Inspection Reports for Complete Care At Green Acres
1931 Lakewood Road, NJ, 08755
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 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
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Abbreviated Survey
Census: 150
Deficiencies: 1
Jul 9, 2024
Visit Reason
A Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19 practices.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure proper handwashing technique by one Certified Nursing Assistant (CNA #1) during observation and interviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure handwashing was performed according to facility policy and CDC standards by CNA #1. | SS=D |
Report Facts
Census: 150
Sample size: 5
Date survey completed: Jul 9, 2024
Plan of correction completion date: Aug 2, 2024
Date of revisit: Aug 6, 2024
Number of staff audits: 4
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Observed and interviewed regarding deficient handwashing technique |
Inspection Report
Annual Inspection
Census: 141
Capacity: 162
Deficiencies: 10
Feb 8, 2024
Visit Reason
A Recertification and Complaint Survey was conducted on behalf of the New Jersey Department of Health from 02/05/24 through 02/08/24.
Findings
The facility was found not in substantial compliance with federal requirements based on deficiencies in reporting alleged violations, baseline care plans, ADL care, activities programming, food palatability, infection prevention and control, and life safety code compliance.
Complaint Details
The inspection included a complaint survey with multiple complaint numbers listed. The facility was found not in substantial compliance based on complaint-related deficiencies including failure to timely report alleged violations and inadequate care planning.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| The facility failed to notify the State Survey Agency within 24 hours of an allegation involving medication tampering. | SS=D |
| The facility failed to ensure baseline care plans contained required care and services upon admission and failed to provide summaries to residents and representatives. | SS=D |
| The facility failed to provide necessary ADL care for dependent residents. | SS=D |
| The facility failed to encourage and arrange activities based on resident preferences. | SS=D |
| Food served was bland and residents did not receive salt, pepper, or seasoning to enhance palatability. | SS=E |
| The facility failed to follow infection prevention and control procedures during wound care and room cleaning for residents on isolation precautions. | SS=E |
| The facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Smoke detectors were not installed in lounges open to corridors on the second and third floors. | SS=F |
| Fire dampers were not inspected every four years as required by NFPA 80. | SS=F |
| Nonmetallic-sheathed wiring was not protected in interior walls or conduit in the dry sprinkler room. | SS=F |
Report Facts
Survey Census: 141
Total Capacity: 162
Sample Size: 28
Deficiency counts: 14
Deficiency counts: 14
Deficiency counts: 28
Deficiency counts: 14
Deficiency counts: 13
Deficiency counts: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication error finding for failure to change gloves during wound care |
| RN1 | Registered Nurse | Interviewed regarding medication and infection control findings |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 2
Jul 8, 2022
Visit Reason
The inspection was conducted based on a complaint survey (Complaint#: NJ 153290) to determine compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
The facility failed to notify the resident's physician of medications that were not administered and failed to follow its policy titled 'Physician/Family Notification.' Additionally, the facility failed to administer medications according to physician orders, adhere to professional nursing standards, and follow policies regarding medication shortages and documentation for 1 of 3 residents reviewed.
Complaint Details
Complaint#: NJ 153290. The complaint investigation revealed failures related to medication administration and notification practices for 1 of 3 residents reviewed.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the resident's physician of medications that were not administered and failure to follow the facility's 'Physician/Family Notification' policy. | SS=D |
| Failure to administer medications according to physician's orders, failure to adhere to professional nursing standards, and failure to follow policies on medication shortages and documentation. | SS=D |
Report Facts
Census: 120
Sample Size: 3
Deficiency Completion Date: Aug 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding notification and documentation practices for medication administration. | |
| Registered Nurse (RN) | Interviewed regarding procedures for notifying physicians about unavailable medications. | |
| Physician | Interviewed regarding expectations for notification when medications are not administered. |
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 4
Nov 10, 2021
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including review of professional standards, physician visits, staffing ratios, and food safety.
Findings
The facility was found non-compliant with New Jersey Administrative Code and federal regulations in multiple areas including failure to maintain minimum direct care staff to resident ratios, failure to ensure proper reconciliation and physician notification for enteral feeding orders, failure to ensure timely physician visits for residents, and failure to maintain kitchen cutting boards in a sanitary condition.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios for 15 out of 42 shifts reviewed. | — |
| Failed to ensure reconciliation and notification of physician for clarification of enteral feeding order for 1 of 24 residents reviewed. | SS=D |
| Failed to ensure physician visits were conducted face to face and documented at least every 30 days for the first 90 days and every 60 days thereafter for 6 residents reviewed. | SS=E |
| Failed to maintain kitchen cutting boards in a sanitary condition; cutting boards were deeply pitted, discolored, and should have been replaced. | SS=D |
Report Facts
Shifts with deficient staffing: 15
Census: 122
Sample size: 24
Physician visits reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Named in relation to failure to clarify enteral feeding order and failure to notify physician. | |
| Licensed Practical Nurse (LPN) | Observed administering enteral feeding without physician clarification. | |
| Director of Nursing (DON) | Interviewed regarding physician visit compliance and staffing issues. | |
| Regional Dietary Director (RDD) | Interviewed regarding cutting board sanitation and replacement. | |
| Dietary Director (DD) | Interviewed regarding kitchen cutting board sanitation. |
Inspection Report
Life Safety
Deficiencies: 3
Nov 8, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/08/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with fire safety requirements including failure to provide proper fire sprinkler coverage in resident bathroom closets, failure to maintain smoke barrier doors to resist smoke transfer due to excessive gaps, and failure to ensure electrical outlets near water sources had required GFCI protection.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide proper fire sprinkler coverage in resident bathroom closets as required by NFPA 13 and NJ Uniform Construction Code. | SS=E |
| Failure to maintain smoke barrier doors to resist transfer of smoke; one door had a 1-1/2 inch gap at the bottom exceeding allowed limits. | SS=D |
| Failure to ensure 2 of 14 electrical outlets near water sources were equipped with Ground-Fault Circuit Interrupter (GFCI) protection as required. | SS=D |
Report Facts
Resident rooms with closets lacking sprinkler protection: 15
Smoke barrier doors tested: 10
Gap size in smoke barrier door: 1.5
Electrical outlets lacking GFCI protection: 2
Electrical outlets inspected near water sources: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Participated in entrance conference, acknowledged lack of sprinkler coverage in closets, and was informed of findings during exit conference. | |
| Maintenance Supervisor | Provided facility layout and list of rooms with sprinkler deficiencies; participated in building tour and inspections. | |
| Maintenance Director | Responsible for conducting audits and providing findings to Quality Assessment and Assurance Committee as part of plan of correction. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Jul 16, 2021
Visit Reason
The inspection was conducted based on complaints NJ142041 and NJ142281 to investigate the facility's compliance with quality of care requirements.
Findings
The facility was found non-compliant with 42 CFR Part 483, Subpart B, due to failure to implement a physician's order for a care consult for one resident, as evidenced by missed wound consultation visits. The deficiency was identified during a complaint survey.
Complaint Details
The complaint investigation (NJ142281) substantiated that the facility failed to implement a resident-directed treatment consistent with physician orders for one resident. The oversight involved a missed wound care consult, although the mistake was not deemed detrimental to the resident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement a physician's order for a care consult for one resident, resulting in missed wound consultation visits. | SS=D |
Report Facts
Census: 125
Sample Size: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor #6 | Medical Doctor | Provided statements regarding the resident's care and the missed consultation |
| Administrator | Administrator | Stated initiation of QAPI process upon learning of failure to manage resident |
| Director of Nursing | Director of Nursing | Described the process for consult orders and acknowledged the oversight in the resident's care |
Inspection Report
Routine
Census: 122
Deficiencies: 0
Apr 19, 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
Routine
Census: 117
Deficiencies: 0
Jan 11, 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
Routine
Census: 128
Deficiencies: 0
Dec 14, 2020
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.
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