Deficiencies (last 2 years)
Deficiencies (over 2 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and to describe 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 NJDHSS's legal duties and responsibilities regarding privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 4
Date: Sep 12, 2023
Visit Reason
The inspection was a complaint investigation triggered by Complaint #NJ00159604 to assess compliance with New Jersey Administrative Code standards for Adult Day Health Services.
Complaint Details
Complaint #NJ00159604 triggered the investigation. The complaint involved issues with administration and nursing services including absence of Administrator and DON during participant hours, and improper nursing documentation.
Findings
The facility was found not in substantial compliance with licensure standards, specifically failing to ensure a full-time Administrator was available during participant care hours, lacking a Director of Nursing (DON) present at all times with no alternate DON, the DON performing duties outside her role, and failure to have a Registered Nurse document nursing assessments for some participants.
Deficiencies (4)
Failed to ensure an Administrator was available on premises during participant program hours or an alternate was designated in writing.
Failed to ensure the Director of Nursing (DON) was present at all times during participant programming hours and failed to have an alternate DON.
Failed to ensure the Director of Nursing did not perform functions of any other position while functioning as the DON.
Failed to ensure a Registered Nurse documented nursing services including initial assessment and evaluation for 2 of 3 participants.
Report Facts
Census: 22
Sample Size: 3
Days without RN or DON present: 5
Program Participant Hours: 8:45 a.m. to 3:30 p.m. Monday through Friday.
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