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, legal duties of NJDHSS, 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for the notice |
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 2
Mar 18, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to the facility being in a COVID-19 outbreak phase, to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility failed to comply with New Jersey infection control regulations and CDC guidelines by not consistently performing required resident COVID-19 screenings three times daily during the outbreak, and by not ensuring staff used full personal protective equipment (PPE) during COVID-19 antigen testing of visitors.
Deficiencies (2)
| Description |
|---|
| Failure to develop and implement a policy ensuring resident screening three times daily during COVID-19 outbreak as required by NJDOH Executive Directive No. 20-026. |
| Failure to implement infection prevention and control program consistent with CDC guidelines, including inadequate use of PPE during COVID-19 antigen testing of visitors. |
Report Facts
Census: 57
Sample Size: 5
Date of COVID-19 outbreak start: Feb 19, 2021
Expected completion date for N95 fit testing: Apr 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named as responsible for policy development and acknowledged facility screening practices | |
| Resident Care Director | Interviewed regarding screening practices and observed performing COVID-19 antigen testing without full PPE |
Inspection Report
Routine
Census: 59
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.
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