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 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 the notice |
Inspection Report
Routine
Census: 32
Capacity: 180
Deficiencies: 6
Aug 14, 2024
Visit Reason
Routine inspection conducted to assess compliance with federal and state regulations for long term care facilities, including resident rights, safe environment, comprehensive care plans, infection control, pharmacy services, and life safety code compliance.
Findings
The facility was found to be substantially compliant with many regulatory requirements but had deficiencies related to resident rights, safe environment, comprehensive care plans, pharmacy services, infection control, and life safety code. Deficiencies included improper resident transport, housekeeping issues, incomplete care plans, medication errors, inadequate infection control practices, and life safety code violations such as missing sprinkler heads and door locking mechanisms.
Deficiencies (6)
| Description |
|---|
| Resident #27 was improperly transported, violating resident rights. |
| Housekeeping staff failed to maintain sanitary and safe environment; multiple rooms had debris, stains, and unclean conditions. |
| Resident care plans were incomplete or not updated timely, affecting residents #372, #126, #137, and others. |
| Medication administration errors including expired medications, lack of proper documentation, and failure to follow physician orders. |
| Infection control program deficiencies including improper handling of soiled linens and lack of proper PPE use. |
| Life Safety Code violations including missing sprinkler heads, improper door locking mechanisms, and inadequate fire safety testing. |
Report Facts
Census: 32
Total Capacity: 180
Deficiencies cited: 6
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Jul 15, 2024
Visit Reason
The inspection was conducted based on complaints NJ175506 and NJ175586 to investigate staffing ratio compliance at the facility.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on 14 of 14 day shifts and 2 of 14 evening shifts reviewed. No negative outcomes to residents were identified, but all residents had the potential to be affected.
Complaint Details
Complaint #: NJ175506, NJ175586. The complaint investigation determined the facility failed to meet staffing ratios as required by New Jersey law. The deficiency was substantiated with detailed staffing data from 06/30/2024 to 07/13/2024.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts and 2 of 14 evening shifts reviewed. |
Report Facts
Census: 169
Deficient day shifts: 14
Deficient evening shifts: 2
Required CNAs per day shift: 21
Actual CNAs on 06/30/24 day shift: 11
Required total staff per evening shift: 17
Actual total staff on 06/30/24 evening shift: 13
Inspection Report
Routine
Census: 154
Deficiencies: 0
Aug 10, 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: 5
Inspection Report
Life Safety
Deficiencies: 0
Jan 5, 2023
Visit Reason
The survey was conducted as a Life Safety Code Survey related to a new construction and renovation project involving the Phase 3 conversion of a main dining room into a newly renovated Rehabilitation Gym and Dining Room on the first floor.
Findings
The facility was found to be in compliance with Medicare/Medicaid participation requirements for Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 for existing health care occupancies in the renovated areas.
Report Facts
Percentage of building powered by generator: 50
Building stories: 3
Number of smoke zones: 8
Inspection Report
Annual Inspection
Census: 155
Capacity: 182
Deficiencies: 15
Dec 16, 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 comprehensive assessments, care planning, medication management, food safety, infection control, staffing, and life safety code compliance. The facility was found to be substantially compliant with emergency preparedness.
Severity Breakdown
SS=D: 2
SS=E: 5
SS=F: 3
SS=C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to conduct comprehensive assessments accurately and timely for residents. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans. | SS=E |
| Failure to meet professional standards for services provided. | SS=E |
| Failure to provide care to dependent residents consistent with their needs. | SS=E |
| Failure to ensure psychotropic drugs are used appropriately with proper monitoring and documentation. | SS=E |
| Failure to procure, store, prepare, and serve food in accordance with food safety standards. | SS=E |
| Failure to dispose of garbage and refuse properly, resulting in unsanitary conditions. | SS=D |
| Failure to conduct and document a comprehensive facility assessment including COVID-19 related resources and procedures. | SS=C |
| Failure to establish and maintain an effective infection prevention and control program including contact tracing and COVID-19 testing. | SS=F |
| Failure to maintain required minimum direct care staff-to-resident ratios for day shifts. | — |
| Failure to obtain criminal background check prior to date of hire for new employees. | — |
| Failure to ensure annual inspection of fire doors and missing required inspection tags. | SS=F |
| Failure to maintain self-closing devices on stairway exit doors. | SS=E |
| Failure to label stairway exit doors with fire rating. | SS=E |
| Failure to perform smoke detection sensitivity testing as required. | SS=F |
Report Facts
Deficiencies cited: 15
Residents present: 155
Total licensed capacity: 182
CNA staffing shortfall: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ICP #1 | Infection Preventionist | Named in findings related to incomplete contact tracing and COVID-19 testing documentation. |
| Director of Nursing | Director of Nursing | Named in staffing and infection control findings and interviews. |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Named in background check deficiency. |
| Maintenance Director | Maintenance Director | Named in fire door inspection and fire alarm system deficiencies. |
| Director of Human Resources | Director of Human Resources | Named in background check deficiency. |
Inspection Report
Life Safety
Census: 157
Capacity: 182
Deficiencies: 4
Dec 9, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/09/22 to assess compliance with fire safety regulations and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including failure to inspect fire doors annually, missing self-closing devices on stairway exit doors, missing fire rating labels on stairway doors, and failure to complete smoke detection sensitivity testing. These deficiencies had the potential to affect all 157 residents.
Severity Breakdown
SS=F: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure fire doors were inspected annually as required by NFPA 101 Life Safety Code (2012 edition) 7.2.1.15. | SS=F |
| Failed to maintain means of egress for one stairway exit door missing a self-closing device in accordance with NFPA 101 Life Safety Code (2012 Edition) Sections 19.2.2.2.7. | SS=E |
| Failed to maintain means of egress for one stairway exit door missing a fire rating label as required by NFPA 101 Life Safety Code (2012 Edition) Sections 19.3.1.1. | SS=E |
| Failed to ensure smoke detection sensitivity testing was completed in accordance with NFPA 72 (2010 edition) section 14.4.5.3.2. | SS=F |
Report Facts
Residents present: 157
Total licensed capacity: 182
Deficiency correction completion date: Jan 30, 2023
Revisit date: Feb 9, 2023
Residents potentially affected by missing self-closing device and missing fire rating label: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified deficiencies related to fire door inspections, missing self-closing device, missing fire rating label, and smoke detector sensitivity testing | |
| Director of Maintenance | Provided fire alarm inspection and testing documentation and verified lack of smoke detection sensitivity testing |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 11, 2022
Visit Reason
The inspection was conducted as a new construction/renovation project, specifically a Phase 3 renovation inspection of the Front Lobby and Administrative Offices.
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 special project survey. The inspected areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Life Safety
Deficiencies: 1
Aug 11, 2022
Visit Reason
A Life Safety Code Survey was conducted as part of a new construction/renovation project (Phase 3 renovation of the Lobby and Administrative Offices) to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance due to improper installation of sprinkler heads in the sprinkler control valves room adjacent to the newly renovated lobby. Specifically, the sprinkler deflector was installed 25 inches below the insulation, exceeding the maximum allowed distance of 12 inches, constituting a fire safety hazard.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Improper installation of sprinkler heads in the sprinkler control valves room; sprinkler deflector was 25 inches below insulation, exceeding NFPA 13 installation requirements. | SS=D |
Report Facts
Distance of sprinkler deflector below insulation: 25
Maximum allowed distance: 12
Survey start time: 9.05
Survey exit time: 10.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Requested to provide architectural plans during survey | |
| Director of Maintenance (DOM) | Present during inspection and confirmed sprinkler installation finding |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 4
Jul 31, 2022
Visit Reason
Complaint survey conducted due to multiple complaint intakes regarding alleged violations and quality of care concerns at the facility.
Findings
The facility was found non-compliant with requirements related to timely reporting and investigation of injuries of unknown origin, proper medication administration and documentation, and maintaining mandated direct care staff-to-resident ratios. Specific deficiencies included failure to immediately report injuries of unknown origin, incomplete investigations, missed medication administration documentation, and insufficient certified nurse aide staffing on multiple shifts.
Complaint Details
Complaint Intake numbers NJ149050, NJ153795, NJ155485, NJ154063, NJ00149157, NJ149169, NJ150827, NJ151895, and NJ155888 triggered the complaint survey. The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on these complaints.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure an injury of unknown origin was immediately reported to the Administrator and State Survey Agency. | SS=D |
| Failure to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment and report results within required timeframes. | SS=D |
| Failure to ensure necessary care and treatments were documented as provided in accordance with accepted standards of nursing practice and physician's orders, including medication administration and wound care. | SS=D |
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law, deficient in CNA staffing for 14 of 14 day shifts and 2 of 14 night shifts reviewed. | — |
Report Facts
Census: 156
Sample Size: 14
Staffing Deficiency Counts: 14
Staffing Deficiency Counts: 2
Medication Administration Missed Initials: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in failure to report injury of unknown origin and failure to investigate. |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Interviewed regarding injury reporting and investigation expectations. |
| Administrator | Facility Administrator | Interviewed regarding staff expectations and staffing challenges. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and documentation. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication administration and resident care. |
| LPN #8 | Licensed Practical Nurse | Interviewed regarding care provided to residents with specific conditions. |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Interviewed regarding medication administration and care standards. |
Inspection Report
Routine
Census: 162
Deficiencies: 0
Apr 26, 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: 13
Inspection Report
Routine
Census: 159
Deficiencies: 0
Oct 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 7
Jul 30, 2021
Visit Reason
Complaint investigation based on multiple complaint intakes regarding facility compliance with regulations related to safe environment, abuse prevention, physical restraints, food temperature, privacy, and laundry services.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to maintain safe environment lighting, failure to prevent physical abuse and use of physical restraints, failure to timely report abuse, failure to serve food at palatable temperatures, failure to ensure privacy curtains provide full visual privacy, and failure to properly label resident clothing. Corrective actions and plans of correction were documented for each deficiency.
Complaint Details
Complaint Intake NJ145796, NJ142317, NJ145807, NJ146081, NJ145021. The investigation substantiated abuse allegations involving tied sleeves of a resident, failure to timely report abuse by four staff members, and other environmental and care deficiencies.
Severity Breakdown
SS=E: 4
SS=D: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure ceiling lights were working on the even numbered side of the hallway affecting 18 residents. | SS=E |
| Facility failed to keep a resident free from physical abuse; resident's sleeves were tied together by staff. | SS=D |
| Facility failed to keep a resident free from physical restraints; resident's sleeves were tied together as a restraint. | SS=D |
| Facility staff failed to timely report an allegation of physical abuse involving tied sleeves of a resident. | SS=E |
| Facility failed to ensure food was served at palatable temperatures; test trays showed food temperatures below safe and appetizing levels. | SS=E |
| Facility failed to ensure privacy curtain was free from damage and provided complete visual privacy; curtain was too short to wrap around resident's bed. | SS=D |
| Facility failed to ensure resident's clothing was inventoried and labeled properly, leading to misappropriation of personal property. | SS=E |
Report Facts
Census: 158
Sample Size: 7
Number of residents affected by lighting deficiency: 18
Number of residents affected by abuse and restraint: 1
Number of employees suspended: 4
Food temperature measurements (Fahrenheit): 126
Food temperature measurements (Fahrenheit): 108
Food temperature measurements (Fahrenheit): 52
Food temperature measurements (Fahrenheit): 133
Number of eye holes in privacy curtain: 25
Number of hooks in ceiling rack: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in physical abuse and failure to report abuse findings |
| Housekeeper #3 | Housekeeper | Named in failure to report abuse |
| Housekeeper #7 | Housekeeper | Named in failure to report abuse |
| Temporary Nurse Aide #4 | Temporary Nursing Assistant | Named in failure to report abuse |
| Director of Maintenance | Interviewed regarding lighting and privacy curtain deficiencies | |
| Nursing Home Administrator | Interviewed regarding multiple deficiencies and corrective actions | |
| Assistant Food Service Director | Interviewed regarding food temperature deficiencies | |
| Housekeeping Supervisor | Interviewed regarding privacy curtain and laundry issues | |
| Social Worker | Interviewed regarding abuse and property misappropriation |
Inspection Report
Abbreviated Survey
Census: 160
Deficiencies: 0
May 4, 2021
Visit Reason
A 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 the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, infection control regulations.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 180
Deficiencies: 0
Feb 24, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 9
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 6
Jan 14, 2021
Visit Reason
Complaint investigation based on multiple complaint numbers regarding compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant in several areas including failure to provide medical records timely, failure to notify responsible parties of resident falls, failure to follow physician medication orders, failure to investigate falls adequately, failure to ensure kitchen staff wore hair restraints and face masks, and failure to maintain infection prevention and control standards.
Complaint Details
Complaint numbers NJ142174, NJ140792, NJ139779, NJ140462, NJ138263 triggered the survey. The facility was found not in compliance based on these complaints.
Severity Breakdown
SS=B: 1
SS=D: 2
SS=G: 1
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide a copy of resident's medical records within the required timeframe. | SS=B |
| Failure to notify the responsible party of a resident's fall. | SS=D |
| Failure to follow physician's orders for medication administration. | SS=D |
| Failure to investigate falls to determine causative factors and prevent future falls. | SS=G |
| Failure to ensure kitchen staff wore hair restraints. | SS=F |
| Failure to ensure kitchen staff wore face masks for source control during COVID-19 pandemic. | SS=F |
Report Facts
Census: 163
Sample Size: 9
Medication administration times: 5
Medication administration times: 4
Fall incident counts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding failure of kitchen staff to wear hair restraints and face masks. |
| Administrator | Administrator | Interviewed regarding observations of kitchen staff and fall notifications. |
| Director of Nursing | Director of Nursing | Interviewed regarding fall notifications and medication administration. |
| Medical Record Coordinator | Medical Record Coordinator | Interviewed regarding delays in providing medical records. |
| Unit Manager #1 | Unit Manager | Interviewed regarding failure to notify family of resident fall. |
| Infection Preventionist | Infection Preventionist Nurse | Interviewed regarding fall investigations and infection control practices. |
| Regional Nurse | Regional Nurse | Interviewed regarding medication administration errors. |
Inspection Report
Routine
Census: 157
Deficiencies: 0
Dec 17, 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 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: 158
Deficiencies: 0
Nov 20, 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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