Complete Care at Regent LLC

Inspectors wroteComplaint #2691795Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide notification to the resident representative regarding resident status and change in condition for 1 of 2 residents (Resident #172) reviewed. This deficient practice was evidenced by the following: On 7/21/26 at 9:28 AM, during an initial meeting with the survey team, the Regional Administrator, who stated he was the current acting Licensed Nursing Home Administrator (LNHA). The LNHA provided the surveyors with access to the electronic medical records (eMR) and stated all medical records were in the eMR, there were no paper medical records for review. [...]

Inspectors wroteComplaint #2691795Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to implement an effective discharge planning process for 1 of 2 residents (Resident #172) reviewed for discharge. This deficient practice was evidenced by the following:On 7/21/26 at 9:28 AM, during an initial meeting with the survey team, the Regional Administrator stated he was the current acting Licensed Nursing Home Administrator (LNHA). The LNHA provided the surveyors with access to the electronic medical records (eMR) and stated all medical records were in the eMR, and there were no paper medical records for review. The surveyor reviewed the eMR for Resident #172, and revealed: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1. On 1/27/25 at 9:16 AM, the surveyor, in the presence of the Food Service Director (FSD) observed the following during the initial kitchen tour: On a shelf in a refrigerator, there was an opened pack of shredded mozzarella cheese. The pack had an open date of 1/17/25 and a use by date of 1/24/25. The FSD stated that the pack of cheese should not be there and took it out to be discarded. The FSD further explained the item was good for seven days after opening and that all dietary staff were responsible for ensuring expired food items were removed. 2. [...]

Inspectors wroteBased on observation and interview on 1/27/2025 in the presence of the Director of Maintenance (DM), it was determined that the facility failed to ensure that the devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at 1:28 PM, revealed that the call bell system did not give audible or visual notification of the activation of the call bell system at the nurse's station when it was test for room [ROOM NUMBER]. Upon further investigation by the DM, it was discovered that the call bell annunciator at the nurse's station was not plugged in. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 3 units, (2nd, 3rd, and 4th units) and 2 of 2 residents' rooms. This deficient practice was evidenced by the following: 1. On 1/27/25 at 1:58 PM, during the initial tour of the 4th floor nursing unit, the surveyor observed a gray, dust or dirt-like substance adhering to the air circulation vent covers on the 4th floor unit in the hallways and above the nursing station. The surveyor observed four vent covers in the 4th floor hallways and one vent cover above the nursing station. On 1/28/25 at 9:30 AM, the surveyor observed the vent covers on the 2nd and 3rd floors. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for 5 of 8 newly hired licensed staff reviewed, Staff Member (SM) #1, #4, #5, #6, and #7 evidenced by the following: On 1/28/25 at 11:12 AM, the surveyor reviewed ten randomly selected newly hired employee files. The review for license verification for eight of the new licensed employees revealed the following: 1. A review of Staff Member #1 (SM#1), a Certified Nursing Assistant (CNA #1), hired on 5/30/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the residents or resident representative written notification of the facility's bed hold policy for 4 of 5 residents, (Residents #12, #84, #94, and #97), reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. On 1/27/25 at 10:59 AM, Surveyor #1 (S#1) observed Resident #12, seated on the side of the bed and informed the surveyor that they were a short-term resident and had been in and out of the facility for more than three times hospitalizations due to a heart condition. The surveyor reviewed the medical records of Resident #12, and revealed the following: [...]

Inspectors wroteBased on observations, interviews, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents receiving oxygen according to the standard of clinical practice and the facility's policy and procedure. This deficient practice was identified for 3 of 3 residents, Residents #23, #88, and #142, reviewed for respiratory care, 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 observation, interview, and record review, it was determined that the facility failed to ensure that the resident's call light was readily accessible within reach. The deficient practice was identified for 1 of 1 resident, Resident #309, reviewed for accommodation of needs. This deficient practice was evidenced by the following: On 1/27/25 at 10:27 AM, the surveyor observed the resident resting in bed, alert, soft spoken, and verbally responsive. The surveyor observed the resident's call light was tied to the left siderail, dangling down towards the floor and not clipped onto the bed within the resident's reach. The surveyor asked Resident #309 about call bell use, and the resident replied that sometimes they could not reach the call bell and stated, like now I don't know where my call bell is. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 3 of 34 residents, (Residents #23, #308, and #309), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:59 AM, the surveyor observed Resident #23 lying on the bed with BIPAP (Bilevel positive airway pressure, is a machine that helps resident breathe and a form of noninvasive ventilation) and nebulizer machine on top of the nightstand table. On 1/28/25 at 11:16 AM, the surveyor observed the resident lying on the bed, and informed the surveyor that they use the oxygen (O2) as PRN (as needed) and the BIPAP at night. [...]

Inspectors wroteBased on observations, interviews, review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 2 of 34 residents (Residents #8 and #146) reviewed for a care plan. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:58 AM, the surveyor observed Resident #8 lying on the bed with eyes closed with the call bell within reach. On 1/28/25 at 11:14 AM, the surveyor observed the resident lying in bed asleep. On 1/29/25 at 10:39 AM, the surveyor observed the Activities Aide Recreation (AAR) with a cart in the hallway near the resident's room. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to adhere to professional standards of clinical practice by failing to a.) ensure the practitioner aware of the situations where other practitioner had potentially misdiagnosed the resident for 1 of 5 residents, Resident #12, reviewed for unnecessary medications (meds) and b.) administer a medication (med) in accordance with the manufacturer's specifications for 1 of 6 residents, Resident #129, reviewed during the med pass observation. 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 observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to carry out activities per resident's care plan for 1 of 1 resident, Resident #8, reviewed for activities. This deficient practice was evidenced by the following: On 1/27/25 at 10:58 AM, the surveyor observed Resident #8 lying on the bed with eyes closed with the call bell within reach. The surveyor reviewed the medical records of Resident #8, and revealed: A review of the Resident's admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (occurs when a resident has abnormally high blood pressure that was not the result of a medical condition), unspecified mood (affective) disorder, and depression unspecified. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) follow the physician's order (PO) for laboratory and daily weight, b.) ensure congestive heart failure assessment was accurately done according to the PO, and c.) follow through the recommendations of the cardiologist. This deficient practice was identified for 1 of 32 residents, Resident #12, 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 observation, interview, and record review, it was determined that the facility failed to clarify physician's orders to ensure appropriate care and services for a resident receiving enteral feedings. This deficient practice was identified for 2 of 3 residents (Residents #7 and #94), reviewed for enteral (tube) feeding. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:19 AM, the surveyor observed Resident #7 lying in their bed with the head of bed elevated and the resident's representative (RR) was visiting at the bedside. The resident was alert and verbally responsive to simple questions. Resident #7 had tube feeding supplies at the bedside. The RR stated that the resident receiving enteral feedings and was also on a diet to receive PO (by mouth) foods. [...]

Inspectors wroteComplaint NJ #176546 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey and b.) answer call bells and provide incontinence care in a timely manner. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. [...]

Inspectors wroteComplaint # 168864 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure and have documented evidence a.) that Temporary Nurse Aides (TNAs) were enrolled in school prior to 5/11/23 and completed their Certified Nurse Aide (CNA) certification by 9/11/23 as mandated by Centers for Medicare and Medicaid Services (CMS) and New Jersey Department of Health (NJDOH) in order to continue to work after 5/11/23; b.) of verification that the non-certified NAs were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program and validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, 2 of 2 non-certified NAs that were previously working as TNAs; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 5 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: 1. On 1/27/25 at 8:52 AM, the survey team entered the facility and met with the Receptionist and the Director of Nursing (DON). The surveyor was unable to see the posted Nursing Home Resident Care Staffing Report (NHRCSR) not until the surveyor had to go inside the Receptionist's area where the NHRCSR was covered by a vase of flowers, which was not easily visible to residents, staff, and visitors. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 2 of the 34 residents reviewed, (Residents #12 and #23). This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:59 AM, the surveyor observed Resident # 12 seated on the side of the bed and informed the surveyor that they were a short-term resident and had been in and out of the facility more than three times hospitalizations due to a heart condition. The surveyor reviewed the medical records of Resident #12, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteComplaint #: NJ00167634 Based on interview, review of resident medical records, and review of other pertinent facility documentation on 10/04/23, it was determined that the facility failed to: a.) follow a physician's order (PO) to remove a midline catheter (an 8-12 centimeter catheter inserted in the upper arm used to administer medications into the bloodstream) prior to discharging the resident and b.) coordinate discharge planning for Resident #1, 1 of 4 residents reviewed for discharges. The deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #1: 1. According to the admission Record, Resident #1 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete and/or timely transmit the Minimum Data Set (MDS) for 5 of 46 residents reviewed, Residents #13, #37, #51, #131, #113. The deficient practice was evidenced by the following: On 9/26/23 at 12:30 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. The following residents were identified as not to having their MDS transmitted timely: 1. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 7 of 29 residents, Resident #3, #135, #8, #15, #126, #204, and #98 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 9/20/2023 at 11:30 AM, the surveyor observed Resident #3 in their room watching television. The surveyor also observed that the resident was only able to communicate in Russian. The surveyor reviewed Resident #3's electronic medical record (EMR). [...]

Inspectors wroteBased on observation, interviews, medical records, and facility policies, it was determined that the facility failed to follow acceptable standards of clinical practice with regards to 1. label and date an Enteral feeding bottle and water flush bag. This deficient practice was observed for Resident #135, 1 of 3 facility residents reviewed for Tube Feeding and 2. accurately following a physician's order (PO) for parameters. This deficient practice was observed for Resident #135, 1 of 5 residents reviewed for following a PO for parameter accuracy. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess and implement interventions for the care and management of a resident with a contracture (a permanent shortening of muscle, tendon, or scar tissue, leading to deformity and rigidity of joints) and limited range of motion (ROM) for 1 of 1 resident, Resident #48, reviewed for rehab and restorative services. This deficient practice was evidenced by the following: On 9/21/23 at 11:13 AM, the surveyor observed Resident #48 lying in bed, alert and conversant. The resident's left hand was observed with a contracture. The resident's fingers were flexed towards the palm of the hand. Resident #48 informed the surveyor that they spend most of the time in bed and required staff assistance with getting out of bed to the wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to secure stored controlled medications, as well as ensure that expired, and discontinued medications were removed from the medication cart in a timely manner. This deficient practice was identified in 3 of 3 facility units inspected. The deficient practice was evidenced by the following: 1. On 9/20/23 at 12:15 PM, the surveyor inspecting the 2nd floor refrigerator. The Narcotic Plastic Lock Box located in the 2nd floor refrigerator was secured to the shelf via a metal chain link and keyed lock. The metal link chain was loosely attached, which allowed the surveyor to insert her hand into the box and remove the control substances (medications that are rated by their abuse risk and placed in Schedules by the Federal Drug Enforcement Administration) stored inside of the box. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documentation, it was determined that the facility failed to follow a Physician's Order (PO) for the use of Oxygen (O2). This deficient practice was identified for one (1) of two (2) residents reviewed, (Resident #67) for respiratory care and was evidenced by the following: On 6/06/22 at 11:16 AM, the surveyor observed Resident #67 in their room watching the news on his/her iPad. The resident was observed wearing O2 at four and a half (4.5) Liters Per Minute (LPM) via nasal cannula. The surveyor asked the resident how much O2 he/she needed to use to help him/her not feel short of breath and the resident stated, whatever they put it on. On 6/08/22 at 11:20 AM, the surveyor observed the resident in his/her room conversing with his/her roommate and another resident. [...]

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 6/6/22 and 6/7/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 33 opportunities, and four (4) errors were observed which calculated to a medication administration error rate of 12.12 %. This deficient practice was identified for two (2) of four (4) residents, (Residents #47 and #57), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: 1. On 6/7/22 at 8:30 AM, the surveyor observed a Certified Nursing Assistant (CNA) carrying food trays to a food cart. [...]