Deficiencies per Year
8
6
4
2
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 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: 131
Capacity: 178
Deficiencies: 8
Jan 9, 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 NJ168504, NJ175432, and NJ176408.
Findings
Deficiencies were cited related to safe environment, abuse/neglect policies, staffing, medication errors, infection control, nutrition, life safety, and fire safety. The facility failed to maintain required staffing ratios, ensure proper medication administration, and maintain fire safety systems. Corrective actions and audits were implemented for all cited deficiencies.
Complaint Details
The survey was triggered by complaints NJ168504, NJ175432, and NJ176408. The complaints involved issues such as staffing deficiencies, abuse/neglect policies, medication errors, and infection control. The complaints were substantiated as evidenced by cited deficiencies.
Severity Breakdown
SS=D: 4
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe, clean, comfortable, and homelike environment; residents observed with dirty overbed tables and wheelchairs. | SS=D |
| Facility failed to develop and implement abuse/neglect policies and procedures, including reporting and investigation. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. | — |
| Facility failed to ensure medication error rates were below 5%, with errors observed in medication administration. | SS=D |
| Facility failed to maintain menus and nutritional adequacy in accordance with nationally accredited standards. | SS=F |
| Facility failed to maintain infection prevention and control program including proper use of PPE and staff training. | SS=D |
| Facility failed to maintain means of egress free of obstructions and maintain sprinkler system in accordance with NFPA standards. | SS=F |
| Facility failed to maintain electrical systems and conduct required testing and maintenance. | SS=F |
Report Facts
Census: 131
Total Capacity: 178
Staffing Ratios: 10
Medication Error Rate: 7.4
Weight Loss Audit: 5
Deficiencies Cited: 8
Inspection Report
Routine
Census: 148
Capacity: 178
Deficiencies: 8
Sep 29, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey was a standard survey conducted on 09/29/2023.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable, homelike environment; failure to develop and implement comprehensive person-centered care plans; failure to provide timely treatment and care; failure to maintain effective pest control; failure to maintain fire alarm and sprinkler systems; failure to maintain smoke barriers; and failure to maintain ongoing communication and documentation related to resident care. Deficiencies were corrected by the facility with plans of correction dated 10/19/2023.
Complaint Details
The survey included complaint investigations for multiple complaint numbers including NJ#: 165453, 159439, 156933, 164687, 157073, 164539. The complaints involved issues such as staffing deficiencies, quality of care, pest control, and environmental conditions. Some complaints were substantiated as evidenced by cited deficiencies.
Severity Breakdown
E: 2
D: 3
F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean, comfortable, homelike environment for residents, evidenced by issues such as broken window coverings, bug infestations, damaged walls, and peeling paint. | E |
| Facility failed to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes. | D |
| Facility failed to provide timely treatment and care, including failure to complete incident/accident reports and follow physician orders. | D |
| Facility failed to maintain effective pest control program, evidenced by presence of insects and rodents in multiple units. | E |
| Facility failed to maintain fire alarm system in accordance with NFPA 101 Life Safety Code, including malfunctioning smoke detector and pull stations. | F |
| Facility failed to maintain sprinkler system and conduct required testing and maintenance. | F |
| Facility failed to maintain smoke barriers, including unsealed gaps and penetrations. | F |
| Facility failed to maintain ongoing communication and documentation related to resident care, including medication administration and care plan updates. | D |
Report Facts
Census: 148
Total Capacity: 178
Deficiency counts: 8
Staffing counts: 12
Resident sample size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager | Licensed Practical Nurse Unit Manager (LPN/UM) | Interviewed regarding holes in walls and resident care documentation. |
| Housekeeping Director | Housekeeping Director (HD) | Interviewed regarding housekeeping responsibilities and pest control. |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding maintenance work and pest control. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding facility commitment to resident comfort and incident report creation. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident reports, care plans, and staff education. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and observations of bugs. |
| Vice President of Clinical Services | Vice President of Clinical Services (VPCS) | Interviewed regarding staff education and resident care. |
Inspection Report
Follow-Up
Census: 145
Deficiencies: 6
May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities and to follow up on previously cited deficiencies.
Findings
The facility was found deficient in maintaining required minimum direct care staff to resident ratios on 2 of 14-day shifts. Life safety code deficiencies were identified including lack of emergency lighting backup, missing illuminated exit signs, incomplete sprinkler coverage, smoke barrier door deficiencies, and malfunctioning bathroom exhaust systems. Corrective actions were implemented and verified in a follow-up revisit.
Severity Breakdown
SS=E: 3
SS=D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 2 of 14-day shifts. | — |
| Failed to provide battery backup emergency lighting above the emergency generator's transfer switch. | SS=E |
| Failed to ensure illuminated exit signs in four locations to clearly identify exit access paths. | SS=E |
| Failed to ensure complete coverage by supervised automatic fire sprinkler system in all areas of the building. | SS=E |
| Failed to maintain smoke barrier doors to resist transfer of smoke when completely closed; one door was warped leaving a gap. | SS=D |
| Failed to ensure proper maintenance and function of ventilation systems for 3 of 11 resident bathroom exhaust systems. | SS=D |
Report Facts
Deficient staffing shifts: 2
Residents present: 145
Required CNAs on deficient days: 19
Actual CNAs on deficient days: 18
Deficient exit signs: 4
Sprinkler coverage gaps: 3
Malfunctioning bathroom exhausts: 3
Smoke barrier doors tested: 7
Smoke barrier doors deficient: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing requirements and compliance |
| Corporate Facility's Maintenance | CFM | Participated in building inspections and confirmed deficiencies |
| Maintenance Assistant | MA | Participated in building inspections and confirmed deficiencies |
| Maintenance Director | Responsible for auditing corrective actions for lighting, sprinkler, smoke doors, and ventilation |
Inspection Report
Routine
Census: 131
Deficiencies: 0
Sep 29, 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 practices.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Aug 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146753, NJ146369, and NJ146203.
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 NJ146753, NJ146369, and NJ146203 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
May 12, 2021
Visit Reason
The inspection was conducted based on complaint #NJ: 140095 to assess compliance with regulatory requirements.
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 visit.
Complaint Details
Complaint #NJ: 140095 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Routine
Census: 112
Deficiencies: 0
Dec 2, 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.
Loading inspection reports...
