Complete Care at Brick violated New Jersey's minimum staffing requirements for months, providing as few as six certified nursing assistants for 93 residents on day shifts when state law required at least 12, according to a federal inspection completed June 6, 2024.
The violations spanned three separate time periods. During a week in September 2023, the facility failed to meet staffing requirements on six of seven day shifts. Over the holidays from December 24, 2023 through January 6, 2024, the facility was understaffed on all 14 day shifts. In the two weeks before the federal inspection, the facility violated staffing laws on nine of 14 day shifts.
On January 4, 2024, the facility provided just seven CNAs for 94 residents, when 12 were required by law.
During the inspection, a certified nursing assistant explained the double briefing practice to investigators. CNA #1 stated that when she last worked at the facility, "they were very short staffed and there were only two aides for the whole floor." She said "another aide on the day shift told me to double brief, so I did."
Inspectors observed the consequences firsthand. When CNA #1 changed Resident #23, who said he had been changed "a couple of hours ago," they found a second soiled brief beneath the outer one. The aide explained that residents wore multiple briefs "either the resident was a heavy wetter or they were short staffed."
Resident #30 wore three briefs. CNA #1 found that only the innermost brief was wet, but the padding directly beneath the resident was "soaked through with urine." When asked how the outer briefs could be dry while the padding was soaked, CNA #1 stated, "The resident was not properly cared for or changed every two hours."
The Licensed Practical Nurse Unit Manager accompanied inspectors to Resident #30's room and immediately smelled urine. When she saw the multiple briefs, she said, "This should not be. The resident was not properly changed." She explained that "staff were not allowed to double brief because it could cause skin breakdown."
Resident #12 told inspectors he was last changed at 5:00 AM and "was not normally changed again until 10:30 AM." He wore two different-sized briefs, and CNA #1 found he had soaked through the inner one.
The Director of Nursing, who started in October 2023, called the practice unacceptable. "Double or triple briefing was never acceptable for a number of reasons such as dignity #1," she said. "There were no reasons to double brief. If the resident was on a diuretic then the resident needed to be changed more frequently, not double briefed."
The understaffing created additional problems beyond incontinence care. Resident #45 missed scheduled showers at least once monthly due to staffing shortages, inspectors found. The facility's shower log showed blanks for the resident's scheduled Friday showers on February 23, March 29, April 5, April 12, May 3, and May 10, 2024.
On May 10, one CNA left the building during the evening shift, leaving two aides to care for 43 residents. One aide had 22 residents, including 10 scheduled for showers that day.
Resident #45 told inspectors, "because of low staffing they did not offer" the scheduled shower, though acknowledged the staff "also did not ask." The resident said this happened "at least once a month."
The understaffing coincided with increased falls. In December 2023 alone, 10 residents fell across all shifts. On December 18, the evening shift had three CNAs for 49 residents, with the aide assigned to one fallen resident caring for 16 people. On December 23, the night shift had three CNAs for 40 residents, with one aide responsible for 16 residents when another fall occurred.
Resident #9 described waiting so long on a portable toilet that he tried to get up himself and fell. "They used the call bell, but no one came to assistance," the resident said, explaining "the facility was very short staffed and residents had to wait a long time for assistance."
The facility also failed to properly document medication administration and wound treatments for three residents, leaving blank spaces in medical records that nurses said indicated medications and treatments were not provided.
During a flu outbreak in October 2023, the facility failed to test five residents for influenza despite CDC guidelines requiring testing for any resident with respiratory symptoms during flu season. All five residents were hospitalized and tested positive for influenza at the hospital.
The Licensed Nursing Home Administrator confirmed that the facility was in a flu outbreak but could not say when testing started at the facility. The Director of Nursing acknowledged that residents with respiratory symptoms should have been tested for both COVID-19 and flu, but confirmed the five residents "were not tested at the facility but at the hospital."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Brick LLC from 2024-06-06 including all violations, facility responses, and corrective action plans.