Inspection Reports for De La Salle Hall
810 Newman Springs Rd, Lincroft, NJ, 07738
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies, focusing instead on informing individuals about privacy practices. Earlier inspections showed a pattern of deficiencies related primarily to life safety code compliance, staffing ratios, documentation, infection control, and food safety. Prior reports cited issues such as incomplete physical exams for new employees, inadequate emergency preparedness, fire safety system maintenance, medication handling, and infection control lapses, including an Immediate Jeopardy finding related to COVID-19 PPE use in 2021. Complaint investigations were not noted in the available reports. The absence of deficiencies in the latest inspection suggests improvement in compliance compared to earlier findings.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
66% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and related components, and describing 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 regarding their health 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
Routine
Census: 21
Capacity: 32
Deficiencies: 8
Date: Dec 31, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey assessed the facility's adherence to professional standards, staffing requirements, infection control, emergency preparedness, and life safety codes.
Findings
The facility was found deficient in documenting weekly weights for residents, maintaining minimum direct care staff-to-resident ratios, ensuring timely health examinations for new employees, emergency preparedness plan updates, and life safety code compliance including exit discharge paths, sprinkler system maintenance, fire extinguisher placement, and corridor door functionality. Corrective actions and preventive measures were planned and scheduled.
Deficiencies (8)
Facility failed to document weekly weights as ordered for residents, affecting professional standards of care.
Facility failed to maintain required minimum direct care staff-to-resident ratios for 1 of 14 day shifts reviewed.
Facility failed to ensure new employees received timely health examinations by a physician or licensed practitioner.
Facility failed to review and update emergency preparedness plan annually as required.
Facility failed to maintain stable, level walking surface at exit discharge paths, posing trip hazards.
Facility failed to inspect and test dry valve sprinkler system and fire hydrant as required.
Facility failed to provide instructional placard for Class K fire extinguisher and ensure staff training.
Facility failed to ensure corridor doors were properly latched and maintained to resist passage of smoke and fire.
Report Facts
Census: 21
Total Capacity: 32
Deficient day shifts: 1
Residents affected: 21
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 6
Date: Jan 8, 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 food safety and infection control practices, including improper food labeling and storage, inadequate cleaning of kitchen equipment, and failure to don appropriate PPE for residents on isolation precautions. Additionally, physical examinations for new employees were incomplete, and life safety code violations were identified including missing illuminated exit signs, sprinkler system installation issues, and compromised smoke barrier integrity.
Deficiencies (6)
Facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross-contamination.
Facility failed to maintain proper infection control practices for donning appropriate PPE prior to entering rooms of residents on isolation precautions.
Facility failed to provide physical examinations for 1 of 5 newly hired employees within required timeframe.
Facility failed to provide two illuminated exit signs to clearly identify exit access paths in courtyard area.
Facility failed to properly install sprinklers; missing escutcheon caps and unsealed ceiling openings around sprinkler heads.
Facility failed to maintain integrity of smoke barrier partitions; unsealed penetration with wires through smoke barrier wall.
Report Facts
Census: 27
Sample Size: 12
Number of Resident Rooms: 27
Number of wires through smoke barrier: 8
Number of unmarked ice cream cups thrown out: 20
Inspection Report
Routine
Census: 26
Deficiencies: 0
Date: Sep 22, 2021
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 the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 7
Date: Aug 20, 2021
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 pharmacy services including inaccurate completion of DEA 222 forms, improper medication storage during medication pass, and food safety violations including improper food storage and lack of labeling. Life safety code deficiencies were also identified including fire door issues, missing fire alarm notification devices, incomplete sprinkler system inspections, and lack of remote annunciator for emergency power system.
Deficiencies (7)
Facility failed to ensure accurate ordering and receiving of narcotic medications on DEA 222 forms with missing details preventing accurate reconciliation.
Facility failed to ensure medications were properly secured and stored during medication pass, with medications left unattended on medication carts.
Facility failed to store potentially hazardous foods at safe temperatures and failed to label foods with prepared or use by dates, with multiple food items uncovered or expired.
Fire rated corridor door to commercial laundry room lacked self-closing and positive latching to maintain one hour fire rated construction.
Facility failed to provide audible and visible fire alarm notification devices in the outdoor enclosed courtyard.
Facility failed to comply with NFPA 25 inspection and testing requirements for sprinkler system, with only two quarterly inspections in 20 months.
Facility failed to provide a remote annunciator for the emergency electrical system to alert staff of system conditions as required by NFPA 99.
Report Facts
DEA 222 forms with deficiencies: 4
Residents reviewed for medication storage: 6
Residents present: 27
Sample size: 13
Date of survey completion: Aug 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged responsibility for completing DEA 222 forms and medication storage issues. |
| Licensed Practical Nurse | LPN | Observed leaving medications unattended on medication cart. |
| Registered Nurse | RN | Observed leaving medication unattended on medication cart. |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food storage and labeling deficiencies. |
| Maintenance Director | Director of Maintenance (MD) | Interviewed and involved in fire safety and sprinkler system deficiencies. |
| Licensed Nursing Home Administrator | LNHA | Acknowledged medication storage safety concerns. |
Inspection Report
Abbreviated Survey
Census: 27
Deficiencies: 3
Date: Jan 27, 2021
Visit Reason
COVID-19 Focused Infection Control Survey conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19 mitigation strategies and testing.
Findings
The facility failed to appropriately utilize Personal Protective Equipment (PPE) for residents exposed to COVID-19 and for readmitted residents identified as persons under investigation (PUI), resulting in an Immediate Jeopardy situation. Additionally, the facility failed to correctly administer COVID-19 antigen tests and did not test staff at the required frequency based on regional positivity rates.
Deficiencies (3)
Failure to utilize appropriate PPE to prevent the spread of COVID-19 for 27 residents exposed and 4 readmitted residents identified as PUI.
Failure to correctly administer COVID-19 antigen tests for 2 surveyors.
Failure to test staff for COVID-19 at a frequency based on the COVID-19 Activity Level Index (CALI) Weekly Report.
Report Facts
Residents exposed to COVID-19: 27
Readmitted residents identified as PUI: 4
Staff COVID-19 tests reviewed: 3
County positivity rate: 11.1
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in deficiency for incorrect PPE use and improper COVID-19 antigen test administration. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named as COVID-19 positive staff member and involved in PPE deficiency. |
| Director of Nursing | Director of Nursing | Provided statements regarding PPE policies and infection control practices. |
| Infection Preventionist | Infection Preventionist | Provided statements and training related to infection control and PPE use. |
| Administrator | Facility Administrator | Provided statements regarding PPE supply and COVID-19 testing policies. |
| Infectious Disease Doctor | Infectious Disease Physician | Consulted remotely and provided guidance on PPE use. |
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