Complete Care at Court House, LLC

Inspectors wroteComplaint #: 2695513 Based on interviews, medical record review, and review of pertinent facility documents on 12/19/25 and 12/23/25, it was determined that the facility failed to adequately assess and implement measures to protect a resident (Resident #3) who was identified as a high risk for elopement on their initial admission nursing assessment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for elopement risk. This was evidenced as follows:Resident #3 was not at the facility at the time of the survey and a closed record review was conducted. According to the admission Record face sheet (an admission summary), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (2nd and 3rd floor) and was evidenced by the following: On 03/06/2025 at 11:06 AM, in the 3rd floor shower/bathroom the surveyor observed the toilet paper holder was rusted and the toilet paper roll was on the floor. There was no roller observed on the toilet paper holder. On 03/11/2025 at 08:45 AM, the surveyor completed environmental rounds on the 3rd floor as follows: *Door trim on all rooms of the 3rd floor noted with chipped paint and black colored marks. *cove base board between rooms [ROOM NUMBERS] has areas bubbled out. *bottom of exit door at both ends of hallway has brown colored marks and what appears to be rust. [...]

Inspectors wroteNJ 173198 Based on observation, interview and record review, and review of other facility documentation, it was determined that the facility failed to; a) ensure proper administration of medication during medication pass observation for 1 of 5 residents observed (Resident #43); b) document the administration of a medication in the Electronic Medication Administration Record (EMAR) for 1 of 2 residents sampled for pain (Resident #196); c) clarify physician's admitting medication orders for 1 of 1 post orthopedic surgery residents admitted for rehabilitation services sampled for anticoagulation therapy (Resident #196), in accordance with professional standards of practice. This deficient practice was evidenced as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, review of medical record and other facility documentation, it was determined that the facility failed to follow a physician's order to promote the prevention of pressure ulcer development. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcer (Resident #86) and was evidenced by the following: On 03/10/2025 at 8:25 AM, the surveyor observed Resident #86 in bed with eyes opened. The resident was lying on their left side with both legs bent on the knees. The surveyor did not observe any heel boots on the resident or visible in the room. On 03/10/2025 at 10:39 AM, the surveyor observed the resident in bed with eyes opened. The resident laid in bed on their left side with both legs bent on the knees. The surveyor did not observe any heel boots on the resident or visible in the room. [...]

Inspectors wroteBased on observation, interviews, record reviews and review of facility provided documents, it was determined that the facility failed to consistently implement a physician order for supplemental oxygen. This deficient practice was identified for 1 of 3 residents (Resident #249) reviewed for respiratory care. The deficient practice was evidenced by the following: On 03/06/2025 at 10:22 AM, during the initial tour of the facility, the surveyor observed Resident #249 seated in their wheel chair with the oxygen (O2) nasal cannula (n/c) (a device that delivers extra oxygen through a tube and into your nose) on his/her lap. The oxygen concentrator was in operation and was observed to be set at two (2) liters (L) per minute (min). Oxygen in use signage was posted on the door frame upon entry to the room. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to properly store medication for 1of 25 residents (Resident #352) reviewed. This deficient practice was evidenced by the following: On 3/10/2025 at 8:31 AM, the surveyor observed Resident #352 in their room seated on the bed and connected to an oxygen concentrator (a medical device that takes in air from the room and filter out nitrogen providing higher amount of oxygen) via nasal cannula (tube used to deliver oxygen through the nostrils) at 2 liters per minute. The resident was cognitively intact and indicated to the surveyor through nodding their head that they were good. The surveyor observed an inhaler (a portable device for administering a drug which is to be breathed in) beside a pink wash basin on top of the bedside table to the right. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice, specifically by a.) failing to transport soiled laundry appropriately and b.) failing to wear a the appropriate Personal Protective Equipment (PPE) while transferring a resident who was on Enhanced Barrier Precautions (EBP). The deficient practice was identified for 1 of 2 residents reviewed for EBP (Resident #86) and was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/25/2023 from 9:47 to 10:43 AM, the surveyors, accompanied by the Director of Dining (DOD) observed the following in the kitchen: 1. Upon entry to the kitchen the surveyors observed a dietary aide (DA) in the cook's area. The female DA had a hair net that only partially covered their hair and the forehead to the middle of the head area was uncovered and exposed. On interview the DOD stated, The hair should be fully enclosed in the hair net. 2. On a lower shelf in the dry storage area, a previously opened bag of egg noodles had no open or use by dates. When interviewed, the DOD responded, It should be labeled with an open date and use by date. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag is maintained off the floor in accordance with professional standards of practice and facility policy. This deficient practice was identified for 1 of 1 Resident reviewed for an indwelling urinary catheter (Resident # 75) and was evidenced by the following: During the initial tour of the unit on 1/25/2023 at 10:17 AM, Resident #75 was observed resting in bed with eyes closed and with an indwelling urinary catheter. The urinary catheter drainage bag was observed resting on the floor. On 1/27/2023 at 8:54 AM Resident #75 was observed awake, alert and nonverbal resting in bed. Resident #75's urinary catheter drainage bag was observed touching the floor. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure nutritional formula connected to a feeding tube (surgically placed tube into the stomach to provide nutritional formula) was accurately labeled for 1 of 1 resident (Resident #26) reviewed for tube feeding. The deficient practice was evidenced by the following: On 1/30/2023 at 9:04 AM, the surveyor observed a bottle of nutritional formula hanging from a pole that was connected to a feeding pump that was attached to Resident #26's feeding tube while he/she was in bed. The feeding pump was operating. At that time, the surveyor observed that the date written on the bottle was 1/27, indicating that the nutritional formula was opened on January 27th. [...]

Inspectors wroteResident #89 Based on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to a.) accurately implement a physician prescribed fluid restriction order for 1 of 2 resident's (Resident #89) reviewed for dialysis, and b.) provide a meal or nourishment to a resident before or after completion of their dialysis treatment for 1 of 2 resident's (Resident #89) reviewed for dialysis. This deficient practice was evidenced by the following: On 01/26/2023 at 12:16 PM the surveyor observed and interviewed Resident #89 in his/her room accompanied by resident's lifelong friend. Resident #89 stated that he/she was up at approximately 4 AM for a 4:30 AM pick-up time to go to dialysis. Resident stated that he/she was provided an apple juice and a bag of Goldfish by nursing prior to leaving the facility, which he/she consumed. [...]

Inspectors wroteFACILITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 1 garbage dumpsters. This deficient practice was evidenced by the following: On 1/25/2023 at approximately 10:30 AM, the surveyors, accompanied by the Director of Dining Services (DODS) and the Senior Maintenance Director (SMD), observed the following in the facility designated garbage area: Two green dumpsters were behind a chain link fence with a gate. The dumpster closest to the building and designated as a garbage dumpster by the DODS and SMD was observed to have 1 of 2 black hinged lids opened and the bagged garbage was exposed. On interview the DOD stated that doors should be closed at all times to prevent access to rodents. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed a) to ensure proper use of personal protective equipment (PPE) for staff on 1 of 2 units (unit 2), a COVID-19 designated unit, in accordance with the Centers for Disease Control and Prevention guidelines for infection control and b). failed to implement infection control measures by maintaining the urine catheter drainage bag off the floor to prevent the spread of infection. This deficient practice was evidenced by the following: On 1/25/2023, during the entrance conference, the facility Assistant Director of Nursing (ADON) provided the surveyors a copy of the facility floor plan. The ADON coded rooms 229, 230, 231, and 232 yellow on the floor plan and stated that these are our COVID-19 positive rooms. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure their resident call system was intact, functioning properly and accessible in 1 of 9 rooms, as well as failed to follow their own facility policy, Call Lights. This deficient practice was evidenced by the following: On 1/25/2023 at 10:34 AM, Resident #61 was noted resting in bed, alert and awake. The cord belonging to the call device was noted attached to the wall, hanging and resting on the floor. On 1/26/2023 at 10:14 AM, a tour of the same room that both Resident #58 and Resident #61 resided in, revealed that the calling device was not functioning. The distal end of the call device was not intact. During an interview with the Surveyor, Resident #61 stated, It's broken, when asked, could you tell me where your call device is located. [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 2/4/2021 from 8:58 AM to 9:45 AM the surveyor, accompanied by the Director of Dining Services (DODS), observed the following in the kitchen: 1. In the dry storage area on a middle rack of a multi-tiered rack, a sleeve of plastic cups for resident use were opened and exposed. The DODS on interview stated, They are exposed, I usually just throw them away. The DOD threw the plastic cups in the trash. 2. A red bucket with a white label dated 2/4 and half filled with a water-like substance was observed on a lower shelf in the prep area. [...]