Inspection Reports for Complete Care At Barn Hill

249 High Street, NJ, 07860

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Notice Deficiencies: 0 Nov 20, 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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees Mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer and contact person for privacy practices
Inspection Report Annual Inspection Census: 139 Capacity: 154 Deficiencies: 14 Aug 13, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to accuracy of assessments, pharmacy services, food safety, licensure compliance, staffing ratios, and multiple life safety code violations including fire safety, hazardous area enclosures, fire alarm system installation and maintenance, sprinkler system maintenance, corridor construction, corridor doors, HVAC ventilation, door maintenance, and electrical equipment testing.
Complaint Details
Complaint numbers NJ 153633, 154221, 156303, 156873, 156875, 157505, 159374, 163096, 165583, 169091, 174420, 175555 were investigated during the survey.
Severity Breakdown
SS=D: 2 SS=F: 10 SS=C: 1
Deficiencies (14)
DescriptionSeverity
Facility failed to code the Minimum Data Set (MDS) accurately for 1 of 28 residents reviewed.SS=D
Facility failed to provide pharmaceutical services by ensuring a resident did not receive medication not ordered by the physician.SS=D
Facility failed to maintain kitchen equipment in a clean and sanitary manner.SS=F
Facility failed to notify CMS and apply for a change in name to include Doing Business As in accordance with 42 CFR 424.516.SS=C
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Facility failed to ensure fire-rated doors to hazardous areas were self-closing, labeled, and separated by smoke resisting partitions.SS=F
Facility failed to provide fire alarm notification by audible and visible signals in the main dining enclosed courtyard.SS=F
Facility failed to ensure smoke detection sensitivity testing of smoke detectors was completed as required.SS=F
Facility failed to maintain fire sprinkler system and ensure sprinkler heads were free of lint and had escutcheon plates in place.SS=F
Facility failed to ensure corridor walls were constructed to resist the passage of smoke; holes were observed above corridor doors.SS=F
Facility failed to ensure corridor doors resisted passage of smoke; multiple doors were not latching, had gaps, or were stuck.SS=F
Facility failed to ensure resident bathroom ventilation systems were functionally maintained.SS=F
Facility failed to ensure annual inspection, testing, and maintenance of fire door assemblies were conducted and documented.SS=F
Facility failed to provide electrical policy, conduct maintenance, and maintain records for patient care related electrical equipment.SS=F
Report Facts
Census: 139 Total Capacity: 154 Sample Size: 31 Deficiency counts: 14 Staffing ratios: 12
Inspection Report Complaint Investigation Census: 140 Deficiencies: 2 Apr 9, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ172653 to investigate allegations related to the facility's compliance with care planning and staffing requirements.
Findings
The facility was found not in substantial compliance due to failure to develop and implement a comprehensive person-centered care plan for one resident and failure to meet required staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed.
Complaint Details
Complaint #NJ172653 was substantiated based on findings that the facility failed to develop and implement a comprehensive care plan for one resident and failed to meet CNA staffing requirements on multiple days.
Severity Breakdown
SS=D: 1
Deficiencies (2)
DescriptionSeverity
Failure to develop and implement a comprehensive person-centered care plan for Resident #2, inconsistent with facility policy.SS=D
Failure to ensure staffing ratios were met for CNAs on 14 of 14 day shifts reviewed.
Report Facts
Census: 140 Sample Size: 3 Deficient CNA staffing days: 14 CNA staffing counts: 9 CNA staffing counts: 12 CNA staffing counts: 16 CNA staffing counts: 14.5 CNA staffing counts: 16.5 CNA staffing counts: 12.5 CNA staffing counts: 14 CNA staffing counts: 15 CNA staffing counts: 12 CNA staffing counts: 15 CNA staffing counts: 15 CNA staffing counts: 17 CNA staffing counts: 11.5 CNA staffing counts: 7
Employees Mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Interviewed regarding care plan for Resident #2
Certified Nursing Aide (CNA)Interviewed regarding care plan implementation for Resident #2
Assistant Director of Nursing (ADON)Interviewed regarding care plan requirements and deficiencies
Director of Nursing (DON)In-serviced staffing coordinator on staffing levels and involved in monitoring plan of correction
Inspection Report Abbreviated Survey Census: 144 Deficiencies: 0 Feb 9, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report Routine Census: 138 Capacity: 154 Deficiencies: 16 Mar 10, 2022
Visit Reason
Routine standard survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including privacy violations, failure to notify families and Ombudsman of transfers, medication administration errors, respiratory care deficiencies, physician order signing, medication labeling and storage issues, hospice care coordination, infection control lapses, staffing shortages, and life safety code violations including emergency lighting, exit signage, fire alarm system, sprinkler system maintenance, corridor door functionality, HVAC ventilation, fire drills, and generator safety.
Severity Breakdown
SS=D: 7 SS=E: 5 SS=F: 4
Deficiencies (16)
DescriptionSeverity
Failed to provide full visual privacy and maintain confidentiality during medication administration and physical assessment for Resident #116.SS=D
Failed to notify resident families, representatives, and Ombudsman in writing for facility-initiated hospital transfers for 6 residents.SS=D
Failed to follow physician's orders and handle medication appropriately for Residents #81 and #115.SS=D
Failed to provide necessary respiratory care and services consistent with professional standards for Resident #15.SS=D
Failed to ensure that residents' primary physicians signed and dated monthly physician orders for 16 residents.SS=F
Failed to properly label and date medications in medication carts and storage rooms.SS=D
Failed to consistently provide coordination between facility staff and hospice agency staff to meet resident's nursing needs for Resident #366.SS=D
Failed to implement infection control procedures properly during urinary drainage bag changes, medication administration, and wound care.SS=E
Failed to maintain emergency lighting above fire pump transfer switch and emergency generator transfer switch.SS=F
Failed to provide illuminated exit signs at two exit access doors in enclosed courtyard.SS=E
Failed to provide fire alarm notification by audible and visible signals in enclosed courtyard.SS=E
Failed to maintain sprinkler system by not performing monthly electric fire pump test and five-year internal obstruction inspection.SS=F
Failed to ensure corridor doors resist passage of smoke due to hardware malfunctions and improper latching in 7 resident rooms.SS=E
Failed to ensure resident bathroom ventilation systems were functioning in 34 of 47 units.SS=E
Failed to conduct fire drills at varied/unexpected times on all shifts.SS=F
Failed to provide remote manual stop station for generator to prevent inadvertent operation.SS=F
Report Facts
Census: 138 Total Capacity: 154 Deficiency count: 16 Staffing Deficiency Days: 14 Resident Rooms with Door Issues: 7 Resident Bathrooms without Ventilation: 34
Employees Mentioned
NameTitleContext
LPN #1Licensed Practical NurseNamed in medication administration and eye drop administration findings
LPN #2Licensed Practical NurseNamed in wound care and medication administration findings
Director of NursingDirector of NursingInterviewed regarding multiple deficiencies including transfers, medication, hospice, and staffing
Maintenance DirectorMaintenance DirectorInterviewed and observed regarding life safety code deficiencies including emergency lighting, fire alarm, sprinkler system, corridor doors, ventilation, and generator
Inspection Report Routine Census: 102 Deficiencies: 0 Sep 28, 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 Abbreviated Survey Census: 111 Deficiencies: 0 Aug 31, 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 related to COVID-19.
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 to prepare for COVID-19.
Report Facts
Sample Size: 17
Inspection Report Routine Census: 114 Deficiencies: 0 Mar 29, 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 Complaint Investigation Census: 106 Deficiencies: 0 Feb 16, 2021
Visit Reason
The inspection was conducted based on a complaint visit to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in compliance with the regulatory requirements during this complaint investigation.
Complaint Details
This was a complaint visit and the facility was found to be in compliance based on this complaint visit.
Report Facts
Sample Size: 5

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