Inspection Reports for
Complete Care At Plainfield Llc
1340 Park Ave, Plainfield, NJ, 07060
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
90% occupied
Based on a March 2025 inspection.
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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Annual Inspection
Census: 95
Capacity: 106
Deficiencies: 6
Date: 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.
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.
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.
Deficiencies (6)
Infection Prevention & Control program deficiencies including failure to use appropriate infection control practices for residents.
Mandatory Access to Care - Inadequate number of CNAs for required shifts.
Mandatory Nurse Staffing - Facility failed to provide minimum staffing levels for certain days.
Means of Egress - Facility failed to maintain clear exit corridors and doors.
Sprinkler System - Facility failed to maintain and test sprinkler system gauges monthly.
Electrical Systems - Facility failed to maintain generator and conduct fuel quality test.
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
Deficiencies: 3
Date: Mar 20, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically related to wound care, use of personal protective equipment (PPE), and proper storage of oxygen administration tubing.
Findings
The facility was found to have multiple deficiencies in infection control practices including improper wound care technique with breaks in hand hygiene and clean field setup, failure to use appropriate PPE for a resident on enhanced barrier precautions, and improper storage of oxygen tubing outside of a protective bag. These deficiencies posed minimal harm or potential for actual harm to some residents.
Deficiencies (3)
Failure to use appropriate infection control practices during wound care for Resident #90, including breaks in hand hygiene, contamination of supplies, and improper clean field setup.
Failure of staff to wear required personal protective equipment (gown and gloves) when providing direct care to Resident #8 on enhanced barrier precautions.
Improper storage of oxygen administration tubing for Resident #70, tubing was draped over oxygen regulator and not stored in a protective bag.
Report Facts
BIMS score: 10
BIMS score: 0
BIMS score: 3
Physician order date: Mar 4, 2025
Physician order date: May 8, 2023
Physician order start date: Oct 2, 2024
Physician order start date: Oct 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing wound care with multiple infection control breaches |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed regarding wound care deficiencies and infection control |
| CNA | Certified Nursing Assistant | Observed and interviewed regarding failure to wear PPE for Resident #8 |
| LPN #2 | Licensed Practical Nurse | Interviewed about proper storage of respiratory tubing |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Interviewed and observed regarding respiratory tubing storage |
| DON | Director of Nursing | Confirmed proper storage requirements for respiratory tubing |
| IP | Infection Preventionist | Interviewed regarding infection control breaches |
| RCS | Regional Clinical Supervisor | Interviewed regarding infection control breaches and policy revision |
Inspection Report
Routine
Census: 88
Deficiencies: 9
Date: 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)
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
Routine
Deficiencies: 5
Date: Feb 17, 2023
Visit Reason
The inspection visit was conducted to assess compliance with regulatory requirements related to resident care, medication management, nutrition, and facility operations at Complete Care at Plainfield LLC.
Findings
The facility was found deficient in completing a Significant Change in Status Assessment for a resident, following physician orders for medication monitoring, addressing significant weight loss and nutritional care for a resident, and proper labeling, storage, and disposal of medications in medication carts.
Deficiencies (5)
Failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set for 1 of 21 residents reviewed.
Failed to follow a physician's order for Keppra blood level monitoring every three months for 1 of 21 residents reviewed.
Failed to identify and address multiple severe weight losses, implement and monitor weekly weights, evaluate and adjust nutritional interventions, comprehensively assess after significant weight change, and revise nutritional care plan for 1 of 5 residents reviewed.
Failed to ensure the physician addressed multiple severe weight losses, implemented and monitored weekly weights, and evaluated and adjusted nutritional interventions for 1 of 5 residents reviewed.
Failed to properly label, store, and dispose of medications in 3 of 4 medication carts inspected, including undated, expired, and unlabeled medications.
Report Facts
Residents reviewed: 21
Residents reviewed: 5
Weight loss: 22.7
Weight loss: 27.9
Weight loss: 24.2
Weight loss: 23.4
Weight loss: 26.9
Weight loss: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/MDS Coordinator | Registered Nurse Minimum Data Set Coordinator | Acknowledged failure to complete Significant Change in Status Assessment for Resident #77 |
| Licensed Nursing Home Administrator | Administrator | Acknowledged failure to complete Significant Change in Status Assessment and discussed findings |
| Director of Nursing | Director of Nursing | Discussed findings related to Significant Change in Status Assessment and medication monitoring |
| RN/UM | Registered Nurse/Unit Manager | Acknowledged missed Keppra levels and failure to notify physician |
| RD | Registered Dietitian | Discussed weight monitoring, nutritional assessments, and lack of documented follow-up for Resident #47 |
| AP | Attending Physician | Acknowledged awareness of Resident #47's weight loss but did not adjust tube feeding or document interventions |
| LPN #1 | Licensed Practical Nurse | Acknowledged medication storage and labeling deficiencies in South Unit medication cart |
| LPN #2 | Licensed Practical Nurse | Acknowledged medication storage and labeling deficiencies in North Unit medication cart |
| RN #1 | Registered Nurse | Acknowledged medication labeling deficiencies in South Unit medication cart |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145741, NJ150737, NJ155497, and NJ155498.
Complaint Details
Complaint numbers NJ145741, NJ150737, NJ155497, and NJ155498 were investigated and found to be unsubstantiated as the facility was 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 based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 92
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (2)
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.
Failure to implement infection control policies and procedures to prevent the spread of infection, evidenced by staff not wearing full PPE in quarantine rooms.
Report Facts
Census: 86
Sample Size: 21
Inspection Report
Routine
Deficiencies: 2
Date: Feb 19, 2021
Visit Reason
The inspection was conducted to evaluate compliance with physician and nurse practitioner visit requirements and infection prevention and control policies during the COVID-19 pandemic.
Findings
The facility failed to ensure required face-to-face physician and nurse practitioner visits were conducted and documented for multiple residents over several months. Additionally, the facility failed to consistently implement infection control policies, as staff did not always wear full PPE when entering quarantine rooms, risking infection spread.
Deficiencies (2)
Failure to ensure physician and nurse practitioner visits were conducted in person and documented at required intervals for multiple residents.
Failure to implement infection control policies properly, including staff not wearing full PPE when entering quarantine rooms.
Report Facts
Residents affected: 6
Months without physician visits: 11
Months without NP visits: 3
Quarantine period: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner (NP) | Interviewed about missed visits and absences in April, October, and November 2020. | |
| Unit Manager/Registered Nurse (UM/RN) | Provided information about physician and NP visits and PPE requirements. | |
| Licensed Practical Nurse (LPN) | Observed during medication pass and PPE use discussion. | |
| Certified Nursing Assistant (CNA) | Observed not wearing full PPE while cleaning in a quarantine room. | |
| Infection Preventionist (IP) | Provided explanation of PPE requirements and in-service training. | |
| Director of Nursing (DON) | Discussed concerns about physician visits and PPE expectations. |
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