Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Notice
Deficiencies: 0
Nov 20, 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 regarding their health 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: 77
Deficiencies: 11
Aug 20, 2024
Visit Reason
The inspection was a standard and complaint survey triggered by complaint NJ00156289, focusing on compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences and related standards.
Findings
The facility was found not in substantial compliance with multiple regulatory standards including administration, resident rights, dining services, pharmaceutical services, emergency services, housekeeping, physical plant, and safety. Deficiencies included delayed call pendant response times, unsecured cleaning chemicals, improper food handling, medication administration issues, lack of secure medication storage, uninspected fire extinguishers, incomplete resident record access, inadequate janitor's closet, unsafe environment in memory care unit, and malfunctioning smoke barrier doors.
Complaint Details
Complaint number NJ00156289 triggered the survey. The complaint involved concerns about call pendant response times, resident safety, medication administration, housekeeping, and facility maintenance.
Deficiencies (11)
| Description |
|---|
| Delayed response to resident call pendants with documented response times up to 498 minutes. |
| Housekeeping cart containing cleaning chemicals was left unlocked and accessible to residents. |
| Facility staff failed to consistently wear hair restraints in the kitchen and failed to properly store and label food items. |
| Medication administered by Certified Medication Aide was not in unit-of-use/unit dose form as required. |
| Medications and supplies were stored unsecured and unlabeled in multiple drawers and cabinets. |
| Fire extinguishers were not inspected monthly for July 2024 as required for 16 units throughout the facility. |
| Requested resident medical records were not fully accessible to surveyors upon entry, with limited EMR access and delays in providing paper copies. |
| Dietary department lacked an adequate janitor's closet; cleaning equipment was stored in open areas. |
| Hot coffee machine left on and unattended in memory care unit, posing risk to residents. |
| Cleaning products and chemicals were not secured in locked compartments, posing safety risks. |
| A set of smoke barrier doors on the 3rd floor failed to close properly due to carpet obstruction, compromising smoke containment. |
Report Facts
Residents present: 77
Longest call pendant response time: 498
Occurrences of call pendant response >15 minutes: 89
Longest call pendant response time for Resident #5: 72
Temperature of coffee machine: 172
Number of fire extinguishers not inspected in July 2024: 16
Number of residents with unavailable medical records: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CHHA #1 | Certified Home Health Aide | Responded to pendant call for Resident #1 |
| CHHA #2 | Certified Home Health Aide | Responded to pendant call for Resident #1 |
| Executive Director | Executive Director (ED) | Interviewed regarding call pendant response and facility policies |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding housekeeping cart locking |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding kitchen hair restraint policy and coffee machine |
| Licensed Practical Nurse | LPN | Interviewed regarding medication administration |
| Health Service Director | Health Service Director (HSD/RN) | Interviewed regarding medication administration and EMR access |
| Building Service Director | Building Service Director (BSD) | Interviewed regarding fire extinguisher inspections and smoke door maintenance |
| Administrator | Facility Administrator | Interviewed regarding EMR access and fire extinguisher inspections |
| Housekeeper | Housekeeping Staff | Interviewed regarding housekeeping cart key and cleaning chemical access |
| Assisted Living Coordinator | Assisted Living Coordinator | Interviewed regarding EMR system usage |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Jul 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00153566 and NJ00155423.
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 numbers NJ00153566 and NJ00155423 were investigated; the facility was found in substantial compliance.
Report Facts
Sample size: 4
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