Inspection Reports for
Complete Care At Fair Lawn Edge

NJ, 07514

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 14.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

173% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

32 24 16 8 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 86% occupied

Based on a April 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Jan 2021 Apr 2021 Jan 2022 Feb 2022 Jun 2023 Apr 2024

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Dec 29, 2025

Visit Reason
The inspection was conducted based on Complaint #2693362 to investigate the facility's procedure for safely acquiring and receiving physician-ordered Methadone from a third-party clinic.

Complaint Details
Complaint #2693362 was substantiated based on observations, interviews, and document reviews that CNA #1, an unlicensed staff member, was assigned to pick up Methadone from a third-party clinic without a proper facility policy in place.
Findings
The facility failed to develop and implement a proper procedure for safely acquiring Methadone, as an unlicensed Certified Nursing Assistant (CNA #1) was assigned to pick up Methadone from an outside clinic and transport it in her personal car. The facility lacked a specific policy for this process and relied on a general narcotic policy, which does not authorize CNAs to handle narcotics.

Deficiencies (1)
Failure to develop and implement a procedure to safely acquire and receive physician ordered Methadone from a third party clinic by assigning an unlicensed CNA to pick up Methadone.
Report Facts
Dates of Methadone pick-up by CNA #1: From 2025-11-19 until 2025-12-15

Employees mentioned
NameTitleContext
CNA #1Certified Nursing AssistantAssigned to pick up Methadone from third-party clinic despite being unlicensed to handle narcotics.
Director of NursingDirector of NursingConfirmed lack of specific policy and described Methadone pick-up process.
RN #1Registered NurseStated that CNAs should not pick up or handle narcotics because they are not licensed.
Licensed Nursing Home AdministratorLicensed Nursing Home AdministratorConfirmed absence of specific policy for Methadone pick-up and reliance on general narcotic policy.
Consultant PharmacistConsultant PharmacistStated Methadone Clinic was not under his jurisdiction.

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 explains 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
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Complaint Investigation
Deficiencies: 5 Date: Aug 18, 2025

Visit Reason
The inspection was conducted to investigate complaints regarding failure to issue required Medicare Non-coverage notices, unsafe and unclean facility environment, failure to follow physician orders for medication administration, failure to provide treatment as per hospital discharge orders, and infection control deficiencies.

Complaint Details
The complaint investigation focused on issues including failure to issue Medicare Non-coverage notices, unsafe and unclean environment, medication administration errors, failure to provide ordered treatments and follow-ups, and infection control lapses. The findings were substantiated with observations, interviews, and record reviews.
Findings
The facility was found deficient in issuing the Notice of Medicare Non-coverage for one resident, maintaining a safe and clean environment in shower rooms and linen areas, following physician orders for medication administration for two residents, providing appropriate treatment and follow-up care for one resident, and implementing proper infection prevention and control practices related to linen handling and garbage disposal.

Deficiencies (5)
Failure to issue the Notice of Medicare Non-coverage (NOMNC) for Resident #182 as required.
Facility failed to maintain a safe, clean, and homelike environment in shower rooms and linen areas, including stained tiles, peeling safety strips, dirty vents, and uncovered clean linens.
Failure to consistently follow physician orders for medication administration and clarify orders for Residents #19 and #21.
Failure to ensure Resident #169 received treatment and care as specified by hospital discharge orders, including missed pulmonology follow-up and CT scan.
Failure to provide and implement an infection prevention and control program, including improper handling and storage of linen and laundry and improper disposal of garbage.
Report Facts
Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents present: 10 Stage 4 pressure ulcer size: 2

Employees mentioned
NameTitleContext
Director of Social ServicesInterviewed regarding NOMNC form for Resident #182
Licensed Nursing Home Administrator (LNHA)Interviewed regarding NOMNC form and other findings
Director of Nursing (DON)Interviewed regarding NOMNC form and medication administration
Housekeeping Director (HD)Provided observations on facility cleanliness and environment
Registered Nurse/Unit Manager (RN/UM)Interviewed regarding facility environment and medication administration
Licensed Practical Nurse/Unit Manager (LPN/UM)Observed medication administration and interviewed regarding medication orders
Assistant Director of Nursing (ADON)Interviewed regarding medication administration and facility environment
President of Clinical Services (VPoCS)Interviewed regarding facility environment and medication administration
Infection Preventionist Nurse/Licensed Practical Nurse (IPN/LPN)Interviewed regarding infection control findings
Regional Registered Nurse (RRN)Present during infection control interview

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Apr 23, 2024

Visit Reason
The inspection was conducted following complaints regarding elopement incidents involving residents, specifically Resident #353 and Resident #355, to investigate the facility's supervision and security measures to prevent elopements.

Complaint Details
Complaint #NJ 165064 and Complaint #NJ 166666 triggered the investigation. The complaints involved inadequate supervision and unsecured exit doors leading to elopements of residents #353 and #355. The Immediate Jeopardy related to Resident #353's elopement was corrected on 06/16/2023. Resident #355 eloped on 08/17/2023 and was arrested, not returning to the facility.
Findings
The facility failed to provide adequate supervision and secure exit doors, resulting in two residents eloping from the facility. An Immediate Jeopardy (IJ) situation was identified related to Resident #353's elopement on 06/15/2023, which was corrected prior to the annual survey. Resident #355 eloped on 08/17/2023 due to a breakdown in communication and policy adherence regarding out-of-pass privileges and supervision.

Deficiencies (1)
Failure to provide adequate supervision for cognitively impaired, exit-seeking residents and failure to ensure exit doors were securely locked, resulting in elopements of Resident #353 and Resident #355.
Report Facts
Elopement risk score: 7 Date of Resident #353 elopement: Jun 15, 2023 Date of Resident #355 elopement: Aug 17, 2023

Employees mentioned
NameTitleContext
LPN #5Licensed Practical NurseDocumented and reported on Resident #353's elopement and care.
Receptionist #1Reported Resident #353's elopement to nursing staff and assisted with search.
Receptionist #2Described out-of-pass procedures and smoking area policies.
Director of NursingDONProvided investigation report and interviews regarding Resident #355 elopement and facility policies.
Licensed Nursing Home AdministratorLNHAParticipated in interviews and meetings regarding elopement incidents and corrective actions.

Inspection Report

Annual Inspection
Deficiencies: 11 Date: Apr 23, 2024

Visit Reason
The inspection was conducted as part of the annual recertification survey and complaint investigations to assess compliance with nursing facility regulations and standards.

Findings
The facility was found deficient in multiple areas including medication administration practices, dialysis medication scheduling, oxygen administration, timely implementation of dietician recommendations, pressure ulcer care and infection control, supervision to prevent resident elopement, physician progress note documentation, medication storage and labeling, dental care provision, and kitchen sanitation practices.

Deficiencies (11)
Medication improperly prepared for administration for multiple residents with unlabeled medication cups and failure to sign out narcotics.
Failure to adjust medication times to accommodate resident dialysis schedules.
Oxygen administered at incorrect flow rate contrary to physician's order.
Failure to timely act on Registered Dietician recommendations for tube feeding resident.
Inadequate infection control practices during pressure ulcer treatment and failure to perform quarterly pressure ulcer risk assessments.
Failure to provide adequate supervision and secure exit doors resulting in resident elopements.
Physician failed to document monthly progress notes for multiple residents over several months.
Medication stored without proper labeling and dating, specifically an opened bottle of Acetylcysteine 20%.
Failure to provide mandatory annual dental care services for a resident.
Failure to maintain proper kitchen sanitation practices including improper thermometer disinfection and improper storage of food items.
Failure to maintain proper hand hygiene during medication administration by nursing staff.
Report Facts
Residents affected: 4 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 2 Residents reviewed: 31 Residents affected: 1 Residents affected: 1 Nurses observed: 3

Employees mentioned
NameTitleContext
LPN #2Licensed Practical NurseNamed in medication preparation deficiency and narcotic inventory issue
Director of NursingDirector of NursingDiscussed medication administration and oxygen administration deficiencies
LPN #3Licensed Practical NurseObserved for improper hand hygiene during medication administration
LPN #4Licensed Practical NurseObserved for improper hand hygiene during medication administration
LPN #5Licensed Practical NurseInvolved in resident elopement incident and investigation
Physician #1PhysicianPrimary physician with deficient documentation of progress notes
Food Service DirectorFood Service DirectorDiscussed kitchen sanitation and food storage deficiencies

Inspection Report

Annual Inspection
Census: 154 Capacity: 179 Deficiencies: 7 Date: Apr 23, 2024

Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.

Complaint Details
Multiple complaints (NJ165064, NJ167260, NJ167255, NJ170551, NJ167044, NJ169248) were investigated during the survey. The Immediate Jeopardy was related to resident elopement and inadequate supervision.
Findings
Deficiencies were cited including Immediate Jeopardy for failure to provide adequate supervision to prevent resident elopement, medication preparation errors, failure to follow physician orders, infection control lapses, inadequate staffing, and sprinkler system inspection deficiencies.

Deficiencies (7)
Failure to provide adequate supervision to prevent resident elopement resulting in Immediate Jeopardy.
Failure to adhere to professional nursing standards including improper medication preparation and administration.
Failure to maintain infection control practices including hand hygiene and wound care.
Failure to maintain proper kitchen sanitation and food storage practices.
Failure to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failure to ensure five-year internal obstruction inspection of the automatic sprinkler system was conducted.
Failure to ensure physician monthly progress notes were completed for residents.
Report Facts
Census: 154 Total Capacity: 179 Deficiencies cited: 7 Staffing ratios: 9 Staffing ratios: 7 Staffing ratios: 9 Staffing ratios: 11 Staffing ratios: 6 Staffing ratios: 16 Staffing ratios: 11

Employees mentioned
NameTitleContext
LPN #2Licensed Practical NurseNamed in medication preparation and administration deficiencies
LPN #3Licensed Practical NurseNamed in hand hygiene deficiency
LPN #4Licensed Practical NurseNamed in hand hygiene deficiency
LPN #5Licensed Practical NurseNamed in resident elopement investigation
Physician #1Primary PhysicianNamed in failure to document monthly progress notes
Director of NursingDirector of NursingNamed in multiple corrective action plans and staff education
Maintenance DirectorMaintenance DirectorNamed in sprinkler system inspection deficiency

Inspection Report

Complaint Investigation
Census: 133 Deficiencies: 1 Date: Jun 16, 2023

Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers between 06/13/2023 and 06/16/2023.

Complaint Details
Complaint numbers NJ00157832, NJ00160960, NJ00160774, NJ00153648, NJ00163667, and NJ00154349 were investigated. The facility was found deficient in staffing ratios but was in substantial compliance overall. The deficiencies had the potential to affect all residents.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code staffing requirements due to failure to meet minimum staff-to-resident ratios on numerous day, evening, and overnight shifts across multiple weeks. The deficiencies had the potential to affect all residents. The facility submitted a plan of correction and was found to be in substantial compliance at the time of the complaint visit.

Deficiencies (1)
Failure to ensure staffing ratios were met for 68 of 70 day shifts, 5 of 70 evening shifts, and 11 of 70 overnight shifts, violating minimum staffing requirements for CNAs and direct care staff.
Report Facts
Survey Census: 133 Sample Size: 8 Staffing Deficiency Counts: 68 Staffing Deficiency Counts: 5 Staffing Deficiency Counts: 11

Inspection Report

Routine
Census: 111 Capacity: 180 Deficiencies: 16 Date: Feb 23, 2022

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Findings
Deficiencies were cited related to safe environment, comprehensive assessments, medication administration, behavior monitoring, infection control, staffing, and life safety code compliance.

Deficiencies (16)
Facility failed to maintain a safe, clean, comfortable environment; observed torn and soiled resident equipment.
Failed to complete timely comprehensive and quarterly Minimum Data Set (MDS) assessments for multiple residents.
Failed to follow professional standards for medication administration including crushing non-crushable meds, inaccurate documentation, and improper disposal.
Failed to provide personal grooming care to a dependent resident.
Failed to follow physician orders for administration of medication and failed to monitor for side effects.
Failed to post oxygen therapy signage and properly store oxygen equipment.
Failed to consistently document and monitor behaviors for residents on psychotropic medications.
Expired biological drugs and supplies found in crash cart.
Improper hand hygiene and improper use of N95 masks by staff.
Failed to maintain required minimum direct care staff to resident ratios for day, evening, and night shifts.
Failed to provide emergency lighting above generator transfer switches.
Fire alarm system in trouble mode; monthly firefighter service test not performed.
Failed to maintain sprinkler system; fire pump not tested under emergency power annually.
Packaged Terminal Air Conditioner (PTAC) units had clogged, dirty, or missing filters.
Elevators not inspected and tested monthly as required.
Generator transfer time not certified within 10 seconds; no remote manual stop station for generator.
Report Facts
Deficiencies cited: 16 Residents present: 111 Total licensed beds: 180 Staffing ratios: 14 Staffing ratios: 8 Staffing ratios: 11 Staffing ratios: 10 Staffing ratios: 7

Employees mentioned
NameTitleContext
RN #3Registered NurseFailed to administer medication but signed MAR; did not clarify order.
LPN #1Licensed Practical NurseCrushed non-crushable medication; improper medication disposal.
LPN #2Licensed Practical NurseAdministered crushed medication; educated after survey.
DONDirector of NursingAcknowledged delays in medication clarification and monitoring; provided policies and education.
ADONAssistant Director of NursingConducted audits and in-services on medication administration and infection control.
Regional Plant Operations DirectorMaintenance DirectorObserved fire alarm trouble and generator issues; coordinated repairs.
CNACertified Nursing AssistantImproper use of masks; educated after observation.

Inspection Report

Routine
Deficiencies: 13 Date: Feb 11, 2022

Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including care, medication administration, infection control, and documentation.

Findings
The facility was found deficient in multiple areas including failure to maintain clean and safe equipment, incomplete and untimely resident assessments, medication administration errors including crushing a non-crushable medication and failure to clarify orders, incomplete behavior monitoring documentation, failure to provide adequate personal care, improper storage and labeling of oxygen equipment, expired emergency supplies, and improper infection control practices including improper use of PPE.

Deficiencies (13)
Failure to maintain a resident's wheelchair and cushion in a clean and homelike manner.
Failure to complete Comprehensive and Quarterly Minimum Data Set (MDS) assessments timely for multiple residents.
Failure to properly monitor and document behavioral symptoms for residents on psychotropic medications.
Failure to provide personal grooming care to a resident dependent on staff for hygiene.
Failure to follow physician orders for administration of Ozempic, including delay in treatment and failure to assess for first dose response.
Failure to clarify medication order from Medical Director when unable to reach ordering physician.
Failure to provide pharmaceutical services ensuring accurate medication administration and pharmacist oversight.
Failure to complete behavior monitoring forms and monthly psychotropic notes as required.
Failure to ensure behavior monitoring forms are consistent with monthly psychotropic notes.
Failure to ensure expired biological drugs and supplies were removed from the crash cart.
Failure to store respiratory care equipment properly, failure to adhere to infection control hand hygiene practices, and improper use of N95 masks by staff.
Failure to follow infection control practices during medication administration including failure to wear gloves when administering injectable medication.
Failure to discard medication dropped on medication cart and use proper hand hygiene.
Report Facts
Residents reviewed for MDS completion: 24 Residents with incomplete MDS assessments: 20 Residents reviewed for medication administration: 23 Residents reviewed for behavior monitoring: 9 Expired items on crash cart: 4 Oxygen flow rate: 2.5 Medication administration hand hygiene duration: 7

Employees mentioned
NameTitleContext
Licensed Practical NurseAdministered crushed Vimpat medication unaware it should not be crushed.
Registered NurseAdministered Ozempic without gloves and did not clarify medication order.
Certified Nursing AssistantWore cloth mask under N95 respirator mask.
Director of NursingAcknowledged deficiencies and provided policies and education.
Consultant PharmacistFailed to identify medication order discrepancy for Ozempic.

Inspection Report

Complaint Investigation
Census: 112 Deficiencies: 3 Date: Jan 12, 2022

Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ149385 and NJ144738, focusing on COVID-19 infection control and food safety practices.

Complaint Details
The visit was complaint-related with complaints NJ149385 and NJ144738. The facility was found not in compliance with infection control regulations and food safety requirements during the complaint survey.
Findings
The facility was found not in compliance with infection control regulations and failed to ensure sanitary food preparation, distribution, and serving practices. Specific deficiencies included improper cleaning of utensils when the dishwasher was broken, failure to perform hand hygiene between tasks and glove changes, and inadequate sanitization of food preparation surfaces.

Deficiencies (3)
Dietary staff failed to utilize the three compartment sink to wash and disinfect food preparation and serving utensils when the dishwasher was broken.
Dietary staff failed to perform hand hygiene between tasks and glove changes.
Dietary staff cleaned food preparation surfaces with plain water instead of sanitizing solution.
Report Facts
Sample Size: 6 Date Survey Completed: Jan 13, 2022

Employees mentioned
NameTitleContext
Cook #1Observed failing to perform hand hygiene and improper cleaning of food preparation surfaces.
Dietary Aide #1Observed not properly washing and disinfecting utensils when dishwasher was broken.
Food Service DirectorFSDProvided interviews and described training and corrective actions related to food safety and sanitation.
Nursing Home AdministratorNHAProvided interviews and documentation regarding incident and corrective actions.
Director of NursingDONProvided interview regarding ongoing hand hygiene training.

Inspection Report

Annual Inspection
Census: 114 Deficiencies: 8 Date: Apr 8, 2021

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Findings
Deficiencies were cited related to failure to follow professional standards in care plans, failure to provide appropriate services for limited mobility residents, failure to maintain nutritional status and hydration, improper medication labeling and storage, failure to ensure food safety and proper food temperatures, incomplete medical records, and inadequate infection prevention and control practices.

Deficiencies (8)
Failed to follow a Dietician's recommendation for nutrition and to set appropriate weight on equipment for residents.
Failed to provide appropriate services to residents with limited mobility.
Failed to verify, monitor, and document resident weights after significant weight changes and modify nutritional interventions accordingly.
Failed to properly label and dispose of medications and maintain medication storage according to regulations.
Failed to ensure safe and appetizing temperatures of cold food and drink served to residents.
Failed to maintain proper kitchen sanitation practices and properly label, date, and store potentially hazardous foods.
Failed to maintain complete, accurate, and readily accessible medical records including missing monthly physician progress notes.
Failed to follow transmission-based precautions, infection control practices during wound treatment, proper PPE disposal, hand hygiene, posting of TBP signs, and PPE use by transport personnel on the PUI unit.
Report Facts
Census: 114 Sample size: 23 Weight changes: 14 Weight changes: 7 Dishwasher temperature: 160 Dishwasher temperature: 180 Dishwasher temperature: 170 Dishwasher temperature: 174 Cold food temperature: 42 Cold food temperature: 48 Cold food temperature: 52 Cold food temperature: 53 Cold food temperature: 54 Cold food temperature: 57 Cold food temperature: 59

Employees mentioned
NameTitleContext
Registered Nurse/Unit ManagerInformed surveyor about resident infection and isolation status
Licensed Practical Nurse #1Observed during wound treatment, failed to perform hand hygiene and PPE use properly
Certified Nursing Aide #1Observed during wound treatment, failed to perform hand hygiene properly
Director of NursingAcknowledged infection control deficiencies and corrective actions
Assistant Director of NursingAcknowledged infection control deficiencies and corrective actions
Food Service DirectorResponsible for food safety, sanitation, and temperature monitoring
Food Service SupervisorResponsible for food safety, sanitation, and temperature monitoring
Licensed Nursing Home AdministratorParticipated in interviews and acknowledged deficiencies

Inspection Report

Life Safety
Deficiencies: 2 Date: Apr 8, 2021

Visit Reason
The inspection was conducted to assess compliance with Life Safety Code requirements, specifically focusing on emergency preparedness, cooking facilities, and sprinkler system maintenance.

Findings
The facility was found not in substantial compliance with minimum Life Safety Code requirements due to improperly positioned exhaust hood grease baffles in the kitchen and failure to maintain and provide records for monthly testing of the electronic fire pump. Corrective actions were initiated during the survey.

Deficiencies (2)
Two of six exhaust hood grease baffles were improperly positioned, creating air gaps that could allow grease and fire to enter the exhaust hood system.
Failure to comply with maintenance and testing requirements for the automatic sprinkler system's electronic fire pump, with no records of monthly testing for the prior 12 months.
Report Facts
Exhaust hood grease baffles: 6 Air gap: 1.5 Air gap: 0.5 Months without fire pump test records: 12 Weekly fire pump checks: 4 Monthly fire pump checks: 2

Employees mentioned
NameTitleContext
Maintenance DirectorAcknowledged grease baffle deficiency, performed corrective actions, and responsible for ongoing monitoring and reporting
Food Service ManagerAcknowledged grease baffle deficiency
Facility AdministratorVerbally informed of findings during Life Safety Code survey exit conference

Inspection Report

Abbreviated Survey
Census: 108 Deficiencies: 3 Date: Jan 5, 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 not to be in compliance with infection control regulations, including failure to provide disinfectant wipes for equipment, inadequate hand hygiene practices by staff, and improper infection control procedures during meal tray service to residents in isolation.

Deficiencies (3)
Failure to provide disinfectant wipes and sanitize equipment used in the COVID-19 screening process.
Inappropriate hand hygiene practices observed in 8 of 14 staff members, including improper handwashing technique and failure to follow hand hygiene protocols.
Failure to follow appropriate infection control procedures while serving meal trays to residents in isolation, including not changing gloves between residents and not performing hand hygiene.
Report Facts
Staff observed for hand hygiene: 14 Staff deficient in hand hygiene: 8 Census: 108

Employees mentioned
NameTitleContext
Director of MaintenanceDirector of MaintenanceObserved performing improper hand hygiene
Assistant Director of MaintenanceAssistant Director of MaintenanceObserved performing improper hand hygiene
HousekeeperHousekeeperObserved performing improper hand hygiene
Certified Nursing Assistant / Staffing CoordinatorCertified Nursing Assistant / Staffing CoordinatorObserved performing improper hand hygiene and improper glove use during meal service
Dietary AideDietary AideObserved performing improper hand hygiene
Kitchen AideKitchen AideObserved performing improper hand hygiene
Dietary SupervisorDietary SupervisorObserved performing improper hand hygiene

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