Inspection Reports for Complete Care At Shrewsbury Llc
89 Avenue At The Common, NJ, 07702
Back to Facility ProfileDeficiencies per Year
20
15
10
5
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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Jan 16, 2025
Visit Reason
The inspection was conducted in response to complaints NJ00175822, NJ00176055, NJ00176481, and NJ00177219 to determine compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with requirements related to food temperature and staffing ratios. Specifically, hot foods were not served at safe temperatures and the facility failed to maintain required minimum staffing ratios for Certified Nurse Aides on multiple days.
Complaint Details
The complaint investigation was based on multiple complaint numbers. The facility was found not in substantial compliance with federal and state regulations. The food temperature deficiency was substantiated with observations, interviews, and documentation review. Staffing deficiencies were documented based on review of facility staffing records and state law requirements.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Food and drink that is palatable, attractive, and at a safe and appetizing temperature was not met; hot foods were served below the required temperature of 135 degrees F. | SS=D |
| Facility failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 4 day shifts. | — |
Report Facts
Census: 90
Sample Size: 5
Certified Nurse Aides (CNAs) staffing: 10
Certified Nurse Aides (CNAs) staffing: 10
Certified Nurse Aides (CNAs) staffing: 10
Certified Nurse Aides (CNAs) staffing: 10
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Jul 23, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00175673 to investigate allegations related to staff certification verification and implementation of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program.
Findings
The facility failed to obtain and keep a record of employee certification verification for one of three sampled agency employees (Certified Nursing Assistant #1) and did not properly implement their Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Additionally, staffing ratios were not met on 5 of 14 day shifts, and the facility did not ensure staff providing direct care were properly vetted for criminal history and certification status.
Complaint Details
Complaint #NJ00175673 involved allegations that the facility failed to verify employee certification and implement abuse prevention policies. The complaint was substantiated based on employee file review and interviews.
Severity Breakdown
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to obtain and keep a record of employee certification verification and implement Abuse, Neglect, Exploitation and Misappropriation Prevention Program for 1 of 3 sampled agency employees. | SS=D |
| Failed to maintain required minimum staff-to-resident ratios on 5 of 14 day shifts. | — |
| Failed to ensure staff providing direct care were in good physical and mental health, emotionally stable, of good moral character, and not convicted of crimes adversely affecting ability to provide care. | — |
Report Facts
Census: 91
Sample Size: 3
Deficient day shifts: 5
Required CNAs for day shift: 12
Actual CNAs on deficient days: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Agency Employee | Named in deficiency for lack of certification verification and suspended certification status |
| Human Resource Director | Involved in verification process and corrective action plan | |
| Staffing Coordinator | Involved in verification process and corrective action plan | |
| Licensed Nursing Home Administrator | Provided in-service training and verification oversight |
Inspection Report
Routine
Census: 95
Deficiencies: 0
Jul 2, 2024
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.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 140
Deficiencies: 19
May 30, 2024
Visit Reason
A Recertification and Complaint survey was conducted at Complete Care at Shrewsbury from 05/21/2024 through 05/30/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified an Immediate Jeopardy related to failure to ensure adequate supervision of Resident #60 to prevent harm to and from other residents. Additional deficiencies included failure to timely report alleged violations, failure to provide transfer notices, inaccurate assessments, incomplete baseline care plans, inadequate assistance with activities of daily living, improper respiratory care, unsafe bedrail use, food safety violations, infection control lapses, fire alarm system deficiencies, sprinkler system coverage issues, corridor door latching problems, smoke barrier penetrations, gas and vacuum system deficiencies, electrical system inspection failures, and improper storage of oxygen cylinders.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed. The survey included a recertification and complaint survey to investigate allegations of abuse, neglect, and failure to comply with regulatory requirements. Immediate Jeopardy was identified related to Resident #60's supervision.
Severity Breakdown
J: 1
D: 7
E: 2
F: 8
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision of Resident #60 to prevent potential harm to and from other residents, constituting Immediate Jeopardy. | J |
| Failure to timely report alleged violations of abuse and neglect. | D |
| Failure to provide required transfer notices to residents and representatives. | D |
| Failure to provide bed hold policy notification upon transfer. | E |
| Minimum Data Set (MDS) assessments did not accurately reflect residents' status. | D |
| Baseline care plans were not discussed or presented to residents and did not address all care needs. | D |
| Failure to provide scheduled assistance with activities of daily living for supplemental residents. | E |
| Failure to provide appropriate respiratory/tracheostomy care and suctioning consistent with physician orders. | D |
| Failure to assess, document, and obtain informed consent for bedrail use; failure to maintain bedrail care plans. | D |
| Failure to ensure food safety: unlabeled, undated, expired food in refrigerator; ice buildup in freezer. | D |
| Failure to maintain an effective infection prevention and control program including lack of PPE availability and use. | D |
| Failure to test and maintain fire alarm system per NFPA standards; deficiencies noted in batteries, detectors, and dialer. | F |
| Failure to provide complete sprinkler coverage in HVAC closet per NFPA 101 and NFPA 13 standards. | F |
| Corridor doors failed to latch properly and resist passage of smoke as required by NFPA 101. | F |
| Unsealed gaps and penetrations in smoke barriers allowing passage of smoke. | F |
| Smoke doors lacked self-closing door closer allowing passage of smoke. | F |
| Oxygen medical gas system alarms active; system not repaired per NFPA 99 requirements. | F |
| Failure to maintain weekly inspection records of emergency generator as required by NFPA 110. | F |
| Oxygen cylinders not properly secured, missing full/empty signage, and stored near combustibles. | F |
Report Facts
Survey Census: 104
Total Licensed Capacity: 140
Sample Size: 21
Supplemental Residents: 17
Deficiency counts: 18
Deficiency counts: 37
Deficiency counts: 40
Deficiency counts: 21
Deficiency counts: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nursing Assistant | Named in infection control finding for failure to don gowns and restock PPE |
| LPN 3 | Licensed Practical Nurse | Named in infection control finding for failure to don gowns and restock PPE |
| LPN 2 | Licensed Practical Nurse | Named in transfer notice finding for describing transfer procedures |
| Director of Nursing Services | Named in multiple findings including supervision of Resident #60, reporting, and corrective actions | |
| Social Services Director | Named in findings related to abuse prevention and reporting | |
| Administrator | Named in findings related to abuse prevention and reporting | |
| Nurse Consultant | Named in MDS accuracy and care plan education | |
| Certified Nurse Aide 1 | CNA | Named in ADL assistance finding describing resident shower schedules |
| Certified Nurse Aide 3 | CNA | Named in interview about Resident #60 supervision |
| Licensed Practical Nurse 3 | LPN | Named in respiratory care and infection control findings |
Inspection Report
Routine
Census: 91
Deficiencies: 0
Apr 5, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 91
Deficiencies: 0
Dec 11, 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: 8
Inspection Report
Routine
Census: 87
Deficiencies: 0
Jul 5, 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: 7
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 6
Mar 10, 2022
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 deficient in multiple areas including failure to maintain required minimum direct care staff ratios, inaccurate resident assessments, improper respiratory care and suctioning, failure to address consultant pharmacist recommendations, inappropriate use of psychotropic medications, and unsafe food handling and temperature control practices.
Severity Breakdown
SS=B: 1
SS=D: 3
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey for multiple shifts. | — |
| Failed to ensure that an accurate Minimum Data Set (MDS) assessment was completed for a sampled resident. | SS=B |
| Failed to implement infection control measures for handling and storage of respiratory equipment and lacked physician order for use of equipment for a resident. | SS=D |
| Failed to address consultant pharmacist recommendations, including lack of documentation of physician acceptance or denial of recommendations. | SS=D |
| Failed to ensure that PRN psychotropic medications were administered for no more than 14 days without further evaluation and documentation of rationale. | SS=D |
| Failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner, including serving foods below minimum hot holding temperatures. | SS=E |
Report Facts
Census: 94
Deficient CNA staffing days: 7
Deficient CNA staffing evening shifts: 2
Resident sample size: 21
Resident sample size: 5
Food temperature: 111.3
Food temperature: 95
Food temperature: 95
Food temperature: 146
Food temperature: 127.1
Food temperature: 106.5
Food temperature: 155
Food temperature: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing schedules and responsibilities |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, respiratory care, medication management, and consultant pharmacist recommendations |
| Registered Dietitian | Registered Dietitian | Interviewed regarding Minimum Data Set assessment accuracy |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Interviewed regarding respiratory care and equipment storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication regimen review and consultant pharmacist recommendations |
| Dietary Supervisor | Dietary Supervisor | Observed monitoring food temperatures and handling food safety |
| Director of Food Service | Director of Food Service | Interviewed and observed regarding food temperature control and reheating procedures |
Inspection Report
Life Safety
Deficiencies: 1
Mar 10, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 03/10/2022 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant due to failure to provide audible and visible fire alarm notification signals in the outside enclosed courtyard area, which could affect residents, visitors, and staff in the event of a fire alarm activation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide notification by audible and visible signals for 1 of 1 outside enclosed courtyards in accordance with NFPA 101 and NFPA 72 standards. | SS=D |
Report Facts
Smoke zones: 7
Stories: 3
Deficiencies cited: 1
Installation completion date: Apr 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Senior Director of Plant Operations | Present during inspection and confirmed findings. | |
| Assistant Administrator | Present during inspection and confirmed findings. | |
| Director of Plant Operations | Present during inspection, confirmed findings, and responsible for corrective actions. |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Dec 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146149 and NJ148771. Additionally, a COVID-19 Focused Infection Control Survey was performed to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, based on the complaint survey. However, the facility was found to be in compliance with infection control regulations related to COVID-19 and had implemented recommended CDC and CMS practices.
Complaint Details
Complaint numbers NJ146149 and NJ148771 triggered the survey. The facility was found not in compliance based on these complaints.
Deficiencies (1)
| Description |
|---|
| Non-compliance with requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on complaint survey |
Report Facts
Sample Size: 7
Inspection Report
Routine
Census: 95
Deficiencies: 0
Apr 8, 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.
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: 5
Inspection Report
Routine
Census: 84
Deficiencies: 0
Feb 22, 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.
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: 8
Inspection Report
Routine
Census: 83
Deficiencies: 0
Jan 11, 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.
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: 5
Inspection Report
Routine
Census: 80
Deficiencies: 0
Dec 14, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Dec 3, 2020
Visit Reason
The inspection visit was conducted in response to complaint #NJ: 141460 to assess compliance with long term care facility regulations.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Complaint Details
Complaint #NJ: 141460 was investigated and the facility was found compliant with no deficiencies cited.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 86
Deficiencies: 0
Nov 27, 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 practices for COVID-19.
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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