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 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
Routine
Census: 60
Deficiencies: 10
Sep 27, 2024
Visit Reason
Routine standard survey inspection conducted on 09/27/2024 to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities, but was not in compliance with certain New Jersey Administrative Code regulations and Life Safety Code requirements. Deficiencies were identified related to the use of the New Jersey Universal Transfer Form, mandatory access to care staffing ratios, and multiple life safety code violations including means of egress, cooking facilities, fire extinguishers, elevators, electrical systems, and gas equipment storage.
Deficiencies (10)
| Description |
|---|
| Failure to use the required New Jersey Universal Transfer Form (NJ UTF) when transferring residents to another licensed healthcare facility. |
| Failure to complete all sections of the NJ Universal Transfer Form for residents transferred to the hospital. |
| Deficient CNA staffing levels for multiple weeks prior to survey, not meeting state mandated minimum direct care staff ratios. |
| Failure to ensure means of egress were continuously maintained free of obstructions in exit access corridors. |
| Failure to perform monthly inspections of the kitchen range-hood fire suppression system as required. |
| Failure to provide instructional placards near Class K fire extinguishers in the kitchen. |
| Failure to maintain elevator emergency communication telephones in working order. |
| Failure to functionally test electrical receptacles in resident rooms annually as required. |
| Failure to provide a letter of reliability from the natural gas supplier for the facility's natural gas generators. |
| Failure to provide proper storage and segregation of oxygen cylinders in the oxygen storage room. |
Report Facts
Census: 60
Sample Size: 18
Deficiency Completion Date: Oct 27, 2024
Staffing Deficiencies: 10
Residents Affected: 60
Oxygen Cylinders: 26
Inspection Report
Routine
Census: 58
Deficiencies: 0
Feb 14, 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
Complaint Investigation
Census: 59
Deficiencies: 6
Jul 14, 2023
Visit Reason
A complaint investigation was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaint NJ #: 00161215.
Findings
The facility was found deficient in multiple areas including failure to notify the Office of the State Long-Term Care Ombudsman about a resident's emergency transfer, inaccurate completion of Minimum Data Set (MDS) assessments for multiple residents, failure to provide nail care to a dependent resident, improper food handling and storage practices in the kitchen, and failure to follow proper hand hygiene during meal service.
Complaint Details
Complaint NJ #: 00161215. The complaint involved failure to notify the Ombudsman of emergency transfers and other care deficiencies.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to notify the Office of the State Long-Term Care Ombudsman about a resident's emergency transfer to the hospital. | SS=D |
| Failed to accurately complete the Minimum Data Set (MDS) assessments for multiple residents, including incomplete sections and inaccurate medication coding. | SS=E |
| Failed to provide nail care to a resident dependent on staff for activities of daily living. | SS=D |
| Failed to properly handle and store potentially hazardous foods and maintain kitchen utensils to prevent microbial growth and cross contamination. | SS=E |
| Failed to follow appropriate infection control practices for hand hygiene during meal service. | SS=D |
| 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: 59
Deficient CNA staffing shifts: 9
Required CNA staffing: 7
Actual CNA staffing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Acknowledged failure to notify Ombudsman and responsibility of Social Worker for notifications | |
| Social Worker (SW) | Responsible for sending emergency transfer notifications; acknowledged failure to send notice | |
| Registered Nurse (RN) | Described process for emergency transfer notification and acknowledged system issues | |
| Certified Nursing Assistant (CNA #1 and CNA #2) | Named in failure to provide nail care to Resident #3 | |
| Executive Chef (EC) | Observed food storage and handling deficiencies in kitchen | |
| Area General Manager (AGM) | Confirmed food labeling and storage deficiencies | |
| Certified Nursing Aide (CNA) observed during meal service | Failed to perform hand hygiene properly during meal service | |
| Director of Nursing (DON) | Acknowledged hand hygiene deficiencies and importance of proper infection control | |
| Staffing Coordinator | Provided staffing requirements and acknowledged deficient CNA staffing on multiple shifts |
Inspection Report
Life Safety
Deficiencies: 4
Jul 12, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/12/2023 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be noncompliant with fire safety requirements including failure to provide two-hour fire resistance-rated elements between nursing and assisted living sections, lack of illuminated exit signage in key locations, stairwell doors not maintaining required fire rating due to improper latching, and malfunctioning bathroom exhaust systems in resident rooms.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide two-hour fire resistance-rated elements and assemblies between the Nursing Facility and Assisted Living section, including penetrations and missing wallboard allowing passage of fire and smoke. | SS=D |
| Exit signage not illuminated in two locations to clearly identify exit access paths, specifically above double doors in second and third floor dining rooms. | SS=E |
| One of six exit access stairwell doors failed to positively latch, compromising the 1-1/2 hour fire rated construction. | SS=D |
| Failure to ensure proper maintenance of ventilation systems; three of six resident bathroom exhaust systems were not functioning properly. | SS=E |
Report Facts
Resident sleeping rooms: 36
Exit access doors tested: 6
Resident bathroom exhaust systems tested: 6
Bathroom exhaust systems malfunctioning: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Building Services Director | Confirmed findings during observations and involved in corrective actions | |
| Administrator | Informed of deficiencies during survey exit | |
| Corporate Director of Building Service | Provided inservice education related to fire safety deficiencies |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 4
Nov 23, 2021
Visit Reason
The inspection was conducted based on complaint NJ147216 to investigate allegations related to the provision of medically related social services, dental services, staffing ratios, and quality of care at the facility.
Findings
The facility was found not in substantial compliance with federal requirements. Deficiencies included failure to ensure completion of Health Drive Enrollment forms and timely dental referrals for residents, failure to maintain required minimum staffing ratios on multiple shifts, and failure to provide at least one bath per week to a sampled resident. The facility also failed to follow its own policies related to social work, dental services, and activities of daily living.
Complaint Details
Complaint NJ147216 was substantiated with findings of deficiencies in social services provision, dental care, staffing, and quality of care.
Severity Breakdown
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure Health Drive Enrollment form completion and timely dental services for Resident #2. | SS=D |
| Failure to promptly refer a resident for needed dental services within three business days after dentures were identified as broken and failure to document delays. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 17 of 28 shifts reviewed. | — |
| Failure to provide at least one bath per week to Resident #2 as required. | — |
Report Facts
Census: 58
Deficient shifts: 17
Sample size: 3
Inspection Report
Routine
Census: 60
Deficiencies: 0
Aug 27, 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: 4
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 1
May 24, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in food safety requirements related to food procurement, storage, preparation, and sanitation practices in the dietary kitchen, including dust buildup on fans, improper storage of clean dishware, lack of internal thermometer in the milk box, wet nesting of baking pans, and exposed plastic food wrap.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness, evidenced by dust buildup on fans blowing onto food and utensils, improper storage of clean plates, lack of internal thermometer in milk box, wet nesting of baking pans, and exposed plastic food wrap. | SS=E |
Report Facts
Census: 63
Sample Size: 20
Deficiency Completion Date: 2021
Temperature: 36
Stacked Baking Pans: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Chef | Accompanied surveyor during kitchen observations and involved in corrective actions | |
| Food Service Director | Accompanied surveyor during kitchen observations, provided statements about deficiencies, and involved in corrective actions |
Inspection Report
Life Safety
Deficiencies: 3
May 19, 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 noncompliant with several Life Safety Code requirements including improper exit signage on two doors, failure to provide audible and visible fire alarm notification in an enclosed courtyard, and failure to maintain the sprinkler system properly with smoke-resisting ceilings in 5 of 10 rooms. Multiple deficiencies were identified related to fire safety systems and maintenance.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to properly identify doors with signage as 'No Exit' for 2 of 2 doors, including a corridor door and dining room door leading to an enclosed courtyard. | SS=D |
| Facility failed to provide notification by audible and visible signals in 1 of 1 enclosed courtyards; horn/strobe device tied to fire alarm was missing. | SS=E |
| Facility failed to maintain sprinkler system ensuring smoke-resisting ceiling at sprinkler level for 5 of 10 rooms; multiple issues noted including missing valves, outdated pendents, lack of hydraulic placard, and improper fire stopping of ceiling penetrations. | SS=F |
Report Facts
Number of doors with improper exit signage: 2
Number of enclosed courtyards without fire alarm notification: 1
Number of rooms with sprinkler system ceiling deficiencies: 5
Date of sprinkler system annual inspection report: Apr 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings related to exit signage and fire alarm deficiencies; confirmed sprinkler system deficiencies during observations and interview | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 1
Apr 27, 2021
Visit Reason
The inspection was conducted as part of a compliance survey to assess the facility's maintenance of mechanical and patient care equipment, specifically focusing on the condition of hot water Baseboard Heating Units in resident rooms.
Findings
The facility failed to maintain its hot water Baseboard Heating Units in safe and optimal working condition in 3 of 8 rooms reviewed. The heating units lacked proper temperature control knobs and fan speed controls, resulting in no means to control temperature or air movement in those rooms.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Baseboard Heating Units in 3 rooms were missing high, medium, and low fan speed control buttons and temperature adjusting knobs, replaced by a toggle switch that only provided full heat or no heat, lacking proper control. | SS=D |
Report Facts
Census: 65
Sample size: 8
Deficiency completion timeframe: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services | Present during the inspection and provided information about heating unit controls | |
| NHA (Nursing Home Administrator) | Responsible for monitoring compliance and reviewing progress in QAPI and safety committee meetings | |
| Building Service Director | Responsible for ensuring compliance, monitoring, providing in-service education, and tracking repair completion |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Apr 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ 144574.
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 # NJ 144574 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 59
Deficiencies: 0
Dec 9, 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.
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.
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