Inspection Reports for Complete Care at Cedar Grove
536 Ridge Rd, Cedar Grove, NJ 07009, United States, NJ, 07009
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
178 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 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 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Deficiencies: 1
Date: Apr 28, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents, focusing on physical conditions of resident rooms.
Findings
The facility failed to maintain a clean and homelike physical environment, evidenced by black dried fungi-like substance behind wallpaper in 2 of 4 bedrooms observed. Maintenance and administrative staff confirmed the presence of the substance and acknowledged the need for repairs and resident relocation.
Deficiencies (1)
Failure to provide a clean and homelike physical environment due to black dried fungi-like substance behind wallpaper in resident rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Confirmed presence of black fungi-like substance behind wallpaper and stated responsibility for ensuring rooms were up to standard. | |
| Administrator | Confirmed black dried fungi-like substance and stated intention to move residents from affected rooms. | |
| RN #1 | Nurse | Noticed black dried substance in resident room and reported it to Administrator and maintenance staff. |
| Regional Director of Operations | Confirmed black spotted areas behind dressers and stated residents would be moved and families contacted. |
Inspection Report
Complaint Investigation
Census: 178
Deficiencies: 2
Date: Apr 28, 2025
Visit Reason
The inspection was conducted based on complaints NJ181957 and NJ183439 to determine compliance with federal and state regulations for long-term care facilities.
Complaint Details
Complaint numbers NJ181957 and NJ183439 triggered the investigation. The facility was found not in substantial compliance based on observations, record reviews, and interviews. The complaint was substantiated as deficiencies were identified.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483 and New Jersey Administrative Code 8:39 due to unsafe, unclean, and non-homelike environment conditions, including black dried fungus behind wallpaper in resident rooms, and failure to maintain adequate staffing ratios for certified nurse aides over multiple days.
Deficiencies (2)
Facility failed to provide a clean and homelike physical environment evidenced by black dried substance behind wallpaper in resident rooms.
Facility failed to ensure staffing ratios were met for 12 of 14-day shifts reviewed, affecting all residents.
Report Facts
Census: 178
Sample Size: 8
Deficient CNA staffing days: 12
CNA staffing required: 22
CNA staffing actual: 18
Inspection Report
Routine
Deficiencies: 5
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, respiratory care, and pharmaceutical services at Complete Care at Cedar Grove nursing home.
Findings
The facility was found deficient in maintaining call bells within residents' reach, following physician medication orders, proper respiratory care including oxygen administration, pharmaceutical services including medication storage and administration, and medication error rates exceeding 5%. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.
Deficiencies (5)
Failed to maintain the call bell within reach of residents #108, #128, and #116.
Failed to follow physician orders for medications with parameters for Resident #148.
Failed to ensure respiratory tubing cannula was stored properly and oxygen therapy was administered according to physician orders for Residents #55, #28, #160, and #273.
Failed to provide pharmaceutical services meeting professional standards including improper storage of intravenous bags, inaccurate dispensing and administration of pain medication, and lack of availability of ordered narcotic medication.
Medication error rate of 7.41% observed during medication pass, including administration of medications without food as ordered.
Report Facts
Residents reviewed for call bell accommodation: 35
Medication error rate: 7.41
Oxycodone tablets discrepancy: 1
Clonazepam tablets removed: 8
BIMS scores: 15
BIMS score: 9
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed medication storage and acknowledged medication administration issues |
| Licensed Practical Nurse #2 | LPN | Administered Oxycodone earlier than scheduled without informing physician |
| Licensed Practical Nurse #3 | LPN | Administered double dose of Clonazepam 0.5 mg due to pharmacy supply issue |
| Director of Nursing | DON | Confirmed call bells should be within reach and acknowledged medication administration errors |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Confirmed oxygen administration issues and discussed corrective actions |
| Certified Nursing Assistant #1 | CNA | Acknowledged failure to place call bell within Resident #128's reach |
| Certified Nursing Assistant #2 | CNA | Acknowledged failure to ensure call bell was within Resident #116's reach |
Inspection Report
Routine
Census: 175
Capacity: 190
Deficiencies: 9
Date: Nov 22, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint numbers NJ 167942, 169146, 170266, 170525, 174465, 174531, 174713, 176577 were investigated during this survey.
Findings
The facility was found to have multiple deficiencies including failure to maintain call bells within reach of residents, failure to follow professional nursing standards for medication administration, respiratory care, pharmacy services, medication error rates, staffing ratios, infection control, and life safety code violations related to fire door inspections.
Deficiencies (9)
Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3) - Facility failed to maintain call bell within reach of residents.
Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) - Facility failed to maintain professional standards of nursing practice for medication orders.
Respiratory/Tracheostomy Care and Suctioning CFR(s): 483.25(i) - Facility failed to ensure respiratory care was provided consistent with professional standards.
Pharmacy Services CFR(s): 483.45(a)(b)(1)-(3) - Facility failed to provide pharmaceutical services in accordance with professional standards.
Free of Medication Error Rates 5 Percent or More CFR(s): 483.45(f)(1) - Facility failed to ensure medication error rates were below 5%.
Mandatory Access to Care NJAC 8:39-5.1(a) - Facility failed to maintain required minimum direct care staff-to-resident ratios.
Mandatory Infection Control and Sanitation NJAC 8:39-19.4(d) - Facility failed to hire a full-time Infection Preventionist and maintain infection control standards.
Life Safety Code - Vertical Openings - Enclosure CFR(s): NFPA 101 - Facility failed to ensure stairway fire rated door assemblies latched when closed.
Life Safety Code - Maintenance, Inspection & Testing - Doors CFR(s): NFPA 101 - Facility failed to ensure fire doors were inspected annually and inspection tags placed.
Report Facts
Census: 175
Total Capacity: 190
Medication Error Rate: 7.41
Number of Deficiencies: 10
Staffing Ratios: 19
Staffing Ratios: 21
Inspection Report
Routine
Deficiencies: 12
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, food service, safety, and quality assurance at Complete Care at Cedar Grove.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination, timely notification of transfers to the Ombudsman, accurate Minimum Data Set assessments, comprehensive care planning, assistance with activities of daily living, fall prevention interventions, respiratory care, medication availability, food palatability and temperature, meal scheduling, kitchen sanitation, and Quality Assurance and Performance Improvement (QAPI) meeting frequency.
Deficiencies (12)
Failed to promote resident self-determination by not allowing Resident 117 to stay in her room instead of being taken to the activity room.
Failed to notify the Ombudsman of hospital transfer for Resident 8.
Failed to ensure Minimum Data Set assessments accurately reflected residents' medication status for Residents 71 and 89.
Failed to develop a complete care plan addressing unnecessary medications for Resident 89.
Failed to provide facial hair removal for Resident 65 despite dependency and cognitive impairment.
Failed to revise care plan and implement fall interventions for Resident 9 after a fall.
Failed to maintain cleanliness of nebulizer mouthpiece for Resident 30, increasing infection risk.
Failed to ensure prescribed medication Xifaxan was available and administered as ordered for Resident 49.
Failed to serve palatable, properly seasoned, and appropriately temperature-controlled food to residents including Residents 49, 53, and 61.
Failed to serve meals and snacks at times in accordance with resident needs and preferences; time span between evening meal and breakfast exceeded 14 hours without resident approval.
Failed to ensure kitchen sanitation including dry storage of coffee pitchers and juice machine nozzle, mold-free ceiling tiles, clean storage racks, and adequate sanitizer concentration in sanitizing buckets.
Failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings as required.
Report Facts
Residents reviewed: 39
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 8
Residents affected: 3
Residents affected: 5
Residents affected: 164
Residents affected: 170
Quaternary ammonia concentration: 0
Quaternary ammonia concentration: 15
Quaternary ammonia concentration: 25
Quaternary ammonia concentration: 400
Quaternary ammonia concentration: 150
Meal time span: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Named in resident self-determination deficiency and nebulizer mouthpiece storage |
| CNA 10 | Certified Nurse Aide | Named in resident self-determination deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding resident self-determination and fall interventions |
| Social Services Director | Social Services Director | Interviewed regarding Ombudsman notification deficiency |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding MDS assessment inaccuracies and care plan deficiencies |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding facial hair removal for Resident 65 |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding facial hair removal for Resident 65 |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding facial hair removal for Resident 65 |
| Unit Manager | Unit Manager | Interviewed regarding fall prevention interventions for Resident 9 |
| Clinical Regional Supervisor 1 | Clinical Regional Supervisor | Interviewed regarding medication availability for Resident 49 |
| Consulting Pharmacist | Consulting Pharmacist | Interviewed regarding medication availability for Resident 49 |
| Director of Food Services | Director of Food Services | Interviewed regarding food palatability, meal delivery times, and kitchen sanitation |
| Administrator | Administrator | Interviewed regarding meal scheduling and QAPI meetings |
Inspection Report
Complaint Investigation
Census: 170
Capacity: 188
Deficiencies: 13
Date: Aug 18, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH). The survey included complaint investigations related to multiple complaints and a recertification review.
Complaint Details
The survey was triggered by multiple complaints identified by complaint numbers NJ146255, NJ150874, NJ152557, NJ151495, and NJ151678. The facility was found deficient in areas related to these complaints, including staffing, resident rights, and safety.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in areas including resident self-determination, notice requirements before transfer/discharge, accuracy of assessments, comprehensive care plans, ADL care for dependent residents, free of accident hazards, medication administration, food and drink safety, staffing ratios, life safety code compliance, and quality assessment and assurance. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (13)
Failure to ensure resident self-determination regarding activity choices.
Failure to notify Ombudsman of resident transfers as required.
Failure to ensure accuracy of Minimum Data Set (MDS) assessments.
Failure to develop and implement comprehensive care plans for residents.
Failure to provide adequate ADL care for dependent residents.
Failure to maintain a safe environment free of accident hazards.
Failure to ensure residents are free of significant medication errors.
Failure to maintain food and drink safety and palatability standards.
Failure to maintain mandated staffing ratios.
Failure to maintain one-hour fire resistance rating of stairways and sprinkler system maintenance.
Failure to maintain oxygen storage requirements and safe storage of oxygen cylinders.
Failure to maintain smoke barriers and fire safety code compliance.
Failure to maintain quality assessment and assurance committee meetings as required.
Report Facts
Survey Dates: 2023-08-14 to 2023-08-17
Survey Census: 170
Total Capacity: 188
Deficiency Counts: 13
Staffing Ratios: 1
Staffing Deficiencies: 14
Fire Safety: 100
Oxygen Cylinders: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to notification of resident activity refusal and corrective actions |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Observed interacting with resident regarding activity room attendance |
| Certified Nurse Aide 10 | Certified Nurse Aide | Involved in resident activity room observation |
| Social Services Director | Social Services Director | Interviewed regarding admission/discharge report and resident listing |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Reviewed resident medical records and assessments |
| Unit Manager | Unit Manager | Interviewed regarding resident care plan interventions and room observations |
| Consulting Pharmacist | Consulting Pharmacist | Interviewed regarding medication availability and administration |
| Director of Food Services | Director of Food Services | Interviewed regarding food service deficiencies and corrective actions |
| Maintenance Director | Maintenance Director | Interviewed regarding fire safety deficiencies and sprinkler system |
Inspection Report
Deficiencies: 0
Date: Sep 3, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Complete Care at Cedar Grove, summarizing the findings of a facility survey conducted on 09/03/2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Follow-Up
Census: 116
Deficiencies: 1
Date: Sep 3, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing regulations and to follow up on previously identified deficiencies related to minimum direct care staff to resident ratios.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to maintain minimum direct care staff to resident ratios for the day shift on 17 of 42 shifts reviewed. The facility implemented multiple corrective actions including contracting staffing agencies, offering bonuses, and increasing wages. A follow-up revisit on 11/12/2021 confirmed correction of the cited deficiency.
Deficiencies (1)
Failure to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey.
Report Facts
Shifts with staffing deficiency: 17
Resident census: 116
Certified Nurse Aides (CNAs) staffing counts: 3
Shift bonus amounts: 75
Shift bonus amounts: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Reviewed schedules and staffing plans to address deficiencies. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed by surveyor and provided information on staffing shortages and corrective actions. |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Jun 18, 2021
Visit Reason
The inspection was conducted based on complaints NJ145152, NJ143204, and NJ140584 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ145152, NJ143204, and NJ140584 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 2
Date: Jan 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ00132608, NJ00134690, NJ00136529, NJ00136482, and NJ00134469) alleging noncompliance with regulatory requirements.
Complaint Details
The complaint investigation involved multiple complaint numbers. The facility failed to provide required written notices of transfer for one resident and failed to prevent a significant medication error for another resident. The medication error involved administration of a medication dose without a valid order. The facility conducted audits and inserviced staff to address these issues.
Findings
The facility was found not in compliance with requirements related to notice before transfer/discharge and medication administration errors. Specifically, the facility failed to provide written notices of transfer for one resident and failed to remain free of a significant medication error for another resident.
Deficiencies (2)
Failure to provide written notices of transfer for one resident of three reviewed for discharge services.
Failure to remain free of a significant medication error for one resident of three reviewed for medication errors.
Report Facts
Census: 129
Sample Size: 13
Deficiencies cited: 2
Inspection Report
Routine
Census: 129
Deficiencies: 0
Date: Jan 15, 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 preparation.
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 to prepare for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
The inspection was conducted in response to complaint #NJ 141124 to assess compliance with regulatory requirements.
Complaint Details
Complaint # NJ 141124 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
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