Complete Care at Laurelton, LLC

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Discharge Planning Process, on 04/21/2026 through 04/23/2026, it was determined that the facility failed to ensure that a resident was discharged to a safe home, including the repair of a water pipe prior to discharge, for 1 of 1 residents (Resident (R) 1) reviewed for appropriate discharge from the facility. As a result, R1 was discharged to an unsafe home without running water or heat. Ten days after discharge, the police were called to the home to find the resident with limited electricity, no running water or working heating system, and unable to walk or get down the stairs, other than sliding down on his/her buttocks. R1 was taken by the Police Department (PD) to the Emergency Department (ED) for care. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently document enteral tube feeding flush administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents (Residents #5), reviewed for enteral tube feeding and was evidenced by the following: Review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). Review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. [...]

Inspectors wroteNJ Complaint: #NJ186246 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 3 of 3 (Resident #77, 110, ) residents reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's quarterly Minimum Data Set (an assessment tool) dated 12/25/2024, revealed that Resident #77 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation it was determined that the facility failed to to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 3 nursing units observed for environment and evidenced by the following: Upon initial tour of Unit 2 on 06/04/2025 at 10:24 AM, the surveyor observed a nurse's call bell wall unit depressed through the drywall with medical tape securing it to the wall. On 06/06/2025 at 11:11 AM, the surveyor observed the same nurse's call bell unit depressed through the drywall with medical tape securing it to the wall. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 34 residents reviewed, Resident #18 as evidenced by the following: Upon initial tour of the Unit 2 on 06/04/2025 at 9:52 AM, the surveyor observed an individual outside room [ROOM NUMBER] putting on personal protective equipment. The surveyor observed the individual's uniform displaying a hospice name and she identified herself as a hospice aide caring for Resident #18. On 06/06/2025 at 10:23 AM, the surveyor observed Resident #18 in resting in bed with family in room holding their hand. Resident #18 was admitted to the facility on [DATE] with diagnosis that included Multiple Sclerosis. A review of the Physician's Orders identified an order for Hospice Evaluation and Treatment on 2/3/2025. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. The deficient practice was identified for 1 of 23 residents (Resident #5) reviewed and was evidenced by the following: A review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 2 residents (Resident #74) reviewed. This deficient practice was evidenced by: A review of the admission Record (admission summary) indicated that Resident #74 was admitted to the facility with the diagnoses which included but was not limited to respiratory conditions due to other external agents, chronic respiratory failure with hypoxia (a condition that occurs when the body tissues do not get sufficient oxygen supply) and chronic obstructive pulmonary disease (COPD) (an ongoing lung condition caused by damage to the lungs). [...]

Inspectors wroteComplaint #: NJ183557 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 04/24/2025 and 04/29/2025, it was determined that the facility failed to follow standards of clinical practice for Physician Orders (POs) for medication administration and follow the Care Plan (CP) interventions for a resident (Resident #5). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 6 residents reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteComplaint #: NJ183557 Based on interview and review of facility documents on 5/22/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 1 of 21 days reviewed. This deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint # NJ00181615, NJ00177959 Based on observations, interviews, and record review, as well as a review of pertinent facility documents on 12/23/24, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication [Sucralfate], an anti-ulcer medication, was administered to a resident (Resident #1) in a timely manner as ordered by a physician. Sucralfate was a medication to be administered before meals. This deficient practice was observed in 1 of 4 residents reviewed for medication administration and was evidenced by the following: 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 interview, record review and document review it was determined that the facility failed to recognize a change in condition and ensure that no delay in treatment occurred, when on 09/23/23, a resident presented with pain accompanied by an externally rotated bruised left lower extremity and the resident was not immediately assessed by a Registered Nurse, and waited over 24 hours to receive an X-ray and was then transferred to the Emergency Room. This deficient practice occurred for 1 of 1 resident (Resident #257) reviewed for fracture of unknown origin. Resident #257 was diagnosed with an impacted comminuted fracture of the base of the left femoral neck (hip fracture) which required surgery on 09/25/23 for Open Reduction and Internal Fixation (ORIF) of the Left Hip. Refer to 610G The evidence was as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, and document review it was determined that the facility failed to ensure meals were served at a palatable temperature for 6 of 6 residents who attended a resident council meeting, and on 2 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 01/30/24 at 11:04 AM, the surveyor conducted a resident council meeting with six residents. The surveyor inquired about the meals served and 6/6 residents interviewed stated the [hot food] was always served cold and especially the coffee. On 01/31/24 at 7:30 AM, surveyor #1 observed the meal truck enter Unit 3. The first meal tray was passed at 7:31 AM, and the last meal tray was passed at 7:49 AM. [...]

Inspectors wroteBased on observation, interview, and document review it was determined that the facility failed to ensure a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) all food items were labeled with a use by date, and c) staff practiced appropriate hand hygiene during meal service to prevent the potential spread of food borne illness. The deficient practice was evidenced by the following: On 01/29/24 at 9:24 AM, the surveyor completed an initial tour of the kitchen with the Food Service Director (FSD) and the Regional Director of Food Service (RDFS) and observed the following: 1. The walk-in refrigerator unit identified as the cold cut box had debris and crumbs on the floor underneath the racks. The surveyor asked when the box was cleaned and the FSD stated, not as often as it should. The door gasket was visibly soiled and ripped. 2. [...]

Inspectors wroteBased on interview and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility self-identified areas for improvement and followed the facility policy to ensure the Quality Assurance and Performance Improvement (QAPI) Program reviewed adverse events. This deficient practice occurred for 1 of 1 fractures of unknown origin and was evidenced by the following: Refer to 610G, 761E, 880E On 02/02/24 at 8:55 AM, the surveyor interviewed the LNHA, in the presence of the survey team, regarding what the process was to determine what became a QAPI. The LNHA stated I haven't done anything because I have only been here one month. The LNHA stated he had a meeting with his staff and the surveyor inquired as to what QAPIs were in place already. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure resident specific prescription medications were stored securely. This deficient practice was identified for 1 of 2 units (Unit 2) observed and was evidenced by the following: On 01/31/24 at 6:13 AM, the surveyor observed two nurses on Unit 2 working at their medication carts. One nurse was at the high end of the hall, and the second nurse was at the low end of the hall. Both nurses were observed actively working at their nursing carts. The surveyor walked down toward the low end of the hall, toward the middle of the unit and observed a third nursing medication cart. The third nursing medication cart was placed up against a wall across from the nursing desk. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to a.) properly don (put on) a Personal Protective Equipment (PPE) gown used to mitigate the spread of infection for Resident #306, 1 of 4 residents reviewed for Transmission Based Precautions (TBP) , b.) maintain appropriate infection control practices for 2 residents (Resident #106 and #306) with an indwelling urinary catheter, and c.) to perform appropriate hand hygiene during meal service on 1 of 3 units (Unit 3) for two meals. This deficient practice was evidenced by the following: a.) On 01/30/24 at 8:21 AM, Surveyor #1 observed a staff member outside of Resident #306's room. The surveyor observed signage posted at the door for enhanced barrier precautions which included but was not limited to; providers and staff must also: [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure all residents had a call bell available and within reach to alert staff for assistance. This deficient practice was identified for 2 of 25 residents reviewed for call bells (Resident 100 and Resident #6) on 2 of 3 resident units (Unit #1 and #2) and was evidenced by the following: On 01/29/24 at 11:40 AM, while in the hallway on the Unit #1, Surveyor #1 heard a staff member calling on the nurse to assist with Resident #106. The surveyor followed the nurse and observed Resident #106 sitting on a low bed and had attempted to get out of the bed unassisted. The resident stated that he/she needed to go the bathroom. The surveyor did not observe a call bell located near the resident. [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for Resident # 257 who sustained a fracture of unknown origin of the left hip. Resident # 257 required an Open Reduction and Internal Fixation (ORIF) of the left hip on 09/25/23 . This deficient practice was identified for 1 of 1 Resident (Resident #257) reviewed for fracture of unknown origin and was evidenced by the following: Refer to 684G On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding reportable events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to revise a resident-centered on-going Care Plan (CP) for a resident who received oxygen therapy. This deficient practice was identified for 1 of 25 residents (Resident #47) reviewed for CP and was evidenced by the following: On 01/29/24 at 11:05 AM, the surveyor observed Resident #47 lying in bed. The resident was observed to be wearing a nasal cannula (nc) with oxygen tubing attached to an oxygen concentrator that was situated on the floor next to the bed. On 01/29/24 at 2:21 PM, the surveyor observed Resident #47 in his/her room lying in bed with a nc on, the oxygen tubing attached to an oxygen concentrator which was situated on the floor next to the bed. Resident #47 stated he/she was not aware of the amount of oxygen that he/she was receiving. [...]

Inspectors wroteComplaint #169841 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by failing to: a.) follow a physician order for weights for 1 of 4 residents (Resident #95) reviewed for nutrition, and b.) administer physician prescribed medications and document physician notification for 1 of 4 closed records (Resident # 256) reviewed. The deficient practice was evidenced by the following: 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, and record review it was determined that the facility failed to follow physician orders for the oxygen settings at liters per minute (lpm). This deficient practice was identified for 2 of 2 residents (Resident #34 and #47) reviewed for oxygen and was evidenced by the following: a.) On 01/29/24 at 9:39 AM, the surveyor toured the Unit 2 and observed Resident #34 lying in bed awake and alert. The surveyor observed that Resident #34 had a nasal cannula (nc) on, and the tubing was attached to an oxygen concentrator which was situated on the floor next to the bed. The oxygen setting was 3.5 lpm. Resident #34 stated that staff had told him/her their oxygen level was low and he/she needed to use oxygen and he/she had never used oxygen before. Resident #34 stated the oxygen dries out my nose. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 3 of 3 medication carts on 3 of 3 nursing units and 1 of 2 medication storage rooms reviewed for medication storage and was evidenced by the following: On 10/14/21 at 9:51 AM, the surveyor in the presence of Licensed Practical Nurse (LPN #1) observed nursing Unit 3's medication cart which contained a total of 16 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #1 collected these pills as they were discovered, counted, and were disposed of using the medication cart drug buster bottle. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to: a.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on five of five medication carts and 2 of 3 medication carts reviewed for medication storage (Unit 1 and 2 high sides). This deficient practice was evidenced by the following: 1. On 10/14/21 at 10:19 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the nursing Unit 3's October 2021 Narcotic Shift Count log which revealed the following: 10/1/21 11 PM - 7 AM shift; 10/3/21 3 PM - 11 PM shift; and 10/6/21 3 PM - 11 PM shift Is the count correct column was blank. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/12/21 at 9:42 AM, the surveyor toured the kitchen with the Food Service Manager (FSM) and observed the following: In the milk walk-in refrigerator 1. One opened nine-pound container of feta cheese labeled received 9/27/21. There was no date when the feta cheese was opened or when to use by. The FSM stated that the cheese should be used within seven days of opening and discarded. 2. One chocolate cake labeled and dated 10/6/21 and 10/8/21. The FSM stated that the chocolate cake should have been discarded on 10/8/21. 3. One five-pound opened cottage cheese container. [...]