Inspection Reports for
Concord Healthcare & Rehabilitation Center
963 Ocean Ave, Lakewood, NJ, 08701
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
76% occupied
Based on a March 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 health 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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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: 91
Deficiencies: 1
Date: Mar 20, 2025
Visit Reason
The inspection was conducted based on complaint NJ181716 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ181716. The complaint was substantiated as the facility failed to meet staffing ratios on one day shift during the review period.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, failing to meet the required Certified Nurse Aide staffing for 1 of 14 day shifts reviewed. No negative outcomes were reported, and a plan of correction was submitted.
Deficiencies (1)
Failed to ensure staffing ratios were met for 1 of 14 day shifts reviewed, specifically CNA staffing was deficient on 03/10/2025 with 10 CNAs for 86 residents instead of the required 11 CNAs.
Report Facts
Census: 91
Deficient staffing day shifts: 1
CNA staffing on deficient day: 10
Required CNA staffing on deficient day: 11
Residents on deficient day: 86
Inspection Report
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with food safety and sanitation standards, specifically focusing on the maintenance and cleanliness of kitchen equipment including ice machines.
Findings
The facility failed to maintain the ice machine in a clean, safe, and sanitary manner, as evidenced by the presence of black mold sediment inside the ice machine dispenser. The Food Service Director and facility administrators acknowledged the issue and the need for more frequent cleaning than the quarterly schedule.
Deficiencies (1)
Facility failed to maintain kitchen equipment, specifically the ice machine, in a clean, safe, and sanitary manner, evidenced by black mold sediment inside the ice machine dispenser.
Report Facts
Date of inspection: Dec 20, 2024
Cleaning frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding ice machine cleanliness and maintenance | |
| Licensed Nursing Home Administrator | Acknowledged findings of black sediment in ice machine | |
| Director of Nursing | Acknowledged surveyor's findings regarding ice machine |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 120
Deficiencies: 3
Date: Dec 20, 2024
Visit Reason
The survey was conducted as a Recertification Survey to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by complaints #179262 and #180212.
Complaint Details
Complaint numbers 179262 and 180212 triggered the survey. The findings were substantiated as deficiencies in food safety and staffing.
Findings
Deficiencies were cited related to food safety, specifically the failure to maintain kitchen equipment, including an ice machine with black sediment. Additionally, staffing deficiencies were found related to minimum direct care staff-to-resident ratios. A Life Safety Code Survey found noncompliance with fire alarm system requirements.
Deficiencies (3)
Facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner, evidenced by black sediment in the ice machine dispenser shoot.
Facility failed to maintain required minimum direct care staff-to-resident ratios for 4 of 14 day shifts reviewed.
Facility failed to ensure each manual fire alarm box on a system was accessible, unobstructed, and visible as required by NFPA 101.
Report Facts
Census: 98
Total Capacity: 120
Staffing Deficiencies: 4
Certified Nurse Aides (CNAs): 11
Certified Nurse Aides (CNAs): 10
Certified Nurse Aides (CNAs): 10
Certified Nurse Aides (CNAs): 11
Inspection Report
Routine
Deficiencies: 3
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with privacy, dignity, medication administration, infection control, and professional standards of care during medication administration.
Findings
The facility failed to provide privacy and promote dignity during medication administration for several residents, failed to follow professional standards in medication administration via gastrostomy tube, and did not maintain proper infection control hand hygiene practices during medication administration. These deficiencies were observed during medication passes and confirmed through interviews and record reviews.
Deficiencies (3)
Failed to provide privacy and promote dignity during medication administration for 3 of 8 residents observed.
Failed to follow professional standards of clinical practice with medication administration for 1 of 8 residents observed, including crushing and administering multiple medications together via gastrostomy tube contrary to facility policy.
Failed to maintain infection control standards by improper hand hygiene for 1 of 3 nurses observed during medication administration.
Report Facts
Residents observed for medication administration: 8
Residents affected by privacy deficiency: 3
Nurses observed: 3
Residents affected by infection control deficiency: 1
Residents affected by professional standards deficiency: 1
Inspection Report
Complaint Investigation
Census: 98
Capacity: 120
Deficiencies: 5
Date: Nov 3, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by multiple complaints (NJ 155581, NJ 156565, NJ 158865, NJ 159099, NJ 159345, NJ 161697, NJ 161302, 164557).
Complaint Details
The survey was complaint-driven based on multiple complaint numbers listed (NJ 155581, NJ 156565, NJ 158865, NJ 159099, NJ 159345, NJ 161697, NJ 161302, 164557). The complaints involved issues of privacy, staffing, and infection control. Substantiation status is not explicitly stated.
Findings
Deficiencies were cited related to personal privacy and confidentiality of records, professional standards of clinical practice regarding medication administration, infection prevention and control, hand hygiene, staffing ratios, and life safety code violations including fire door assemblies and smoke barriers. The facility failed to provide privacy during medication administration for several residents and did not maintain required staffing levels. Life safety code deficiencies involved fire door inspections and maintenance.
Deficiencies (5)
Failure to provide privacy and promote dignity during medication administration for 3 of 8 residents observed.
Failure to meet professional standards of clinical practice with medication administration for 1 of 8 residents observed.
Failure to establish and maintain an infection prevention and control program including hand hygiene compliance.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law.
Failure to maintain fire rated door assemblies leading to the dining room and failure to maintain smoke barriers in the attic.
Report Facts
Census: 98
Total Capacity: 120
Deficiencies cited: 5
Staffing ratios: 11
Staffing ratios: 12
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Mar 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ151264.
Complaint Details
Complaint # NJ151264 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.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Nov 5, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ148560.
Complaint Details
Complaint #: NJ148560. The facility was found compliant based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Deficiencies: 2
Date: Aug 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care and nutrition services at Concord Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in providing appropriate pressure ulcer care for one resident, failing to follow proper wound care procedures including glove changes and hand hygiene. Additionally, the facility failed to provide the correct consistency of diet according to physician's orders for another resident.
Deficiencies (2)
Failed to ensure a resident received treatment and services to promote healing of a chronic stage two pressure ulcer, including improper wound care technique with missed glove changes and hand hygiene.
Failed to provide the correct consistency of diet according to physician's orders, serving thin liquids instead of nectar thick liquids to a resident.
Report Facts
Residents reviewed for pressure ulcers: 3
Residents reviewed for nutrition: 4
Pressure ulcer size: 2
Pressure ulcer size: 2.5
Pressure ulcer size: 0.2
BIMS score for Resident #19: 12
BIMS score for Resident #58: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Performed wound care with missed glove changes and hand hygiene | |
| Registered Nurse/Unit Manager (RN/UM) | Observed wound care and interviewed regarding wound care procedures | |
| Director of Nursing (DON) | Interviewed about wound care procedures and presence during surveyor interview | |
| Certified Nursing Aide (CNA) | Observed serving incorrect meal tray to resident | |
| Speech Therapist (ST) | Interviewed regarding resident's diet and speech therapy | |
| Licensed Nursing Home Administrator | Present during surveyor interview addressing diet tray concern | |
| Regional Nurse | Present during surveyor interview addressing diet tray concern |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 2
Date: Aug 6, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to provide proper wound care for a resident with a pressure ulcer and failure to provide the correct diet consistency according to physician's orders for another resident. Plans of correction were implemented and verified.
Deficiencies (2)
Failure to ensure a resident received treatment and services to promote healing of a chronic stage two pressure ulcer.
Failure to provide the correct consistency of diet according to physician's orders for a resident.
Report Facts
Sample size: 23
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in wound care deficiency for Resident #19 | |
| Registered Nurse/Unit Manager (RN/UM) | Observed wound care and interviewed regarding wound care procedures | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding wound care procedures and cited in wound care deficiency |
| Certified Nursing Aide (CNA) | Observed giving wrong meal tray to Resident #58 | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Confirmed meal tray error for Resident #58 | |
| Speech Therapist (ST) | Interviewed regarding Resident #58's diet and swallowing status | |
| Dietician | Responsible for meal tray accuracy education and monitoring |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ136330, NJ136401, NJ141373, and NJ143868.
Complaint Details
Complaint numbers NJ136330, NJ136401, NJ141373, and NJ143868 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 15
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
The inspection visit was conducted in response to complaint NJ 142873 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint NJ 142873 was investigated and the facility was found to be in compliance with all applicable requirements.
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: 3
Inspection Report
Routine
Census: 73
Deficiencies: 0
Date: Jan 28, 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 CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, infection control regulations, and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Dec 3, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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