Inspection Reports for Complete Care At Laurelton, Llc
475 Jack Martin Blvd, NJ, 08724
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Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform covered components and the public about the privacy practices related to medical information, including how information may be used, disclosed, and the rights of individuals regarding their health information.
Findings
The notice explains 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 the department 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
Complaint Investigation
Census: 118
Deficiencies: 3
Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (NJ00171995, NJ00179158, NJ00181714, NJ00183557) to determine compliance with professional standards and regulatory requirements.
Findings
The facility was found not in substantial compliance with requirements, with deficiencies related to medication administration, failure to follow physician orders and care plans, and failure to ensure a Registered Nurse worked at least eight consecutive hours a day for 1 of 21 days reviewed. Staffing ratios for Certified Nursing Assistants (CNAs) were also deficient for several days prior to the survey.
Complaint Details
The complaint investigation was based on complaints NJ00171995, NJ00179158, NJ00181714, and NJ00183557. The facility was found not in substantial compliance with professional standards and regulatory requirements. Specific complaints included failure to follow medication administration protocols and staffing deficiencies. The complaint was substantiated as evidenced by the deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice for Physician Orders for medication administration and Care Plan interventions for a resident. | SS=D |
| Failure to ensure a Registered Nurse worked for at least eight consecutive hours a day for 1 of 21 days reviewed. | SS=D |
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey. | — |
Report Facts
Survey Census: 118
Sample Size: 5
Days RN coverage deficient: 1
CNA staffing deficient days: 5
CNA staffing deficient days: 7
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Dec 23, 2024
Visit Reason
The inspection was conducted based on complaints NJ00181615 and NJ00177959 regarding medication administration and staffing issues at the facility.
Findings
The facility was found not in substantial compliance with pharmacy services regulations due to failure to administer medication to Resident #1 in a timely manner as ordered by a physician. Additionally, the facility failed to maintain required minimum staffing ratios on 9 of 14 day shifts reviewed.
Complaint Details
Complaint # NJ00181615, NJ00177959. The facility was not in substantial compliance based on these complaints related to medication administration and staffing.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services in accordance with professional standards by not ensuring timely administration of medication to Resident #1 as ordered by a physician. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the State of New Jersey on 9 of 14 day shifts. | — |
Report Facts
Census: 104
Deficient CNA staffing days: 9
CNA staffing counts: 12
CNA staffing counts: 12
CNA staffing counts: 12
CNA staffing counts: 11
CNA staffing counts: 10
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 11
CNA staffing counts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Named in medication administration deficiency |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration procedures |
| RN #1 | Registered Nurse Unit Manager | Interviewed regarding medication administration and documentation |
Inspection Report
Re-Inspection
Census: 102
Capacity: 118
Deficiencies: 15
Feb 9, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations.
Findings
Deficiencies were cited related to emergency preparedness plan maintenance, complaint investigation thoroughness, care plan revisions, medication administration, quality of care, oxygen therapy, medication storage, food temperature and safety, infection control, resident call system, staffing ratios, and life safety code compliance. The facility submitted a Plan of Correction and was found in compliance on reinspection.
Complaint Details
Complaint numbers 163428, 166005, 166077, 166569, 169841 were investigated. The facility was found not in substantial compliance based on complaint visit findings.
Severity Breakdown
SS=D: 7
SS=E: 3
SS=F: 3
SS=G: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure Emergency Preparedness Plan was maintained, reviewed, and updated at least annually and available at required locations. | SS=D |
| Failed to conduct a complete and thorough investigation for a resident who sustained an injury, including lack of witness statements and root cause analysis. | SS=G |
| Failed to revise resident-centered on-going care plan to reflect current oxygen therapy orders and care needs. | SS=D |
| Failed to follow physician orders for monitoring and medication administration, and failed to document physician notification for omitted medications. | SS=D |
| Failed to recognize and respond timely to a resident's change in condition requiring transfer to hospital. | SS=G |
| Failed to ensure resident-specific prescription medications were stored securely on unit 2 medication cart. | SS=E |
| Failed to serve meals at palatable temperature and failed to properly use utensils and hand hygiene during meal service. | SS=F |
| Failed to ensure food safety including kitchen cleanliness, food labeling, and hand hygiene during meal service. | SS=F |
| Failed to maintain an effective QAPI program that identifies and addresses quality deficiencies including adverse events. | SS=F |
| Failed to properly don PPE gown and maintain appropriate infection control practices including catheter care and hand hygiene. | SS=E |
| Failed to ensure all residents had call bells available and within reach to alert staff for assistance. | SS=E |
| Failed to provide one designated exit access door with illuminated exit sign readily accessible and free of obstructions. | SS=D |
| Failed to ensure corridor doors resist passage of smoke due to a 1/2 inch gap along the top edge of a door. | SS=D |
| Failed to ensure electrical outlet adjacent to a water source was equipped with required Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey for 14 of 14 day shifts reviewed. | — |
Report Facts
Deficient CNA staffing day shifts: 14
Residents present during inspection: 102
Facility licensed capacity: 118
Meal temperature: 112
Meal temperature: 120
Meal temperature: 51
Meal temperature: 56
Meal temperature: 114.3
Meal temperature: 111.7
Meal temperature: 42
Meal temperature: 136
Meal temperature: 112
Meal temperature: 112
Meal temperature: 154
Gap in corridor door: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in infection control gown donning deficiency and meal service hand hygiene. |
| Certified Nursing Assistant #2 | CNA | Named in infection control gown donning deficiency and meal service hand hygiene. |
| Director of Nursing | DON | Named in complaint investigation and QAPI deficiencies. |
| Regional Administrator | Named in education on emergency preparedness and complaint investigation. | |
| Regional Director of Food Services | Named in food temperature and safety deficiencies. | |
| Surveyor | Interviewed staff and observed deficiencies. |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Nov 9, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers from 11/07/2023 to 11/09/2023.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet minimum staffing ratios for Certified Nurse Aides (CNAs) on 17 of 28 day shifts, potentially affecting all residents. The facility leadership has implemented corrective actions including recruitment efforts, increased pay, and monitoring to address staffing deficiencies.
Complaint Details
Complaint investigation involved multiple complaint numbers (NJ00149749, NJ00158244, NJ00159114, NJ00159548, NJ00160165, NJ00162593, NJ00164070, NJ00166914). The facility was found deficient in staffing ratios but was in substantial compliance with federal requirements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios met minimum requirements for CNAs on 17 of 28 day shifts. |
Report Facts
Survey Census: 100
Sample Size: 6
Deficient day shifts: 17
CNA staffing shortfalls: 11
CNA staffing shortfalls: 6
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 9
May 10, 2023
Visit Reason
Complaint investigation triggered by NJ155753 and NJ163142 regarding facility compliance with care and safety regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to provide proper therapeutic diets, failure to develop and implement comprehensive care plans, failure to timely conduct physician visits, failure to provide adequate staffing, and failure to ensure proper documentation of care and treatments.
Complaint Details
Complaint NJ155753 and NJ163142 triggered the inspection. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
J: 1
D: 1
E: 3
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure a resident was provided a carbohydrate controlled diet with chopped texture, resulting in a resident found deceased after receiving an incorrect meal. | J |
| Failure to develop and implement an Incontinence Care Plan for a resident dependent on staff for care. | D |
| Failure to revise Care Plans after Speech Therapist assessments for 5 residents with physician orders for modified diets. | E |
| Failure to follow professional standards by not administering medications and treatments as ordered for 2 residents. | E |
| Failure to consistently document Activities of Daily Living care as being provided to residents dependent on staff for ADLs. | E |
| Failure to ensure physician conducted face-to-face visits and wrote progress notes at least every 60 days for 8 residents. | F |
| Failure to employ sufficient qualified dietary staff with appropriate competencies and skills to meet nutritional needs of residents. | F |
| Failure to ensure therapeutic diets were prescribed by the attending physician and properly implemented, including failure to provide proper diet texture and consistency. | — |
| Failure to meet mandatory staffing ratios for Certified Nurse Aides on 9 of 28 day shifts reviewed. | — |
Report Facts
Census: 93
Sample size: 19
Deficient CNA staffing shifts: 9
Required CNA staffing: 12
Actual CNA staffing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Named in relation to improper meal tray setup and failure to return incorrect meal | |
| Dietary Director | Named in relation to dietary staff training and meal tray audits | |
| Cook | Named in relation to preparation of therapeutic diets and meal tray errors | |
| Licensed Practical Nurse | Named in relation to response to resident fall and meal tray incident | |
| Registered Nurse | Named in relation to response to resident fall and documentation | |
| Speech Therapist | Named in relation to diet texture assessments and care plan recommendations | |
| Director of Nursing | Named in relation to care plan oversight, staff education, and policy compliance | |
| Dietician | Named in relation to care plan development and dietary recommendations |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
May 12, 2022
Visit Reason
The inspection was conducted based on complaint NJ153985 to investigate staffing ratio compliance at the facility.
Findings
The facility failed to meet the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 10 of 14-day shifts reviewed, potentially affecting all residents. The facility was found to be in noncompliance with New Jersey staffing regulations but no residents were directly affected.
Complaint Details
Complaint NJ153985 was investigated and the facility was found deficient in CNA staffing ratios on multiple days in February 2022. The complaint was substantiated with documentation of staffing shortages on specific dates.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 10 of 14-day shifts reviewed. |
Report Facts
Census: 107
Deficient CNA staffing days: 10
CNA staffing shortfalls: 1
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 0
Apr 13, 2022
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 residents: 5
Sample staff: 5
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Oct 22, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ145919 and NJ147333 to investigate staffing ratio deficiencies at the facility.
Findings
The facility failed to meet the minimum staffing ratios required by New Jersey law for 14 of 14 shifts reviewed between 07/04/2021 and 07/17/2021, with insufficient certified nurse aides scheduled for day shifts. The facility acknowledged staffing shortages and described extensive recruitment and retention efforts to address the issue.
Complaint Details
Complaint Intake #: NJ147333 and NJ145919. The complaint was substantiated as the facility failed to meet staffing ratios, potentially affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 shifts reviewed, violating mandatory access to care staffing requirements. |
Report Facts
Census: 110
Certified Nurse Aides (CNAs) staffing shortfall: 14
Staffing agencies contracted: 9
Gift card bonuses: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interviewed on 10/22/2021 regarding staffing scheduling and shortages. | |
| Administrator | Interviewed on 10/22/2021 acknowledging staffing shortages and recruitment efforts. |
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 3
Oct 19, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to pharmacy services including inaccurate narcotic shift count logs and medication administration documentation, improper storage and labeling of drugs and biologicals, and food procurement and storage issues leading to potential food safety risks.
Severity Breakdown
SS=E: 1
SS=F: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure accountability of narcotic shift count logs and accurate documentation of controlled medication administration. | SS=E |
| Failure to properly store medications, maintain clean medication storage areas, and properly label opened multidose medications. | SS=F |
| Failure to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner to prevent foodborne illness. | SS=D |
Report Facts
Census: 114
Medication carts reviewed: 5
Medication carts with deficiencies: 5
Medication storage rooms reviewed: 2
Medication storage rooms with deficiencies: 1
Loose medication pills found: 16
Loose medication pills found: 6
Dented cans observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding narcotic shift count logs and medication cart observations |
| LPN #2 | Licensed Practical Nurse | Observed narcotic count and medication storage |
| LPN #3 | Licensed Practical Nurse | Observed narcotic medication review and medication cart observations |
| LPN #4 | Licensed Practical Nurse | Observed medication storage room and refrigerator |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding narcotic count procedures and medication administration documentation |
| Food Service Manager | Food Service Manager (FSM) | Interviewed regarding food storage and sanitation issues |
| Licensed Nursing Home Administrator | Administrator | Present during interviews and acknowledged findings |
Inspection Report
Life Safety
Deficiencies: 1
Oct 18, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to properly maintain ventilation systems in 6 of 9 resident bathroom exhaust systems, which did not function properly during testing. Corrective actions included replacing two burnt-out fan motors and instituting ongoing maintenance audits.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure proper maintenance of ventilation systems for 6 of 9 resident bathroom exhaust systems, which did not function properly when tested. | SS=E |
Report Facts
Resident bathrooms with non-functioning exhaust: 6
Date of survey completion: Oct 18, 2021
Date of plan of correction completion: Dec 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present during inspection and notified of findings | |
| Maintenance Director | Present during inspection and confirmed ventilation issues |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Jun 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ136194, NJ136601, NJ143187, NJ144226, and NJ145570 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to notify the responsible party of a resident's significant change in condition, specifically regarding test results and new medication administration for Resident #2. The Director of Nursing took immediate corrective actions including re-education of staff and implementation of monitoring procedures.
Complaint Details
The complaint investigation revealed that the facility failed to notify the responsible party of Resident #2's positive test results and new medication orders. Interviews with the Director of Nursing and Administrator confirmed no documentation of notification. The involved Licensed Practical Nurse was no longer employed and could not be counseled.
Severity Breakdown
Scope and Severity = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the responsible party of a resident's change in condition, including positive test results and new medication orders. | Scope and Severity = D |
Report Facts
Census: 102
Sample Size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in relation to failure to notify responsible party; no longer employed |
| Director of Nurses | Director of Nursing | Interviewed and verified lack of notification; took corrective actions |
| Administrator | Administrator | Interviewed and verified lack of notification |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Apr 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ 144305 to investigate medication storage and security concerns on the dementia unit.
Findings
The facility was found not in substantial compliance due to failure to ensure medications that could cause significant harm were stored securely and inaccessible to cognitively impaired residents. An Immediate Jeopardy (IJ) was identified on 4/5/2021 due to unsecured medications on the nursing station accessible to residents. The IJ was removed after the facility implemented a removal plan including staff in-servicing on medication storage.
Complaint Details
Complaint # NJ 144305. The facility was found in Immediate Jeopardy status due to unsecured medications accessible to residents on the dementia unit. The IJ was identified on 4/5/2021 and removed the same day after corrective actions were implemented.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medications which could cause significant harm were stored securely and inaccessible to cognitively impaired residents on the dementia unit. | J |
Report Facts
Census: 98
Sample Size: 8
Immediate Jeopardy Duration (hours): 6.42
Medication Delivery Times: 2
Medication Storage Audits Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Notified of Immediate Jeopardy on 4/5/2021 at 4:22 p.m. | |
| Director of Nursing (DON) | Notified of Immediate Jeopardy on 4/5/2021 at 4:22 p.m.; provided details on medication delivery and storage procedures | |
| LPN #1 | Licensed Practical Nurse | Observed leaving medications unsecured on nursing station counter on 4/5/2021 |
| LPN #2 | Licensed Practical Nurse | Reported recently in-serviced on delivery and storage of medications |
| Unit Manager (UM) | Reported recently in-serviced on delivery and storage of medications and knowledgeable about proper handling |
Inspection Report
Routine
Census: 90
Deficiencies: 0
Dec 21, 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.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 81
Deficiencies: 0
Dec 2, 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 had implemented the CMS and CDC recommended practices for COVID-19.
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