Inspection Reports for
Alaris Health At Cedar Grove
110 Grove Ave, Cedar Grove, NJ, 07009
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
83% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to an allegation that Resident #182 was dropped by transport personnel during ambulance transport on 6/14/25 and 6/15/25, and to investigate concerns regarding Resident #178's nutritional care plan and monitoring.
Complaint Details
The complaint involved an allegation that Resident #182 was dropped by transport personnel on 6/14/25 and 6/15/25. The investigation was incomplete, missing RN assessment and full contact with transport personnel. The complaint was substantiated with findings of deficient investigation.
Findings
The facility failed to thoroughly investigate the incident involving Resident #182 being dropped by transport, including lack of a Registered Nurse assessment immediately after the fall and incomplete investigation efforts. Additionally, the facility failed to ensure Resident #178's care plan was individualized, consistent with assessments, and that nutritional status was properly monitored, including weekly weights and full assistance during meals.
Deficiencies (2)
Failed to thoroughly investigate an incident/accident involving Resident #182 being dropped by transport, including missing RN assessment and incomplete investigation.
Failed to ensure Resident #178's care plan was individualized and reflective of assessments, failed to provide consistent full assistance with eating, and failed to monitor nutritional status by following weekly weight interventions.
Report Facts
Residents reviewed for accidents: 3
Residents reviewed for nutrition: 1
Weight loss threshold: 3
Shifts with CNA documentation of independence while eating: 24
Shifts with CNA documentation of set-up or clean-up assistance: 3
Weight measurement: 113.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Discussed concerns regarding missing RN assessment and incomplete investigation | |
| Licensed Nursing Home Administrator (LNHA) | Discussed concerns regarding missing RN assessment and incomplete investigation | |
| Regional Registered Nurse (R/RN) | Discussed concerns regarding missing RN assessment and incomplete investigation | |
| Speech-Language Pathologist (SLP) | Interviewed regarding Resident #178's diet texture and nutritional status | |
| Registered Dietician (RD) | Interviewed regarding nutritional assessment and care plan for Resident #178 |
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (23)
Failed to provide emergency preparedness training to all existing staff annually.
Failed to provide full visual privacy during treatment for one resident.
Failed to verify licensed staff credentials upon hire for three licensed staff.
Failed to provide written notification of hospital transfer to resident, representative, and Ombudsman for two residents.
Failed to accurately code Minimum Data Set discharge status for one resident.
Failed to follow physician's medication orders with parameters for two residents.
Failed to develop and implement care plan for resident with incontinence.
Failed to ensure physician visits at least every 60 days for one resident.
Non-certified nurse aide worked beyond allowed 120 days without completing training.
Failed to post nurse staffing information daily in a prominent place.
Medication administration errors observed with missing dosage information and improper handling.
Failed to store and label medications properly including expired items and improper refrigeration.
Failed to perform proper hand hygiene and PPE doffing during resident care.
Infection preventionist position not filled full-time with specialized training.
Failed to offer and document influenza and pneumococcal immunizations and education for one resident.
Facility environment deficiencies including dirty air vents, missing smoke detector, and damaged shower stall.
Missing instructional signage above Class K fire extinguisher in kitchen.
Failed to annually inspect all five private fire hydrants and maintain smoke resistant ceiling.
Smoke barrier doors had gaps compromising smoke resistance.
Electrical outlet near water source lacked required GFCI protection.
Failed to maintain complete, accessible medical records including missing physician notes and incident reports for three residents.
Failed to maintain minimum direct care staff to resident ratios for day and evening shifts.
Failed to maintain copy of New Jersey Universal Transfer Form in medical record for hospital transfers.
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
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of incomplete, unavailable, and inaccessible medical records for three residents, and an incident involving resident-to-resident altercation and abuse.
Complaint Details
Complaint NJ#172727 regarding failure to maintain complete, available, and readily accessible medical records and inadequate investigation and documentation of resident-to-resident altercation and abuse incidents.
Findings
The facility failed to maintain complete, available, and readily accessible medical records for three residents. Additionally, the investigation revealed inadequate documentation and follow-up related to a resident-to-resident altercation and incidents of aggressive behavior, with delayed collection of statements and incomplete monitoring and de-escalation documentation.
Deficiencies (1)
Failure to maintain complete, available, and readily accessible medical records for residents #86, #134, and #196.
Report Facts
Residents reviewed: 31
Residents affected: 3
BIMS score: 9
BIMS score: 15
BIMS score: 5
Incident report date: Apr 4, 2024
Number of progress notes found late: 12
Timeframe for investigation summary: 5
Inspection Report
Routine
Deficiencies: 18
Date: Jul 9, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication administration, infection control, staffing, and environmental safety.
Complaint Details
Complaint NJ#172727 involved failure to maintain complete, available, and readily accessible medical records for three residents (#86, #134, and #196).
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during wound care, failure to verify licensed staff credentials prior to hire, failure to provide timely transfer notifications, inaccurate resident assessments, medication administration errors, incomplete discharge summaries, inadequate splinting documentation, lack of incontinence care planning, failure to ensure physician face-to-face visits every 60 days, nurse aide training compliance issues, failure to post nurse staffing information, improper medication storage and labeling, infection control breaches, incomplete immunization documentation, incomplete medical records, and environmental safety concerns.
Deficiencies (18)
Failure to provide full visual privacy during wound care treatment for one resident.
Failure to verify licensed staff credentials prior to hire for three newly hired licensed staff.
Failure to provide timely written notification of hospital transfer to resident, representative, and Ombudsman for two residents.
Failure to accurately code Minimum Data Set (MDS) discharge status for one resident.
Failure to follow physician orders for medications with parameters for two residents.
Failure to complete discharge summaries for two residents discharged to home.
Failure to ensure consistent daily treatment and documentation of hand splint for one resident.
Failure to develop and implement an incontinence care plan for one resident with frequent urine and occasional bowel incontinence.
Failure to ensure physician face-to-face visits and progress notes at least every 60 days for one resident.
Non-certified nurse aide worked beyond allowed 120 days without certification.
Failure to post 24-hour nurse staffing report in a prominent, accessible location.
Medication administration errors including incorrect dosing and signing errors resulting in a 12% error rate.
Improper medication storage and labeling including unlabeled medications, expired supplies, and improper refrigeration.
Failure to follow infection control practices including improper urinary drainage bag placement, inadequate hand hygiene during wound care, and improper doffing of PPE.
Failure to designate a qualified infection preventionist working at least part-time with specialized training for several months.
Failure to offer, educate, and document influenza and pneumococcal vaccinations for one resident.
Failure to maintain complete, available, and readily accessible medical records for three residents.
Failure to maintain a safe, clean, and comfortable environment including dust accumulation, rust, missing smoke detector, and unsecured electrical room.
Report Facts
Medication administration error rate: 12
Number of residents reviewed: 28
Number of residents with deficient medical records: 3
Number of nurse aides reviewed: 2
Number of medication carts inspected: 5
Number of medication storage rooms inspected: 2
Number of units inspected for medication storage: 4
Number of residents with medication errors observed: 2
Number of nurses observed administering medications: 4
Number of residents with incomplete discharge summaries: 2
Number of residents with incomplete immunization documentation: 1
Number of residents with inadequate splint documentation: 1
Number of residents with inadequate incontinence care planning: 1
Number of residents with missed physician visits: 1
Number of residents with unnecessary medication: 1
Number of residents with infection control breaches: 1
Number of residents with wound treatment hand hygiene breaches: 1
Number of residents with PPE doffing breaches: 1
Number of residents with environmental safety issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication error finding and wound care hand hygiene observation |
| Licensed Practical Nurse #2 | LPN | Named in medication error finding |
| Licensed Nursing Home Administrator | LNHA | Named in multiple findings including staff credential verification, transfer notification, infection control, and environmental safety |
| Director of Nursing | DON | Named in multiple findings including staff credential verification, transfer notification, infection control, and environmental safety |
| President of Operations | VPoO | Named in multiple findings including staff credential verification, transfer notification, infection control, and environmental safety |
| Registered Nurse Coordinator | RNC | Named in immunization and medical record findings |
| Infection Preventionist | IP | Named in infection control program deficiency |
| Consultant Pharmacist | CP | Named in medication administration observation |
| Director of Rehab | DoR | Named in splinting documentation deficiency |
| Registered Nurse/Unit Manager | RN/UM | Named in medication administration and immunization findings |
| Business Office Manager | BOM | Named in staff credential verification and nurse aide employment findings |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Alaris Health at Cedar Grove, summarizing the findings of a regulatory survey completed on 08/08/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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
Date: 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
Routine
Census: 39
Deficiencies: 12
Date: Jan 20, 2023
Visit Reason
The inspection was a routine survey to assess compliance with healthcare regulations, including resident care, abuse prevention, infection control, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care and timely incontinence care, inadequate bed maintenance, failure to protect a resident from abuse and to follow abuse investigation protocols, insufficient staffing levels impacting resident care, delayed physician progress notes, inadequate infection control practices including hand hygiene and PPE use, failure to timely report abuse allegations, and failure to provide adequate supervision to prevent falls resulting in resident injury.
Deficiencies (12)
Failure to provide dignified care including oral and incontinence care, timely clothing changes, and respect for residents.
Failure to identify and repair a broken bed causing discomfort to a resident.
Failure to protect a resident from abuse by a Certified Nurse Aide and failure to follow abuse investigation protocols including immediate removal of alleged staff and protection of all residents.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft including protection of all residents during abuse investigations.
Failure to timely report suspected abuse to the Department of Health within required timeframes.
Failure to document medication administration or refusal on the Medication Administration Record (MAR).
Failure to provide appropriate incontinence care, personal hygiene, oral hydration, and mouth care to dependent residents.
Failure to provide appropriate care and timely treatment for a resident with a change in condition resulting in hospitalization for sepsis and hypernatremia.
Failure to provide adequate supervision and implement fall prevention interventions resulting in multiple falls including one with injury requiring hospitalization.
Failure to enter signed physician progress notes in the hybrid medical record at each required visit, with delays ranging from 2 to 26 days.
Failure to implement infection control practices including hand hygiene during medication administration, proper storage of Foley catheter drainage bags, visitor mask use, PPE use in isolation rooms, and adherence to Covid-19 exposure control and response plan.
Failure to provide sufficient and competent nursing staff to meet residents' needs and minimum staffing requirements, resulting in inadequate care and supervision.
Report Facts
Resident census: 39
Staffing: 2
Staffing: 3
Fall risk score: 15
Medication administration delay: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in abuse allegation and failure to protect resident from abuse |
| Director of Nursing | Director of Nursing | Named in abuse investigation and infection control interviews |
| Licensed Nursing Home Administrator | Administrator | Named in abuse investigation and infection control interviews |
| Unit Manager | Unit Manager | Named in abuse investigation, staffing, and resident care supervision |
| Director of Housekeeping | Director of Housekeeping | Named in infection control and Covid-19 symptom reporting |
| Registered Nurse | RN | Named in medication administration and infection control observations |
Inspection Report
Life Safety
Deficiencies: 6
Date: 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.
Deficiencies (6)
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.
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.
Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions.
Failed to install sprinklers in required areas including stairwell, basement medical supply room, main electrical room, and attic motor access areas.
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.
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.
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
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
Failure to report an allegation of swollen eyes and a cut on the nose for Resident #3 to nursing as required.
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
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145054 and NJ143853.
Complaint Details
Complaint numbers NJ145054 and NJ143853 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample Size: 6
Inspection Report
Routine
Deficiencies: 3
Date: Feb 5, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether residents' care plans were comprehensive and included all relevant medical conditions and treatments.
Findings
The facility failed to develop comprehensive, person-centered care plans for 3 of 35 residents reviewed, as care plans did not include focus, goals, or interventions related to residents' infections and oxygen therapy. Interviews with staff confirmed these omissions and acknowledged that care plans should have been updated promptly to reflect changes in residents' conditions.
Deficiencies (3)
Failure to develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically missing documentation of urinary tract infection and antibiotic therapy for Resident #234.
Care plan for Resident #121 did not include focus, goal, or intervention related to respiratory infection and antibiotic therapy.
Care plan for Resident #94 did not include focus, goal, or intervention related to oxygen therapy.
Report Facts
Residents reviewed for care plans: 35
Residents with deficient care plans: 3
BIMS score: 14
BIMS score: 3
Oxygen order: 3.5
Antibiotic dosage: 875
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RN/UM) | Responsible for updating care plans and confirmed omissions in residents' care plans | |
| Licensed Practical Nurse (LPN) | Observed Resident #94's oxygen therapy and stated oxygen should be included on care plans | |
| LPN Unit Manager (LPN/UM) | Discussed care plan updates during interdisciplinary team meetings and acknowledged oxygen therapy omission | |
| Director of Nursing (DON) | Confirmed care plan deficiencies and described care plan policy and procedures | |
| Administrator | Confirmed care plan deficiencies for residents |
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