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
Complaint Investigation
Census: 158
Capacity: 180
Deficiencies: 16
May 2, 2024
Visit Reason
Complaint investigations were conducted for multiple complaint numbers to determine compliance with federal and state regulations for long term care facilities.
Findings
Deficiencies were cited in multiple areas including resident rights, advanced directives, abuse reporting, accuracy of assessments, pressure ulcer care, range of motion, dialysis care, medication administration, food safety, hospice services, infection control, and life safety code compliance.
Complaint Details
Complaint investigations were conducted for complaint numbers #157139, #157797, #159358, #167071, and #171606.
Severity Breakdown
SS=F: 5
SS=E: 3
SS=D: 6
SS=C: 1
: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to protect resident rights by posting unauthorized signage on resident doors and failing to follow HIPAA privacy requirements. | SS=D |
| Facility failed to update physician orders and care plans according to resident's advance directives (POLST). | SS=D |
| Facility failed to report alleged abuse incidents timely to the New Jersey Department of Health and other authorities. | SS=D |
| Facility failed to accurately code Minimum Data Set (MDS) assessments for residents. | SS=C |
| Facility failed to follow physician orders and provide comprehensive care for pressure ulcers, including proper treatment, care plans, and hand hygiene. | SS=D |
| Facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decline. | SS=D |
| Facility failed to provide adequate dialysis monitoring and care consistent with professional standards. | SS=D |
| Facility failed to provide accurate medication administration, reconciliation, and documentation, including failure to remove discontinued medications and maintain tamper seals. | SS=F |
| Facility failed to maintain proper kitchen sanitation, clean equipment, safe food storage, and proper disposal of cooking oil. | SS=F |
| Facility failed to maintain sanitary nursing unit kitchenettes and ice machines, including cleaning and replacing equipment as needed. | SS=F |
| Facility failed to maintain water management program and accountability logs, including cleaning of shower heads and eyewash stations. | SS=E |
| Facility failed to ensure concealed sprinkler escutcheon caps were not painted, violating fire safety code. | SS=F |
| Facility failed to conduct required electrical outlet testing on schedule. | SS=F |
| Facility failed to ensure hospice services were coordinated and documented properly between hospice and facility staff. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law. | — |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment in laundry and linen storage rooms and shower rooms. | SS=E |
Report Facts
Residents present: 158
Total licensed capacity: 180
Deficient CNA staffing day shifts: 28
Deficient CNA staffing evening shifts: 1
Deficient CNA staffing day shifts (specific weeks): 8
Deficient CNA staffing day shifts (specific weeks): 11
Deficient CNA staffing evening shifts (specific weeks): 1
Deficient CNA staffing day shifts (specific weeks): 7
Deficient CNA staffing day shifts (specific weeks): 2
Medication doses unaccounted: 13
Medication doses administered incorrectly: 6
Number of residents reviewed for hospice: 3
Number of residents reviewed for dialysis: 3
Number of residents reviewed for pressure ulcers: 5
Number of residents reviewed for range of motion: 3
Number of residents reviewed for medication regimen: 7
Number of kitchenettes inspected: 4
Number of shower rooms inspected: 2
Number of stairwell heaters with unsealed recessed heaters: 6
Number of electrical outlet testing years reviewed: 2
Number of painted sprinkler escutcheon caps: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #4 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #6 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| RN #1 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #2 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #3 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #4 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #5 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #6 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #7 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #9 | Registered Nurse | Named in medication administration and documentation deficiencies |
| LPN #7 | Licensed Practical Nurse | Named in kitchen sanitation and fryer oil disposal deficiencies |
| Director of Housekeeping | Named in laundry and housekeeping sanitation deficiencies | |
| Food Service Director | Named in kitchen sanitation and fryer oil disposal deficiencies | |
| Maintenance Director | Named in sprinkler and electrical testing deficiencies | |
| Operations Director | Named in sprinkler and electrical testing deficiencies | |
| Administrator | Named in staffing and infection control deficiencies | |
| Risk Manager/Facility Educator | Named in multiple deficiencies including medication, infection control, and hospice services | |
| Licensed Practical Nurse | Named in hospice services documentation deficiencies | |
| Certified Nursing Assistant (CNA) | Named in infection control and resident care deficiencies | |
| Licensed Practical Nurse (LPN) | Named in hospice services and resident care deficiencies |
Inspection Report
Routine
Census: 161
Deficiencies: 0
Feb 8, 2024
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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 164
Deficiencies: 0
Sep 7, 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
Complaint Investigation
Census: 160
Deficiencies: 1
Jun 9, 2023
Visit Reason
The inspection was conducted based on a complaint (NJ 00164733) alleging failure of the facility staff to report incidents of abuse, neglect, or injuries of unknown origin as required by regulations.
Findings
The facility failed to report injuries of unknown origin involving two residents to the New Jersey Department of Health as required by federal and state regulations. Investigations revealed incidents where residents had injuries but the facility did not notify the appropriate authorities within the mandated timeframes.
Complaint Details
Complaint NJ 00164733 was substantiated as the facility did not report incidents involving injuries of unknown origin for two residents as required by regulation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source to the appropriate authorities within required timeframes. | SS=D |
Report Facts
Sample size: 3
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rick Manager | Assistant Director of Nursing (ADON) | Responsible for re-educating after-hours and weekend supervisors on reporting requirements. |
| Director of Nursing | Director of Nursing (DON) | Named in relation to failure to report incidents and responsible for auditing incident reports. |
| Licensed Practical Nurse #1 | LPN | Provided statement regarding observation of resident injury. |
| Licensed Practical Nurse #2 | LPN | Noticed injuries during medication administration. |
| Certified Nursing Assistant #1 | CNA | Reported observation of resident injury during rounds. |
| Certified Nursing Assistant #2 | CNA | Provided morning care and reported no noted changes in resident condition. |
| Unit Manager/Registered Nurse | UM/RN | Observed resident injury and provided information during survey. |
| Licensed Nursing Home Administrator | LNHA | Participated in interview explaining reporting responsibilities. |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Jul 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (NJ 151228, 152246, 152424, 153710) regarding the facility's compliance with long term care regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to report an incident involving Resident #6 to the New Jersey Department of Health as required and not following their Elopement/Missing Residents Policy and Procedure. Resident #6 left a doctor's office without authorization or a doctor's order, and the facility failed to notify appropriate authorities timely.
Complaint Details
Complaint # NJ 151228, 152246, 152424, 153710. The facility failed to report an incident involving Resident #6 as required and did not follow their policy for elopement/missing residents. Resident #6 left a doctor's office without authorization, and the facility was unaware until the police notified them. The complaint was substantiated based on interviews, medical record review, and facility documents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving Resident #6 to the New Jersey Department of Health and failure to follow the facility's Elopement/Missing Residents Policy and Procedure. | SS=D |
Report Facts
Census: 169
Sample Size: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged the incident involving Resident #6 and the failure to report | |
| Unit Manager | Involved in searching for Resident #6 and provided statements about the incident | |
| Administrator | Acknowledged the safety concern and lack of authorization for Resident #6 leaving the doctor's office |
Inspection Report
Follow-Up
Census: 167
Deficiencies: 1
Dec 29, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing regulations following a prior deficiency related to failure to maintain required minimum direct care staff to resident ratios.
Findings
The facility was found deficient in Certified Nursing Aide (CNA) staffing for 13 of 14 day shifts and deficient in CNAs to total staff on 2 of 14 evening shifts during late November and early December 2021. Interviews with staff confirmed awareness of staffing requirements but difficulty meeting them consistently. The facility's staffing policy did not include the required minimum direct care staff to resident ratios.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff to resident ratios for day and evening shifts as mandated by the State of New Jersey. |
Report Facts
Residents: 167
CNA staffing deficiency: 13
CNA staffing deficiency: 2
Required CNAs: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed regarding awareness of staffing ratios and facility efforts | |
| Director of Nursing | Interviewed regarding awareness of staffing ratios and facility compliance | |
| Licensed Nursing Home Administrator | Interviewed regarding awareness of staffing ratios and facility staffing levels |
Inspection Report
Life Safety
Census: 165
Capacity: 356
Deficiencies: 3
Dec 28, 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 NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including lack of emergency lighting above the emergency generator's transfer switch, obstructed exit signage, and failure to perform and document monthly firefighter service inspections on elevators.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system and emergency generator. | SS=D |
| Failed to maintain exit directional signs illuminated and unobstructed, with one exit sign obstructed by ceiling-mounted light fixtures. | SS=D |
| Failed to ensure elevators were inspected and tested monthly for firefighter service as required, with no records of monthly tests for 2 of 2 elevators. | SS=D |
Report Facts
Certified beds: 356
Census: 165
Exit signs observed: 14
Elevators inspected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Plant Operations Director | Verified emergency lighting deficiency and provided education on emergency lighting and elevator inspection requirements | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Oct 24, 2021
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ147259) to assess compliance with long term care facility regulations.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint survey. Additionally, a COVID-19 Focused Infection Control Survey found the facility compliant with infection control regulations and CDC recommended practices.
Complaint Details
Complaint #: NJ147259. The facility was found to be in compliance based on this complaint survey.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Jun 24, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ140616, NJ133458, NJ144291, NJ138526, and NJ140926.
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 survey.
Complaint Details
Complaint numbers NJ140616, NJ133458, NJ144291, NJ138526, NJ140926 were investigated and found to be in compliance.
Report Facts
Sample Size: 9
Inspection Report
Routine
Census: 149
Deficiencies: 0
Jan 5, 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: 5
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 5
Dec 10, 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 COVID-19 related practices.
Findings
The facility failed to properly screen visitors for COVID-19 symptoms and temperature, did not follow proper PPE removal and disposal protocols, lacked designated housekeeping equipment on the COVID-19 positive unit, and had deficiencies in hand hygiene practices. Additionally, the facility failed to ensure COVID-19 testing compliance for an agency transport staff, lacked a policy for rapid antigen testing, and did not effectively track COVID-19 test results for staff.
Complaint Details
The visit was complaint-related as it was a COVID-19 focused infection control survey triggered by concerns about infection prevention and control practices during the pandemic.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to appropriately screen visitors for COVID-19 symptoms and temperature using non-contact thermometers correctly. | SS=E |
| Failed to ensure proper removal and disposal of personal protective equipment (PPE), including covered and emptied receptacles to prevent overflow. | SS=E |
| Failed to provide designated housekeeping equipment on the COVID-19 positive cohort unit. | SS=E |
| Failed to ensure proper hand hygiene techniques by staff, including washing hands for the recommended 20 seconds and proper faucet handling. | SS=E |
| Failed to ensure COVID-19 testing compliance for an agency transport staff and lacked a system to track COVID-19 test results for staff. | SS=E |
Report Facts
Census: 148
Sample size: 8
Temperature readings: 86
Temperature readings: 97.6
Temperature readings: 96.8
Temperature readings: 90.2
Temperature readings: 93.7
Temperature readings: 90.8
Temperature readings: 91.3
Temperature readings: 90.2
Temperature readings: 89.7
Temperature readings: 92.9
Temperature readings: 93.1
Temperature readings: 94.5
Staff testing dates: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Screener | Failed to properly screen visitors for COVID-19 symptoms and temperature. | |
| Certified Nursing Aide (CNA) | Interviewed regarding PPE disposal and hand hygiene practices. | |
| Housekeeper | Interviewed regarding PPE disposal and housekeeping equipment on COVID-19 unit. | |
| Licensed Practical Nurse (LPN) | Observed improper hand hygiene during meal tray distribution. | |
| Registered Dietitian (RD) | Observed improper PPE doffing and hand hygiene practices. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding COVID-19 testing policies and practices. | |
| Director of Nursing (DON) | Interviewed regarding COVID-19 testing policies and practices. | |
| Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Interviewed regarding infection control practices and COVID-19 testing. | |
| Employee Health/Registered Nurse (EH/RN) | Responsible for conducting COVID-19 tests for staff and maintaining testing logs. | |
| Certified Home Health Aide/Transport (CHHA/T) | Agency staff member who was not properly tested or tracked for COVID-19 testing. |
Inspection Report
Abbreviated Survey
Census: 154
Deficiencies: 3
Nov 19, 2020
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 infection control.
Findings
The facility failed to ensure proper use of personal protective equipment (PPE) by housekeeping staff, lacked designated housekeeping equipment for COVID-19 positive units, and had incomplete and inaccurate employee COVID-19 entry screening logs. These deficiencies were observed during interviews, observations, and record reviews.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Housekeeper did not wear the required gown when entering a resident's room on Contact Precautions. | SS=D |
| Housekeeping equipment and supplies were not designated for the COVID-19 positive unit, risking cross-contamination. | SS=D |
| Employee COVID-19 entry screening logs were incomplete and inaccurate, missing temperatures and last names, and included implausible temperature readings without rechecks. | SS=D |
Report Facts
Census: 154
Sample size: 4
Missing temperature entries: 5
Low temperature readings: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Observed not wearing gown in Contact Precautions room; medically excused from N-95 respirator mask; involved in PPE use deficiency | |
| Director of Housekeeping | Acknowledged oversight in designating housekeeping equipment for COVID-19 unit and PPE use issues | |
| Licensed Nursing Home Administrator | LNHA | Acknowledged deficiencies in screening logs and PPE compliance |
| Regional Director/Registered Nurse | RN | Confirmed PPE requirements and deficiencies |
| Screener | Responsible for employee COVID-19 screening and temperature logging; logs found incomplete and inaccurate |
Loading inspection reports...
