Inspection Reports for
Complete Care At Laurelton, Llc

Complaint #NJ186246 regarding medication errors was substantiated by findings of late insulin administration for 3 residents reviewed.

The facility was found to have administered insulin medications late for multiple residents (Resident #77, #110, and #28), failing to meet timely administration standards as per physician orders and facility policy. Interviews with staff confirmed the late administration and acknowledged the deficiencies.

The facility was found deficient in maintaining a safe and homelike environment, completing required resident assessments, ensuring accurate and resident-specific care plans, consistent documentation and administration of feeding tube flushes, providing appropriate respiratory care including oxygen humidification, and timely administration of insulin medications.

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.

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 NJ183557 was substantiated based on observations, interviews, and document reviews indicating medication administration errors and insufficient RN staffing.

The facility failed to follow standards of clinical practice for physician orders and care plan interventions for medication administration for Resident #5, including failure to administer prescribed morphine. Additionally, the facility failed to ensure a Registered Nurse was on duty for at least eight consecutive hours on one day reviewed. These deficiencies were found to pose minimal harm with few residents affected.

Complaint # NJ00181615, NJ00177959. The facility was not in substantial compliance based on these complaints related to medication administration and staffing.

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 # NJ00181615, NJ00177959. The complaint was substantiated based on observations, interviews, and record review showing late administration of medication without physician notification.

The facility failed to administer Sucralfate, an anti-ulcer medication, to Resident #1 in a timely manner as ordered by a physician. Multiple instances of late medication administration were documented between 11/1/2024 and 11/30/2024, with no evidence that the attending physician was notified. Resident #1 confirmed frequent late medication administration, especially in the mornings. No harm to the resident was documented.

Complaint numbers 163428, 166005, 166077, 166569, 169841 were investigated. The facility was found not in substantial compliance based on complaint visit 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 investigation included review of fracture of unknown origin for Resident #257 and other quality of care concerns including medication administration, care planning, infection control, and resident safety. The fracture investigation was incomplete and not substantiated as the fracture was determined to have occurred at home.

The facility failed to conduct a thorough investigation of a fracture of unknown origin for Resident #257, delayed X-ray and treatment, failed to revise care plans for oxygen therapy, failed to follow physician orders for weights and medication administration, failed to maintain secure medication storage, failed to serve meals at proper temperatures, failed to maintain kitchen sanitation and proper food handling, failed to implement infection control practices including proper PPE use and catheter care, and failed to ensure call bells were accessible to residents.

Complaint #169841 was substantiated based on observations, interviews, record reviews, and facility documentation showing failures in nursing practice standards related to weight monitoring and medication administration.

The facility failed to follow the physician's order to obtain weekly weights for Resident #95, documenting only 1 out of 4 weeks in November, December, and January. Additionally, the facility failed to administer two prescribed medications to Resident #256 and did not document the reason for omission or notify the physician as required.

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.

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 NJ155753 and NJ163142 triggered the inspection. The facility was found not in substantial compliance based on these complaints.

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.

The complaint investigation revealed multiple deficiencies including failure to develop care plans, medication administration errors, incomplete documentation of ADLs, lack of physician face-to-face visits, and dietary service failures. An immediate jeopardy was identified due to a resident choking on improperly prepared food, leading to death.

The facility failed to develop and implement appropriate care plans, administer medications and treatments as ordered, document activities of daily living consistently, ensure physician face-to-face visits every 60 days, and provide proper training and competency for dietary staff regarding therapeutic diets including carbohydrate controlled diets (CCD). An immediate jeopardy was identified related to a resident receiving an incorrect chopped diet tray which contributed to a fatal choking incident.

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.

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 Intake #: NJ147333 and NJ145919. The complaint was substantiated as the facility failed to meet staffing ratios, potentially affecting all residents.

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.

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.

The facility was found deficient in ensuring proper accountability and documentation of controlled medications, maintaining clean and sanitary medication storage areas, properly labeling opened multidose medications, and handling and storing food safely to prevent foodborne illness.

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.

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.

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 # 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.

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.