Inspection Reports for Complete Care at Shorrock Gardens
75 Old Toms River Rd, Brick Township, NJ 08723, United States, NJ, 08723
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
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, the circumstances under which health information may be used or disclosed, and the legal duties and rights of individuals regarding their health information 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: 180
Deficiencies: 1
Apr 9, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00175128 and NJ00183951 regarding staffing ratios at the facility.
Findings
The facility failed to maintain the required minimum certified nursing assistant (CNA) staffing ratios as mandated by New Jersey state law for multiple day shifts during three separate weeks in 2024 and 2025. The facility was found deficient in CNA staffing on multiple days, with fewer CNAs than required for the resident census.
Complaint Details
The complaint investigation found the facility deficient in maintaining minimum CNA staffing ratios on multiple days during the weeks of 06/16/2024 to 06/22/2024, 02/16/2025 to 02/22/2025, and 03/23/2025 to 04/05/2025. The facility was not in compliance with New Jersey staffing requirements as per N.J.S.A. 30:13-18.
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 13-day shifts. |
Report Facts
Census: 180
Deficient CNA staffing days: 7
Deficient CNA staffing days: 4
Deficient CNA staffing days: 6
Required CNAs: 19
Required CNAs: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as re-educated on minimum staffing requirements. | |
| Human Resources Director | Named as re-educated on minimum staffing requirements. | |
| Staffing Coordinator | Named as re-educated on minimum staffing requirements. | |
| Administrator | Provided re-education on minimum staffing requirements on 4/28/2025. |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Jul 24, 2024
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ00175701) to investigate allegations related to staffing ratios at Complete Care at Shorrock.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39-5.1(a) regarding mandatory access to care due to failure to maintain required minimum direct care staff-to-resident ratios on 14 of 14 day shifts reviewed. The facility failed to meet the minimum Certified Nurse Aide (CNA) staffing requirements as mandated by the state.
Complaint Details
Complaint #: NJ00175701. The facility was found deficient in CNA staffing for residents on 14 of 14 day shifts. The complaint survey determined the facility failed to meet minimum staffing requirements. The facility was monitored for adverse effects with none noted.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey on 14 of 14 day shifts. |
Report Facts
Census: 148
Deficient CNA staffing days: 14
Required CNAs vs Actual CNAs: 19
Actual CNAs: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as re-educated on minimum staffing requirements. | |
| Human Resources Director | Named as re-educated on minimum staffing requirements. | |
| Staffing Coordinator | Named as re-educated on minimum staffing requirements. | |
| Administrator | Provided re-education on staffing requirements and implemented corrective actions. |
Inspection Report
Annual Inspection
Census: 158
Capacity: 180
Deficiencies: 17
May 29, 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 reporting and investigating alleged violations, ADL care provision, dialysis care, physician visits, staffing, food safety, infection control, and life safety code compliance.
Complaint Details
Multiple complaints (NJ #: 157735; 160630; 161027; 164199; 169902; 170619; 172027) triggered the survey. The facility failed to notify the Clearing House Coordinator of a CNA terminated for impairment discovered during duty as mandated by the State of New Jersey.
Severity Breakdown
SS=D: 7
SS=E: 5
SS=F: 4
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to notify the New Jersey Department of Health of an allegation of neglect for a Certified Nursing Aide found impaired during a shift. | SS=D |
| Failure to investigate an allegation of neglect when a Certified Nursing Aide was discovered impaired during a shift. | SS=D |
| Failure to ensure ADL care was provided to dependent residents for 5 of 8 residents observed during rounds. | SS=E |
| Failure to ensure residents receiving dialysis were assessed and care planned according to professional standards. | SS=E |
| Failure to ensure physician visits were documented and timely for residents reviewed. | SS=D |
| Failure to ensure sufficient and competent nursing staff were available to provide care to residents. | SS=E |
| Failure to properly store potentially hazardous foods, maintain food-contact surfaces, and maintain sanitary storage areas. | SS=E |
| Failure to properly dispose and maintain cardboard waste in dumpster areas. | SS=E |
| Failure to maintain infection control standards including hand hygiene during meal service and resident care. | SS=E |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
| Failure to notify the Clearing House Coordinator of a Certified Nursing Aide terminated for impairment discovered during duty. | — |
| Failure to have a Registered Nurse on duty at all times in a facility with more than 150 licensed beds. | SS=D |
| Failure to separate hazardous areas from other parts of the facility with required self-closing doors. | SS=D |
| Failure to ensure interior wall finishes had a flame spread rating in accordance with NFPA 101 Life Safety Code. | SS=F |
| Failure to maintain the sprinkler system in accordance with NFPA 25 Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. | SS=F |
| Failure to ensure penetrations in smoke barriers were protected by a system or material capable of restricting the transfer of smoke and smoke barriers were continuous. | SS=F |
| Failure to ensure oxygen cylinders were secured in accordance with NFPA 99 Health Care Facilities Code. | SS=F |
Report Facts
CNA staffing deficiency: 63
Deficient RN shifts: 12
Residents present: 158
Total licensed beds: 180
Deficiency completion dates: Most deficiencies corrected by 07/10/2024 or 07/19/2024 as per revisit report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA #1) | Named in neglect and impairment findings, terminated after being found impaired on duty. | |
| Licensed Practical Nurse (LPN #1) | Named in infection control hand hygiene deficiency. | |
| Activity Aide (AA #1) | Named in infection control hand hygiene deficiency. | |
| Restorative Aide (RA #1) | Named in infection control hand hygiene deficiency. | |
| Licensed Practical Nurse (LPN #2) | Named in wound care infection control deficiency. | |
| Certified Nursing Aide (CNA #3) | Named in infection control hand hygiene deficiency. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding reporting of impaired CNA and staffing. | |
| Director of Nursing (DON) | Interviewed regarding reporting of impaired CNA and staffing. | |
| Staffing Coordinator | Interviewed regarding staffing deficiencies. | |
| Regional Director of Maintenance | Conducted trainings and audits related to fire safety and oxygen cylinder deficiencies. |
Inspection Report
Routine
Census: 154
Deficiencies: 0
Aug 22, 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: 6
Inspection Report
Routine
Census: 114
Deficiencies: 8
May 10, 2022
Visit Reason
A Recertification Survey was conducted on 05/10/22 to determine compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Findings
The facility was found to be in wide-spread system failure resulting in Immediate Jeopardy related to failure to initiate COVID-19 testing promptly and failure to follow infection control guidance. Multiple deficiencies were cited including issues with reasonable accommodations, comprehensive care plans, infection control, life safety code violations, and COVID-19 testing.
Severity Breakdown
S=S: E: 1
S=S=E: 1
S=F: 1
S=L: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to respond to a resident call light in a timely manner to provide toileting assistance. | S=S: E |
| Failure to develop and implement a comprehensive person-centered care plan with measurable objectives and individualized interventions. | S=S=E |
| Failure to establish and maintain an infection prevention and control program. | S=F |
| Failure to conduct COVID-19 testing of residents and staff as required. | S=L |
| Failure to maintain required staffing ratios for Certified Nurse Aides. | — |
| Failure to provide proper fire sprinkler coverage in all areas of the facility. | — |
| Failure to maintain emergency lighting and exit signage as required. | — |
| Failure to maintain smoke barrier partitions in the building. | — |
Report Facts
Census: 114
Sample size: 56
Deficiency units: 3
Residents tested positive: 9
Certified Nurse Aides required: 15
Certified Nurse Aides present: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to call light response and infection control findings |
| Certified Nursing Assistant | CNA #1 | Named in relation to COVID-19 exposure and failure to report symptoms |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Named in relation to call light response and resident care |
| Temporary Nursing Assistant | TNA | Named in relation to resident care and call light response |
| Administrator | Facility Administrator | Named in relation to infection control and outbreak management |
| Director of Maintenance | Director of Maintenance (DOM) | Named in relation to life safety and fire safety deficiencies |
| Licensed Nursing Home Administrator | LNHA | Named in relation to life safety and fire safety deficiencies |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Jan 13, 2022
Visit Reason
The inspection was conducted due to a complaint (NJ151121) regarding the facility's compliance with staffing ratios as mandated by the state of New Jersey.
Findings
The facility failed to meet the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 11 of 14 day shifts reviewed, potentially affecting all residents. The facility implemented corrective actions including recruitment efforts and monitoring to address the staffing deficiencies.
Complaint Details
Complaint NJ151121 was substantiated as the facility did not meet minimum CNA staffing ratios on multiple day shifts between 12/26/2021 and 01/08/2022.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios for CNAs on 11 of 14 day shifts. |
Report Facts
Census: 109
Deficient day shifts: 11
Required CNAs: 14
Actual CNAs: 9
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Oct 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted based on complaint NJ149449 to assess compliance with infection control regulations during the COVID-19 pandemic.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure dietary staff performed proper hand hygiene during food preparation and service, and housekeeping staff failed to observe manufacturer recommended disinfectant contact times and proper hand hygiene between cleaning tasks.
Complaint Details
Complaint #: NJ149449. The survey was triggered by a complaint and focused on infection control practices during the COVID-19 pandemic. The facility was found non-compliant with infection control regulations.
Severity Breakdown
F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure dietary staff performed hand hygiene between tasks, including improper glove use and contamination of residents' meal plates. | F |
| Failure to implement an effective infection prevention and control program, including housekeeping staff not observing disinfectant contact times and improper hand hygiene. | F |
Report Facts
Census: 109
Sample Size: 5
Deficiency Completion Date: Nov 18, 2021
Deficiency Completion Date: Dec 14, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Observed failing to perform hand hygiene and glove changes while handling residents' meal plates. | |
| Dietary Aide #2 | Observed failing to perform hand hygiene and glove changes while preparing food. | |
| Dietary Aide #3 | Observed failing to perform hand hygiene while serving meals. | |
| Chef #1 | Observed holding serving dishes against contaminated clothing and failing to maintain sanitary conditions. | |
| Housekeeper #1 | Observed not performing hand hygiene, improper disinfectant use, and cross-contamination risks during cleaning. | |
| Housekeeper #2 | Observed not performing hand hygiene, improper disinfectant use, and cross-contamination risks during cleaning. | |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control deficiencies and risks. |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control program deficiencies and training. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Jun 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ137675, NJ140304, and NJ141995.
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 NJ137675, NJ140304, and NJ141995 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 97
Deficiencies: 0
Dec 10, 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 related to COVID-19.
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: 3
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