Inspection Reports for
Wedgwood Gardens Care Center
3419 Highway 9, Freehold, NJ, 07728
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 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/year
Deficiencies per year
16
12
8
4
0
Occupancy
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 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 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
Routine
Census: 92
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, privacy, care planning, infection control, and water management.
Findings
The facility failed to post State survey inspection results in a prominent location accessible to residents and visitors, breached resident confidentiality by posting identifiable health information, did not develop a comprehensive care plan for oxygen therapy for one resident, and failed to implement an effective water management program to reduce the risk of Legionella exposure.
Deficiencies (4)
Failure to ensure State survey inspection results were readily accessible and posted in prominent areas for residents and visitors.
Failure to maintain privacy and confidentiality of health information for a resident diagnosed with norovirus.
Failure to develop a comprehensive care plan for oxygen therapy for a resident with congestive heart failure.
Failure to implement a water management program to reduce the potential for exposure to Legionella and other waterborne pathogens.
Report Facts
Residents affected: 92
Residents affected: 26
Oxygen therapy liters per minute: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding posting of State survey inspection results and care plan for oxygen therapy. | |
| Receptionist | Interviewed regarding location of State survey inspection results and posting of norovirus sign. | |
| Acting Activity Director/Building Manager | Interviewed about discussion of survey results at Resident Council meetings. | |
| Assistant Administrator | Interviewed regarding posting of health information and water management program responsibility. | |
| Licensed Practical Nurse (LPN) 1 | Interviewed regarding oxygen therapy for Resident 7. | |
| MDS Coordinator | Interviewed regarding care plan development for Resident 7. | |
| Nurse Navigator | Interviewed regarding communication failures related to oxygen therapy care plan. | |
| Infection Preventionist | Interviewed regarding water management program and facility water flow diagram. | |
| Administrator | Interviewed regarding water management program and facility blueprints. |
Inspection Report
Census: 92
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to assess whether the nursing home ensured that the State survey inspection results were readily accessible and posted in prominent areas for residents and family members to view.
Findings
The facility failed to post the State survey inspection results in prominent, accessible locations for residents and visitors, with the survey results only available behind the receptionist desk in a non-prominent location. Resident council meetings did not discuss or inform residents about the survey results posting.
Deficiencies (1)
Failure to ensure the State survey inspection results were readily accessible and posted in prominent areas for residents and family members.
Report Facts
Residents affected: 92
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding location of State survey inspection results |
| Receptionist | Receptionist | Interviewed regarding location and accessibility of State survey inspection results |
| Acting Activity Director/Building Manager | Acting Activity Director/Building Manager | Interviewed about discussion of survey results at Resident Council meeting |
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
Annual Inspection
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
Annual inspection survey of Wedgwood Gardens Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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
Routine
Deficiencies: 6
Date: Mar 3, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident assessments, staffing, medication management, infection control, and medication administration.
Findings
The facility was found deficient in accurately completing resident assessments, posting daily nurse staffing information, maintaining controlled medication accountability, ensuring medication administration without errors, and following infection prevention and control protocols including hand hygiene and use of personal protective equipment.
Deficiencies (6)
Failed to accurately complete the Minimum Data Set (MDS) for a resident receiving hospice care, incorrectly coding ADL eating assistance.
Failed to post updated 24-hour nurse staffing information daily at the front receptionist desk.
Failed to maintain accurate accountability and reconciliation for controlled medications on one medication cart.
Medication administration error rate of 19.35% observed during medication pass, including an incident where a nurse almost administered insulin to the wrong resident.
Immediate jeopardy due to failure of a nurse to follow the five rights of medication administration, including identifying the correct resident before administering high-risk medications.
Failed to follow appropriate infection control practices including hand hygiene between residents during meal service, failure to wear appropriate PPE for a resident on transmission-based precautions, and improper hand hygiene during medication administration.
Report Facts
Medication administration opportunities: 31
Medication administration errors: 6
Medication administration error rate: 19.35
Number of residents affected by deficiencies: 1
Number of residents affected by deficiencies: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration error and immediate jeopardy incident |
| LPN Charge Nurse | Licensed Practical Nurse Charge Nurse | Interviewed regarding medication accountability and administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing and medication administration policies |
| Staffing Coordinator/Receptionist | Staffing Coordinator/Receptionist | Interviewed regarding nurse staffing posting |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Observed during meal service with hand hygiene deficiencies |
| Registered Nurse | Registered Nurse | Interviewed regarding resident care and infection control |
| Licensed Practical Nurse/Unit Manager | Licensed Practical Nurse/Unit Manager | Interviewed regarding resident care and medication administration |
| Social Worker | Social Worker | Interviewed regarding resident care needs |
| Dietitian | Dietitian | Interviewed regarding resident nutrition and hospice status |
| MDS Coordinator/RN | MDS Coordinator/Registered Nurse | Interviewed regarding MDS assessment process |
| Assistant Administrator | Assistant Administrator | Interviewed regarding staffing and infection control |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Observed and interviewed regarding infection control practices |
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
Complaint Investigation
Deficiencies: 2
Date: Jan 20, 2021
Visit Reason
The inspection was conducted to investigate complaints related to infection prevention and control practices, specifically the failure to offer residents hand hygiene prior to meals and inconsistent use of Personal Protective Equipment (PPE) by staff.
Complaint Details
The complaint investigation found that staff did not offer hand hygiene to residents prior to meals and failed to consistently wear required PPE when entering rooms under Droplet Precautions. Resident statements and observations confirmed these issues. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to consistently offer hand hygiene to residents before meals and did not consistently don appropriate PPE to minimize infection spread. These deficiencies were observed across multiple units and involved several residents and staff members.
Deficiencies (2)
Failure to offer residents hand hygiene prior to meals.
Inconsistent use of appropriate Personal Protective Equipment (PPE) by staff, including gowns, gloves, and eye protection.
Report Facts
Date of survey completion: Jan 20, 2021
Number of residents observed without hand hygiene offered: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices and meal setup |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices and meal setup |
| CNA #4 | Certified Nursing Assistant | Observed passing trays and not offering hand hygiene |
| CNA #5 | Certified Nursing Assistant | Observed not wearing full PPE and interviewed about PPE use |
| RN #1 | Registered Nurse | Observed delivering trays without offering hand hygiene |
| LPN #2 | Licensed Practical Nurse | Interviewed about offering hand hygiene to residents |
| Director of Administrative Service/Infection Preventionist | Director | Interviewed about infection prevention policies and hand hygiene |
| Food Service Director | Food Service Director | Interviewed about meal tray setup and hand hygiene supplies |
| Facility Educator | Facility Educator | Interviewed about PPE policies and staff training |
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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