Inspection Reports for
Complete Care At Kresson View, Llc

The facility failed to maintain a clean and sanitary environment in resident rooms and pantry ice machines across all four units. Observations included food and debris on floors, stained linens and furniture, unclean air conditioner units, and sediment buildup inside ice machines, posing potential infection risks.

The facility was found deficient in maintaining a clean and sanitary environment in resident rooms and ice machines, accurately documenting controlled medication administration, honoring resident dietary preferences, and following infection control practices including proper use of PPE during Enhanced Barrier Precautions. Deficiencies were noted in housekeeping, maintenance, medication administration, dietary services, and infection prevention.

Complaint #: NJ00175034. The facility was found deficient in CNA staffing for 28 day shifts and 2 evening shifts during the periods 06/16/2024 to 06/29/2024 and 08/04/2024 to 08/17/2024. Residents affected were monitored with no adverse effects noted.

The facility was found not in compliance with New Jersey Administrative Code 8:39 due to failure to meet required minimum staff-to-resident ratios for Certified Nursing Assistants (CNAs) during multiple day and evening shifts over several weeks. The facility was deficient in CNA staffing on 28 day shifts and 2 evening shifts as mandated by state law.

Complaint investigations included issues with care planning (#152906), anticoagulation monitoring (#150996), pressure ulcer care (#152805, #153069), staffing (#152805), food quality (#152906), and snack provision (#153846).

The facility was found deficient in multiple areas including failure to revise person-centered care plans accurately, failure to monitor therapeutic lab values for anticoagulation, inadequate pressure ulcer care and prevention, insufficient nursing and CNA staffing, serving food at unsafe temperatures and poor palatability, and inconsistent provision of evening snacks to residents.

Complaint numbers 150996, 153069, 152906, 152805, 153846 related to dignity during dining, care planning, incontinence care, pain management, staffing, meal quality, dialysis care, wound care, and infection control.

The facility was found deficient in multiple areas including failure to ensure residents received meals simultaneously to promote dignity, inaccurate resident assessments, incomplete and untimely care plan revisions, inadequate incontinence and personal hygiene care, delayed pain medication administration, insufficient dialysis monitoring and documentation, inadequate staffing levels, poor meal temperature and palatability, inconsistent evening snack offerings, improper dish machine sanitization, incomplete medical records access, and failure to follow infection control protocols during wound care.

The complaint investigation involved multiple complaint numbers (NJ150953, NJ151583, NJ155641, NJ168428). The facility was found deficient in staffing ratios for all day shifts reviewed and one overnight shift. The deficient practice had the potential to affect all residents. No specific residents were identified as affected.

The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and deficient total staff on 1 of 14 overnight shifts. No specific residents were affected by this deficient practice.

Complaint #NJ00162198 involved allegations that CNA #1 verbally abused Resident #4 and did not follow the resident's transfer preferences. The complaint was substantiated by interviews and record reviews showing the facility failed to report the abuse allegations immediately as required.

The facility failed to immediately report allegations of verbal abuse by CNA #1 towards Resident #4 to the Administrator and the New Jersey Department of Health as required by policy. Interviews with residents, CNAs, Human Resource Manager, Director of Nursing, and Administrator confirmed the failure to report and investigate the allegations timely.

Complaint # NJ00162198 involved allegations of abuse for Resident #4. The facility failed to report the abuse allegations immediately and did not notify the NJ Department of Health as required. Interviews with residents, CNAs, Human Resources Manager, Director of Nursing, and Administrator confirmed the failure to timely report and investigate the allegations. The facility implemented re-education and corrective actions starting 03/16/2023.

The facility was found not in compliance with requirements related to reporting alleged violations of abuse. Specifically, the facility failed to report allegations of abuse immediately to the Administrator and notify the New Jersey Department of Health for one sampled resident. Interviews and record reviews confirmed delays and failures in reporting and investigating abuse allegations.

The visit was complaint-related, investigating allegations of inadequate resident care and regulatory noncompliance, including issues with call bell accessibility, medication errors, pressure ulcer prevention, catheter care documentation, and dialysis medication scheduling.

The facility was found deficient in multiple areas including failure to maintain call bell within reach for a resident, medication administration errors, inadequate pressure ulcer care, inconsistent catheter care documentation, and failure to properly sequence medication administration around a resident's hemodialysis schedule. All deficiencies were assessed as causing minimal harm or potential for actual harm.

The facility was found to be in noncompliance due to failure to ensure that two illuminated exit signs were posted to clearly identify the exit access path above the enclosed center courtyard doors. The deficiency was observed during a facility tour in the presence of the Maintenance Director.