Deficiencies per Year
8
6
4
2
0
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 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
Complaint Investigation
Census: 62
Deficiencies: 6
Jul 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations involving Resident #3 and others, focusing on abuse reporting, resident rights, care plan implementation, and notification procedures.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards. Deficiencies included failure to implement abuse reporting policies, failure to ensure frequent safety checks per a resident's General Service Plan, failure to send a resident to a hospital timely after an incident, failure to provide prompt notification to family and healthcare providers, failure to develop and implement a Health Service Plan for a resident exhibiting specific symptoms, and failure to have a Registered Nurse reassess a resident upon return from hospital.
Complaint Details
Complaint #NJ00175329 triggered the investigation focusing on abuse reporting, resident safety checks, hospital transfers, notifications, and care planning for Residents #2 and #3.
Deficiencies (6)
| Description |
|---|
| Failure to implement and enforce the facility's abuse reporting and investigation policy for Resident #3. |
| Failure to implement Resident #3's General Service Plan to ensure frequent safety checks. |
| Failure to send Resident #3 to a community hospital for evaluation in a timely manner after an incident. |
| Failure to provide documented evidence of prompt notification to family, physician, and RN for Residents #2 and #3 at the time of incidents. |
| Failure to develop and implement a written Health Service Plan for Resident #2 who exhibited specific symptoms. |
| Failure to have a Registered Nurse reassess Resident #3 upon return from hospital. |
Report Facts
Census: 62
Sample Size: 3
Occurrences of specific symptom: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Health and Wellness (ADHW) | Interviewed regarding abuse reporting, notifications, and resident care | |
| Alternate Executive Director (ED) | Interviewed regarding incident notifications and facility policies | |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident rounds and care |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
May 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00154452, NJ00148940, and NJ00152127 regarding the facility's compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Findings
The facility failed to develop and implement a revised service plan with specific interventions to reduce risk for Resident #6, particularly regarding monitoring when outside in the courtyard. Staff allowed residents to wander unaccompanied, and no assigned staff monitored Resident #6 despite known elopement risk. The courtyard gate led to a highway with a 45 mph speed limit, posing safety risks.
Complaint Details
Complaint investigation based on complaints NJ00154452, NJ00148940, and NJ00152127. The facility was found not in substantial compliance with licensure standards due to failure in resident monitoring and care planning.
Deficiencies (1)
| Description |
|---|
| Failure to develop and ensure that a service plan was revised and implemented to include specific interventions to reduce risk for Resident #6, especially when outside in the courtyard. |
Report Facts
Census: 69
Sample Size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Documented observations and notes regarding Resident #6's behavior and monitoring | |
| Registered Nurse (RN) | Reported phone call regarding Resident #6's elopement event | |
| Care Partner (CP) | Interviewed about resident wandering and monitoring practices | |
| Director of Maintenance (DM) | Provided information about courtyard gate and fencing | |
| Health and Wellness Director (HWD) | Provided information about monitoring practices and records for Resident #6 |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 1
Feb 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 during the COVID-19 pandemic.
Findings
The facility failed to consistently implement its infection control prevention program, specifically regarding proper mask use by two dietary aides and a resident's family member, potentially exposing residents to COVID-19. The facility was found not in compliance with New Jersey Administrative Code 8:36 infection control regulations.
Deficiencies (1)
| Description |
|---|
| Failure to ensure two staff members and a resident family member wore face masks appropriately while at the facility. |
Report Facts
Census: 66
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Dietary Aide | Named in finding for not wearing mask appropriately |
| Dietary Aide #2 | Dietary Aide | Named in finding for not wearing mask appropriately |
| Resident #1's family member | Named in finding for not wearing mask appropriately | |
| Executive Director | Executive Director | Provided statements about vaccination status and mask policies |
| Director of Health and Wellness | Director of Health and Wellness | Provided statements about outbreak status and mask policy enforcement |
| Director of Environmental Services | Director of Environmental Services | Present during observation of dietary aides not wearing masks |
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