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 explains 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
Complaint Investigation
Census: 130
Deficiencies: 9
Mar 31, 2025
Visit Reason
A Recertification Survey was conducted from 3/25/2025 to 3/31/2025 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaints NJ00174183 and NJ00180900.
Findings
Deficiencies were cited related to medication administration errors, specifically a medication administration error rate of 6.25% involving Resident #79 and three nurses. The facility failed to ensure all medications were administered without error. A plan of correction included re-education and competency training for involved staff. Additional Life Safety Code deficiencies were found related to means of egress, emergency lighting, hazardous areas, sprinkler systems, corridor doors, and electrical equipment maintenance.
Complaint Details
Complaint numbers NJ00174183 and NJ00180900 triggered the survey. The medication administration error deficiency was substantiated based on observation, interview, and record review.
Severity Breakdown
SS=D: 3
SS=F: 6
Deficiencies (9)
| Description | Severity |
|---|---|
| Medication administration error rate of 6.25% identified during observation of Resident #79, involving three nurses. | SS=D |
| Means of egress not maintained free of obstructions and impediments. | SS=F |
| Emergency lighting battery backup not provided above emergency generator transfer switch. | SS=F |
| Hazardous areas fire-rated doors not self-closing or automatic-closing and not separated by smoke resisting partitions. | SS=F |
| Sprinkler heads loaded with dust and debris in multiple locations. | SS=F |
| Corridor doors not resisting passage of smoke and gaps present on doors. | SS=D |
| Fire doors assemblies not inspected, tested, and documented annually. | SS=F |
| Electrical equipment maintenance and testing not conducted or documented as required. | SS=D |
| Emergency generator not exercised for 4 continuous hours every 36 months. | SS=F |
Report Facts
Census: 130
Medication administration error rate: 6.25
Sample size: 27
Number of residents involved in medication error deficiency: 5
Number of nurses involved in medication error deficiency: 3
Number of medication administration opportunities observed: 32
Number of medication administration errors observed: 2
Dates of survey: 2025-03-25 to 2025-03-31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed preparing and administering medications to Resident #79; involved in medication error deficiency. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding medication administration for Resident #79. |
| Certified Nursing Aide #1 | Certified Nursing Aide | Interviewed regarding care of Resident #79 and breakfast tray delivery. |
| Director of Nursing | Director of Nursing | Provided in-service education and competency training related to medication administration. |
| Director of Maintenance | Director of Maintenance | Responsible for correcting Life Safety Code deficiencies including means of egress, emergency lighting, sprinkler system maintenance, door repairs, and electrical equipment inspections. |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 0
Dec 12, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health from 12/09/24 through 12/12/24.
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 visit.
Complaint Details
Complaint survey conducted on behalf of the New Jersey Department of Health from 12/09/24 through 12/12/24; facility found in compliance.
Report Facts
Sample Size: 13
Inspection Report
Annual Inspection
Census: 121
Deficiencies: 6
Mar 6, 2023
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 timely transmission of Minimum Data Set (MDS) assessments, failure to develop comprehensive care plans for residents with nutritional concerns, failure to maintain acceptable nutritional and hydration status, failure to ensure physician supervision addressing nutritional issues, and failure to maintain safe and appetizing food temperatures. Staffing ratios for Certified Nurse Aides (CNAs) did not meet state minimum requirements on multiple days.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to timely transmit a resident's Minimum Data Set (MDS) assessment to CMS within required timeframes. | SS=D |
| Failure to develop a comprehensive, person-centered care plan for residents with nutritional concerns. | SS=D |
| Failure to maintain acceptable parameters of nutritional status, including failure to identify and address significant weight loss and failure to provide recommended nutritional supplements. | SS=G |
| Failure to ensure physician supervision addressed significant nutritional issues for a resident. | SS=E |
| Failure to ensure food and drink were served at safe and appetizing temperatures. | SS=D |
| Failure to maintain required minimum direct care staffing ratios for Certified Nurse Aides (CNAs) on day shifts. | — |
Report Facts
Census: 121
Deficiencies cited: 6
Staffing ratios: 12
Staffing ratios: 9
Staffing ratios: 13
Staffing ratios: 12
Staffing ratios: 13
Staffing ratios: 13
Staffing ratios: 12
Staffing ratios: 13
Staffing ratios: 15
Staffing ratios: 15
Staffing ratios: 15
Staffing ratios: 12
Food temperatures: 117
Food temperatures: 119.3
Food temperatures: 124
Food temperatures: 53
Food temperatures: 141.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Named in relation to findings on untimely MDS transmission and care plan development | |
| Registered Dietitian | Named in relation to nutritional assessment and care plan deficiencies | |
| Director of Nursing (DON) | Named in relation to oversight of care plan and nutritional deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Named in relation to oversight and interviews | |
| Unit Manager/Licensed Practical Nurse (UM/LPN) | Named in relation to nutritional supplement administration and communication | |
| Food Service Director (FSD) | Named in relation to food temperature and meal service findings | |
| Certified Nursing Aide (CNA) | Named in relation to nutritional supplement administration and staffing | |
| Staff Coordinator | Named in relation to staffing ratio findings | |
| Nurse Practitioner (NP) | Named in relation to physician supervision and nutritional care |
Inspection Report
Life Safety
Capacity: 82
Deficiencies: 5
Mar 6, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 3/02/2023 and 3/06/2023 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety code standards.
Findings
The facility was found noncompliant with fire safety requirements including failure to have self-closing fire-rated doors on hazardous areas, malfunctioning bathroom exhaust systems, non-functional GFCI electrical outlets near water sources, lack of annual electrical receptacle testing, and absence of a remote emergency stop button for the emergency generator.
Severity Breakdown
SS=E: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions. | SS=E |
| Failure to ensure ventilation systems were properly maintained; exhaust systems in 2 of 12 resident bathrooms were not functioning. | SS=D |
| One of 18 electrical outlets near water sources was not equipped with a safe and secured Ground-Fault Circuit Interrupter (GFCI). | SS=D |
| Failure to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=E |
| Failure to ensure a remote manual stop station for the emergency generator was installed. | SS=E |
Report Facts
Resident sleeping rooms: 82
Resident bathrooms inspected: 12
Bathrooms with non-functioning exhaust: 2
Electrical outlets tested near water sources: 18
Electrical outlets with deficient GFCI: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present during survey and informed of findings. | |
| Director of Maintenance | Present during survey, involved in corrective actions and confirmations of findings. | |
| Maintenance Assistant | In-serviced regarding regulations and corrective actions. |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Jul 11, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers alleging violations related to abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility failed to report the results of all alleged violation investigations to the New Jersey Department of Health within prescribed timeframes. The investigation found no evidence to corroborate the allegations of racial verbiage by a housekeeper or unknown origin injuries to a resident, but the facility did not report the allegations to the state agency as required.
Complaint Details
The complaint investigation involved multiple complaint numbers alleging abuse, neglect, exploitation, or mistreatment, including racial verbiage used by a housekeeper and injuries of unknown origin to a resident. The facility investigated and found no evidence to support the allegations but failed to report the results to the NJDOH as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report the results of all alleged violation investigations to the NJDOH within prescribed timeframes. | SS=D |
Report Facts
Census: 102
Sample Size: 15
Plan of Correction Completion Date: Sep 2, 2022
Survey Date Range: 2022-07-11 to 2022-07-13
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 28, 2021
Visit Reason
The inspection was conducted to assess compliance with mandatory staffing ratios as required by New Jersey law, following review of staffing reports and interviews.
Findings
The facility failed to meet required staffing ratios for 5 of 14 shifts reviewed, potentially affecting all residents. The facility has implemented corrective actions including increased staffing rates, advertising, job fairs, agency contracts, and ongoing monitoring by the Director of Nursing.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 5 of 14 shifts reviewed. |
Report Facts
Staffing ratio: 7
Staffing ratio: 12
Staffing ratio: 11
Staffing ratio: 11
Staffing ratio: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for conducting weekly meetings and monthly audits of staffing patterns and ratios |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 6
Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a Recertification Survey were conducted to determine compliance with infection control regulations and long term care facility requirements.
Findings
Deficiencies were cited related to medication administration not following physician hold parameters, inaccurate documentation of skin condition, failure to implement restorative nursing programs as per physical therapy recommendations, inadequate pain management including delayed administration of breakthrough medication, and improper destruction and documentation of controlled medications.
Severity Breakdown
SS=E: 4
SS=G: 1
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Medication used to treat was administered outside of physician hold parameters multiple times by various nurses over six months. | SS=E |
| Inaccurate documentation of a resident's skin condition and failure to properly document wound treatments as ordered. | SS=E |
| Failure to apply positioning devices and implement restorative nursing program as per physical therapy discharge recommendations, including lack of measurable goals in care plan. | SS=E |
| Failure to timely administer breakthrough pain medication and assess pain prior to wound dressing changes; failure to use seat cushion as ordered to reduce pain. | SS=G |
| Improper destruction and documentation of controlled drug (Schedule IV) including lack of witnessing nurse signature and disposal in regular trash. | SS=D |
| Consultant Pharmacist recommendations regarding medication errors and hold parameters were not acted upon timely; repeated medication errors occurred without documented physician rationale or disciplinary action. | SS=E |
Report Facts
Medication administration outside hold parameters: 33
Medication refusal: 12
Medication refusal: 15
Medication destruction: 2
Medication error repeat: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided statements about medication error protocols, education, and quality assurance plans. | |
| Licensed Practical Nurse/Unit Manager | Discussed medication error protocol, education, and medication administration practices. | |
| Consultant Pharmacist | Provided drug regimen reviews and discussed medication errors and follow-up with facility. | |
| Physical Therapist | Provided physical therapy discharge recommendations and caregiver training. | |
| Certified Nursing Aides | Involved in resident care and positioning; provided statements about resident responses and use of devices. | |
| Licensed Practical Nurse | Administered medications, described medication refusal and destruction, and discussed pain management. |
Inspection Report
Routine
Census: 95
Deficiencies: 0
Jan 29, 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
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