Deficiencies per Year
16
12
8
4
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 outlines 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 this notice |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Jun 9, 2025
Visit Reason
The inspection was conducted based on complaints NJ186877 and NJ186923 to investigate the facility's compliance with physical restraint regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to the right to be free from physical restraints. Specifically, Resident #2 was subjected to inappropriate use of restraints, including being placed and secured with a bedside tray table and wheelchair, which was not justified by medical symptoms. The facility failed to ensure proper staff response and documentation, and corrective actions were required.
Complaint Details
Complaint investigation for NJ186877 and NJ186923 was substantiated based on observations, interviews, medical record review, and video evidence showing improper restraint use on Resident #2 during the night shift. The Licensed Practical Nurse failed to return phone calls during the investigation.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure a resident's bed was not placed against a bedside tray table and wheelchair, restricting the resident's ability to move freely, constituting improper use of physical restraints. | Level D |
Report Facts
Sample Size: 3
Random Audits: 15
Performance Improvement Plan Duration: 30
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was conducted in response to a complaint identified as NJ185906 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #: NJ185906; The facility is in substantial compliance based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 133
Capacity: 135
Deficiencies: 10
Feb 25, 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 numbered 171958, 176667, and 181275.
Findings
Deficiencies were cited related to PASARR screening for mental disorders and intellectual disabilities, comprehensive care plans, ADL care provision, psychotropic medication use, food safety, life safety code compliance including exit ramps, emergency lighting, fire alarm system maintenance, sprinkler system maintenance, and infection prevention and control. Corrective actions and plans of correction were documented with completion dates.
Complaint Details
The survey included complaint investigations numbered 171958, 176667, and 181275. The complaints were substantiated as deficiencies were cited in multiple areas including PASARR screening and care planning.
Severity Breakdown
Level 3: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure PASARR screening for mental disorder and intellectual disability was completed accurately for newly admitted residents. | Level 3 |
| Failure to revise individualized comprehensive care plans with resident preferences and needs. | Level 3 |
| Failure to provide proper ADL care to dependent residents. | Level 3 |
| Failure to ensure psychotropic medications were administered according to regulations including PRN orders and documentation. | Level 3 |
| Failure to maintain kitchen equipment and food service areas in a clean and sanitary manner. | Level 3 |
| Failure to maintain exit ramps compliant with NFPA 101 Life Safety Code. | Level 3 |
| Failure to maintain emergency lighting and battery backup systems. | Level 3 |
| Failure to maintain fire alarm system and conduct required testing and maintenance. | Level 3 |
| Failure to maintain sprinkler system in optimal condition. | Level 3 |
| Failure to establish and maintain an infection prevention and control program. | Level 3 |
Report Facts
Census: 133
Total Capacity: 135
Deficiencies cited: 10
Completion Dates: 2025
Inspection Report
Abbreviated Survey
Census: 122
Deficiencies: 0
Jan 17, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Routine
Census: 123
Deficiencies: 0
Jul 15, 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.
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: 7
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 1
Aug 11, 2023
Visit Reason
The inspection was conducted based on complaints NJ00144545 and NJ00146272 to investigate compliance with staffing requirements and other regulatory standards.
Findings
The facility was found deficient in maintaining the required minimum direct care staff-to-resident ratio for Certified Nursing Assistants (CNAs) on 22 of 28 day shifts, potentially affecting all residents. Despite the deficiencies, no care concerns were reported during the identified shifts. The facility has ongoing recruitment and retention efforts and plans to monitor staffing closely.
Complaint Details
Complaint #: NJ00144545, NJ00146272. The facility was found non-compliant with staffing requirements but no care concerns were substantiated during the complaint survey.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratio for Certified Nursing Assistants (CNA) on 22 of 28 day shifts. |
Report Facts
Census: 127
Deficient CNA staffing shifts: 22
Sample Size: 5
Correction completion date: Plan of correction completion date set for 08/23/2023 as per revisit report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding staffing deficiencies and ongoing efforts. | |
| Regional Licensed Nursing Home Administrator (LNHA) | Interviewed regarding staffing regulations awareness and recruitment efforts. | |
| Facility Staffing Coordinator | In-service on staffing requirements and responsible for reviewing staff attendance and recruitment efforts. | |
| Facility Administrator | Involved in weekly and monthly staffing review meetings. |
Inspection Report
Annual Inspection
Census: 125
Capacity: 135
Deficiencies: 8
Jan 24, 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 food safety practices including improper labeling and storage of food, hand hygiene, and use of cutting boards. Additional deficiencies included failure to maintain required staffing ratios, fire safety code violations including lack of annual fire door inspections, inadequate illumination of means of egress, incomplete fire alarm system inspections, sprinkler system maintenance issues, HVAC system deficiencies, and generator remote manual stop station absence.
Severity Breakdown
SS=D: 1
SS=E: 2
SS=F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain multiuse food-contact surface cutting boards to prevent microbial growth; store, label, and date potentially hazardous foods; and perform hand hygiene according to infection control standards. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 9 out of 42 shifts reviewed. | — |
| Failed to inspect fire doors annually in accordance with NFPA 80 for 8 fire doors. | SS=F |
| Failed to provide emergency illumination that operates automatically along means of egress in one occupied access area. | SS=E |
| Failed to inspect fire alarm system semi-annually and ensure smoke alarm sensitivity inspection report was documented. | SS=F |
| Failed to maintain automatic sprinkler system in optimal condition; dry system pressure test failed. | SS=F |
| Resident bathroom ventilation systems not adequately maintained and PTAC units not operating in optimal condition. | SS=E |
| Failed to ensure a remote manual stop station for the generator as required by NFPA 110. | SS=F |
Report Facts
Census: 125
Total Capacity: 135
Shifts with staffing deficiencies: 9
Fire doors inspected: 8
Resident bathrooms with ventilation issues: 13
PTAC units with issues: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in multiple findings including fire door inspections, fire alarm system, sprinkler system, HVAC, and generator issues | |
| Director of Nursing | Interviewed regarding staffing and hand hygiene practices | |
| Licensed Nursing Home Administrator | Present during inspections and informed of findings | |
| Food Service Director | Interviewed regarding food safety deficiencies | |
| Dietary Aide | Observed performing improper hand hygiene | |
| Regional Food Service Director | Interviewed regarding hand hygiene practices |
Inspection Report
Routine
Census: 135
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.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jun 3, 2021
Visit Reason
The inspection was conducted based on a complaint visit 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 during this complaint investigation.
Complaint Details
The facility was inspected due to a complaint visit and was found to be in compliance.
Report Facts
Sample Size: 4
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 1
Apr 28, 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 not in compliance with infection control procedures, specifically failing to properly doff personal protective equipment (PPE) to prevent the spread of infection among residents on transmission-based precautions. Observations and interviews revealed staff and visitors did not consistently follow PPE protocols, including improper removal and disposal of gowns.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow proper infection control procedures by not doffing personal protective equipment (PPE) to prevent the spread of infection for residents on transmission based precautions. | SS=D |
Report Facts
Census: 114
Sample size: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about cohorting groups and PPE requirements during entrance conference | |
| Licensed Nursing Home Administrator (LNHA) | Present during entrance conference and survey team observations | |
| Licensed Practical Nurse (LPN)/Unit Manager (UM) | Interviewed regarding PPE requirements and observed instructing housekeeper on PPE removal | |
| Housekeeper (HK) | Observed not properly doffing PPE and walking in hallway with contaminated gown | |
| Receptionist | Observed handling visitor's used gown and interviewed about PPE procedures for visitors | |
| Registered Nurse/Infection Preventionist (RN/IP) | Interviewed about PPE procedures for visitors and consent forms | |
| Licensed Nursing Home Administrator (LNHA) | Commented on visitor gown procedures and need for re-education |
Inspection Report
Life Safety
Census: 111
Capacity: 135
Deficiencies: 13
Apr 8, 2021
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted following a state survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with multiple life safety code requirements including egress door signage and operation, exit discharge obstructions, emergency lighting, exit signage, hazardous area enclosures, fire alarm system installation and maintenance, sprinkler system installation and maintenance, portable fire extinguisher inspection, corridor wall construction, smoke barrier door integrity, and improper use of electrical extension cords.
Severity Breakdown
SS=F: 7
SS=E: 5
SS=D: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide signs at exits with delayed egress locking devices indicating operation procedure and failed to ensure all required exit passageways were free of obstructions. | SS=F |
| Exit discharge path was obstructed by trash compactor and timber storage box limiting access to public way. | SS=D |
| Failed to provide battery backup emergency lighting above generator transfer switch. | SS=F |
| Failed to properly identify non-exit doors with 'No Exit' signs; some doors displayed incorrect signage. | SS=F |
| Failed to provide and maintain self-closing devices on hazardous area doors, penetrations not properly fire stopped, and walls not constructed with fire resistive materials. | SS=E |
| Failed to provide audible and visible fire alarm notification signals in enclosed courtyards. | SS=F |
| Failed to maintain supervised smoke detection in operating condition at all times; smoke detector covered with tape in kitchen area. | SS=F |
| Failed to provide complete sprinkler coverage in storage closets and fabric roof overhang exceeding 4 feet lacked sprinkler protection. | SS=F |
| Failed to maintain sprinkler system including missing ceiling tiles allowing smoke passage, loaded sprinklers with debris, obstructed sprinklers, incorrect spare sprinklers, and failure to perform monthly electric fire pump no-flow test. | SS=F |
| Failed to visually inspect fire extinguishers monthly; K type extinguisher required recharging and was obstructed and not readily accessible. | SS=E |
| Corridor walls had unprotected openings and ladders leading to attic openings allowing smoke passage. | SS=E |
| Smoke barrier doors had gaps preventing resistance to passage of smoke, flame, or gases during fire. | SS=E |
| Improper use of electrical extension cords beyond temporary installation; cords run through ceiling and walls not properly fire stopped. | SS=E |
Report Facts
Certified beds: 135
Census: 111
Force applied to delayed egress door: 15
Gap size: 3
Gap size: 0.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified multiple findings including exit door signage, exit discharge obstructions, sprinkler system issues, and smoke barrier door gaps | |
| Maintenance A | Assisted in bypassing delayed egress door mechanism and verified exit door signage findings | |
| Administrator | Interviewed regarding emergency lighting and fire alarm system requirements and verified findings | |
| Kitchen Supervisor | Verified smoke detector covered with tape in kitchen |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 5
Apr 2, 2021
Visit Reason
A Federal Comparative survey was conducted from 03/30/2021 to 04/02/2021 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 federal requirements, with deficiencies noted in pharmacy services related to controlled medication accounting and storage, infection prevention and control practices, and environmental maintenance in the Food Service Department.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to consistently maintain an accurate accounting of controlled medications in the backup medication system, including missing Narcotic Inventory Sheets and expired medications not removed. | SS=E |
| Failed to ensure medications for discharged residents were removed from active inventory in medication carts and storage units. | SS=E |
| Failed to label and store drugs and biologicals properly, including expired medications and lack of documentation of receipt and disposition. | SS=E |
| Failed to establish and maintain an infection prevention and control program, including failure to adhere to infection control practices and failure to provide policy and procedure related to dating and changing tubing and equipment for 5 residents. | SS=E |
| Failed to provide a safe, functional, sanitary, and comfortable environment in the Food Service Department, including improper location of paper towel dispenser leading to cross contamination risk, broken trash receptacle pedal, dirty and rusted portable air cooling unit, and unfinished floor repairs. | SS=E |
Report Facts
Census: 114
Sample Size: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding controlled medication system and confirmed findings | |
| Director of Nursing (DON) | Interviewed and confirmed findings related to medication management and infection control | |
| Consultant Pharmacist (CP) | Interviewed regarding medication destruction policies | |
| Licensed Practical Nurse (LPN) | Confirmed findings related to medication storage for discharged residents | |
| Infection Control Nurse | Interviewed regarding infection control policies | |
| Food Service Director (FSD) | Interviewed and acknowledged environmental concerns in Food Service Department | |
| Charge Nurse (LPN #1) | Confirmed infection control findings related to equipment labeling and cleaning |
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 3
Mar 9, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey was also conducted to assess compliance with infection control regulations.
Findings
Deficiencies were cited related to resident rights and dignity during meal service, pharmacy services including medication storage and administration errors, and nutritive value and temperature of food served to residents requiring feeding assistance. The facility implemented plans of correction including staff re-education, audits, and quality assurance monitoring.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were served meals in a dignified manner, with delays in meal delivery and lack of timely feeding assistance. | SS=D |
| Facility failed to properly store medication and accurately administer medication for 2 residents, including leaving medications unattended and borrowing medication from another resident. | SS=D |
| Facility failed to ensure food was served at palatable temperature and was appetizing for a resident requiring feeding assistance, with meal trays delayed and food served cold. | SS=D |
Report Facts
Census: 127
Sample size: 25
Inspection Report
Life Safety
Deficiencies: 0
Mar 9, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and met the minimum Life Safety Code requirements as surveyed using CMS-2786R.
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