Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Aug 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to failure to implement pharmacy policies ensuring medications were ordered, received, and administered according to prescriber's orders for Resident #2.
Findings
The facility failed to ensure medications were ordered, received, and administered in accordance with prescriber's orders for Resident #2, resulting in the resident not receiving medication for seven days, becoming unresponsive, and being transferred to the hospital. The facility lacked a system to verify medication orders and pharmacy receipt, and there was no documented reconciliation of medications received versus ordered.
Complaint Details
Complaint #: NJ 00156837. The complaint was substantiated based on findings that Resident #2 did not receive prescribed medication from 7/27/22 to 8/2/22, leading to hospitalization and subsequent death.
Deficiencies (3)
| Description |
|---|
| Failure to implement pharmacy policy to ensure medications were ordered and received according to prescriber's orders. |
| Failure to ensure pharmaceutical services were provided in accordance with prescriber's orders and applicable laws. |
| Medications were not accurately administered and documented according to prescribed orders. |
Report Facts
Census: 92
Days medication not administered: 7
Sample size: 4
Completion date for plan of correction: September 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Responsible for faxing prescription to pharmacy on 7/27/22 but did not follow up to ensure receipt |
| LPN #3 | Licensed Practical Nurse | On duty 7/27/22, responsible for approving medication orders but did not find Resident #2's order in system |
| Health Services Director | Interviewed regarding pharmacy order system and acknowledged lack of system prior to incident | |
| Executive Director | Interviewed and confirmed Resident #2 was not administered medication as ordered |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 6
May 18, 2022
Visit Reason
Complaint investigation triggered by complaint #NJ00154805 regarding failure to ensure coordination and implementation of outside provider consultations into residents' plans of care and other related deficiencies.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards for assisted living residences. Deficiencies included failure to coordinate psychiatric consultations into care plans for residents #1 and #2, failure to develop and revise service plans addressing psychosocial behaviors, failure to notify nursing staff and physicians of significant changes in residents' conditions, failure to document resident refusal of lab tests, and lack of social work services for residents in need.
Complaint Details
Complaint #NJ00154805 involved issues with coordination of psychiatric consultations, care planning, notification of nursing and medical staff, medication administration monitoring, and lack of social work services for residents #1 and #2.
Deficiencies (6)
| Description |
|---|
| Failure to ensure consultations from outside providers were coordinated and implemented into residents' plans of care for residents #1 and #2. |
| Failure to develop, revise, and implement service plans with specific interventions to address psychosocial behaviors for residents #1 and #2. |
| Failure to notify a Registered Nurse of a resident's change in condition and need for physician evaluation for resident #1. |
| Failure to notify the physician and document resident refusal of a prescribed lab test for resident #1. |
| Failure to implement a system for monitoring and accountability of self-administration of medications for residents #1, #2, #5, and #6. |
| Failure to ensure residents received social work services during times of need for residents #1 and #2. |
Report Facts
Census: 85
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding psychiatric consults and resident behavior changes; was on leave during some events. |
| Assisted Living Director | Assisted Living Director (ALD) | Interviewed regarding resident activities and care coordination. |
| Health Service Director | Health Service Director (HSD) | Interviewed regarding awareness of resident issues and social work services. |
| Memory Care Director | Memory Care Director (MCD) | Interviewed regarding resident activities and psychiatric referrals. |
| Advanced Practice Nurse Psychiatrist | APNP | Evaluated Resident #2 and prescribed interventions. |
| Licensed Practical Nurse | LPN | Interviewed regarding notification of resident condition changes. |
| Executive Director | Executive Director (ED) | Interviewed regarding medication self-administration monitoring and social work services. |
Inspection Report
Routine
Census: 85
Capacity: 100
Deficiencies: 0
Apr 26, 2022
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 4/26/2022 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: 4
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Feb 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 00143150.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.
Complaint Details
Complaint number NJ 00143150 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 5
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