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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties 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: 98
Deficiencies: 4
Apr 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00167692 and NJ00173247 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 implement and enforce the Workplace Violence Policy, failure to ensure resident rights including freedom from abuse and neglect, failure to protect the resident's right to voice complaints without fear of reprisal, and failure to develop and implement a written health service plan for Resident #2.
Complaint Details
The complaint investigation was triggered by complaints NJ00167692 and NJ00173247. The investigation found substantiated deficiencies related to Resident #2, including workplace violence incidents involving a server, use of profanity by staff, and failure to protect resident rights and develop appropriate care plans.
Deficiencies (4)
| Description |
|---|
| Failure to implement and enforce the facility's Workplace Violence Policy for Resident #2. |
| Failure to ensure that Resident #2 was free from physical and mental abuse and/or neglect. |
| Failure to ensure Resident #2's right to voice complaints without being threatened or punished. |
| Failure to develop and implement a written health service plan for Resident #2, including goals, interventions, and assessment of treatment effects. |
Report Facts
Census: 98
Sample Size: 3
Inspection Report
Routine
Census: 101
Deficiencies: 0
Dec 22, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with the infection control regulations and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Sep 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #NJ00165915 at Brandywine Living at the Sycamore.
Findings
The facility was found to be in substantial compliance with New Jersey standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs for this complaint investigation.
Complaint Details
Complaint #NJ00165915 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
May 10, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00163896 to investigate compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance due to failure by the Executive Director to implement and enforce the facility's Resident Fall Interventions Policy, specifically regarding monitoring and documenting post-fall assessments for 5 out of 5 residents reviewed.
Complaint Details
Complaint investigation NJ00163896 found the facility non-compliant with post-fall assessment documentation requirements for 5 residents. Nursing staff failed to document post assessments for multiple shifts following resident falls.
Deficiencies (1)
| Description |
|---|
| Failure to implement and enforce the Resident Fall Interventions Policy regarding monitoring and documenting post-fall assessments for residents. |
Report Facts
Census: 89
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Failed to implement and enforce facility policies | |
| Director of Nursing | Interviewed regarding post-fall assessment documentation requirements | |
| Licensed Practical Nurse (LPN) #6 | Documented resident observations but failed to document post assessments for required shifts | |
| Licensed Practical Nurse (LPN) #2 | Documented resident observations but failed to document post assessments for required shifts | |
| Licensed Practical Nurse (LPN) #3 | Documented resident observations but failed to document post assessments for required shifts | |
| Licensed Practical Nurse (LPN) #4 | Documented resident observations but failed to document post assessments for required shifts | |
| Licensed Practical Nurse (LPN) #11 | Interviewed about nursing staff documentation requirements | |
| Licensed Practical Nurse (LPN) #12 | Interviewed about nursing staff documentation requirements | |
| Memory Care Coordinator | Documented resident absence and return but failed to document post assessments | |
| Wellness Director | Provided policy and interviewed regarding post-fall assessment documentation |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Feb 19, 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 New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Sep 7, 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 standards for licensure of assisted living residences and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 3
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