Inspection Reports for
Complete Care At Holiday City
4 Plaza Drive, Toms River, NJ, 08757
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
119% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
81% occupied
Based on a March 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
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 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
Routine
Deficiencies: 4
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to the facility's environment, resident assessments, activities of daily living care, and food service sanitation.
Findings
The facility was found deficient in maintaining a clean, comfortable, and homelike environment; accurately coding resident assessments; providing adequate nail care during activities of daily living; and maintaining kitchen and nourishment room equipment in a clean and sanitary manner.
Deficiencies (4)
Failed to maintain residents' living environment in a clean, comfortable, homelike manner, including peeling laminate, chipped paint, stains, and spills in nourishment rooms on 3 nursing units.
Failed to accurately code the Minimum Data Set (MDS) for 3 of 27 residents, including incorrect tobacco use and feeding tube status.
Failed to provide nail care during activities of daily living for 1 of 2 residents reviewed, resulting in long fingernails with dirt and discoloration.
Failed to maintain kitchen equipment and nourishment room refrigerators in a clean and sanitary manner on 3 of 3 units, including dirty microwaves, ovens, steamers, stoves, plate warmers, steam tables, and refrigerators.
Report Facts
Residents reviewed for MDS: 27
Residents with MDS deficiencies: 3
Residents reviewed for ADL care: 2
Residents affected by nail care deficiency: 1
Nursing units with nourishment room deficiencies: 3
Units with kitchen equipment deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Present during observation of nourishment room deficiencies | |
| Licensed Practical Nurse (LPN) | Present during observation of nourishment room deficiencies and interviewed about resident care | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Present during observation of nourishment room deficiencies and interviewed about resident care | |
| Housekeeping Director (HD) | Interviewed about cleaning schedules and acknowledged deficiencies | |
| Regional Maintenance Director (RMD) | Interviewed about maintenance and work orders | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed and acknowledged surveyor concerns | |
| Director of Nursing (DON) | Interviewed and acknowledged surveyor concerns and discussed nursing care expectations | |
| MDS Coordinator (MDSC) | Interviewed about MDS coding and acknowledged errors | |
| Certified Nursing Aide (CNA) | Interviewed about nail care responsibilities | |
| Food Service Director (FSD) | Interviewed and acknowledged kitchen equipment cleaning deficiencies | |
| Regional Food Service Director (RFSD) | Present during kitchen equipment observations |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 13, 2025
Visit Reason
The inspection was conducted based on complaint investigations regarding resident dignity, thoroughness of investigations into resident-to-resident altercations, accuracy of resident assessments, care plan development, diabetic management, medication administration, and food temperature compliance.
Complaint Details
The complaint investigation included issues related to resident dignity, resident-to-resident altercation investigation, accuracy of resident assessments, care plan development, diabetic management, medication administration, and food service temperature compliance. Some deficiencies were substantiated with observations, interviews, and record reviews.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity during dining, incomplete investigations of resident altercations, inaccurate Minimum Data Set (MDS) assessments, incomplete and untimely care plans, failure to follow professional standards in diabetic management, failure to administer medications as ordered, and failure to serve food at appropriate temperatures.
Deficiencies (9)
Failed to protect a resident's right to dignity while dining; resident was exposed due to untied hospital gown.
Failed to conduct a thorough investigation of a resident-to-resident altercation.
Failed to accurately code Minimum Data Set (MDS) assessments for falls, pressure ulcers, and pain.
Failed to develop comprehensive care plans with measurable goals and resident-specific interventions for pain and diabetes management.
Failed to review and revise care plan for insulin administration within required timeframe.
Failed to follow professional standards in diabetic management including lack of blood sugar monitoring and physician notification.
Failed to administer physician-ordered medications to residents, resulting in missed doses.
Failed to properly administer nasal spray medication as ordered, including failure to shake bottle and incorrect dosing.
Failed to serve food at appropriate temperatures; hot foods served below minimum temperature and cold foods above maximum temperature.
Report Facts
Residents sampled: 22
Resident BIMS scores: 5
Resident BIMS scores: 15
Resident BIMS scores: 13
Food temperatures: 133
Food temperatures: 111
Food temperatures: 136
Food temperatures: 53
Food temperatures: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 2 | Unit Manager | Acknowledged failure to cover resident during dining and incomplete investigation of resident altercation |
| Director of Nursing | Director of Nursing | Confirmed staff should maintain resident dignity, care plan deficiencies, and medication administration errors |
| Regional MDS Coordinator | Regional MDS Coordinator | Confirmed inaccurate coding of resident assessments |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding care plan development and blood sugar monitoring |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding diabetic management and blood sugar monitoring |
| Physician 1 | Physician | Interviewed regarding blood sugar monitoring standards |
| Physician 2 | Physician | Interviewed regarding expectations for blood sugar monitoring |
| Unit Manager 1 | Unit Manager | Explained medication ordering and administration process |
| Unit Manager 2 | Unit Manager | Commented on medication administration error with nasal spray |
| Licensed Practical Nurse 7 | LPN | Observed administering nasal spray medication incorrectly |
| Dietary Manager | Dietary Manager | Reported on food temperature complaints and monitoring |
| Regional Food Service Director | Regional Food Service Director | Reported on food temperature complaints and corrective actions |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
The inspection was conducted based on complaint NJ160317 to investigate staffing ratio concerns at the facility.
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.
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.
Deficiencies (1)
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
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted based on a complaint (#154756) regarding the facility's failure to provide appropriate care to a resident (Resident #20) who sustained a distal humerus fracture and was re-admitted with a soft cast, which led to a mechanical device pressure injury with necrosis.
Complaint Details
Complaint #154756 regarding inadequate care for Resident #20 who developed a pressure injury with necrosis under a soft cast after hospital readmission. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure proper care and physician assessments for Resident #20 with a soft cast, resulting in a pressure injury with necrosis. The resident was not seen by a primary physician within the required timeframe after hospital readmission, and nursing staff did not perform necessary skin checks or obtain physician orders for cast care. The facility lacked a cast care policy and failed to follow professional standards for resident care.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in a mechanical device pressure injury with necrosis under a soft cast.
Report Facts
Residents reviewed for quality of care: 27
Physician antibiotic orders: 5
Pain level documentation: 17
Time without physician visit: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Primary Physician | Responsible for resident care until retirement; last documented visit 10/15/21 |
| Physician #2 | Primary Physician | Took over care from 3/1/22; provided progress notes on 3/18/22 and 4/7/22 |
| NP #1 | Nurse Practitioner | Saw acute issues; not part of attending physicians' practices; did not see resident monthly as required |
| Certified Nursing Aide #1 | CNA | Reported foul smell and black discoloration under cast |
| Certified Nursing Aide #2 | CNA | Confirmed foul smell and reported to nurse |
| Director of Nursing | DON | Provided documentation and interviews regarding care failures and policies |
| Licensed Practical Nurse (UM/LPN) | Unit Manager/LPN | Provided information about resident care and cast management |
| Director of Rehabilitation | Director of Rehab | Provided information about cast type and care expectations |
| Medical Director | MD | Provided standards of practice and physician responsibilities |
| Licensed Practical Nurse #1 | LPN | Described nursing standards for cast care and assessments |
| Licensed Nursing Home Administrator | LNHA | Provided additional documentation and interviews |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dialysis care, medication administration, and food safety in a nursing home facility.
Findings
The facility was found deficient in providing appropriate dialysis care and fluid restriction adherence for residents on dialysis, accurate documentation of controlled medication administration, and maintaining food safety standards including handwashing supplies, food temperatures, and kitchen equipment maintenance.
Deficiencies (3)
Failure to ensure residents on dialysis and fluid restriction diets received appropriate fluid amounts as per physician orders.
Failure to accurately document administration of controlled medications on declining inventory sheets for three residents.
Failure to maintain kitchen hand washing sinks with accessible paper towels, maintain multi-use food-contact surface plates to prevent microbial growth, and maintain potentially hazardous food temperatures above 135°F.
Report Facts
Fluid restriction: 1500
Fluid restriction: 1200
Medication discrepancies: 4
Food temperature: 122
Food temperature: 125
Medication tablets count discrepancy: 1
Medication tablets count discrepancy: 1
Medication tablets count discrepancy: 1
Medication tablets count discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Assigned aide to Resident #80, interviewed about fluid restriction knowledge and water cup refilling | |
| Registered Nurse (RN) | Interviewed regarding Resident #80's dialysis schedule and fluid restriction adherence | |
| Unit Manager/Licensed Practical Nurse (UM/LPN) | Interviewed about fluid restriction awareness and water cup management for residents | |
| Director of Nursing (DON) | Confirmed fluid restriction policies and nursing responsibilities | |
| Registered Dietitian (RD) | Interviewed about residents' dialysis and fluid restriction diets | |
| Licensed Practical Nurse (LPN) | Interviewed about fluid restriction knowledge and observed removing excess fluids from Resident #35 | |
| CNA #2 | Interviewed about fluid restriction knowledge for Resident #35 | |
| Licensed Practical Nurse (LPN) | Interviewed during medication cart inspection regarding declining inventory sheets | |
| Assistant Director of Nursing (ADON) | Interviewed regarding medication administration and declining inventory sheet procedures | |
| Regional Dietary Director (RDD) | Interviewed about kitchen food safety, chipped plates, handwashing, and food temperature standards | |
| Dietary Director (DD) | Interviewed about kitchen paper towel incident and staff responsibilities |
Inspection Report
Routine
Census: 106
Capacity: 180
Deficiencies: 11
Date: 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.
Deficiencies (11)
Facility failed to inspect fire doors annually; 8 of 9 fire doors had missing or broken parts with no follow-up.
Three fire doors did not release and open upon fire alarm activation as designed.
Facility failed to provide battery back-up emergency light above electric fire pump transfer switch.
Exit signs missing in locations where direction of travel to nearest exit was not apparent.
Failed to ensure smoke detection sensitivity testing was completed and updated fire alarm inspection reports provided.
Failed to annually inspect private property fire hydrants and perform 5-year sprinkler system internal inspection.
Corridor doors failed to resist passage of smoke; multiple resident room doors did not latch or were warped.
HVAC mechanical rooms lacked proper combustion air from outside; exposed wires and doors did not close properly.
Fire drills lacked variation in activation types and simulation of specific emergency conditions for 10 of 12 drills.
Failed to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension.
Failed to certify generator transfer time within required 10 seconds during monthly load testing.
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
Date: Mar 30, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
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.
Findings
Deficiencies were cited related to quality of care, dialysis fluid restrictions, medication administration, food safety, fire safety, emergency preparedness, and staffing ratios.
Deficiencies (17)
Facility failed to ensure a resident with a cast received appropriate care including physician visits and assessments every shift, resulting in untreated infection.
Facility failed to ensure residents on dialysis and fluid restriction diets received appropriate amounts of fluids daily.
Facility failed to accurately document administration of controlled medications and sign narcotic count logs.
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.
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.
Facility failed to ensure exit doors in the means of egress released and opened upon fire alarm activation.
Facility failed to provide battery back-up emergency light above electric fire pump transfer switch.
Facility failed to provide illuminated exit signs showing direction of travel to nearest exit where direction was not apparent.
Facility failed to ensure smoke detection sensitivity testing was completed and failed to provide updated fire alarm system inspection report.
Facility failed to annually inspect private property fire hydrants and failed to ensure 5-year inspection of automatic sprinkler system.
Facility failed to ensure corridor doors resist passage of smoke and close completely to confine fire and smoke products.
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.
Facility failed to conduct fire drills with varying activation types and simulation of specific emergency fire conditions.
Facility failed to functionally test electrical receptacles in residents' rooms annually for grounding, polarity, and blade tension.
Facility failed to certify that emergency generator transfers power to building within 10 seconds during monthly load testing.
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
Annual Inspection
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility Complete Care at Holiday City.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 118
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Complaint Details
Complaint #NJ 153984 was substantiated as the facility was found not in substantial compliance with requirements based on the complaint visit.
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.
Deficiencies (1)
Failure to follow Consultant's wound care recommendations and notify the Primary Physician for approval.
Report Facts
Sample Size: 4
Audit Frequency: 3
Audit Duration Weeks: 4
Audit Duration Months: 3
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: 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.
Complaint Details
Complaint #NJ149531 was investigated and the facility was found to be in compliance.
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.
Report Facts
Sample Size: 5
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 0
Date: 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
Date: Sep 23, 2021
Visit Reason
The inspection was conducted in response to complaints numbered NJ 145986, NJ 148435, and 148606.
Complaint Details
Complaint numbers NJ 145986, NJ 148435, and 148606 were investigated and the facility was found to be in substantial compliance.
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.
Report Facts
Sample size: 6
Inspection Report
Routine
Census: 108
Deficiencies: 0
Date: 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
Date: Jun 13, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ143537, NJ142359, NJ141819, and NJ134553.
Complaint Details
The survey was complaint-related with multiple complaint numbers cited, and the facility was found compliant.
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.
Report Facts
Sample Size: 9
Inspection Report
Routine
Deficiencies: 3
Date: May 11, 2021
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration, pharmaceutical services, and infection prevention and control at the nursing facility.
Findings
The facility failed to follow physician-prescribed pain level parameters for administering Percocet to a resident, inaccurately documented controlled substance administration for two residents, and did not properly clean reusable medical equipment between residents during medication pass.
Deficiencies (3)
Facility failed to follow professional standards of clinical practice with respect to administering Percocet according to prescribed pain level parameters for Resident #3.
Facility staff failed to accurately document administration of controlled substances for Residents #82 and #75, with discrepancies in medication counts and delayed signing on inventory sheets.
Facility failed to follow proper infection control procedures by not cleaning reusable medical equipment (blood pressure cuff) between residents during medication pass.
Report Facts
Times Percocet administered outside prescribed pain parameters: 26
Clonazepam tablets discrepancy: 1
Tramadol tablets discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Primary nurse for Resident #3 who administered Percocet. | |
| Applewood LPN Unit Manager (LPN/UM) | Interviewed regarding controlled substance administration procedures. | |
| Director of Nursing (DON) | Provided policy information and acknowledged deficiencies in medication administration and infection control. | |
| Licensed Nursing Home Administrator (LNHA) | Present during survey team meeting. | |
| Assistant Licensed Practical Nurse (ALPN) | Present during survey team meeting. | |
| Infection Preventionist | Confirmed proper cleaning procedures for reusable equipment. |
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
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.
Facility staff failed to accurately document the administration of controlled substance medications for Residents #82 and #75.
Facility failed to follow proper infection control procedures by not cleaning reusable medical equipment (blood pressure cuff) between residents during medication pass.
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
Date: 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.
Deficiencies (4)
Failure to provide notification by audible and visible signals (horn/strobe) tied to the fire alarm in enclosed courtyards.
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.
Failure to ensure resident bathroom ventilation systems were functioning properly in specified units.
Failure to maintain required clearance around electrical panels and equipment, with storage of items blocking access.
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
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.
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
Viewing
Loading inspection reports...
