Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
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 explains 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: 101
Deficiencies: 3
Sep 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #NJ00152344 concerning compliance with New Jersey licensure standards for assisted living residences.
Findings
The facility was found not in substantial compliance with licensure standards due to failure to provide surveyors access to electronic medical records, missing documentation for residents' medical records, failure to notify family of new diagnoses, incomplete incident reports, and inadequate documentation of assessments and treatments for residents.
Complaint Details
Complaint #NJ00152344 was substantiated as the facility failed to comply with multiple regulatory requirements related to medical record documentation, family notification, and incident reporting.
Deficiencies (3)
| Description |
|---|
| Failure to provide surveyors access to electronic medical records and missing documentation for three residents' medical records. |
| Failure to notify Resident #1's family following a new diagnosis and failure to complete an incident report. |
| Failure to maintain documented evidence of assessments and treatments according to professional standards for Residents #1 and #2. |
Report Facts
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding access to medical records and documentation issues |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Sep 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ152235 and NJ155567.
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, based on this complaint survey.
Complaint Details
Complaint investigation for complaints NJ152235 and NJ155567; facility found in substantial compliance.
Report Facts
Sample size: 1
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
May 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00154853.
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 NJ00154853 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 4
Jul 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to an elopement incident involving a resident at the assisted living facility.
Findings
The facility failed to ensure policies were implemented to decrease the risk of elopement for one resident. The resident exited the facility through an unlocked Assisted Living (AL) door during after-hours, wandered outside on a busy road, and was found by police and transported to a hospital. The facility did not notify police within 30 minutes of the resident being missing, and lacked proper security measures such as locking the AL door and maintaining a list of residents at risk of wandering at the front desk.
Complaint Details
Complaint # NJ00146650 regarding an elopement incident where a resident left the facility unsupervised and was found by police wandering outside in pajamas. The complaint was substantiated by observations, interviews, and record reviews.
Deficiencies (4)
| Description |
|---|
| Failure to ensure policies were implemented to decrease the risk of elopement for one resident. |
| Failure to lock the Assisted Living door from 8 p.m. to 8 a.m. as required by facility policy, allowing resident to exit unsupervised. |
| Failure to notify local police within 30 minutes after resident was confirmed missing. |
| Lack of a list with pictures and identifiers of residents at risk for wandering at the front desk. |
Report Facts
Census: 120
Time resident last seen: 3.54
Time police notified: 4.55
Speed limit: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | On duty nurse who was notified of resident missing, searched for resident, and did not notify police within 30 minutes. |
| Wellness Director | Wellness Director | Completed Facility Reportable Event, interviewed by surveyor, confirmed events and security issues. |
| Administrator | Facility Administrator | Interviewed regarding elopement and door monitoring; acknowledged door was not locked as required. |
| Concierge #1 | Concierge | Reported no list of residents at risk at front desk and that AL door was not locked. |
| Concierge #2 | Concierge | Confirmed events of elopement and door not locked. |
| Environmental Service Director | Environmental Service Director | Responsible for enforcing security measures; confirmed door was checked and no malfunction found. |
Loading inspection reports...
