Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
40% occupied
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 3
Date: Nov 25, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, including incontinent care, laundry handling, and water management for Legionella bacteria.
Findings
The facility failed to maintain proper infection control measures during incontinent care for one resident, separation of clean and soiled laundry, and in implementing a water management program for Legionella bacteria, placing residents at risk of cross-contamination and health complications.
Deficiencies (3)
Failure to ensure hand hygiene and glove change during incontinent care for Resident 5.
Laundry room layout and procedures allowed clean laundry to pass through soiled areas without proper protective equipment or disinfectant placement.
Lack of a designated water management plan to identify potential sites of pooling water and testing for Legionella bacteria.
Report Facts
Residents reviewed for incontinent care: 29
Assessment Reference Date: Aug 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Named in infection control deficiency related to incontinent care |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices and deficiencies |
| Laundry Aide (LA)1 | Laundry Aide | Observed laundry procedures contributing to infection control issues |
| Housekeeping Supervisor | Housekeeping Supervisor | Observed laundry procedures and acknowledged infection control concerns |
| Director of Environmental Services | Director of Environmental Services | Observed laundry procedures and acknowledged infection control concerns |
| Infection Preventionist | Infection Preventionist | Interviewed about awareness of laundry room infection control issues |
| Maintenance Director | Maintenance Director | Interviewed about water management plan and Legionella prevention |
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
Census: 86
Deficiencies: 4
Date: 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)
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
Deficiencies: 2
Date: Jun 21, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report an allegation of abuse and to thoroughly investigate an injury of unknown origin for two residents.
Complaint Details
Complaint # NJ171657 involved failure to thoroughly investigate an injury of unknown origin for Resident #157. The investigation lacked staff interviews from the 02/19/24 11-7 shift. The allegation of abuse for Resident #156 was not reported within two hours as required.
Findings
The facility failed to report an allegation of abuse within two hours as required by state regulations and did not thoroughly investigate an injury of unknown origin due to missing staff interviews. Both deficiencies were determined to cause minimal harm or potential for actual harm to a few residents.
Deficiencies (2)
Failure to timely report suspected abuse to the New Jersey Department of Health within two hours for Resident #156.
Failure to thoroughly investigate an injury of unknown origin for Resident #157 due to missing staff interviews from the shift prior to injury identification.
Report Facts
Residents reviewed for abuse: 2
Residents reviewed for injury investigation: 2
BIMS score: 2
Dates of events: Abuse event on 3/18/23; injury identified on 2/20/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding abuse reporting and investigation | |
| Director of Nursing (DON) | Interviewed regarding abuse reporting and investigation; acknowledged reporting requirements and investigation deficiencies | |
| Regional Director of Operations/Registered Nurse (RDoO/RN) | Interviewed regarding investigation of injury of unknown origin and acknowledged missing staff interviews |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 21, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including abuse reporting, resident notifications, assessments, medication administration, infection control, and food safety.
Findings
The facility was found deficient in timely reporting of abuse allegations, providing written bed hold notifications, accurate resident assessments, proper documentation of dialysis and behavior monitoring, accurate medication administration records, enteral feeding order accuracy, pharmacist medication review, kitchen sanitation practices, and infection preventionist training.
Deficiencies (10)
Failed to report an allegation of abuse within two hours to the New Jersey Department of Health for one resident.
Failed to provide written notification of bed hold and reserve payment policy upon hospital transfer for two residents.
Failed to accurately code Minimum Data Set (MDS) assessments for three residents.
Failed to complete dialysis post assessment forms for one resident.
Failed to complete behavior monitoring sheets for one resident.
Failed to document medication administration properly, with multiple unsigned and blank entries on Medication Administration Records for one resident.
Failed to identify and correct an enteral feeding order discrepancy for one resident.
Consultant Pharmacist failed to clarify medication route for one resident during monthly medication reviews.
Facility staff wore prohibited jewelry in the kitchen, violating food safety policies.
Infection Preventionist did not complete specialized infection prevention and control training prior to assuming the role.
Report Facts
Residents reviewed for MDS coding accuracy: 3
Residents reviewed for dialysis documentation: 1
Residents reviewed for behavior monitoring: 5
Unsigned medication administration entries: 30
Enteral feeding order discrepancy: 1
Residents reviewed by Consultant Pharmacist: 6
Facility staff observed wearing prohibited jewelry: 2
Infection Preventionist training modules: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Notified of multiple deficiencies and participated in interviews | |
| Director of Nursing (DON) | Interviewed regarding abuse reporting, medication administration, and other deficiencies | |
| Regional Director of Operations/Registered Nurse (RDoO/RN) | Present during notifications of deficiencies | |
| Administrator in Training (AIT) | Present during notifications of deficiencies | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about dialysis and medication documentation | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about behavior monitoring and dialysis communication | |
| Unit Manager North Unit (UM/NU) | Interviewed about dialysis communication and behavior monitoring | |
| Social Worker (SW) | Interviewed about PASRR screening | |
| Director of Social Services (DSS) | Provided PASRR Level I screening documentation | |
| Consultant Pharmacist (CP) | Interviewed regarding medication review deficiencies | |
| Food Service Director (FSD) | Observed wearing prohibited jewelry in kitchen | |
| Dietary Aide #1 (DA#1) | Observed wearing prohibited jewelry in kitchen | |
| Infection Preventionist (IP) | Interviewed regarding training deficiencies | |
| Registered Dietitian (RD) | Interviewed about enteral feeding order discrepancy |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Date: 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.
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.
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.
Deficiencies (4)
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
Date: 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.
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.
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.
Deficiencies (6)
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. |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 11, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, facility environment, medication management, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide a functioning air conditioner for a resident, incomplete person-centered care planning, improper medication labeling and storage, inadequate attendance at Quality Assurance meetings, lapses in infection prevention and control practices, and failure to maintain a safe and sanitary environment in the laundry and folding rooms.
Deficiencies (6)
Failure to accommodate a resident's need for a functioning air conditioner.
Failure to develop a comprehensive person-centered care plan including resident preferences.
Failure to properly label, store, and dispose of medications in medication carts.
Failure to assure Licensed Nursing Home Administrator attended quarterly Quality Assurance meetings.
Failure to ensure proper infection prevention and control practices including handling of linens and Covid-19 staff screening.
Failure to maintain a safe and sanitary environment in the folding and laundry rooms.
Report Facts
Residents reviewed for air conditioner accommodation: 18
Residents affected by air conditioner deficiency: 1
Residents reviewed for care plan: 3
Residents affected by care plan deficiency: 1
Medication carts inspected: 4
Quality Assurance meetings reviewed: 3
QA meetings missed by LNHA: 2
QA meetings missed by Medical Director: 2
Dates CNA worked without Covid screening: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Named in relation to Quality Assurance meeting attendance and care plan deficiencies |
| Director of Nursing | DON | Named in relation to infection control, care plan, and Quality Assurance meetings |
| Regional Registered Nurse | RRN | Named in relation to care plan and infection control findings |
| Maintenance Director | MD | Named in relation to air conditioner repair and Quality Assurance meetings |
| Laundry Aide #1 | LA#1 | Named in relation to sanitation deficiencies in folding and laundry rooms |
| Laundry Aide #2 | LA#2 | Named in relation to sanitation deficiencies in folding and laundry rooms |
| Housekeeping Director | HK Director | Named in relation to sanitation and maintenance issues in laundry room |
| Certified Nursing Assistant | CNA | Named in relation to failure to perform Covid-19 screening |
| Registered Nurse | RN | Named in relation to medication cart inspection |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in a nursing facility, including medication administration, oxygen therapy, elopement risk assessment, dialysis care, and pharmaceutical services.
Findings
The facility was found deficient in multiple areas including improper oxygen equipment management, failure to accurately document and follow physician orders for oxygen therapy and elopement risk reassessment, inadequate dialysis care coordination and medication administration, and pharmaceutical service deficiencies related to medication labeling, administration timing, and inventory accountability.
Deficiencies (6)
Failure to ensure oxygen concentrator was turned off when not in use and humidification bottle was not changed weekly as ordered.
Failure to document re-assessment of elopement risk and inconsistent application of wander-guard alarm system.
Failure to apply neck pillow and absorbent pad as ordered and inaccurate documentation of their application.
Failure to administer anti-anxiety medication (Xanax) prior to dialysis as ordered and lack of dialysis care plan specificity.
Failure to timely address dialysis communication recommendations, including initiation of Vitamin D3 therapy.
Failure to ensure appropriate dose and timely administration of antiviral medication Tamiflu, and inaccurate medication inventory accountability.
Report Facts
Deficiencies cited: 6
Tamiflu capsules delivered: 14
Tamiflu doses administered: 9
Tamiflu capsules missing: 4
Dialysis days per week: 3
Xanax dose: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding oxygen concentrator use and medication administration for Resident #43. | |
| Director of Nursing (DON) | Acknowledged deficiencies related to oxygen therapy, elopement risk assessment, dialysis care, and medication management. | |
| Registered Nurse (RN) | Provided information on Resident #38's wander-guard alarm and Resident #48's dialysis care. | |
| Certified Nursing Aide (CNA) | Provided information on Resident #38's supervision and Resident #48's condition. | |
| Assistant Director of Nursing (ADON) | Reviewed medication discrepancies and dialysis communication issues. | |
| Consultant Pharmacist (CP) | Interviewed regarding medication inventory and dialysis communication review. |
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