Inspection Reports for
Complete Care At Green Knoll

The visit was complaint-related with multiple complaint numbers listed, including NJ157602, NJ159021, NJ159131, NJ159472, NJ160729, NJ161981, NJ167419, NJ172055, NJ173797, NJ174205, NJ174945, NJ175542. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance with federal long term care requirements based on deficiencies in grievance process, bed hold policy notification, resident safety during transport and transfers, bed rail use, medication labeling, food temperature, staffing ratios, and multiple life safety code violations including fire safety and emergency preparedness.

The facility was found deficient in multiple areas including failure to provide information on anonymous grievance filing, failure to provide written bed hold notices including cost information, unsafe resident transport and transfer practices without gait belts, lack of informed consent and alternative measures for side rail use, improper labeling of medications with only room numbers instead of resident names, and serving food at temperatures below the required safe range leading to poor palatability.

The complaint investigation found that a resident (R298) was dropped off at his personal residence instead of the facility after an appointment due to an error by a previous unit clerk who provided the transportation company with the resident's home address. Additionally, two residents (R119 and R121) were transferred without gait belts despite requiring assistance, and the facility did not typically use gait belts unless approved by therapy.

The facility failed to ensure a resident's safety during transport when one resident was dropped off at his personal residence instead of the facility, and failed to ensure safe resident transfers using gait belts for two other residents. These deficiencies posed potential risks to residents dependent on the facility for safe transfers.

Complaint investigation based on complaints NJ163545, NJ163595, NJ163682 regarding medication errors and staffing deficiencies.

The facility failed to protect residents from significant medication errors when a Licensed Practical Nurse administered the wrong medication to two residents, resulting in hospital transfers. The facility also failed to implement comprehensive care plans for residents on certain medications and did not maintain professional standards in medication administration, including failure to follow pharmacy warnings and physician orders. Staffing ratios were also found deficient for day shifts.

The complaint investigation was triggered by allegations of failure to implement comprehensive care plans for residents on anticoagulants and medication errors involving administration of wrong medications to residents, including insulin given instead of heparin, resulting in hypoglycemia and hospitalizations. The investigation confirmed these deficiencies and identified immediate jeopardy to resident health and safety.

The facility failed to develop and implement comprehensive care plans for residents on anticoagulants and failed to maintain professional standards in medication administration, resulting in significant medication errors including administration of insulin instead of heparin to non-diabetic residents, causing hypoglycemia and hospitalizations. The facility also failed to follow its policies on medication administration, care planning, and medication error management.

The facility was found not in substantial compliance due to failure to meet minimum certified nursing assistant (CNA) staffing ratios on 14 of 42 shifts reviewed between 09/11/2022 and 09/24/2022, potentially affecting all residents. The facility acknowledged staffing shortages and implemented corrective actions including increased monitoring, recruitment efforts, and incentives.

The facility was found deficient in completing quarterly Minimum Data Set (MDS) assessments timely for 2 of 4 sampled residents, failed to complete Level II PASRR screenings when new mental illness diagnoses were made for 1 of 3 sampled residents, failed to accurately reflect mental illness diagnoses on PASRR for 1 of 4 sampled residents, and failed to maintain consistent and accurate medical records regarding code status for 1 of 3 sampled residents.

The facility was found noncompliant with several Life Safety Code requirements including non-illuminated exit signs, fire alarm system maintenance issues, improper labeling of fire department connections, improperly located kitchen fire extinguisher, and smoke barrier deficiencies such as unsealed penetrations and smoke doors not fully closing.

The facility was found not in compliance with infection control regulations due to failure to adhere to infection prevention and control practices, specifically staff not wearing appropriate PPE (goggles or face shields) in three resident rooms designated as PUI (persons under investigation for COVID-19).

The facility was found deficient in multiple areas including failure to provide timely written notification of hospital transfers and bed hold policies, incomplete care plans, inadequate neurological checks, failure to assess elopement risk, medication errors and discrepancies in controlled substance documentation, improper medication administration and storage, infection control breaches including improper use of PPE and failure to notify local health authorities of an outbreak, and failure to maintain proper sanitation and hand hygiene practices.