Inspection Reports for
Complete Care At Monmouth, Llc

Complaint NJ184628 was substantiated based on interviews, record reviews, and facility documentation showing failures in medication administration documentation and controlled substance record keeping for Resident #3.

The facility failed to provide required controlled substance administration records and did not document medication refusals properly for Resident #3. The facility also failed to follow its policies on medication administration and documentation, resulting in missing signatures and blanks on the eMAR.

Complaint investigation based on complaints NJ182074, NJ182256, and NJ182526. The facility was found not in substantial compliance with professional standards related to medication administration.

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 numbers NJ182074 and NJ182526 were investigated. The deficiencies were substantiated based on observations, interviews, and record reviews indicating failure to follow medication administration orders and documentation requirements.

The facility failed to follow standards of clinical practice for medication administration and the Care Plan interventions for Resident #2, including failure to administer Lorazepam as ordered on specific dates and failure to document medication administration properly. The facility also did not follow its Medication Administration policy.

The facility was found deficient in multiple areas including dignity in meal service, employee reference checks, individualized care planning, medication administration, pressure ulcer care, smoking contract compliance, respiratory care, dialysis care, pharmaceutical services, dental services, and kitchen sanitation.

The investigation was complaint-driven with NJ Complaint numbers 174208, 172455, 173605, and 172281 cited in relation to meal service dignity, transfer documentation, medication administration, and kitchen sanitation respectively.

The facility was found deficient in serving meals in a dignified manner by using disposable plates, failing to complete transfer forms and discharge summaries, administering medications untimely and borrowing medications between residents, and maintaining poor kitchen sanitation including improper food storage and labeling.

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.

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.

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.

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.

The complaint investigation found that medications were administered outside the scheduled times for residents R136 and R69. The Director of Nursing confirmed these delays during interviews on 11/16/2023.

The facility staff failed to administer medications within the prescribed time to two residents (R136 and R69) out of a sample of 21 residents, with medications given outside the scheduled hour. The Director of Nursing confirmed these delays. The facility policy requires medications to be administered within one hour of the prescribed time.

The complaint involved an allegation by Resident 79 that a Certified Nursing Assistant pushed a food tray into her chest causing injury to her already broken ribs. The facility became aware of the allegation on 11/02/23 via a letter from the resident's insurance company but did not report it to the State Survey Agency. The investigation was limited to interviews with the resident and the alleged perpetrator only, with no other staff or residents interviewed. The facility failed to prevent further abuse during the investigation.

The facility failed to timely report the suspected abuse allegation to the State Agency, failed to thoroughly investigate the allegation, and failed to prevent further abuse or neglect during the investigation. Additional deficiencies included failure to develop comprehensive care plans for some residents, failure to administer medications timely, providing oxygen therapy without physician orders, and failure to serve food in a sanitary manner.

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.

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 #NJ00162301 involved allegations of resident-to-resident inappropriate touching by Resident #3 and failure to report and intervene appropriately, as well as issues related to Resident #4's substance use while out on pass and discharge planning.

The facility failed to implement policies to prevent inappropriate touching between residents, failed to timely report allegations of abuse to the state, and failed to update care plans and discharge plans timely for residents at risk. Resident #3 was involved in inappropriate touching incidents with Residents #1 and #2, which were not properly reported or managed. Resident #4 had incidents related to substance use while out on pass, with inadequate care plan updates and discharge planning.

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.

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.

The facility failed to maintain water temperatures at a safe level not exceeding 110 degrees Fahrenheit, failed to develop an accurate water temperature policy consistent with state standards, and failed to properly implement water temperature logs. Excessively high water temperatures were observed in 6 of 13 resident sinks.

Complaint Intake: NJ133668. The facility was found not in compliance based on this complaint survey.

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.