Inspection Reports for Complete Care At St Vincents Llc
315 East Lindsley Road, NJ, 07009
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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 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, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Jan 25, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to failure to ensure medication orders and documentation were accurate for residents, improper storage and labeling of medications in medication carts, and failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Complaint Details
Complaint numbers NJ 163099, 164140, 164735, 164747, 167673, 168219, 165875 were investigated. The facility was found deficient in maintaining minimum direct care staffing ratios on 23 of 28 day shifts reviewed, with specific CNA shortages documented for multiple dates between 08/27/2023 and 01/06/2024.
Severity Breakdown
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure there was an order for administration of medication to Resident #189 and failure to accurately document medication administration for Resident #35. | SS=E |
| Failure to ensure medications were stored and labeled appropriately in medication carts, including undated opened nebulizer solution packages and improper storage of PPD Tubersol and insulin. | SS=E |
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
Report Facts
Census: 111
Sample Size: 31
Deficiency count: 3
Staffing Deficiency Days: 23
Inspection Report
Routine
Census: 133
Deficiencies: 0
Mar 2, 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: 5
Inspection Report
Routine
Census: 113
Deficiencies: 0
Dec 14, 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
Follow-Up
Census: 118
Deficiencies: 1
Sep 28, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey minimum staffing requirements for Certified Nursing Assistants (CNAs) and to follow up on previously identified deficiencies related to staffing ratios.
Findings
The facility was found not in compliance with the state-mandated minimum direct care staff-to-resident ratios during multiple day shifts between August 22, 2021 and September 4, 2021, with census ranging from 118 to 120 residents. The facility acknowledged staffing shortages and described ongoing corrective actions including recruitment efforts, use of staffing agencies, and incentive programs.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Census range: 118
Census range: 120
Dates of non-compliance: 13
Number of staffing agencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed staffing ratio concerns with surveyor | |
| Director of Nursing | Discussed staffing ratio concerns with surveyor and involved in weekly meetings to address staffing | |
| Assistant Director of Nursing | Involved in weekly meetings to address staffing | |
| Director of HR Talent Acquisition | Involved in weekly meetings to review hiring progress | |
| HR Recruitment Specialist | Involved in weekly meetings to review hiring progress |
Inspection Report
Follow-Up
Deficiencies: 4
Jul 26, 2021
Visit Reason
The visit was a follow-up inspection to evaluate the facility's compliance with infection prevention and control requirements, specifically related to Transmission-Based Precautions (TBP) and COVID-19 protocols following a prior deficiency.
Findings
The facility failed to consistently follow appropriate isolation precaution protocols for residents on TBP, including improper use of PPE such as failure to don gowns, gloves, and eye protection before entering isolation rooms or units, and improper disposal of PPE. Hand hygiene practices were also inadequate, with staff washing hands for less than the recommended duration and not performing hand hygiene at appropriate times. The facility provided in-services and implemented corrective actions including staff training, competency reviews, and audits to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Failure to follow appropriate isolation precaution protocols for residents on Transmission-Based Precautions, including inadequate use of PPE (gown, gloves, eye protection) by staff. |
| Improper disposal of PPE outside of designated covered garbage cans inside isolation rooms. |
| Inadequate hand hygiene practices by staff, including insufficient handwashing duration and failure to perform hand hygiene at required times. |
| Maintenance staff entering isolation unit without eye protection and bringing a cart with supplies into the unit, risking cross-contamination. |
Report Facts
Date of survey completion: Jul 26, 2021
Correction completion date: Sep 30, 2021
Hand hygiene competency date: Jun 9, 2021
In-service dates: Jul 20, 2021
In-service dates: Apr 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided statements about staff and resident TBP status, confirmed PPE and hand hygiene deficiencies, and corrective actions | |
| Infection Preventionist (IP) | Provided information on facility procedures for TBP and handwashing expectations | |
| Housekeeper #1 (HK #1) | Observed not wearing eye protection and improper PPE disposal | |
| Housekeeper #2 (HK #2) | Observed doffing PPE and improper disposal outside resident room | |
| Certified Nursing Assistant (CNA) | Observed entering isolation room without donning PPE and not wearing eye protection | |
| Registered Nurse (RN) | Observed performing inadequate handwashing | |
| Maintenance Worker (MW) | Observed entering isolation unit without eye protection and bringing a cart with supplies | |
| Unit Manager (UM) | Confirmed PPE and cart usage protocols for isolation unit |
Inspection Report
Routine
Census: 106
Deficiencies: 0
Apr 26, 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: 104
Deficiencies: 0
Mar 15, 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: 84
Deficiencies: 0
Dec 15, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 14
Sample size: 1
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 4
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 related to COVID-19.
Findings
The facility was found not in compliance with infection control regulations, including failure to provide disinfectant wipes and sanitize equipment used by visitors, improper hand hygiene by staff, improper use of PPE, and failure to sanitize the testing table between specimen collections. The facility had an ongoing COVID-19 outbreak with 8 residents testing positive.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide disinfectant wipes and sanitize equipment used by visitors in the COVID-19 screening process. | SS=E |
| Failure to practice appropriate hand hygiene for 1 of 4 staff observed. | SS=E |
| Failure to ensure proper use of personal protective equipment (PPE) for 2 of 2 staff observed. | SS=E |
| Failure to ensure that workers sanitize the table used for staff testing in accordance with CDC guidelines. | SS=E |
Report Facts
Sample size: 2
Residents positive for COVID-19: 8
Staff COVID-19 testing frequency: 2
Observation period for new admissions: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding screening process and disinfectant wipes availability | |
| Registered Nurse/Unit Manager (RN/UM) | Provided information about new admissions and testing procedures | |
| Certified Nursing Aide (CNA) | Observed not wearing gown or gloves and improper hand hygiene | |
| Infection Preventionist Nurse (IPN) | Provided training and information on infection control procedures | |
| RN/MDS Coordinator | Observed not sanitizing specimen collection table between tests | |
| Licensed Nursing Home Administrator (LNHA) | Met with survey team | |
| Director of Nursing (DON) | Met with survey team and involved in infection control oversight |
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