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 amend 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: 54
Deficiencies: 1
May 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to complaint number NJ00134344 concerning compliance with New Jersey Administrative Code 8:36 for assisted living residences.
Findings
The facility was found not in substantial compliance due to failure to maintain closed medical records for discharged residents as required by state regulations. Specifically, the facility could not provide the complete closed medical record for Resident #3.
Complaint Details
Complaint NJ00134344 was investigated and substantiated by the finding that the facility failed to provide the closed medical record for Resident #3 as required.
Deficiencies (1)
| Description |
|---|
| Failure to maintain closed medical records for Resident #3 for the required period of 10 years after discharge. |
Report Facts
Census: 54
Sample Size: 5
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 1
Nov 14, 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 during a COVID-19 outbreak.
Findings
The facility failed to ensure increased disinfection and cleaning practices on the affected unit during a COVID-19 outbreak, potentially affecting all 14 residents on that unit. Cleaning schedules were inadequate, with common areas and high-touch surfaces cleaned only once per week despite outbreak conditions.
Deficiencies (1)
| Description |
|---|
| Failure to increase disinfection and cleaning practices on the affected unit during a COVID-19 outbreak. |
Report Facts
Residents affected: 14
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding housekeeping and cleaning schedules | |
| Housekeeper | Interviewed about cleaning frequency on the second floor | |
| Executive Director | Interviewed regarding cleaning schedules and policies | |
| Home Health Aide (HHA) | Interviewed about cleaning duties during 3:00 PM - 11:00 PM shift | |
| Regional Infection Prevention and Control Program (IPCP) Nurse | Interviewed by telephone about housekeeping expectations |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Jul 9, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 7/9/2021 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
Abbreviated Survey
Census: 39
Deficiencies: 0
Jun 23, 2021
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 06/23/2021 to assess compliance with infection control regulations and CDC recommended practices.
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.
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