Inspection Reports for Complete Care At Brick Llc
415 Jack Martin Blvd, NJ, 08724
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
56% occupied
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Annual Inspection
Census: 77
Capacity: 137
Deficiencies: 17
Jun 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights, notification of changes, safe environment, activities of daily living, incontinence care, pressure ulcer prevention, medication management, pharmacy services, psychotropic medication use, food safety, resident records, quality assurance, infection prevention and control, and life safety code compliance.
Complaint Details
Complaint investigations NJ # 167481, 167682, 167725, 168787, 169584, 169666, 169916, 170088, and 170896 were part of the survey.
Severity Breakdown
SS=D: 9
SS=E: 6
SS=F: 2
: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to provide care and services in a manner that maintained and promoted dignity for Resident #24. | SS=D |
| Failed to notify resident's representative of a significant change in condition for Resident #231. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment; observed unclean conditions and improper waste disposal. | SS=D |
| Failed to provide care and services according to resident's needs and update care plans accurately for Resident #24. | SS=D |
| Failed to provide timely incontinence care for Residents #23, #30, and #12. | SS=E |
| Failed to ensure air mattress settings were appropriate and incident reports were initiated for newly developed wounds for Residents #131 and #182. | SS=D |
| Failed to ensure sufficient nursing staff on a 24-hour basis to maintain required minimum direct care staff-to-resident ratios and provide appropriate care. | — |
| Failed to ensure shift-to-shift controlled substance counts were accurately documented. | SS=D |
| Failed to ensure psychotropic medications were used appropriately with documented rationale and gradual dose reductions for Resident #24. | SS=E |
| Failed to properly secure medications during administration and resident's home supply medications for Resident #28. | SS=D |
| Failed to label, date, and store potentially hazardous foods appropriately and maintain kitchen equipment to prevent microbial growth. | SS=E |
| Failed to maintain complete and accurate medical records documenting medication and treatment administration for Residents #19, #131, and #182. | SS=E |
| Failed to ensure required members were present during quarterly Quality Assurance and Performance Improvement (QAPI) Program committee meetings. | SS=D |
| Failed to follow infection prevention and control practices including use of personal protective equipment (PPE), obtaining physician orders for isolation, maintaining catheter care, and testing residents for influenza and COVID-19. | SS=E |
| Failed to provide automatic fire sprinkler protection to all areas; sprinklers were missing under the first accessible landing for 3 of 4 stairwells. | SS=F |
| Failed to ensure corridor doors resist passage of smoke; 6 of 52 resident room doors were warped and did not latch properly. | SS=E |
| Failed to prohibit use of extension cords beyond temporary installation; 4 of 4 electrical wires for computer tablets were improperly installed through holes in walls and plugged into outlets. | SS=F |
Report Facts
CNA staffing deficiency days: 29
Residents affected by corridor door deficiencies: 42
Residents census: 77
Facility licensed capacity: 137
Residents affected by sprinkler deficiency: 50
Missing CNA staffing: 6
Missing signatures on controlled substance logs: 6
Residents with incomplete medication documentation: 3
Residents on contact isolation without proper PPE use: 1
Residents with improper catheter care: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed leaving medication bottle unsecured on medication cart. |
| LPN #2 | Licensed Practical Nurse | Observed leaving medication cart unlocked during medication administration. |
| CNA #1 | Certified Nursing Assistant | Observed providing care without PPE for resident on contact isolation. |
| CNA #2 | Certified Nursing Assistant | Observed providing care without PPE for resident on contact isolation. |
| Director of Nursing | Director of Nursing | Provided education and conducted audits for multiple deficiencies. |
| Environmental Services Supervisor | Environmental Services Supervisor | Re-educated staff on cleaning and waste disposal policies. |
| Food Service Director | Food Service Director | Conducted audits and re-educated dietary staff on food safety. |
| Maintenance Director | Maintenance Director | Oversaw repairs and inspections related to fire safety and electrical issues. |
| Infection Preventionist | Infection Preventionist | Provided education and audits on infection control practices. |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Aug 31, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers between 08/29/23 and 08/31/23.
Findings
The facility was found not in substantial compliance with federal requirements for long term care facilities based on the complaint visit. Key findings included failure to ensure residents who self-administer medications had proper assessments, physician orders, and care plans; insufficient nursing staff to meet resident needs and provide timely care; and failure to secure medication carts and medications properly.
Complaint Details
The complaint investigation was based on multiple complaint numbers NJ00166461, NJ00166489, NJ00166505, NJ00166617, NJ00166695, NJ00164716. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure residents who self-administered medications had a self-administration assessment, physician's order, and care plan. | SS=D |
| Failed to have sufficient nursing staff to meet resident needs and provide timely care, resulting in extended wait times and unmet resident needs. | SS=E |
| Failed to ensure medication carts were locked when unattended and medication was not left unsecured, placing residents at risk of inaccurate medication dosage. | SS=D |
Report Facts
Survey Census: 95
Sample Size: 18
Deficient CNA staffing days: 15
Deficient CNA staffing evening shifts: 11
Residents: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R5 | Resident | Resident reviewed for self-administration of medications and interviewed regarding medication administration concerns. |
| Interim Director of Nursing | Regional Nurse | Interviewed regarding medication administration and staffing issues. |
| LPN2 | Licensed Practical Nurse | Observed leaving medication cart unlocked and unattended. |
| CNA1 | Certified Nursing Assistant | Interviewed about staffing shortages and resident care. |
| CNA6 | Certified Nursing Assistant | Reported staffing shortages and unsafe working conditions. |
| R15 | Resident Council President | Reported resident concerns about staffing shortages. |
| Regional Administrator | Administrator | Interviewed about staffing shortages and recruitment efforts. |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 3
Jul 6, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to food safety practices including improper food labeling and sanitation, and infection prevention and control including inadequate hand hygiene practices. Additionally, the facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness, including unlabeled opened food items and uncovered meat slicer. | SS=E |
| Facility failed to perform adequate handwashing to prevent the spread of infection and failed to follow their own Hand Hygiene policy. | SS=D |
| Facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
Report Facts
Census: 73
Deficiencies cited: 3
CNA staffing deficiency counts: 3
CNA staffing deficiency counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding food safety deficiencies and corrective actions | |
| Dietary Aide | Observed not wearing hair net in kitchen area | |
| Licensed Practical Nurse (LPN) | Observed and interviewed regarding inadequate hand hygiene during medication administration | |
| Registered Nurse (RN) Unit Manager | Interviewed regarding hand hygiene standards | |
| Director of Nursing (DON) | Interviewed regarding hand hygiene policy and staffing | |
| RN Educator | Interviewed regarding hand hygiene procedures and competencies | |
| Certified Nursing Assistant (CNA) | Interviewed regarding staffing levels and workload | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding staffing requirements and facility staffing status |
Inspection Report
Life Safety
Census: 78
Capacity: 137
Deficiencies: 8
Jul 6, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/05/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including delayed egress door signage, stair tread marking, self-closing devices on hazardous area doors, sprinkler system maintenance, corridor door smoke resistance, electrical panel clearance, generator remote stop station, and improper use of extension cords. Corrective actions were planned and later verified as completed during a revisit on 10/05/2022.
Severity Breakdown
SS=F: 3
SS=E: 3
SS=D: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Exit doors with delayed egress devices lacked required instructional signage. | SS=F |
| Stair tread marking stripes were missing on all four stairwells. | SS=F |
| Self-closing devices and hardware were not provided on doors to hazardous areas. | SS=E |
| Sprinkler system ceiling was not smoke resistant and fire rated due to oversized ceiling cuts near sprinkler head. | SS=D |
| Corridor doors failed to resist passage of smoke due to improper door hardware causing gaps. | SS=E |
| Electrical panels and equipment lacked required 36 inch clearance; storage blocked access. | SS=E |
| Generator lacked a remote manual stop station outside the enclosure housing the prime mover. | SS=F |
| Extension cords were used beyond temporary installation as a substitute for fixed wiring in resident room. | SS=D |
Report Facts
Certified beds: 137
Census: 78
Deficiencies identified: 8
Rooms with door gaps: 6
Rooms with extension cord use: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to multiple findings and confirmations during survey | |
| Regional Plant Operations Director | Named in relation to multiple findings and confirmations during survey | |
| Administrator | Informed of findings during exit conference | |
| Director of Plant Operations | Responsible for corrective actions and compliance audits |
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 1
May 31, 2022
Visit Reason
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19. However, a separate deficiency was noted regarding failure to maintain required minimum direct care staff to resident ratios as mandated by New Jersey state law.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey, evident for 3 of 14 day shifts and deficient in Certified Nursing Assistants (CNAs) to total staff on 6 of 14 evening shifts. |
Report Facts
Census: 83
Deficient day shifts: 3
Deficient evening shifts: 6
Sample size: 5
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
May 9, 2022
Visit Reason
The inspection was conducted in response to complaint #NJ 152764 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #NJ 152764 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Apr 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint # NJ 141368.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ 141368 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 80
Deficiencies: 0
Jan 27, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
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.
Report Facts
Sample size: 8
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