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 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
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
Routine
Census: 122
Capacity: 124
Deficiencies: 12
Apr 17, 2025
Visit Reason
A Recertification/LSC survey was conducted from 4/10/25 through 4/17/25 to determine compliance with 43 CFR Part 483 requirements for Long Term Care Facilities, including complaint investigations.
Findings
The facility was found not in compliance with multiple regulatory requirements including dietary orders, personal privacy, ADL care, infection control, medication administration, emergency preparedness, and life safety code. Immediate Jeopardy was identified related to failure to ensure dietary orders and special instructions for residents at risk of choking and aspiration. Corrective actions and re-education plans were implemented and verified.
Complaint Details
Complaint investigation was conducted based on multiple complaint numbers NJ 170566, NJ 170732, NJ 175978, NJ 177289, NJ 178091, NJ 178739, NJ 182695, NJ 183695. The complaint findings were substantiated as evidenced by multiple deficiencies cited.
Severity Breakdown
Immediate Jeopardy: 1
Level F: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure dietary orders and special instructions for residents at risk of choking and aspiration, resulting in Immediate Jeopardy. | Immediate Jeopardy |
| Failure to ensure personal privacy was maintained when implementing video monitoring devices inside resident rooms. | Level F |
| Failure to provide appropriate and timely personal hygiene care for dependent residents. | Level F |
| Failure to provide adequate supervision and assistance to prevent accidents and timely response to call lights. | Level F |
| Failure to ensure medication administration was conducted according to physician orders and nursing standards. | Level F |
| Failure to maintain emergency preparedness plan and documentation as required. | Level F |
| Failure to post nurse staffing data as required by regulation. | Level F |
| Failure to ensure infection prevention and control measures including proper use of PPE and hand hygiene. | Level F |
| Failure to ensure proper storage, labeling, and disposal of medications and biologicals. | Level F |
| Failure to ensure therapeutic diets were prescribed and followed according to physician orders. | Level F |
| Failure to comply with licensure requirements including Medicaid acceptance and admission agreements. | Level F |
| Failure to comply with life safety code requirements including fire door inspections and fire extinguisher maintenance. | Level F |
Report Facts
Census: 122
Total Capacity: 124
Sample Size: 30
Deficiency Count: 12
Date Survey Completed: Apr 17, 2025
Plan of Correction Completion Date: May 13, 2025
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Jun 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ00171568, NJ00171569, NJ00173253, and NJ00174253.
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. No deficiencies were cited.
Complaint Details
The complaint investigation was based on four complaint numbers. The facility was found compliant with no deficiencies.
Report Facts
Sample size: 8
Inspection Report
Annual Inspection
Census: 118
Capacity: 124
Deficiencies: 11
Dec 8, 2023
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 medication order clarification, pharmacy services, medication labeling and storage, facility name compliance, infection control, and life safety code violations including egress door locking, hazardous area enclosure, corridor door maintenance, smoke barrier door gaps, electrical receptacle safety, and generator maintenance.
Severity Breakdown
SS=D: 5
SS=E: 4
SS=C: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to clarify a physician's order for medication application location for Resident #94. | SS=D |
| Failed to promptly record removal of controlled drugs from narcotic inventory for 1 of 3 nurses observed. | SS=D |
| Failed to secure medication administration cart during medication pass and maintain proper labeling/dating of medications on carts. | SS=D |
| Facility name displayed and used did not correspond with CMS licensed and approved name. | SS=C |
| Failed to follow infection control practices by placing loose medication into the same medication cup with unopened packets. | SS=D |
| Egress doors had locking devices that could restrict emergency use of exit doors. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and properly labeled. | SS=E |
| Failed to maintain 49 of 120 corridor doors to resident rooms to close and provide smoke protection. | SS=E |
| Failed to maintain smoke barrier doors to resist transfer of smoke due to gaps when closed. | SS=E |
| Failed to ensure electrical outlet near water source was equipped with Ground-Fault Circuit Interrupter (GFCI). | SS=D |
| Failed to provide remote manual stop station for generator and failed to document monthly load test transfer times. | SS=F |
Report Facts
Sample size: 27
Number of residents observed with medication order issue: 1
Number of nurses observed with narcotic record issue: 1
Number of medication carts inspected: 8
Number of doors with latching issues: 49
Facility licensed bed capacity: 124
Facility census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Involved in medication order clarification and narcotic record deficiencies | |
| Director of Nursing (DON) | Interviewed regarding medication order clarification and narcotic record deficiencies | |
| Housekeeping Director (HD) | Interviewed and observed during life safety code deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding facility name change and compliance | |
| Regional LNHA | Interviewed regarding CMS 855A application for name change | |
| Pharmacy Consultant (PC) | Interviewed regarding medication labeling and dating | |
| Registered Nurse Infection Preventionist (RN/IP) | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 3
May 24, 2023
Visit Reason
The inspection was conducted in response to Complaint #NJ164303 to investigate allegations of noncompliance with staffing ratios, medication administration, and notification procedures at Promedica Total Rehab + (Moorestown).
Findings
The facility was found deficient in maintaining required minimum direct care staff to resident ratios on multiple evening shifts. The facility failed to notify physicians when residents refused medications and did not follow its documentation policies. Additionally, there was a failure to document administration of medication for one resident, indicating possible missed medication doses.
Complaint Details
Complaint #NJ164303 involved allegations of inadequate staffing ratios, failure to notify physicians of medication refusals, and improper medication administration documentation. The complaint was substantiated with findings of deficiencies in these areas.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios on 7 of 14 evening shifts from 5/7/2023 to 5/20/2023. | — |
| Failed to notify physicians when residents refused medications for 2 residents and failed to follow documentation policies. | SS=D |
| Failed to provide evidence that medication was administered according to physician's order and failed to follow medication administration and infusion policies for 1 resident. | SS=D |
Report Facts
Census: 90
Evening shifts deficient in CNA staffing: 7
Sample size: 4
Required CNAs on deficient shifts: 13
Actual CNAs on deficient shifts: 10
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Dec 3, 2021
Visit Reason
The inspection was conducted based on complaints NJ142054, NJ142662, NJ144197, and NJ149476 to investigate compliance with staffing ratios and resident assessments.
Findings
The facility failed to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple shifts, potentially affecting all residents. Additionally, the facility nursing staff failed to have a Registered Nurse complete a timely assessment for a resident after a fall, indicating deficient resident assessment practices.
Complaint Details
Complaint investigation based on complaints NJ142054, NJ142662, NJ144197, and NJ149476. The facility was found deficient in staffing and resident assessment practices. The facility was ultimately found in compliance with 42 CFR, Part 483, Subpart B, for long term care facilities based on this complaint visit.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 22 of 28 shifts reviewed. |
| Failure to have a Registered Nurse complete a timely assessment for a resident after a fall. |
Report Facts
Census: 81
Shifts reviewed: 28
Shifts deficient: 22
Sample size: 5
Staffing ratios required: 11
Staffing ratios actual: 5
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 2
Aug 23, 2021
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 failure to maintain required minimum direct care staff to resident ratios for the day shift and failure to follow professional standards of clinical practice during medication administration for one resident.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. | — |
| Facility failed to follow professional standards of clinical practice during medication administration for 1 of 4 residents observed. | SS=D |
Report Facts
Census: 81
Deficiency count: 2
Staffing ratios not met: 13
CNA staffing counts: 8
Sign on bonus: 3000
Referral bonus: 500
Staffing bonus: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated there is a CNA shortage and described staffing efforts and bonuses | |
| Licensed Practical Nurse (LPN) | Observed administering medication incorrectly during medication pass | |
| Care Manager | Stated nurses should perform three checks during medication administration | |
| Director of Nursing (DON) | Stated nurses should review physician orders and perform checks prior to medication administration |
Inspection Report
Routine
Census: 81
Deficiencies: 0
Aug 23, 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
Life Safety
Deficiencies: 1
Aug 20, 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 for existing health care occupancies.
Findings
The facility was found to be in noncompliance due to failure to provide battery backup emergency lighting in the main electrical room above the emergency generator's transfer switch, independent of the building's electrical system and emergency generator.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide a battery backup emergency light in the main electrical room above the emergency generator's transfer switch, independent of the building's electrical system and emergency generator. | SS=D |
Report Facts
Smoke zones: 15
Building stories: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified the deficiency of missing emergency lighting in the main electrical room during inspection. |
Inspection Report
Routine
Census: 85
Deficiencies: 0
Mar 9, 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: 8
Sample size: 3
Inspection Report
Routine
Census: 75
Deficiencies: 0
Jan 25, 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: 3
Inspection Report
Routine
Census: 89
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 and recommended practices for 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: 6
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