Inspection Reports for Complete Care At Regent Llc
50 Polifly Road, NJ, 07601
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 19, 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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health data, 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: 157
Deficiencies: 1
Feb 22, 2024
Visit Reason
The inspection was conducted based on complaint #NJ00170087 to investigate staffing ratio compliance at Complete Care at Regent LLC.
Findings
The facility failed to meet the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 27 of 28 day shifts reviewed, indicating a deficiency in staffing levels as mandated by New Jersey state law.
Complaint Details
Complaint #NJ00170087 was substantiated as the facility failed to meet minimum CNA staffing ratios on 27 of 28 day shifts reviewed. No residents were directly affected, but all had the potential to be affected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 27 of 28 day shifts. |
Report Facts
Census: 157
Days deficient in CNA staffing: 27
Required CNA staffing: 19
Actual CNA staffing: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided in-service training to Staffing Coordinator regarding appropriate staffing levels | |
| Staffing Manager/Human Resources | Scheduled additional staff to meet minimum staffing ratios | |
| Scheduling Manager or designee | Conducts weekly and monthly audits to ensure staffing compliance |
Inspection Report
Annual Inspection
Census: 147
Capacity: 180
Deficiencies: 9
Oct 2, 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 timely and accurate completion and transmission of Minimum Data Set (MDS) assessments, accuracy of MDS coding, failure to follow professional standards in medication administration and labeling, failure to maintain proper staffing ratios, and life safety code violations including fire safety system deficiencies.
Severity Breakdown
SS=E: 3
SS=D: 2
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to accurately complete and timely transmit Minimum Data Set (MDS) for 5 of 46 residents reviewed. | SS=E |
| Facility failed to accurately code the Minimum Data Set (MDS) for 7 of 29 residents reviewed for accuracy. | SS=E |
| Facility failed to follow acceptable standards of clinical practice with regards to labeling and dating enteral feedings and following physician's orders for medication parameters. | SS=D |
| Facility failed to secure stored controlled medications and ensure expired and discontinued medications were removed timely from medication carts. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
| Doors in hazardous areas were held open by door wedges instead of automatic release devices. | SS=E |
| Fire alarm system lacked automatic smoke detection at the fire alarm control unit location. | SS=F |
| Fire alarm system and components were not tested and maintained in accordance with NFPA requirements; missing semi-annual inspections and smoke detector sensitivity tests. | SS=F |
| Sprinkler system was not inspected on a quarterly basis as required. | SS=F |
Report Facts
Residents reviewed for MDS transmission: 46
Residents reviewed for MDS coding accuracy: 29
Current census: 147
Total licensed capacity: 180
Deficient CNA staffing days: 14
Required CNA staffing: 18
Actual CNA staffing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed resident communication needs and medication administration |
| LPN #2 | Licensed Practical Nurse | Acknowledged failure to label enteral feeding water and flush bags |
| DON | Director of Nursing | Educated MDS coordinator, acknowledged late MDS transmissions, discussed staffing and medication concerns |
| MDS Coordinator | Registered Nurse | Responsible for MDS completion and coding, acknowledged errors and late transmissions |
| LNHA | Licensed Nursing Home Administrator | Informed of staffing deficiencies and MDS concerns |
| Maintenance Director | Maintenance Director | Confirmed door wedge use and fire alarm system deficiencies |
| Consultant Pharmacist | Consultant Pharmacist | Could not explain why expired medications were not removed during inspections |
| Restorative Nursing Aide | Restorative Nursing Aide | Responsible for restorative nursing exercises, acknowledged lack of care for Resident #48 |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 6
Jun 14, 2022
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/tracheostomy care and suctioning, medication administration errors, emergency lighting, fire alarm system installation, HVAC maintenance, and essential electrical system maintenance and testing.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to follow a Physician's Order for oxygen use for one resident. | SS=D |
| Medication administration error rate exceeded 5%, with errors observed in medication passes to residents. | SS=D |
| Facility failed to provide battery backup emergency lighting for the generator's transfer switch. | SS=F |
| Facility failed to provide audible and visible fire alarm notification signals in an outside fenced courtyard. | SS=E |
| Facility failed to maintain ventilation systems properly; two resident bathroom exhaust fans and one rooftop exhaust fan were not functioning. | SS=E |
| Facility failed to provide a remote manual stop station for the emergency generator. | SS=F |
Report Facts
Census: 136
Medication administration error rate: 12.12
Number of residents reviewed for respiratory care: 2
Number of residents with medication errors: 2
Number of medication opportunities observed: 33
Number of medication errors observed: 4
Number of residents with deficient oxygen care: 1
Number of exhaust fans not working: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to education and audits for medication administration and respiratory care deficiencies |
| Assistant Director of Nursing/Staff Development | ADON/SD | Responsible for education of staff and medication pass observations |
| Certified Nursing Assistant | CNA | Observed during medication administration and respiratory care |
| Licensed Practical Nurse | LPN | Observed administering medications and respiratory care |
| Consultant Pharmacist | CP | Provided medication pass observations and in-services |
| Maintenance Director | Maintenance Director | Interviewed and involved in correction of emergency lighting, fire alarm, HVAC, and generator deficiencies |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 0
Jul 9, 2021
Visit Reason
The inspection was conducted as a complaint survey related to complaint numbers NJ144813, NJ139992, and NJ142480.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities on this complaint survey.
Complaint Details
Complaint numbers NJ144813, NJ139992, and NJ142480 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 5
Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 1
Mar 12, 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 to be in compliance with infection control regulations, specifically failing to ensure proper sanitization and disinfection of equipment used by visiting providers, which posed a risk for infection spread among residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow infection control regulations for proper equipment sanitization and disinfection of instruments used to examine residents' eyes. | SS=D |
Report Facts
Sample size: 11
Deficiency correction completion date: Jun 9, 2021
Follow-up revisit date: Jul 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed infection control issues with surveyor | |
| Administrator | Discussed infection control issues with surveyor |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Dec 10, 2020
Visit Reason
The inspection was conducted as a complaint survey identified by Complaint #: NJ00135037.
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 #: NJ00135037; the facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 127
Deficiencies: 0
Nov 25, 2020
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 and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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