Inspection Reports for Complete Care At Plainfield Llc
1340 Park Ave, NJ, 07060
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 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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Annual Inspection
Census: 95
Capacity: 106
Deficiencies: 6
Mar 20, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and life safety code survey.
Findings
The facility was found to have deficiencies related to infection prevention and control, staffing shortages, and life safety code violations. Deficiencies were cited in areas including infection control practices, staffing levels, and maintenance of fire safety systems.
Complaint Details
Complaint numbers NJ00163677, NJ00164854, NJ00182708 were investigated as part of the survey. The complaint related to infection control and staffing deficiencies were substantiated.
Severity Breakdown
Level 3: 4
Level 2: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Infection Prevention & Control program deficiencies including failure to use appropriate infection control practices for residents. | Level 3 |
| Mandatory Access to Care - Inadequate number of CNAs for required shifts. | Level 2 |
| Mandatory Nurse Staffing - Facility failed to provide minimum staffing levels for certain days. | Level 2 |
| Means of Egress - Facility failed to maintain clear exit corridors and doors. | Level 3 |
| Sprinkler System - Facility failed to maintain and test sprinkler system gauges monthly. | Level 3 |
| Electrical Systems - Facility failed to maintain generator and conduct fuel quality test. | Level 3 |
Report Facts
Census: 95
Total Capacity: 106
Deficiencies cited: 6
Staffing ratios: 1
Staffing ratios: 1
Staffing ratios: 1
Staffing deficiency days: 14
Staffing deficiency days: 12
Staffing hours required: 269.75
Staffing hours actual: 264
Staffing hours difference: -5.75
Residents affected by exit door deficiency: 22
Residents affected by sprinkler system deficiency: 95
Residents affected by electrical system deficiency: 95
Inspection Report
Routine
Census: 88
Deficiencies: 9
Feb 17, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had deficiencies related to significant change in status assessments, professional standards for services, nutrition and hydration, physician supervision, medication labeling and storage, staffing ratios, fire safety, and life safety code violations.
Deficiencies (9)
| Description |
|---|
| Failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for 1 of 21 residents reviewed. |
| Failed to follow a physician's order for blood levels in Resident #47. |
| Failed to maintain acceptable nutritional status and hydration for Resident #47, including failure to monitor weight loss and adjust care plans accordingly. |
| Failed to ensure physician supervision and monitoring of multiple severe conditions for Resident #47. |
| Failed to properly label, store, and dispose of medications in 3 of 4 medication carts. |
| Failed to maintain required minimum direct care staff ratios on six of 14 day shifts reviewed. |
| Failed to provide two illuminated exit signs to clearly identify exit access paths to reach an exit discharge door. |
| Failed to install portable fire extinguishers at required heights and locations. |
| Failed to ensure emergency generator had a remote manual stop station and emergency stop button inside the building. |
Report Facts
Census: 88
Sample size: 21
Deficient CNA staffing shifts: 6
Medication carts inspected: 4
Medication carts with deficiencies: 3
Exit signs missing: 2
Portable fire extinguishers height noncompliance: 5
Fire extinguishers inspected: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #77 | N/A | Named in deficiency related to failure to complete Significant Change in Status Assessment |
| Resident #47 | N/A | Named in deficiencies related to physician orders, nutrition, hydration, and medication supervision |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Observed medication storage and labeling deficiencies |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Observed medication storage and labeling deficiencies |
| Registered Nurse (RN) #1 | Registered Nurse | Observed medication storage and labeling deficiencies |
| Director of Nursing (DON) | Director of Nursing | Involved in multiple findings including medication supervision, staffing, and corrective actions |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing deficiencies |
| Director of Maintenance | Director of Maintenance | Responsible for fire safety inspections and maintenance |
| Administrator | Administrator | Informed of findings and deficiencies during survey exit |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Nov 30, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145741, NJ150737, NJ155497, and NJ155498.
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
Complaint numbers NJ145741, NJ150737, NJ155497, and NJ155498 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 92
Deficiencies: 0
Jul 13, 2022
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 practices.
Report Facts
Sample size: 8
COVID+ in house: 0
Inspection Report
Routine
Census: 86
Deficiencies: 2
Feb 19, 2021
Visit Reason
The inspection was a standard routine survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to ensure timely and documented physician and nurse practitioner visits for several residents, and failure to implement infection control policies properly, particularly regarding PPE use in quarantine rooms.
Severity Breakdown
SS=B: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure physician and nurse practitioner visits were conducted in person and documented at required intervals, with unsigned physician orders and missed visits for several residents. | SS=B |
| Failure to implement infection control policies and procedures to prevent the spread of infection, evidenced by staff not wearing full PPE in quarantine rooms. | SS=D |
Report Facts
Census: 86
Sample Size: 21
Loading inspection reports...
