Inspection Reports for
Juniper Village At Williamstown, Wellspring Memory
1648 S. Black Horse Pike, Williamstown, NJ, 08094
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
56% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
27 residents
Based on a May 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and outlining their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health data, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy policies and rights |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 6
Date: May 9, 2024
Visit Reason
Complaint investigation triggered by complaints NJ00158614 and NJ00170860 regarding failure to ensure implementation and enforcement of policies and procedures related to Health Care Plans, General Service Plans, Skin Integrity, Abuse, Incident Reports, and Resident Rights.
Complaint Details
Complaint investigation for complaints NJ00158614 and NJ00170860. Substantiation status not explicitly stated. An Imminent Danger was identified and reported to the Licensed Assisted Living Administrator.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:36 standards. Deficiencies included failure to update Health Service Plans and General Service Plans timely for residents with changes in condition, failure to protect residents from abuse, failure to notify the Department of Health of alleged abuse, and failure to develop and revise care plans based on residents' needs and responses to care. An Imminent Danger was identified related to these deficiencies. A revisit survey on 2024-07-26 verified that all cited deficiencies were corrected.
Deficiencies (6)
Failure to ensure implementation and enforcement of policies and procedures for Health Care Plans, General Service Plans, Skin Integrity, Abuse, Incident Reports, and Resident Rights for residents reviewed.
Failure to ensure residents' right to be free from physical and mental abuse and/or neglect, evidenced by incidents involving Resident #1 and Resident #2.
Failure to notify the Department of Health immediately of suspected resident abuse or exploitation.
Failure to update initial health care assessments as required for residents with changes in condition.
Failure to update residents' General Service Plans based on individual needs, response to care, and changes in physical status.
Failure to develop and revise Health Service Plans quarterly and as needed based on residents' responses to care and changes in condition.
Report Facts
Census: 27
Sample size: 6
Date of revisit survey: Jul 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) | Named in incident report and interview related to abuse allegation involving Resident #1 and Resident #2 | |
| Regional Director of Wellness (RDW) | Interviewed regarding updating service plans and abuse investigation | |
| Regional Executive Director (RED) | Interviewed regarding resident abuse incident and resident interviews | |
| Executive Director (ED) | Interviewed regarding facility policies and resident care plans |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Date: Oct 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00167542) to determine compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs.
Complaint Details
Complaint investigation related to Complaint #NJ00167542. The facility was found not in substantial compliance with licensure standards.
Findings
The facility was found not in substantial compliance with licensure standards, with deficiencies including failure to implement and enforce the 'Elopement and Wandering' policy for one resident, and failure to maintain a safe environment by leaving a mechanical room door unlocked in the secured memory care community.
Deficiencies (2)
Failure to ensure implementation and enforcement of the facility policy titled 'Elopement and Wandering' for 1 out of 3 residents reviewed for elopement, Resident #2.
Failure to maintain a safe environment by not ensuring that 1 out of 3 facility mechanical room doors were locked in the facility's secured memory care community.
Report Facts
Census: 27
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director (ED) | Interviewed regarding Resident #2 and facility policies on elopement and wandering. | |
| Certified Medication Aide (CMA) #1 | Interviewed and stated the facility does not utilize wander guards. | |
| Certified Medication Aide (CMA) #2 | Interviewed and described the facility's alarm system and lack of wander guards. | |
| Certified Medication Aide (CMA) #3 | Interviewed and stated the facility does not use wander guards and all exit doors are alarmed. | |
| Certified Medication Aide (CMA) #4 | Observed responding to door alarm and interviewed about wander guard system. | |
| Regional Director of Nursing (RDON) | Interviewed regarding facility policies and confirmed no use of wander guards or exit seeking bracelets. |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to COVID-19, triggered by complaints NJ 00147234, NJ 00147223, and NJ 00147232.
Complaint Details
Complaint investigation related to COVID-19 with complaints NJ 00147234, NJ 00147223, and NJ 00147232. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code Chapter 8:36 and infection control regulations, including CDC recommended practices for COVID-19 preparation.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Apr 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00144653) to determine compliance with New Jersey Administrative Code 8:36 for assisted living residences and related programs.
Complaint Details
Complaint #NJ00144653 involved failure to report an elopement incident for Resident #2. The complaint was substantiated by interviews and record reviews showing the resident exited the building multiple times and the facility did not report the incident to the Department of Health as required.
Findings
The facility was found not in substantial compliance due to failure to notify the Department of Health of an elopement incident involving Resident #2. The resident exited the building multiple times without staff knowledge, and the facility did not report the incident as required by regulations.
Deficiencies (1)
Failure to notify the Department of Health of an elopement incident involving Resident #2.
Report Facts
Census: 21
Sample Size: 3
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