Complete Care At Woodlands
COMPLETE CARE AT WOODLANDS in PLAINFIELD, NJ — inspection on November 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Director of Nursing (DON) stated that the expectation when the resident refused the treatment was to first retry by making another attempt to do the treatment, then if not successful, document and make the doctor aware that the treatment was not done, to make sure the resident was getting optimal care.During a telephone interview with the surveyor on 10/24/25 at 1:39 PM, the Registered Nurse (RN) reported that on the 10/22/25 and 10/23/25 evening shifts, Resident #2 refused both dressing changes.
The RN stated that she coded the wound care for both shifts wrong, and that the process when the resident refused treatment, was to document in the PNs.
The RN stated that because it was coded wrong, she did not get the option to document the Resident #2's refusal note.
The RN further stated that she did not make anyone, including the doctor, aware that the treatment was not done.
The RN stated that for continuity of care and the incoming nurse aware that Resident #2's wound treatment was not done.In an interview on 10/24/25 at 3:15 PM, the Medical Doctor (MD) stated that she was aware that Resident #2 refused treatments at times but was not made aware of their refusals on the 10/22/25 evening shift, the 10/23/25 morning shift, or the 10/23/25 evening shift.
The MD stated that the expectation was for the nurses to inform them [medical staff] and they would then reach out to the wound care specialist.
The MD stated that the nurses could have also called the wound care specialist and they reach out to them [medical staff].
The MD stated it was important for the nurses to notify the doctor in case of any change in wound status.
The MD stated that there was no harm done because the area was gangrenous and a dead area but indicated that not cleaning the wound could cause discomfort to the normal area of skin. A review of the facility policy Documentation of Wound Treatments with an implementation date of 6/1/2025, revealed under Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment.
Under Policy Explanation and Compliance Guidelines: 3.
Wound treatments are documented at the time of each treatment.4.
Additional documentation shall include, but is not limited to a.
Date and time of wound management treatments.e.
Notifications to physician and/or responsible party regarding wound or treatment changes. A review of the facility policy Charting and Documentation with a reviewed date on 1/2023, revealed under the policy statement .
The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Under Policy Interpretation and Implementation, .7.
Documentation of procedures and treatments will include care-specific details, including: e.
Whether the resident refused the procedure/treatment; f.
Notification of family, physician or other staff. NJAC 8:39-27.1 (e)
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