Inspection Reports for
Complete Care At Shrewsbury Llc
89 Avenue At The Common, Shrewsbury, NJ, 07702
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
64% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident dignity, assessments, care planning, infection control, immunizations, and safety measures.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete or inaccurate resident assessments and care plans, inadequate monitoring of wander guards, failure to ensure proper use of personal protective equipment for residents on enhanced barrier precautions, and failure to offer pneumococcal and COVID-19 vaccinations to residents.
Deficiencies (11)
Failure to ensure one resident was treated with dignity in toileting.
Failure to complete a Significant Change Minimum Data Set (MDS) for one resident.
Failure to ensure accurate coding of Minimum Data Set (MDS) assessments for five residents.
Failure to develop and implement complete care plans for five residents.
Failure to revise care plans timely for two residents.
Failure to provide nursing assessments of a surgical incision for one resident.
Failure to monitor effectiveness of wander guards and modify interventions for two residents.
Failure to complete Comprehensive Social Services Assessment upon admission for one resident.
Failure to ensure staff wore proper personal protective equipment when caring for residents on Enhanced Barrier Precautions.
Failure to offer and/or provide pneumococcal immunizations to four residents.
Failure to offer and/or provide COVID-19 immunizations to four residents.
Report Facts
Residents sampled: 33
Residents affected by dignity deficiency: 1
Residents affected by MDS coding deficiency: 5
Residents affected by care plan deficiencies: 7
Residents affected by PPE deficiency: 2
Residents affected by immunization deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Commented on dignity and care plan deficiencies |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan development, wander guard assessments, and immunization responsibilities |
| Registered Dietician 1 | Registered Dietician | Responsible for nutrition care plan updates |
| Registered Dietician 2 | Registered Dietician | Responsible for MDS nutrition coding |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Observed not wearing PPE for resident on Enhanced Barrier Precautions |
| Social Services Director | Social Services Director | Interviewed regarding incomplete social services assessment |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Unit manager, responsible for immunization education and consent |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Involved in dignity deficiency incident |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Observed not wearing PPE for resident on Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
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.
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
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted based on complaint NJ00176055 regarding food temperatures and adherence to the facility's Test Tray Policy during meal service.
Complaint Details
Complaint NJ00176055 was substantiated; the facility failed to maintain appropriate food temperatures and did not comply with its Test Tray Policy as required.
Findings
The facility failed to serve hot foods at an acceptable temperature, with measured food temperatures below the required 135 degrees Fahrenheit. Additionally, the facility did not follow its Test Tray Policy, as test trays were only conducted when complaints were received and no documentation was provided.
Deficiencies (2)
Failure to serve hot foods at an acceptable temperature for residents.
Failure to follow the facility's Test Tray Policy requiring weekly test trays at random mealtimes.
Report Facts
Food temperature - Baked Ham: 117.7
Food temperature - Roasted Potatoes: 123.9
Food temperature - Broccoli: 121.6
Residents meals on cart: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding food temperature complaints and test tray policy; observed calibrating thermometer and measuring food temperatures | |
| Administrator | Interviewed regarding food temperature findings | |
| Director of Nursing | Interviewed regarding food temperature findings |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
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.
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
Complaint Investigation
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
The inspection was conducted based on complaint NJ00175673 to investigate the facility's failure to obtain and keep a record of an employee certification verification and to implement their Abuse, Neglect, Exploitation and Misappropriation Prevention Program.
Complaint Details
Complaint NJ00175673 was substantiated based on interviews, employee file review, and document review showing failure to verify CNA #1's certification which was suspended since 3/7/24.
Findings
The facility failed to verify and document the certification status of a Certified Nursing Assistant (CNA #1) before providing care, despite the CNA's certification being suspended since 3/7/24. The facility was unable to provide evidence of certification verification prior to care dates 5/22/24 and 6/15/24.
Deficiencies (1)
Failure to obtain and keep a record of an employee certification verification and to implement the Abuse, Neglect, Exploitation and Misappropriation Prevention Program for agency staff.
Report Facts
Residents Affected: 3
Certification Suspended Since: Mar 7, 2024
Certification Verification Dates Missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in deficiency for failure of certification verification |
| Human Resources Director | Interviewed regarding certification verification process | |
| Licensed Nursing Home Administrator | Interviewed regarding certification verification process |
Inspection Report
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility Complete Care at Shrewsbury LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 95
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (19)
Failure to ensure adequate supervision of Resident #60 to prevent potential harm to and from other residents, constituting Immediate Jeopardy.
Failure to timely report alleged violations of abuse and neglect.
Failure to provide required transfer notices to residents and representatives.
Failure to provide bed hold policy notification upon transfer.
Minimum Data Set (MDS) assessments did not accurately reflect residents' status.
Baseline care plans were not discussed or presented to residents and did not address all care needs.
Failure to provide scheduled assistance with activities of daily living for supplemental residents.
Failure to provide appropriate respiratory/tracheostomy care and suctioning consistent with physician orders.
Failure to assess, document, and obtain informed consent for bedrail use; failure to maintain bedrail care plans.
Failure to ensure food safety: unlabeled, undated, expired food in refrigerator; ice buildup in freezer.
Failure to maintain an effective infection prevention and control program including lack of PPE availability and use.
Failure to test and maintain fire alarm system per NFPA standards; deficiencies noted in batteries, detectors, and dialer.
Failure to provide complete sprinkler coverage in HVAC closet per NFPA 101 and NFPA 13 standards.
Corridor doors failed to latch properly and resist passage of smoke as required by NFPA 101.
Unsealed gaps and penetrations in smoke barriers allowing passage of smoke.
Smoke doors lacked self-closing door closer allowing passage of smoke.
Oxygen medical gas system alarms active; system not repaired per NFPA 99 requirements.
Failure to maintain weekly inspection records of emergency generator as required by NFPA 110.
Oxygen cylinders not properly secured, missing full/empty signage, and stored near combustibles.
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
Complaint Investigation
Deficiencies: 12
Date: May 30, 2024
Visit Reason
The inspection was conducted due to complaints and allegations related to resident abuse, injury of unknown origin, failure to report incidents timely, inadequate investigation of abuse, failure to notify ombudsman of transfers, inaccurate resident assessments, failure to provide baseline care plans timely, inadequate assistance with activities of daily living, improper respiratory care, unsafe use of bed rails, and infection control deficiencies.
Complaint Details
The complaint investigation revealed multiple issues including immediate jeopardy related to resident abuse by Resident #60, failure to timely report injuries and abuse, failure to investigate abuse incidents thoroughly, failure to notify Ombudsman of resident transfers, inaccurate resident assessments, failure to provide baseline care plans timely, inadequate assistance with showers, improper respiratory care, unsafe use of bed rails, and infection control deficiencies related to PPE availability and use.
Findings
The facility failed to ensure adequate supervision to prevent resident-to-resident abuse, timely reporting of injuries and abuse, thorough investigation of abuse incidents, notification of ombudsman for resident transfers, accurate resident assessments, timely baseline care plans, adequate assistance with showers, proper respiratory care including oxygen therapy, assessment and care planning for bed rail use, and proper infection prevention including availability and use of PPE.
Deficiencies (12)
Failure to ensure adequate supervision to prevent resident-to-resident abuse leading to immediate jeopardy.
Failure to timely report injury of unknown origin and abuse allegations to proper authorities.
Failure to thoroughly investigate resident-to-resident abuse incident.
Failure to notify Ombudsman of resident transfers and provide transfer rights information.
Failure to provide copies of bed hold policy to residents or responsible parties upon transfer.
Failure to ensure Minimum Data Set (MDS) assessments accurately reflected resident wandering behaviors.
Failure to discuss and present baseline care plan within 48 hours of admission and failure to address use of wander-guard in care plan.
Failure to provide scheduled showers to seven residents, risking decline in ability to perform activities of daily living.
Failure to change nebulizer tubing per physician's orders and lack of physician order for continuous oxygen therapy.
Failure to assess, document, and care plan for use of bed rails and failure to obtain informed consent.
Failure to ensure PPE was available and staff donned appropriate PPE for residents on Enhanced Barrier Precautions.
Failure to ensure food in refrigerator was labeled, dated, and free of dirt and sticky shelves; freezer had ice buildup.
Report Facts
Residents reviewed for abuse: 2
Sample size of residents reviewed: 21
BIMS scores: 3
BIMS score: 15
Number of residents not receiving scheduled showers: 7
Date of survey completion: May 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nurse Aide | Named in infection control finding for not having gowns available while caring for Resident #9 |
| LPN 3 | Licensed Practical Nurse | Named in infection control finding for not wearing gown while caring for Resident #140 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including abuse investigation, care plans, and shower assistance |
| Administrator | Administrator | Interviewed regarding abuse findings, shower assistance, and bed rail assessment |
| Unit Manager/LPN | Unit Manager/Licensed Practical Nurse | Interviewed regarding oxygen therapy and PPE restocking |
| Business Office Manager | Business Office Manager | Interviewed regarding transfer notifications and bed hold notices |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: May 30, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident supervision, abuse, injury reporting, transfer notifications, care planning, and infection control at Complete Care at Shrewsbury LLC.
Complaint Details
The complaint investigation focused on allegations of inadequate supervision leading to resident abuse, failure to report injuries and abuse timely, failure to investigate abuse incidents, failure to notify residents and ombudsman of transfers, failure to provide bed hold policy information, inaccurate resident assessments, inadequate assistance with showers, improper respiratory care, unsafe use of bed rails, improper food storage, and inadequate infection control practices including PPE availability and use.
Findings
The facility failed to ensure adequate supervision to prevent resident-to-resident abuse, timely reporting of injuries and abuse allegations, thorough investigations of abuse incidents, notification of transfers and bed hold policies, accurate resident assessments and care plans, adequate assistance with showers, proper respiratory care, safe use of bed rails, proper food storage and labeling, and availability and use of personal protective equipment for residents on Enhanced Barrier Precautions.
Deficiencies (12)
Failure to ensure adequate supervision to prevent resident-to-resident abuse, resulting in immediate jeopardy.
Failure to timely report suspected abuse and injury of unknown origin to proper authorities.
Failure to thoroughly investigate resident-to-resident abuse incidents.
Failure to provide timely notification of transfers to residents and ombudsman.
Failure to provide residents with bed hold policy information upon transfer.
Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting resident wandering behaviors.
Failure to discuss and present baseline care plan within 48 hours of admission and address use of wander-guard.
Failure to ensure adequate assistance with showers for seven supplemental residents.
Failure to change nebulizer tubing per physician's orders and lack of physician order for continuous oxygen therapy.
Failure to assess, obtain informed consent, and care plan for use of bed rails for one resident.
Failure to ensure food in refrigerator was labeled, dated, and free of dirt and sticky shelves; freezer had ice buildup.
Failure to ensure personal protective equipment was available and used appropriately for residents on Enhanced Barrier Precautions.
Report Facts
Deficiencies cited: 12
Resident BIMS scores: 3
Resident BIMS scores: 14
Resident shower frequency: 1
Oxygen tubing change date: May 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nurse Aide | Mentioned in relation to failure to don gowns for resident on Enhanced Barrier Precautions. |
| LPN 3 | Licensed Practical Nurse | Mentioned in relation to failure to don gowns and failure to change oxygen tubing. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan development and shower assistance issues. |
| Unit Manager/LPN | Unit Manager/Licensed Practical Nurse | Interviewed regarding PPE availability and oxygen tubing change responsibilities. |
| Administrator | Administrator | Confirmed lack of assessment and policies for bed rail use and acknowledged shower documentation issues. |
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: 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
Annual Inspection
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Complete Care at Shrewsbury LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: 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
Annual Inspection
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
Annual survey inspection of Complete Care at Shrewsbury LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 87
Deficiencies: 0
Date: 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
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Complete Care at Shrewsbury LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 6
Date: 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.
Deficiencies (6)
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.
Failed to implement infection control measures for handling and storage of respiratory equipment and lacked physician order for use of equipment for a resident.
Failed to address consultant pharmacist recommendations, including lack of documentation of physician acceptance or denial of recommendations.
Failed to ensure that PRN psychotropic medications were administered for no more than 14 days without further evaluation and documentation of rationale.
Failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner, including serving foods below minimum hot holding temperatures.
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
Date: 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.
Deficiencies (1)
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.
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
Routine
Deficiencies: 5
Date: Mar 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, respiratory care, food safety, and facility sanitation.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, lack of physician orders for oxygen use, failure to follow pharmacist recommendations, improper administration of psychotropic medications, and unsafe food handling and temperature control practices.
Deficiencies (5)
Failure to ensure an accurate Minimum Data Set (MDS) assessment for Resident #13.
Failure to implement infection control measures for respiratory equipment and lack of physician order for oxygen use for Resident #54.
Failure to address Consultant Pharmacist recommendations regarding medication regimen for Resident #37.
Failure to ensure PRN psychotropic medications were administered for no more than 14 days without further evaluation for Resident #35.
Failure to handle potentially hazardous food and maintain kitchen sanitation, including serving hot foods below required temperatures.
Report Facts
Residents reviewed for MDS accuracy: 21
Residents reviewed for respiratory care: 2
Residents reviewed for medication regimen: 5
Residents reviewed for unnecessary medication use: 5
Temperature readings: 111.3
Temperature readings: 95
Temperature readings: 95
Temperature readings: 146
Temperature readings: 127.1
Temperature readings: 106.5
Temperature readings: 155
Temperature readings: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) | Acknowledged inaccurate MDS completion for Resident #13 | |
| Registered Nurse Unit Manager (RNUM #1) | Noted improper oxygen tubing handling and lack of physician order for Resident #54 | |
| Director of Nursing (DON) | Provided information on oxygen use and PRN psychotropic medication policies | |
| Registered Nurse Unit Manager (RNUM #2) | Reviewed medication administration records for Resident #37 | |
| Assistant Director of Nursing (ADON) | Spoke with physician regarding pharmacist recommendations and acknowledged lack of documentation | |
| Corporate Nurse | Confirmed no documentation of pharmacy recommendation acknowledgment | |
| Dietary Supervisor (DS) | Observed serving food below safe temperature and improper thermometer use | |
| Director of Food Service (DOFS) | Reheated food and explained food temperature requirements | |
| Consultant Pharmacist (CP) | Provided medication regimen review and recommendations | |
| Nurse Practitioner (NP) | Documented rationale for PRN psychotropic medication use for Resident #35 | |
| President of Nursing (CVPN) | Discussed physician rationale documentation for PRN medication orders |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: 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.
Complaint Details
Complaint numbers NJ146149 and NJ148771 triggered the survey. The facility was found not in compliance based on these complaints.
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.
Deficiencies (1)
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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.
Complaint Details
Complaint #NJ: 141460 was investigated and the facility was found compliant with no deficiencies cited.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: 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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