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
Census: 86
Deficiencies: 4
Jun 28, 2024
Visit Reason
The inspection was conducted as a Renovation Project of Phase 1 of 18 Inspection Survey to assess 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 deficiencies including lack of proper fire sprinkler coverage in all areas, absence of Ground Fault Circuit Interrupter (GFCI) electrical outlets in wet locations, and failure to meet smoke door tolerance requirements.
Deficiencies (4)
| Description |
|---|
| Failure to provide proper fire sprinkler coverage to all areas of the facility as required by New Jersey Uniform Construction Code and NFPA 13 standards. |
| Failure to provide Ground Fault Circuit Interrupter (GFCI) electrical outlets within wet locations as required by code. |
| Smoke door tolerance not met; a 1/4 inch gap was observed between corridor double smoke doors. |
| Quick Response fire sprinkler head had white paint covering the frangible glass head. |
Report Facts
Census: 86
Gap measurement: 0.25
Electrical outlet location: 46
Number of renovated apartments inspected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Informed of deficiencies on 06/28/2024 | |
| Project Manager | Present during inspection and confirmed paint on sprinkler head |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Feb 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00171334 and NJ00147345 regarding alleged resident abuse and failure to follow policies.
Findings
The facility was found not in substantial compliance with standards due to failure to report and investigate an incident of staff-to-resident abuse involving Resident #1, failure to implement the resident's health service plan related to behavioral issues, and failure to retain a completed Universal Transfer Form for Resident #1's hospital transfer. The Housekeeper involved was terminated and the facility implemented a removal plan.
Complaint Details
Complaint investigation based on complaints NJ00171334 and NJ00147345 regarding alleged abuse of Resident #1 by a Housekeeper. The complaint was substantiated with findings of staff-to-resident abuse and failure to follow reporting and care plan procedures.
Deficiencies (4)
| Description |
|---|
| Failure to ensure implementation and enforcement of policies regarding incident/accident reporting and abuse investigation, specifically failure to report an altercation between Housekeeper and Resident #1 to an immediate supervisor and local law enforcement within 24 hours. |
| Failure to ensure each resident's right to be free from physical and mental abuse, evidenced by staff-to-resident abuse of Resident #1 by a Housekeeper. |
| Failure to implement the written health service plan for Resident #1 when the resident became verbally aggressive, including failure to follow interventions to safely manage the resident's behavior. |
| Failure to retain a completed copy of the Universal Transfer Form in Resident #1's medical record when transferred to the hospital. |
Report Facts
Census: 91
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Pecci | Executive Director | Named in relation to failure to ensure implementation and enforcement of policies regarding incident reporting and abuse investigation. |
| Kathleen Kelly Malaver | Executive Director | Signed plan of correction and responsible for education and monitoring compliance. |
| Jennifer Tuttle | Wellness Director | Signed plan of correction and responsible for audits and education related to Universal Transfer Form. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 6
Feb 21, 2024
Visit Reason
The inspection was a standard survey combined with complaint investigations related to multiple complaint numbers (NJ00167489, NJ00156306, NJ00153168, NJ00147345) at Allendale Senior Living.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, with deficiencies including failure to ensure employee physical examinations upon hire, failure to complete initial resident assessments by a Registered Nurse for one resident, failure to document annual fire door inspections, failure to maintain the emergency generator annunciator panel in a constantly attended area, and failure to obtain physician orders and develop care plans for the use of restraining devices for a resident.
Complaint Details
The visit was complaint-driven with multiple complaint numbers investigated: NJ00167489, NJ00156306, NJ00153168, NJ00147345. The complaints included issues related to employee physicals, resident assessments, fire safety, and use of restraining devices.
Deficiencies (6)
| Description |
|---|
| Failure to ensure all employees received physical examinations upon hire (5 of 5 employees). |
| Failure to ensure an initial resident assessment was completed by a Registered Nurse for 1 out of 6 residents reviewed (Resident #4). |
| Failure to document the required annual fire door inspection as per NFPA 80 standards. |
| Failure to ensure the emergency standby generator annunciator panel was located in a constantly attended area as required by NFPA 110. |
| Failure to obtain a physician's order for the use of a restraining device for 1 of 9 residents (Resident #8). |
| Failure to develop and implement a specific plan of care for the use of a restraining device for 1 of 6 residents (Resident #8). |
Report Facts
Census: 90
Sample size: 9
Smoke compartments affected: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Director | Human Resources Director | Interviewed regarding lack of employee physical examinations. |
| LPN #2 | Licensed Practical Nurse | Conducted initial resident assessments and interviewed about Resident #4 assessment. |
| Director of Maintenance | Director of Maintenance | Interviewed about fire door inspections and location of emergency generator annunciator panel. |
| Executive Director | Executive Director | Interviewed about awareness of fire door inspections and emergency generator annunciator panel location. |
| Administrator | Facility Administrator | Interviewed about resident assessments and employee physicals. |
| Regional Director of Nursing | Regional Director of Nursing | Asked for physician's order for restraining device use. |
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