Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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 details 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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 5
Oct 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ 00173126, NJ 00172816, and NJ 00177371 regarding compliance with New Jersey Administrative Code standards for Assisted Living Residences.
Findings
The facility was found not in substantial compliance with standards, with deficiencies including failure to ensure snacks and beverages were always available to residents, lack of annual physician certification for residents, absence of a Registered Dietician to assess nutrition needs, failure to maintain resident diet records for meal preparation, and failure to develop and implement a planned activity program.
Complaint Details
Complaint investigation based on complaints NJ 00173126, NJ 00172816, and NJ 00177371. The facility was found not in substantial compliance with applicable standards.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure snacks and beverages were always available for residents, including sugar free snacks for 3 of 4 residents. |
| Facility failed to ensure annual Physician certification to show residents' care needs could continue to be met for 4 of 4 residents reviewed. |
| Facility failed to provide services of a Registered Dietician to assess nutrition needs of residents. |
| Facility failed to ensure resident diet record was available for cooks to reference when meals were prepared for residents. |
| Facility failed to develop and implement an activity program to meet the needs of residents, with no activity calendars for most months and no planned activity program calendar until October 2024. |
Report Facts
Census: 12
Sample Size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident snacks, physician certifications, and nutrition assessments |
| Executive Director | Executive Director (ED) | Interviewed regarding resident snacks, physician certifications, nutrition assessments, and activity calendars |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding sugar free snacks, resident diet lists, and menu review |
| Director of Therapeutic Services | Director of Therapeutic Services (DTS) | Interviewed regarding resident activities and activity calendars |
| Cook #1 | Cook | Interviewed regarding meal preparation and resident diet lists |
| Cook #2 | Cook | Interviewed regarding resident diets for meal preparation |
Inspection Report
Routine
Census: 7
Deficiencies: 2
Mar 23, 2022
Visit Reason
The inspection was a standard routine survey to assess compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences and comprehensive personal care homes.
Findings
The facility was found not in substantial compliance with state standards, with deficiencies including failure to administer medications according to prescriber's orders and failure to document rationale for missed medications, as well as failure to complete initial RN assessments and General Service Plans for residents upon admission.
Deficiencies (2)
| Description |
|---|
| Failure to administer medications in accordance with prescriber's orders and failure to document rationale for missed medications for 1 of 7 residents reviewed. |
| Failure to ensure that the Registered Nurse completed initial assessments and General Service Plans for residents upon admission for multiple residents reviewed. |
Report Facts
Census: 7
Sample size: 7
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