Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform recipients about the privacy practices of NJDHSS, including how medical information may be used and disclosed, and the rights of individuals regarding their health 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
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 5
Sep 18, 2024
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 professional standards in clinical practice, failure to ensure RN staffing requirements, unsanitary food service conditions, failure to complete LGBTQI+ training for designated staff, and failure to maintain HVAC air filters properly.
Complaint Details
Complaint #: NJ00172520. The complaint triggered a recertification survey to determine compliance with long term care facility regulations.
Severity Breakdown
SS=D: 1
SS=F: 2
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain professional standards of clinical practice by not notifying the physician of a significant clinical issue for 1 of 2 residents. | SS=D |
| Facility failed to ensure a registered nurse worked 7 days a week for at least 8 consecutive hours a day as required. | SS=F |
| Facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination and potential food borne illness. | SS=F |
| Facility failed to ensure that one administrative staff member and one direct care staff member completed the required LGBTQI+ and HIV+ training program. | — |
| Facility failed to maintain resident room air conditioning unit filters in a clean condition as required by NFPA standards. | SS=E |
Report Facts
Census: 54
Total Capacity: 60
Deficiencies cited: 5
PBJ Staffing Infractions: 15
Inspection Report
Routine
Census: 54
Deficiencies: 0
Jan 22, 2024
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
Annual Inspection
Census: 56
Capacity: 60
Deficiencies: 8
Sep 26, 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 care plan timing and revision, failure to notify physician of incomplete pacemaker checks, and food safety violations including improper food labeling and sanitation. Life safety code deficiencies were also noted including emergency illumination, exit signage, and electrical system maintenance.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to revise care plans timely for 2 of 14 residents reviewed. | SS=D |
| Failed to notify physician of incomplete pacemaker checks for Resident #39. | SS=D |
| Failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. | SS=F |
| Failed to maintain minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey. | — |
| Did not offer residents evening activities two nights per week. | — |
| Failed to provide emergency illumination that would operate automatically along the means of egress. | SS=E |
| Failed to provide exit signs with continuous illumination indicating direction of travel where direction was not apparent. | SS=F |
| Failed to functionally test non-hospital grade electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=E |
Report Facts
Census: 56
Total Capacity: 60
Sample Size: 17
Deficient CNA staffing days: 11
Deficiency completion dates: Multiple deficiencies corrected by 11/6/2023 as per revisit report
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing and care plan revision |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding life safety code deficiencies and electrical system maintenance |
| Regional Director | Regional Director (RD) | Interviewed regarding life safety code deficiencies |
| Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding care plan revision and staffing issues |
| Minimum Data Set Coordinator | MDS Coordinator | Responsible for updating care plans following hospitalization |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food safety and sanitation deficiencies |
| Activities Assistant | Activities Assistant (AA) | Interviewed regarding lack of evening activities |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 1
Aug 12, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey staffing regulations, specifically to verify if the facility maintained the required minimum direct care staff-to-resident ratios for the day shift as mandated by state law.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios for the day shift on 10 of 14 days reviewed, with CNA to resident ratios ranging from 1:9.5 to 1:19, exceeding the state minimum of 1 CNA to 8 residents. The facility implemented corrective actions including policy revisions, staff re-education, and increased recruitment efforts.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios for the day shift as mandated by the state of New Jersey. |
Report Facts
Census: 38
Deficiencies cited: 1
Staffing ratios: 19
Staffing ratios: 9.5
Staffing ratios: 12.6
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Jun 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ136976; NJ142606; NJ142848; NJ143888; NJ144058) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to ensure that three residents (Residents #10, #11, and #12) had their call bell activators within reach, posing safety concerns. Observations revealed call bells were out of reach and staff did not ensure accessibility. The Director of Nursing acknowledged the safety risk and corrective actions were planned.
Complaint Details
The visit was complaint-related involving multiple complaint numbers. The facility was found non-compliant with regulations regarding accident hazards and supervision related to call bell accessibility for residents.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents had call bell activators within reach to prevent accidents. | SS=E |
Report Facts
Census: 39
Sample Size: 14
Number of residents with call bell deficiency: 3
Plan of Correction Completion Date: Aug 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Stated the importance of residents having call bell access and acknowledged safety concerns. | |
| Certified Nurse Aide (CNA) #1 | Verified that residents' call bell activators were out of reach and residents were unable to use them. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to concerns about the facility's failure to implement timely Transmission Based Precautions (TBP) to prevent COVID-19 transmission after staff tested positive.
Findings
The facility failed to timely identify residents exposed to COVID-19 positive staff and implement TBP, resulting in an Immediate Jeopardy situation. The facility did not conduct documented contact tracing and delayed TBP implementation from 11/23/2020 to 12/06/2020. Additionally, infection control protocols regarding doffing of soiled isolation gowns were not properly followed.
Complaint Details
The investigation was complaint-driven based on concerns about COVID-19 infection control practices, specifically failure to identify exposed residents and implement TBP timely after two CNAs tested positive for COVID-19. The facility was notified of Immediate Jeopardy on 01/06/2021 at 4:45 PM.
Severity Breakdown
SS=L: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement Transmission Based Precautions in a timely manner to prevent COVID-19 transmission after staff tested positive. | SS=L |
| Failure to follow appropriate infection control protocols regarding doffing of soiled isolation gowns. | SS=D |
Report Facts
Census: 43
Deficiency duration: 13
Residents at risk: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Named in failure to ensure timely implementation of TBP and contact tracing. | |
| Director of Nursing/Infection Preventionist (DON/IP) | Named in failure to ensure timely implementation of TBP and contact tracing. | |
| Corporate Registered Nurse (CRN) | Involved in infection control and contact tracing efforts. | |
| Licensed Practical Nurse (LPN #1) | Observed failing to properly doff soiled isolation gown. | |
| Certified Nursing Assistants (CNA #1 and CNA #2) | Staff who tested positive for COVID-19 and exposed residents. |
Inspection Report
Routine
Census: 49
Deficiencies: 0
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 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: 8
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