Inspection Reports for Alaris Health At Cedar Grove
110 Grove Ave, NJ, 07009
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Moderate
Unclassified
Census Over Time
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 details 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Renewal
Deficiencies: 0
Jan 29, 2025
Visit Reason
Re-Licensure Survey for their Behavioral Health Unit was conducted to assess compliance with New Jersey Administrative Code standards for Behavioral Health Nursing Facility for Long Term Care.
Findings
The facility was found to be in substantial compliance with all applicable standards.
Inspection Report
Annual Inspection
Census: 141
Deficiencies: 23
Jul 9, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to emergency preparedness training, resident privacy, staff license verification, transfer notifications, assessment accuracy, medication administration, care planning, physician visits, nurse aide certification, nurse staffing, medication labeling and storage, infection control, immunizations, environment safety, fire safety, and electrical safety.
Severity Breakdown
SS=F: 3
SS=E: 5
SS=D: 13
REPEAT: 1
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to provide emergency preparedness training to all existing staff annually. | SS=F |
| Failed to provide full visual privacy during treatment for one resident. | SS=D |
| Failed to verify licensed staff credentials upon hire for three licensed staff. | SS=E |
| Failed to provide written notification of hospital transfer to resident, representative, and Ombudsman for two residents. | SS=D |
| Failed to accurately code Minimum Data Set discharge status for one resident. | SS=D |
| Failed to follow physician's medication orders with parameters for two residents. | SS=D |
| Failed to develop and implement care plan for resident with incontinence. | SS=D |
| Failed to ensure physician visits at least every 60 days for one resident. | SS=E |
| Non-certified nurse aide worked beyond allowed 120 days without completing training. | SS=D |
| Failed to post nurse staffing information daily in a prominent place. | SS=D |
| Medication administration errors observed with missing dosage information and improper handling. | SS=D |
| Failed to store and label medications properly including expired items and improper refrigeration. | SS=D |
| Failed to perform proper hand hygiene and PPE doffing during resident care. | SS=D |
| Infection preventionist position not filled full-time with specialized training. | SS=D |
| Failed to offer and document influenza and pneumococcal immunizations and education for one resident. | SS=D |
| Facility environment deficiencies including dirty air vents, missing smoke detector, and damaged shower stall. | SS=E |
| Missing instructional signage above Class K fire extinguisher in kitchen. | SS=F |
| Failed to annually inspect all five private fire hydrants and maintain smoke resistant ceiling. | SS=F |
| Smoke barrier doors had gaps compromising smoke resistance. | SS=D |
| Electrical outlet near water source lacked required GFCI protection. | SS=D |
| Failed to maintain complete, accessible medical records including missing physician notes and incident reports for three residents. | SS=D |
| Failed to maintain minimum direct care staff to resident ratios for day and evening shifts. | REPEAT |
| Failed to maintain copy of New Jersey Universal Transfer Form in medical record for hospital transfers. | SS=D |
Report Facts
Residents present: 141
Deficiency counts: 21
Medication administration errors: 3
Staffing deficiency days: 12
Residents affected by smoke door gap: 35
Residents affected by electrical outlet issue: 8
Residents reviewed for hospital transfer: 3
Residents reviewed for immunizations: 5
Residents reviewed for medication administration: 28
Residents reviewed for care planning: 28
Residents reviewed for physician visits: 28
Non-certified nurse aides reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADON-Training Coordinator | Responsible for monitoring emergency preparedness training compliance | |
| Director of Nursing | Interviewed regarding license verification and staffing ratios | |
| Assistant Director of Nursing | Provided in-service education on medication administration and infection control | |
| Licensed Practical Nurse #1 | Observed medication administration errors | |
| Licensed Practical Nurse #2 | Observed medication administration errors | |
| Licensed Nursing Home Administrator | Interviewed regarding nurse aide hiring and staffing | |
| Plant Operations Director | Responsible for fire safety and environmental inspections | |
| Infection Preventionist Nurse | Interviewed regarding infection control program | |
| Surveyor | Observed multiple deficiencies and conducted interviews |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 1
Nov 15, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers from 11/13/2023 to 11/15/2023.
Findings
The facility was found to be in substantial compliance with federal long term care requirements but was not in compliance with New Jersey state licensure standards due to failure to meet minimum staff-to-resident ratios on one day shift during the review period.
Complaint Details
The complaint investigation involved multiple complaint numbers and concluded that the facility was in substantial compliance with federal requirements but deficient in state staffing ratio requirements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios met the mandated minimum staff-to-resident ratios for certified nurse aides on 1 of 14 day shifts, specifically on 11/04/23 where 15 CNAs were present for 142 residents instead of the required 18 CNAs. |
Report Facts
Survey Census: 142
Sample Size: 24
Deficient CNA staffing count: 1
Required CNAs on deficient day: 18
Actual CNAs on deficient day: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to reviewing nurse staffing and corrective actions |
| Staffing Coordinator | Staffing Coordinator (SC) | Named in relation to nurse staffing compliance |
| Administrator | Administrator | Named in relation to educating staffing coordinator and monitoring staffing reports |
Inspection Report
Abbreviated Survey
Census: 151
Deficiencies: 0
Aug 8, 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: 6
Inspection Report
Original Licensing
Deficiencies: 0
Aug 2, 2023
Visit Reason
Certification Licensure Survey for the Behavioral Health Unit was conducted on 8/1/23-8/2/23.
Findings
The facility is in substantial compliance with all of the standards in the New Jersey Administrative Code, Chapter 8:85-2.1-2.21 standards for Behavioral Health Nursing Facility for Long Term Care.
Document
Deficiencies: 0
Jan 20, 2023
Visit Reason
Document is not related to regulatory oversight or inspection of a healthcare or care facility; it is a prompt to open the PDF portfolio in specific software.
Findings
No inspection or regulatory content is present; the document only contains instructions for opening the PDF portfolio.
Inspection Report
Life Safety
Deficiencies: 6
Jan 17, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 01/17/2023 through 01/19/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance with multiple Life Safety Code requirements including exit discharge surfaces, exit signage, hazardous area door enclosures, sprinkler system installation, portable fire extinguisher maintenance and placement, corridor area openings, and fire safety features. Deficiencies were observed in exit discharge surfaces, illuminated exit signs, self-closing fire-rated doors, sprinkler coverage in several areas, fire extinguisher inspections and mounting heights, and corridor openings exceeding allowed size without proper fire alarm integration.
Severity Breakdown
SS=E: 4
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide 1 of 15 exit discharges with a stable, hard packed all-weather travel surface and maintain a level walking surface free of obstructions. | SS=E |
| Failed to maintain 2 of 35 illuminated exit signs in proper working condition and failed to provide 2 illuminated exit signs to clearly identify exit access paths. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions. | SS=E |
| Failed to install sprinklers in required areas including stairwell, basement medical supply room, main electrical room, and attic motor access areas. | SS=F |
| Failed to inspect 5 of 38 portable fire extinguishers annually and install 2 fire extinguishers within required height; also failed to provide proper access to extinguishers locked in cabinets. | SS=E |
| Failed to ensure open areas to corridors did not exceed 1,500 square feet and that openings were properly sealed or equipped with fire alarm tied closures. | SS=F |
Report Facts
Exit discharges inspected: 15
Illuminated exit signs inspected: 35
Portable fire extinguishers inspected: 38
Dining room area size: 5000
Allowed corridor open area size: 1500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Maintenance | Participated in facility tours and confirmed findings | |
| Director of Maintenance | Participated in facility tours and confirmed findings |
Inspection Report
Original Licensing
Deficiencies: 0
Jul 18, 2022
Visit Reason
Initial state licensure survey for the Behavioral Health Unit conducted by the New Jersey Department of Health.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies.
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 1
Nov 7, 2021
Visit Reason
The inspection was conducted based on complaints NJ148517, NJ148459, and NJ149564 alleging violations related to abuse, neglect, exploitation, or mistreatment at the facility.
Findings
The facility failed to ensure that an activities aide reported an allegation of swollen eyes and a cut on the nose of Resident #3 to nursing, which is required for injuries of unknown origin. The aide did not report the injury because it did not appear serious, despite family concerns. The facility took corrective actions including suspension and re-education of the aide and in-service training for all staff on abuse prevention and reporting.
Complaint Details
The complaint investigation found the facility was not in compliance with 42 CFR Part 483, Subpart B, based on allegations of abuse and failure to report injuries of unknown origin. The allegation was substantiated by observation, interviews, and record review.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of swollen eyes and a cut on the nose for Resident #3 to nursing as required. | SS=D |
Report Facts
Census: 138
Sample Size: 7
Suspension Duration: 2
Reporting Timeframe: 2
Reporting Timeframe: 24
Investigation Reporting Timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse, Unit Manager | Interviewed and stated unawareness of injury to Resident #3 |
| Activities Aide | Failed to report the injury to nursing; suspended and re-educated | |
| Activities Director | Activities Director | Interviewed and stated expectation that staff report family concerns |
| Director of Nursing | Director of Nursing (DON) | Present during phone call with Activities Aide; stated all team members must report injuries |
| LPN #1 | Licensed Practical Nurse | Interviewed; completed weekly body assessment on Resident #3 and reported no noted injuries |
| CNA #1 | Certified Nursing Assistant | Interviewed; familiar with Resident #3 and did not recall seeing injuries |
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 0
Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145054 and NJ143853.
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 NJ145054 and NJ143853 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 6
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