Inspection Reports for Complete Care at Woodlands
1400 Woodland Ave, Plainfield, NJ 07060, NJ, 07060
Back to Facility ProfileDeficiencies per Year
16
12
8
4
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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties 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 questions about the notice |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
May 20, 2025
Visit Reason
The inspection was conducted based on multiple complaints received (NJ00174376, NJ00174932, NJ00181413, NJ00182680, NJ00182975, NJ00183400) to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to meet required minimum staffing ratios on 1 of 14 day shifts during the complaint investigation period. Specifically, the facility had insufficient Certified Nursing Assistants (CNAs) on 05/11/2025, with 12 CNAs for 104 residents instead of the required 13 CNAs.
Complaint Details
The complaint investigation included multiple complaint numbers and found the facility deficient in CNA staffing on one day shift during the period 05/04/2025 to 05/17/2025. The facility was not in substantial compliance based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| 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 1 of 14 day shifts. |
Report Facts
Census: 106
Sample Size: 8
Staffing Deficiency: 1
Certified Nursing Assistants on 05/11/2025: 12
Required Certified Nursing Assistants on 05/11/2025: 13
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Sep 25, 2024
Visit Reason
The inspection was conducted based on Complaint #: NJ00175265 to investigate allegations related to the facility's compliance with 42 CFR Part 483, Subpart B, specifically regarding resident records and staffing.
Findings
The facility was found not in substantial compliance due to failure to maintain accurate and complete medical records for a resident with a change in condition and failure to meet required minimum staffing ratios for Certified Nursing Assistants on multiple day shifts.
Complaint Details
Complaint #: NJ00175265. The complaint investigation found the facility was not in substantial compliance with requirements based on failure to maintain proper resident records and inadequate staffing levels.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain an accurate and complete medical record in accordance with accepted standards and practice, including failure to document a registered nurse's assessment of a resident with a change in condition. | SS=D |
| Failure to ensure staffing ratios met the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 3 day shifts. | — |
Report Facts
Census: 110
Sample Size: 3
Deficient CNA staffing day shifts: 3
Required CNAs on deficient days: 14
Actual CNAs on deficient days: 13
Inspection Report
Routine
Census: 110
Deficiencies: 0
Mar 15, 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 and recommended practices for COVID-19.
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
Census: 115
Capacity: 120
Deficiencies: 14
Feb 1, 2024
Visit Reason
The inspection was a Recertification and Complaint Survey conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH).
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident rights, resident assessments, baseline care plans, professional standards of care, discharge planning, quality of care, and life safety code compliance.
Severity Breakdown
SS=D: 6
SS=E: 6
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to provide one resident a dignified dining experience by not providing regular silverware. | SS=D |
| Failed to ensure ten residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. | SS=E |
| Failed to develop baseline care plans for five residents including necessary interventions. | SS=E |
| Failed to follow professional standards of practice by leaving medications unattended for one resident. | SS=D |
| Failed to ensure safe discharge for residents leaving Against Medical Advice by not notifying community agencies or providing prescriptions. | SS=D |
| Failed to accurately screen residents for elopement risk and document exit seeking behaviors prior to use of wander guard for one resident. | SS=D |
| Failed to obtain physician orders for pressure ulcer treatment changes and admission care for two residents. | SS=D |
| Failed to maintain building structure meeting height and construction requirements; ceiling tiles lacked fire resistance rating. | SS=F |
| Failed to maintain one exit free of obstructions and impediments for instant use due to raised threshold. | SS=E |
| Failed to ensure illumination was available at the exit discharge from the Physical Therapy room. | SS=E |
| Failed to ensure three hazardous area room doors were compliant with fire safety codes. | SS=E |
| Failed to ensure two photo electric smoke detectors were installed greater than 36 inches from ceiling air diffusers. | SS=E |
| Failed to ensure natural gas fueled fireplace was installed and used in accordance with code; lacked combustion air and safety shutoff. | SS=E |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Survey Census: 115
Total Capacity: 120
Sample Size: 27
Supplemental Residents: 10
Deficient CNA staffing days: 8
Deficient CNA staffing counts: 12
Smoke detectors: 2
Hazardous area doors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication left unattended finding |
| LPN1 | Licensed Practical Nurse | Named in resident leaving AMA documentation finding |
| UM1 | Unit Manager | Named in resident leaving AMA and care plan findings |
| Physician 1 | Physician | Named in resident leaving AMA and discharge planning findings |
| LPN2 | Licensed Practical Nurse | Named in resident leaving AMA finding |
| LPN3 | Licensed Practical Nurse | Named in wander guard and resident care findings |
| CNA1 | Certified Nurse Aide | Named in wander guard and resident care findings |
| UM2 | Unit Manager | Named in pressure ulcer care findings |
| LPN4 | Licensed Practical Nurse | Named in pressure ulcer care findings |
| Maintenance Director | Maintenance Director | Named in fire safety and building construction findings |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 4
Nov 16, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaints (NJ00157992, NJ00159180, NJ00165144, NJ00168238, and NJ00168734) from 11/14/23 through 11/16/23.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. Deficiencies included inaccurate resident assessments, failure to implement COVID-19 outbreak policies, unclean bedrails, and failure to maintain required staffing ratios.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility not in substantial compliance with federal long term care requirements. Specific complaints included inaccurate assessments, infection control failures, environmental cleanliness, and staffing shortages.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure the Minimum Data Set (MDS) assessment was accurately coded for one resident (Resident 4). | SS=D |
| Failure to implement COVID-19 outbreak policy to mitigate spread when an employee returned to work prematurely. | SS=D |
| Failure to ensure bedrails were clean in one resident room (room 124-B). | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by New Jersey for Certified Nursing Assistants (CNAs). | — |
Report Facts
Survey Census: 102
Sample Size: 9
Staffing Deficiencies: 27
Staffing Deficiencies: 7
Staffing Deficiencies: 3
Staffing Deficiencies: 4
Staffing Deficiencies: 4
Staffing Deficiencies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in infection prevention deficiency for returning to work prematurely during COVID-19 outbreak. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for accurate MDS coding. |
| Registered Dietician | Registered Dietician | Responsible for coding section of MDS; verified coding error for Resident 4. |
| Housekeeping Director | Housekeeping Director | Observed unclean bedrails and responsible for housekeeping audits. |
| HK1 | Housekeeper | Assigned to clean room 124 but failed to clean bedrails properly. |
| Infection Preventionist | Infection Preventionist | Confirmed COVID-19 outbreak policy was not followed. |
| Administrator | Administrator | Acknowledged infection control policy breach and staffing issues. |
Inspection Report
Routine
Census: 108
Deficiencies: 0
Oct 19, 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: 9
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Jan 13, 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 related to COVID-19.
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: 46
Deficiencies: 1
Aug 19, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically regarding mandatory minimum direct care staff-to-resident ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey state law during multiple shifts in late July and early August 2021. The facility acknowledged staffing shortages and reported efforts to address them including increased wages and use of agency staff.
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: 43
Census: 46
Deficiency dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA | Interviewed about resident assignments on 7-3 shift | |
| Staffing Coordinator | Interviewed and acknowledged awareness of staffing shortages and use of agency staff | |
| Regional Director of Operations | Interviewed and acknowledged staffing concerns and efforts to increase wages and use agencies |
Inspection Report
Routine
Census: 88
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: 3
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Jan 6, 2021
Visit Reason
The inspection was conducted as a complaint survey related to complaint number NJ130683.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities on this complaint survey.
Complaint Details
Complaint number NJ130683 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 8
Inspection Report
Routine
Census: 88
Deficiencies: 0
Jan 6, 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 and recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 423 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
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