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 explains 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: 50
Deficiencies: 2
Jun 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00164281) to assess the facility's compliance with New Jersey licensure standards for assisted living residences, specifically regarding the management of significant weight changes in residents.
Findings
The facility was found not in substantial compliance due to failure to implement and enforce policies related to significant weight changes. Two residents experienced significant unaddressed weight loss without documented dietician consultation or appropriate nutritional assessments. The Registered Dietician failed to conduct required assessments, revise care plans, or provide adequate documentation. The facility lacked evidence of dietician visits since an unspecified date.
Complaint Details
Complaint #NJ00164281 was substantiated with findings that the facility did not comply with policies regarding significant weight changes and dietician involvement for residents.
Deficiencies (2)
| Description |
|---|
| Failure to implement and enforce the facility's policy on significant weight change, evidenced by unaddressed weight loss in residents and lack of dietician consultation. |
| Failure to ensure that a Registered Dietician conducted nutritional assessments and dietary needs evaluations for residents with significant weight loss. |
Report Facts
Census: 50
Sample size: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed during survey; reported lack of documentation review for resident weights | |
| Executive Director (ED) | Interviewed during survey |
Inspection Report
Abbreviated Survey
Census: 76
Deficiencies: 0
Apr 27, 2022
Visit Reason
A Gastrointestinal Illness Focused Infection Control Survey was conducted by the State Agency on 4/27/22 to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations standards for licensure of assisted living residences and CDC recommended practices.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 5
Mar 2, 2022
Visit Reason
Complaint investigation triggered by multiple complaints regarding resident abuse, failure to notify responsible parties and registered nurses of changes in condition, and failure to update care plans after falls.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards due to multiple deficiencies including failure to prevent resident-to-resident abuse, failure to notify responsible parties and registered nurses of resident falls and changes in condition, failure to update General Service Plans after falls, and failure to timely report incidents of abuse to the Department of Health.
Complaint Details
Complaints NJ 00152594, NJ 00152687, NJ 00152681, NJ 00152689 triggered the investigation. Multiple resident-to-resident abuse incidents were substantiated, including physical altercations and failure to protect residents. Delays in reporting abuse to the Department of Health and failure to notify responsible parties of falls were documented.
Deficiencies (5)
| Description |
|---|
| Failure to ensure residents were free from physical and mental abuse, including resident-to-resident abuse incidents. |
| Failure to notify responsible parties immediately on the day of resident falls. |
| Failure to update General Service Plans and care plans after resident falls. |
| Failure to notify registered nurse at onset of illness, injury, or change in condition for residents. |
| Failure to immediately report suspected cases of resident abuse to the Department of Health. |
Report Facts
Census: 55
Sample Size: 4
Complaint Numbers: 4
Falls: 3
30-day notice: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to failure to ensure policies were implemented and failure to report abuse incidents. | |
| Wellness Director | Interviewed regarding falls, abuse incidents, and failure to notify responsible parties and registered nurses. | |
| Licensed Practical Nurse (LPN) #5 | Documented resident abuse incident and resident statements. | |
| Licensed Practical Nurse (LPN) #6 | Documented resident abuse incident and called 911. | |
| Staff Member #1 | Assigned to monitor resident with abusive behaviors. | |
| Staff Member #2 | Provided information about resident behaviors and supervision. |
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Dec 20, 2021
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 and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 0
Nov 14, 2020
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 for COVID-19 preparation.
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