Inspection Reports for Brookdale Echelon Lake

NJ, 08043

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 2.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

54% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 122 residents

Based on a August 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

60 80 100 120 140 Dec 2021 Jun 2022 Apr 2023 Jul 2024 Aug 2025

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 regarding their health information, and the legal duties of NJDHSS to protect privacy.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, NJDHSS Privacy OfficerListed as contact person for privacy practices and rights

Inspection Report

Complaint Investigation
Census: 122 Deficiencies: 2 Date: Aug 6, 2025

Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 00188368 regarding medication administration and resident records at Brookdale Echelon Lake.

Complaint Details
Complaint # NJ 00188368 was substantiated based on evidence that Resident #3 did not receive medications as ordered for a total of 11 days and 11 doses, and documentation deficiencies were found in the resident's medical records and medication administration records.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards, specifically failing to ensure medications were administered as prescribed and documentation of health care and service providers was incomplete for Resident #3. The deficiencies were evidenced by interviews, record reviews, and medication administration records showing missed doses and lack of proper communication and documentation.

Deficiencies (2)
Failure to ensure medications were administered to Resident #3 as prescribed by the physician.
Failure to ensure documentation of health care and service providers was complete and according to professional standards for Resident #3.
Report Facts
Census: 122 Sample Size: 3 Missed doses: 11 Missed days: 11

Inspection Report

Complaint Investigation
Census: 108 Deficiencies: 2 Date: Jul 16, 2024

Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NJ00175460) to determine compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.

Complaint Details
Complaint #NJ00175460. The complaint investigation found that the facility failed to document RN and Physician notification for Resident #2's hospital transfer. The Regional RN and Executive Director confirmed notification occurred but was not documented.
Findings
The facility was found not in substantial compliance due to failure to follow and implement its documentation policy, specifically failing to document notification of the Registered Nurse and Physician regarding a resident's hospital transfer for pain management. The deficiency was related to Resident #2 and involved incomplete medical record documentation.

Deficiencies (2)
Failure to follow and implement the facility's Documentation Policy to show that the Registered Nurse and Physician were notified of Resident #2's transfer to the hospital for pain management.
Failure to ensure that Registered Nurse and Physician notification were documented in the resident's Medical Record when Resident #2 was transferred.
Report Facts
Census: 108 Sample Size: 3

Inspection Report

Complaint Investigation
Census: 114 Deficiencies: 1 Date: Feb 1, 2024

Visit Reason
The inspection was conducted due to complaints NJ00164461, NJ00168931, and NJ00166555 regarding sanitation and odor issues in the facility.

Complaint Details
Complaint investigation for NJ00164461, NJ00168931, NJ00166555. The facility was found not in substantial compliance with sanitation standards due to strong odors and insufficient housekeeping staffing and cleaning.
Findings
The facility failed to keep residents' areas free from strong odors, particularly in the main corridors and units, as evidenced by observations and interviews with staff and residents. Housekeeping staff shortages and inadequate cleaning schedules contributed to the deficient practice.

Deficiencies (1)
Facility failed to keep residents' areas free from strong odors in main corridors and units.
Report Facts
Census: 114 Resident rooms: 116 Sample size: 5

Employees mentioned
NameTitleContext
Interim Executive DirectorInterim Executive DirectorAcknowledged the noxious odor and staffing issues during survey
Director of MaintenanceDirector of MaintenanceReported housekeeping staffing and cleaning challenges

Inspection Report

Complaint Investigation
Census: 124 Deficiencies: 5 Date: Apr 27, 2023

Visit Reason
This was a complaint survey conducted due to a complaint (NJ00161128) regarding failure to retain a completed Universal Transfer Form and medication administration issues.

Complaint Details
Complaint #: NJ00161128. The complaint involved failure to retain a Universal Transfer Form and failure to provide prescribed medication to Resident #2, resulting in ongoing pain and lack of physician notification.
Findings
The facility failed to retain a completed Universal Transfer Form for one resident transferred to the hospital. Additionally, the facility failed to provide prescribed pain medication to one resident for several days, did not notify the physician timely, and failed to document nurse notification of the resident's change in condition.

Deficiencies (5)
Failure to retain a completed Universal Transfer Form for a resident transferred to the hospital.
Failure to provide prescribed pain medication (oxycodone) to Resident #2 for multiple days.
Failure to notify the Registered Nurse of missed medication doses for Resident #2.
Failure to notify the physician timely about the absence of medication and resident's condition change.
Failure to document physician notification regarding medication absence and resident condition.
Report Facts
Census: 124 Sample Size: 5 Missed medication doses: 21

Employees mentioned
NameTitleContext
Health and Wellness DirectorInterviewed and stated unawareness of missed medication and missing Universal Transfer Form.
Certified Medication Assistant (CMA)Interviewed and confirmed responsibility for medication administration and failure to notify RN of missed doses.
Executive DirectorInterviewed and stated unawareness of missed medication for Resident #2.

Inspection Report

Complaint Investigation
Census: 108 Deficiencies: 1 Date: Sep 18, 2022

Visit Reason
The inspection was conducted as a complaint investigation based on complaints #NJ148378 and #NJ154407 regarding the facility's failure to maintain a sanitary and safe environment.

Complaint Details
Complaint investigation based on complaints #NJ148378 and #NJ154407. The black substance growth was determined to be a serious threat to residents' health and safety. The facility was not in substantial compliance at the time of the complaint survey.
Findings
The facility was found to have black substance growth (mold) in multiple apartments and common areas, posing a serious threat to residents' health and safety. The Maintenance Director acknowledged the issue, and a Removal Plan was requested and later approved. The facility had multiple work orders related to leaks and mold. A follow-up revisit on 12/17/2022 found the facility in substantial compliance.

Deficiencies (1)
Failure to maintain a sanitary and safe environment evidenced by black substance (mold) growing on walls and ceilings in multiple apartments and common areas.
Report Facts
Census: 108 Sample Size: 4 Work Orders: 7 Revisit Census: 122 Revisit Sample Size: 6

Employees mentioned
NameTitleContext
Executive DirectorInformed of the urgency of the black substance issue and involved in follow-up interviews and corrective actions.
Maintenance DirectorAcknowledged the black substance, described cleaning and maintenance efforts, and accompanied surveyor during observations.

Inspection Report

Complaint Investigation
Census: 99 Deficiencies: 0 Date: Jun 21, 2022

Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00154407.

Complaint Details
Complaint investigation related to complaint number NJ00154407; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.

Report Facts
Census: 99 Sample Size: 0

Inspection Report

Complaint Investigation
Census: 95 Deficiencies: 0 Date: Mar 16, 2022

Visit Reason
The inspection was conducted as a complaint investigation and a COVID-19 focused infection control survey.

Complaint Details
Complaint number NJ148378 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences and related infection control regulations, including CDC recommended practices for COVID-19.

Report Facts
Sample Size: 6

Inspection Report

Routine
Census: 84 Capacity: 110 Deficiencies: 1 Date: Dec 3, 2021

Visit Reason
Standard survey of 110 residential units to assess compliance with New Jersey Administrative Code 8:36 for licensure of assisted living residences.

Findings
The facility was found not in substantial compliance due to failure to ensure proper hand hygiene and appropriate glove use during lunch meal services on 12/02/2021 and 12/03/2021, posing potential risk to residents.

Deficiencies (1)
Failure to ensure hand hygiene and appropriate use of gloves during lunch meal service, including staff not changing gloves or washing hands when handling dirty dishes and serving food.
Report Facts
Census: 84 Total capacity: 110 Sample size: 6

Employees mentioned
NameTitleContext
CNA #4Certified Nursing AssistantObserved repeatedly failing to change gloves or wash hands during meal service, contributing to deficiency
CMT #9Certified Medication TechnicianObserved failing to change gloves or wash hands while assisting residents during meal service
Administrator (ADM)AdministratorAcknowledged violations when informed of observations
Wellness Director (WD)Wellness DirectorStated it was unacceptable to serve food with gloves used to remove dirty plates

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