Complete Care at Ocean Grove LLC

Inspectors wroteComplaint: 2696252 & 2692885Based on interviews, medical record review, and review of pertinent facility documentation on 1/6/26, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 2 of 6 residents reviewed for ADLs (Resident #1, Resident #6). The facility also failed to follow its policy titled, ADLs. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) label, date, and store potentially hazardous foods appropriately to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner to prevent microbial growth. This deficient practice was evidenced by the following:On 7/16/25 at 9:50 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and the Regional Food Service Director (RFSD). The following was observed:1. Condensation on the outside of the ice machine on the top of lid and when opened an unidentified yellow substance was observed on the inside cover.2. Duct tape on the left and right corner above the ice machine lid and what appeared to be a white bonding material applied to the front lower left side. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 7/18/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 30 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 10 %. This deficient practice was identified for one (2) of five (5) residents, (Resident #16 and Resident #56), that were administered medications by one (1) of three (3) nurses. The deficient practice was evidenced as follows:1. On 07/18/2025 at 08:50 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare five medications for Resident #56, for medication pass observation. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a. ) follow the prescriber's orders and accepted professional standards and principles by administering the incorrect medication and dosage for 1 of 4 (Resident #24 ) residents reviewed for Medication Administration; [...]

Inspectors wroteBased on observations, interview, and review of facility policy, it was determined that the facility failed to a) appropriately dispose of medication in accordance with currently accepted professional standards and b) ensure medications were stored securely at all times. This deficient practice was identified for 3 of 3 nurses observed during the Medication Administration task. The deficient practice was evidenced by the following: 1. On 7/18/25 at 8:50 AM, during medication pass observation on first floor West, Licensed Practical Nurse #1 (LPN #1) poured one tablet of aspirin 81 mg and one tablet of multi-vitamin tablet for Resident #56. After review of the resident's Medication Administration Record (MAR) it was determined the nurse had poured the incorrect medication. The nurse then took the medicine cup and disposed of it in the small trash container attached to the medication cart. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1 of 3 floors (1st floor). This deficient practice was evidenced by the following:On 07/17/2025 at 9:19 AM, the surveyor observed light brown splattered debris on the wall near a resident's bed in room [ROOM NUMBER] A. On 07/17/2025 at 9:30 AM, the surveyor inspected the 1st floor shower room and observed a shower chair inside the shower stall with a hospital gown, towel, and wet blanket placed on top of the chair. In addition, loose particles of trash were visible inside of the drain. [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents involving medication errors. This deficient practice was identified for 2 of 4 Residents (Resident #24 & 59) reviewed for medication administration and was evidenced by the following:1.) On 07/17/2025 at 10:45 AM, during the Resident Counsel Meeting, Resident #24 that they had concerns regarding late insulin. A review of the admission Record Face (admission summary) reflected that Resident #24 was admitted to the facility with a diagnosis that included, but was not limited to: diabetes mellitus (DM) (elevated blood glucose levels). [...]

Inspectors wroteNumber of residents sampled: 25Number of residents cited: 1Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 1 of 25 residents (Resident #76) reviewed for standards of practice 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 wroteNumber of residents sampled: 6Number of residents cited: 2Complaint NJ #00174809Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living. This deficient practice was identified for 1 unsampled resident (Resident #34) and 1 sampled resident (Resident #67) out of 6 residents observed during incontinence rounds on 1 of 2 nursing units and was evidenced by the following:1. On 7/21/2025 at 8:54 AM, the surveyor performed incontinence rounds with Licensed Practical Nurse/ Unit Manager (LPN/UM) #1 and observed Resident #34 in bed. LPN/UM #1 exposed the resident's green incontinence brief from the front and stated that the resident was wet. LPN/UM #1 proceeded to close the brief. [...]

Inspectors wroteBased on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 day reviewed during the period of 02/02/2025 to 02/08/2025. Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 6 days reviewed. This deficient practice was evidenced by the following:A review of the Nurse Staffing Reports completed by the facility for the week of 02/02/2025 through 02/08/2025, revealed the facility had no RN coverage for all shifts on 02/08/2025. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, the facility failed to ensure that food brought to residents by family and other visitors were stored, handled, and consumed in a safe and sanitary manner. This deficient practice was identified for 2 of 2 residents (Resident # 1 and Resident # 20) who had personal refrigerators in their bedrooms. The deficient practice was evidenced by the following: On 07/16/2025 at 12:33 PM, the surveyor observed that Resident # 20's personal refrigerator, located in bedroom [ROOM NUMBER]B, was missing temperature log entries for the 4th, 5th, 6th, 8th, and 11th of the month. The log also lacked documentation of the current month, year, and the location of the refrigerator. Additionally, there was no thermometer inside of the refrigerator. [...]

Inspectors wroteNumber of residents sampled: 25Number of residents cited: 0REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) handle trash and soiled linen appropriately for two housekeeping staff during cleaning of residents' rooms and b.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 housekeeping staff during handling of soiled laundry, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was evidenced by the following:Reference: [...]

Inspectors wroteNJ175245, NJ184348 Based on interview and review of facility documents on 5/15/25, 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: Review of the Nurse Staffing Reports completed by the facility for the weeks of 06/23/24 through 06/29/24, 04/20/25 through 04/26/25, and 4/27/25 through 5/3/25, revealed that the facility had no RN coverage for all shifts on 04/20/25. During interview with the surveyor on 5/15/25 at 3:12 p.m., the surveyor inquired about RN staffing in the building. The Regional Clinical Director and Interim Director of Nursing (IDON) stated, Yes, there should be an RN in the building within a 24-hour period to assist with assessments and overall care of the residents. [...]

Inspectors wroteComplaint # NJ175245 Based on observations, interviews, medical records review, and review of other pertinent facility documentation 5/5/25 and 5/15/25, it was determined that the facility failed to maintain a complete and accurate medical record. This deficient practice was identified for 1 of 4 sampled residents (Resident #2) and was evidenced by the following: According to the admission Record (AR), Resident #2 had diagnoses that included but were not limited to: Infection and Inflammatory Reaction due to Internal Right Knee Prosthesis, Arthritis due to other Bacteria, Right Knee, Pyrogenic Arthritis, Unspecified, and Other Chronic Pain. A review of Resident #2's Minimum Data Set (MDS), an assessment tool dated 6/9/2024, revealed a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicated the resident's cognition was intact. [...]

Inspectors wroteComplaint #: NJ00173104 Based on interviews and record review, as well as a review of pertinent facility documents on 06/27/24 and 06/28/24, it was determined that the facility failed to administer the medications in accordance with the acceptable standard of nursing practice and follow the facility policy on Administering Medications for 2 of 4 sampled residents (Residents#1 and #2), reviewed for medication administrations. This deficient practice was evidenced by the following: 1. According to the admission RECORD (AR), Resident #1 was admitted with diagnoses including but not limited to Hypertension and Pain. A review of the Minimum Data Set (MDS), an assessment tool dated 04/18/24, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #1 had intact cognition and required assistance with Activity of Daily Living (ADLs). [...]

Inspectors wroteC #: NJ00173104 and NJ00171706 Based on interviews, medical record review, and review of other pertinent facility documents on 6/27/24 and 6/28/24, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to the facility policy and protocol for 2 of 4 residents (Resident #1 and Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission RECORD (AR), Resident #1 was admitted with diagnoses including but not limited to Muscle Weakness and Encounter for Orthopedic Aftercare Following Surgical Amputation. [...]

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the QIO (Quality Improvement Organization) and the TTY (teletypewriters) a special telecommunications equipment for the deaf or hard of hearing for three of three residents (Resident (R) 23, R188, and R189.) This failure could prevent a Medicare beneficiary with hearing impairment from being able to file an appeal in a timely manner.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure residents were free from physical abuse for four of six residents reviewed for resident-to-resident abuse (Resident (R) 136, R18, R27 and R139). Findings Include: 1. Review of R27's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including dementia in other diseases classified elsewhere severe, and anxiety disorder. Review of R27's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/11/23, revealed a Brief Interview for Mental Status (BIMS), score of 02 out of 15 which indicated severe cognitive impairment. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to report resident to resident incident and injury of an unknown origin timely to the state survey agency for three of six incidents reviewed for abuse (Resident (R) R18, and R27). Refer to F600 Findings Include: 1. Review of a Nurse's Note, in the electronic medical record (EMR), written by Registered Nurse (RN) 3 and dated 04/13/23 at 2:09 PM indicated, R18 called me in to her room and stated while she had been sleeping and R27 entered her room, took her fly swatter, and began hitting her with it. R18 asked R27 why she did it and she stated, because you are fat. During an interview on 02/14/24 at 9:33 AM, RN3 stated she became aware of the incident on 04/13/23 at 2:09 PM and reported it to the Director of Nursing (DON). [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to investigate injuries of an unknown origin for one of six residents reviewed for abuse (Resident R27). Findings Include: Review of a Nurse's Note, in the EMR, written by Licensed Practical Nurse (LPN) 6 and dated 07/18/23 at 1:46 PM indicated, R27 was found with a bruise to the left wrist measuring about 2 inches long and 1 inch wide. R27 stated That a guy grabbed her a statement was received from CNA. The family and nurse practitioner (NP) was made aware. During an interview on 02/14/24 at 12:57 PM LPN 6 stated she became aware of the bruise on R27 wrist on 07/18/23 at 1:46 PM and reported it to the DON and former Administrator. Review of the facility's Reportable Event Record revealed the incident occurred on 07/18/23 at 12:00 PM. [...]

Inspectors wroteBased on staff interview, medical record review and policy review, the facility staff failed to complete a baseline care plan within 48 hours of admission for one of 39 residents in the survey sample (Resident (R)72).

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to provide two (Resident (R) 21 and R51) of three dependent residents reviewed for Activities of Daily Living (ADLs) with showers twice a week as scheduled in a total sample of 25.

Inspectors wroteBased on observation, record review, and staff interview, the facility staff failed to ensure the facility was free of a medication error rate of five percent or greater for two of five residents in the medication administration observation (Resident (R)22 and R6. Resident (R)22 had a physician order for acetaminophen to treat mild pain and R6 had a physician order for spironolactone to treat edema.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medical records were readily accessible for one (Resident (R)137) of 25 sampled residents whose medical records were reviewed in a total sample of 25.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure one hospitality aide (HA1) donned a N-95 face mask and eye protection when entering resident (Resident (R) 77) room and was positive for COVID-19. The facility failed to ensure one certified nursing assistant (CNA9) doffed his personal protective equipment (PPE) inside R186's room before exiting her room. A licensed practical nurse (LPN 4) failed to wear gloves when cleaning a glucometer prior to a finger stick for R44. These failures could lead to residents being exposed to COVID-19 and blood borne pathogens.

Inspectors wrote2. Review of the face sheet revealed the facility admitted Resident #46 to the facility on [DATE] with multiple diagnoses that included anemia, cancer, hypertension, viral hepatitis, cerebrovascular accident, and seizure disorder. A review of the Pre-admission Screening and Resident Review (PASRR) Level 1 screen on 05/19/2018 revealed Resident #46's PASRR level outcome and certification of screening professional completing level 1 form was noted as negative (no mental illness). The facility had no other PASRR screening completed after 05/19/2018. The significant change Minimum Data Set (MDS) assessment, dated 10/15/2021, indicated Resident #46's active diagnoses included major depressive disorder, schizoaffective disorder, and anxiety disorder. Resident #46's care plan, dated 10/15/2021, revealed the resident had a history of physical aggression and yelling to the point of exhaustion. [...]