Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
58% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS 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 NJDHSS's legal duties and policies regarding 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: 50
Capacity: 86
Deficiencies: 15
Sep 27, 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 residents' rights to be free from physical restraints, complaint investigations, accuracy of assessments, comprehensive care plans, medication administration, food safety, immunizations, staffing ratios, and life safety code compliance.
Complaint Details
Complaint numbers NJ00171237, 00172349, 00172381, 00173377 related to abuse, neglect, and other allegations were investigated with findings of deficient investigations and documentation.
Severity Breakdown
SS=D: 9
SS=E: 2
SS=F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure residents' rights to be free from physical restraints including lack of assessment, consent, monitoring, and documentation for Resident #19. | SS=D |
| Failure to maintain documentation and conduct thorough investigations of alleged abuse for Residents #5 and #45. | SS=D |
| Failure to accurately assess resident status in Minimum Data Set (MDS) for Resident #37. | SS=D |
| Failure to develop and implement comprehensive interdisciplinary care plans reflecting resident preferences and medical needs for Residents #40 and #48. | SS=D |
| Failure to follow physician's orders for assistive devices and supervise medication administration for Residents #8 and #27. | SS=D |
| Failure to ensure urinary catheter was secured properly to prevent contamination for Resident #48. | SS=D |
| Failure to provide appropriate assistive eating devices and ensure accessibility for Resident #8. | SS=D |
| Failure to procure, store, prepare, and serve food in accordance with professional food safety standards including unlabeled, expired, or improperly stored food items and lack of beard guards for kitchen staff. | SS=F |
| Failure to ensure influenza and pneumococcal immunizations were offered and documented for Residents #4 and #32. | SS=D |
| Failure to provide battery back-up emergency lighting above the emergency generator transfer switch in accordance with NFPA 101. | SS=E |
| Failure to provide required instructional signage above Class K portable fire extinguishers in the kitchen. | SS=E |
| Failure to perform monthly testing of firefighter's service Phase I and Phase II emergency elevator recall for 1 of 1 elevator. | SS=F |
| Failure to ensure annual inspection of fire doors by qualified personnel with documented records. | SS=F |
| Failure to establish Inspection, Testing and Maintenance (ITM) intervals and documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failure to maintain required minimum direct care staff to resident ratio for Certified Nurse Aides (CNAs) on multiple day shifts. | — |
Report Facts
CNA staffing deficiency: 3
CNA staffing deficiency: 4
Resident census: 50
Total licensed capacity: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to staffing and investigation deficiencies. | |
| Staff Educator | Named in relation to staff in-service and corrective actions. | |
| Licensed Practical Nurse | Interviewed regarding resident care and investigations. | |
| Certified Nursing Assistant | Interviewed regarding resident care and investigations. | |
| Plant Operations Director | Named in relation to life safety code corrective actions. | |
| Food Service Director | Named in relation to food safety corrective actions. |
Inspection Report
Routine
Census: 53
Capacity: 85
Deficiencies: 10
Jul 21, 2023
Visit Reason
A routine standard survey inspection was conducted to assess compliance with federal and state regulations for long term care facilities, including emergency preparedness, quality of care, nutrition, infection control, and life safety.
Findings
The facility was found to be not in substantial compliance with several regulatory requirements, including failure to promote a home-like dining environment, failure to follow physician orders and care plans, inadequate nutrition and hydration status maintenance, improper respiratory care, food safety violations, and life safety code deficiencies. Corrective actions were implemented for all cited deficiencies.
Severity Breakdown
Level 1: 8
Level 2: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to promote a home-like dining atmosphere; residents received meals on trays in the dining room. | Level 1 |
| Failed to follow physician orders and care plans for Resident #41, including medication administration and bed mobility. | Level 2 |
| Failed to maintain acceptable nutritional and hydration status for Resident #28. | Level 2 |
| Failed to provide proper parenteral/IV fluids care for Resident #21, including labeling and storage. | Level 2 |
| Failed to provide adequate respiratory/tracheostomy care and suctioning, including mask storage and replacement. | Level 1 |
| Failed to maintain mandatory access to care staffing ratios as required by state regulations. | Level 1 |
| Failed to maintain food safety requirements, including proper labeling, storage, and sanitation in the kitchen and dry storage areas. | Level 1 |
| Failed to maintain sanitary environment for garbage disposal and refuse properly. | Level 1 |
| Failed to maintain infection prevention and control program, including sanitary practice for resident care equipment and handling of contaminated items. | Level 1 |
| Failed to maintain life safety code requirements, including emergency exit signage, sprinkler system installation, HVAC ventilation, and electrical system maintenance. | Level 1 |
Report Facts
Census: 53
Total Capacity: 85
Sample Size: 27
Deficiency Count: 10
Staffing Deficiency: 6
Resident Rooms: 85
Resident Bathroom Exhaust Systems Tested: 14
Resident Bathrooms with Exhaust Issues: 5
Weight Change Threshold: 5
Frequency of Generator Testing: 12
Inspection Report
Follow-Up
Census: 39
Deficiencies: 1
Nov 23, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing regulations and to follow up on previously cited deficiencies related to minimum direct care staff to resident ratios.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to maintain the required minimum direct care staff to resident ratios for 1 out of 42 shifts reviewed. Specifically, on 11/13/21, the facility had 4 CNAs for 39 residents on the day shift, while 5 CNAs were required. A plan of correction was submitted and later verified as completed on 12/21/2021.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 1 out of 42 shifts reviewed. |
Report Facts
Shifts reviewed: 42
Residents on day shift: 39
CNAs on day shift: 4
Required CNAs on day shift: 5
Loading inspection reports...
