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 to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Response time: 30
Disclosure accounting period: 6
Disclosure accounting period for electronic records: 3
Complaint filing address: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer listed as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 251
Capacity: 297
Deficiencies: 7
Apr 9, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to accuracy of assessments, physician visit frequency, psychotropic medication monitoring, staffing ratios, and life safety code violations including illumination of means of egress, linen chute fire rating, and fire door inspections.
Complaint Details
Multiple complaints (NJ00166492, NJ00168703, NJ00172195, NJ00171859, NJ00169098, NJ00169722, NJ00165993, NJ00171738, NJ00168609, NJ00169823) were investigated during the survey.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set (MDS) for residents #200 and #655. | SS=D |
| Facility failed to ensure primary physician conducted face-to-face visits at least every 60 days for Resident #658. | SS=D |
| Facility failed to adequately monitor psychotropic medication use and behavioral interventions for Resident #656. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | — |
| One out of seven stairways was not illuminated as required by NFPA 101 Life Safety Code. | SS=F |
| Linen chute opened into a two-hour fire rated room with holes in drywall, not maintaining required fire rating. | SS=E |
| Fire doors were not inspected annually and lacked required inspection tags. | SS=F |
Report Facts
Deficient CNA staffing shifts: 28
Current census: 251
Total licensed capacity: 297
Inspection Report
Complaint Investigation
Census: 274
Deficiencies: 0
Jul 25, 2023
Visit Reason
The inspection was conducted as a complaint survey in response to complaint number 165880.
Findings
The facility was found to be in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Complaint Details
Complaint number 165880 was investigated during the survey; the facility was found compliant with no deficiencies noted.
Inspection Report
Complaint Investigation
Census: 272
Deficiencies: 2
Jul 7, 2023
Visit Reason
The inspection was conducted as a complaint survey on behalf of the New Jersey Department of Health, triggered by multiple complaint numbers related to the facility.
Findings
The facility was found not in substantial compliance with state and federal regulations, including failure to meet mandatory staffing ratios on multiple day shifts and failure to protect residents from abuse by other residents, resulting in injuries requiring hospitalization.
Complaint Details
The complaint investigation involved multiple complaint numbers. The facility failed to meet minimum staffing requirements on 14 of 21 day shifts from 06/18/2023 to 07/08/2023. The facility also failed to protect the rights of residents to be free from abuse, with documented incidents of resident-on-resident abuse resulting in injuries requiring emergency room visits and hospitalizations. The incidents were reported timely to the state agency and police. The facility conducted investigations and implemented corrective actions including staff re-education and quality assurance monitoring.
Severity Breakdown
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staffing ratios were met for 14 of 21 day shifts reviewed, deficient in CNA staffing. | — |
| Failure to protect residents from abuse by other residents, resulting in physical injuries requiring hospitalization for multiple residents. | SS=G |
Report Facts
Survey Census: 272
Sample Size: 32
Day shifts deficient in CNA staffing: 14
CNA staffing required per day shift: 34
CNA staffing present on deficient days: Varied from 17 to 33 CNAs on deficient days as detailed in the report.
Inspection Report
Complaint Investigation
Census: 274
Deficiencies: 1
Jan 13, 2023
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ160624, NJ153610, NJ153387, NJ153453, NJ160500) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to ensure that residents receiving Personal Needs Allowance (PNA) were consistently provided quarterly financial statements. Specifically, Residents #3, #4, and #5 did not receive timely quarterly PNA statements as required, indicating a deficiency in accounting and records of personal funds.
Complaint Details
The complaint investigation was based on multiple complaints (NJ160624, NJ153610, NJ153387, NJ153453, NJ160500). The facility was found not in substantial compliance with requirements related to accounting and records of personal funds, specifically failure to provide quarterly PNA statements to residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide quarterly financial statements of Personal Needs Account (PNA) to Residents #3, #4, and #5. | SS=D |
Report Facts
Census: 274
Deficiencies cited: 1
Plan of correction audit sample size: 30
Plan of correction audit frequency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Provided information about PNA account management and statement distribution | |
| Business Office/HR Manager | Business Office/HR Manager | Responsible for recording cash-out receipts and reconciling with contracted company; initially unsure about statement distribution responsibility |
| Director of Nursing | Director of Nursing | Stated that PNA statements should be distributed and reviewed quarterly with residents |
| Regional VP of Nursing | Regional VP of Nursing | Stated that PNA statements should be distributed and reviewed quarterly with residents |
| Assistant Administrator | Assistant Administrator | Stated that Business Office/HR Manager is now responsible for distributing quarterly PNA statements |
Inspection Report
Complaint Investigation
Census: 277
Deficiencies: 0
Oct 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on NJ Complaint # NJ00158861.
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 investigation NJ00158861 resulted in a finding of substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 284
Deficiencies: 1
Aug 10, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ155108, NJ155950, NJ156092, NJ156587, NJ156808) alleging abuse and failure to report incidents properly.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report a staff-to-resident allegation of abuse involving Resident #3 to the New Jersey Department of Health as required. Interviews and record reviews confirmed the incident was reported internally but not to the state agency within the mandated timeframe.
Complaint Details
The complaint investigation involved multiple allegations of abuse and failure to report incidents. Resident #3 reported being physically abused by staff during the overnight shift. The facility failed to report this allegation to the NJDOH as required by state and federal regulations. Interviews with staff including Licensed Practical Nurses, Unit Manager, Director of Nursing, and Vice President Clinical confirmed the failure to report. The facility policy mandates reporting within 2 hours to the Administrator or Director of Nursing and to the state agency within 5 working days.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged abuse involving Resident #3 to the New Jersey Department of Health within required timeframes. | SS=D |
Report Facts
Census: 284
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented care and incident involving Resident #3 |
| LPN #2 | Licensed Practical Nurse | Confirmed reporting of abuse incident to Unit Manager and Director of Nursing |
| UM #1 | Unit Manager | Reported abuse incident to Director of Nursing |
| Director of Nursing | Director of Nursing | Received report of abuse incident but failed to report to NJDOH |
| Vice President Clinical | Vice President Clinical | Confirmed incident was not reported to NJDOH and stated reporting is required |
Inspection Report
Routine
Census: 217
Deficiencies: 0
Feb 25, 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: 3
Inspection Report
Annual Inspection
Census: 215
Capacity: 300
Deficiencies: 20
Jan 19, 2022
Visit Reason
Annual recertification survey to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident dignity and respect, safe and clean environment, professional standards of care, medication administration, quality of care, range of motion, respiratory care, dialysis, pharmacy services, medication errors, medication labeling and storage, staffing ratios, infection prevention and control, resident call system, and life safety code compliance including emergency lighting, exit signage, sprinkler system, corridor doors, smoke barriers, HVAC, and electrical systems.
Severity Breakdown
SS=D: 16
SS=E: 6
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to maintain respect and dignity for a resident during incontinence care. | SS=D |
| Failure to maintain cleanliness of residents' wheelchairs and equipment. | SS=D |
| Failure to follow physician's orders for PRN medication administration. | SS=D |
| Failure to document and carry out physician's order for lab specimen collection and notify physician of inability to obtain specimen. | SS=E |
| Failure to apply and maintain splinting device as ordered and maintain accountability. | SS=E |
| Failure to obtain appropriate physician orders for respiratory care and tracheostomy care. | SS=D |
| Failure to schedule medications appropriately for dialysis residents. | SS=D |
| Failure to provide pharmaceutical services ensuring medication orders match medications administered. | SS=E |
| Medication administration error rate exceeded 5% due to improper medication measurement and administration. | SS=D |
| Failure to ensure residents are free of significant medication errors, including excessive dosing of antipsychotic medication. | SS=E |
| Failure to maintain required minimum direct care staff to resident ratios for day and night shifts. | SS=E |
| Failure to provide automatic emergency illumination along means of egress and exit signage illumination. | SS=D |
| Failure to provide complete sprinkler coverage in kitchen janitor closet and unit manager office closet. | SS=D |
| Failure to ensure corridor doors latch properly to resist passage of smoke. | SS=E |
| Failure to ensure smoke barrier doors completely close to resist passage of smoke, flame or gases. | SS=D |
| Failure to maintain bathroom ventilation systems in resident rooms. | SS=D |
| Electrical panel missing breaker/spacer creating shock hazard. | SS=D |
| Failure to ensure emergency generator annunciator panel is functional and labeled. | SS=D |
| Failure to maintain proper PPE use and hand hygiene by staff caring for residents on transmission based precautions and failure to disinfect multiuse medical equipment between residents. | SS=E |
| Failure to maintain functioning resident call bell system for multiple residents. | SS=D |
Report Facts
Residents present: 215
Total licensed beds: 300
Medication administration opportunities: 33
Medication administration errors: 2
Staffing ratios: 11
Staffing ratios: 10
Staffing ratios: 13
Staffing ratios: 11
Staffing ratios: 12
Staffing ratios: 18
Staffing ratios: 16
Staffing ratios: 11
Staffing ratios: 9
Staffing ratios: 15
Staffing ratios: 16
Expired medications: 2
Resident rooms with non-functioning bathroom ventilation: 52
Resident room doors with latching issues: 13
Resident rooms with smoke barrier door issues: 2
Electrical panels missing breaker: 1
Resident rooms with no emergency bathroom ventilation: 17
Resident rooms with no emergency lighting: 1
Exit signs not illuminated: 2
Resident rooms with doors not latching: 13
Resident rooms with sprinkler coverage missing: 2
Medication administration error rate: 6.06
Medication administration opportunities: 33
Medication administration errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Medication administration and PPE use deficiencies |
| LPN #2 | Licensed Practical Nurse | Medication administration and equipment cleaning deficiencies |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed about resident care and call bell system |
| RN/UM #2 | Registered Nurse/Unit Manager | Interviewed about call bell system and staffing |
| DON | Director of Nursing | Interviewed about staffing, medication orders, infection control, and call bell system |
| LNHA | Licensed Nursing Home Administrator | Interviewed about staffing and infection control |
| VP | Vice President Clinical | Interviewed about staffing and medication administration |
| Maintenance Director | Maintenance Director | Interviewed about facility maintenance issues including lighting, doors, sprinkler, HVAC, electrical panels |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Interviewed about infection control practices |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed about medication orders and pharmacy services |
| CNA #1 | Certified Nursing Assistant | Interviewed about resident care and call bell system |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident care and call bell system |
| CNA #3 | Certified Nursing Assistant | Interviewed about resident care and call bell system |
| Recreation Aide | Recreation Aide | Observed and interviewed about PPE and hand hygiene practices |
| Pharmacy Representative | Pharmacy Representative | Interviewed about medication orders and pharmacy services |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Interviewed about antipsychotic medication orders |
| Staffing Coordinator | Staffing Coordinator | Interviewed about staffing and scheduling |
Inspection Report
Life Safety
Census: 215
Capacity: 300
Deficiencies: 9
Jan 19, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be in noncompliance with several life safety code requirements including emergency lighting, exit signage, sprinkler system installation, corridor door latching, smoke barrier doors, HVAC ventilation, electrical panel safety, and emergency generator annunciator functionality.
Severity Breakdown
SS=D: 7
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide automatic emergency illumination along means of egress; emergency lighting not operational in corridors and stairwells. | SS=D |
| Failed to provide emergency lighting above emergency generator transfer switches. | SS=D |
| Exit signs not illuminated at all times to clearly identify exit access paths. | SS=D |
| Incomplete sprinkler coverage in kitchen janitor closet and unit manager office closet. | SS=D |
| Corridor doors failed to latch properly, compromising smoke and fire containment. | SS=E |
| Smoke barrier doors failed to close completely, allowing passage of smoke and gases. | SS=D |
| Resident bathroom ventilation systems for 52 of 85 units were not functioning adequately. | SS=E |
| Electrical panel missing breaker/spacer, exposing live parts and shock hazard. | SS=D |
| Emergency generator annunciator panel was non-functional and lacked proper labeling. | SS=D |
Report Facts
Certified beds: 300
Census: 215
Resident bathrooms with ventilation issues: 52
Resident rooms with door latching issues: 13
Exit signs not illuminated: 2
Smoke barrier doors with closure issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and present during observations of deficiencies including emergency lighting, sprinkler coverage, door latching, ventilation, electrical panel, and annunciator panel. | |
| Administrator | Present during survey observations and informed of all findings at exit conference. |
Inspection Report
Complaint Investigation
Census: 214
Deficiencies: 2
Sep 30, 2021
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to resident rights and care at the facility.
Findings
The facility was found non-compliant with federal regulations based on two main complaints: failure to notify a cognitively impaired resident's next of kin when accessing financial information, and failure to monitor and document changes in condition after a fall, including delayed notification of the physician and improper transfer procedures.
Complaint Details
Complaint #NJ00145568 involved failure to notify next of kin regarding financial access for Resident #10. Complaint #NJ00146239 involved failure to monitor and notify physician after Resident #1's fall of unknown origin.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify Resident #10's next of kin when seeking access to the resident's financial information despite cognitive impairment. | SS=D |
| Failure to monitor and document changes in condition after a fall of unknown origin for Resident #1, including failure to notify the physician timely and improper transfer to hospital. | SS=D |
Report Facts
Sample Size: 10
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented observations and care related to Resident #1's fall. |
| LPN #2 | Licensed Practical Nurse | Observed Resident #1 post-fall and failed to notify supervisor and physician timely. |
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficiencies and described facility policies. |
| LNHA | Licensed Nursing Home Administrator | Discussed Resident #10's financial authorization and family notification. |
| NRNS | Night Registered Nurse Supervisor | Assessed Resident #1 after fall. |
Inspection Report
Complaint Investigation
Census: 221
Deficiencies: 3
Jun 25, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ142853; NJ141483; NJ140253; NJ138759 and NJ135971) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant due to failure to serve food at palatable temperatures affecting multiple residents, failure to maintain food safety and sanitary practices including improper hand hygiene by dietary staff, and failure to process a medical records request within two working days as required.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ142853; NJ141483; NJ140253; NJ138759 and NJ135971). The facility was found not in compliance based on these complaints, including issues with food temperature, food safety, and medical record access.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure food items were served at a palatable temperature for 3 of 3 residents (Resident #6, Resident #9, and Resident #10), with hot meals served cold due to delays in meal tray delivery. | SS=E |
| Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including improper food temperatures and failure to observe proper hand hygiene by dietary staff. | SS=F |
| Failure to provide a copy of medical records within two working days of request for 1 of 3 residents reviewed (Resident #3), due to delays related to verification of legal authority. | — |
Report Facts
Census: 221
Sample Size: 16
Meal tray temperatures: 101
Meal tray temperatures: 105
Meal tray temperatures: 108
Meal tray temperatures: 102
Meal tray temperatures: 61
Meal tray temperatures: 119
Meal tray temperatures: 138
Meal tray temperatures: 135
Meal tray temperatures: 128
Meal tray temperatures: 118
Meal tray temperatures: 51
Medical record request processing time: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #2 | Dietary Aide | Observed adjusting mask and scratching head without changing gloves or performing hand hygiene, potentially contaminating residents' plates. |
| Dietary Aide #1 | Dietary Aide | Observed handling coffee maker and trash without changing gloves or performing hand hygiene. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food temperature monitoring and meal tray delivery process. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding medical record request processing and facility policies. |
| Director of Social Services | Director of Social Services | Interviewed regarding medical record request and processing delays. |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding hand hygiene training and infection control practices in the kitchen. |
Inspection Report
Routine
Census: 215
Deficiencies: 0
Apr 19, 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
Inspection Report
Routine
Census: 204
Deficiencies: 0
Jan 19, 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 CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 14
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