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 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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 8
Nov 8, 2024
Visit Reason
The inspection was a Standard with Complaint survey conducted due to complaint #NJ00178154 to assess compliance with New Jersey Administrative Code standards for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance with standards, with deficiencies in administration, resident notification of condition changes, annual physical examinations, dining services sanitation, medication administration, emergency services, infection prevention, and resident records documentation.
Complaint Details
Complaint #NJ00178154 triggered the survey. The facility was found not in substantial compliance with standards and required to submit a Plan of Correction.
Deficiencies (8)
| Description |
|---|
| Failure to ensure enforcement of Health Safety and Wellness Manual policy on correct food temperatures during activities. |
| Failure to provide documented evidence that a resident's responsible party was notified of a change in condition. |
| Failure to ensure annual physical examinations with physician certification for residents. |
| Failure to maintain sanitary environment in kitchen and ensure temperature logs were maintained. |
| Failure to ensure medication was accurately administered by authorized personnel, resulting in imminent danger for one resident. |
| Failure to conduct required emergency drills monthly and document staff participation. |
| Failure to ensure proper infection prevention and control practices including hand hygiene and cleaning of equipment. |
| Failure to ensure certified medication aide accurately documented and administered medications according to orders. |
Report Facts
Census: 31
Sample Size: 10
Temperature Logs Requested: 3
Employees: 53
Fire Drills Required: 12
Residents Reviewed: 10
Residents Reviewed for Medication: 10
Residents with Deficiencies: 2
Employees Reviewed for TB Testing: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA #1 | Certified Medication Aide | Named in medication administration and infection prevention deficiencies |
| CMA #2 | Certified Medication Aide | Named in medication administration deficiency and training |
| Regional Director of Wellness | RDW | Interviewed regarding policies and medication administration |
| Executive Director | ED | Interviewed regarding policies, training, and corrective actions |
| Director of Nursing | DON | Acting DON involved in policy and medication administration discussions |
| Business Office Manager | OM | Assisted in providing employee files and information on TB testing |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Feb 8, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ144652 and NJ155760 to assess 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 ensure residents and their family members were invited to and participated in care plan meetings, with documentation missing for 2 of 6 sampled residents. The facility admitted lapses in scheduling and documenting multidisciplinary care conferences.
Complaint Details
Complaint investigation based on complaints NJ144652 and NJ155760. The facility was found not in substantial compliance with standards related to resident assessments and care plans.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents and their family members or representatives were invited to care plan meetings and that their participation was documented in the resident's record for 2 of 6 sampled residents. |
Report Facts
Sample size: 6
Resident census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Manager | Nursing Manager | Interviewed regarding care conferences and scheduling |
| Director of Wellness | Director of Wellness | Confirmed lack of documentation of multidisciplinary care conferences |
| Executive Director | Executive Director | Confirmed lack of documentation of multidisciplinary care conferences and discussed best practices for contacting power of attorney |
Inspection Report
Routine
Census: 61
Deficiencies: 0
Jan 27, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the applicable infection control regulations and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Aug 11, 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.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations standards and CDC recommended practices for COVID-19 preparation.
Report Facts
Sample Size: 2
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Sep 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ157977 and NJ157978.
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 investigation for NJ157977 and NJ157978; facility found in substantial compliance.
Report Facts
Sample size: 4
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