Complete Care at Brick LLC

Complaint # NJ169666, NJ170088, NJ167481 Based on observation, interview, and review of the medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner. This deficient practice was identified for 3 of 3 residents (Residents #23, #30 and #12) on 1 of 2 nursing units (Starlight Unit) observed for incontinence care and was evidenced by the following: Refer to F725 1.) On 05/20/24 at 9:17 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated the unit census was 42 residents, six (6) aides and three (3) nurses. On 05/20/24 at 9:23 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to nine (9) residents. CNA #1 further stated that seven of the nine residents that she was assigned to were incontinent and that she still had four incontinent residents left to change. At that time, CNA #1 entered Resident #23's room and requested permission to provide incontinence care to the resident in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ 169584, 169666, 169916, 167481, and 170088 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis in accordance with the facility assessment to a.) maintain the required minimum direct care staff-to resident ratios as mandated by the State of New Jersey, b.) provide appropriate incontinence care to dependent residents (Resident #12, #23 and #30), c.) provide residents with scheduled showers (Resident #45), and d.) prevent the increase of falls for (Resident #9, #56, #232, #233, #234, #235, #236, #237, #238, #241 and #242). This deficient practice was identified for 6 of 6 residents and 9 of 9 closed records reviewed, affected all residents on 2 of 2 units, and was evidenced by the following: Refer to F677 1.) 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to provide a gradual dose reduction (GDR) of psychoactive medication (mood altering drug) in the absence of targeted behaviors and obtain a psychiatric consult for the use of a psychotropic medication. This deficient practice was identified for 1 of 5 residents (Resident #24) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, Resident #24 was admitted to the facility with diagnoses which included, but were not limited to, depression and unspecified dementia with other behavior disturbances. The quarterly Minimum Data Set (MDS), an assessment that facilitates care, dated 03/04/24, indicated that Resident #24 was sometimes understood, and ability was limited to making concrete request. The MDS also indicated that the resident responded to simple direct communication however able. The MDS reflected that the resident was taking psychotropic medications and was not exhibiting behaviors. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility documentation, 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 manner to prevent microbial growth. This deficient practice was evidenced by the following: On 05/15/24 at 09:52 AM, accompanied by the Licensed Nursing Home Administrator (LNHA), the surveyor made the following observations in the kitchen during the initial tour: 1.) The surveyor observed the can opener blade, shaft, and base of the can opener had sticky brown food particles throughout. The surveyor interviewed the Executive Chef (EC) at that time who stated that the can opener was usually cleaned daily, however, was not cleaned yet. 2.) The surveyor observed a large plastic bin of dry rice with scooper left inside the bin. The EC stated that the scooper should not be left inside the bin and removed it. 3.) On a bottom shelf of a preparation table, the surveyor observed a large bin of loose onions, some of the onions were whole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ169584 Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were complete by not documenting the completion of medications and treatments for 3 of 22 (Resident #19, #131, and #182) sampled residents. This deficient practice was evidenced by the following: 1.) According to the admission Record (AR), Resident #19 was admitted with diagnoses which included, but were not limited to, end stage renal disease and dependence on renal dialysis. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/10/24, revealed that Resident #19 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of Resident #19's Order Summary Report (OSR) with active orders as of 05/01/2024, revealed a physician order dated 03/04/2024 for atorvastin calcium oral tablet give one tablet by mouth at bedtime for HLD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ168787 Based on observation, interview, and review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) follow transmission-based precautions (TBP) to prevent the potential spread of infection by not utilizing personal protectice equipment (PPE) for a resident on contact precautions for 1 of 1 resident (Resident #63) reviewed for TBP, b.) obtain a physician's order to include a resident's transmission-based precautions (TBP) for 1 of 3 residents (Resident #182) reviewed for pressure ulcers, c.) maintain a resident's urinary catheter bag off the floor for 1 of 1 resident (Resident #5) reviewed for urinary catheter, and d.) test residents for influenza (flu) in accordance with the Center for Disease Control and Prevention (CDC) guidelines for 5 of 5 residents (Resident #2, #8, #231, #239, and #240) reviewed. This deficient practice and was evidenced by the following: 1.) According to the admission Record, Resident #63 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in a manner that maintained and promoted dignity by not applying an appropriate device to protect a resident's clothing for 1 of 19 residents (Resident #24) reviewed. This deficient practice was evidenced by the following: According to the admission Record, Resident #24 was admitted to the facility with the diagnoses which included, but were not limited to, depression and unspecified dementia with other behavior disturbances. The quarterly Minimum Data Set (MDS), an assessment that facilitates resident care, dated 03/04/24, indicated that Resident #24 was sometimes understood, and ability was limited to making concrete request and that the resident responded to simple direct communication, however able. The MDS also indicated that the resident was dependent with activities of daily living ADLs. On 05/15/24 at 10:56 AM, during the initial tour, the surveyor observed Resident #24 sitting up in a wheelchair with a shower blanket (medical linen that provides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ168787 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to notify the resident's representative of a change in condition for 1 of 22 residents (Resident #231) reviewed. This deficient practice was evidence by the following: According to the admission Record, Resident #231 was admitted to the facility with diagnosis which included, but were not limited to, acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in the body), Alzheimer's Disease, and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Further review of the admission Record included contact information for the resident's responsible party. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/02/23, included the resident's cogntion was moderately impaired. A review of the individualized Care Plan (CP), initiated 05/12/23, included a focus that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep a resident's room clean by placing a soiled incontinence brief in a garbage receptacle without a bag liner, leaving used disposable gloves on the floor, and not emptying a closed-lid garbage receptacle with exposed personal protective equipment. The deficient practice effected 2 of 7 residents (Resident #22 & #57) and was evidenced by the following: On 05/20/2024 at 12:09 PM, while visiting Resident #22 in his/her room, the surveyor observed a soiled incontinence brief in the garbage receptacle adjacent to his/her bed. The receptacle did not have a bag liner in it. The surveyor also observed a pair of inside-out disposable gloves on the floor. On 05/21/2024 at 08:42 AM, while outside of the same room, the surveyor observed the closed-lid garbage receptacle overflowing with yellow, disposable, protective gowns. The surveyor also observed a disposable glove and a piece of paper-like product on the floor near Resident #57's bed. On 05/21/2024 at 09:33 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to a.) provide services according to the resident's communication needs documented on the Care Plan (CP) and b.) update the CP to accurately reflect the communication needs for 1 of 1 resident (Resident #24) evaluated for communication. This deficient practice was evidenced by the following: According to the admission Record, Resident #24 was admitted to the facility with the diagnoses, which included but were not limited to, depression and unspecified dementia with other behavior disturbances. The quarterly Minimum Data Set (MDS), an assessment that facilitates resident care, dated 03/04/24, indicated that Resident #24 was sometimes understood, and ability was limited to making concrete request. The MDS also indicated that the resident responded to simple direct communication, however able. On 05/15/24 at 10:56 AM, the surveyor observed Resident #24 sitting in his/her wheelchair. The resident's call bell was observed in reach of the resident's right hand. The resident was unable to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ167481, NJ169584 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure that an air mattress was accurately set according to the resident's weight, and b.) thoroughly investigate a facility acquired pressure ulcer. This deficient practice was identified for 2 of 3 residents (Resident #131 and #182) reviewed for pressure ulcers and was evidenced by the following: 1.) On 05/17/24 at 10:15 AM, the surveyor observed Resident #182 lying in bed asleep. The resident had an air mattress which was set to 280 lbs. (pounds). On 05/20/24 at 9:46 AM, the surveyor observed Resident #182 lying in bed asleep and the resident's air mattress was set to 280 lbs. On 05/21/24 at 9:30 AM, the survey observed Resident #182 lying in bed awake and the resident's air mattress was set to 280 lbs. When asked about the air mattress, the resident stated he/she thought the mattress was not set correctly because he/she could feel a dimple in the mattress on his/her backside. The resident further stated that he/she had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding, specifically by having the enteral feeding pump running while disconnected resulting in nutritional formula dripping onto the floor, failing to replace the irrigation syringe every twenty-four hours, and failing to clean nutritional formula residue off of the pole supporting the enteral feeding pump. This deficient practice was identified for 1 of 1 resident (Resident #22) investigated for tube feeding and was evidenced by the following: According to the admission Record, Resident #22 had a diagnosis which included, but was not limited to, Unspecified Severe Protein-Calorie Malnutrition. A review of Resident #22's physician's orders located in the Electronic Medical Record (EMR) revealed an order for Enteral Feed four times a day for prevention of clogging use 225mL (Milliliters) water for flush. Further, the EMR revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts and was evidenced by the following: On 05/16/24 at 11:44 AM, during medication storage observations, the surveyor, in the presence of Licensed Practical Nurse #1 (LPN #1), observed the controlled substances inventory and count logs for the Seabreeze nursing unit's medication Cart 3. The following was observed: Narcotic Shift Count log for May 2024 was missing a nursing signature for: -05/03/24 11 PM - 7 AM shift going off duty nurse -05/04/24 3 PM - 11 PM shift going off duty nurse -05/06/24 11 PM - 7 AM shift going off duty nurse -05/07/24 11 PM - 7 AM shift coming on duty nurse -05/07/24 7 AM - 3 PM shift going off duty nurse -05/09/24 11 PM - 7 AM shift going off duty nurse At that time, LPN #1 confirmed that there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly secure medications during medication administration, and b.) properly secure a resident's home supply medications. This deficient practice was identified for 2 of 2 nurses observed during medication administration, and 1 of 1 resident (Resident #28) reviewed for pain management, and was evidenced by the following: 1.) On [DATE] at 8:34 AM, during medication administration observation, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare to administer medications to Resident #21. After preparing the ordered medications including docusate sodium (a facility stock supply of over-the-counter stool softener), LPN #1 left the bottle of docusate sodium, which contained medication, on top of the locked medication cart in the hallway and proceeded into the resident's room to administer their medications. At 8:38 AM, the LPN returned to the medication cart, at that time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Program committee meetings. This deficient practice occurred during 3 of the 4 quarterly QAPI meetings reviewed and was evidenced by the following: On 05/21/2024 at 09:40 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the Quality Assurance Performance Improvement (QAPI) process in the facility. The surveyor reviewed the quarterly QAPI meeting sign in sheets in the presence of the LNHA. According to the quarterly sign in sheets provided by the facility, there was no Infection Preventionist (IP) in attendance at the quarterly QAPI meeting that was held on 04/18/2024. When the surveyor reviewed the sign in sheets for the quarterly meetings, the sign in sheets were missing the Director of Nursing (DON) signature indicating that the DON had not been in attendance for two of the four meetings held on 07/26/2023 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ 166617, NJ 166695, NJ 166489, NJ 166505, NJ 166489, NJ 166461 Based on interview, review of staffing sheets, facility assessment, and policy review, the facility failed to have sufficient nursing staff to meet resident needs and/or provide care in a timely manner for nine out of 18 sampled residents (R9, R2, R4, R18, R16, R6, R5, R15, and R10). Residents expressed concerns related to staffing not being able to go to the dining room and extended wait times for assistance. Findings include: 1. During an entrance conference on 08/29/23 at 10:30 AM, the Administrator and Interim Director of Nursing (DON) confirmed staffing has been an issue for the facility. They stated the facility used agency for both nurses and Certified Nursing Assistants (CNA), sometimes the agency would call out one hour before their shift because they can go to another facility and make more money. They stated the facility has been offering sign-on bonuses, flexible hours, overtime and giving extra $200.00 bonuses for working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ 166617, NJ 166695 Based on observation, interview, and record review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for one of one resident (Resident (R) 5) reviewed for self-administration of medications. Failure to assess and care plan resident for self-administration of medications increases the potential of medication errors for residents. Findings include: During interview on 08/29/23 at 12:12 PM, R5 stated she had been at the facility for about two weeks due to a stroke which left her right side weak. R5 stated last night on the 11-7 shift, she asked about getting a pain pill because she was having pain (seven out of ten) and asked the Certified Nursing Assistant (CNA) three times to speak with the nurse, who never came. R5 said she was having pain in her chest, and she had to take a nitroglycerine pill twice, which she keeps on her person. R5 stated she wanted the nurse to take her blood pressure. R5 indicated she was a retired nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ 166617, NJ 166695 Based on observation, interview, and facility policy review, the facility failed to ensure one out of three medication carts were locked on one of two floors. In addition, the facility failed to ensure medication was locked in a secure place when out of nurse's eyesight. This failure placed residents at risk of receiving an inaccurate dosage of medication. Findings include: Upon arriving on the floor on 08/30/23 at 5:23 AM, Licensed Practical Nurse (LPN) 2 was observed entering the medication room, located behind the nursing station with another staff member. Surveyor then walked down the middle hallway and observed the unnumbered medication cart parked on the left side of the hallway. The cart was unlocked and had a clear plastic cup sitting on top of the medication cart with orange crushed unknown substance inside of the cup. The nurse did not return to the medication cart until five minutes later. LPN2 confirmed the medication cart had been left unattended and unlocked. LPN2 confirmed medication cups should not be left on top of the cart. LPN2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 6/21/2022 from 9:37 AM to 10:24 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the walk-in freezer an opened bag of chicken fingers on a middle shelf had no dates. The FSD stated, They should be labeled with an open and use by date. 2. In the same walk-in freezer on a lower shelf, an opened package of frozen hash browns removed from its original container had no label or dates. On interview the FSD responded, Same thing. Needs an opened and use by date. On an upper shelf a plastic bag contained frozen garlic bread and was removed from its original container. The garlic bread had no label or dates. 3. A Dietary Aide (DA) was observed working in the dish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to perform adequate handwashing to prevent the spread of infection as well as failed to follow their own Hand Hygiene policy. This deficient practice was identified for 1 of 3 Licensed Practical Nurses (LPN) observed during medication administration. The deficient practice was evidenced by the following. On 06/24/22 at 8:19 AM, the surveyor observed the LPN begin medication administration for an unsampled resident. The LPN went to the resident room to obtain a blood pressure (BP) reading. After obtaining the BP reading, the LPN entered the resident's bathroom. At 8:20 AM, the surveyor observed the LPN turn on the faucet, wet her hands, apply soap, create friction outside the stream of water for 11 seconds, rinse her hands, dry her hands, and turn off the faucet. The LPN did not use alcohol-based hand sanitizer. The time was counted on the New Jersey Department Of Health computer clock. The LPN returned to the medication cart and gathered the resident's medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.