Inspection Reports for
Complete Care At Prospect Heights Llc

Complaint NJ#384180 and NJ#s: 384182, 384183, 384186, 384188, 2573473, and 2615149. The complaints involved environmental concerns and staffing inadequacies affecting resident care. The complaint was substantiated based on observations, interviews, and record reviews.

The facility was found to have environmental deficiencies including low temperatures in common areas, peeling laminate on tables, stained rugs and walls, and improperly maintained privacy curtains. Additionally, staffing shortages resulted in inadequate incontinent care for at least one resident, with documentation and care plan deficiencies noted.

Complaint numbers NJ00183692 and NJ00183376 triggered the visit. The facility was found deficient based on these complaints, specifically regarding care plan compliance and staffing ratios.

The facility was found not in compliance with federal and state regulations related to clinical care plans and staffing ratios. Deficiencies included failure to follow acceptable clinical practice standards for resident assessments and inadequate staffing levels for Certified Nurse Aides and nursing staff over multiple days.

The facility failed to follow acceptable clinical practice standards for weight assessments and accurate implementation of physician orders for 3 of 4 residents reviewed. Weights were not consistently collected as ordered, and there was no documentation explaining the omissions.

The facility failed to properly screen outside vendors and ensure that Personal Protective Equipment (PPE) was worn on the COVID unit, as two EMT staff were observed transporting a resident without masks, potentially increasing the risk of infection spread.

The survey included complaint investigation for multiple complaint numbers (NJ00166884, NJ00170399, NJ00172105, NJ00174237, NJ00177137, NJ00169244, NJ00176606, NJ00162439). The Immediate Jeopardy was identified during the complaint survey related to infection control. The facility submitted a removal plan and corrective actions were validated as completed by 09/27/24.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B requirements, including an Immediate Jeopardy related to infection control due to failure to properly disinfect multi-use glucometers. Additional deficiencies were noted in respiratory care, nurse staffing information posting, infection prevention and control, mandatory access to care, cooking facilities, fire alarm system maintenance, and life safety code compliance.

The visit was complaint-related, triggered by concerns about infection control practices. Immediate Jeopardy was substantiated due to failures in glucometer disinfection and PPE handling, affecting multiple residents.

The facility failed to disinfect a multi-use glucometer with an EPA-registered disinfectant for one of four residents reviewed, creating an Immediate Jeopardy situation due to increased risk of blood-borne pathogen transmission. Additionally, staff failed to properly doff and dispose of PPE for two residents on isolation precautions, increasing infection spread risk. The facility submitted and implemented an acceptable removal plan to address these deficiencies.

The facility was found deficient in multiple areas including failure to have active physician orders for oxygen use and proper labeling of oxygen equipment, failure to post nurse staffing information where residents could view it, and failure to properly disinfect multi-use glucometers and ensure proper PPE doffing and disposal, resulting in an Immediate Jeopardy situation that was later resolved.

Complaint #NJ00171849 triggered the investigation. The complaint involved issues with resident care including wound assessment accuracy, pain management, care plan revisions, incontinence care, and staffing adequacy.

The facility was found noncompliant with multiple federal requirements including accuracy of resident assessments, care plan timing and revision, activities of daily living assistance, pain management, and sufficient nursing staff. Specific deficiencies involved inaccurate wound coding in MDS, failure to revise care plans for pain, inadequate assistance with incontinence care, inconsistent pain medication administration, and insufficient staffing levels impacting resident care.

Complaint NJ00171849 involved allegations of inaccurate resident assessments, failure to implement and revise care plans for pain management, inadequate toileting assistance, and insufficient nursing staff. The complaint was substantiated with findings of actual and potential harm to residents.

The facility failed to accurately encode a resident's wound in the MDS assessment, failed to implement and revise care plans for pain management resulting in actual harm to a resident, failed to provide timely toileting assistance leading to soiled conditions, and failed to ensure adequate nursing staff to meet resident needs.

Complaint #NJ00171288 was substantiated with findings of Immediate Jeopardy related to Resident #3's care and staffing deficiencies. The Immediate Jeopardy was identified on 2/15/24 and was past non-compliance at the time of the survey.

The facility failed to ensure Resident #3 received care according to a physician's order, resulting in Immediate Jeopardy due to a Certified Nursing Assistant providing care to the wrong resident. Additionally, the facility failed to meet required minimum staffing ratios for Certified Nurse Aides (CNAs) on multiple day shifts and one evening shift.

The complaint investigation found that Resident #3, who was NPO, was given a meal tray by CNA #1 without verification, leading to choking and death. Immediate Jeopardy was identified as past non-compliance from 12/4/23 to 12/11/23. The facility provided a Plan of Correction and staff education to address the issue.

The facility failed to ensure that Resident #3, who was ordered NPO, did not receive a meal tray and was served food by a CNA, leading to choking, emergency intervention, and death. The facility identified immediate jeopardy, suspended and terminated the CNA involved, and implemented corrective actions including staff education and new meal distribution policies. The facility was found to be in substantial compliance at the time of the survey.

Deficiencies were cited related to medication administration, respiratory care, infection prevention and control, staffing ratios, and fire safety compliance. Specific issues included failure to follow physician orders for medication and treatment, improper respiratory therapy administration, inadequate infection control practices including PPE use and hand hygiene, failure to maintain required staffing ratios, and missing fire safety information on evacuation diagrams.

The facility failed to ensure proper medication administration and documentation, adherence to physician orders, appropriate oxygen therapy administration, and infection control practices including hand hygiene and use of personal protective equipment. Deficiencies were observed in wound care procedures and respiratory care for multiple residents.

The facility was found to be noncompliant with several life safety code requirements including emergency lighting failure, stairwell doors not positively latching, inadequate fire sprinkler coverage, improper electrical receptacle protection, and lack of a remote emergency generator stop station.

The facility failed to accurately follow physician orders for medication administration, timely obtain controlled medications, properly account for fluid volume in a resident on fluid restriction, and accurately document administration of controlled pain medication. Additionally, the facility failed to ensure appropriate management and labeling of enteral feeding formula for a resident with a feeding tube.