Notice
Deficiencies: 0
Nov 19, 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: 74
Capacity: 75
Deficiencies: 4
Mar 6, 2024
Visit Reason
The inspection was a standard survey with complaint investigations triggered by complaint numbers NJ00138041 and NJ00156466, focusing on compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Findings
The facility was found not in substantial compliance with all standards, with deficiencies including failure to secure resident personal property, medication administration errors including incorrect dosing and medication borrowing, and safety hazards such as lack of barriers on steam tables in the Memory Care Unit.
Complaint Details
The complaint investigations NJ00138041 and NJ00156466 involved issues with resident rights regarding personal property and pharmaceutical services including medication errors and borrowing.
Deficiencies (4)
| Description |
|---|
| Failure to consistently ensure the security and proper handling of a resident's personal property, resulting in loss or misplacement. |
| Failure to administer medications in accordance with prescriber orders and facility policy, including incorrect dosing and transcription errors for Resident #2. |
| Medication prescribed for one resident was administered to another resident, violating pharmaceutical service requirements. |
| Failure to maintain a safe environment by not having a barrier in place in front of steam tables filled with hot water in the Memory Care Unit. |
Report Facts
Census: 74
Total Capacity: 75
Sample Size: 8
Medication doses administered incorrectly: 10
Steam table water temperature: 193
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding resident property procedures and medication administration issues. |
| Registered Nurse #1 | Registered Nurse | Involved in medication order transcription and communication failures. |
| Licensed Practical Nurse | LPN/Medication Care Manager | Reported medication supply issues to RN. |
| Maintenance Director | Maintenance Director | Interviewed regarding removal of steam table barriers during renovations. |
| General Contractor | General Contractor | Provided information about facility renovations and removal of steam table barriers. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 6
May 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ00163750) to assess compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences and personal care homes.
Findings
The facility was found not in substantial compliance due to multiple deficiencies related to food safety and sanitation, including unlabeled and uncovered food items in the freezer, unclean cooking equipment with encrusted grease and food residue, dirty kitchen floors and surfaces, and damaged cutting boards. The Food Service Director was unable to provide completed sanitation checklists to verify cleaning compliance.
Complaint Details
Complaint # NJ00163750 triggered the inspection. The complaint was substantiated as deficiencies were found placing residents at risk for foodborne illnesses.
Deficiencies (6)
| Description |
|---|
| Unlabeled frozen food items and unsealed bags of bread stored open to air in the walk-in freezer. |
| Braising pan covered with food particles and encrusted grease deposits; old dried food found inside. |
| Seven baking sheets and four muffin pans with encrusted grease deposits and soil accumulations. |
| Grease deposits and soil accumulation on food scale and mixer. |
| Dirt, food residue, and debris on kitchen floors including dishwashing, food prep, cooking, and storage areas; dust and food particles on top of dishwasher machine. |
| Cutting boards with scoring and scratching stacked inside a pan rack, potentially compromising food safety. |
Report Facts
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding sanitation practices and cleaning checklists; unable to provide completed sanitation checklists. | |
| Cook #1 | Cook | Interviewed about cleaning responsibilities and identified old food item in braising pan. |
| Dishwasher | Interviewed and confirmed dishwashing area floor and dishwasher top were not clean. |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 3
Mar 10, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to an active COVID-19 outbreak at the facility to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found not in compliance with New Jersey infection control regulations and CDC guidelines, specifically failing to implement required resident screenings during Phase 0 reopening and not ensuring proper use of PPE by staff during COVID-19 antigen testing of visitors.
Deficiencies (3)
| Description |
|---|
| Failure of the Executive Director to develop and implement a policy ensuring resident screenings during Phase 0 reopening as required by NJDOH Executive Directive No. 20-026. |
| Failure to consistently conduct vital signs screenings for residents as required during COVID-19 outbreak. |
| Failure to implement infection prevention and control program consistent with CDC guidelines, including improper PPE use by staff during COVID-19 antigen testing. |
Report Facts
Residents reviewed for screening: 5
Residents with deficient screening: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Registered Nurse | Wellness Registered Nurse (WRN) | Observed and interviewed regarding improper PPE use during COVID-19 antigen testing. |
| Executive Director | Executive Director (ED) | Interviewed regarding facility's COVID-19 screening policies and PPE requirements. |
| Director of Nursing | Director of Nursing (DON) | Informed WRN about updated PPE requirements for COVID-19 antigen testing. |
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