Inspection Reports for
Wedgwood Gardens Care Center
3419 Highway 9, Freehold, NJ, 07728
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
61% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase 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 health 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 named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 92
Capacity: 151
Deficiencies: 8
Date: Mar 19, 2025
Visit Reason
A Recertification and Complaint Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations. The survey included review of staffing, resident rights, privacy, infection control, life safety, and other regulatory requirements.
Complaint Details
The survey included complaint investigations for complaint numbers NJ165593, NJ165671, NJ174138, NJ176421, and NJ181604. The facility was found not to be in substantial compliance with regulations based on these complaints.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies cited in areas including resident rights, privacy/confidentiality, staffing ratios, infection control, life safety code violations, and care planning. Deficiencies had the potential to affect all 92 residents. Corrective actions and plans of correction were documented.
Deficiencies (8)
Failure to ensure State survey inspection results were posted in a prominent and accessible location for residents and family members.
Failure to respect residents' right to personal privacy and confidentiality of medical records for two residents.
Failure to develop and implement a comprehensive care plan for two residents.
Failure to establish and maintain an infection prevention and control program.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state.
Failure to maintain the sprinkler system in accordance with NFPA 25 standards.
Failure to ensure corridor doors closed and latched without impediment and resist passage of smoke.
Failure to meet travel distance requirements for smoke compartments in accordance with NFPA 101 Life Safety Code.
Report Facts
Survey Census: 92
Total Capacity: 151
Sample Size: 26
Staffing Deficiency Counts: 7
Staffing Deficiency Counts: 4
Staffing Deficiency Counts: 11
Required Staffing Hours: 304.75
Actual Staffing Hours: 288
Staffing Hours Deficit: -16.75
Number of Residents Affected: 92
Inspection Report
Abbreviated Survey
Census: 98
Deficiencies: 0
Date: Aug 24, 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 and preparedness for 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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Nov 9, 2022
Visit Reason
Complaint investigation triggered by complaint NJ159023 regarding failure to activate the Emergency Response System (ERS) for Resident #2 found unresponsive.
Complaint Details
Complaint NJ159023 substantiated. Immediate Jeopardy identified on 11/1/2022 due to failure to activate ERS for Resident #2. IJ removed after corrective actions on 11/9/2022.
Findings
The facility failed to activate the ERS including calling for assistance, calling 911, and using emergency supplies for Resident #2 who was found unresponsive and later pronounced deceased. The Registered Nurse did not call a code or 911 immediately and failed to follow facility emergency policies. The Director of Nursing did not investigate or report the incident. The facility was found not in substantial compliance and Immediate Jeopardy was identified and later removed after staff education and corrective actions.
Deficiencies (1)
Failure to activate Emergency Response System (ERS) including calling for assistance, calling 911, and using emergency supplies for Resident #2.
Report Facts
Census: 91
Sample size: 4
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Named in failure to activate ERS and delayed response to Resident #2 | |
| Director of Nursing (DON) | Did not investigate or report the incident involving Resident #2 | |
| Licensed Practical Nurse (LPN) | Interviewed regarding incident and lack of emergency code call | |
| Assistant Administrator (AA) | Interviewed regarding RN failure to follow emergency protocol | |
| Social Worker (SW) | Interviewed regarding Resident #2 and emergency response | |
| Medical Director (MD) | Interviewed regarding expected nurse response to emergency |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
The inspection was conducted in response to Complaint # NJ 151660 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint # NJ 151660 was investigated and the facility was found compliant with no deficiencies cited.
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 visit.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 84
Deficiencies: 2
Date: Jan 20, 2021
Visit Reason
The inspection was a standard routine survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities, focusing on infection prevention and control.
Findings
The facility was found not in substantial compliance due to failure to consistently offer residents hand hygiene prior to meals and failure to consistently don appropriate Personal Protective Equipment (PPE) to minimize infection spread. Observations and interviews revealed multiple instances where residents were not offered hand hygiene and staff did not properly use PPE, especially on the COVID-19 observation unit.
Deficiencies (2)
Failure to offer residents hand hygiene prior to meals.
Failure to consistently don appropriate PPE including gowns, gloves, and eye protection on the COVID-19 observation unit.
Report Facts
Census: 84
Sample Size: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices during meal setup |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices and availability of hand wipes |
| Housekeeping Porter | Interviewed regarding stocking of linens and hand hygiene supplies | |
| CNA #5 | Certified Nursing Assistant | Observed not properly using PPE on COVID-19 observation unit; reassigned and reeducated |
| Director of Administrative Service/Infection Preventionist | Director of Administrative Service/Infection Preventionist | Interviewed regarding hand hygiene policies and supply availability |
| Food Service Director | Food Service Director | Interviewed regarding meal tray setup and hand hygiene supplies |
| Facility Educator | Facility Educator | Interviewed regarding PPE policies and staff training |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 20, 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 in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 83
Deficiencies: 0
Date: Dec 14, 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.
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