Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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 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: 80
Deficiencies: 3
Aug 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of improper documentation and failure to follow facility policies regarding incident reporting and resident care.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards due to failure to properly document incidents involving two residents, failure to revise and implement resident care plans after incidents, and failure to notify physicians of significant changes in residents' conditions. The facility also failed to document family notifications related to the incidents.
Complaint Details
Complaint # NJ00166316. The complaint involved failure to follow incident reporting policies, failure to update resident care plans, and failure to notify physicians of significant changes in residents' conditions. The complaint was substantiated based on interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Failure to properly document incidents involving two residents in their charts as required by facility policy. |
| Failure to revise and implement the resident General Service Plan for two residents following an incident. |
| Failure to provide documented evidence that the physician was notified of significant changes in two residents' conditions after an incident. |
Report Facts
Sample size: 4
Temperature: 66
Temperature: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding incident documentation and family notification; confirmed failure to document family contacts. | |
| Health and Wellness Director | Interviewed regarding incident documentation and physician notification; confirmed errors in documentation and lack of physician notification. | |
| Licensed Practical Nurse #1 | Interviewed and confirmed failure to document incident in resident charts; gave verbal statement only. | |
| Licensed Practical Nurse #2 | Mentioned as involved in the incident but no direct interview or detailed role described. |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jan 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00160075.
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 number NJ00160075 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Apr 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00153947.
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 NJ00153947 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 66
Capacity: 50
Deficiencies: 0
Dec 6, 2021
Visit Reason
Standard Survey of 50 residential units to assess compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences.
Findings
The facility was found to be in substantial compliance with all applicable standards for licensure of assisted living residences, comprehensive personal care homes, and assisted living programs.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 72
Deficiencies: 0
Nov 18, 2020
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 related to COVID-19.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code 8:36 infection control regulations standards for licensure of assisted living residences and CDC recommended practices to prepare for COVID-19.
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