Inspection Reports for
Complete Care At Green Knoll
875 Route 202-206 North, Bridgewater, NJ, 08807
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
84% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS, and outlining their rights related to their health information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 176
Deficiencies: 17
Date: Sep 26, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to multiple complaint investigations and recertification requirements.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed, including NJ157602, NJ159021, NJ159131, NJ159472, NJ160729, NJ161981, NJ167419, NJ172055, NJ173797, NJ174205, NJ174945, NJ175542. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with federal long term care requirements based on deficiencies in grievance process, bed hold policy notification, resident safety during transport and transfers, bed rail use, medication labeling, food temperature, staffing ratios, and multiple life safety code violations including fire safety and emergency preparedness.
Deficiencies (17)
Failed to provide information on how to file an anonymous grievance for six residents.
Failed to provide written notice of bed hold policy and cost when residents were transferred to hospital for five residents.
Failed to ensure resident safety during transport and transfers for three residents.
Failed to obtain informed consent and explore alternatives prior to bed rail installation for one resident.
Failed to label medication containers with resident names for two of six medication carts reviewed.
Failed to ensure food was served at palatable temperature for five residents.
Failed to maintain required minimum direct care staff-to-resident ratios for multiple dates over 2022-2024.
Janitor carts stored in exit stairways obstructing means of egress.
Mechanical room door did not close and latch properly.
Corridor smoke barrier doors and door to room 101 were not fire rated.
Emergency lighting was not operational in emergency generator room, occupational therapy, and activities room.
Stairway doors were not fire rated and did not latch when closed.
Fire alarm pull station at main entrance was obstructed by a glass door.
Sprinklers of different types installed in the same compartment.
Nonmetallic Sheathed Cable exposed without proper fire rated protection and missing panel schedules in electrical panels.
Linen chute doors were not fire rated and locks were not fire rated.
Fire doors were not inspected by qualified personnel and fire rating labels were painted over and not legible.
Report Facts
Survey Census: 148
Total Capacity: 176
Sample Size: 40
Deficiency Counts: 63
Deficiency Counts: 7
Deficiency Counts: 7
Deficiency Counts: 7
Deficiency Counts: 7
Deficiency Counts: 14
Deficiency Counts: 7
Deficiency Counts: 7
Deficiency Counts: 7
Deficiency Counts: 14
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 5
Date: Apr 24, 2023
Visit Reason
Complaint investigation based on allegations of significant medication errors involving incorrect medication administration to residents.
Complaint Details
Complaint investigation based on complaints NJ163545, NJ163595, NJ163682 regarding medication errors and staffing deficiencies.
Findings
The facility failed to protect residents from significant medication errors when a Licensed Practical Nurse administered the wrong medication to two residents, resulting in hospital transfers. The facility also failed to implement comprehensive care plans for residents on certain medications and did not maintain professional standards in medication administration, including failure to follow pharmacy warnings and physician orders. Staffing ratios were also found deficient for day shifts.
Deficiencies (5)
Significant medication errors occurred when the LPN administered incorrect medication to residents #1 and #3.
Failure to implement comprehensive care plans for residents #2 and #3 on specific medications.
Failure to maintain professional standards in medication administration, including failure to follow pharmacy cautionary warnings and physician orders for residents #7 and #8.
Residents #1 and #3 were not free from significant medication errors resulting in hospital transfers and an Immediate Jeopardy situation.
Facility failed to ensure staffing ratios were met for 14 of 14 day shifts reviewed.
Report Facts
Census: 151
Deficient CNA staffing shifts: 14
Required CNAs: 19
Actual CNAs: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in medication error involving administration of wrong medication to residents #1 and #3; suspended pending investigation. | |
| Registered Nurse Supervisor (RNS #1) | Found residents #1 and #3 with adverse effects after medication error; involved in follow-up and reporting. | |
| Registered Nurse Supervisor (RNS #2) | Involved in care and follow-up of residents after medication error. | |
| Director of Nursing (DON) | Involved in investigation, education, and corrective actions related to medication errors and staffing. | |
| Assistant Director of Nursing (ADON) | Involved in investigation and education related to medication errors. | |
| Unit Manager/Licensed Practical Nurse (UM/LPN) | Provided statements regarding care plans and medication administration policies. | |
| Pharmacist | Provided information on medication refill status and pharmacy consultation. |
Inspection Report
Renewal
Census: 154
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The inspection was a recertification survey to assess compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to meet minimum certified nursing assistant (CNA) staffing ratios on 14 of 42 shifts reviewed between 09/11/2022 and 09/24/2022, potentially affecting all residents. The facility acknowledged staffing shortages and implemented corrective actions including increased monitoring, recruitment efforts, and incentives.
Deficiencies (1)
Failure to ensure staffing ratios were met; deficient CNA staffing on 14 of 42 shifts reviewed.
Report Facts
Census: 154
Sample Size: 31
Shifts with deficient CNA staffing: 14
CNA staffing required vs actual: 19
CNA staffing actual: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding staffing and scheduling | |
| Administrator | Acknowledged staffing shortages and efforts to address them |
Inspection Report
Life Safety
Census: 154
Capacity: 160
Deficiencies: 5
Date: Sep 26, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 09/26/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Complete Care at Green Knoll.
Findings
The facility was found noncompliant with several Life Safety Code requirements including non-illuminated exit signs, fire alarm system maintenance issues, improper labeling of fire department connections, improperly located kitchen fire extinguisher, and smoke barrier deficiencies such as unsealed penetrations and smoke doors not fully closing.
Deficiencies (5)
Exit signs were not illuminated over exit discharge doors in 2 stairwells and 1 activity room.
Fire alarm system trouble alert was not promptly addressed and junction boxes housing fire alarm control modules were uncovered.
Fire department connection for sprinkler and standpipe system was improperly labeled as 'STANDPIPE' only.
Kitchen fire extinguisher was not located along normal paths of travel, posing a risk to kitchen staff.
Smoke doors on the third floor failed to fully close and penetrations in smoke barriers on second and third floors were not sealed.
Report Facts
Census: 154
Total Capacity: 160
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Administrator | Acknowledged observations of deficiencies | |
| Director of Maintenance | Acknowledged observations and involved in corrective actions | |
| Director of Housekeeping | Acknowledged observations of deficiencies | |
| Maintenance Director | Interviewed regarding fire alarm trouble alert and responsible for maintenance corrective actions |
Inspection Report
Routine
Census: 130
Deficiencies: 0
Date: Feb 9, 2022
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 for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 108
Deficiencies: 0
Date: Feb 23, 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 for COVID-19.
Report Facts
Sample size: 12
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 1
Date: Jan 13, 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 in compliance with infection control regulations due to failure to adhere to infection prevention and control practices, specifically staff not wearing appropriate PPE (goggles or face shields) in three resident rooms designated as PUI (persons under investigation for COVID-19).
Deficiencies (1)
Failure to wear appropriate PPE (goggles or face shields) in PUI rooms on the first floor.
Report Facts
Sample size: 7
Deficiency correction completion date: Mar 18, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in PPE non-compliance finding |
| Certified Nursing Assistant #2 | CNA | Named in PPE non-compliance finding |
| Agency Licensed Practical Nurse | LPN | Named in PPE non-compliance finding |
Report
Sep 26, 2024
Report
Sep 26, 2024
Report
Apr 24, 2023
Report
Sep 29, 2022
Report
Feb 13, 2020
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