Inspection Reports for The Pointe at Teaneck
655 Pomander Walk, Teaneck, NJ 07666, United States, NJ, 07666
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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
Complaint Investigation
Census: 35
Deficiencies: 5
Jul 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ 00187502 and NJ 00188091 regarding deficiencies in resident care and facility compliance.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards for assisted living residences. Deficiencies included failure to implement and enforce policies on wandering and elopement, failure to provide a safe environment, failure to develop or update individual service plans, failure to ensure annual physician certifications, and failure to document assessments in medical records.
Complaint Details
The complaint investigation was based on complaints NJ 00187502 and NJ 00188091. The investigation substantiated deficiencies related to resident safety, policy enforcement, service plan updates, and medical documentation.
Deficiencies (5)
| Description |
|---|
| Failure to implement and enforce the facility policy titled 'Wandering and Elopement' including not providing resident pictures at the front desk for 1 of 4 residents reviewed. |
| Failure to provide a safe environment for 1 of 4 residents reviewed, evidenced by resident elopement without staff notification. |
| Failure to develop and/or update a resident's Individual Service Plan (ISP) for 1 of 4 residents reviewed. |
| Failure to ensure that a resident received an annual physician certification for Assisted Living for 1 of 3 residents reviewed. |
| Failure to document assessments in the resident's medical record for 1 of 4 residents reviewed. |
Report Facts
Census: 35
Sample Size: 4
Inspection Report
Routine
Census: 39
Capacity: 40
Deficiencies: 5
Dec 4, 2024
Visit Reason
The inspection was a Renovation Project Survey/Inspection to include an expanded Community room and Resident Apartment #111.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code standards for licensure of Assisted Living Residences. Deficiencies included admitting residents without proper licensure approval, failure to ensure the administrator held required certifications, and failure to maintain an up-to-date resident census register.
Deficiencies (5)
| Description |
|---|
| Facility occupied a newly recreated Resident Apartment prior to initial inspection and approval by the Department of Health. |
| Facility admitted two residents to a recreated apartment without Department of Health approval. |
| Facility failed to ensure the appointed Administrator had a current Certified Assisted Living Administrator (CALA) certification as required. |
| Facility failed to implement and enforce the policy titled 'Professional Licenses' requiring valid licenses or credentials at time of hire. |
| Facility failed to keep the resident census register up-to-date for 3 of 19 residents reviewed. |
Report Facts
Census: 39
Total Capacity: 40
Residents with outdated census records: 3
Residents allowed to move in without approval: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in findings related to lack of CALA certification and census policy enforcement |
| Director of Health and Wellness | Director of Health and Wellness | Named in findings related to staff roles and census policy enforcement |
| Business Office Manager | Business Office Manager | Named in relation to census policy and administrative roles |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 6
Apr 2, 2024
Visit Reason
Revisit survey conducted to verify correction of previously cited deficiencies including life safety code violations and compliance with licensure standards.
Findings
The facility was found not in substantial compliance with licensure standards and life safety code during the initial survey. Deficiencies included failure to develop and implement policies for Universal Transfer Form, job descriptions, staff orientation and training, staffing policy, and maintenance of fire suppression systems. A Removal Plan was implemented to address immediate fire safety threats. Subsequent revisits confirmed that corrective actions were completed and the facility achieved compliance.
Complaint Details
Complaint numbers NJ00161519, NJ00168083, NJ00171315 were investigated during the survey.
Deficiencies (6)
| Description |
|---|
| Failure to develop, implement, and enforce a Universal Transfer Form policy and procedure for resident transfers. |
| Failure to ensure written job descriptions for employees to confirm duties align with education and competencies. |
| Failure to provide documented evidence of required in-service training for employees on topics including Pain Management, Dementia Training, Abuse and Neglect, Assisted Living Concepts, Resident Rights, Infection Control, and Emergency plans. |
| Failure to develop, implement, and enforce a staffing policy to ensure adequate care and assistance for residents. |
| Failure to maintain a fire suppression system; sprinkler heads and smoke detectors were removed during renovation, creating an immediate threat to resident safety. |
| Failure to maintain a safe and secure environment during renovation, including unsealed penetrations in smoke barriers, non-compliant doors, and lack of required fire wall separation. |
Report Facts
Census: 31
Number of employees reviewed: 8
Number of employees lacking job descriptions: 3
Number of employees lacking required training documentation: 6
Number of residents potentially affected by fire safety deficiencies: 32
Number of residents in immediate renovation area: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Universal Transfer Form policy and inability to provide UTF for Resident #4. |
| Human Resource Manager | Human Resource Manager | Interviewed regarding employee personnel files and training documentation. |
| Operations Specialist | Operations Specialist | Interviewed regarding staffing policy and confirmed no staffing policy existed. |
| Director of Maintenance | Director of Maintenance | Interviewed regarding fire sprinkler removal and lack of environmental surveillance policy. |
| Administrator | Facility Administrator | Interviewed regarding fire safety deficiencies and corrective actions. |
| Site Supervisor | Construction Company Site Supervisor | Interviewed regarding removal of fire sprinklers and smoke detectors during demolition. |
| Concierge #1 | Concierge | Assigned to fire watch during removal plan implementation. |
| Concierge #2 | Concierge | Assigned to fire watch during removal plan implementation. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Oct 5, 2022
Visit Reason
The inspection was a standard and complaint survey triggered by multiple complaints (NJ00136651, NJ00141797, NJ00142731) 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 with licensure standards, with deficiencies including failure to provide required in-service training documentation for employees, failure to notify the Department of Health of a major incident involving a resident, lack of a current dietary manual for staff, and failure to ensure meal menus identified portion sizes.
Complaint Details
The complaint investigation included three complaint numbers (NJ00136651, NJ00141797, NJ00142731). The facility failed to notify the Department of Health of a major incident involving Resident #3, which was substantiated by review of the resident's medical record and interviews.
Deficiencies (4)
| Description |
|---|
| Failure to provide documented evidence that 3 of 6 employees received required in-service training on Assisted Living Concepts, Resident Rights, Infection Control, Abuse and Neglect, Dementia Training, and Pain Management. |
| Failure to notify the Department of Health of a major occurrence involving Resident #3 as required by regulation. |
| Failure to have a current diet manual available for dining service and nursing personnel. |
| Failure to ensure that posted meal menus and menus provided to residents identified portion sizes. |
Report Facts
Employees lacking documented in-service training: 3
Resident census: 34
Sample size: 5
Inspection Report
Routine
Census: 34
Deficiencies: 0
Feb 13, 2022
Visit Reason
A COVID-19 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 for licensure of assisted living residences and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 30
Deficiencies: 1
Nov 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and CDC recommended practices during the COVID-19 pandemic.
Findings
The facility was found to be non-compliant with infection control requirements due to failure to institute universal eye protection for staff when social distancing could not be maintained. Staff and residents were observed and interviewed, confirming lack of eye protection use despite directives. The facility had PPE available but did not enforce the use of eye protection.
Deficiencies (1)
| Description |
|---|
| Failure to institute universal eye protection for staff when six feet of social distancing could not be maintained in resident care areas, affecting 2 residents and 10 staff. |
Report Facts
Census: 30
PPE Inventory: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and observed not wearing eye protection | |
| Infection Preventionist | Interviewed and stated not wearing eye protection | |
| Regional Nurse | Interviewed and stated eye protection directive was a recommendation only | |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed and stated eye protection was only worn when COVID-19 was 'very heavy' |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed and stated eye protection was worn only when there was a positive COVID-19 resident |
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