Inspection Reports for Complete Care at Brakeley Park LLC

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The inspection was conducted as a complaint investigation based on complaint numbers NJ00176509 and NJ00171054 to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.

The facility was found not in substantial compliance due to failure to provide special eating equipment and appropriate assistance to a resident during meal service, as required by the resident's Comprehensive Care Plan. Specifically, Resident #2 did not receive the ordered assistive devices or supervision during meals.

Complaint numbers NJ00176509 and NJ00171054 triggered the visit. The facility was found not in substantial compliance based on these complaints.

The inspection was conducted based on complaint numbers NJ175583 and NJ176533 to investigate allegations related to staffing ratios and failure to obtain appropriate physician orders for residents.

The facility was found not in substantial compliance with professional standards of care due to failure to obtain appropriate physician orders for one resident and failure to meet required staffing ratios on multiple shifts over several weeks. The facility had deficient CNA staffing for many day shifts and total staff shortages on evening and night shifts, potentially affecting all residents.

Complaint numbers NJ175583 and NJ176533 triggered the investigation. The complaint was substantiated as the facility failed to obtain appropriate physician orders for Resident #1 and failed to meet staffing requirements on numerous shifts.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.

Deficiencies were cited including failure to initiate emergency response for a resident, failure to treat residents with dignity during meal service, failure to communicate and respond to resident council concerns, failure to develop comprehensive care plans, failure to follow physician orders and consultant recommendations, failure to initiate CPR and call emergency services, failure to provide respiratory and dialysis care according to standards, failure to ensure physician orders were signed timely, medication administration errors, and food safety violations.

Complaint investigations were completed during this survey for multiple complaint numbers including NJ163658, 163827, 163852, 164702, 165037, 165040, 165610, 169353. The Immediate Jeopardy was related to failure to initiate emergency response for Resident #112.

The inspection was conducted as a complaint survey based on complaints NJ165331, NJ167365, and NJ168017 to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.

The facility was found not in substantial compliance due to failure to ensure accident hazards were prevented and adequate supervision was provided during resident transfers. Specifically, Resident #2 was injured during a transfer when care plan interventions were not followed, resulting in a fall and hospital visit. The facility failed to follow its policies on safe resident handling and transfers.

Complaint investigation based on complaints NJ165331, NJ167365, and NJ168017. The facility was found not in substantial compliance. Resident #2 was injured during transfer due to failure to follow care plan interventions. The staff involved were suspended and terminated. The Director of Nursing initiated audits and education to ensure compliance.

A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers between 05/28/2023 and 06/01/2023.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. Deficiencies included failure to maintain medical equipment in safe operating condition and failure to meet required staffing ratios.

The complaint investigation involved multiple complaint numbers (NJ00163992, NJ00157854, NJ00161866, NJ00155616, NJ00158139, NJ00163824, NJ00159823, NJ00149794, NJ00160741). The facility was found not in substantial compliance based on these complaints.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited related to failure to obtain physician orders for self-releasing seatbelts, failure to implement appropriate nutritional interventions for residents with significant weight loss, and failure to maintain proper food storage temperatures. Additionally, the facility failed to maintain required minimum direct care staff-to-resident ratios and had a fire alarm system deficiency related to occupant notification in an enclosed courtyard.

The inspection was conducted as a complaint survey based on allegations of abuse involving Resident #1, specifically regarding failure to report verbal abuse by staff to the New Jersey Department of Health.

The facility failed to report an alleged verbal abuse violation involving Resident #1 to the NJDOH. The Nursing Home Administrator and Director of Nursing investigated and concluded no verbal abuse occurred, but the facility did not comply with reporting requirements under 42 CFR §483.12(c).

Complaint NJ144286 involved failure to report allegations of staff to resident verbal abuse against Resident #1. The allegation was not reported to the NJDOH despite investigation. Resident #1 was no longer in the facility at the time of the report.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint survey based on multiple complaint numbers NJ135407, NJ139777, NJ140101, and NJ140554.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.

Complaint numbers NJ135407, NJ139777, NJ140101, and NJ140554 were investigated and found to be in compliance.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.