 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
Routine
Census: 117
Deficiencies: 10
Feb 3, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations for multiple complaint numbers.
Findings
The facility was found to have multiple deficiencies related to resident rights, safe environment, care planning, treatment and prevention of pressure ulcers, pain management, pharmacy services, food safety, infection control, and life safety code compliance. Corrective actions were implemented and documented for all cited deficiencies.
Complaint Details
Complaint numbers NJ 172211, #175979, #177635, #182108 were investigated as part of this survey. Deficiencies were substantiated and corrective actions were implemented.
Severity Breakdown
Level 3: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to promote and maintain resident dignity during dining assistance and seating. | Level 3 |
| Failure to maintain a safe, clean, comfortable, homelike environment including housekeeping and maintenance. | Level 3 |
| Failure to conduct timely and comprehensive care plan assessments and revisions. | Level 3 |
| Failure to implement individualized care plan interventions for residents with mental illness. | Level 3 |
| Failure to provide care and services to prevent pressure ulcers and ensure proper wound care. | Level 3 |
| Failure to provide adequate pain management and monitoring. | Level 3 |
| Failure to provide pharmaceutical services with accurate medication administration and documentation. | Level 3 |
| Failure to maintain safe food procurement, storage, preparation, and sanitation practices. | Level 3 |
| Failure to maintain infection prevention and control program and proper handling of soiled linens and equipment. | Level 3 |
| Failure to maintain life safety code compliance including exit discharge, smoke barrier doors, sprinkler system, fire extinguishers, and electrical receptacles. | Level 3 |
Report Facts
Census: 117
Sample size: 31
Deficiency count: 10
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Nov 25, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ00176534 and NJ00179295.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities.
Complaint Details
Complaint numbers NJ00176534 and NJ00179295 were investigated and found to be unsubstantiated as the facility was in compliance with all applicable standards.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Feb 8, 2024
Visit Reason
The inspection was conducted as a complaint survey to determine 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 to be in compliance.
Report Facts
Sample size: 4
Inspection Report
Life Safety
Census: 103
Capacity: 126
Deficiencies: 3
Dec 19, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including missing required signage on delay-egress doors, failure to conduct smoke detection sensitivity testing every other year, and failure to inspect fire doors annually. These deficiencies potentially affected all 103 residents.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| 15 out of 19 exit doors equipped with delay-egress locking systems lacked the required signage stating 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS'. | SS=F |
| Failed to ensure smoke detection sensitivity testing of smoke detectors was completed every alternate year as required. | SS=F |
| Failed to ensure fire doors were inspected annually in accordance with NFPA 101 Life Safety Code. | SS=F |
Report Facts
Deficient exit doors lacking signage: 15
Current occupied beds: 103
Total licensed capacity: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed deficiencies related to delay-egress door signage, smoke detector sensitivity testing, and fire door inspections |
Inspection Report
Annual Inspection
Census: 103
Capacity: 126
Deficiencies: 4
Dec 19, 2023
Visit Reason
A Recertification and Complaint Survey was conducted to assess compliance with federal regulations including 42 CFR 483 subpart B and Life Safety Code requirements.
Findings
The facility was found not in substantial compliance with certain regulatory requirements including timely transmission of Minimum Data Set (MDS) assessments, missing signage on delay-egress doors, lack of biennial smoke detector sensitivity testing, and failure to conduct annual fire door inspections. Corrective actions and re-education plans were implemented.
Complaint Details
The survey included a complaint investigation component but no deficiencies were issued related to specific complaint intakes listed (NJ149370, NJ151215, NJ152516, NJ153172, NJ153308, NJ156275, NJ156731, NJ157698).
Severity Breakdown
SS=E: 1
SS=F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days after completion for six of 11 sampled residents. | SS=E |
| Failed to ensure 15 of 19 exit doors with delay-egress locking had required signage stating 'PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS'. | SS=F |
| Failed to ensure smoke detection sensitivity testing of smoke detectors was completed every alternate year as required. | SS=F |
| Failed to ensure fire doors were inspected annually in accordance with NFPA 80 standards. | SS=F |
Report Facts
Survey Census: 107
Sample Size: 28
Number of delay-egress doors lacking signage: 15
Facility capacity: 126
Current occupied beds: 103
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Jun 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00148819 and NJ00164462 to determine compliance with staffing ratio requirements.
Findings
The facility was found deficient in maintaining the required minimum staff-to-resident ratios mandated by New Jersey for multiple day, evening, and night shifts over several weeks. The deficiency had the potential to affect all residents, though no specific residents were identified as affected.
Complaint Details
Complaint numbers NJ00148819 and NJ00164462 were investigated. The facility was found in noncompliance with staffing requirements but was ultimately found in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
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 21 of 21 day shifts, 1 of 21 evening shifts, and 1 of 21 night shifts reviewed. |
Report Facts
Census: 106
Sample Size: 3
Days deficient in staffing ratios: 21
Evening shifts deficient: 1
Night shifts deficient: 1
Required CNAs on 09/19/21: 11
Actual CNAs on 09/19/21: 8
Required CNAs on 05/14/23: 14
Actual CNAs on 05/14/23: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 06/02/23 regarding staffing shortages and recruitment efforts. |
| Staffing Coordinator | Staffing Coordinator | Educated by the Administrator regarding mandatory staffing ratios and instructed to update contact information and staffing schedules. |
| Administrator | Administrator | Educated Staffing Coordinator and responsible for auditing staffing reports and monitoring compliance. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Nov 10, 2021
Visit Reason
The inspection was conducted based on Complaint #NJ00149893 to investigate the facility's compliance with safety and environmental regulations.
Findings
The facility failed to maintain a safe environment for 2 of 3 residents observed during the environmental tour due to the presence of a portable electric heater in a resident room, which is against facility policy and safety regulations. The heater was removed immediately and corrective actions were implemented to prevent recurrence.
Complaint Details
Complaint #NJ00149893 was substantiated as the facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on the presence of a portable electric heater in resident rooms, which posed a safety risk.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a safe environment due to use of a portable electric heater in resident rooms. | SS=D |
Report Facts
Census: 92
Deficiency completion date: Nov 30, 2021
Inspection Report
Routine
Census: 93
Deficiencies: 0
Oct 7, 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 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: 6
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Sep 27, 2021
Visit Reason
The inspection was conducted as a complaint survey based on allegations of abuse, neglect, exploitation, or mistreatment involving an unwitnessed injury to a resident.
Findings
The facility failed to report an unwitnessed injury for one resident as required by regulations. The investigation revealed deficiencies in reporting alleged violations involving abuse or injuries of unknown origin.
Complaint Details
Complaint numbers NJ146992 and NJ148000 were investigated. The complaint intake NJ146992 found that the facility failed to report an unwitnessed injury for Resident #1. The complaint was substantiated as the requirement was not met.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an unwitnessed injury for a resident within required timeframes. | SS=D |
Report Facts
Census: 93
Sample Size: 5
Inspection Report
Life Safety
Census: 86
Deficiencies: 3
Jul 21, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 07/16/21 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with fire safety requirements including failure to provide occupant notification devices in the enclosed courtyard, incomplete sprinkler system coverage in a storage room, and improper maintenance of sprinkler escutcheon plates. Corrective actions and plans for ongoing monitoring were outlined.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide notification by audible and visible signals in the enclosed courtyard as part of the fire alarm system. | SS=E |
| Failure to provide complete sprinkler coverage in the north linen closet across from resident room 211. | SS=D |
| Failure to maintain sprinkler system by using improper escutcheon plates around sprinkler heads, leaving gaps in the ceiling. | SS=E |
Report Facts
Census: 86
Deficiency completion date: Aug 6, 2021
Deficiency completion date: Aug 11, 2021
Deficiency completion date: Aug 21, 2021
Inspection Report
Life Safety
Deficiencies: 3
Jul 16, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 EXISTING Health Care Occupancy.
Findings
The facility was found to be in noncompliance with fire safety requirements including failure to provide audible and visible fire alarm notification devices in the enclosed courtyard, incomplete sprinkler coverage in a linen closet, and improper sprinkler escutcheon plates on 25 of 50 sprinkler heads. Corrective actions were planned and completed as verified in a follow-up revisit.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide notification by audible and visible signals in the enclosed courtyard tied into the fire alarm system. | SS=E |
| Failed to provide complete sprinkler coverage in the north linen closet across from resident room 211. | SS=D |
| Failed to maintain sprinkler system by using incorrect escutcheon plates around 25 of 50 fire sprinkler heads, leaving gaps that could affect activation. | SS=E |
Report Facts
Fire sprinkler heads with incorrect escutcheon plates: 25
Number of smoke zones in facility: 12
Percentage of building covered by generator: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and involved in corrective actions for fire alarm and sprinkler deficiencies | |
| Housekeeping Director | Present during observations of deficiencies | |
| Administrator | Notified of findings at Life Safety Code exit conference | |
| Regional Plant Operations Director | Present during observations of deficiencies |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Apr 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint# NJ 141848 to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to follow physician's orders and facility policies regarding medication and oxygen administration for one of three residents sampled. Deficient practices included missing vital signs documentation and improper adherence to physician orders.
Complaint Details
Complaint# NJ 141848 was investigated and found the facility not in substantial compliance with regulatory requirements based on the complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet professional standards of quality in following physician's medication and oxygen administration orders for Resident #2. | SS=D |
Report Facts
Sample Size: 4
Deficiencies cited: 1
Inspection Report
Routine
Census: 71
Deficiencies: 0
Jan 19, 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: 4
Inspection Report
Routine
Census: 93
Deficiencies: 0
Dec 16, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Loading inspection reports...
