Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
42 residents
Based on a February 2025 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: 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, the circumstances under which health information may be used or disclosed, the legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 42
Deficiencies: 1
Date: Feb 3, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00182844 to investigate allegations related to resident rights violations at the assisted living facility.
Complaint Details
Complaint #NJ00182844 was substantiated based on interviews, record reviews, and facility policy review indicating failure to protect Resident #1 from neglect resulting in the resident leaving the facility unattended and being found outside the premises.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:36 standards, specifically failing to protect one resident's right to be free from physical and mental abuse and/or neglect. The investigation revealed that Resident #1 left the facility unattended due to inadequate supervision and alarm system issues, resulting in a missing resident event.
Deficiencies (1)
Failure to protect Resident #1's right to be free from physical and mental abuse and/or neglect.
Report Facts
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist #5 | Interviewed regarding the resident being observed in the front common area before leaving shift | |
| Manager on Duty (MOD) | Provided detailed account of the missing resident event and actions taken | |
| Health and Wellness Director (HWD) | Confirmed Resident #1's ability status during interview | |
| Executive Director (ED) | Instructed staff during the missing resident event and confirmed details during interview |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted as a complaint survey to investigate two Facility Reportable Events (FREs) and complaints NJ 00180358 and NJ 00176077.
Complaint Details
Complaint numbers NJ 00180358 and NJ 00176077 were investigated. The complaint was substantiated by the finding that surveyors were denied full access to electronic medical records and investigation documents, impeding the investigation.
Findings
The facility failed to provide full access to all resident electronic medical records and pertinent facility documents to Department of Health surveyors, impeding the investigation process. Surveyors were unable to independently access the electronic medical records system and were not provided with original investigation documents.
Deficiencies (1)
Failure to provide full access to resident electronic medical records and facility documents to surveyors, impeding the Department of Health's investigation.
Report Facts
Census: 42
Sample size: 4
Completion date for correction: Jan 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Interviewed regarding electronic medical record system and provided surveyors with login credentials and documents. | |
| Executive Director (ED) | Interviewed and involved in providing access to electronic medical records and investigation reports; coordinated with IT and DDCS. | |
| District Director of Clinical Services (DDCS) | Instructed that surveyors were not allowed full access to EMR and that investigation reports were internal. |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00163521, NJ00163571, and NJ00175627 regarding compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Complaint Details
Complaint investigation based on complaints NJ00163521, NJ00163571, and NJ00175627. The facility was found not in substantial compliance with licensure standards, with deficiencies related to resident assessments and care plans.
Findings
The facility was found not in substantial compliance with standards, specifically failing to update resident health service plans and reassess residents upon return from hospitalizations. Deficiencies were noted in updating Health Service Plans (HSP) for Resident #2 and failure of Registered Nurses to reassess Residents #1 and #2 after hospital returns.
Deficiencies (2)
Failure to ensure that a Health Service Plan (HSP) was updated with interventions in response to Resident #2's condition changes.
Failure of Registered Nurse to reassess Residents #1 and #2 upon return from hospitalizations to determine medical needs.
Report Facts
Census: 41
Sample Size: 4
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Oct 22, 2021
Visit Reason
The inspection was a Standard/COVID-19 survey conducted from 10/20/21 to 10/22/21 to assess compliance with New Jersey Administrative Code, Chapter 8:36, for licensure of Assisted Living Residences and related programs.
Findings
The facility was found to be in substantial compliance with the applicable New Jersey Administrative Code standards and CDC recommended practices for COVID-19 infection control.
Report Facts
Sample size: 11
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