Notice
Deficiencies: 0
Nov 20, 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 their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and NJDHSS's legal duties to protect 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: 68
Deficiencies: 3
Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00184290 and NJ00184447 regarding concerns at Sunrise Assisted Living of Morris Plains.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, with deficiencies related to administration, resident rights, and failure to retain the Universal Transfer Form during resident transfers to the hospital. Deficient practices involved failure to ensure enforcement of policies on abuse, neglect, and exploitation, and failure to ensure a safe environment during investigations.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and facility policy reviews related to abuse, neglect, exploitation, and transfer documentation for residents #1, #2, and #3.
Deficiencies (3)
| Description |
|---|
| Administrator failed to ensure implementation and enforcement of the facility policy titled 'Abuse, Neglect & Exploitation - Prevention, Reporting and Investigation' for 2 of 3 residents. |
| Facility failed to ensure a safe environment during an investigation of Resident #2. |
| Facility failed to retain the Universal Transfer Form when Resident #2 was transferred to the Emergency Room for evaluation. |
Report Facts
Census on 4/10/25: 68
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Martinez | Executive Director | Named as the Executive Director providing re-training and involved in the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 4
Jan 29, 2025
Visit Reason
Complaint survey conducted from January 27-29, 2025, triggered by multiple complaints regarding the facility's compliance with New Jersey Administrative Code standards for assisted living residences.
Findings
The facility was found not in substantial compliance with standards, with deficiencies related to administration, emergency response, resident rights, assessments, care plans, and pharmaceutical services. The facility failed to ensure proper emergency protocols, resident safety, and accurate medication administration.
Complaint Details
Complaint survey based on multiple complaint numbers NJ00182946, NJ00182601, NJ00170697, NJ00162330. The facility was found non-compliant with standards likely causing serious injury, harm, impairment, or death to residents.
Deficiencies (4)
| Description |
|---|
| Failure of the Executive Director to ensure staff implemented emergency services policies, resulting in delayed emergency response for a resident. |
| Failure to ensure residents' right to be free from physical and mental abuse and neglect, including failure to ensure emergency services were contacted promptly. |
| Failure to revise residents' service plans after exhibiting elopement risk. |
| Failure to administer medications as ordered for one resident. |
Report Facts
Census: 72
Sample Size: 8
Survey Dates: 2025-01-27 to 2025-01-29
Plan of Correction Completion Date: Apr 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Martinez | Executive Director | Named in findings related to failure to ensure emergency services policies and staff training; signed Plan of Correction. |
| RN #3 | Resident Care Director | Interviewed regarding emergency response and medication administration; involved in resident care plan reviews. |
| Care Manager #1 | Involved in emergency response failure and protocol violations leading to termination. | |
| Care Manager #2 | Assisted Care Manager #1 during emergency; involved in incident reporting. | |
| Lead Care Manager #7 | Responded to elopement incident involving Resident #3. | |
| Care Manager #8 | Observed Resident #3 during elopement incident. | |
| Reminiscence Coordinator #10 | Involved in emergency response and communication with nursing staff. | |
| Licensed Nurse/Team Member | Responsible for calling 911 in emergencies as per facility policy. |
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 2
Dec 19, 2021
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 during the COVID-19 pandemic.
Findings
The facility failed to ensure that two nursing staff performed proper hand hygiene between resident contacts and tasks, and failed to disinfect shared medical equipment between resident use. These deficiencies had the potential to affect all residents and occurred during the COVID-19 pandemic.
Deficiencies (2)
| Description |
|---|
| Failure to ensure that two nursing staff performed hand hygiene between resident contact and between tasks. |
| Failure to disinfect shared medical equipment between resident use for four residents observed during medication pass. |
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Care Manager #1 | Named in findings related to failure to perform hand hygiene and disinfect shared medical equipment. | |
| Lead Care and Medication Care Manager #1 | Named in findings related to failure to perform hand hygiene and disinfect shared medical equipment. | |
| Infection Control Preventionist (ICP) | Interviewed regarding infection control training and monitoring. | |
| Executive Director (ED) | Interviewed regarding retraining and monitoring of staff for compliance. |
Inspection Report
Abbreviated Survey
Census: 72
Deficiencies: 3
Nov 17, 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 during the COVID-19 pandemic.
Findings
The facility was found not in compliance with infection control standards, including failure to ensure resident privacy during toileting, inadequate use of personal protective equipment (PPE) for residents under investigation for COVID-19, and failure of a staff member to perform hand hygiene after providing care.
Deficiencies (3)
| Description |
|---|
| Failure to ensure a resident was treated with consideration and dignity while toileting, as the resident was fully exposed with the apartment door left open. |
| Failure to follow infection prevention and control policies, including inadequate use of PPE for residents on isolation for possible COVID-19 exposure and lack of signage or PPE carts outside isolation apartments. |
| A staff member (Certified Medication Aide #1) did not perform hand hygiene after providing toileting care to a resident. |
Report Facts
Residents under investigation (PUI): 4
Resident census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide #1 | Named in findings for failing to provide resident privacy and not performing hand hygiene after care | |
| Wellness Director | Wellness Director | Interviewed regarding infection control policies and resident privacy expectations |
| Executive Director | Executive Director | Interviewed regarding training needs for privacy and handwashing |
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