Complete Care at Monmouth, LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Monmouth, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 21, 2023

  Complaint #: NJ 162301 Based on observation, interviews, review of the medical records (MRs), and other facility documentation on 3/14/23, 3/16/23, and 3/21/23, it was determined that the facility failed to implement their policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating to prevent reoccurrence of a resident-to-resident inappropriate touching by Resident #3 and to protect 2 of 2 sampled residents (Resident #1 and Resident #2). Approximately 2 weeks prior to 3/7/2023, Certified Nursing Assistant (CNA #1) witnessed Resident # 3 hug and kiss Resident #1 on her/his face in the unit hallway, Resident #1 has diagnoses of Deafness and Autism, had moderately impaired cognition and was able to communicate via writing and non-verbal gestures. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2024

  NJ 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 16, 2023

  Based 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. Findings include: On 11/15/23 at 11:07 AM, Cook1 was observed at the steam table placing soup in bowls when a metal steam table divider fell on the floor. Cook1 picked the metal steam table divider up and placed it on the shelf just below the serving counter of the steam table. […]

• No harm, potential for more than minimal, patternF698May 7, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880May 7, 2026

  Based 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. […]