Inspection Reports for
Complete Care At Marcella

Complaint #185832 and #186185 were investigated and substantiated based on observation, interview, record review, and review of facility documents showing medication administration timing errors.

The facility failed to administer medications within the scheduled times for two residents, Resident #12 and Resident #159, as evidenced by medication audit reports and interviews with nursing staff. The facility policy requires medications to be administered within 60 minutes before or after the scheduled time, but documentation and administration times showed deviations.

Complaint #185832 and #186185 triggered the investigation. The complaints were substantiated based on observations, interviews, and record reviews indicating medication administration delays and improper infection control.

The facility failed to administer medications within the scheduled times for 2 residents, and failed to ensure proper infection control practices for respiratory equipment for 1 resident. Medication administration times were often delayed beyond the scheduled times, and respiratory equipment was improperly stored and exposed to air.

Complaint #: NJ00180123. The complaint was substantiated based on interviews, medical record review, and other facility documents indicating failure to document ADL care for 4 residents.

The facility failed to consistently document ADL care for 4 residents reviewed, with multiple instances of missing documentation for eating, meal intake, turning and repositioning, personal hygiene, toileting hygiene, and transfers across various dates and shifts. Interviews with staff confirmed documentation lapses and emphasized the importance of documentation for accountability.

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.

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 #NJ00174308 regarding failure to perform skin scrapings to confirm scabies. The complaint was substantiated with findings that skin scrapings were not done for residents diagnosed or treated for scabies.

The facility failed to perform skin scrapings for scabies confirmation in 2 of 4 sampled residents despite treatment orders. Interviews with staff and physicians confirmed no skin scrapings were done, and no positive cases were reported. The facility's scabies policy requires skin scrapings, but they were not performed for the affected residents.

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.

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.

The facility failed to develop a person-centered baseline care plan for a fall risk resident within 48 hours of admission. Resident #185, who had a history of falls and was at risk for falls, did not have a fall care plan in place prior to a fall incident on 03/05/23; the care plan was only initiated on 03/06/23 following the fall.

The facility was found deficient in multiple areas including failure to provide appropriately sized beds for residents, inaccurate Minimum Data Set (MDS) assessments, delayed baseline care plans for fall risk residents, lack of physician orders for oxygen tubing and gastrostomy site care, improper medication administration not following cautionary instructions, unsafe food handling and storage practices, inadequate infection prevention and control practices including hand hygiene and wound care procedures.

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.

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.

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.

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 Intake #NJ148670 was substantiated by findings that the facility did not meet required staffing ratios for multiple shifts, potentially affecting all residents.

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.

The facility failed to complete timely Minimum Data Set (MDS) assessments for multiple residents due to a records transfer issue, failed to follow a physician's order for pressure ulcer care for one resident, and had a medication error rate exceeding 5% due to incorrect medication administration by a nurse.

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.