Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Notice
Deficiencies: 0
Nov 20, 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 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: 73
Deficiencies: 2
Jun 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00168849 and NJ00174340 regarding the facility's compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance due to failure to notify the Department of Health of a major occurrence involving Resident #2 and failure to update the Health Service Plan with interventions related to Resident #2's behaviors. The facility must submit a Plan of Correction to address these deficiencies.
Complaint Details
Complaint investigation based on complaints NJ00168849 and NJ00174340. The facility was found not in substantial compliance with licensure standards due to failure to report a major occurrence and failure to update care plans for Resident #2.
Deficiencies (2)
| Description |
|---|
| Failure to notify the Department of Health of a major occurrence involving Resident #2. |
| Failure to ensure that the Health Service Plan was updated with interventions in response to behaviors related to Resident #2. |
Report Facts
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Clinical Director | Regional Clinical Director | Interviewed regarding Resident #2's behaviors and care plan |
| Executive Director | Previous Executive Director | Interviewed regarding managed risk agreement and reporting of incidents related to Resident #2 |
| Licensed Practical Nurse | Licensed Practical Nurse | Documented progress notes related to Resident #2's whereabouts and incidents |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00162507) to assess compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to secure residents' personal possessions from theft or loss, failure to notify family and registered nurses when residents were transferred to the hospital, and failure to maintain closed medical records for discharged residents as required by state regulations.
Complaint Details
Complaint #NJ00162507 involved issues with resident rights, family and RN notification upon hospital transfer, and maintenance of resident records. The complaint was substantiated based on interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Facility failed to consistently ensure residents' personal possessions were secure from theft, loss, or misplacement for 1 of 5 residents reviewed (Resident #5). |
| Facility failed to provide documented evidence that the resident's family was notified for 1 of 5 residents transferred to the hospital (Resident #3) and failed to provide documented evidence that the Registered Nurse was notified when 3 of 5 residents were transferred to the hospital (Residents #1, #3, and #4). |
| Facility failed to maintain closed medical records for 1 of 5 residents reviewed (Resident #2) for the required 10 years after discharge. |
Report Facts
Residents reviewed: 5
Residents in hospital: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Interviewed regarding room locking procedures and aware of unlocked room finding for Resident #5 | |
| Regional Nursing Director | Stated lack of access to previous records prior to facility sale | |
| Regional Nursing Supervisor | Reported inability to locate Resident #2's medical record |
Inspection Report
Routine
Census: 72
Deficiencies: 0
Oct 25, 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 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.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Mar 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation and a COVID-19 focused infection control survey.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code Chapter 8:36 for licensure standards and infection control regulations, including CDC recommended practices for COVID-19.
Complaint Details
Complaint number NJ150400 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 12
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Dec 3, 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 New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
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