Inspection Reports for
Complete Care At Court House, Llc
144 Magnolia Drive, Cape May Court House, NJ, 08210
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
88% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 29, 2025
Visit Reason
The inspection was conducted based on complaint #2695513 to investigate the facility's failure to adequately assess and implement measures to protect a resident identified as high risk for elopement.
Complaint Details
Complaint #2695513 was substantiated based on interviews, medical record review, and facility document review conducted on 12/19/25 and 12/23/25. The complaint involved Resident #3 eloping from the facility without proper assessment or care planning.
Findings
The facility failed to properly assess and manage elopement risk for Resident #3, who eloped from the facility without a care plan or interventions in place. Conflicting documentation regarding the resident's elopement risk was found, and the facility did not complete required elopement assessments or develop appropriate interventions.
Deficiencies (1)
Failure to adequately assess and implement measures to protect a resident identified as high risk for elopement.
Report Facts
Elopement Risk Score: 11
Elopement Risk Score: 99
BIMS score: 14
Date of elopement event: Dec 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NS #1 | Nursing Supervisor | Completed Nursing Comprehensive Assessment and provided information about elopement risk assessment. |
| CNA #1 | Certified Nursing Assistant | Observed Resident #3 missing from room and reported the elopement event. |
| LPN #1 | Licensed Practical Nurse | Reported details of the elopement event and initiated elopement protocol. |
| LPN #2 | Licensed Practical Nurse | Completed progress notes that did not reference elopement history or risk. |
| DON | Director of Nursing | Provided statements regarding assessment and intervention expectations for elopement risk. |
| LNHA | Licensed Nursing Home Administrator | Participated in joint interview regarding elopement event and facility policies. |
| MD | Medical Director | Stated expectations for elopement risk assessment and interventions upon resident admission. |
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 regarding the notice |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 120
Deficiencies: 7
Date: Mar 13, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey was complaint-driven with multiple complaint numbers referenced.
Complaint Details
Complaint numbers NJ 163463, 164350, 169831, 173198, 174555 were investigated. The survey was complaint-driven and focused on multiple areas including staffing, environment, medication administration, pressure ulcer prevention, infection control, and life safety.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper medication administration, prevention of pressure ulcers, infection control, and life safety code compliance. Deficiencies were identified in environmental cleanliness, medication pass procedures, pressure ulcer prevention, infection control practices, and fire safety exit door hardware.
Deficiencies (7)
Facility failed to maintain a clean and sanitary environment in 2 of 2 units.
Facility failed to ensure proper administration of medication during medication pass observation for 1 of 5 residents observed.
Facility failed to follow a physician's order to promote the prevention of pressure ulcers for 1 of 1 resident reviewed.
Facility failed to properly store medication for 1 of 25 residents reviewed.
Facility failed to use appropriate infection control practices to prevent the potential spread of infection.
Facility failed to ensure one out of four exit discharges was equipped with illumination in accordance with NFPA 101 Life Safety Code.
Facility failed to ensure two of nine fire rated door assemblies for stairway exit doors were equipped with approved fire exit hardware.
Report Facts
Census: 106
Total Capacity: 120
Deficiency counts: 7
Staffing Deficiencies: 7
Residents reviewed for medication storage: 25
Residents reviewed for infection control: 2
Residents reviewed for pressure ulcer prevention: 1
Inspection Report
Routine
Deficiencies: 3
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, specifically focusing on medication administration, documentation, and clarification of physician medication orders for residents.
Findings
The facility failed to ensure proper medication administration during a medication pass, failed to document medication administration in the Electronic Medication Administration Record for pain management, and failed to clarify physician's medication orders for anticoagulation therapy for a post orthopedic surgery resident. These deficiencies were acknowledged by facility leadership.
Deficiencies (3)
Improper administration of medication during medication pass observation for Resident #43, including reusing pills that were spat out instead of discarding them.
Failure to document administration of pain medication (tramadol) in the Electronic Medication Administration Record for Resident #196.
Failure to clarify physician's admitting medication orders regarding anticoagulation therapy (Eliquis) for Resident #196 post orthopedic surgery.
Report Facts
Medication doses removed: 7
Medication doses documented administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed improperly administering medication during medication pass |
| Director of Nursing | Director of Nursing | Acknowledged medication administration deficiencies and reviewed findings with surveyor |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Participated in review of medication pass concerns and findings |
| Licensed Practical Nurse/Unit Manager #2 | Licensed Practical Nurse/Unit Manager | Interviewed regarding medication order clarification process |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication order verification and admission process |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 13, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards related to facility environment, medication administration, pressure ulcer care, respiratory care, medication storage, and infection control practices.
Findings
The facility was found deficient in maintaining a clean and sanitary environment, proper medication administration and documentation, pressure ulcer prevention, consistent implementation of physician orders for respiratory care, proper medication storage, and infection prevention and control practices including appropriate use of PPE and handling of soiled laundry.
Deficiencies (7)
Facility failed to maintain a clean and sanitary environment with multiple issues observed on 2nd and 3rd floors including rusted toilet paper holders, chipped paint, scuff marks, food on floor, and dirty equipment wheels.
Improper medication administration observed where nurse reused pills that resident had spat out instead of discarding and pouring new ones.
Failure to document administration of medication in EMAR and failure to clarify physician's medication orders for anticoagulation therapy for a post orthopedic surgery resident.
Failure to follow physician's order for pressure ulcer prevention by not using heel boots as ordered for a resident at risk.
Failure to consistently implement physician order for continuous supplemental oxygen for a resident; oxygen concentrator was removed and resident was not receiving oxygen as ordered.
Failure to properly store medication; resident had an unlabeled inhaler at bedside contrary to facility policy.
Failure to use appropriate infection control practices including dragging soiled laundry bags on floor and failure to wear gowns when transferring a resident on Enhanced Barrier Precautions.
Report Facts
Residents observed for medication pass: 5
Residents sampled for pain medication documentation: 2
Residents reviewed for respiratory care: 3
Medication doses removed but not documented: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication error finding for reusing pills that resident spat out |
| Licensed Practical Nurse/Unit Manager #2 | LPN/Unit Manager | Interviewed regarding medication order clarification and oxygen administration |
| Director of Nursing | DON | Acknowledged medication administration errors and oxygen order issues |
| Licensed Nursing Home Administrator | LNHA | Participated in review of medication administration and oxygen order findings |
| Certified Nursing Assistant #1 | CNA | Observed dragging soiled laundry bag on floor |
| Certified Nursing Assistant #2 | CNA | Observed transferring resident without wearing gown as required by EBP |
| Certified Nursing Assistant #3 | CNA | Unaware of EBP requirements and PPE use during resident transfer |
| Infection Preventionist | IP | Provided interview on proper handling of soiled laundry and PPE use |
| Licensed Practical Nurse #3 | LPN | Observed during medication storage deficiency involving unlabeled inhaler |
Inspection Report
Routine
Census: 98
Capacity: 101
Deficiencies: 11
Date: Feb 2, 2023
Visit Reason
Routine standard survey conducted to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including incontinence care, nutritional management, dialysis, infection control, food safety, garbage disposal, infection prevention, resident call system, staffing ratios, and life safety code requirements related to fire alarm, sprinkler, and electrical systems.
Deficiencies (11)
Failure to ensure catheter bags were kept off the floor and proper continence care was provided.
Failure to ensure nutritional formula and enteral feeding were properly managed and labeled.
Failure to ensure dialysis services were provided consistent with professional standards and resident preferences.
Failure to maintain kitchen sanitation including proper hair net use, food labeling, storage, and temperature control.
Failure to properly cover garbage dumpsters to prevent access by rodents and pests.
Failure to ensure proper use of personal protective equipment (PPE) on a COVID-19 designated unit and failure to maintain catheter bags off the floor.
Failure to ensure resident call system was intact, functioning properly, and accessible in all resident rooms.
Failure to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey.
Failure to complete smoke detection sensitivity testing for all photo electric smoke detectors as required by NFPA 72.
Failure to ensure sprinkler coverage was provided under exit staircase landings for all stairways.
Failure to provide a remote emergency stop switch for the 250 KW diesel emergency generator as required by NFPA 110.
Report Facts
Census: 98
Total Capacity: 101
Deficiency counts: 11
Staffing ratios: 7
Staffing ratios: 12
Staffing ratios: 4
Staffing ratios: 6
Staffing ratios: 6
Staffing ratios: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed failing to wear full PPE on COVID-19 designated unit. |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed regarding PPE requirements and confirmed COVID-19 room designation. |
| Maintenance Director | Interviewed regarding fire safety, sprinkler coverage, generator remote stop switch, and kitchen sanitation. | |
| Administrator | Interviewed regarding PPE compliance and call bell system maintenance. | |
| Human Resource/Staffing Coordinator | Interviewed regarding staffing shortages and recruitment efforts. |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 2, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, infection control, dietary services, and facility safety.
Findings
The facility was found deficient in multiple areas including improper catheter care with urinary catheter bags resting on the floor, inaccurate labeling and handling of feeding tube nutritional formula, failure to implement prescribed fluid restrictions and provide meals before/after dialysis, poor kitchen sanitation and food safety practices, uncovered garbage dumpsters, improper use of PPE in COVID-19 designated units, and malfunctioning resident call light systems.
Deficiencies (7)
Urinary catheter drainage bag was observed resting on the floor contrary to facility policy and professional standards.
Nutritional formula connected to a feeding tube was not accurately labeled and was hung beyond recommended time limits.
Failure to accurately implement physician prescribed fluid restriction and failure to provide meals before or after dialysis treatment.
Kitchen sanitation deficiencies including uncovered food, improperly labeled and stored food items, wet pans, and improper hair net use.
Garbage dumpster lids were left open exposing bagged garbage.
Staff failed to wear full PPE when entering COVID-19 designated rooms as required by droplet precaution signage.
Resident call system was not functioning properly in one resident room and call device was broken for 1-2 weeks.
Report Facts
Fluid restriction: 1000
Feeding tube formula hang time: 48
Feeding tube formula hang time: 24
Meal fluid volume: 600
Meal fluid volume: 1080
Meal fluid volume: 100
Hair net coverage: 2
Temperature of dessert: 42
Number of uncovered sandwiches: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Failed to wear full PPE entering COVID-19 designated room. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding catheter bag placement and feeding tube formula. |
| NA #1 | Nurse's Aide | Interviewed regarding catheter bag placement. |
| RN/UM #2 | Registered Nurse/Unit Manager | Interviewed regarding catheter bag placement and call light system. |
| DOD | Director of Dining | Interviewed regarding dietary procedures and food safety. |
| DON | Director of Nursing | Interviewed regarding fluid restriction and infection control breaches. |
| IP | Infection Preventionist | Interviewed regarding PPE requirements and infection control. |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding fluid restriction implementation. |
| NA #2 | Nursing Assistant | Interviewed regarding fluid restriction monitoring. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding infection control breach and staff education. |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding call light system checks. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding call light system and resident care. |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed regarding PPE use and COVID-19 precautions. |
Document
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
Document is not related to regulatory oversight or inspection; it is a prompt to open the PDF portfolio in specific software.
Findings
No inspection or regulatory content present; document only contains instructions to open the PDF portfolio.
Inspection Report
Routine
Census: 81
Deficiencies: 0
Date: Sep 8, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 6
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Aug 10, 2021
Visit Reason
The inspection was conducted based on complaint NJ146424 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Complaint Details
Complaint NJ146424 triggered the visit. The facility was found not in substantial compliance based on this complaint visit.
Findings
The facility was found not in substantial compliance due to failure to develop and implement comprehensive person-centered care plans for 2 of 3 residents reviewed, specifically Resident #1 and Resident #3, with missing care plans for certain diagnoses and failure to follow the facility's own care plan policy.
Deficiencies (1)
Failure to develop a comprehensive care plan for Resident #1 and Resident #3 consistent with their diagnoses and facility policy.
Report Facts
Sample Size: 3
Residents identified as diabetic: 28
Diabetic residents with appropriate care plans: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed and updated care plans for Resident #1 and Resident #3; stated that the care plan policy was not followed | |
| MDS Coordinator | Interviewed and stated that care plans should be developed for residents receiving certain treatments and diagnoses | |
| Administrator | Conducted audit and reeducation of interdisciplinary team on care plan policy and procedures | |
| RNAC | Will conduct weekly audits on new admissions to assure accuracy of care plans |
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: Aug 4, 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.
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: 5
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: May 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00143872 and NJ00143772.
Complaint Details
Complaint numbers NJ00143872 and NJ00143772 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: 5
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 1
Date: Feb 10, 2021
Visit Reason
The inspection was a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent foodborne illness. Specific issues included uncovered disposable cups, inadequate sanitizer concentration, and unclean kitchen equipment.
Deficiencies (1)
Failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including uncovered disposable cups, sanitizer solution at 0 ppm instead of required 200 ppm, and food debris on kitchen equipment.
Report Facts
Census: 93
Sanitizer concentration increase: 200
Sample size: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Interviewed regarding food safety and sanitation deficiencies |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 10, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012, specifically focusing on the facility's cooking facilities and fire safety measures.
Findings
The facility was found not in substantial compliance with the minimum Life Safety Code requirements due to deficiencies in the cooking facilities. Specifically, 5 of 7 exhaust hood grease baffles were improperly positioned with gaps and bent frames, posing a fire hazard by allowing grease and fire to enter above the exhaust hood system.
Deficiencies (1)
Five of seven exhaust hood grease baffles over the main cooking area had gaps and bent frames, failing to protect against grease and fire entering above the exhaust hood system as per NFPA 96.
Report Facts
Exhaust hood grease baffles improperly positioned: 5
Total exhaust hood grease baffles: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview regarding the grease baffle deficiencies. | |
| Facility Administrator | Present during observation and interview regarding the grease baffle deficiencies. | |
| Dietary Director | Present during observation and interview regarding the grease baffle deficiencies and received education on maintenance requests. |
Inspection Report
Deficiencies: 3
Date: Feb 10, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food handling, sanitation, and safety standards to prevent food borne illness.
Findings
The facility failed to properly handle potentially hazardous foods and maintain sanitation, as evidenced by exposed plastic cups, ineffective sanitizer solution with 0 ppm concentration, and food debris on a sanitized stand-up mixer.
Deficiencies (3)
Exposed plastic cups in dry storage area.
Sanitizer solution tested at 0 ppm concentration, below required 200 ppm.
Food debris observed on sanitized stand-up mixer.
Report Facts
Sanitizer concentration: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Interviewed regarding sanitation practices and sanitizer testing. |
Inspection Report
Routine
Census: 101
Deficiencies: 0
Date: Jan 14, 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.
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: 5
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