Inspection Reports for Complete Care At Marcella, Llc
2305 Rancocas Road, NJ, 08016
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform covered components and the public about the privacy practices related to medical information handled by NJDHSS, including how information may be used, disclosed, and the rights of individuals.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health data, legal duties of NJDHSS, and contact information for privacy concerns.
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 and contact person for privacy practices |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 2
Jan 21, 2025
Visit Reason
The inspection was conducted based on complaint NJ00180123 to investigate compliance with federal and state regulations regarding resident records and staffing ratios.
Findings
The facility was found not in substantial compliance with requirements for resident-identifiable information and medical record documentation, specifically failing to consistently document Activities of Daily Living (ADL) for four residents. Additionally, the facility failed to ensure adequate staffing ratios for Certified Nursing Assistants (CNAs) over a 14-day period.
Complaint Details
Complaint #: NJ00180123. The facility was not in substantial compliance based on this complaint visit. The complaint was substantiated with findings related to resident records and staffing.
Deficiencies (2)
| Description |
|---|
| Failure to consistently document Activities of Daily Living (ADL) status and care for residents, not following CNA job description and facility policy. |
| Failure to ensure staffing ratios met minimum requirements for Certified Nursing Assistants (CNAs) on three of fourteen days reviewed. |
Report Facts
Census: 143
Sample Size: 4
Staffing Deficiency Days: 3
CNA Staffing Required: 18
CNA Staffing Actual: 16
CNA Staffing Actual: 17
Inspection Report
Routine
Census: 138
Deficiencies: 0
Aug 20, 2024
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 and CDC recommended practices.
Findings
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.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 2
Jun 7, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00174308 to investigate the facility's compliance with infection prevention and control requirements and staffing ratios.
Findings
The facility was found not in substantial compliance with infection prevention and control regulations, specifically failing to confirm the presence of scabies in residents and not maintaining required minimum staff-to-resident ratios on 9 of 14 day shifts.
Complaint Details
Complaint #NJ00174308 was substantiated as the facility failed to confirm scabies diagnosis for 2 of 4 sampled residents and did not maintain required staffing ratios on multiple days.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to perform required diagnostic confirmation for scabies in residents, leading to inadequate infection control measures. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the State of New Jersey for 9 of 14 day shifts. | — |
Report Facts
Census: 135
Deficient day shifts: 9
Required CNAs per day shift: 17
Actual CNAs on deficient days: 12
Inspection Report
Complaint Investigation
Census: 139
Capacity: 148
Deficiencies: 8
Nov 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by multiple NJ complaints (NJ00163758, NJ00163736, NJ00166680, NJ00167359, NJ00165499, NJ00163063, NJ00165288).
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for resident needs, inaccurate assessments, incomplete baseline care plans, failure to obtain and follow physician orders, medication administration errors, inadequate infection control practices, and failure to maintain required minimum direct care staff-to-resident ratios.
Complaint Details
The visit was complaint-related based on multiple NJ complaint numbers (NJ00163758, NJ00163736, NJ00166680, NJ00167359, NJ00165499, NJ00163063, NJ00165288). The facility was found deficient in staffing ratios and other areas. Residents affected include all residents due to staffing and care deficiencies. No adverse effects were noted for some deficiencies; others involved specific residents monitored for adverse effects.
Deficiencies (8)
| Description |
|---|
| Failed to provide reasonable accommodations for resident needs and preferences. |
| Failed to accurately complete the Minimum Data Set (MDS) assessments for residents. |
| Failed to develop and implement baseline care plans within required timeframes. |
| Failed to obtain and follow physician orders for residents' care and treatments. |
| Failed to administer medications in accordance with medication orders and manufacturer specifications. |
| Failed to maintain infection prevention and control practices, including hand hygiene and use of personal protective equipment. |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. |
| Failed to ensure smoke barriers were protected by a system or material capable of restricting the transfer of smoke. |
Report Facts
Census: 139
Total Capacity: 148
Staffing Deficiencies: 14
Staffing Deficiencies: 6
Staffing Deficiencies: 7
Staffing Deficiencies: 14
Inspection Report
Abbreviated Survey
Census: 125
Deficiencies: 0
Apr 7, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Routine
Deficiencies: 0
Jan 9, 2023
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 and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Nov 18, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ150423, NJ152064, NJ151042, NJ153516, NJ153724, NJ153952, NJ153925, NJ155583, and NJ156394) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to ensure that mail was delivered unopened to protect a resident's right to private communications for one sampled resident (Resident #8). Staff accidentally opened the resident's mail on multiple occasions. The facility has since in-serviced staff and implemented monitoring to prevent recurrence.
Complaint Details
The complaint investigation involved multiple complaints including NJ155583 and NJ156394. It was substantiated that Resident #8's mail was accidentally opened more than once by staff members, violating the resident's right to private communication.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure mail was delivered unopened to protect a resident's right to private communications for Resident #8. | SS=D |
Report Facts
Census: 121
Sample Size: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Office Manager | Office Manager | Responsible for opening facility mail; accidentally opened Resident #8's mail and was in-serviced. |
| Admission Coordinator | Admission Coordinator | Accidentally opened Resident #8's mail while helping with facility mail; was in-serviced. |
| Administrator | Administrator | Acknowledged that Resident #8's mail was accidentally opened on multiple occasions and confirmed staff were in-serviced. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Nov 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ149211 and NJ148670 to investigate staffing ratio compliance at the facility.
Findings
The facility failed to meet the minimum staffing ratios for 13 of 14 shifts reviewed between 10/24/2021 and 11/06/2021, potentially affecting all residents. The facility implemented multiple corrective actions including recruitment efforts, bonuses, and contracts with staffing agencies to address the deficiencies.
Complaint Details
Complaint Intake #NJ148670 was substantiated by findings that the facility did not meet required staffing ratios for multiple shifts, potentially affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 13 of 14 shifts reviewed, violating New Jersey minimum staffing requirements. |
Report Facts
Census: 125
Staffing ratios not met: 13
Staffing bonuses paid: 5000
Staffing agencies contracted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 11/14/2021 regarding staffing concerns. |
| Administrator | Administrator | Interviewed on 11/15/2021 regarding staffing measures and corrective actions. |
Inspection Report
Follow-Up
Census: 92
Deficiencies: 1
Aug 11, 2021
Visit Reason
The visit was a follow-up to verify correction of previously cited deficiencies related to staffing ratios at the facility.
Findings
The facility was found to have failed to maintain the required minimum direct care staff to resident ratios for the day shift on 13 of 14 days reviewed. The facility implemented corrective actions including hiring efforts, bonuses, use of agency staff, and recruitment strategies. The follow-up report dated 11/1/2021 indicates that the deficiency was corrected.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. |
Report Facts
Census: 92
Deficiencies cited: 1
Bonuses paid: 10000
Staffing ratios not met: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated facility gave bonuses and described recruitment efforts | |
| Director of Nursing | DON | Reported use of agency staffing and recruitment efforts |
| Assistant Director of Nursing | Interviewed regarding staffing and corrective actions |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
May 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ 139977.
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 139977 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 79
Deficiencies: 0
Feb 10, 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 and recommended practices for COVID-19.
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: 5
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