Inspection Reports for
Complete Care At Wall Llc
1725 Meridian Trail, Wall, NJ, 07719
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
14% occupied
Based on a August 2025 inspection.
This facility has shown a decline 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 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: 18
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted due to allegations of abuse and rough handling of two cognitively intact residents (Resident #109 and Resident #110) by Certified Nurse Aides, following complaints from residents and their representatives.
Complaint Details
The complaint investigation was substantiated. Two residents reported abuse: Resident #110 reported rough handling by CNAs causing pain to a surgical site, and Resident #109 reported verbal abuse and threats, including being called 'crazy' and being moved to a psychiatric room without proper documentation or family notification. The facility did not properly investigate or document these allegations in a timely manner.
Findings
The facility failed to initiate an investigation or report allegations of abuse timely after receiving complaints from residents and their representatives. Documentation and follow-up assessments were lacking, and staff did not adhere to abuse reporting policies. Residents reported verbal and physical mistreatment, including rough handling and threats.
Deficiencies (1)
Failure to initiate an investigation for allegations of abuse and prevent further potential abuse after reports from residents.
Report Facts
Resident census: 18
Days after allegation: 5
Incident report date: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM #1 | Licensed Practical Nurse Unit Manager | Named in failure to investigate and document abuse allegations |
| LNHA | Licensed Nursing Home Administrator / Compliance Officer / Abuse Coordinator | Responsible for abuse investigations but failed to initiate investigation or report allegations timely |
| DON | Director of Nursing | Interviewed regarding abuse reporting and grievance process; unaware of abuse allegations documentation |
| CNA #1 | Certified Nurse Aide | Named in allegations of rough handling Resident #110; provided statements denying rough care |
| CNA #2 | Certified Nurse Aide | Named in allegations of rough handling Resident #110; provided statements denying rough care |
| SW #1 | Social Worker / Grievance Officer | Interviewed about grievances and abuse reporting; not aware of abuse allegations initially |
| SW #2 | Social Worker | Interviewed and documented grievance for Resident #109; not involved in abuse investigation |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Aug 6, 2025
Visit Reason
The inspection was conducted in response to complaints alleging abuse, neglect, medication errors, nutritional deficiencies, and other quality of care concerns at the facility.
Complaint Details
Complaint investigations included allegations of abuse (physical and verbal), neglect, medication errors, nutritional deficiencies, and quality of care concerns for multiple residents including #109, #110, #115, #49, #7, #13, #94, #96, #103, #95, #97, #101, #125.
Findings
The facility was found deficient in multiple areas including failure to properly investigate and report abuse allegations, failure to provide adequate nutritional care and documentation, medication administration errors, failure to maintain a sanitary kitchen environment, inadequate dialysis care competencies, and failure to maintain a working resident call system.
Deficiencies (12)
Failure to ensure appropriate investigation and reporting of abuse allegations involving residents #109 and #110, including lack of social worker involvement.
Failure to provide documented evidence of care for activities of daily living (ADLs) for residents #95, #97, #101, and #125, including incomplete CNA documentation.
Failure to maintain the kitchen and food storage areas in a clean and sanitary condition, including soiled racks, debris, and expired food items.
Failure to ensure menus were followed and standardized recipes were used, resulting in inconsistent portion sizes and poor nutritional quality of meals served to residents #7 and #49.
Failure to provide timely administration of pain medication for residents #94, #96, and #103, including delayed administration of prescribed analgesics.
Failure to clarify physician's order and provide appropriate dialysis care for resident #13, including lack of staff competencies in hemodialysis.
Failure to ensure social workers were incorporated into the abuse process and provided medically related social services to residents alleging abuse.
Failure to follow physician's order for insulin medication and acceptable professional standards of practice for resident #115, including administration of incorrect insulin.
Failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures, with consistent portion sizes and proper recipes followed.
Failure to maintain food preparation, storage areas, kitchen equipment and food transport equipment in a clean and sanitary manner, including lack of cleaning schedules and improper food storage temperatures.
Failure to ensure a comprehensive Quality Assurance Performance Improvement (QAPI) program that includes abuse investigations and grievance reviews.
Failure to ensure that a working call system was available in each resident's bathroom and bathing area.
Report Facts
Weight loss: 12
Temperature: 77
Medication delay: 7
Medication delay: 12
Medication dose: 15
Meal portion size: 3.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM #1 | Unit Manager | Named in abuse investigation and failure to follow up on resident concerns. |
| LNHA | Licensed Nursing Home Administrator | Responsible for abuse investigations and QAPI program; acknowledged gaps in abuse process and social worker involvement. |
| SW #1 | Social Worker | Not made aware of abuse allegations; responsible for grievance process but not abuse investigations. |
| SW #2 | Social Worker | Documented grievance for Resident #109; not involved in abuse investigations. |
| FSD | Food Service Director | Acknowledged lack of recipes and cleaning schedules in kitchen. |
| FSC | Food Service Consultant | Confirmed lack of recipes and improper portion sizes affecting nutritional content. |
| DON | Director of Nursing | Confirmed medication administration delays and abuse investigation process gaps. |
| ADON | Assistant Director of Nursing | Confirmed medication administration expectations and dialysis care training gaps. |
| RN | Registered Nurse | Demonstrated assessment of bruit and thrill for dialysis access. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error where a resident (Resident #2) was administered the wrong dose and form of Methadone, resulting in an overdose and hospital admission.
Complaint Details
Complaint #NJ184446 involved a medication error where Resident #2 was given 105 mg liquid Methadone instead of the ordered 10 mg tablet, resulting in overdose and hospital admission. The immediate jeopardy began on 03/14/2025 and ended on 03/17/2025 after staff re-education and corrective actions.
Findings
The facility failed to protect Resident #2 from a significant medication error when an LPN administered 105 mg of liquid Methadone intended for Resident #6 instead of the ordered 10 mg Methadone tablet. This error led to the resident becoming lethargic, requiring emergency intervention and hospital transfer. The facility was found to be in immediate jeopardy but corrected the non-compliance by re-educating staff and implementing new medication administration procedures.
Deficiencies (1)
Failure to protect Resident #2 from significant medication error by administering incorrect dose and form of Methadone.
Report Facts
Medication dose administered: 105
Medication dose ordered: 10
Medication dose ordered: 105
Date of medication error: Mar 14, 2025
Date of survey completion: May 2, 2025
BIMS score: 11
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered incorrect dose of Methadone to Resident #2 |
| LPN #1 | Licensed Practical Nurse | Discovered medication error and initiated emergency response |
| DON | Director of Nursing | Oversaw investigation and stated expectations for medication administration |
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
Annual Inspection
Deficiencies: 0
Date: Mar 17, 2023
Visit Reason
Annual inspection survey completed to assess compliance with health and safety regulations at Complete Care at Wall LLC.
Findings
No health deficiencies were found during the inspection.
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
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Complete Care at Wall LLC, summarizing the findings of a regulatory survey completed on January 8, 2021.
Findings
No health deficiencies were found during the survey.
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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