Inspection Reports for Complete Care At Monmouth, Llc
229 Bath Avenue, NJ, 07740
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Notice
Deficiencies: 0
Nov 20, 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 outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health 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
Routine
Census: 80
Deficiencies: 0
Mar 5, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Jan 27, 2025
Visit Reason
The inspection was conducted based on complaints NJ182074, NJ182256, and NJ182526 to determine compliance with professional standards of care related to medication administration.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to meet professional standards in medication administration for Resident #2. Deficiencies included failure to administer medications timely and document administration properly.
Complaint Details
Complaint investigation based on complaints NJ182074, NJ182256, and NJ182526. The facility was found not in substantial compliance with professional standards related to medication administration.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice for medication administration and care plan interventions for Resident #2, including failure to administer medications timely and document administration. | SS=D |
Report Facts
Census: 86
Sample Size: 8
Inspection Report
Routine
Census: 93
Capacity: 120
Deficiencies: 13
Dec 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 related to resident rights, abuse/neglect policies, transfer and discharge requirements, comprehensive care plans, medication administration, skin integrity, respiratory care, dental services, food safety, and life safety code compliance.
Findings
The facility was found deficient in multiple areas including resident rights regarding meal service, abuse/neglect policies, transfer and discharge documentation, comprehensive care planning, medication administration, skin integrity, respiratory care, dental services, food safety, and life safety code compliance. Deficiencies were substantiated through observations, interviews, and record reviews. Corrective actions and plans of correction were submitted and completed by 01/17/2025.
Complaint Details
Complaints investigated included NJ Complaint #172281, 172455, 173605, 174208, 180147. Substantiated deficiencies were found related to resident rights, abuse/neglect policies, transfer and discharge documentation, comprehensive care planning, medication administration, skin integrity, respiratory care, dental services, food safety, and life safety code compliance.
Severity Breakdown
SS=D: 9
SS=E: 2
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to serve meals in a dignified, home-like manner by using disposable containers and plates for some residents. | SS=D |
| Facility failed to implement policies to prevent abuse, neglect, and exploitation, including incomplete reference checks for new hires. | SS=E |
| Facility failed to ensure complete and accurate transfer and discharge documentation including the New Jersey Universal Transfer Form and physician discharge summary. | SS=D |
| Facility failed to develop individualized comprehensive care plans for residents. | SS=D |
| Facility failed to maintain professional standards of practice in medication administration, including borrowing medications and improper documentation. | SS=D |
| Facility failed to provide adequate care to prevent and treat pressure ulcers. | SS=D |
| Facility failed to ensure a resident's environment was free of accident hazards related to smoking contracts. | SS=D |
| Facility failed to provide adequate respiratory care including proper storage and labeling of equipment. | SS=E |
| Facility failed to provide adequate dialysis care and documentation. | SS=D |
| Facility failed to provide timely dental services to residents. | SS=D |
| Facility failed to maintain kitchen sanitation and food safety standards. | SS=D |
| Facility failed to maintain adequate life safety code compliance including delayed egress locking arrangements and sprinkler system maintenance. | SS=F |
| Facility failed to maintain accurate drug regimen review and medication administration records. | SS=D |
Report Facts
Residents present: 93
Total licensed capacity: 120
Deficiencies cited: 13
Completion date for corrections: Jan 17, 2025
Date of inspection: Dec 9, 2024
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 9
Nov 16, 2023
Visit Reason
A Recertification and Complaint survey was conducted due to a complaint investigation and recertification survey to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with multiple deficiencies including failure to report and investigate an allegation of abuse, failure to develop comprehensive care plans, untimely medication administration, oxygen therapy without physician orders, improper food handling, staffing shortages, and life safety code violations including exit discharge issues, fire alarm system testing, corridor smoke barrier penetrations, and handrail maintenance.
Complaint Details
The complaint investigation focused on an allegation of abuse involving Resident #79, where a Certified Nursing Assistant allegedly placed an overbed table on the resident and lifted the bed causing injury. The facility failed to report this allegation timely to the State Survey Agency and did not thoroughly investigate the allegation, interviewing only the alleged perpetrator and not the resident or other staff. The investigation concluded the abuse was unsubstantiated. The facility also failed to prevent further abuse or neglect during the investigation.
Severity Breakdown
SS=D: 4
SS=F: 3
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure an allegation of abuse was reported to the State Agency and thoroughly investigated, and failed to prevent further abuse/neglect while the investigation was in progress for Resident #79. | SS=D |
| Failed to develop and implement comprehensive care plans according to resident needed care areas for Residents #18 and #36. | SS=D |
| Failed to administer medications timely to Residents #69 and #136. | SS=D |
| Implemented oxygen therapy without physician's orders for Resident #20. | SS=D |
| Failed to serve food in a sanitary manner; employee did not wash hands or change gloves after contamination. | SS=F |
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Exterior stair handrails were rusted, broken, and not properly secured. | SS=E |
| Failed to perform smoke detection sensitivity testing every alternate year as required by NFPA 72. | SS=F |
| Penetrations in smoke barriers were not protected by a system or material capable of restricting the transfer of smoke. | SS=F |
Report Facts
Survey Census: 81
Total Capacity: 120
Sample Size: 21
Supplemental Residents: 8
Deficiency Counts: 11
Deficiency Counts: 13
Deficiency Counts: 22
Deficiency Counts: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse / Unit Manager | Interviewed regarding Resident #79 abuse allegation and care plan responsibilities. |
| CNA6 | Certified Nursing Assistant | Alleged perpetrator in Resident #79 abuse allegation. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse allegation reporting and investigation, medication administration, oxygen therapy, and staffing. |
| Cook1 | Cook | Observed failing to wash hands and change gloves properly during food service. |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed regarding Resident #20 oxygen therapy orders. |
| Maintenance Director | Maintenance Director | Interviewed regarding handrail maintenance, smoke detector testing, and smoke barrier penetrations. |
| Regional Maintenance Director | Regional Maintenance Director | Interviewed regarding smoke detector testing and smoke barrier penetrations. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 6
Mar 21, 2023
Visit Reason
Complaint investigation regarding allegations of abuse and neglect involving Resident #3 and failure to report incidents to the New Jersey Department of Health.
Findings
The facility failed to prevent abuse and neglect involving Resident #3 and other residents, failed to report incidents timely to the NJ Department of Health, failed to update care plans timely for residents at risk, failed to develop discharge plans and notify physicians for a resident discharged to the community, and failed to maintain required minimum direct care staffing ratios.
Complaint Details
Complaint #NJ00162301 involved allegations of abuse and neglect by Resident #3 towards other residents and failure to report incidents to the New Jersey Department of Health.
Severity Breakdown
SS=E: 1
SS=D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to prevent verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion involving Resident #3 and other residents. | SS=E |
| Failure to immediately report allegations of abuse, neglect, exploitation, or mistreatment to the administrator and appropriate authorities. | SS=D |
| Failure to update and/or initiate care plan interventions timely for a resident at risk for substance use while on pass. | SS=D |
| Failure to develop a discharge care plan, update discharge goals based on resident's needs, and notify physician of discharge for a resident to the community. | SS=D |
| Failure to implement interventions and establish procedure for a resident who left the facility on pass and did not return on time or as expected. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios for the day, evening, and night shifts as mandated by the State of New Jersey. | — |
Report Facts
Census: 74
Sample size: 5
Deficient CNA staffing days: 26
Deficient CNA staffing evening shifts: 1
Deficient total staff overnight shifts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Mentioned in relation to failure to notify about resident missing from pass and failure to update care plan. |
| CNA #1 | Certified Nursing Assistant | Witnessed abuse incidents involving Resident #3 and reported to nurse. |
| UM/LPN #2 | Unit Manager / Licensed Practical Nurse | Confirmed awareness of incidents but failure to report to NJDOH and update care plans. |
| Resident #4's attending physician | Physician | Not notified timely of resident's discharge and condition changes. |
| Staffing Coordinator | Staffing Coordinator | Provided information on staffing shortages and recruitment efforts. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
May 3, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint # NJ 153496.
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.
Complaint Details
Complaint # NJ 153496 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 1
Jul 19, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to maintain water temperatures at a safe level not exceeding 110 degrees Fahrenheit, failed to develop an accurate facility policy consistent with state maximum water temperatures, and failed to implement proper water temperature logs to protect residents from accident hazards.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain water temperatures at a safe temperature not in excess of 110 degrees Fahrenheit, failed to develop an accurate facility policy in accordance with state maximum water temperatures, and failed to implement facility policy for water temperature logs to ensure resident safety. | SS=E |
Report Facts
Census: 73
Sample Size: 18
Water Temperature: 129
Water Temperature: 129.9
Water Temperature: 123.1
Water Temperature: 121.4
Water Heater Setting: 145
Water Temperature: 112.4
Water Temperature: 119.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Participated in entrance conference and survey exit |
| Maintenance Director | MD | Provided water temperature logs, participated in facility tour, and responsible for corrective actions |
| Registered Nurse/Unit Manager | RN/UM | Present during water temperature measurements |
Inspection Report
Life Safety
Deficiencies: 4
Jul 14, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 7/14/2021 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with several Life Safety Code requirements including improper positioning of cooking stove exhaust hood grease baffles, lack of automatic fire sprinkler protection in a basement storage room, smoke barrier doors that did not fully close, and failure to conduct quarterly fire drills on each shift with proper documentation.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Main cooking stove exhaust hood grease baffles had a three-inch gap, failing to prevent fire extension as required by NFPA 96. | SS=D |
| Automatic fire sprinkler protection was missing in a 27 inch deep by 5 feet 4 inch wide air conditioning/sump pump room in the basement. | SS=D |
| One of seven sets of double smoke barrier doors failed to self-close properly, leaving a 43 inch opening that could allow passage of smoke, flame, or gases. | SS=D |
| Fire drills or staff training for fire response procedures were not conducted quarterly on each shift with proper documentation for 3 of 4 quarters. | SS=E |
Report Facts
Deficiencies cited: 4
Fire drill staff participants: 29
Fire drill quarters missing documentation: 3
Fire drill planned additional drills: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Food Service Director | Present during inspection of cooking stove exhaust hood grease baffles and involved in corrective actions. | |
| Maintenance Director | Involved in inspection and corrective actions for cooking hood baffles, sprinkler system, smoke barrier doors, and fire drills. | |
| Corporate Food Service Director | Present during inspection of cooking stove exhaust hood grease baffles. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Jun 23, 2021
Visit Reason
The inspection was conducted based on multiple complaints received against the facility, specifically complaint NJ133668 among others, to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to administer medications on time for one of three sampled residents reviewed for medication administration. The Licensed Practical Nurse responsible for the delay was no longer employed. The facility initiated audits and re-education of nursing staff to ensure compliance with medication administration timing policies.
Complaint Details
Complaint Intake: NJ133668. The facility was found not in compliance based on this complaint survey.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer medications on time for one resident as per physician's orders. | SS=D |
Report Facts
Census: 72
Sample Size: 10
Medication administration delay: 6.83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Named as responsible for late medication administration; no full name provided | |
| Director of Nurses (DON) | Interviewed regarding medication administration policies and audits |
Inspection Report
Routine
Census: 82
Deficiencies: 0
Dec 10, 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.
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: 3
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