Inspection Reports for Brandywine Mountain Ridge
680 Mountain Blvd, Watchung, NJ 07069, United States, NJ, 07069
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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 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Mar 28, 2023
Visit Reason
Complaint investigation related to failure to retain a completed Universal Transfer Form and failure to implement emergency transfer procedures for Resident #2.
Findings
The facility failed to retain a completed Universal Transfer Form for Resident #2 transferred to the hospital, failed to implement emergency transfer procedures, failed to monitor and address Resident #2's changing physical and psychosocial needs, and failed to notify the physician of the resident's change in condition. Resident #2 was found intoxicated outside the facility, was not sent to the ER promptly despite declining condition, and subsequently expired at the hospital.
Complaint Details
Complaint # NJ00162369 regarding failure to retain Universal Transfer Form and failure to provide appropriate emergency care and monitoring for Resident #2.
Deficiencies (5)
| Description |
|---|
| Failure to retain a completed Universal Transfer Form for Resident #2. |
| Failure to implement emergency transfer policy for Resident #2. |
| Failure to monitor and address Resident #2's changing physical and psychosocial needs. |
| Failure to notify physician of Resident #2's change in condition and failure to send resident to ER timely. |
| Failure to revise and update Resident #2's care plan to address psychosocial needs. |
Report Facts
Census: 78
Sample size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Documented Resident #2's condition and transfer; did not notify physician. |
| LPN #1 | Licensed Practical Nurse | Documented vital signs; did not notify physician or send resident to ER. |
| WD | Wellness Director | Provided documentation and interviews regarding Resident #2's condition and transfer. |
| RN #3 | Assistant Wellness Director | Assessed Resident #2 and initiated emergency transfer to hospital. |
| CM #2 | Care Manager | Assisted with Resident #2's transfer from car to wheelchair. |
| Marie Milano | Executive Director | Signed plan of correction letter. |
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 3
Feb 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to the facility's compliance with infection control regulations and CDC recommended practices during the COVID-19 pandemic.
Findings
The facility failed to consistently screen residents for COVID-19 symptoms and vital signs every shift, failed to maintain social distancing during group activities and communal dining, and staff did not consistently perform adequate hand hygiene according to CDC guidelines and facility policies.
Deficiencies (3)
| Description |
|---|
| Failure to ensure residents were appropriately screened for COVID-19 symptoms and vital signs every shift as required by NJDOH Executive Directive and facility policy. |
| Failure to implement infection prevention and control program including limiting group activities and communal dining with proper social distancing during a COVID-19 outbreak. |
| Failure to consistently perform adequate hand hygiene by staff, including improper handwashing technique and failure to use clean paper towels to turn off faucets. |
Report Facts
Residents reviewed for screening: 5
Residents involved in group activity social distancing failure: 7
Residents involved in communal dining social distancing failure: 6
Length of couch seating area: 64
Length of dining table: 37
Handwashing duration observed: 10
Handwashing duration observed: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reflections Coordinator | Licensed Practical Nurse | Interviewed regarding resident screening and social distancing practices. |
| Executive Director | Interviewed regarding COVID-19 outbreak, screening requirements, and facility policies. | |
| Wellness Director | Interviewed regarding infection control practices and handwashing procedures. | |
| Activities Assistant | Observed leading group activities and interviewed about mask use and social distancing. | |
| Housekeeper | Observed and interviewed regarding hand hygiene and keypad use. | |
| Certified Nursing Assistant | Observed performing hand hygiene. |
Inspection Report
Routine
Census: 86
Deficiencies: 0
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 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 and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 86
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