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, the circumstances under which health information may be used or disclosed, the rights of individuals 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 named as contact for privacy practices |
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Oct 24, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 100
Deficiencies: 1
Oct 18, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19.
Findings
The facility was found to be not in compliance with 42 CFR §483.80 infection control regulations, specifically related to staff vaccination and booster dose compliance. Deficiencies were identified for 8 out of 17 staff members reviewed, with issues in documentation and timely vaccination/booster administration.
Deficiencies (1)
| Description |
|---|
| Failure to implement staff vaccination policy ensuring staff were up to date with COVID-19 vaccinations and boosters as required by federal, state, and local regulations. |
Report Facts
Staff members reviewed: 17
Staff members deficient: 8
Sample size: 5
Inspection Report
Follow-Up
Census: 107
Deficiencies: 1
Aug 18, 2022
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically regarding minimum direct care staff-to-resident ratios.
Findings
The facility was found not in compliance with staffing requirements, failing to maintain the required minimum direct care staff-to-resident ratios on multiple shifts during the review period. A follow-up report dated 10/26/2022 indicates that corrective actions were completed by 09/30/2022.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. |
Report Facts
Residents present: 107
CNA staffing deficiency days: 12
Evening shift total staff deficiency days: 5
Overnight shift total staff deficiency days: 1
Required CNAs on 07/31/22 day shift: 13
Actual CNAs on 07/31/22 day shift: 8
Required total staff on 07/31/22 evening shift: 11
Actual total staff on 07/31/22 evening shift: 10
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Jun 8, 2022
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found to be in compliance.
Inspection Report
Routine
Census: 62
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 13
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Dec 18, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00138747.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint number NJ00138747 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
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