Inspection Reports for Alaris Health at Belgrove
195 Belgrove Dr, Kearny, NJ 07032, USA, NJ, 07032
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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 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 | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Mar 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ184029) to determine compliance with federal regulations regarding resident records and treatment administration documentation.
Findings
The facility was found not in substantial compliance with requirements related to resident-identifiable information and medical record documentation. Specifically, staff failed to document treatment administration records (TAR) according to physician orders for three sampled residents, with call bell documentation blanks noted on multiple shifts.
Complaint Details
Complaint # NJ184029 was substantiated based on interviews, medical record reviews, and facility documents showing deficient documentation practices for treatment administration records for three sampled residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff documented on the Treatment Administration Record (TAR) according to physician's orders and accepted standards of practice for 3 of 3 sampled residents. | SS=D |
Report Facts
Census: 103
Sample Size: 3
Correction Completion Date: Apr 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Agency Nurse | Interviewed post-survey; stated she checked call bells and was unsure about documentation sign-off |
| Registered Nurse (RN) #2 | Interviewed post-survey; stated she checked call bells, documented work, and emphasized importance of documentation | |
| Registered Nurse (RN) #3 | Interviewed post-survey; stated she checked call bells and ensured call bells were within reach |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 120
Deficiencies: 15
Dec 5, 2024
Visit Reason
A Recertification and Complaint Survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, triggered by multiple complaints.
Findings
The survey identified an Immediate Jeopardy due to failure to ensure emergency equipment was available and staff trained for a resident with a tracheostomy. Additional deficiencies included failure to update advance directives, inadequate notice for transfers and bed hold policies, incomplete baseline and comprehensive care plans, improper medication storage, and fire/life safety code violations.
Complaint Details
The survey was complaint-driven with multiple complaint numbers listed (NJ 165484, NJ 168458, NJ 173095, NJ 173654, NJ 178621, NJ 178654, NJ 179132, NJ 179373, NJ 179453, NJ 179852).
Severity Breakdown
Immediate Jeopardy: 1
Level E: 3
Level D: 6
Level F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure emergency equipment was available at the bedside and staff were trained for a resident with a tracheostomy. | Immediate Jeopardy |
| Failure to update resident's advance directives in the medical record accurately. | Level D |
| Failure to provide proper notice before transfer or discharge including appeal rights and contact information. | Level E |
| Failure to provide written bed hold notice including cost per day information. | Level E |
| Failure to provide written summary of baseline care plan to resident or representative within 48 hours. | Level D |
| Failure to develop comprehensive care plans with resident specific goals and interventions for antipsychotic medication use. | Level D |
| Failure to maintain emergency tracheostomy care supplies and ensure staff competency. | Level D |
| Failure to clean oxygen concentrator filters regularly as per facility policy. | Level D |
| Failure to properly store medications; loose pills found in medication carts. | Level D |
| Failure to ensure binding arbitration agreements were signed only after residents or representatives had capacity and understanding. | Level E |
| Failure to maintain infection prevention and control program including proper isolation signage and antibiotic stewardship documentation. | Level D |
| Delayed egress door failed to sound an audible alarm after 15 seconds of pressure. | Level F |
| Stairwell door lacked required fire exit latching hardware and was secured by a magnetic lock. | Level F |
| Smoke and heat detectors in elevator equipment room were hanging from wires and not properly secured. | Level F |
| Sprinkler system supervisory devices were not installed on two OS&Y valves, impairing system monitoring. | Level F |
Report Facts
Sample Size: 31
Deficiencies cited: 14
Residents affected: 88
Total licensed capacity: 120
Bed hold duration: 10
BIMS score: 0
Loose medications: 15.5
Delayed egress alarm delay: 15
Number of residents potentially affected by delayed egress door: 12
Number of residents potentially affected by stairwell door issue: 40
Number of residents potentially affected by smoke detector issue: 120
Number of residents potentially affected by sprinkler system impairment: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Primary nurse for Resident #86, lacked knowledge of emergency tracheostomy equipment. |
| LPN #1 | Licensed Practical Nurse | Primary nurse for Resident #86, unable to locate emergency tracheostomy supplies. |
| LPN #2 | Licensed Practical Nurse | Interviewed about Resident #66's advance directive status. |
| Director of Nursing | Director of Nursing | Responsible for oversight of tracheostomy supplies, care plans, and staff education. |
| Director of Social Services | Director of Social Services | Responsible for advance directive updates and audits. |
| Maintenance Director | Maintenance Director | Responsible for fire safety repairs, sprinkler system supervision, and equipment maintenance. |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Responsible for infection control audits and staff education. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Dec 6, 2023
Visit Reason
The inspection was conducted based on a complaint survey (Complaint # NJ00163892) to investigate allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility was found not in substantial compliance with regulations due to failure to report an alleged abuse incident to the New Jersey Department of Health as required, and failure to follow professional standards for medication administration, including leaving medications at a resident's bedside without ensuring ingestion.
Complaint Details
Complaint # NJ00163892 involved allegations of abuse, neglect, exploitation, or mistreatment. The facility failed to report an incident involving Resident #1 to the NJDOH as required. The complaint was substantiated with findings of deficient practice.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged abuse incident to the New Jersey Department of Health within required timeframes. | SS=D |
| Failure to follow professional standards for medication administration, including leaving medications at resident's bedside without ensuring ingestion. | SS=D |
Report Facts
Sample size: 3
Deficiency completion date: Dec 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Documented incident involving Resident #1 and reported to Director of Nursing but did not report to NJDOH. |
| Director of Nursing | Director of Nursing (DON) | Acknowledged responsibility to report abuse incidents to NJDOH and supervised medication administration. |
| Licensed Nursing Home Administrator | LNHA | Acknowledged responsibility to report abuse incidents to NJDOH. |
| RN #2 | Registered Nurse | Signed medication administration record for Resident #2 but failed to ensure medication ingestion. |
| LPN #1 | Licensed Practical Nurse | Administered medication to Resident #2 but did not witness ingestion. |
| Registered Nurse/Unit Manager | RNUM | Observed medication left at bedside and notified LPN #1 of medication not taken. |
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Sep 27, 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: 7
Inspection Report
Recertification
Census: 81
Capacity: 118
Deficiencies: 8
Jun 29, 2023
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health from 06/26/23 to 06/29/23. The survey included a complaint investigation based on complaint # NJ00160113.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to accuracy of assessments (F641) and residents being free of significant medication errors (F760). The facility failed to accurately code Minimum Data Set (MDS) assessments and ensure prescribed medications were administered properly. Life Safety Code deficiencies were also noted in a separate survey.
Complaint Details
Complaint # NJ00160113 was substantiated with a deficiency at F760 related to medication errors. The facility failed to ensure one resident (R186) received prescribed medication, with no corrective action taken as the resident was discharged.
Severity Breakdown
Level D: 2
Level E: 1
Level F: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to accurately code the Minimum Data Set (MDS) assessments for residents, increasing potential for missed opportunities of care or services. | Level D |
| Failure to ensure residents were free of significant medication errors, including missed medications and incomplete documentation. | Level D |
| Failure to ensure the facility was protected by an approved automatic sprinkler system in accordance with NFPA 13, affecting 81 residents. | Level F |
| Failure to ensure portable fire extinguishers were provided for protection of building structure and occupancy hazards, affecting 83 residents. | Level E |
| Failure to ensure a metal container with a self-closing cover was available in the smoking area for ashtray disposal, affecting 5 residents. | Level F |
| Failure to ensure junction boxes were provided with covers compatible with the box, affecting 50 residents. | Level F |
| Failure to ensure cover plates for electrical receptacles had distinctive color or marking as required, affecting 83 residents. | Level F |
| Failure to ensure disconnecting means were legibly marked to indicate their purpose for the Life Safety Code Branch of the Emergency Electrical System, affecting 83 residents. | Level F |
Report Facts
Survey Census: 81
Total Capacity: 118
Sample Size: 18
Deficiency Count: 8
Residents affected by sprinkler deficiency: 81
Residents affected by fire extinguisher deficiency: 83
Residents affected by junction box deficiency: 50
Residents affected by electrical receptacle marking deficiency: 83
Residents affected by Life Safety Code disconnecting means marking deficiency: 83
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Mar 7, 2023
Visit Reason
The inspection was conducted based on complaints #NJ161781 and #NJ161918 to investigate compliance with transfer and discharge requirements and medication administration standards at Alaris Health at Belgrove.
Findings
The facility was found not in substantial compliance with transfer and discharge requirements, failing to provide proper written notices and documentation for resident discharges and transfers. Additionally, the facility failed to administer and document medication administration accurately for certain residents. Deficient practices were identified related to discharge planning, medication administration, wound care, and narcotic medication documentation.
Complaint Details
Complaint investigation based on complaints #NJ161781 and #NJ161918. The complaints were substantiated as the facility was found not in substantial compliance with regulatory requirements.
Severity Breakdown
Level 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide a 3-day written notice prior to voluntary discharge and document discharge requirements in residents' medical records. | Level 3 |
| Failure to administer and accurately document medication administration according to physician's orders and facility policy for Resident #16. | Level 3 |
| Failure to meet professional standards in services provided, including wound care and medication administration documentation. | Level 3 |
Report Facts
Census: 79
Sample Size: 16
Deficiencies cited: 3
Completion date for plan of correction: May 5, 2023
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jun 13, 2022
Visit Reason
The inspection was conducted as a complaint survey to assess compliance with regulatory requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 71
Deficiencies: 0
Jan 26, 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.
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: 9
Inspection Report
Routine
Census: 48
Deficiencies: 0
Aug 5, 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: 5
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Jul 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints #NJ 146299, 146371, and 146446 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to follow physician's orders and facility policy regarding documentation and administration of treatments for 3 of 4 residents reviewed. Missing documentation was noted for treatments and monitoring as ordered, indicating deficient practice in meeting professional standards of quality.
Complaint Details
Complaint investigation based on complaints #NJ 146299, 146371, and 146446. The facility was found not in substantial compliance with requirements due to failure to follow physician orders and document treatments properly.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician's orders and document treatments for residents #1, #2, and #4 as required by facility policy. | SS=D |
Report Facts
Census: 68
Sample Size: 4
Completion Date: Aug 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #1) | Interviewed regarding documentation of care rendered | |
| Assistant Director of Nursing (ADON) | Interviewed regarding monitoring and documentation policies and corrective actions |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 2
May 18, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to failure to maintain professional nursing standards in documenting physician's orders and failure to ensure proper infection prevention and control practices by staff and visiting physicians, including improper use of PPE and inadequate wound care procedures.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain professional standards of nursing practice in accurately documenting physician's orders for one resident. | SS=D |
| Failure to ensure infection prevention and control program compliance, including improper PPE use by visiting Physiatrist and nurse during wound care for four residents. | SS=D |
Report Facts
Sample Size: 17
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to findings about documentation errors and infection control deficiencies |
| Nurse Practitioner | Facility Nurse Practitioner (NP) | Interviewed regarding discrepancies in physician orders documentation |
| Physiatrist | Visiting Physiatrist | Observed failing to follow proper PPE and infection control procedures |
| Registered Nurse | Registered Nurse (RN) | Observed failing to follow proper infection control procedures during wound care |
Inspection Report
Life Safety
Deficiencies: 1
May 11, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/11/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance due to a 6-inch diameter hole in the concrete floor of an electrical room closet on the first floor, which compromised the fire resistance and smoke integrity of the floor construction. The hole was caused by contracted vendors who failed to seal it after completing work.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A 6-inch diameter hole in the floor of an electrical room closet breached the concrete floor, compromising fire resistance and smoke integrity. | SS=D |
Report Facts
Diameter of hole: 6
Thickness of concrete floor: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and verified the hole; educated by Regional Maintenance Director and Administrator; responsible for corrective actions | |
| Regional Maintenance Director | Educated Maintenance Director and inspected repairs | |
| Corporate Representative | Present during observation and verified the hole |
Inspection Report
Routine
Census: 53
Deficiencies: 0
Feb 9, 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: 5
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jan 10, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00127212, NJ00127958, and NJ00130859.
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 numbers NJ00127212, NJ00127958, and NJ00130859 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 8
Inspection Report
Routine
Census: 79
Deficiencies: 0
Jan 10, 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 and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 57
Deficiencies: 0
Nov 24, 2020
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: 3
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