Inspection Reports for All American Assisted Living at Hillsborough
351 US-206, Hillsborough Township, NJ 08844, United States, NJ, 08844
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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 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Mar 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00171330) to determine compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Findings
The facility was found not in substantial compliance due to failure to follow policies regarding care plans/service plans and notification of Power of Attorney for changes in residents' conditions. Specifically, deficiencies were noted in updating service plans and notifying POAs for Residents #1, #2, and #3.
Complaint Details
Complaint #NJ00171330 involved review of three residents' records and interviews, revealing failures in care plan updates and notification procedures.
Deficiencies (3)
| Description |
|---|
| Failure to follow policy and procedures for care plan/service plan updates for Residents #1 and #2, including missing interventions and updates. |
| Failure to notify Power of Attorney of significant changes in Resident #2's condition and lack of documentation of such notification. |
| Failure to update General Service Plan to include specific interventions and use of wheelchair for Residents #1, #2, and #3. |
Report Facts
Census: 79
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director (RCD) | Interviewed regarding deficiencies in service plans and notification of POA. | |
| Executive Director (ED) | Present during interview with Resident Care Director regarding deficiencies. | |
| Assistant Resident Care Director (Assistant RCD) | Interviewed regarding Resident #2's personal equipment and care. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 112
Deficiencies: 4
Feb 7, 2024
Visit Reason
The inspection was a standard survey of 112 residential units, complaint investigation, and Life Safety Code survey conducted due to multiple complaints.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards for licensure of assisted living residences. Deficiencies included failure to complete incident reports for a resident, incomplete personnel files for nursing assistants, unaddressed foul odors and maintenance issues in the laundry area, and incomplete fire sprinkler testing.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed: NJ00141850, NJ00142668, NJ00147404, NJ00168414, NJ00169932. The facility was found not in substantial compliance with licensure standards.
Deficiencies (4)
| Description |
|---|
| Failure to ensure all incident report forms were completed for one resident. |
| Failure to maintain personnel files with required health examinations and tuberculin testing for two certified nursing assistants. |
| Failure to ensure a resident washing machine on the second floor was in good repair and free of foul odors. |
| Failure to conduct two of four required quarterly fire sprinkler tests during 2022 and 2023. |
Report Facts
Census: 78
Total Capacity: 112
Sample Size: 10
Fire Sprinkler Tests Conducted: 4
Fire Sprinkler Tests Missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Lacked required health examination and tuberculin testing in personnel file |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Lacked required health examination and tuberculin testing in personnel file |
| Certified Medical Assistant #3 | Certified Medical Assistant | Interviewed regarding incident report procedures for Resident #6 |
| Director of Nursing | Director of Nursing | Interviewed regarding incident report procedures and resident assessments |
| Executive Director | Executive Director | Interviewed regarding incident report expectations and facility maintenance policies |
| Housekeeper #5 | Housekeeper | Interviewed regarding cleaning responsibilities and awareness of laundry room odor |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance of laundry washer and fire sprinkler testing |
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 2
Jan 9, 2024
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency due to an outbreak of Covid-19 to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to enforce proper use of personal protective equipment (PPE) and proper hand hygiene techniques among staff, including a certified nursing assistant, cook, and dietary server.
Deficiencies (2)
| Description |
|---|
| Facility's administrator failed to implement and enforce the facility's policy and procedure titled 'Personal Protective Equipment' for facility staff, evidenced by improper doffing of PPE by a CNA. |
| Facility failed to perform proper hand hygiene technique in accordance with CDC and facility policy for three of five staff members observed (one cook, one CNA, and one dietary server). |
Report Facts
Staff observed for hand hygiene: 5
Staff failed proper hand hygiene: 3
Census: 81
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
May 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation and a COVID-19 focused infection control survey.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code Chapter 8:36 for licensure standards and infection control regulations, including CDC recommended practices for COVID-19.
Complaint Details
Complaint number NJ00160903 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Follow-Up
Census: 74
Deficiencies: 0
Jan 26, 2021
Visit Reason
A Covid-19 Revisit 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 for COVID-19 preparation.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Jan 20, 2021
Visit Reason
Complaint investigation triggered by complaints NJ 00142326 and NJ 00142442 regarding elopement incidents involving Resident #1 and failure to ensure a safe environment and proper implementation of elopement and door alarm policies.
Findings
The facility failed to ensure a safe environment and proper implementation of its elopement and door alarm policies, resulting in Resident #1 eloping twice without staff awareness. Door alarms were found to be malfunctioning or not properly monitored, and staff failed to maintain required hourly monitoring logs. The facility was unaware of the resident's whereabouts for extended periods, and the resident was found by police at locations several miles away. The facility also failed to provide documented evidence of implementation of the resident's service plan, including hourly safety checks.
Complaint Details
Complaint #: NJ 00142326, NJ 00142442. The complaint involved incidents of Resident #1 eloping from the facility on multiple occasions, with failure of staff to monitor and respond appropriately, and failure of door alarms to function properly. The complaint was substantiated by observations, interviews, and record reviews.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a safe environment and implementation of elopement and door alarm policies for Resident #1. |
| Failure to provide documented evidence of implementation of Resident #1's service plan including hourly safety checks. |
Report Facts
Census: 83
Duration of unawareness of resident whereabouts: 60
Duration of unawareness of resident whereabouts: 160
Door alarm response time: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding elopement incidents and door alarm issues. | |
| Resident Care Director | Interviewed and provided information about door alarms and resident monitoring. | |
| Licensed Practical Nurse (LPN) / Manager on Duty | Received call from police, picked up Resident #1 from restaurant, and documented events. | |
| Certified Medication Aide (CMA) | Provided care to Resident #1 and reported resident behavior and monitoring. | |
| Certified Home Health Aide (CHHA) | Provided direct care and monitored Resident #1 hourly. | |
| Director of Maintenance | Responsible for door alarm maintenance and inspections. | |
| Concierge #1 | Received police call about Resident #1 and was unaware of resident elopement. | |
| Concierge #2 | Interviewed about elopement protocols and resident identification at front desk. |
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