Complete Care At Brick Llc
Complete Care at Brick LLC in BRICK, NJ — inspection on June 6, 2024.
Found 17 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
who stated that they were provided with clothing protectors if needed during meals.
(LPN/UM) who stated that she asked the CNA to provide Resident # 24 with a clothing protector.
She
that if the resident drooled, then he/she should have been provided with a clothing protector.
The LPN/UM then accompanied the surveyor to the area where the clothing protectors were stored.
The surveyor observed that the clothing protectors were located with the other clean linen, that all staff had access to.
The LPN/UM stated that it was a dignity issue not to apply the appropriate clothing protector and that if the supplies were available then it should have been provided to the resident.
On 05/17/24 at 11:03 AM, the surveyor interviewed the Director of Nursing (DON) who stated if any resident had the potential to drool, then a clothing protector should be provided to the resident to protect the resident's clothing.
She stated that it would not be appropriate to drape a shower blanket around a resident's neck.
She stated that was a dignity issue for the resident.
There was no documentation on Resident #24's Care Plan that indicated it was Resident #24's preference to drape a shower blanket around his/her neck to protect his/her clothing from drool.
The facility policy titled; Quality of Life-Dignity dated 01/2024 indicated that each resident shall be cared for in a manner that promotes dignity and enhances quality of life, dignity, respect, and individuality.
Treated with dignity meant that the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth.
NJAC 8:39-4.1(a)12
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
they occurred.
She stated that if a resident was started on an antibiotic, then the family would be
physician ordered anything.
The LPN/UM stated that she would notify the resident's representative in real time of any change in condition.
She stated if something occurred during the late hours/early morning, the nurses should not wait until the afternoon or the next day to notify the family.
The LPN/UM stated that it was important to keep the family aware of any significant changes that occurred with the resident.
On 05/21/24 at 10:29 AM, the surveyor and the DON reviewed the PN in the electronic medical record (EMR) which revealed the resident's representative was not notified of the change in condition until 10/15/23 at 3 PM.
The DON acknowledged the family should have been notified on 10/14/23 or 10/15/23 in the morning, and not on 10/15/23 in the afternoon.
A review of the facility's Notification policy, updated 1/2024, included, 3.
The Nurse/Supervisor/Charge Nurse will notify the resident's family or representative when: 2.
There is a significant change in the resident's physical, mental, or psychosocial status. 6.
The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
NJAC 8:39-13.1(c)
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The surveyor also observed a pair of inside-out disposable gloves on the floor.
On 05/21/2024 at 08:42 AM, while outside of the same room, the surveyor observed the closed-lid garbage receptacle overflowing with yellow, disposable, protective gowns.
The surveyor also observed a disposable glove and a piece of paper-like product on the floor near Resident #57's bed.
On 05/21/2024 at 09:33 AM, during an interview with the surveyor, a family member confirmed that the trash receptacle was emptied by the family at least one time a day.
On 05/21/2024 at 11:20 AM, during an interview the surveyor, the Environmental Services Supervisor (ESS) stated that trash bags were removed daily and as needed from resident rooms.
Secondly, he confirmed that housekeeping was responsible for removing them during their shift.
Thirdly, the ESS confirmed that soiled briefs should not be placed in resident garbage cans and that the trash receptacles should have bag-liners. At that time, the surveyor showed the ESS a photo of the trash receptacle with the soiled brief and the ESS confirmed that it was not okay.
Lastly, after viewing the photo of the overflowing closed-top trash receptacle, the ESS confirmed that it was not okay.
On the same date at 12:43 PM, during an interview with the surveyor, the [NAME] President of Clinical Services replied, No when the surveyor asked if soiled incontinence briefs should be placed in a resident's trash can, especially without a bag liner.
A review of the undated facility-provided policy titled, Routine Cleaning and Disinfection revealed under, Policy that, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.
NJAC 8:39-31.4 (a)
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communication and communication tablet was implement on 08/28/23, however, the program must
the resident was only screened by ST for dysphasia on 03/04/24 for dysphasia, not cognition or
On 05/21/24 at 11:04 AM, the surveyor interviewed the LPN/UM who stated that she could not provide the surveyor with any documentation that Resident #24 participated in a ST maintenance program 1x/week or that the resident had a communication tablet.
On 05/22/24 at 09:35 AM, the DON stated that the CP should have been updated quarterly to reflect the accurate care the resident was receiving.
The DON confirmed that the CP was not an accurate reflection of the communication needs that the resident was receiving.
The DOR provided the surveyor with a ST evaluation dated 05/21/24, after surveyor inquiry.
The facility policy titled; Communication dated 01/2024 indicated that the facility was to provide necessary supportive services for adaptive communication to help individuals with language skills to express themselves.
The policy also indicated that the facility would have knowledge of resident specific communication methods and interventions such as use of communication devices i.e. (communication apps on tablets).
The facility policy titled; Care Plans, Comprehensive Person-Centered indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.
The policy indicated that areas of concern were identified during the resident assessment and would be evaluated before interventions were added to the care plan.
The policy also indicated that the resident's care plan would be updated and revised as information about residents and the residents' condition changed.
The policy indicated that care plans were updated at least quarterly.
NJAC 8:37-27.1 (a)
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the following:
their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .elimination (toileting); NJAC 8:39-27.1(a), 27.2(h)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
During an interview with the surveyor on 05/21/24 at 9:50 AM, the Licensed Practical Nurse (LPN) stated that if a resident had a new pressure ulcer, the nurse would notify the supervisor and complete an incident report and obtain statements from the primary nurse and CNAs.
The LPN further stated that it was important for the facility to investigate facility acquired pressure ulcers to determine if the wound was preventable or unavoidable.
During an interview with the surveyor on 05/21/24 at 10:04 AM, the LPN/UM stated if a resident had a new pressure ulcer, the nurse would complete an incident report and obtain statements from the nurses and CNAs going back 48 hours.
The LPN/UM further stated that it was important for the facility to investigate facility acquired pressure ulcers to determine the cause and to develop interventions to promote wound healing or prevent further pressure ulcer development.
During an interview with the surveyor on 05/21/24 at 10:16 AM, the Director of Nursing (DON) stated if a resident had a new pressure ulcer, the nurse would complete an incident report and obtain statements from the CNAs.
The DON further stated that completed incident reports are given to the DON and that it was important to investigate facility acquired pressure ulcers to determine how the wound was obtained and implement new interventions.
During an interview with the surveyor on 05/21/24 at 10:50 AM, the Licensed Nursing Home Administrator verified that the facility did not have any incident reports for Resident #131.
During a follow-up interview with the surveyor on 05/21/24 at 10:56 AM, the surveyor informed the DON of the missing incident report for Resident #131.
The DON stated that when the wound was discovered, the nurse should have completed an incident report for the facility acquired pressure ulcer.
Review of the facility's Accidents and Incidents - Investigating and Reporting policy, updated 01/2024, included, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident, and, The following data, as applicable, shall be included on the Report of Incident/Accident form: the nature of the injury/illness (e.g. bruise, fall, nausea, etc.).
NJAC 8:39-27.1(a)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
Clinical Services (VPCS) replied, Daily when the surveyor asked when should the syringe be replaced.
Statement that, Adequate nutritional support through enteral feeding will be provided to residents as ordered.
NJAC 8:39-27.1
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Review of the facility policy, Activities of Daily Living (ADLs), Supporting (Updated 01/2023) revealed the following: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .elimination (toileting) A review of the facility's the policy, Staffing, update, did 1/2024.
The policy statement indicated that the facility provides sufficient members of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the Facility Assessment.
The facility Assessment Tool dated 08/18/2017 B.) Staffing RNs, LPNs, CNAs, PTs reflected the We provide adequate staff to meet it's resident needs, preferences and routines.
This includes services of a registered nurse for a least eight (8) consecutive hours a day, 7 days a week, a designated licensed nurse to serve as a charge nurse on each tour of duty and adequate staffing on each shift to ensure that our residents' needs are met by registered and licensed nursing staff, certified/state tested assistants, and other support services that include, but not limited to, dietary, activities/recreational, social, therapy, and environmental services.
The facility tries to maintain and meet the state required minimum ratios.
We listen to reviews and provide adequate staffing based on census, acuity, and diagnoses of out resident population commensurate to their needs.
NJAC 8:39-25.2 (a); 27.1(a)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
Review of the facility's Controlled Substance policy updated 3/2024 included but was not limited to: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. 4. If the count is correct, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance . 9.
Nursing staff must count controlled medications at the end of each shift.
The nurse coming on duty and the nurse going off duty must make the count together.
They must document and report any discrepancies to the Director of Nursing Services.
NJAC 8:39-29.7(c)
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staff and practitioner would consider tapering as one approach to finding an optimal dose or
of the original target symptoms have resolved.
The policy reflected that within the first year after the
separate quarters (with at least one month between attempts), unless clinically contraindicated.
After the first year an attempt a least annually unless clinically contraindicated.
NJAC 8:39-27.1(a)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
Review of Resident #28's admission Minimum Data Set (MDS; a comprehensive assessment tool), dated [DATE], indicated the resident had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment.
Further review of the resident's medical record did not indicate the resident was assessed or care planned to self-administer or keep medications at their bedside.
Review of the facility's Administering Medication policy updated 1/2024 included but was not limited to: during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide.
Review of the facility's Storage of Medication policy updated 1/2024, included but was not limited to: compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.
Unlocked medication carts are not left unattended.
Review of the facility's Self-Administration of Medications policy updated 1/2024 included but was not limited to: any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party . the nursing staff routinely checks self-administered medication ad removes expired, discontinued, or recalled medications.
NJAC 8:39-29.4
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
The surveyor interviewed the Executive Chef (EC) at that time who stated that the can opener was usually cleaned daily, however, was not cleaned yet. 2.) The surveyor observed a large plastic bin of dry rice with scooper left inside the bin.
The EC stated that the scooper should not be left inside the bin and removed it. 3.) On a bottom shelf of a preparation table, the surveyor observed a large bin of loose onions, some of the onions were whole and were cut up some cut up, stored uncovered next to a trash can.
The EC stated that the onions were usually stored in the fridge and removed the onions. 4.) The surveyor observed on a shelf a bread toaster full of crumbs and debris. 5.) On the bottom shelf of the preparation table, the surveyor observed 3 (three) 25-pound (lb.) tubs of beef base with brown debris all over the top of the lids. 6.) The surveyor observed a 10 lb. box of bacon stored in the with no open date.
The plastic that covered the bacon was opened exposing the meat to air.
On 05/15/24 10:23 AM, the surveyor interviewed the Regional Food Service Director (RFSD) who accompanied the surveyor and observed the can opener, three 25-lbs tubs of beef base, and opened box of bacon and stated that the beef base lids should be free of debris, onions should not have been stored uncovered next to the trash can, and that bacon should have had an opening date.
The facility undated policy titled; Equipment Cleaning) indicated that the toaster should be cleansed with soap and water after each use.
The policy also indicated that the can opener shaft should be ran through the dish 3 compartment sink and the base of the can opener and holder should be cleansed with soap and water.
The facility undated policy titled; Receiving and Storage indicated that all foods follow the first in, first out method and are dated and labeled.
The facility undated policy titled; Dry Food Policy indicated that dry product were to be kept in the original packaging or in a tightly covered, clearly labeled containers.
NJAC 8:39-17.2(g)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
During an interview with the surveyor on 05/21/24 at 9:50 AM, the Licensed Practical Nurse (LPN)
there was a blank on the TAR, it was considered not done.
The LPN further stated that it was important for nurses to document on the TAR so that staff would know the resident was taken care of and the treatment was completed as ordered.
During an interview with the surveyor on 05/21/24 at 10:04 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that nurses sign off treatments in the TAR when the treatment was completed and that a blank on the TAR indicated that the nurse did not document the treatment.
The LPN/UM further stated that it was important for nurses to document on the TAR to show that the treatment was completed.
During an interview with the surveyor on 05/21/24 at 10:16 AM, the Director of Nursing (DON) stated that nurses sign off treatments in the TAR when the treatment was completed and that a blank on the TAR would look like the treatment wasn't completed.
The DON further stated that it was important for nurses to document on the TAR to assure the treatment was complete.
During a follow-up interview with the surveyor on 05/21/24 at 10:56 AM, the surveyor informed the DON of the blanks on the TARs for Resident #131.
The DON stated the nurses should have documenting on the TAR whether the treatment was completed or not.
Review of the facility's Charting and Documentation policy, updated 01/2024, included, The following information is to be documented in the resident medical record: .
Treatments or services provided, and, Documentation in the medical record will be objective, complete, and accurate.
NJAC 8:39-35.2 (d)
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The surveyor presented the 04/18/2024 sign in sheet to the IP who confirmed that she did not sign the sign in sheet as she did not attend the meeting.
On 05/21/2024 at 11:29 AM, the surveyor interviewed the Director of Nursing (DON) who stated, I did not attend the QAPI meeting on 01/22/2024 because I had to leave early that day.
On 05/21/2024 at 12:09 PM, a review of the facility policy and procedure for Quality Assurance and Performance Improvement (QAPI) Program, updated 11/2022 revealed the following under Authority section: 3.
The administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.
On 05/22/2024 at 12:35 PM, a review of the facility policy and procedure for Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, updated 11/2022 revealed the following under Policy Interpretation and Implementation: 6.
The following individuals serve on the committee: a.
Administrator, or a designee who is in a leadership role; b.
Director of Nursing Services; c.
Medical Director; d.
Infection Preventionist.
NJAC 8:39-33.1(b)
flu, and that the residents were only offered Tamiflu.
The LPN/UM revealed she was unsure if the
they would test the residents.
She further stated that if the resident exhibited respiratory signs and symptoms then they would test for covid, flu, and RSV. At that time, the DON confirmed the facility did test the residents for covid but not for flu during the influenza outbreak.
The DON stated based on the resident exhibiting signs and symptoms she would expect the residents to been tested for both covid and the flu.
She stated the 5 residents were not tested at the facility but at the hospital.
The DON concluded if the facility was in an outbreak, she would expect all residents to be tested.
On 05/22/24 at 09:41 AM, the LNHA stated in the presence of the DON, the Infection Preventionist (IP), the Regional Nurse and the survey team that during the flu outbreak they provided testing and Tamiflu. He stated that the guidance the previous IP and DON received was to provide Tamiflu, the influenza vaccine and to track the symptoms of residents.
A review of the email provided from the local DOH guidance dated 10/16/23, included the CDC Interim guidance for Influenza Outbreak and the NJDOH [New Jersey Department of Health] also recommended that residents who become symptomatic in the affected unit should be tested and a respiratory panel must be obtained.
Tamiflu must be offered to all staff on that unit and all residents.
Further guidance to review the influenza management and testing guidance on the CDC.
A review of the facility's Influenza, Prevention and Control of Seasonal policy revised 1/2019, included, Surveillance 1.
The Infection Preventionist has established procedures for monitoring and reporting influenza activity in the facility.
A review of the facility's Outbreak of Communicable Diseases policy reviewed 3/2024, included, 1. An outbreak of most communicable diseases can be defined as one of the following: a. one case of an infection that is highly communicable. c.
Occurrence of three (3) or more cases of the same infection over a specific period of time and in a defined area. 4. An outbreak of influenza is defined as anything exceeding the endemic rat, or a single case if unusual for the facility. A single case of influenza is reportable to the Department of Health.
NJAC 8:39-19.4 (m)(n), 27.1 (a)
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Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
The surveyor asked if any other residents that she had already changed wore double briefs this morning. CNA #1 stated, yes, Resident #9 and Resident #24.
The surveyor asked CNA #1 if she placed two briefs on Resident #9 and Resident #24 when she changed them and she stated, Another aide on the day shift told me to double brief, so I did. CNA #1 stated that when she last worked at the facility, date unknown, she observed residents that wore two briefs. CNA #1 stated on that date, they were very short staffed and there were only two aides for the whole floor.
315342
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315342 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
The surveyor asked if any other residents that she had already changed wore double briefs this morning. CNA #1 stated, yes, [Resident #9] and [Resident #24].
The surveyor asked CNA #1 if she placed two briefs on Resident #9 and Resident #24 when she changed them and she stated, Another aide on the day shift told me to double brief, so I did. CNA #1 further stated that when she last worked at the facility, date unknown, she observed residents that wore two briefs. CNA #1 stated on that date, they were very short staffed and there were only two aides for the whole floor.
Review of Resident #23's Admission Record (an admission summary) revealed that the resident was admitted with diagnoses which included, but were not limited to, retention of urine, type 2 diabetes mellitus without complications (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and acquired absence of left leg below knee.
Review of Resident #23's Quarterly Minimum Data Set (MDS, an assessment tool) revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact.
Further review of the MDS revealed that the resident was always incontinent of both bowel and bladder.
315342
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315342 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Brick LLC 415 Jack Martin Blvd Brick, NJ 08724
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.