Deficiencies per Year
4
3
2
1
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: 196
Deficiencies: 3
Feb 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00132870 and NJ00141008 regarding the facility's compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance with standards, with deficiencies including failure to report an injury of unknown origin for Resident #4, failure to administer medication according to prescriber orders for Resident #2, and failure to develop and implement specific plans of care for the use of bed rails for Residents #1 and #3. The facility also failed to enforce its abuse policy and ensure proper documentation and follow-up.
Complaint Details
Complaint investigation based on complaints NJ00132870 and NJ00141008. The facility was found deficient in reporting injuries and medication administration, and in care planning related to bed rails.
Deficiencies (3)
| Description |
|---|
| Failure to report an injury of unknown origin to the New Jersey Department of Health and failure to implement and enforce the facility's abuse policy for Resident #4. |
| Failure to ensure medication was administered in accordance with prescriber's orders for Resident #2. |
| Failure to develop and implement a specific plan of care for the monitoring and safe use or need of bed rails for Residents #1 and #3, and failure to implement the policy titled 'Assisting in the Use of A Bed Rail.' |
Report Facts
Census: 196
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 0
Sep 10, 2021
Visit Reason
The inspection visit was conducted in response to Complaint #NJ00148336 to assess compliance with standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs.
Findings
The facility was found to be in compliance with the applicable standards for licensure of assisted living residences and related programs.
Complaint Details
Complaint #NJ00148336 was investigated and the facility was found to be in compliance with all applicable standards.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 143
Deficiencies: 0
Feb 12, 2021
Visit Reason
Annual inspection to assess compliance with standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs.
Findings
The facility was found to be in compliance with the applicable licensure standards with no deficiencies noted.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 4
Jan 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of staff to resident abuse at the assisted living facility.
Findings
The facility failed to ensure staff were properly educated on abuse prevention and reporting, failed to protect a resident from abuse, and failed to report the abuse incident timely to the appropriate authorities. The facility also lacked a complete policy including the required 1-800 number for reporting abuse and did not notify local law enforcement as required.
Complaint Details
Complaint # NJ 142601 involved allegations of staff to resident abuse of Resident #1. The complaint was substantiated based on video evidence and interviews. Staff witnesses failed to report the incident timely. The facility delayed reporting to administration and failed to notify local authorities.
Deficiencies (4)
| Description |
|---|
| Failure to ensure staff education/in-service on abuse to protect, prevent, and report. |
| Failure to protect a resident from physical abuse by staff and failure to follow facility abuse and incident reporting policies. |
| Failure to develop and implement a complete policy and procedure for reporting abuse allegations to the State including the 1-800 number. |
| Failure to notify the New Jersey Department of Health and local law enforcement of a staff to resident abuse incident. |
Report Facts
Census: 140
Sample size: 3
Days worked by alleged perpetrator: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Reported on abuse incident, staff education gaps, and failure to notify local authorities. |
| Director of Nursing | Director of Nursing (DON) | Monitors staff for abuse prevention and confirmed lack of in-service training during COVID. |
| Medication Aide #1 | Medication Aide | Alleged perpetrator of abuse against Resident #1. |
| Medication Aide #2 | Medication Aide | Witness to abuse incident who failed to report it timely. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Witness to abuse incident who failed to report it timely. |
| Life Guardian Program Specialist | Life Guardian Program Specialist (LGPS) | Informed by MA #2 of the incident but did not notify administration. |
| Life Guardian Director | Life Guardian Director (LGD) | Verified no prior notification of the abuse incident. |
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