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: 65
Deficiencies: 5
Aug 27, 2024
Visit Reason
Complaint investigation triggered by complaints NJ00172272 and NJ00175250 regarding medication errors and failure to notify about elevator outage.
Findings
The facility was found not in substantial compliance with New Jersey licensure standards due to medication errors involving Resident #2, failure to implement preventive maintenance policy for the community elevator outage, failure to notify the NJ Department of Health of the elevator service resumption date, and failure to coordinate healthcare services for Resident #2. Additionally, requested facility records and the Facility Reportable Event (FRE) were not fully provided to surveyors.
Complaint Details
Complaint investigation based on complaints NJ00172272 and NJ00175250. Substantiation status not explicitly stated.
Deficiencies (5)
| Description |
|---|
| Failure to implement and enforce medication error policy resulting in medication errors for Resident #2, including an Imminent Danger. |
| Failure to implement and enforce preventive maintenance policy for the community elevator during a scheduled outage. |
| Failure to notify the NJ Department of Health of the date the community elevator was back in service after planned outage. |
| Failure of Director of Nursing to coordinate health care services for Resident #2, including lack of communication and documentation of medication changes. |
| Failure to provide requested facility documentation and Facility Reportable Event (FRE) to surveyors, including lack of full access to Electronic Medical Records. |
Report Facts
Census: 65
Sample Size: 3
Elevator outage planned duration (days): 6
Date of revisit survey: Feb 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding medication error and EMR system. | |
| Health Service Director (HSD) | Interviewed regarding medication errors, preventive maintenance, elevator outage, and coordination of care. | |
| Director of Maintenance (DOM) | Interviewed regarding elevator outage and notification procedures. | |
| Dining Service Director (DSD) | Interviewed regarding notification of elevator outage. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00169900.
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 NJ00169900 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
May 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00164235.
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 NJ00164235 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 79
Deficiencies: 0
Feb 13, 2023
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.
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: 82
Deficiencies: 3
May 10, 2022
Visit Reason
A Gastrointestinal Illness Focused Infection Control Survey was conducted due to an outbreak of gastroenteritis.
Findings
The facility was found not in compliance with infection control regulations, including improper housekeeping cleaning procedures, failure to ensure the infection preventionist was employed according to state requirements, and multiple staff failing to perform proper hand hygiene in accordance with CDC guidelines.
Deficiencies (3)
| Description |
|---|
| Housekeeping staff failed to follow proper cleaning procedures to prevent cross contamination, including not changing mop heads or mop water between resident rooms. |
| The Registered Nurse serving as Infection Control Preventionist was employed at more than five locations and failed to perform infection surveillance, staff training, and audits as required. |
| Staff members including Dining Servers and Dishwasher failed to perform proper hand hygiene and handwashing techniques according to CDC and facility policy. |
Report Facts
Census: 82
Sample Size: 3
Number of staff observed for hand hygiene: 4
Number of resident rooms cleaned without changing mop head or water: 2
Number of resident rooms cleaned daily by Housekeeper #1: 6
Number of facilities served by Infection Control Preventionist: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeping Staff | Observed not changing mop head or mop bucket water between resident rooms. |
| Maintenance Director | Maintenance Director | Interviewed and confirmed mop heads were not changed between rooms and mop bucket water should be changed between rooms. |
| RN (Infection Control Preventionist) | Registered Nurse / Infection Control Preventionist | Employed at this facility and 7 others; failed to provide infection surveillance, training, and audits. |
| Dishwasher | Dishwasher | Observed improper hand hygiene technique including turning off faucet with bare hands before drying. |
| Dining Server #1 | Dining Server | Failed to perform hand hygiene between delivering meal trays to four residents; acknowledged lack of training. |
| Dining Server #2 | Dining Server | Failed to perform hand hygiene between delivering meal trays to two residents; wore same gloves for multiple residents. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Feb 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints alleging abuse at the facility.
Findings
The Executive Director failed to conduct a thorough and complete investigation of an allegation of assault, including not assessing all potentially affected residents or interviewing all relevant staff and residents. The facility was found not in substantial compliance with New Jersey standards for licensure of assisted living residences.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ 00150667, NJ 00150410, NJ 00150534, NJ 00152165, NJ 00152194). The facility received a Facility Reportable Event regarding an allegation of abuse against a resident. The investigation was found deficient as the Executive Director did not protect residents from possible continued abuse during the investigation.
Deficiencies (1)
| Description |
|---|
| Failure to follow facility policy and procedures to conduct a thorough and complete investigation of an allegation of assault, including failure to identify and assess all residents potentially affected and failure to interview all staff and residents with knowledge of the allegation. |
Report Facts
Sample Size: 4
Inspection Report
Routine
Census: 73
Deficiencies: 0
Jan 15, 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 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.
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