Inspection Reports for
Complete Care At Ocean Grove Llc

Complaint investigation based on complaints 2696252 and 2692885. The deficient practice was substantiated by interviews, medical record review, and facility documentation review.

The facility failed to consistently document ADL care for 2 of 6 residents reviewed, violating its own ADL policy. Documentation blanks were found in the Electronic Medical Record for multiple shifts and dates, indicating incomplete ADL care records.

The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, medication administration errors including wrong medication and late administration, failure to follow medication hold parameters, inadequate incontinence care, insufficient RN staffing coverage, medication storage and disposal issues, unsafe food handling and storage practices, improper handling of food brought by visitors, and lapses in infection prevention and control practices.

Complaint NJ #00174809 regarding inappropriate incontinence care for residents dependent on staff for Activities of Daily Living. The complaint was substantiated with observations of improper double brief use and inadequate care plans.

The facility was found deficient in providing proper incontinence care, including the inappropriate use of double incontinence briefs on residents. Additionally, the facility failed to properly label, date, and store potentially hazardous foods and maintain kitchen equipment in a clean and sanitary manner, which could lead to foodborne illness.

Complaint numbers NJ175245 and NJ184348 triggered the investigation. The facility was found not in substantial compliance with federal and state regulations based on these complaints.

The facility was found not in substantial compliance with requirements, specifically failing to ensure a Registered Nurse worked at least 8 consecutive hours for 1 of 21 days reviewed, and failing to maintain complete and accurate medical records for sampled residents. Additionally, the facility failed to meet staffing ratios for Certified Nursing Assistants on multiple days, potentially affecting all residents.

Complaint #NJ175245 was investigated. The facility was found to have failed in RN staffing requirements and in maintaining complete medical records. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure a Registered Nurse was on duty for at least eight consecutive hours on one day reviewed, and failed to maintain complete and accurate medical records for one sampled resident, specifically missing Controlled Drug Administration Records for Oxycodone.

The visit was triggered by complaints NJ00171706, NJ00171459, NJ00172188, NJ00172527, NJ00173104, and NJ00174056. The facility was found not in compliance with 42 CFR Part 483, Subpart B, and New Jersey Administrative Code Chapter 8:39. Specific complaints included medication administration errors and inadequate staffing. Substantiation status is not explicitly stated.

The facility was found not in compliance with several regulatory requirements including pharmacy services, medication administration, resident records, and staffing ratios. Deficiencies were identified in medication administration timeliness, documentation of resident care, and maintaining adequate staffing levels as mandated by state law.

Complaint numbers NJ00173104 and NJ00171706 were investigated. The complaints involved medication administration errors and inadequate documentation of resident care. The complaints were substantiated with findings of minimal harm or potential for harm.

The facility failed to administer medications according to the prescribed schedule for two residents and failed to consistently document Activities of Daily Living (ADL) care for two residents, resulting in minimal harm or potential for harm.

The survey included complaint investigations for multiple complaint numbers (NJ162382, NJ163457, NJ164001, NJ165865, NJ166922, NJ169240, NJ169555, NJ170247, NJ170346, NJ170898, NJ171116). Findings included substantiated failures in abuse prevention, reporting, and resident care.

The facility was found not in substantial compliance with federal and state regulations, including deficiencies in Medicaid/Medicare coverage notices, freedom from abuse and neglect, reporting of alleged violations, baseline care plans, activities of daily living, medication error rates, infection control, and resident records. Corrective actions and plans of correction were required.

The complaint investigation included allegations of failure to provide proper Medicare Non-Coverage notices, resident-to-resident abuse, failure to timely report abuse, failure to investigate injuries, failure to complete baseline care plans timely, failure to provide scheduled showers, medication errors, failure to maintain accessible medical records, and infection control breaches. The investigation substantiated these deficiencies with minimal harm or potential for actual harm.

The facility was found deficient in multiple areas including failure to include required information on Medicare Non-Coverage notices, failure to protect residents from abuse and timely report incidents, failure to investigate injuries properly, failure to complete baseline care plans within 48 hours, failure to provide scheduled showers to dependent residents, medication administration errors, failure to maintain accessible medical records for a resident, and failure to follow infection prevention protocols including PPE use and cleaning procedures.

The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for 11 of 14 day-shifts reviewed, potentially affecting all residents. A plan of correction was required to address staffing shortages and ensure compliance with state staffing requirements.

The facility failed to make referrals for PASRR Level II re-evaluation after changes in mental health status for two residents. Staff interviews revealed a lack of awareness about the requirement to complete PASRR Level II screenings when residents were newly diagnosed with serious mental illness disorders.