Complete Care at Monmouth, LLC

Inspectors wroteBased on observation, interviews, record review, and review of facility provided documents, it was determined that the facility failed to obtain and update physician's orders for dialysis services, care of a dialysis access site, and document care related to dialysis services, for one of one resident (Resident #2) reviewed for dialysis. This deficient practice was evidenced by the following: On 5/1/26 at 9:21 AM, during an initial tour, Resident #2 was not in their room. A housekeeper nearby stated Resident #2 was out at dialysis. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #2. A review of the Physician's Orders (PO's) had not reflected an order for the resident to receive dialysis treatments. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents it was determined that the facility failed to a.) ensure there was appropriate Transmission Based Precaution (TBP; are designed to reduce the risk of airborne, droplet and contact transmission; used to help stop the spread of germs from one person to another) sign to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 2 residents (Resident #10 and #97) reviewed for Infection Control on 1 of 2 units and b.) appropriately disinfect multiuse medical equipment for one (1) of two (2) nurses during the medication administration observation. These deficient practices were evidenced by the following: Reference: CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents it was determined that the facility failed to maintain the dignity of a resident who required contact/droplet isolation precautions signage related to COVID + (positive) status. This deficient practice was identified for 1 of 2 residents (Resident #97) reviewed for infection control. This deficient practice was evidenced by the following:Refer to F880On 4/30/26 at 10:33 AM, during an initial tour, the surveyor observed Resident #97's door closed. There were Personal Protective Equipment (PPE; specialized garments or gear [protective clothing, gloves, face shields, masks etc.] worn by healthcare personnel to create a barrier between them and infectious materials) supplies hanging in a plastic storage organizer on the door. [...]

Inspectors wroteBased on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop an Individualized Comprehensive Care Plan (ICCP) to address the needs of a resident who received antibiotic therapy (medicines that fight bacterial infections) for cellulitis (a serious bacterial infection of deeper layers of the skin). This deficient practice was observed for one 1 of 18 residents (Resident #9) reviewed for antibiotic therapy. This deficient practice was evidenced by the following:On 4/30/26 at 10:49 AM, the surveyor observed Resident #9 sitting in their wheelchair. The resident was cooperative and did not present any care concerns. The surveyor reviewed the electronic medical records (EMR) for Resident #9. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of pertinent facility documents, it was determined that the facility failed to revise a comprehensive care plan with interventions for a resident who alters the settings on an oxygen concentrator (device that delivers oxygen). This deficient practice was identified for 1 of 38 residents (Resident #74) reviewed for care plans. This deficient practice was evidenced by the following:On 4/30/26 at 10:13 AM, the surveyor observed Resident #74 lying in bed receiving oxygen (O2) via nasal cannula tubing (n/c - device that delivers additional oxygen through the nose) connected to an O2 concentrator administering 8 liters per minutes (lpm). On 5/1/26 at 9:11 AM, the surveyor observed the O2 concentrator administering 8 lpm of oxygen to the resident. The resident stated I don't touch it, the nurses touch it. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1.) obtain physician orders to ensure that a resident received the appropriate care to maintain a centrally inserted intravenous catheter (CVC) (a long, flexible tube inserted into a large vein that goes near the heart for long-term intravenous (IV) antibiotics), 2.) develop and implement a comprehensive person-centered care plan (ICCP) for a resident with a CVC and 3.) discontinue a CVC after the completion of IV antibiotics consistent with professional standards of practice. This deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for IV therapy. The deficient practice was evidenced by the following:On 5/6/26 at 9:41 AM, the surveyor observed Resident #5 resting in their bed. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice when administering oxygen therapy, incentive spirometry and maintaining oxygen tubing (replace current tubing with new tubing) per physician orders. This deficient practice was identified for 2 of 4 residents (Residents #33 and #74) reviewed for respiratory care. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteRepeat DeficiencyBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident # 8) reviewed for medication administration times. This 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 observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond timely to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #14). The deficient practice was evidenced by the following:On 4/30/2026 at 11:24 AM, during the initial tour, the surveyor went to Resident # 14's room. The resident was lying in bed, awake, alert, and stated the staff was friendly and competent. On 5/1/2026 at 9:58 AM, during a follow up tour, the surveyor observed Resident #14 sitting on the bed, in their room. [...]

Inspectors wroteComplaint: NJ184628 Based on interviews, record review, and review of other pertinent facility documentation on 04/15/2025, it was determined that the facility failed to provide a) Individual Patient Controlled Substance Administration Record for a resident (Resident #3) b) facility failed to document refusal on the Electronic Medication Administration Record (eMAR). The facility also failed to follow its policies titled, Medication Administration and Documentation in Medical Record. This deficient practice was identified for one of three residents, Resident #3. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to Resident #3's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteComplaint #: NJ182074, NJ182526 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 01/23/2025 and 1/27/2025, 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 #2). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 8 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 wroteNJ Complaint #: 174208 Based on observation, interview, and review of pertinent facility documentation, 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 12/3/24 at 9:41 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the facility's kitchen. The following was observed in the kitchen freezer: One unlabeled, undated opened box of hotdogs/kielbasa, which was opened, the plastic bag inside the box also opened exposing the hotdogs/kielbasa links, which had the appearance of freezer burn, to air. One opened 15-pound box of single slice bacon. The plastic bag inside the box was also opened and exposing the bacon to air. At that time, the FSD stated that those items should not be stored like that. [...]

Inspectors wroteBased on interview, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks on employees before their start date. The deficient practice was identified for 5 of 10 employees reviewed for new hires (Employee #3, #6, #8, #9 and Employee #10), and was evidenced by the following: A review of facility's Abuse Policy dated 9/1/24, included in the section titled Screening Components that it is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include 1. verification of references shall be conducted on potential employees .3. The facility will maintain documentation of proof that the screening occurred. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) respiratory equipment was stored and dated properly and b) ensure a physician's order was in place for a resident who received oxygen. This deficient practice was identified for 3 of 3 residents reviewed for respiratory care (Resident #19, Resident #54, and Resident #239), and the evidence was as follows: 1. On 12/3/24 at 10:38 AM, the surveyor observed Resident #19 in the bathroom performing morning care. [...]

Inspectors wroteNJ Complaint # 174208 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to serve meals in a dignified, home-like manner by using disposable containers to serve food for residents who dinned in 1 of 2 main dining rooms (second floor). The deficient practice was evidenced by the following: On 12/3/24 at 12:10 PM, the surveyor observed residents in the second floor main dining room being served lunch from the on-site serving station/steam table and being plated on reusable plates and silverware. Once lunch was served to all residents present in the dining room, the surveyor observed that four (4) out of the 14 residents were served lunch on red plastic disposable plates. [...]

Inspectors wroteComplaint NJ #: 172455; 173605 Based on interview and review of pertinent facility documents, it was determined that the facility failed to a) ensure the New Jersey Universal Transfer Form (UTF) used to communicate with the receiving long-term care (LTC) facility where a resident was being transferred was complete and b) complete the physician discharge summary. The deficient practice was identified for 1 of 3 resident reviewed for discharge (Resident #289), and was evidenced by the following: Reference: NJ.gov: https://www.nj.gov/health/forms/hfel-7instr_1.pdf: INSTRUCTIONS FOR COMPLETING THE NEW JERSEY UNIVERSAL TRANSFER FORM dated August 2011, The purpose of the New Jersey Universal Transfer Form: A form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to develop an individualized comprehensive care plan (ICCP) for a resident with a new left below knee amputation who was receiving wound care to a surgical site. This deficient practice was identified for 1 of 22 residents reviewed for comprehensive care plans (Resident #189), and was evidenced by the following: On 12/3/24 at 10:40 AM, during the initial tour of the facility the surveyor observed Resident #189 out of bed sitting in a wheelchair. The resident told the surveyor that they were receiving therapy on the left leg, showing the surveyor that the resident had a below knee amputation. The surveyor reviewed the medical record for Resident #189. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with medical diagnoses which included; [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to a) revise an individual comprehensive care plan (ICCP) for a resident with a fracture following a fall, and b) revise an (ICCP) for a resident after a fall. This deficient practice was identified for 2 of 2 residents reviewed for falls (Resident #14 and Resident #55), and was evidenced by the following: 1. On 12/3/24 at 9:50 AM, during the initial tour of the facility, the surveyor went to see Resident #55 and was informed that the resident was hospitalized . On 12/9/24 at 10:23 AM, the surveyor reviewed the medical record for Resident #55. The medical record indicated that the resident was readmitted back to the facility on [DATE]. [...]

Inspectors wroteNJ Complaint # 172281 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain professional standard of practice by a) ensuring medications were administered in a timely manner in accordance with the resident's physician's order for Resident #48, and b) ensuring proper medication management by borrowing medications from one resident's supply to administer to another resident for Resident #60 and Resident #4. This deficient practice was identified for 3 of 21 residents (Resident #48, Resident #60 and Resident #4) reviewed for professional standards of practice. 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 observations, interviews, and review of pertinent facility documentation it was determined that the facility failed to provide pressure ulcer prevention and skin protective devices as ordered by the physician. This deficient practice was identified for 1 of 2 residents (Resident #85) reviewed for pressure ulcers and was evidenced by the following: On 12/3/24 at 11:05 AM, during the initial tour of the facility the surveyor observed Resident # 85 in the bed. Resident #85 told the surveyor they were receiving physical therapy but could not wear shoes because of a sore on their right heel. The surveyor asked if it had healed and the resident stated, one nurse said it was closed, and one said it was open a little bit. On 12/4/24 at 11:00 AM, the surveyor observed Resident #85 in bed. The resident did not have a low air loss mattress or heel boots in place. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to have a resident who smoked sign the Smoking Contract/Agreement upon admission. This deficient practice was identified for 1 of 3 residents (Resident #82) reviewed for accidents. A review of the resident's Smoking Contract/Agreement provided by the facility was signed by the resident on 7/17/24. The facility could not provide a smoking contract upon admission. This deficient practice was evidenced by the following: On 12/3/24 at 10:53 AM, during the initial tour the surveyor observed Resident #82 ambulating in the hallway with their walker. On 12/6/24 at 1:03 PM, the surveyor observed Resident #82 in their bedroom. Resident #82 stated, I am going to eat my lunch now. The resident was not sure if they were going outside to smoke later. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a physician's order was in place to properly assess a resident's dialysis access site. This deficient practice was identified for 1 of 1 residents reviewed for dialysis (Resident #81), and was evidenced by the following: On 12/3/24 at 12:04 PM, during initial tour of the facility, the surveyor observed Resident #81 in their room. The resident informed the surveyor that they recently had a medical emergency where the resident's dialysis shunt started to bleed, and they had to be sent to the hospital for emergency surgery. On 12/6/24 at 1:42 PM, the surveyor reviewed Resident #81's medical record. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) dispensed and administered controlled substance (narcotic) medication was accurately counted, and b) the Individual Patient Controlled Substance Administration Record (IPCSAR)reconciliation sheet was incorrect for 8 shifts with 16 occurrences on Medication Cart A, 2nd floor. This deficient practice was identified on 1 of 2 medication carts reviewed for medication storage, and was evidenced by the following: On 12/05/24 at 09:33 AM, the surveyor observed the Licensed Practical Nurse Unit Manager (LPN/UM) with the Director of Nursing (DON) begin the cycle count for the controlled substance (narcotic) medications on medication Cart A on the 2nd floor. [...]

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist (CP) were acted upon in a timely manner for 2 of 5 residents (Resident #54 and Resident #35) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 12/04/24 at 12:15 AM, the surveyor reviewed the medical records for Resident #54. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with the diagnoses which included but was not limited to; chronic obstructive pulmonary disease (COPD) (a group of lung diseases that damage the airways and air sacs in the lungs, making it hard to breathe). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide the mandatory annual dental care and services. This deficient practice was identified for 1 of 21 residents reviewed (Resident #15), and was evidenced by the following: On 12/3/24 at 10:55 AM, the surveyor observed that Resident #15's teeth were brown and discolored with their front teeth chipped and some missing teeth. On 12/4/24 at 9:00 AM the surveyor reviewed the electronic medical record (eMAR). A review of the admission Record (AR) revealed the resident was admitted with a diagnosis of but not limited to: [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to serve food in a sanitary manner as evidenced by one employee not washing his hands and changing his gloves after they became contaminated. This had the potential to affect 80 of the 81 facility residents who consumed food from the facility kitchen.

Inspectors wroteBased on interviews, documentation review, and policy review, the facility failed to ensure an allegation of abuse was reported to the State Agency for one of four residents (Resident (R) 79) reviewed for abuse.

Inspectors wroteBased on interviews, documentation review, and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated and failed to prevent further abuse/neglect while the investigation was in progress for one resident of four residents (Resident (R) 79) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans according to resident needed care areas for three of twenty-one residents sampled (Resident (R) 18 and R36).

Inspectors wroteBased on staff interview, record review, and policy review, the facility staff failed to administer medications timely to two of four residents (Resident (R)136 and R69) out of a total sample of 21 residents.

Inspectors wroteBased on interview, record review, and observations, the facility implemented oxygen therapy without physician's orders for one of one resident (Resident (R) R20) reviewed for oxygen use.