Alaris Health at Cedar Grove

In the surveyor’s words

From the most serious findings on record at Alaris Health at Cedar Grove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 20, 2023

  Based on interview, record review and review of pertinent documents, it was determined that the facility failed to protect a resident (Resident #182) from abuse by a Certified Nurse Aide (CNA #1) by failing to ensure: a.) the facility policy was followed to identify an allegation of abuse, b.) that upon receiving an allegation of abuse on 01/17/23 during the 7:00 AM to 3:00 PM shift, the facility immediately protected Resident #182, and other residents from potential abuse, and c.) a thorough investigation was immediately initiated. This deficient practice occurred for 1 of 2 residents reviewed for abuse, and on 1 of 4 resident units. […]

• Actual harm, isolatedF689Jan 20, 2023

  Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) provide adequate supervision, b.) follow the facility accident policy and initiate new fall prevention interventions in response to falls, and c.) implement existing interventions to prevent falls (5 of 6 falls reviewed were determined that the resident was left unsupervised). These failures resulted in Resident #92 sustaining multiple falls including a fall on 11/08/21 that required an emergency room transfer on 11/08/21, when Resident #92 fell out of a wheelchair, hit a tray table, sustained a laceration to the right frontal scalp, and was admitted to the hospital with a mechanical fall with head trauma and laceration without obvious intracranial… […]

• No harm, potential for more than minimal, widespreadF607Jan 20, 2023

  Based on interview, and review of pertinent documents it was determined that the facility failed to have written procedures in place to ensure: a.) all residents were protected from abuse when an allegation of staff to resident abuse occurred, b.) a process was in place for identifying other potential victims of abuse, and c.) a process to ensure all potential witnesses/persons aware of the allegation were interviewed. This deficient practice was evidenced for 4 of 4 resident units, and for 1 of 2 residents reviewed for abuse, and occurred when an allegation of abuse by a Certified Nurse Aide (CNA #1) against a resident (Resident #182) was received on 01/17/23 and CNA #1 proceeded to work a resident care shift the following day, 01/18/23, and had access to Resident #182 and other residents… […]

• No harm, potential for more than minimal, patternF842Sep 18, 2025

  REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to maintain and provide readily accessible medical documents for 1 (one) of 32 residents (Resident #4) reviewed for medical records. This deficient practice was evidenced by the following: On 9/11/25 at 11:42 AM, the surveyor observed Resident #4 in bed, awake, and able to answer the surveyor's inquiry. On 9/16/25 at 10:54 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #4 was admitted with diagnoses that included but were not limited to diabetes mellitus (increased blood sugar level) due to… […]

• No harm, potential for more than minimal, patternF607Jul 9, 2024

  Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of five (5) newly hired licensed staff reviewed, (Staff #5, #8 and #10). This deficient practice was evidenced by the following: 1. On On 6/27/24 at 12:00 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Staff #5, a Social Worker, hired 8/21/23, had a New Jersey Division Consumer Affairs license verification printout was dated 10/02/23. The verification was completed after the staff member was hired. […]