Inspection Reports for Complete Care At Holiday City
4 Plaza Drive, NJ, 08757
Back to Facility ProfileDeficiencies per Year
20
15
10
5
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 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 about the notice |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted based on complaint NJ160317 to investigate staffing ratio concerns at the facility.
Findings
The facility was found to be in substantial compliance overall but was deficient in meeting minimum staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint #: NJ160317. The facility failed to meet minimum staffing requirements for CNAs on all 14 day shifts reviewed, affecting all residents. The complaint was substantiated with findings of deficient CNA staffing.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts reviewed, with CNA staffing below required minimums. |
Report Facts
Census: 145
Deficient CNA staffing days: 14
CNA staffing counts: 10
CNA staffing counts: 10
CNA staffing counts: 13
CNA staffing counts: 12
CNA staffing counts: 13
CNA staffing counts: 14
CNA staffing counts: 10
CNA staffing counts: 14
CNA staffing counts: 15
CNA staffing counts: 13
CNA staffing counts: 13
CNA staffing counts: 16
CNA staffing counts: 15
CNA staffing counts: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to re-education on minimum staffing requirements. | |
| Human Resources Director | Named in relation to re-education on minimum staffing requirements. | |
| Staffing Coordinator | Named in relation to re-education on minimum staffing requirements. | |
| Administrator | Conducted re-education and implemented staffing improvement measures. |
Inspection Report
Routine
Census: 106
Capacity: 180
Deficiencies: 11
Mar 30, 2023
Visit Reason
Routine inspection of the nursing home facility to assess compliance with fire safety, electrical, and other regulatory requirements.
Findings
The inspection identified multiple deficiencies including failure to inspect fire doors annually, malfunctioning fire door releases, inadequate emergency lighting, missing exit signage, incomplete fire alarm system testing, lack of sprinkler system inspections, corridor doors not resisting smoke passage, HVAC combustion air issues, deficient fire drills, incomplete electrical receptacle testing, and generator transfer time certification.
Severity Breakdown
SS=F: 8
SS=E: 2
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to inspect fire doors annually; 8 of 9 fire doors had missing or broken parts with no follow-up. | SS=F |
| Three fire doors did not release and open upon fire alarm activation as designed. | SS=F |
| Facility failed to provide battery back-up emergency light above electric fire pump transfer switch. | SS=D |
| Exit signs missing in locations where direction of travel to nearest exit was not apparent. | SS=E |
| Failed to ensure smoke detection sensitivity testing was completed and updated fire alarm inspection reports provided. | SS=F |
| Failed to annually inspect private property fire hydrants and perform 5-year sprinkler system internal inspection. | SS=F |
| Corridor doors failed to resist passage of smoke; multiple resident room doors did not latch or were warped. | SS=F |
| HVAC mechanical rooms lacked proper combustion air from outside; exposed wires and doors did not close properly. | SS=F |
| Fire drills lacked variation in activation types and simulation of specific emergency conditions for 10 of 12 drills. | SS=F |
| Failed to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=E |
| Failed to certify generator transfer time within required 10 seconds during monthly load testing. | SS=F |
Report Facts
Certified beds: 180
Census: 106
Fire doors inspected: 9
Fire doors deficient: 8
Fire doors not releasing: 3
Fire drills reviewed: 12
Fire drills deficient: 10
Resident rooms with untested receptacles: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Involved in interviews and acknowledged deficiencies related to fire door inspections, fire alarm testing, HVAC issues, and electrical testing. | |
| Regional Plant Operations Director | Participated in interviews and observations regarding fire safety, HVAC, and electrical system deficiencies. | |
| Licensed Nursing Home Administrator | Informed of all findings during Life Safety Code exit conference. | |
| Assistant Director of Nursing | Interviewed regarding awareness of emergency door release activation. | |
| Licensed Practical Nurse | Interviewed regarding awareness of emergency door release activation. | |
| Certified Nursing Aide | Interviewed regarding awareness of emergency door release activation. |
Inspection Report
Annual Inspection
Census: 106
Capacity: 180
Deficiencies: 17
Mar 30, 2023
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 quality of care, dialysis fluid restrictions, medication administration, food safety, fire safety, emergency preparedness, and staffing ratios.
Complaint Details
Complaint #: NJ 159371. Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 13 out of 42 shifts reviewed.
Severity Breakdown
SS=G: 1
SS=E: 3
SS=D: 1
SS=F: 7
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident with a cast received appropriate care including physician visits and assessments every shift, resulting in untreated infection. | SS=G |
| Facility failed to ensure residents on dialysis and fluid restriction diets received appropriate amounts of fluids daily. | SS=E |
| Facility failed to accurately document administration of controlled medications and sign narcotic count logs. | SS=D |
| Facility failed to maintain kitchen hand washing sinks with accessible paper towels, maintain food-contact plates free of chips, and maintain hot food temperatures above 135°F. | SS=E |
| Facility failed to ensure appetizing and palatable temperature of food for breakfast meals; hot foods served below required temperature. | — |
| Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Facility failed to inspect fire doors annually and address missing or broken parts noted in inspection reports. | SS=F |
| Facility failed to ensure exit doors in the means of egress released and opened upon fire alarm activation. | SS=F |
| Facility failed to provide battery back-up emergency light above electric fire pump transfer switch. | SS=D |
| Facility failed to provide illuminated exit signs showing direction of travel to nearest exit where direction was not apparent. | SS=E |
| Facility failed to ensure smoke detection sensitivity testing was completed and failed to provide updated fire alarm system inspection report. | SS=F |
| Facility failed to annually inspect private property fire hydrants and failed to ensure 5-year inspection of automatic sprinkler system. | SS=F |
| Facility failed to ensure corridor doors resist passage of smoke and close completely to confine fire and smoke products. | SS=F |
| Facility failed to provide combustion air from outside to fuel fired HVAC units; mechanical room doors did not close freely and allowed air from occupied areas. | SS=F |
| Facility failed to conduct fire drills with varying activation types and simulation of specific emergency fire conditions. | SS=F |
| Facility failed to functionally test electrical receptacles in residents' rooms annually for grounding, polarity, and blade tension. | SS=E |
| Facility failed to certify that emergency generator transfers power to building within 10 seconds during monthly load testing. | SS=F |
Report Facts
Census: 106
Total Capacity: 180
Deficiency Count: 16
Deficiency Count: 3
Deficiency Count: 31
Deficiency Count: 10
Temperature: 122
Temperature: 125
Temperature: 110
Temperature: 110
Temperature: 106
Medication Count: 89
Medication Count: 17
Medication Count: 12
Medication Count: 9
Staffing Ratio: 13
Staffing Ratio: 12
Staffing Ratio: 13
Staffing Ratio: 12
Staffing Ratio: 12
Staffing Ratio: 11
Staffing Ratio: 10
Staffing Ratio: 12
Staffing Ratio: 12
Staffing Ratio: 11
Staffing Ratio: 12
Staffing Ratio: 11
Staffing Ratio: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Nurse Practitioner | Involved in care of Resident #20; facility unable to locate documentation of follow-up visits |
| Physician #1 | Primary Physician | Retired; last documented visit for Resident #20 was 10/15/21 |
| Physician #2 | Orthopedic Physician | Provided follow-up care for Resident #20 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding care standards for residents with casts |
| DON | Director of Nursing | Interviewed regarding policies and care for Resident #20 and fluid restrictions |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding staffing and medical record documentation |
| CNA #1 | Certified Nursing Aide | Observed care and reported concerns for Resident #20 and fluid restrictions |
| CNA #2 | Certified Nursing Aide | Observed care and reported concerns for Resident #20 |
| Cook | Cook | Interviewed regarding food temperatures and kitchen practices |
| DA #1 | Dietary Aide | Interviewed regarding kitchen practices and food handling |
| RDD | Regional Dietary Director | Interviewed regarding food safety and temperatures |
| MD | Maintenance Director | Interviewed regarding fire safety, HVAC, electrical, and generator maintenance |
| RPOD | Regional Plant Operations Director | Interviewed regarding fire safety, HVAC, electrical, and generator maintenance |
Inspection Report
Routine
Census: 118
Deficiencies: 0
Mar 7, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Nov 22, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 11/22/2022 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: 103
Deficiencies: 1
May 12, 2022
Visit Reason
The inspection was conducted based on complaint #NJ 153984 to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility failed to ensure that their policy on 'Physician Orders' was followed for the Consultant's recommendations for treatment administration for 1 of 4 residents reviewed. Specifically, Nurse Practitioner's wound care recommendations were not implemented and the Primary Physician was not notified as required.
Complaint Details
Complaint #NJ 153984 was substantiated as the facility was found not in substantial compliance with requirements based on the complaint visit.
Severity Breakdown
S/S = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow Consultant's wound care recommendations and notify the Primary Physician for approval. | S/S = D |
Report Facts
Sample Size: 4
Audit Frequency: 3
Audit Duration Weeks: 4
Audit Duration Months: 3
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Feb 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ149531 and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and infection control regulations related to COVID-19.
Complaint Details
Complaint #NJ149531 was investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 5
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 0
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 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.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Sep 23, 2021
Visit Reason
The inspection was conducted in response to complaints numbered NJ 145986, NJ 148435, and 148606.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ 145986, NJ 148435, and 148606 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 6
Inspection Report
Routine
Census: 108
Deficiencies: 0
Aug 30, 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: 104
Deficiencies: 0
Jun 13, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ143537, NJ142359, NJ141819, and NJ134553.
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
The survey was complaint-related with multiple complaint numbers cited, and the facility was found compliant.
Report Facts
Sample Size: 9
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 3
May 11, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a complaint investigation.
Findings
Deficiencies were cited related to failure to follow professional standards in medication administration, inaccurate documentation of controlled substances, and failure to properly clean reusable medical equipment between residents.
Complaint Details
Complaint #NJ00144405 was investigated and the facility was found in compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to follow professional standards of clinical practice with respect to administering medication according to physician's prescribed pain level parameters for Resident #3. | SS=D |
| Facility staff failed to accurately document the administration of controlled substance medications for Residents #82 and #75. | SS=D |
| Facility failed to follow proper infection control procedures by not cleaning reusable medical equipment (blood pressure cuff) between residents during medication pass. | SS=D |
Report Facts
Medication administration outside prescribed parameters: 26
Controlled substance tablets count discrepancy: 1
Controlled substance tablets count discrepancy: 1
Census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided policies, acknowledged medication administration deficiencies, and confirmed infection control lapses. | |
| Licensed Practical Nurse (LPN) | Administered medications and was observed failing to clean BP cuff between residents and not properly documenting controlled substances. | |
| Licensed Nursing Home Administrator (LNHA) | Participated in survey team meeting. | |
| Assistant Licensed Practical Nurse (ALPN) | Participated in survey team meeting. | |
| Infection Preventionist | Confirmed proper infection control procedures and educated staff. | |
| Applewood LPN Unit Manager (LPN/UM) | Explained proper controlled substance administration and documentation procedures. |
Inspection Report
Life Safety
Deficiencies: 4
May 5, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/04/21 and 05/05/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including failure to provide audible and visible fire alarm notification in enclosed courtyards, failure to maintain sprinkler system smoke-resisting ceilings, inadequate ventilation in resident bathrooms, and improper clearance around electrical panels and equipment.
Severity Breakdown
SS=F: 1
SS=D: 1
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide notification by audible and visible signals (horn/strobe) tied to the fire alarm in enclosed courtyards. | SS=F |
| Failure to maintain sprinkler system with complete smoke-resisting ceiling at the level of installed sprinklers, including missing ceiling tiles allowing smoke to bypass sprinklers. | SS=D |
| Failure to ensure resident bathroom ventilation systems were functioning properly in specified units. | SS=E |
| Failure to maintain required clearance around electrical panels and equipment, with storage of items blocking access. | SS=E |
Report Facts
Date of survey completion: May 11, 2021
Date of compliance: Jun 11, 2021
Number of glass storm windows stored improperly: 30
Number of framed mirrors stored improperly: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified findings related to fire alarm, sprinkler system, ventilation, and electrical clearance deficiencies | |
| Administrator in training | Interviewed and verified findings related to fire alarm and sprinkler system deficiencies | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Routine
Census: 115
Deficiencies: 0
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.
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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