Inspection Reports for
Complete Care At St Vincents Llc

The facility failed to ensure a physician's order was present for oxygen administration to Resident #189 and failed to accurately document medication administration per physician's orders for Resident #35. These deficiencies were identified through review of electronic medical records, progress notes, and interviews with staff.

The facility was found deficient in ensuring physician orders for oxygen administration and accurate medication documentation for residents. Additionally, medications were not stored or labeled properly, with undated opened medication packages and improper storage conditions observed in multiple medication carts.

Complaint numbers NJ 163099, 164140, 164735, 164747, 167673, 168219, 165875 were investigated. The facility was found deficient in maintaining minimum direct care staffing ratios on 23 of 28 day shifts reviewed, with specific CNA shortages documented for multiple dates between 08/27/2023 and 01/06/2024.

Deficiencies were cited related to failure to ensure medication orders and documentation were accurate for residents, improper storage and labeling of medications in medication carts, and failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.

The complaint investigation was triggered by concerns about resident privacy violations, failure to complete required assessments, inadequate care planning, failure to provide appropriate wound and nephrostomy care, failure to initiate CPR for a full code resident, and failure to properly monitor dialysis access sites.

The facility was found deficient in multiple areas including failure to provide physical privacy for residents, incomplete and untimely comprehensive assessments, inadequate care plan development and updates, failure to initiate CPR for a full code resident resulting in immediate jeopardy, improper pressure ulcer care, improper nephrostomy care increasing infection risk, and failure to consistently assess dialysis vascular access sites before and after transport to dialysis.

The facility was found not in compliance with the state-mandated minimum direct care staff-to-resident ratios during multiple day shifts between August 22, 2021 and September 4, 2021, with census ranging from 118 to 120 residents. The facility acknowledged staffing shortages and described ongoing corrective actions including recruitment efforts, use of staffing agencies, and incentive programs.

The facility failed to consistently follow appropriate isolation precaution protocols for residents on TBP, including improper use of PPE such as failure to don gowns, gloves, and eye protection before entering isolation rooms or units, and improper disposal of PPE. Hand hygiene practices were also inadequate, with staff washing hands for less than the recommended duration and not performing hand hygiene at appropriate times. The facility provided in-services and implemented corrective actions including staff training, competency reviews, and audits to address these deficiencies.

The facility was found not in compliance with infection control regulations, including failure to provide disinfectant wipes and sanitize equipment used by visitors, improper hand hygiene by staff, improper use of PPE, and failure to sanitize the testing table between specimen collections. The facility had an ongoing COVID-19 outbreak with 8 residents testing positive.