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 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
Abbreviated Survey
Census: 68
Deficiencies: 1
Feb 21, 2022
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically related to food handling practices. Two dietary staff members handled ready-to-eat food with bare hands and placed paper meal tickets directly on residents' meals, posing contamination risks.
Deficiencies (1)
| Description |
|---|
| Failure to comply with N.J.A.C. 8:24 regarding sanitation in retail food establishments, including handling ready-to-eat food with bare hands and placing meal tickets directly on food. |
Report Facts
Census: 68
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Observed placing meal tickets directly on pancakes and acknowledged the practice | |
| Server #1 | Observed handling ready-to-eat food with bare hands by removing meal tickets without hand hygiene | |
| Executive Director | ED | Acknowledged the deficiency and lack of food handling training |
Inspection Report
Routine
Census: 69
Capacity: 138
Deficiencies: 5
Dec 7, 2021
Visit Reason
Standard Survey of 138 residential units to assess compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Findings
The facility was found not in substantial compliance with multiple standards including dining services, pharmaceutical services, emergency services, fire safety, housekeeping, and electrical system maintenance. Deficiencies included food safety violations, medication administration errors, lack of fire drill documentation, failure to inspect fire extinguishers, and absence of annual electrical inspections.
Deficiencies (5)
| Description |
|---|
| Failed to comply with food safety regulations including unlabeled and undated food items, unclean kitchen equipment, staff not wearing hair restraints, unwashed vegetables before slicing, improper food storage, and failure to check food temperatures. |
| Medications were pre-poured by unqualified staff and administered without physician orders for some residents. |
| Lack of documentation of fire drill participation for two employees in the past 12 months. |
| Failure to perform monthly visual inspections and annual servicing of fire extinguishers as required. |
| Failure to have a licensed electrician perform annual inspection of electrical circuits and wiring. |
Report Facts
Census: 69
Total Capacity: 138
Sample Size: 5
Date of last documented food temperature check: Nov 23, 2021
Number of fire extinguishers observed: 19
Date of last fire extinguisher service: 202010
Date of last fire extinguisher inspection: 202110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed pre-pouring medications and administering medication without physician order. |
| Cook | Interviewed regarding food safety practices and kitchen sanitation. | |
| General Manager | GM | Interviewed regarding deficiencies and facility policies. |
| Maintenance Director | MD | Interviewed regarding fire extinguisher and electrical system inspections. |
| Activities Director | AD | Observed in kitchen without hair restraint. |
| Housekeeper | Observed in kitchen without hair restraint. |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Feb 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an anonymous staff-to-resident allegation of verbal abuse reported on 1/26/2021.
Findings
The facility failed to implement its policy on reporting alleged/suspected resident abuse for 5 of 5 residents reviewed. The General Manager did not suspend the Certified Nursing Assistant (CNA #1) involved in the alleged verbal abuse as required by policy, and the CNA continued to work while being 'overshadowed' by an LPN who later stated she was not aware of the incident or side-by-side monitoring.
Complaint Details
Complaint # NJ00142723 involved an anonymous allegation of verbal abuse by CNA #1 on 1/26/2021. The allegation was not substantiated by resident interviews or medical record reviews. The facility did not suspend the CNA as required by policy pending investigation.
Deficiencies (1)
| Description |
|---|
| Failure to implement policy and procedures on reporting alleged/suspected resident abuse for 5 of 5 residents reviewed. |
Report Facts
Census: 31
Sample Size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the verbal abuse allegation and investigation. |
| General Manager | Received anonymous call, interviewed CNA #1, and did not suspend CNA #1 as required by policy. | |
| Health and Wellness Director | Interviewed regarding the alleged verbal abuse and investigation. | |
| LPN | Licensed Practical Nurse | Assigned to 'overshadow' CNA #1 but was not aware of the incident and did not monitor side-by-side. |
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