Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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 regarding their health 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 the notice |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 6
Oct 8, 2024
Visit Reason
The inspection was conducted in response to a complaint (Complaint # NJ00166408) to assess compliance with New Jersey Administrative Code standards for licensure of dementia care homes.
Findings
The facility was found not in compliance with multiple standards including failure to ensure staff CPR certification, resident safety issues related to unsecured access to the kitchenette and hazardous chemicals, failure to ensure licensed or certified staff provided care, lack of required electrical inspections, restricted emergency exit access, and failure to properly monitor and record food temperatures.
Complaint Details
Complaint # NJ00166408 triggered the inspection. An Imminent Danger was identified related to resident safety. The complaint was substantiated based on observations, interviews, and record reviews.
Deficiencies (6)
| Description |
|---|
| Facility administration failed to ensure staff certified in CPR/AED were scheduled at all times. |
| Facility failed to ensure resident right to a safe living environment; unsecured access to kitchenette and hazardous chemicals present. |
| Facility failed to ensure all staff providing care were licensed or certified; one Home Health Aide's certification issues noted. |
| Facility failed to provide required annual electrical inspections. |
| Facility failed to provide one of six designated exit doors free of obstructions and with proper egress. |
| Facility staff failed to consistently monitor and record food temperatures, placing 19 of 19 residents at risk. |
Report Facts
Census: 19
Sample size: 11
Residents at risk: 19
Staff files reviewed: 6
Licensed/certified staff deficiency: 1
Designated exit doors: 6
Exit doors failed: 1
Inspection Report
Routine
Census: 16
Deficiencies: 0
Dec 15, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations standards and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 2
Jun 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 00142232 to assess compliance with standards for licensure of residential health care facilities and dementia care homes.
Findings
The facility was found non-compliant with infection control policies during medication administration by a Licensed Practical Nurse who failed to perform hand hygiene for 4 of 8 residents observed. Additionally, the facility failed to secure potentially harmful cleaning products, placing all 17 residents at risk.
Complaint Details
Complaint number NJ 00142232 triggered the survey. The facility was found non-compliant with infection control and safety standards based on observations and record review.
Deficiencies (2)
| Description |
|---|
| Failure to ensure hand hygiene during medication administration for 4 of 8 residents observed. |
| Failure to secure potentially toxic and harmful cleaning products in a locked cabinet or room, accessible to residents. |
Report Facts
Residents observed for medication administration: 8
Residents affected by hand hygiene deficiency: 4
Residents at risk due to unsecured cleaning products: 17
Time waited for Administrator to secure bleach: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene during medication administration | |
| Registered Nurse (RN) | Informed about hand hygiene concern and confirmed presence of hand sanitizer dispenser | |
| Facility Owner | Acknowledged LPN should have performed hand hygiene and noted recent in-service training | |
| Administrator | Requested to secure bleach bottle in locked location |
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