Complete Care at Wall LLC

Inspectors wroteComplaint #: 2993624 Based on interviews, medical record reviews, and review of other pertinent facility documents on 04/29/2026, it was determined that the facility failed to ensure a nurse (Licensed Practical Nurse #1) identified a resident prior to administering medication to the resident. Resident #2 was given methadone by mouth that was prescribed for another resident (Resident #1). On 12/25/2025, LPN #1 administered 110 milligrams (MG) of methadone (opioid medication used for addiction treatment and pain management) liquid by mouth to Resident #2. The medication was prescribed for Resident #1. LPN #1 realized the error and immediately administered Narcan to Resident #2. Narcan is a medication designed to reverse opioid overdose rapidly. Resident #2 was sent by ambulance to the hospital Emergency Department (ED) for evaluation and was admitted . [...]

Inspectors wroteCOMPLAINT#: 2794629 Based on interview, review of medical records and other pertinent facility documents on 4/29/26, it was determined that the facility failed to monitor a resident's weight upon admission, and then weekly for 4 weeks in accordance with facility protocols and professional standards of practice. This deficient practice was identified for 1 of 3 residents (Resident #7) reviewed and was evidenced by the following:Resident #7 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #7 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction, aphasia, and congestive heart failure. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the food preparation, storage area, kitchen equipment and food transport equipment in a clean and sanitary manner, and ensure staff had access to clean hand washing facilities and covered all facial hair appropriately to prevent contamination from foreign substances and limit the potential for food borne illness. This deficient practice effected all residents who resided at the facility and was evidenced by the following:On 07/29/2025 at 8:48 AM, in the presence of the Food Service Director (FSD) the surveyor conducted an initital tour of the kitchen and additional food storage areas and observed the following: The white ceiling tiles throughout the entire kitchen had various spatter type debris and stained areas. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a comprehensive Quality Assurance Performance Improvement (QAPI) program self-identified areas for improvement which included to ensure all staff were knowledgeable and a consistent abuse process was in place to ensure residents were protected from abuse, investigations were initiated and appropriate staff participated in the investigations per their Job Description. This deficient practice affected all residents who resided in the facility and was evidenced by the following:On 08/06/2025 8:42 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, about the facility QAPI program. The LNHA informed the surveyor that he was responsible for the QAPI process. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) within 2 hours, an allegation of abuse for 2 of 4 residents reviewed for abuse, (Resident #110 and #109), and the deficient practice was evidenced by the following: A. On 7/29/25 at 9:01 AM, during the initial tour of the facility, Resident #110 informed the surveyor that Certified Nurse Aides (CNA #1) and (CNA #2) rough handled them during care, they pressed on their incision line, they pushed them and would not stop although they were screaming. Resident #110 stated that they reported the incident to RR #1 who had made the facility aware of what happened on Monday 7/28/25. Resident #110 informed the surveyor, I had a shattered femur, and it hurts. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to initiate an investigation for an allegation of abuse and prevent further potential abuse, after two cognitively intact residents made allegations of abuse. The deficient practice occurred for 2 of 4 residents reviewed for abuse (Resident #109 and Resident 110) and was evidenced by the following:The evidence was as follows:A. On 7/29/25 at 9:01 AM, during the initial tour of the facility, Resident #110 informed the surveyor that Certified Nurse Aides (CNA #1) and (CNA #2) rough handled them during care, they pressed on their incision line, they pushed them and would not stop although they were screaming. Resident #110 stated that they reported the incident to RR #1 who had made the facility aware of what happened on Monday 7/28/25. [...]

Inspectors wroteC#: NJ166356 (397035), NJ173415 (397032)Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 7/29/2025 through 8/6/2025, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #95, #97, #101, and Resident #125). The facility also failed to follow the Certified Nursing Assistant's job description, and its policies titled, Activities of Daily Living (ADLs), and Documentation in Medical Record for 4 of 4 residents (Resident #95, # 97, #101, and Resident #125) reviewed for ADLs and was evidenced by the following: Complaint # NJ168103(397036), # NJ183496 (397046), #NJ166356 (397035), and #NJ 173415 (397032) 1. Surveyor #1 reviewed the closed medical records for Resident #101. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to consistently implement identified nutritional interventions for a resident, including providing timely assistance with meals, for a resident who was identified as having severe fat and muscle wasting and had increased nutritional needs. This deficient practice occurred for 1 of 4 residents reviewed for nutrition and for the dining task (Resident #49), and was evidenced by the following: Refer to F 803, F 804On 07/30/2025 10:51 AM, the surveyor conducted a meal observation during the lunch meal tray service preparation in the kitchen. The surveyor observed the [NAME] use a green handled scoop to scoop Super Mashed Potatoes. At that time, upon interview, the [NAME] confirmed he did not utilize recipes for the super mashed potatoes, or super cereal, or puree white lasagna. [...]

Inspectors wroteComplaint #s NJ 168330, NJ 168408, NJ 179527Based on observation, interview, and record review, it was determined that the facility failed to ensure all residents received their pain medication in a timely manner and in accordance with a physician order. This deficient practice was identified for 3 of 3 closed resident records reviewed for pain (Resident #94, Resident #96 and Resident #103) and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #94,#96 and Resident # 103. A review of the admission Record face sheet (an admission summary) reflected that Resident #94 was admitted to the facility on [DATE] and had diagnoses which included but were not limited to, pain due to internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, difficulty in walking, aftercare following joint replacement surgery. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to; a.) clarify physician's order to monitor bruit (a whooshing or swishing sound that can be heard over an artery) and thrill (a vibrating or buzzing sensation that can be felt over an artery, often caused by a turbulent blood flow as well) to right arm at Permacath (is a durable and flexible catheter / medical device that is inserted into a large vein in the body for long term dialysis) site; b.) facility staff were trained and received competencies in Hemodialysis (HD; a treatment that removes wastes and extra fluid from your blood when your own kidneys have failed). [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure the social workers were incorporated into the abuse process and provided medically related social services to residents who alleged physical and verbal abuse by staff to ensure residents maintained their highest physical, mental and psychosocial well-being. This deficient practice was identified for 2 of 2 residents reviewed for abuse (Resident #109 and Resident #110) and was evidenced by the following: On 7/29/2025 at 9:01 AM, during the initial tour of the facility (on the same resident unit that Resident #109 resided-2 East), the surveyor interviewed Resident #110 who was alert and oriented. Resident #110 stated CNA #1 and CNA #2 rough handled them during care, they pressed very hard on their incision line and hurt them, they pushed them around and would not stop the care when they screamed. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure recipes were followed for therapeutic food supplements, and proper portions were provided to residents who required the items to improve nutritional intake and were served modified diets. The deficient practice was evidenced for 2 of 2 resident (Resident #7 and Resident #49) meal trays observed, for 1 of 1 resident reviewed for nutrition (Resident # 49) and was evidenced by the following: Refer to F804 On 07/30/2025 at 10:35 AM, a surveyor conducted a Resident Council meeting with 5 residents and all 5 residents stated they felt the portions of the meals were too small.07/30/2025 10:51 AM, the surveyor conducted a meal observation during the lunch meal tray service preparation in the kitchen. [...]

Inspectors wroteComplaint NJ #176091, NJ #179258Based on observation, interview and document review it was determined that the facility failed to ensure the menus were followed and standardized recipes were consistently utilized to ensure resident meals were consistently palatable and consistent portion sizes were served to ensure nutritional adequacy of the meals served. The deficient practice was identified for 5 of 5 residents (Resident #39, Resident #63, Resident # 79, Resident # 85 and Resident #116) who attended a resident council meeting and was evidenced by the following:On 07/30/2025 at 10:35 AM, a surveyor conducted a Resident Council meeting with five residents with the following meal concerns: -5 of 5 residents stated the portions that were served were too small. [...]

Inspectors wroteBased on observations and interview on 8/5/2025 and 8/6/2025 in the presence of the Maintenance Director (MD), it was determined that the facility failed to ensure that all portions of the resident call system were functioning in accordance with 483.90(g) Resident Call System. This deficient practice had the potential to affect all 33 residents and was evidenced by the following:An observation by surveyor #2 on 8/5/2025 at approximately 10:35 AM revealed that the call system computer monitor on 2 [NAME] was not turned ON. An observation by surveyor #1 on 8/6/2025 at 8:00 AM in the presence of the Maintenance Director (MD), revealed the call system computer monitor was not turned ON. In an interview at 8:02 AM, the MD confirmed the observation. [...]

Inspectors wroteBased on interview and document review it was determined that the facility to ensure that a room transfer was appropriate and ensure the resident and resident representative were notified of the room change. This deficient practice occurred for 1 of 1 residents reviewed for 1 of 2 residents reviewed for abuse (Resident #109) and was evidenced by the following: Complaint # NJ168408Based on interview and document review it was determined that the facility to ensure that a room transfer was appropriate and ensure the resident and resident representative were notified of the room change. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #109) and was evidenced by the following: On 7/29/25, during the initial tour of the facility, the surveyor interviewed Resident #109 who was alert and oriented and who was visibly upset and was crying. [...]

Inspectors wroteBased on observation and interviews on 8/5/2025 in the presence of the Assistant Administrator (Assist. Admin), Regional Director of Maintenance (RDM) and Maintenance Director (MD), it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible, in accordance with 483.25(d)(1). This deficient practice had the potential to affect all residents, staff and visitors within unit 2 East and was evidenced by the following:An observation at approximately 11:06 AM revealed the vinyl plank floor of room [ROOM NUMBER] A and B was bubbled and lifted from its substrate. In an interview at approximately 11:08 AM, the unsampled B side resident stated, isn't that awful, someone could trip on the floor. In an interview at the time of observation the Assist. Admin., RDM, and MD, confirmed the findings. [...]

Inspectors wroteComplaint #NJ174026 (397043)Based on observation, interview, and record review it was determined the facility failed to follow a physician's order for an insulin medication and acceptable professional standards of practice for 1 of 3 residents reviewed (Resident #115). This deficient practice is 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 registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteComplaint #: NJ184446 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 03/24/2025, it was determined that the facility failed to protect a resident (Resident #2) from significant medication error and follow the physician's order when the Licensed Practical Nurse (LPN #2) administered an incorrect dose of Methadone and failed to follow its policy titled Medication Administration and follow the Licensed Practical Nurse Job Description. On 03/14/2025 at approximately 6:04 A.M., LPN #2 administered 105 MG [milligram] of liquid Methadone ordered for Resident #6 for opioid dependence to Resident #2 instead of the Methadone 10MG tablet ordered for the Resident for pain. Resident #2 was found by LPN #1 at approximately 8:15 A.M. to be lethargic and semi-responsive; [...]