Deficiencies per Year
8
6
4
2
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 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
Complaint Investigation
Census: 110
Deficiencies: 2
Apr 11, 2023
Visit Reason
The inspection was conducted due to a complaint (NJ00163251) regarding the facility's failure to meet social work service needs and ensure resident safety.
Findings
The facility was found not in substantial compliance with New Jersey standards, specifically failing to provide social work services for Resident #2 and failing to implement 24-hour measurable interventions to ensure resident safety, including inadequate monitoring of Resident #2's smoking in the apartment.
Complaint Details
Complaint #NJ00163251 was substantiated by findings that the facility failed to provide social work services and failed to implement safety interventions for Resident #2, who was found smoking in his/her apartment contrary to facility policy.
Deficiencies (2)
| Description |
|---|
| Failure to meet social work service needs for Resident #2. |
| Failure to implement twenty-four-hour measurable interventions to ensure safety of all residents, specifically regarding Resident #2's smoking in the apartment. |
Report Facts
Census: 110
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding lack of social work services and safety interventions |
| Executive Director | Executive Director (ED) | Interviewed regarding lack of social work services and safety interventions |
| Business Office Manager | Business Office Manager (BOM) | Interviewed during facility tour regarding Resident #2's apartment |
| Activity Director | Activity Director (AD) | Interviewed during facility tour regarding Resident #2's apartment |
| Certified Medication Aid | Certified Medication Aid (CMA) | Interviewed about awareness of smoking and reporting procedures |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed about awareness of smoking and room checks |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Sep 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on standard complaint types NJ 00157375 and NJ 00156858.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:36 standards for assisted living residences. Deficiencies included failure to document notification of medical condition changes for residents and failure to provide proper fire sprinkler coverage throughout the facility.
Complaint Details
Complaint Type: Standard with Complaint; Complaint # NJ 00157375, NJ 00156858; The facility failed to provide proper documentation and notification related to resident medical conditions.
Deficiencies (2)
| Description |
|---|
| Failure to provide documented evidence that the Medical Doctor and Responsible Party were notified of a change in condition for Resident #6 and failure to consistently document in the medical record. |
| Failure to provide proper fire sprinkler coverage to all areas of the facility as required by the New Jersey Uniform Construction Code and National Fire Protection Association standards. |
Report Facts
Sample size: 7
Time of surveyor interview: 10.43
Time of observation: 10.35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding notification of resident diagnosis and documentation | |
| Maintenance Director | Present during tour and inspection of sprinkler system |
Inspection Report
Routine
Census: 69
Capacity: 110
Deficiencies: 8
Jul 21, 2021
Visit Reason
Standard survey of 110 residential units to assess compliance with New Jersey Administrative Code 8:36 for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance with multiple standards including dining services sanitation, food temperature control, medication administration errors, emergency services documentation, fire safety drills, ventilation in bathrooms, and fire door safety. Deficiencies had potential to impact all residents.
Deficiencies (8)
| Description |
|---|
| Failed to ensure sanitizer concentrations in three-compartment sink and sanitizing buckets met required levels; dishwashing machine did not reach required sanitizing temperature; food thermometer was not sanitized between uses. |
| Meals were not served at proper temperature; food temperature logs were incomplete and food was served below required temperature. |
| Medication administration error: omission of medication doses for a resident due to lack of communication about resident's absence for appointment, resulting in an 11% medication error rate. |
| Failed to conduct and document monthly emergency fire drills with complete details including description, date, time, and participants. |
| Failed to request local fire department to conduct at least one joint fire drill annually. |
| Failed to test at least one manual pull fire alarm each month and maintain documentation of tests. |
| Failed to provide ventilation in 7 out of 10 bathrooms inspected; mechanical ventilation was not functioning and no windows were present. |
| Fire-rated doors to basement and water heater room were propped open, preventing automatic closing and latching, posing fire hazard. |
Report Facts
Census: 69
Total Capacity: 110
Medication error rate: 11
Sanitizer concentration: 400
Dishwasher temperature: 167
Food temperature: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Food Service Director (FSD) | Interviewed regarding sanitizer concentrations, dishwasher temperature, food thermometer sanitization, and food temperature monitoring |
| Certified Medication Aide #3 | Certified Medication Aide | Interviewed regarding medication administration errors for Resident #3 |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding medication orders and administration policies |
| Activity Director | Activity Director (AD) | Interviewed regarding resident outings and meal arrangements |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding fire drills, fire safety, ventilation issues, and fire door deficiencies |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Jun 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ 00146304 regarding alleged improper use of a dietary supplement and failure to investigate incidents properly.
Findings
The facility was found not in substantial compliance with standards due to failure of the Executive Director to conduct a thorough investigation of alleged misuse of a dietary supplement on residents, failure to report a fracture of unknown origin to the Department of Health, and failure to protect residents from potential abuse by allowing a staff member under investigation to continue working.
Complaint Details
Complaint #NJ 00146304 involved allegations of improper administration of a dietary supplement to residents and failure to investigate and report incidents. The complaint was substantiated by observations, interviews, and record reviews showing the facility's failure to investigate and report as required.
Deficiencies (4)
| Description |
|---|
| Failure of the Executive Director to conduct a thorough investigation of the alleged use of a dietary supplement as a medication without physician's orders. |
| Failure to immediately report and investigate an incident involving administration of a dietary supplement to a resident. |
| Failure to protect residents by allowing a staff member under investigation to continue working. |
| Failure to notify the Department of Health of a fracture of unknown origin sustained by a resident. |
Report Facts
Census: 68
Sample Size: 7
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