Inspection Reports for Complete Care At Court House, Llc
144 Magnolia Drive, NJ, 08210
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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 regarding the notice |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 120
Deficiencies: 7
Mar 13, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey was complaint-driven with multiple complaint numbers referenced.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper medication administration, prevention of pressure ulcers, infection control, and life safety code compliance. Deficiencies were identified in environmental cleanliness, medication pass procedures, pressure ulcer prevention, infection control practices, and fire safety exit door hardware.
Complaint Details
Complaint numbers NJ 163463, 164350, 169831, 173198, 174555 were investigated. The survey was complaint-driven and focused on multiple areas including staffing, environment, medication administration, pressure ulcer prevention, infection control, and life safety.
Severity Breakdown
E: 1
D: 4
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean and sanitary environment in 2 of 2 units. | E |
| Facility failed to ensure proper administration of medication during medication pass observation for 1 of 5 residents observed. | D |
| Facility failed to follow a physician's order to promote the prevention of pressure ulcers for 1 of 1 resident reviewed. | D |
| Facility failed to properly store medication for 1 of 25 residents reviewed. | D |
| Facility failed to use appropriate infection control practices to prevent the potential spread of infection. | D |
| Facility failed to ensure one out of four exit discharges was equipped with illumination in accordance with NFPA 101 Life Safety Code. | F |
| Facility failed to ensure two of nine fire rated door assemblies for stairway exit doors were equipped with approved fire exit hardware. | F |
Report Facts
Census: 106
Total Capacity: 120
Deficiency counts: 7
Staffing Deficiencies: 7
Residents reviewed for medication storage: 25
Residents reviewed for infection control: 2
Residents reviewed for pressure ulcer prevention: 1
Inspection Report
Routine
Census: 98
Capacity: 101
Deficiencies: 11
Feb 2, 2023
Visit Reason
Routine standard survey conducted 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 incontinence care, nutritional management, dialysis, infection control, food safety, garbage disposal, infection prevention, resident call system, staffing ratios, and life safety code requirements related to fire alarm, sprinkler, and electrical systems.
Severity Breakdown
SS=D: 6
SS=F: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure catheter bags were kept off the floor and proper continence care was provided. | SS=D |
| Failure to ensure nutritional formula and enteral feeding were properly managed and labeled. | SS=D |
| Failure to ensure dialysis services were provided consistent with professional standards and resident preferences. | SS=D |
| Failure to maintain kitchen sanitation including proper hair net use, food labeling, storage, and temperature control. | SS=F |
| Failure to properly cover garbage dumpsters to prevent access by rodents and pests. | SS=D |
| Failure to ensure proper use of personal protective equipment (PPE) on a COVID-19 designated unit and failure to maintain catheter bags off the floor. | SS=D |
| Failure to ensure resident call system was intact, functioning properly, and accessible in all resident rooms. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey. | — |
| Failure to complete smoke detection sensitivity testing for all photo electric smoke detectors as required by NFPA 72. | SS=F |
| Failure to ensure sprinkler coverage was provided under exit staircase landings for all stairways. | SS=F |
| Failure to provide a remote emergency stop switch for the 250 KW diesel emergency generator as required by NFPA 110. | SS=F |
Report Facts
Census: 98
Total Capacity: 101
Deficiency counts: 11
Staffing ratios: 7
Staffing ratios: 12
Staffing ratios: 4
Staffing ratios: 6
Staffing ratios: 6
Staffing ratios: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed failing to wear full PPE on COVID-19 designated unit. |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed regarding PPE requirements and confirmed COVID-19 room designation. |
| Maintenance Director | Interviewed regarding fire safety, sprinkler coverage, generator remote stop switch, and kitchen sanitation. | |
| Administrator | Interviewed regarding PPE compliance and call bell system maintenance. | |
| Human Resource/Staffing Coordinator | Interviewed regarding staffing shortages and recruitment efforts. |
Document
Deficiencies: 0
Jul 26, 2022
Visit Reason
Document is not related to regulatory oversight or inspection; it is a prompt to open the PDF portfolio in specific software.
Findings
No inspection or regulatory content present; document only contains instructions to open the PDF portfolio.
Inspection Report
Routine
Census: 81
Deficiencies: 0
Sep 8, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Aug 10, 2021
Visit Reason
The inspection was conducted based on complaint NJ146424 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to develop and implement comprehensive person-centered care plans for 2 of 3 residents reviewed, specifically Resident #1 and Resident #3, with missing care plans for certain diagnoses and failure to follow the facility's own care plan policy.
Complaint Details
Complaint NJ146424 triggered the visit. The facility was found not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a comprehensive care plan for Resident #1 and Resident #3 consistent with their diagnoses and facility policy. | SS=D |
Report Facts
Sample Size: 3
Residents identified as diabetic: 28
Diabetic residents with appropriate care plans: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed and updated care plans for Resident #1 and Resident #3; stated that the care plan policy was not followed | |
| MDS Coordinator | Interviewed and stated that care plans should be developed for residents receiving certain treatments and diagnoses | |
| Administrator | Conducted audit and reeducation of interdisciplinary team on care plan policy and procedures | |
| RNAC | Will conduct weekly audits on new admissions to assure accuracy of care plans |
Inspection Report
Routine
Census: 86
Deficiencies: 0
Aug 4, 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: 89
Deficiencies: 0
May 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00143872 and NJ00143772.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ00143872 and NJ00143772 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 1
Feb 10, 2021
Visit Reason
The inspection was a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent foodborne illness. Specific issues included uncovered disposable cups, inadequate sanitizer concentration, and unclean kitchen equipment.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including uncovered disposable cups, sanitizer solution at 0 ppm instead of required 200 ppm, and food debris on kitchen equipment. | SS=E |
Report Facts
Census: 93
Sanitizer concentration increase: 200
Sample size: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Interviewed regarding food safety and sanitation deficiencies |
Inspection Report
Life Safety
Deficiencies: 1
Feb 10, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012, specifically focusing on the facility's cooking facilities and fire safety measures.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements due to deficiencies in the cooking facilities. Specifically, 5 of 7 exhaust hood grease baffles were improperly positioned with gaps and bent frames, posing a fire hazard by allowing grease and fire to enter above the exhaust hood system.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Five of seven exhaust hood grease baffles over the main cooking area had gaps and bent frames, failing to protect against grease and fire entering above the exhaust hood system as per NFPA 96. | SS=D |
Report Facts
Exhaust hood grease baffles improperly positioned: 5
Total exhaust hood grease baffles: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview regarding the grease baffle deficiencies. | |
| Facility Administrator | Present during observation and interview regarding the grease baffle deficiencies. | |
| Dietary Director | Present during observation and interview regarding the grease baffle deficiencies and received education on maintenance requests. |
Inspection Report
Routine
Census: 101
Deficiencies: 0
Jan 14, 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
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