Complete Care At Clark Llc

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Complaint #2636077Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement a comprehensive person-centered care plan (CP) that included two-hour checks for assistance with toileting.

The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for Care Plans.On 10/23/25 at 10:40 AM, the surveyor interviewed Resident #1 in their room. Resident #1 revealed the facility staff has not been checking on them every two hours as per their care plan.

Resident further revealed there was a sign in sheet that confirms the checks were not being completed.

Surveyor reviewed the daily sign in sheets from 10/13/25 through 10/23/25 which confirmed multiple missing checks on Resident #1. A review of Resident #158's Face sheet (FS) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (a chronic disease that is characterized by high levels of sugar in the blood), acute kidney failure (a rapid fall in the rate of glomerular filtration, which effects the kidneys) and acute respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia).A review of the admission MDS, (an assessment tool used to facilitate care management) dated 9/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicates the resident's cognition was intact.

The MDS also revealed the resident was frequently incontinent of urine. A review Resident #1's care plan (CP) with a start date of 9/11/25 and a last reviewed date of 10/8/25, revealed a care plan intervention, to provide two hour checks on the resident for assistance with toileting.On 10/27/25 at 9:25 AM, the surveyor conducted an interview with the Certified Nursing Assistant (CNA#1), who is the primary CNA for Resident #1 during the 7AM to 3PM shift.

The CNA revealed the resident was on two-hour checks to assess if the resident needed to use the restroom and that the daily sheet needs to be filled out when the check was completed.

The CNA further stated if there were blanks on the daily sheet, it is unknown if a CNA performed the two hour check on the resident.On 10/27/25 at 9:45 AM, the surveyor conducted an interview with the Director of Nursing (DON), who revealed residents who were on hourly or two-hour checks need to have their sign in sheets completed by their CNA.

The DON further stated if there was a blank section of the sign in sheet, they could not confirm if the resident had been seen per their care plan. On 10/27/25 at 10:41 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 10/2022.

Under the policy interpretation and implementation section it revealed, 4.

Each resident will .g. receive the services and/or items included in the plan of care.On 10/27/25 at 11:30 AM, the surveyor met with the LNHA and DON to review facility concerns and were made aware of the surveyor findings.

The DON stated corrective actions will begin immediately.

On 10/27/25 at 12:15 PM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff. NJAC 8:39-11.2 (e)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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