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: 37
Deficiencies: 12
Jun 19, 2024
Visit Reason
The inspection was a standard and complaint survey triggered by multiple complaints (NJ00167074, NJ00164651, NJ00166646, NJ00158043) to assess compliance with New Jersey Administrative Code 8:36 for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance with licensure standards, with deficiencies including failure to provide surveyors access to electronic medical records, lack of a designated alternate executive director, failure to enforce shift report and AED policies, inadequate resident care plans, inaccurate staffing schedules, lack of required staff training documentation, failure to notify the Department of Health of administrator changes timely, food safety violations in the kitchen, failure to ensure quarterly pharmacy inspections, improper medication storage, and building maintenance issues including fire safety hazards.
Complaint Details
The inspection was complaint-related with multiple complaint numbers: NJ00167074, NJ00164651, NJ00166646, NJ00158043. The facility was found not in substantial compliance with licensure standards.
Deficiencies (12)
| Description |
|---|
| Failed to provide surveyors access to electronic medical records for all sampled residents. |
| Failed to designate an alternate executive director in writing and ensure availability. |
| Failed to enforce policies including Shift Report Policy and Automated External Defibrillator (AED) maintenance. |
| Failed to develop and implement resident General Service Plans (GSP) to guide care. |
| Failed to maintain accurate staffing schedules documenting actual hours worked. |
| Failed to provide documented evidence of required staff orientation and annual in-service training. |
| Failed to notify Department of Health timely of Executive Director termination and replacement. |
| Failed to comply with food safety regulations including improper food labeling, storage, and sanitation in kitchen and dry storage areas. |
| Failed to ensure quarterly inspections of medication storage areas by Consultant Pharmacist. |
| Failed to store ointments and creams separately for each resident within the medication cart. |
| Failed to store medications according to manufacturer instructions, including failure to date opened medications. |
| Failed to maintain building and grounds free from fire hazards and other hazards, including unclean kitchen and lack of sprinkler protection for exterior overhangs exceeding 4 feet. |
Report Facts
Census: 37
Sample size: 7
Overhang height: 6.83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Regional Nurse | Interviewed regarding EMR access, alternate ED, shift report policy, AED maintenance, and staffing |
| BOC | Business Office Coordinator | Interviewed regarding EMR access, facility administration, and staffing |
| RN #1 | Regional Nurse | Interviewed regarding alternate ED and staffing |
| SM #1 | Staff Member | Interviewed regarding aide assignment sheets and resident care |
| SM #2 | Staff Member | Interviewed regarding aide assignment sheets and resident care |
| ED | Executive Director | Interviewed regarding staff training records and notification to DOH |
| RN #3 | Regional Nurse | Interviewed regarding pharmacy consultant reports |
| RN #4 | Registered Nurse | Observed writing dates on medication boxes and interviewed regarding medication storage |
| LPN | Licensed Practical Nurse | Interviewed regarding medication storage practices |
| Maintenance Manager | Interviewed regarding kitchen cleaning and sprinkler requirements | |
| Food Coordinator | Interviewed regarding kitchen cleaning checklist | |
| FSD | Food Service Director | Interviewed regarding kitchen sanitation and food storage |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Aug 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00166753.
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 investigation based on complaint number NJ00166753; facility found in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Aug 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ147506.
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 NJ147506 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Abbreviated Survey
Census: 34
Deficiencies: 0
Feb 10, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 2/10/21 to assess compliance with New Jersey infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 0
Dec 15, 2020
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 and CDC recommended practices for COVID-19 preparation.
Loading inspection reports...
