Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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, the circumstances under which health information may be used or disclosed, and the legal duties and rights of individuals regarding their health information 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: 88
Capacity: 108
Deficiencies: 5
Dec 4, 2024
Visit Reason
Complaint investigation based on multiple complaint numbers (169289, 179188, 179362, 179561) conducted from 12/4/2024 to 12/11/2024 to assess compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with federal and state regulations. Deficiencies included failure to follow resident care plans leading to accident hazards, failure to maintain required minimum direct care staff ratios, fire safety code violations including non-compliant fire-rated doors and smoke barriers, and malfunctioning emergency communication systems in elevators.
Complaint Details
Complaint investigation based on complaint numbers 169289, 179188, 179362, 179561. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to follow prevention interventions as written on the resident's individual comprehensive care plan for Resident #44, leading to accident hazards. | SS=D |
| Failure to maintain required minimum direct care staff-to-shift ratios for 3 of 14 day shifts reviewed. | — |
| Fire-rated door to hazardous area (basement activities room) did not self-close and automatic door closure was removed. | SS=E |
| Failed to maintain integrity of smoke barrier partitions for three of twelve smoke barriers with unsealed penetrations above ceiling tiles. | SS=F |
| Elevator emergency communication telephones for 2 of 4 elevators were not functioning properly, disconnecting calls and lacking pre-recorded messages. | SS=F |
Report Facts
Census: 88
Total Capacity: 108
Sample Size: 18
Staffing Deficiency Days: 3
Square Feet: 91.875
Number of Elevators: 4
Elevators with Deficient Emergency Phones: 2
Inspection Report
Routine
Census: 70
Deficiencies: 0
Sep 27, 2023
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: 76
Capacity: 108
Deficiencies: 8
Aug 17, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, based on a complaint visit.
Findings
The facility was found not in substantial compliance due to failure to report and thoroughly investigate an injury of unknown origin for Resident #21, failure to maintain required minimum direct care staff-to-resident ratios, failure to provide qualified LGBTQI+ and HIV+ training, failure to maintain sprinkler system integrity, corridor doors not resisting smoke passage, failure to perform required elevator firefighter service tests, failure to serve food at acceptable temperatures, and failure to maintain essential electrical system requirements.
Complaint Details
The complaint investigation focused on failure to report and investigate an injury of unknown origin for Resident #21. The facility failed to report the injury to the New Jersey Department of Health and did not obtain statements from all staff involved in the resident's care. The Director of Nursing and Unit Manager concluded the injury was from the resident's drinking cup without adequate investigation.
Severity Breakdown
SS=D: 2
S 560: 2
SS=F: 2
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to report and thoroughly investigate an injury of unknown origin for Resident #21. | SS=D |
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | S 560 |
| Failure to ensure required LGBTQI+ and HIV+ training was provided by a qualified entity. | S 560 |
| Failure to maintain sprinkler system with smoke resistant and fire rated ceiling components. | SS=F |
| Corridor doors failed to resist the passage of smoke; several resident room doors did not close or latch properly. | SS=E |
| Failure to provide documented evidence of monthly firefighter service testing for elevators. | SS=F |
| Failure to install a remote manual stop station for an outside emergency generator. | SS=E |
| Failure to serve foods at an acceptable temperature for Resident #67 and others. | SS=D |
Report Facts
CNA staffing deficiency days: 5
Resident census: 76
Total licensed beds: 108
Food temperature: 119
Food temperature: 128
Food temperature: 63
Food temperature: 62
Number of high-hat light fixtures per floor: 38
Elevator count: 4
Generator power: 750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to report and investigate injury of unknown origin. | |
| Unit Manager | Named in relation to failure to report and investigate injury of unknown origin. | |
| Maintenance Director | Named in relation to sprinkler system, corridor doors, elevator testing, and generator deficiencies. | |
| Licensed Nursing Home Administrator | Named in relation to LGBTQI+ training deficiency. |
Inspection Report
Routine
Census: 67
Deficiencies: 0
Jan 13, 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
Plan of Correction
Deficiencies: 1
Jul 30, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically regarding staffing ratios as mandated by new minimum staffing requirements effective 02/01/2021.
Findings
The facility failed to meet required staffing ratios for 16 of 42 shifts, with posted CNA to resident ratios exceeding mandated limits on day, evening, and night shifts. The facility acknowledged staffing shortages and implemented corrective actions including wage increases, signing bonuses, closing a subacute wing, and contracting with staffing agencies.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 16 of 42 shifts, violating NJAC 8:39-5.1(a) Mandatory Access to Care. |
Report Facts
Shifts with staffing ratio deficiencies: 16
Total shifts reviewed: 42
Staff to resident ratios: 11.3
Staff to resident ratios: 9.7
Staff to resident ratios: 8.9
Staff to resident ratios: 10.7
Staff to resident ratios: 9.2
Staff to resident ratios: 10.5
Staff to resident ratios: 10.7
Staff to resident ratios: 14.5
Staff to resident ratios: 24
Staff to resident ratios: 16.4
Staff to resident ratios: 16
Staff to resident ratios: 16.6
Staff to resident ratios: 19.8
CNA wage increase: 1.5
CNA wage increase planned: 2
Subacute wing beds closed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information about staffing challenges, wage increases, and recruitment efforts during interviews on 07/29/21 and 07/30/21. | |
| Director of Nursing (DON) | Discussed staffing efforts, recruitment challenges, and time spent on staffing issues during interviews on 07/29/21 and 07/30/21. |
Inspection Report
Routine
Census: 79
Deficiencies: 0
Jan 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.
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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