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 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: 6
Nov 6, 2024
Visit Reason
The inspection was a standard survey with complaint investigation triggered by complaints NJ 00156977, NJ 00170578, and NJ 00173012, focusing on compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Findings
The facility was found not in substantial compliance with standards, with deficiencies including failure to implement incident reporting policies, incomplete job descriptions for employees, lack of annual emergency training documentation for staff, failure to maintain documentation of emergency drills, and inadequate documentation of a facility reportable event involving resident abuse.
Complaint Details
The complaint investigation was substantiated as the facility failed to properly document and implement policies related to incident reporting, staff training, emergency drills, and resident abuse documentation as evidenced by multiple interviews and record reviews.
Deficiencies (6)
| Description |
|---|
| Failure to implement incident reporting policy for Resident #2 regarding a Facility Reportable Event (FRE) on 4/14/24. |
| Facility failed to ensure written job descriptions were developed and implemented for employees, including Employee #10. |
| Facility failed to ensure 8 of 10 employees received mandatory annual staff education, including emergency training. |
| Facility failed to maintain and provide documentation of employee participation in annual emergency drills for 10 employees. |
| Facility failed to implement and ensure documentation of an alleged incident of staff to resident abuse for Resident #2. |
| Facility failed to have written policies and procedures requiring annual Mantoux tuberculin skin tests for employees. |
Report Facts
Census: 50
Sample Size: 13
Employees reviewed: 10
Employees missing annual emergency training documentation: 8
Number of emergency drills required annually: 12
Inspection Report
Abbreviated Survey
Census: 49
Deficiencies: 0
Jul 15, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on July 15, 2024.
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 to prepare for COVID-19.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 4
May 20, 2021
Visit Reason
Complaint investigation triggered by complaints NJ00143849, NJ00142722, and NJ00144135 regarding resident rights violations and medication administration errors.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, with deficiencies including failure to treat residents with respect and dignity, failure to notify the Department of Health of suspected abuse, medication administration errors involving giving medication to the wrong resident, and failure to properly report and document medication errors.
Complaint Details
Complaint investigation based on complaints NJ00143849, NJ00142722, and NJ00144135. The complaints involved allegations of resident rights violations and medication errors. The facility was found deficient in multiple areas related to these complaints.
Deficiencies (4)
| Description |
|---|
| Failure to ensure residents were treated with respect, courtesy, consideration, and dignity, specifically involving Residents #4 and #6. |
| Failure to notify the Department of Health of suspected resident abuse or exploitation involving Residents #4 and #6. |
| Failure to administer medications in accordance with prescribers' orders and facility policy, resulting in Resident #9 receiving Resident #3's medication. |
| Failure to follow and implement policy and procedures on medication error reporting and documentation for Resident #9. |
Report Facts
Census: 64
Sample Size: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in resident rights violation involving Resident #4. |
| Executive Director | Interviewed regarding incidents and complaints; provided statements and documentation. | |
| Director of Nursing | Director of Nursing | Interviewed regarding incidents and medication error procedures. |
| RN | Registered Nurse | Involved in medication administration error giving Resident #3's medication to Resident #9. |
| LPN #2 | Licensed Practical Nurse | Documented Resident #9's condition post medication error. |
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