Inspection Reports for
Complete Care At Barn Hill
249 High Street, Newton, NJ, 07860
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
90% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for privacy practices |
Inspection Report
Annual Inspection
Census: 139
Capacity: 154
Deficiencies: 14
Date: 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.
Complaint Details
Complaint numbers NJ 153633, 154221, 156303, 156873, 156875, 157505, 159374, 163096, 165583, 169091, 174420, 175555 were investigated during the 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.
Deficiencies (14)
Facility failed to code the Minimum Data Set (MDS) accurately for 1 of 28 residents reviewed.
Facility failed to provide pharmaceutical services by ensuring a resident did not receive medication not ordered by the physician.
Facility failed to maintain kitchen equipment in a clean and sanitary manner.
Facility failed to notify CMS and apply for a change in name to include Doing Business As in accordance with 42 CFR 424.516.
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.
Facility failed to provide fire alarm notification by audible and visible signals in the main dining enclosed courtyard.
Facility failed to ensure smoke detection sensitivity testing of smoke detectors was completed as required.
Facility failed to maintain fire sprinkler system and ensure sprinkler heads were free of lint and had escutcheon plates in place.
Facility failed to ensure corridor walls were constructed to resist the passage of smoke; holes were observed above corridor doors.
Facility failed to ensure corridor doors resisted passage of smoke; multiple doors were not latching, had gaps, or were stuck.
Facility failed to ensure resident bathroom ventilation systems were functionally maintained.
Facility failed to ensure annual inspection, testing, and maintenance of fire door assemblies were conducted and documented.
Facility failed to provide electrical policy, conduct maintenance, and maintain records for patient care related electrical equipment.
Report Facts
Census: 139
Total Capacity: 154
Sample Size: 31
Deficiency counts: 14
Staffing ratios: 12
Inspection Report
Routine
Deficiencies: 3
Date: Aug 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, food service sanitation, and proper facility licensing and naming.
Findings
The facility was found deficient in accurately coding resident assessments, maintaining kitchen equipment in a clean and sanitary manner, and failing to notify CMS and apply for a change in the facility's Doing Business As (DBA) name as required by federal regulations.
Deficiencies (3)
Facility failed to code the Minimum Data Set (MDS) accurately for 1 of 28 residents reviewed, incorrectly indicating discharge to hospital instead of home.
Facility failed to maintain kitchen equipment in a clean and sanitary manner, including dirty microwave interior and oven grill plates with solidified grease.
Facility failed to notify CMS and apply for a change in name to include Doing Business As in accordance with 42 CFR 424.516.
Report Facts
Residents reviewed: 28
Cast iron grill plates observed dirty: 3
Facility license expiration date: Mar 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding kitchen equipment sanitation | |
| Regional Food Service Director | Interviewed regarding kitchen equipment sanitation | |
| MDS Coordinator | Interviewed regarding inaccurate MDS coding | |
| Director of Nursing | Informed of MDS coding concerns | |
| Administrator | Informed of MDS coding concerns | |
| Licensed Nursing Home Administration (LNHA) | Interviewed regarding facility name and CMS notification |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 13, 2024
Visit Reason
The inspection was conducted based on a complaint (#NJ00174420) regarding a medication error where a resident received a medication not ordered by the physician.
Complaint Details
Complaint #NJ00174420 regarding medication error where metformin was administered to the wrong resident without a valid physician order. The resident had no negative outcomes and was monitored closely. The nurse responsible was educated and medication pass training was reviewed.
Findings
The facility failed to provide pharmaceutical services by administering metformin to Resident #395 without a valid physician order. The medication error was identified, the resident was monitored with no negative outcomes, and the responsible nurse was educated.
Deficiencies (1)
Failure to provide pharmaceutical services by ensuring the resident did not receive a medication not ordered by the physician (metformin given without valid order).
Report Facts
Residents reviewed for medication management: 28
Medication dose administered: 500
Blood sugar readings: 131
Blood sugar readings: 162
Blood sugar readings: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency LPN #1 nurse | Nurse who accidentally administered metformin to the wrong resident | |
| Unit Manager (UM), LPN #2 | Interviewed regarding the medication error and patient condition | |
| Director of Nursing (DON) | Interviewed regarding the medication error, nurse education, and facility policies |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failure to develop and implement a comprehensive person-centered care plan for Resident #2, inconsistent with facility policy.
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
| Name | Title | Context |
|---|---|---|
| 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
Complaint Investigation
Deficiencies: 1
Date: Apr 9, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ172653) to investigate the facility's failure to develop and implement a Nothing by Mouth (NPO) Care Plan for a resident with a PEG tube.
Complaint Details
Complaint NJ172653 was substantiated based on interviews, medical record review, and facility document review conducted on 04/08/2024 and 04/09/2024, confirming the deficiency related to Resident #2's care plan.
Findings
The facility failed to develop and implement an NPO Care Plan for Resident #2, who had a PEG tube and was admitted with NPO status. Interviews and record reviews confirmed the absence of the required care plan despite documentation of the resident's NPO status and staff awareness.
Deficiencies (1)
Failure to develop and implement a complete NPO Care Plan for Resident #2 with a PEG tube.
Report Facts
Residents reviewed for care plans: 3
Brief Interview of Mental Status (BIMS) score: 3
Care Plan initiation date: Feb 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding the absence of the NPO care plan for Resident #2 | |
| Certified Nursing Aide (CNA) | Interviewed about awareness of Resident #2's NPO status | |
| Assistant Director of Nursing (ADON) | Interviewed about the purpose of the care plan and confirmed absence of NPO care plan for Resident #2 |
Inspection Report
Abbreviated Survey
Census: 144
Deficiencies: 0
Date: 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
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of the nursing home facility Complete Care at Barn Hill.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 138
Capacity: 154
Deficiencies: 16
Date: 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.
Deficiencies (16)
Failed to provide full visual privacy and maintain confidentiality during medication administration and physical assessment for Resident #116.
Failed to notify resident families, representatives, and Ombudsman in writing for facility-initiated hospital transfers for 6 residents.
Failed to follow physician's orders and handle medication appropriately for Residents #81 and #115.
Failed to provide necessary respiratory care and services consistent with professional standards for Resident #15.
Failed to ensure that residents' primary physicians signed and dated monthly physician orders for 16 residents.
Failed to properly label and date medications in medication carts and storage rooms.
Failed to consistently provide coordination between facility staff and hospice agency staff to meet resident's nursing needs for Resident #366.
Failed to implement infection control procedures properly during urinary drainage bag changes, medication administration, and wound care.
Failed to maintain emergency lighting above fire pump transfer switch and emergency generator transfer switch.
Failed to provide illuminated exit signs at two exit access doors in enclosed courtyard.
Failed to provide fire alarm notification by audible and visible signals in enclosed courtyard.
Failed to maintain sprinkler system by not performing monthly electric fire pump test and five-year internal obstruction inspection.
Failed to ensure corridor doors resist passage of smoke due to hardware malfunctions and improper latching in 7 resident rooms.
Failed to ensure resident bathroom ventilation systems were functioning in 34 of 47 units.
Failed to conduct fire drills at varied/unexpected times on all shifts.
Failed to provide remote manual stop station for generator to prevent inadvertent operation.
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
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and eye drop administration findings |
| LPN #2 | Licensed Practical Nurse | Named in wound care and medication administration findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including transfers, medication, hospice, and staffing |
| Maintenance Director | Maintenance Director | Interviewed and observed regarding life safety code deficiencies including emergency lighting, fire alarm, sprinkler system, corridor doors, ventilation, and generator |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 10, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident privacy, notification of transfers, medication administration, respiratory care, physician order signatures, medication labeling, hospice care coordination, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during medication administration, failure to provide written notification of hospital transfers to families and ombudsman, failure to follow physician orders for repositioning and medication administration, failure to provide appropriate respiratory care and CPAP equipment cleaning, failure to ensure physicians signed monthly orders, improper medication labeling and storage, inadequate hospice documentation, and lapses in infection control practices during wound care, medication administration, and urinary drainage bag changes.
Deficiencies (9)
Failed to provide full visual privacy and maintain confidentiality during medication administration and physical assessment for Resident #116.
Failed to notify resident families, representatives, and Ombudsman in writing for facility-initiated hospital transfers for 6 residents.
Failed to follow physician's orders for repositioning Resident #115 and failed to handle medication administration appropriately for Residents #115 and #81.
Failed to provide necessary respiratory care and services including cleaning CPAP equipment for Resident #15.
Failed to ensure physicians signed and dated monthly physician orders for 16 residents.
Failed to properly label and date medications in medication carts and storage rooms, including insulin vials and pens.
Failed to consistently provide coordination and documentation between facility staff and hospice agency staff for Resident #366.
Failed to implement infection control procedures properly during wound care, medication administration, and urinary drainage bag changes.
Used the same tissue for both eyes when administering eye drops to Resident #116.
Report Facts
Residents reviewed: 24
Residents with unsigned physician orders: 16
Residents affected by hospital transfer notification deficiency: 6
Medication carts inspected: 8
Medication storage rooms inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in medication administration and privacy deficiency findings | |
| Licensed Practical Nurse (LPN) #2 | Named in repositioning, respiratory care, wound care, and infection control deficiency findings | |
| Licensed Practical Nurse Unit Manager (LPNUM) | Interviewed regarding respiratory care and physician order signing process | |
| Director of Nursing (DON) | Interviewed and involved in discussions of multiple deficiencies | |
| Administrator | Interviewed and involved in discussions of multiple deficiencies | |
| Regional Clinical Specialist | Interviewed and involved in discussions of multiple deficiencies | |
| Regional Administrator | Interviewed and involved in discussions of multiple deficiencies | |
| Certified Nursing Assistant (CNA) | Observed and interviewed regarding urinary drainage bag change and infection control | |
| Registered Nurse Supervisor (RNS) | Spoke with surveyor regarding hospice documentation requirements |
Inspection Report
Routine
Census: 102
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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.
Complaint Details
This was a complaint visit and the facility was found to be in compliance based on this complaint visit.
Findings
The facility was found to be in compliance with the regulatory requirements during this complaint investigation.
Report Facts
Sample Size: 5
Inspection Report
Deficiencies: 2
Date: Nov 20, 2019
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration for pain management and food safety practices in the nursing facility.
Findings
The facility failed to follow physician's orders for administering pain medication to a resident, resulting in minimal harm or potential for harm. Additionally, the facility failed to properly prepare, sanitize, and store food and dishware, posing a risk for foodborne illness.
Deficiencies (2)
Failure to follow physician's orders for administering medication to treat varying pain levels for Resident #46.
Failure to prepare potentially hazardous foods properly, failure to sanitize and air dry dishware, steam table pans, and silverware, and failure to store potentially hazardous foods properly.
Report Facts
Deficiencies cited: 2
Medication dosage: 650
Date of medication order: Sep 4, 2019
Date of inspection: Nov 20, 2019
Milk expiration date: Nov 11, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Informed by surveyor about medication administration deficiency | |
| Food Service Director | Present during food safety observations | |
| Resident #46's nurse | Interviewed regarding pain medication administration |
Viewing
Loading inspection reports...
