Inspection Reports for Complete Care at Park Place
2 Deerpark Dr, Monmouth Junction, NJ 08852, United States, NJ, 08852
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 86
Capacity: 94
Deficiencies: 9
Aug 30, 2024
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 respiratory care, staffing ratios, life safety code violations including egress door locking mechanisms, emergency lighting, cooking facility inspections, sprinkler system installation and maintenance, fire extinguisher inspections, and emergency generator controls.
Complaint Details
Complaint #: NJ167385, 168213, and 168532. The complaint investigation identified deficiencies in respiratory care and staffing ratios.
Severity Breakdown
SS=E: 2
SS=F: 7
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to follow a physician's order for respiratory care for Resident #33. | SS=E |
| Failed to maintain required minimum direct care staff to resident ratio for 5 of 5 weeks prior to survey. | — |
| Failed to provide 4 of 10 designated exit access/discharge doors readily accessible and free of obstructions; thumb turn locks on egress doors. | SS=F |
| Failed to provide functioning battery backup emergency lighting for one of two emergency generator switch locations. | SS=F |
| Failed to inspect kitchen range-hood fire suppression system semi-annually. | SS=F |
| Failed to install sprinklers as required; missing ceiling tile in laundry room allowing heat to bypass sprinkler head. | SS=F |
| Failed to conduct quarterly inspections of the automatic fire sprinkler system. | SS=F |
| Failed to perform monthly examination for 14 of 14 portable fire extinguishers. | SS=F |
| Failed to ensure a remote manual stop station for emergency generator was installed. | SS=E |
Report Facts
Census: 86
Total Capacity: 94
Deficiencies cited: 9
Staffing ratio deficiencies: 5
Fire sprinkler inspections missed: 1
Semi-annual kitchen hood inspections missed: 1
Fire extinguisher monthly inspections missed: 14
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Jun 6, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00163941 and NJ00162670, focusing on dental services and staffing ratios.
Findings
The facility was found not in substantial compliance due to failure to timely order a dental consult for one resident, placing the resident at risk for unmet care needs, and failure to maintain required minimum staff-to-resident ratios on multiple day shifts.
Complaint Details
Complaint #: NJ00163941 and NJ00162670. The facility was found not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to order a dental consult in a timely manner for one resident, risking unmet care needs and diminished quality of life. | SS=D |
| Failure to ensure staffing ratios met the minimum state requirements for Certified Nurse Aides on 8 of 28 day shifts. | — |
Report Facts
Survey Census: 80
Sample Size: 12
Deficient CNA staffing day shifts: 8
CNA staffing deficits on specific days: 6
CNA staffing deficits on specific days: 2
CNA staffing required vs actual: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor 2 | Registered Nurse Supervisor | Interviewed regarding scheduling of dental appointment for Resident 11. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for scheduling dental appointments and staffing. |
Inspection Report
Annual Inspection
Census: 89
Capacity: 94
Deficiencies: 10
Dec 7, 2022
Visit Reason
A Recertification Survey was conducted from 11/29/22 through 12/02/22 to assess compliance with federal regulations and state requirements for Complete Care at Park Place, LLC.
Findings
The facility was found not to be in substantial compliance with multiple deficiencies identified, including failures in medication self-administration assessment and care planning, comprehensive care planning, discharge planning, range of motion and mobility care, incontinence care, respiratory/tracheostomy care, physician supervision, nursing staff competency, emergency preparedness, fire alarm system maintenance, and staffing ratios. Immediate jeopardy was identified related to emergency supplies and staff training for one resident, which was removed by 12/02/22.
Severity Breakdown
SS=D: 5
SS=J: 1
SS=G: 1
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure one resident had a physician's order and was assessed and care planned for self-administration of medications. | SS=D |
| Failure to develop and implement comprehensive care plans including emergency care interventions for one resident. | SS=D |
| Failure to provide an effective discharge planning process for one resident. | SS=D |
| Failure to ensure residents with limited range of motion received appropriate treatment and services. | SS=D |
| Failure to provide appropriate treatment and services for urinary and bowel incontinence for two residents. | SS=D |
| Failure to provide necessary respiratory/tracheostomy care and emergency supplies for one resident, and failure to train staff on emergency management. | SS=J |
| Failure to ensure physician supervision and accurate physician orders for one resident. | SS=G |
| Failure to ensure nursing staff competency and skills to provide safe care and emergency treatment for one resident. | SS=E |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Failure to ensure smoke detection sensitivity testing was completed in accordance with NFPA 72. | — |
Report Facts
Survey Census: 89
Total Capacity: 94
Deficiencies cited: 14
CNA staffing: 7
CNA staffing required: 11
Resident sample size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident (R) 23 | Resident | Named in multiple deficiencies related to medication self-administration, emergency care, respiratory care, and care planning |
| Unit Manager (UM) 1 | Registered Nurse | Named in emergency management training deficiency and emergency kit availability |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in emergency management training deficiency |
| Director of Nursing (DON) | Director of Nursing | Named in emergency management training deficiency and medication order clarification |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Named in medication administration and emergency kit availability deficiencies |
| Certified Nursing Assistant (CNA) 2 | Certified Nursing Assistant | Named in medication administration deficiency |
| Medical Director | Medical Director | Named in physician order and supervision deficiencies |
| Social Services Director (SSD) | Social Services Director | Named in discharge planning deficiency |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
May 24, 2022
Visit Reason
The inspection was conducted in response to complaint NJ152973 to investigate staffing ratio deficiencies at the facility.
Findings
The facility was found to be out of compliance with New Jersey staffing requirements, failing to meet required staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and 3 of 14 overnight shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint NJ152973 was substantiated with findings that the facility failed to meet minimum staffing requirements as per New Jersey Department of Health regulations.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts and 3 of 14 overnight shifts reviewed, violating mandatory access to care requirements. |
Report Facts
Census: 91
Deficient CNA staffing day shifts: 14
Deficient total staff overnight shifts: 3
Required CNAs on day shifts: 11
Actual CNAs on day shifts: 5
Required total staff overnight shifts: 7
Actual total staff overnight shifts: 5
Inspection Report
Routine
Census: 79
Deficiencies: 0
Jan 5, 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.
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: 72
Deficiencies: 0
Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ146289.
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 number NJ146289 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 1
Feb 4, 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 42 CFR §483.80 infection control regulations due to failure to utilize appropriate personal protective equipment (PPE), specifically improper donning of N95 masks by a housekeeper wearing an N95 over a surgical mask, which compromised infection prevention efforts.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Improper donning of N95 mask; housekeeper wearing N95 mask over surgical mask. | SS=D |
Report Facts
Census: 71
Sample size: 5
Deficiency completion date: Mar 29, 2021
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