Inspection Reports for Complete Care At Wall Llc
1725 Meridian Trail, Wall, NJ, 07719
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies and focused on informing individuals about privacy practices. Earlier inspections showed a mixed pattern, with prior routine and complaint investigations generally finding the facility in substantial compliance, though a March 17, 2023 routine inspection cited multiple deficiencies related to fire safety, sprinkler systems, elevator testing, fire drills, and generator equipment. A complaint investigation in March 2022 found deficiencies in maintaining required certified nursing assistant staffing ratios, but corrective actions were implemented. Complaint investigations were mostly unsubstantiated except for the staffing issue, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed earlier issues, with recent inspections showing improvement in compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
77 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy 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 explains 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 | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The inspection was conducted in response to complaint NJ176466 to assess compliance with long term care facility regulations.
Complaint Details
Complaint NJ176466 was investigated and the facility was found to be in substantial compliance with no deficiencies cited.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and the New Jersey Administrative Code, Chapter 8:39, based on this complaint visit.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ162639.
Complaint Details
Complaint #: NJ162639 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit. Additionally, the facility was in compliance with New Jersey Administrative Code, Chapter 8:39 standards for licensure of long term care facilities.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 85
Capacity: 130
Deficiencies: 7
Date: Mar 17, 2023
Visit Reason
Routine inspection conducted to assess compliance with federal and state regulations for long term care facilities, including life safety and physical environment standards.
Findings
The facility was found to be in substantial compliance overall but had multiple deficiencies related to fire safety, sprinkler system installation and maintenance, elevator testing, fire drills, and generator equipment. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (7)
Failure to inspect fire doors annually in accordance with NFPA 80 for 12 of 12 fire doors observed.
Failure to ensure cooking equipment was protected according to NFPA 96; combustible materials stored near electric food warming system.
Failure to provide complete sprinkler coverage in HVAC closet approximately 5' x 2'.
Failure to have 4 private fire hydrants inspected annually as required by NFPA 25.
Failure to provide documented evidence of monthly firefighter's service testing for 2 elevators.
Failure to conduct fire drills with varying activation types and simulation of specific emergency fire conditions.
Failure to ensure a remote manual stop station was installed for the exterior generator as required by NFPA 110.
Report Facts
Deficiencies cited: 7
Fire doors inspected: 12
Fire hydrants: 4
Elevators: 2
Certified beds: 130
Current census: 85
Inspection Report
Routine
Census: 85
Capacity: 130
Deficiencies: 7
Date: Mar 17, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with fire safety, sprinkler systems, cooking facilities, elevator safety, fire drills, and electrical systems at the nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to inspect fire doors annually, inadequate protection of cooking equipment, incomplete sprinkler coverage, lack of annual fire hydrant inspections, missing documentation for elevator firefighter service testing, insufficient fire drill variety and simulation, and absence of a remote manual stop station for the generator.
Deficiencies (7)
Facility failed to inspect fire doors annually in accordance with NFPA 80 for 12 of 12 fire doors observed.
Cooking equipment was not protected in accordance with NFPA 96; electric food warming system surrounded by combustible cardboard boxes.
Facility failed to provide complete sprinkler coverage; no sprinkler head in HVAC closet approximately 5' x 2'.
Facility failed to have 4 of 4 private fire hydrants inspected annually as required by NFPA 25.
No documented evidence that all elevators had monthly firefighter service testing (Phase I and Phase II).
Facility failed to conduct fire drills with varying activation types and simulation of specific emergency fire conditions for 13 of 13 drills.
Facility failed to ensure a remote manual stop station was installed for the exterior diesel generator as required by NFPA 110.
Report Facts
Fire doors deficient: 12
Fire hydrants deficient: 4
Elevators deficient: 2
Fire drills deficient: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Regional Plant Operations Director | Present during observations and interviews related to deficiencies |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Date: May 31, 2022
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: 3
Sample size: 5
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Mar 22, 2022
Visit Reason
The inspection was conducted in response to complaint NJ149795 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint NJ149795 was investigated and the facility was found to be deficient in CNA staffing ratios. The facility was in substantial compliance with 42 CFR Part 483, Subpart B based on this complaint visit.
Findings
The facility was found deficient in maintaining required minimum staffing ratios for certified nursing assistants (CNAs) on multiple day and evening shifts during the weeks of 10/24/2021 through 11/06/2021, due to a global acute shortage of staff. The facility implemented corrective actions including staffing audits, use of staffing agencies, and incentive programs.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the State of New Jersey, specifically deficient CNA staffing on 5 of 14 day shifts and 2 of 14 evening shifts.
Report Facts
Census: 73
Sample Size: 3
Deficient CNA staffing days: 5
Deficient CNA staffing evenings: 2
Required CNAs on day shift: 11
Actual CNAs on day shift: 8.5
Required CNAs on evening shift: 12
Actual CNAs on evening shift: 9.5
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a complaint investigation (Complaint # NJ 145156) were conducted by the New Jersey Department of Health.
Complaint Details
Complaint # NJ 145156 was investigated and the facility was found to be in compliance with regulatory requirements.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 and met the requirements of 42 CFR Part 483, Subpart B for long term care facilities based on the complaint visit.
Report Facts
Sample size: 7
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and met the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
Annual survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample size: 21
Inspection Report
Routine
Census: 87
Deficiencies: 0
Date: Dec 4, 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 had implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 4
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