The aide was caring for Resident #30 when federal inspectors arrived at Complete Care at Brick in May. When she pulled back the bed linens, she found three briefs on the resident. Only the innermost brief was wet, but the absorbent pads beneath the resident were soaked with urine.
"The resident was not properly cared for or changed every two hours," the aide explained to inspectors. She added that multiple briefs and pads "could lead to skin breakdown."
Complete Care at Brick violated New Jersey's minimum staffing requirements on 29 of 35 shifts reviewed by federal inspectors during a June inspection. The facility fell short of required certified nursing aide ratios for residents during multiple periods spanning September 2023 through May 2024.
New Jersey law requires one certified nursing aide for every eight residents during day shifts. The facility had eight aides for 93 residents on September 10, 2023, when it needed at least 12. On January 6, 2024, seven aides covered 92 residents who required 11.
During the two weeks around Christmas and New Year's, the facility failed to meet staffing requirements every single day. On Christmas Day, six aides cared for 87 residents.
The staffing coordinator told inspectors the facility "did its best to follow the regulation." The director of nursing said they "attempted to follow the CNA staffing guidelines" and "tried its best to recover from call outs."
But the consequences reached residents directly.
Resident #45 missed scheduled showers at least once monthly due to staffing shortages, according to inspection records. The resident told inspectors they didn't receive their Friday shower on May 10 "because of low staffing they did not offer."
Shower logs showed blanks on multiple Fridays throughout early 2024. On the evening of May 10, the unit had 43 residents but only two certified nursing aides after one left the building. The remaining aides each had more than 20 residents, with one responsible for 22 people including 10 scheduled for showers.
The practice of multiple briefing appeared systematic. The same aide who explained triple-briefing Resident #30 said another day-shift aide had instructed her to "double brief" other residents. She had already changed Residents #9 and #24 with two briefs each that morning.
When inspectors accompanied the unit manager to check residents, they found strong urine odors and multiple soiled briefs. The unit manager stated "This should not be" and "staff were not allowed to double brief because it could cause skin breakdown."
Resident #23 told inspectors they had been changed "a couple of hours ago," but wore two briefs with the inner one soiled. Resident #12 said they were last changed at 5:00 AM and wouldn't be changed again until 10:30 AM.
The director of nursing called double or triple briefing "never acceptable" and "poor practice." She said if residents were on diuretics, "the resident needed to be changed more frequently, not double briefed."
The facility administrator said if multiple briefing was discovered, "a severe education was done."
Multiple violations extended beyond staffing. Nurses left controlled substances unsecured during medication rounds. One nurse left a bottle of stool softener on top of an unlocked medication cart in the hallway. Another administered medications while leaving the cart unlocked outside a resident's room.
Narcotic count logs were missing nursing signatures on multiple shifts. One nurse failed to document dispensing anxiety medication to a resident, signing it out in the electronic record but not in the required narcotic log.
The facility kept a resident on antipsychotic medication for nearly a year without attempting dose reduction or documenting behaviors that would justify continued use. Monthly reviews from June 2023 through April 2024 showed no episodes of the "babbling and yelling" behaviors the medication was prescribed to treat.
Medical records contained numerous gaps. Nurses failed to document administering medications on multiple dates for three residents, leaving blank spaces in medication administration records. Treatment records for pressure ulcer care were incomplete, with missing signatures indicating wound treatments weren't documented as completed.
Food safety violations included a can opener covered with sticky brown particles, uncovered onions stored next to a trash can, and an opened box of bacon without a date label. Three 25-pound containers of beef base had debris covering the lids.
The facility also failed to maintain infection control protocols. Staff entered rooms of residents on contact isolation without required gowns and gloves. A urinary catheter drainage bag was observed resting on the floor, creating infection risk.
During an October 2023 influenza outbreak, the facility failed to test symptomatic residents for flu despite federal guidelines requiring testing. Five residents were hospitalized and tested positive for influenza A at hospitals, but records showed no evidence they were tested at the facility when symptoms first appeared.
Quality assurance meetings lacked required participants. The infection preventionist missed the April 2024 meeting, and the director of nursing was absent from meetings in July 2023 and January 2024.
The volunteer ombudsman reported concerns about unmet resident needs during visits, including the missed shower and a recent fall where a resident said they used their call bell but "no one came to assistance." The resident was "trying to get off the commode because they were sitting so long."
Resident #9 fell after waiting extended periods for help. "The facility was very short staffed and residents had to wait a long time for assistance," the resident told inspectors.
Federal inspectors documented ten resident falls in December 2023 alone across all shifts. On December 18, one aide was responsible for 16 residents when a fall occurred during the evening shift.
The facility's own policies prohibited the practices inspectors observed. An undated staff training document stated "Double diapering is not allowed" and "can potentially cause skin impairment." The policy required residents be "rounded and checked on every 2 hours or as needed."
Complete Care at Brick received citations for insufficient staffing, medication security failures, incomplete medical records, food safety violations, and infection control breakdowns. The facility serves approximately 80-95 residents according to inspection records.
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.
