Inspection Reports for
Complete Care at Shorrock Gardens

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.

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 #: 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.

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.

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.

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.

The investigation was triggered by multiple complaint numbers (NJ#: 160630; 169902; 170619; 172027; 161027; 157735; 164199) alleging inadequate incontinence care, missed showers, insufficient staffing, and failure to ensure physician documentation and visits. The complaints were substantiated with observations, interviews, and record reviews confirming deficiencies.

The facility failed to provide adequate incontinence care and assistance with activities of daily living for multiple residents, failed to provide scheduled showers consistently due to staffing shortages, and failed to ensure timely physician progress notes and face-to-face visits. Deficiencies were observed in care practices, staffing adequacy, and documentation.

The investigation was triggered by multiple complaints (NJ# 160630, 169902, 170619, 172027, 161027, 157735) alleging neglect, inadequate care, and regulatory violations.

The facility was found deficient in timely reporting suspected abuse and neglect, providing adequate incontinence and ADL care, ensuring safe dialysis care, maintaining proper physician documentation and visits, staffing adequacy, food safety and sanitation, waste disposal, and infection control practices.

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.

The complaint investigation was triggered by allegations of delayed response to call lights, inadequate care planning for residents, and failure to control and prevent the spread of COVID-19, including delayed testing and contact tracing after a staff member tested positive.

The facility failed to respond timely to a resident's call light for toileting assistance, did not develop comprehensive person-centered care plans for residents with documented needs, and failed to immediately conduct COVID-19 testing and contact tracing after a symptomatic unvaccinated staff member tested positive, resulting in an outbreak.

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.

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 #: 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.

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.

The investigation was complaint-driven, focusing on medication administration errors, environmental safety hazards, expired emergency medications, and call light responsiveness. The complaint was substantiated with findings of multiple deficiencies.

The facility failed to administer medication according to physician orders, failed to notify physicians about missing medications, allowed medical equipment to be plugged into power strips contrary to policy, failed to remove expired medications from emergency carts, and had a call light system that was inaudible and not answered timely by staff.