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 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: 146
Deficiencies: 3
Apr 5, 2024
Visit Reason
The inspection was conducted as a complaint survey (Complaint #NJ00152007) to investigate allegations related to medication administration and record-keeping deficiencies at the assisted living facility.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards due to failure to administer medications as prescribed for Resident #2, failure to provide requested medical records for review, and failure to document a resident's discharge in accordance with professional standards.
Complaint Details
Complaint #NJ00152007 was substantiated based on interviews and record reviews showing medication administration failures and incomplete medical records for Resident #2.
Deficiencies (3)
| Description |
|---|
| Failure to ensure medications were administered to residents in accordance with prescriber's orders, evidenced by Resident #2 not receiving prescribed medications due to delayed delivery from contracted pharmacy. |
| Failure to ensure requested medical records were available for review by the Department of Health surveyor for Resident #2, including missing Physician Order Sheet, History and Physical, Registered Nurse Assessment, General Service Plan, and others. |
| Failure to document Resident #2's discharge from the facility in the medical record according to standards of practice. |
Report Facts
Census: 146
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding medication administration failures and medical record availability for Resident #2. |
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 0
Aug 24, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 08/24/2023 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.
Report Facts
Sample Size: 6
Inspection Report
Abbreviated Survey
Census: 162
Deficiencies: 1
Jan 28, 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 the COVID-19 pandemic.
Findings
The facility failed to implement an effective infection prevention and control program, specifically failing to ensure the high-temperature dishwasher reached the manufacturer's recommended rinse temperature of 180°F, lacking a backup sanitizer, which compromised proper sanitation of utensils and dishes and potentially affected all residents.
Deficiencies (1)
| Description |
|---|
| Failed to ensure the high-temperature dishwashing machine reached the manufacturer's recommended rinse temperature of 180°F and lacked a backup disinfecting chemical, risking improper sanitation of utensils and dishes. |
Report Facts
Dishwasher rinse temperature: 175
Census: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Dietary Supervisor | Operated the dishwasher and confirmed meals were served with utensils and dishes from the dishwasher that did not reach recommended temperature. |
| Director of Wellness | Director of Wellness | Part of quality assessment committee, conducted training with dietary staff on infection control and prevention practices. |
Inspection Report
Abbreviated Survey
Census: 133
Deficiencies: 0
Dec 10, 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 for licensure of assisted living residences and CDC recommended practices to prepare for COVID-19.
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