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 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: 90
Deficiencies: 1
Jul 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ00165789) to determine compliance with New Jersey Administrative Code 8:36, focusing on resident rights and privacy in an assisted living facility.
Findings
The facility failed to protect residents' right to privacy in a double occupancy apartment unit shared by Resident #3 and Resident #4, where the roommate had to pass through the other's sleeping and living areas to access the bathroom, kitchenette, or exit. The facility acknowledged the issue and provided a plan of correction including offering alternative rooms and auditing shared apartments to ensure privacy.
Complaint Details
Complaint #: NJ00165789. The complaint was substantiated based on observations, interviews, and record reviews indicating privacy violations for residents in shared rooms.
Deficiencies (1)
| Description |
|---|
| Failure to protect residents' right to privacy in a double occupancy apartment unit. |
Report Facts
Census: 90
Sample Size: 4
Completion Date: Aug 17, 2023
Date of Revisit: Nov 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during the survey and provided information about facility population and resident roster. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Apr 8, 2022
Visit Reason
The inspection was a standard survey combined with complaint investigations and a focused infection control survey, triggered by multiple complaints identified by complaint numbers NJ 00152281, NJ 00153241, NJ 00149368, NJ 00153239, NJ 00144711, NJ 00149588, NJ 00153240, and NJ 00151705.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards for licensure of assisted living residences. Deficiencies included failure to develop and implement written job descriptions for employees, incomplete resident assessments and care plans, failure to update general service plans to address fall risks, and failure to maintain closed medical records for discharged residents.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The complaints involved issues such as lack of written job descriptions, incomplete resident assessments, failure to update care plans after falls, and missing closed medical records.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure written job descriptions were developed and implemented for 7 of 8 employees reviewed. |
| Facility failed to ensure that care assessments were completed and maintained by the Registered Nurse for 1 of 13 residents reviewed (Resident #2). |
| Facility failed to ensure that the General Service Plan was updated or revised to include specific interventions to reduce the risk of falls with injuries for 1 of 13 residents reviewed (Resident #2). |
| Facility failed to maintain closed medical record for 1 of 6 residents reviewed (Resident #13) for a period of 10 years after discharge. |
Report Facts
Census: 80
Sample Size: 13
Employees reviewed: 8
Employees without job descriptions: 7
Residents reviewed for closed records: 6
Residents with missing closed records: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tahira Smith | Surveyor | Named as surveyor conducting the inspection and findings |
| Business Office Manager | Responsible for maintaining employee personnel files; confirmed missing job descriptions | |
| Executive Director | Failed to provide written job descriptions and closed medical records during surveyor interviews | |
| Regional Director of Nursing | Interviewed regarding resident assessments and care plan updates; unable to locate RN assessments for Resident #2 |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00146426.
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 NJ00146426 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
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