Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS regarding their medical information, including how it may be used and disclosed, and the rights individuals have concerning their health information.
Findings
The notice details the types of information covered, the circumstances under which health information may be used or disclosed, the legal duties of NJDHSS to protect privacy, and the rights of individuals to access, amend, and restrict their health information.
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
Routine
Census: 84
Deficiencies: 0
Dec 6, 2023
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.
Findings
The facility was found to be in compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 63
Deficiencies: 0
Feb 17, 2022
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.
Inspection Report
Routine
Census: 53
Capacity: 101
Deficiencies: 9
Sep 14, 2021
Visit Reason
Standard Survey of 101 residential units to assess compliance with New Jersey Administrative Code 8:36 for Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs.
Findings
The facility was found not in substantial compliance with multiple regulatory standards including staff education, infection control, dining services, food storage, emergency services, and physical plant safety. Deficiencies included lack of annual in-service training for staff, improper kitchen hygiene and food handling practices, failure to maintain proper fire drill schedules, and obstructed emergency exits.
Deficiencies (9)
| Description |
|---|
| Failure to provide annual in-service education on Assisted Living Concepts, Resident Rights, Infection Control, Emergency Training, Alzheimer's Dementia, and Pain Management for multiple staff members. |
| Food service staff not wearing required hair restraints and improper glove use leading to potential contamination. |
| Food storage violations including unlabeled and expired food items, improper storage on floor, and lack of temperature logs for refrigerators and freezers. |
| Kitchen cleanliness issues including food debris on outlets and knobs, dusty shelves, scratched cutting boards, wet nesting of bowls, and leaking water in storage area. |
| Use of unpasteurized eggs in food preparation despite risk of foodborne illness. |
| Waste management deficiencies with dumpster lids open, garbage bags outside dumpsters, and unsecured dumpster enclosures. |
| Failure to use standardized recipes and inconsistent meal portion sizes served to residents. |
| Failure to conduct monthly fire drills for 2 of 12 months and failure to ensure four drills occurred on first and third shifts annually. |
| Obstruction of emergency exit door by trash barrel blocking means of egress. |
Report Facts
Census: 53
Total Capacity: 101
Sample Size: 6
Fire Drills Missed: 2
Fire Drills Conducted: 10
Fire Drills per Shift: 3
Fire Drills per Shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Cook | Named in findings related to infection control, food handling, recipe non-compliance, and meal portion sizes |
| Cook #2 | Cook | Named in infection control finding for not wearing hair or beard restraint |
| LPN #1 | Licensed Practical Nurse | Named in staff education deficiency for lack of annual in-service training |
| LPN #2 | Licensed Practical Nurse | Named in staff education deficiency for lack of annual in-service training |
| CNA #1 | Certified Nursing Assistant | Named in staff education deficiency for lack of annual in-service training |
| CMA #1 | Certified Medication Aide | Named in staff education deficiency for lack of annual in-service training |
| Food Services Director | Food Services Director | Named in infection control, food storage, recipe, and meal portion size findings and interviews |
| Executive Director | Executive Director | Interviewed regarding staff education, fire drills, and emergency exit obstruction |
| Maintenance Assistant #1 | Maintenance Assistant | Named in emergency exit obstruction finding |
| Dietary Aid #2 | Dietary Aid | Interviewed regarding refrigerator temperature logs |
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