Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Brick Llc during CMS and state inspections, most recent first.
A CNA was observed standing while feeding a resident with severe cognitive impairment, a chopped diet, and swallowing concerns. The resident's care plan and MAR note called for meal assistance, distant supervision, safe swallow strategies, and upright positioning during meals, and the UM and RRD stated staff should not stand while feeding because it is a dignity and safety issue.
A resident with a living will and intact cognition had DNR/DNI documented in the care plan, DNR/DNI protocol form, and progress note, but the EMR still showed a Full Code order along with the DNR/DNI order. An LPN, DON, Administrator, and palliative NP all acknowledged the conflicting code status entries and that the old order had not been discontinued when the resident requested DNR/DNI.
A resident re-admitted with dependence on renal dialysis had a physician order for dialysis and was receiving dialysis, but the baseline care plan incorrectly indicated no dialysis need. The resident reported the dialysis catheter had not been cleaned or cared for since the last treatment, and the catheter dressing was observed hanging with the insertion site exposed. The DON confirmed dialysis was omitted from the baseline care plan, despite policy requiring dialysis needs to be included within 48 hours of admission.
The facility failed to develop comprehensive care plans for two residents. One resident had dialysis and a dialysis catheter, but the care plan did not address either, even though the resident was cognitively intact and the catheter dressing was observed hanging with the insertion site exposed. Another resident had orthopedic aftercare and out-patient PT/OT orders, but no therapy or rehab care plan was found in the EMR; the DON confirmed no therapy care plan had been entered because the resident was considered respite.
Failure to hold regular care plan conferences and include residents in care planning. Two cognitively intact residents had no documented evidence of scheduled care plan meetings after MDS assessments, and both stated they had not been invited to or attended care conferences. One resident had cancer, HF, and DM; the other had iron deficiency anemia, HTN, and anxiety disorder. The facility policy required resident and/or representative participation in regularly scheduled care plan conferences.
A resident’s dialysis catheter was left without proper care after dialysis stopped, with the dressing hanging and the insertion site exposed, and no order for catheter care was in place at the time. In a separate event, another resident’s wound vac was found set at 150 mmHg continuous suction instead of the ordered 120 mmHg. The DON and RN verified the issues, and the facility policies required catheter site assessment and NPWT settings to match physician orders.
A resident with severe cognitive impairment, dementia, and mobility limitations had bilateral side rails ordered for bed mobility and a perimeter mattress added as a fall intervention. Surveyors observed a 4.5-inch gap between the right side rail and the mattress, which was verified by the UM and MD; the MD said the hospice bed had not been touched during routine checks, and no documentation showed the bed was checked after the new mattress was placed. A hospice aide noted the gap earlier that morning and stated a resident could get caught in it.
Failure to provide an ordered packed breakfast for dialysis occurred for a resident with DM, CKD, and dependence on renal dialysis. The physician ordered a packed breakfast for dialysis days, but MAR review showed multiple missed breakfasts with no documented reason, and the resident reported not receiving the meal and being starving when he returned home. Dietary staff said the meal was prepared for placement in the pantry refrigerator, but observation found no packed breakfast available, and the RD stated the ordered breakfast was expected on each dialysis day.
Failure to reassess bed rail entrapment risk after a new mattress was added. A resident with dementia, severe cognitive impairment, and mobility limitations had side rail safety care plan focuses, but the most recent side rail assessment did not address mattress fit, gaps, or entrapment risk. After a perimeter mattress was added for fall prevention, no documented bed, mattress, and siderail safety reassessment was found, and staff observed a 4.5-inch gap between the siderail and mattress.
A resident with chronic myeloid leukemia and cancer received an incorrect dose of Gleevec (Imatinib Mesylate) when an RN administered one 400-mg tablet instead of the ordered 800 mg dose of two 400-mg tablets. The RN confirmed the MAR and resident record ordered 800 mg, and the DON stated medications should be given as ordered using the six rights of medication administration; Imatinib was identified as a significant chemotherapy medication.
A survey revealed that a facility failed to provide timely incontinence care to residents, with instances of double or triple briefing noted. One resident was found wearing two briefs, with the inner brief soiled, while another was wearing three briefs, with the inner brief wet and the chux beneath soaked through. A third resident was found wearing two briefs, with the inner brief soaked through. Staff interviews indicated that double briefing was a common practice due to staffing shortages. The DON and LNHA acknowledged the deficiency and stated that double briefing was not acceptable.
A facility was found deficient in maintaining required staffing ratios, leading to inadequate care. Residents experienced insufficient incontinence care, missed showers, and increased falls due to staffing shortages. Instances of double and triple briefing were observed, which can cause skin breakdown. The facility's Volunteer Ombudsman and residents reported unmet needs due to low staffing levels.
A resident with depression and dementia was prescribed Seroquel without documented behaviors justifying its use, and the facility failed to attempt a gradual dose reduction (GDR) or obtain a psychiatric consult. Despite facility policies requiring GDR attempts, there was no documentation of such efforts or clinical contraindications. Interviews revealed a lack of communication and documentation regarding the resident's medication management.
The facility failed to properly label, date, and store potentially hazardous foods and maintain kitchen equipment. Observations included a dirty can opener, a scooper left in a rice bin, uncovered onions near a trash can, a crumb-filled toaster, debris on beef base lids, and an undated, exposed box of bacon. These findings indicate non-compliance with the facility's policies on equipment cleaning and food storage.
The facility failed to maintain complete medical records for three residents, resulting in missing documentation of medication and treatment administration. A resident with multiple diagnoses had several medications not signed off as administered, while another resident at risk for pressure ulcers had missing documentation for wound care treatments. A third resident with a worsening pressure ulcer also had incomplete treatment records. Interviews with staff confirmed that blanks in records indicated non-compliance with treatment orders.
The facility failed to follow infection control protocols, including not using PPE for a resident on contact isolation, lacking a physician's order for contact precautions for a resident with a sacral wound, and not maintaining a urinary catheter bag off the floor. Additionally, during an influenza outbreak, the facility did not test residents for influenza as per CDC guidelines, despite symptoms and hospitalizations.
A resident with dementia and behavioral disturbances was observed with a shower blanket used as a clothing protector instead of a proper one, compromising their dignity. Staff interviews revealed that this practice was common despite the availability of appropriate protectors, and the facility's policy emphasized the importance of dignity.
A resident with acute respiratory failure, Alzheimer's, and COPD experienced a change in condition, including a fever and diminished lung sounds. Despite the facility's policy to notify families in real time, the resident's family was not informed until the following day. Interviews with the DON and LPN/UM confirmed the notification delay, which was identified as a deficiency.
The facility failed to maintain a clean environment by improperly disposing of soiled incontinence briefs and PPE. A resident's room had a soiled brief in a garbage can without a liner, and gloves were left on the floor. An overflowing garbage receptacle with protective gowns was also observed. The Environmental Services Supervisor confirmed these practices were not acceptable, and the facility's cleaning policy was not followed.
A resident with dementia and communication difficulties did not receive the communication support outlined in their Care Plan, such as a communication tablet and Speech Therapy. Staff interviews revealed a lack of awareness and implementation of these interventions, and the Care Plan was not updated to reflect the resident's current needs. The facility's policies on communication and care plans were not followed, resulting in a deficiency.
The facility failed to set an air mattress according to a resident's weight, contributing to the worsening of a pressure ulcer. Despite a physician's order, the mattress was not adjusted to the resident's current weight. Additionally, the facility did not investigate a new pressure ulcer for another resident, as required by policy. Staff interviews confirmed these lapses in following procedures.
A resident with severe protein-calorie malnutrition did not receive appropriate enteral feeding care. The feeding pump was observed running while disconnected, causing formula to drip on the floor. Additionally, dried formula residue was found on the feeding pump pole, and an irrigation syringe was not replaced within the required 24-hour period. The LPN and VPCS confirmed these practices were against facility policy.
The facility failed to ensure proper accountability of narcotic shift count logs on two medication carts, with missing nursing signatures for several shifts. An LPN confirmed the absence of required signatures, indicating a lack of reconciliation of controlled substances at shift changes. Additionally, an LPN administered alprazolam to a resident but did not sign it out on the narcotic inventory sheet, although it was recorded in the electronic MAR. The DON confirmed the necessity of real-time documentation and compliance with the facility's Controlled Substance policy.
The facility failed to secure medications properly during administration and allowed a resident to keep medications in their room without proper assessment or authorization. Two LPNs were observed leaving medication carts unlocked or medications unsecured, and a resident with moderate cognitive impairment had unauthorized medications in an unlockable drawer. Facility policies require medication carts to be locked and unauthorized bedside medications to be secured.
The facility failed to ensure required members attended quarterly QAPI meetings, with the Infection Preventionist absent from one meeting and the DON absent from two meetings, violating policy and regulatory requirements.
Standing While Feeding Resident During Meal
Penalty
Summary
The facility failed to ensure dignity during dining for one resident who had non-Alzheimer's dementia, gastritis without bleeding, depression, a BIMS score of 5 out of 15 indicating severe cognitive impairment, and a mechanically altered/chopped diet with thin liquids. The resident's care plan identified the need for limited assistance with eating, and a later care plan noted a swallowing problem with monitoring for signs and symptoms of dysphagia. The medication administration note also stated the resident required distant supervision at all meals to increase safety and to use safe swallow strategies, including upright positioning during meals. During a meal observation, a CNA was seen feeding the resident lunch while standing beside the resident's wheelchair. The CNA looked for a chair but stated there was no chair available and continued standing while feeding the resident. The Unit Manager stated the CNA should not have been standing and should have been at the same level as the resident, and the Regional Registered Dietitian confirmed CNAs should not stand when feeding the resident because it is a dignity and safety issue. The facility policy on promoting and maintaining resident dignity states residents are to be treated with respect and dignity in an environment that maintains or enhances quality of life.
Code Status Not Updated to Match Resident's DNR/DNI Orders
Penalty
Summary
The facility failed to ensure that the code status in the electronic medical record matched the code status ordered for one resident who was reviewed for advance directives and code status. The resident was admitted and later readmitted with diagnoses including a fracture of the left femur, had a care plan that identified the resident's advance directive as Do Not Resuscitate and No Intubation, and had a DNR/DNI protocol form signed by both the resident and the nurse practitioner. The resident's quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the EMR showed that Full Code remained ordered on one date, while DNR and DNI were ordered on a later date. A progress note documented that the palliative NP discussed medical decisions and the resident stated she had a living will, named her cousin as surrogate decision maker, and requested DNR/DNI. During interviews, the resident stated she wished to be DNR and did not want life-saving measures. An LPN stated the resident's code status appeared as DNR, DNI, Full Code in the EMR and that full code would be initiated until the status was clarified. The DON and Administrator stated that if both DNR and Full Code appeared in the EMR, CPR would be initiated until the code status could be clarified, and the DGPCMS stated the old code status order should have been discontinued when the new order was entered.
Baseline Care Plan Did Not Address Dialysis Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care related to dialysis within 48 hours of admission for one resident. The resident was re-admitted with diagnoses including dependence on renal dialysis and surgical aftercare following surgery on the circulatory system, and had a physician order for dialysis dated 08/22/25. The five-day MDS with an ARD of 08/29/25 indicated the resident received dialysis on admission and while a resident and had a BIMS score of 15 out of 15, showing the resident was cognitively intact. During an interview on 09/09/25, the resident stated he had a dialysis catheter that had not been cleaned or cared for since he last had dialysis, and the right chest dialysis catheter was observed with the dressing hanging from the catheter and the insertion site exposed. Review of the baseline care plan dated 08/22/25 showed that the item asking whether the resident required dialysis was marked No. During an interview on 09/12/25, the DON confirmed dialysis was not included on the baseline care plan and stated that dialysis should have been included. The facility policy required the baseline care plan to be developed within 48 hours of admission and to include special needs such as dialysis.
Failure to Include Dialysis, Catheter, and Out-Patient Therapy in Care Plans
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for out-patient therapy, dialysis, and/or a dialysis catheter for two residents reviewed. One resident was re-admitted with diagnoses including dependence on renal dialysis and surgical aftercare following surgery on the circulatory system. The resident’s MDS indicated dialysis was received on admission and while a resident, and the resident was cognitively intact with a BIMS score of 15 out of 15. During interview, the resident stated he had a dialysis catheter and had been on dialysis until 08/27/25. The resident’s right chest dialysis catheter was observed with the dressing hanging from the catheter and the insertion site exposed. Although there was an order for dialysis, the care plan did not indicate the resident was on dialysis or had a dialysis catheter. Another resident had diagnoses including hip fracture, orthopedic aftercare, and rhabdomyolysis, and had a BIMS score of 15 out of 15. The resident was not receiving in-house therapy, but records showed orthopedic consult and treatment orders, an OT eval and treat order, and outpatient orthopaedics notes with a PT plan of care for therapy three times a week for four weeks. The resident stated she received out-patient therapy due to managed care insurance limits and used transportation provided by insurance. The DOR stated the resident was receiving out-patient therapy locally, and the RSW stated the resident received therapy benefits under respite status. Review of the care plan revealed no care plan for therapy or rehabilitation services, and the DON confirmed there was no therapy care plan in the EMR because the resident was considered respite and a care plan for out-patient therapy was not thought to be required.
Failure to Hold Regular Care Plan Conferences and Include Residents
Penalty
Summary
The facility failed to ensure regularly scheduled care conferences were conducted and that residents were invited to participate in their care plan processes for two residents reviewed for care planning. One resident had an admission date of 04/30/22, a BIMS score of 15/15, and diagnoses of cancer, heart failure, and diabetes mellitus. The record showed a care plan meeting note dated 02/12/25 documenting attendance by the resident, a family member, SW, and UM, but the resident’s comprehensive MDS was submitted on 05/12/25 and a quarterly MDS was submitted on 08/15/25 with no documented evidence of care plan conferences after those assessments. When asked, the resident stated he had not been invited to or attended a care conference in a very long time. A second resident was admitted with diagnoses including iron deficiency anemia, hypertension, and anxiety disorder, and had a BIMS score of 15/15 on the annual MDS, indicating cognitive intactness. The EMR contained no documented evidence of care plan meetings for this resident, and the resident stated she did not recall being invited to or attending any care plan meetings since admission. The Regional Social Worker confirmed no documentation of care plan meetings had been found for this resident since admission and stated a care plan meeting had been scheduled for 09/15/25 at 2:00 PM. The facility policy stated residents and/or representatives are to be informed of and participate in care planning at regularly scheduled care plan conferences.
Dialysis Catheter Care Not Provided and Wound Vac Set Incorrectly
Penalty
Summary
The facility failed to provide care for a dialysis catheter for one resident after dialysis was discontinued. The resident was re-admitted with diagnoses including dependence on renal dialysis and surgical aftercare following surgery on the circulatory system. The resident’s MDS indicated dialysis was received on admission and while a resident, and the resident was cognitively intact with a BIMS score of 15 out of 15. During interview and observation, the resident stated the dialysis catheter had not been cared for since dialysis stopped, and the catheter dressing was observed hanging from the catheter with the insertion site exposed. Review of the resident’s physician orders showed no order for dialysis catheter care. The DON stated the resident no longer needed dialysis and that the physician was monitoring blood work for a couple of weeks. The DON was initially unable to provide information about catheter care, then later stated orders for catheter care were obtained and the site had been cleaned and dressed. The DON also stated the type of dressing needed was a sterile central line dressing change and that LPNs had been training in sterile dressing changes. The facility policy for central venous catheter care required routine assessment of the site and that the dressing be clean, dry, and intact, with immediate change if soiled, wet, or dislodged. The facility also failed to ensure correct wound vac settings for another resident. That resident was admitted with diagnoses including cutaneous abscess of the groin and disruption of an external surgical wound. The resident’s MDS indicated a wound infection, surgical wound care, and moderate cognitive impairment with a BIMS score of 12 out of 15. The care plan and physician orders specified a wound vac to the left groin with continuous suction at 120 mmHg. During observation, the wound vac was found set at 150 mmHg continuous suction, and RN1 verified the setting against the order before adjusting it to 120 mmHg. The facility policy for NPWT required therapy to be provided in accordance with physician orders, including the prescribed pressure setting.
Large Gap Between Side Rail and Mattress
Penalty
Summary
A deficiency was identified for failure to ensure a resident area was free from accident hazards and provided adequate supervision to prevent accidents when Resident 6 had a large gap between the right side rail and the mattress. Resident 6’s care plan included side rail safety focuses with goals for maintaining independence and mobility using side rails without injury. The resident’s significant change MDS documented degenerative dementia, upper and lower extremity impairments on one side, moderate assistance needed for rolling and sitting to standing, and a BIMS score of 3 out of 15, indicating severe cognitive impairment. A physician order dated 09/01/25 directed bilateral side rails for bed mobility. The resident’s fall assessment added a perimeter mattress as a fall prevention intervention. During observation, Resident 6 was lying in bed with the top two side rails up on both sides and a perimeter mattress in place. On 09/11/25, surveyors observed and measured a 4.5-inch gap between the right side rail and the mattress extending from the head of the bed toward the foot of the bed for about two feet. The Unit Manager verified the measurement, and the Maintenance Director confirmed the gap. The Maintenance Director stated safety checks had been completed on all beds on 01/25/25, but Resident 6’s bed was a hospice bed and he was not allowed to touch it. A side rail check dated 07/16/25 was provided, but there was no documentation showing the bed had been checked after the new mattress was placed. A Hospice Aide stated the gap had been noted earlier that morning and that a resident could get caught in it. The facility policy titled Proper Use of Bed Rails stated beds should be checked for the risk of entrapment between bedrails and mattresses.
Failure to Provide Ordered Packed Breakfast for Dialysis
Penalty
Summary
The facility failed to provide a packed breakfast for dialysis according to the physician order for one resident who was admitted with diagnoses including type II diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema, dependence on renal dialysis, and chronic kidney disease. The physician order dated 09/03/25 directed that the resident receive a packed breakfast to take to dialysis on Tuesdays, Thursdays, and Saturdays, and the care plan dated 09/05/25 directed the resident to eat 50% of meals and follow the ordered diet. Review of the MAR for 09/2025 showed no documented evidence that the resident received the packed breakfast on 09/04/25, 09/09/25, or 09/11/25, and no reason was listed for the missed breakfasts. The MAR noted on 09/06/25 that the packed breakfast was not provided due to diarrhea. During interview, the resident stated he did not receive the packed breakfast for dialysis on 09/11/25 and said he was starving when he returned home. The Dietary Manager stated dietary staff printed snack tickets each day for preparation and distribution to the first-floor pantry refrigerator, including the resident's packed breakfast for dialysis, but during observation the pantry refrigerator did not contain the previous day's packed breakfast or a packed breakfast for the next dialysis day, and the Dietary Manager confirmed it was not there. The Registered Dietician stated it was her expectation that the packed breakfast ordered by the physician be provided on each day of dialysis.
Failure to Reassess Bed Rail Entrapment Risk After New Mattress
Penalty
Summary
The facility failed to assess the entrapment risk of a new perimeter mattress used as a fall-prevention intervention for one resident. The resident was admitted with diagnoses including unspecified dementia, psychotic disturbance, mood disturbance and anxiety, muscle weakness, and delusional disorder. The resident’s care plan included side rail safety focuses, and a significant change MDS showed degenerative dementia, one-sided upper and lower extremity impairments, moderate assistance needed for rolling and standing, and a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s most recent side rail assessment did not address the mattress type and fit to the bed, gaps between the bed and siderails, or whether there was a threat of entrapment. A fall assessment later identified a new perimeter mattress intervention, but there was no documented evidence that the bed, mattress, and siderails were reassessed for accident hazards after the mattress was provided. During observation, a 4.5-inch gap was seen between the right siderail and the mattress, and both the Unit Manager and Maintenance Director confirmed the measurement. The Maintenance Director provided an earlier side rail check, but no documentation was provided showing the bed had been checked for safety after the new mattress was placed. The facility policy required assessment of hazards such as climbing over or through the rails and assessment of entrapment risk between bedrails and mattresses.
Incorrect Dose of Chemotherapy Medication Administered
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when one resident with chronic myeloid leukemia not having achieved remission received an incorrect dose of Gleevec (Imatinib Mesylate). The resident was admitted with a diagnosis that included cancer, and the September 2025 MAR showed an order for Gleevec 400 mg, two tablets by mouth one time a day, originating on 09/07/25. During a medication administration observation, an RN retrieved a medication card containing Imatinib 400-mg tablets, entered the resident's room, and administered only one 400-mg tablet before returning to the cart and documenting the dose as completed. In interview, the RN confirmed that only one 400-mg tablet had been given even though the MAR and resident record ordered 800 mg, and stated that two 400-mg tablets should have been administered. The DON stated medications should be administered as ordered by the physician following the six rights of medication administration, and identified Imatinib as a significant chemotherapy medication.
Inadequate Incontinence Care and Double Briefing
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed during a survey. Three residents on the Starlight Unit were found to be inadequately cared for, with instances of double or triple briefing noted. Resident #23 was found wearing two briefs, with the inner brief soiled but not soaked through to the outer brief. The resident was fully cognitively intact and had a history of incontinence and potential for skin breakdown. The care plan for Resident #23 included regular incontinence care and monitoring for skin integrity, which was not adhered to. Resident #30 was discovered wearing three briefs, with the inner brief wet and the chux beneath soaked through. The resident was cognitively intact and had a history of pressure ulcers and incontinence. The care plan emphasized frequent position changes and avoiding prolonged pressure on the sacrum, which was not followed. The LPN/UM confirmed the improper care and noted that double briefing was against protocol due to the risk of skin breakdown. Resident #12 was found wearing two briefs, with the inner brief soaked through. The resident was cognitively intact and had a history of urinary tract infection and sepsis. The care plan included regular incontinence care and monitoring for skin breakdown, which was not provided. Interviews with staff revealed that double briefing was a common practice, attributed to staffing shortages and an attempt to reduce the frequency of changes. The DON and LNHA acknowledged the deficiency and stated that double briefing was not acceptable practice.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility was found to be deficient in providing sufficient nursing staff on a 24-hour basis, as mandated by the State of New Jersey. The report highlights that the facility failed to maintain the required minimum direct care staff-to-resident ratios, which resulted in inadequate care for residents. Specifically, the facility did not have enough Certified Nurse Aides (CNAs) on multiple occasions, leading to insufficient incontinence care, missed scheduled showers, and an increase in resident falls. The staffing deficiencies were observed over several weeks, with the facility consistently failing to meet the required CNA-to-resident ratios during day shifts. The report details specific instances of inadequate care due to staffing shortages. For example, a CNA was observed providing incontinence care to a resident who was double briefed, which is against protocol and can lead to skin breakdown. The CNA admitted that double briefing was done due to being short-staffed. Another resident was found to be triple briefed, with the inner brief wet and the chux beneath soaked through, indicating that the resident was not changed regularly. These practices were confirmed by the Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON), who acknowledged that double or triple briefing was not acceptable and could lead to skin issues. Additionally, the report notes that residents did not receive their scheduled showers due to low staffing levels. One resident reported missing a scheduled shower because it was not offered, and the shower log confirmed multiple missed showers. The facility's Volunteer Ombudsman also raised concerns about staffing levels, noting that residents' needs were not being fully met. The report further documents several resident falls, with residents attributing the falls to long wait times for assistance due to staffing shortages. Despite the facility's attempts to schedule staffing according to guidelines, the consistent call-outs and insufficient coverage led to these deficiencies.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to provide a gradual dose reduction (GDR) of psychoactive medication for a resident who was not exhibiting targeted behaviors, and did not obtain a psychiatric consult for the use of a psychotropic medication. The resident, who was admitted with diagnoses including depression and unspecified dementia with behavioral disturbances, was observed to be taking Seroquel, an antipsychotic medication, without documented behaviors that would justify its continued use. The facility's records from June 2023 to April 2024 did not show any episodes of the behaviors for which the medication was prescribed, nor was there documentation of a GDR attempt or a psychiatric evaluation. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's medication management. The Director of Nursing (DON) admitted that the resident had not been seen by the facility psychiatrist and that the psychotropic medications were managed by the primary care physician. The Licensed Practical Nurse (LPN) and the Unit Manager confirmed that there was no documentation of behaviors or a rationale for not attempting a GDR. The facility's psychiatrist had recommended a GDR, but the Nurse Practitioner (NP) did not implement any changes, and the primary care physician was under the impression that the psychiatrist was managing the medication. The facility's policies on psychotropic medication use and tapering required GDR attempts unless clinically contraindicated, but these were not followed. The policies stated that within the first year of starting a psychotropic medication, a GDR should be attempted in two separate quarters, and annually thereafter. However, there was no documentation of such attempts or clinical contraindications for the resident in question, highlighting a significant oversight in medication management and compliance with regulatory requirements.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to properly label, date, and store potentially hazardous foods, as well as maintain kitchen equipment to prevent microbial growth. During an inspection, the surveyor observed several deficiencies in the kitchen. The can opener blade, shaft, and base were found to have sticky brown food particles, indicating it had not been cleaned as per the facility's policy. A large plastic bin of dry rice was found with a scooper left inside, which was against the standard practice. Additionally, a large bin of loose onions, some whole and some cut, were stored uncovered next to a trash can, which is not appropriate storage practice. Further observations included a bread toaster full of crumbs and debris, and three 25-pound tubs of beef base with brown debris on the lids. A 10-pound box of bacon was found without an open date, and the plastic covering was opened, exposing the meat to air. The facility's policies on equipment cleaning and food storage were not adhered to, as evidenced by these findings. The Regional Food Service Director acknowledged these issues during the surveyor's interview.
Incomplete Documentation of Medications and Treatments
Penalty
Summary
The facility failed to maintain complete medical records for three residents, as evidenced by missing documentation of medication and treatment administration. Resident #19, who was cognitively intact and had multiple diagnoses including end-stage renal disease and atrial fibrillation, had several medications not signed off as administered on specific dates in May 2024. These medications included atorvastatin, apixaban, colace, gabapentin, and others, which were left blank in the Medication Administration Record (MAR), indicating they were not given. Interviews with the LPN and DON confirmed that blanks in the MAR suggest the medications were not administered. Resident #131, who was at risk for pressure ulcers, had a deep tissue pressure ulcer on the right buttock. The Treatment Administration Record (TAR) for September and October 2023 showed missing documentation for wound care treatments on several dates. The care plan required treatments to be administered as ordered, and the facility's policy mandated documentation of treatments provided. Interviews with nursing staff and the DON confirmed that blanks in the TAR indicated treatments were not completed. Resident #182, admitted with a Stage III pressure ulcer, had a worsening condition to Stage IV. The TAR for April and May 2024 revealed missing documentation for sacral wound care treatments on multiple dates. The facility's policy required complete and accurate documentation of treatments, which was not adhered to in this case. Interviews with nursing staff and the DON reiterated the importance of documenting treatments to ensure they were completed, and the presence of blanks suggested non-compliance with treatment orders.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to transmission-based precautions (TBP) for infection control, as evidenced by multiple staff members not wearing personal protective equipment (PPE) when entering the room of a resident on contact isolation due to MRSA and VRE infections. Despite clear signage and available PPE, a CNA and a housekeeper entered the resident's room without donning the required gown and gloves. The CNA admitted to not reading the sign, while the housekeeper was unaware of the need for PPE unless performing direct patient care. The Infection Preventionist and Director of Nursing confirmed the importance of following TBP to prevent infection spread, yet staff failed to comply. Another deficiency involved the lack of a physician's order for contact precautions for a resident with a sacral wound infected with antibiotic-resistant bacteria. Although the resident's care plan indicated contact precautions, there was no corresponding physician's order. Staff interviews revealed that nurses should obtain such orders when placing residents on TBP, but this was not done, leading to inconsistencies in the implementation of precautions. Additionally, the facility did not maintain a resident's urinary catheter bag off the floor, as observed during the survey. The catheter bag was found in contact with the floor, contrary to the facility's policy, which requires the bag to be kept off the floor to prevent infection. Staff interviews confirmed the importance of this practice for infection control, yet it was not followed. Furthermore, during an influenza outbreak, the facility failed to test residents for influenza in accordance with CDC guidelines, despite several residents exhibiting symptoms and being sent to the hospital where they tested positive for influenza.
Failure to Provide Appropriate Clothing Protector
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident by not providing an appropriate clothing protector. Resident #24, who was admitted with diagnoses including depression and unspecified dementia with behavioral disturbances, was observed on two occasions with a shower blanket draped around their neck instead of a proper clothing protector. The resident, who was dependent on assistance for activities of daily living and had difficulty communicating, was seen drooling and mumbling, indicating a need for a clothing protector to maintain their dignity during meals. Interviews with staff revealed that the use of shower blankets, sheets, and towels as clothing protectors was a common practice since the new company took over, despite the availability of proper clothing protectors. The CNA and LPN both acknowledged the use of inappropriate items to protect the resident's clothing, and the LPN/UM confirmed that the supplies were accessible to all staff. The Director of Nursing also stated that using a shower blanket was not appropriate and recognized it as a dignity issue. The resident's care plan did not document any preference for using a shower blanket, and the facility's policy emphasized the importance of promoting dignity and self-worth for each resident.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for a resident who was admitted with diagnoses including acute respiratory failure with hypoxia, Alzheimer's Disease, and COPD. The resident's cognition was moderately impaired, and their care plan included an intervention to keep the family informed of changes in condition. On a specific date, the resident experienced a fever and diminished lung sounds, prompting the physician to order a urinalysis, urine culture, chest x-ray, and lab work. Despite these changes, there was no evidence that the resident's family was notified until the following day. Interviews with the Director of Nursing (DON) and the Licensed Practical Nurse/Unit Manager (LPN/UM) revealed that the facility's policy required families to be notified in real time of any change in condition. The DON acknowledged that the family should have been notified earlier, as per the facility's updated notification policy. The policy stated that the nurse or charge nurse must notify the resident's family or representative of significant changes in the resident's status and document this in the medical record. The failure to notify the family in a timely manner was identified as a deficiency by the surveyors.
Improper Disposal of Waste in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the improper disposal of soiled incontinence briefs and personal protective equipment. During a survey, a soiled incontinence brief was found in a garbage receptacle without a bag liner in a resident's room, and disposable gloves were left on the floor. Additionally, an overflowing closed-lid garbage receptacle with yellow disposable protective gowns was observed outside the same room. These observations were confirmed by the Environmental Services Supervisor, who acknowledged that the trash receptacles should have bag liners and that soiled briefs should not be placed in resident garbage cans. Interviews conducted during the survey revealed that the trash receptacle was being emptied by a family member at least once a day, indicating a lapse in the facility's housekeeping responsibilities. The Environmental Services Supervisor confirmed that housekeeping staff were responsible for removing trash bags daily and as needed. The facility's policy on routine cleaning and disinfection was reviewed, which stated the importance of maintaining a safe and sanitary environment to prevent infections. However, the observed practices did not align with this policy, leading to the identified deficiencies.
Failure to Update and Implement Communication Care Plan
Penalty
Summary
The facility failed to provide services according to a resident's communication needs as documented in the Care Plan (CP) and did not update the CP to accurately reflect these needs. The resident, who was admitted with diagnoses including depression and unspecified dementia with behavior disturbances, was observed to have difficulty communicating, with slurred and mumbled speech. Despite the CP indicating the use of a communication tablet and participation in a Speech Therapy (ST) maintenance program, these interventions were not being provided, and no communication devices were observed in the resident's room. Interviews with staff, including a Certified Nursing Assistant (CNA), Licensed Practical Nurses (LPNs), and the Licensed Practical Nurse Unit Manager (LPN/UM), revealed a lack of awareness and implementation of the communication interventions listed in the CP. The Speech Language Pathologist (ST) confirmed no involvement with the resident for communication needs, and the Director of Rehabilitation (DOR) indicated that the interventions were likely added by the Unit Manager without proper evaluation. The resident's Responsible Party also noted the absence of a communication tablet and suggested a need for evaluation by ST for alternative communication methods. The Director of Nursing (DON) acknowledged that the CP should have been updated quarterly to reflect the resident's current needs and confirmed that it was not an accurate reflection of the care being provided. The facility's policies on communication and care plans emphasized the need for accurate, updated CPs tailored to residents' needs, but these were not adhered to in this case, leading to the deficiency.
Failure to Properly Set Air Mattress and Investigate Pressure Ulcer
Penalty
Summary
The facility failed to ensure that an air mattress was accurately set according to a resident's weight, which was a contributing factor to the worsening of a pressure ulcer. Resident #182, who was admitted with a Stage III pressure ulcer and weighed 97 lbs, was observed multiple times with an air mattress set to 280 lbs. Despite a physician's order to monitor the air mattress for proper placement and functioning, the mattress was not adjusted to the resident's current weight of 85 lbs. Interviews with staff, including a CNA, LPN, and the Director of Nursing, confirmed that the responsibility for setting the mattress correctly lay with the nursing staff, yet this was not done, potentially impeding the healing process of the resident's pressure ulcer. The facility also failed to thoroughly investigate a facility-acquired pressure ulcer for another resident, Resident #131. This resident was admitted without any pressure ulcers, but a deep tissue pressure ulcer was identified shortly after admission. Despite the facility's policy requiring incident reports and investigations for new pressure ulcers, no incident report was completed for Resident #131. Interviews with staff, including a CNA, LPN, and the Director of Nursing, indicated that the standard procedure was to complete an incident report and gather statements from staff when a new pressure ulcer was identified, but this was not followed in this case. The facility's policies on support surfaces and incident reporting were not adhered to, leading to deficiencies in the care and investigation of pressure ulcers for the residents involved. The lack of proper mattress settings and failure to investigate new pressure ulcers as per the facility's guidelines contributed to the identified deficiencies.
Inadequate Enteral Feeding Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving enteral feeding, leading to several deficiencies. The resident, diagnosed with unspecified severe protein-calorie malnutrition, had an order for enteral feeding to be administered via a pump. However, the surveyor observed the enteral feeding pump running while disconnected from the resident, causing nutritional formula to drip onto the floor. This was confirmed by the LPN/Unit Manager, who acknowledged that the feeding tube should have been connected to the resident. Additionally, the facility did not adhere to proper hygiene and equipment replacement protocols. The surveyor noted dried formula residue on the base of the pole supporting the enteral feeding pump and an irrigation syringe on the bedside table that had not been replaced within the required 24-hour period. The LPN and the Vice President of Clinical Services confirmed that the syringes should be changed daily and that the feeding formula should not run while disconnected from the resident. These observations indicate a failure to follow the facility's policy on providing adequate nutritional support through enteral feeding.
Deficiency in Narcotic Shift Count Logs and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, as observed by surveyors on two of three medication carts. During medication storage observations, it was found that the narcotic shift count logs for the Seabreeze nursing unit's medication Cart 3 were missing nursing signatures for several shifts in May 2024. Licensed Practical Nurse #1 confirmed that signatures were required to indicate that the incoming and outgoing nurses had counted and reconciled the controlled substances at the change of shift. Similarly, the Starlight nursing unit's medication Cart 1 also had missing signatures for specific shifts, which was acknowledged by Licensed Practical Nurse #2. Additionally, it was noted that LPN #2 administered alprazolam to a resident but failed to sign it out on the narcotic declining inventory sheet, although it was recorded in the resident's electronic Medication Administration Record. The Director of Nursing confirmed that there should be no missing signatures or documentation on the narcotic shift count log and that the declining inventory log should be updated by the administering nurse at the time of dispensing. The facility's Controlled Substance policy requires compliance with laws and regulations related to handling, storage, disposal, and documentation of controlled substances, including the requirement for nursing staff to count controlled medications at the end of each shift.
Medication Security Deficiencies
Penalty
Summary
The facility failed to properly secure medications during administration, as observed with two nurses. One nurse left a bottle of docusate sodium unsecured on top of a locked medication cart while administering medications to a resident. Another nurse left a medication cart unlocked in the hallway while attending to a resident's blood pressure, acknowledging the oversight but continuing with the task before securing the cart. The Director of Nursing confirmed that medication carts should be locked when unattended, and medications should not be left unsecured. Additionally, the facility did not properly secure a resident's home supply medications. A resident was observed with a bottle of Tylenol and an albuterol inhaler in an unlockable drawer in their room. The resident stated that the facility was aware of this arrangement. However, the LPN Unit Manager indicated that residents should be assessed and approved by a physician to self-administer medications, and such medications should be secured. The resident in question had not been assessed or approved for self-administration, and their medical record did not reflect any such authorization. The facility's policies on administering and storing medications require that medication carts be locked when not in use and that unauthorized medications found at the bedside be secured by nursing staff. The resident involved had a moderate cognitive impairment, as indicated by their BIMS score, and there was no care plan in place for self-administration of medications. The facility's failure to adhere to these policies resulted in unsecured medications both during administration and in the resident's room.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Program committee meetings. This deficiency was identified during a review of the quarterly QAPI meeting sign-in sheets and interviews with facility staff. Specifically, the Infection Preventionist (IP) was not present at the QAPI meeting held on April 18, 2024, as confirmed by both the Licensed Nursing Home Administrator (LNHA) and the IP herself, who stated she was conducting wound rounds at the time of the meeting. Additionally, the Director of Nursing (DON) was absent from two of the four meetings reviewed, specifically those held on July 26, 2023, and January 22, 2024. The DON confirmed her absence from the January meeting due to having to leave early. The facility's policy and procedure for the QAPI Program, updated in November 2022, requires the presence of specific individuals, including the Administrator, Director of Nursing Services, Medical Director, and Infection Preventionist, at these meetings. The LNHA acknowledged the absence of the required members and confirmed the discrepancies in the attendance records. The failure to have the required members present at the QAPI meetings is a violation of the facility's policy and regulatory requirements, as outlined in NJAC 8:39-33.1(b).
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Laurelton, Llc | 0.4 mi | ★★★★★ | 1 | 1 |
| Willow Springs Rehabilitation And Healthcare Ctr | 1.2 mi | ★★★★★ | 14 | 0 |
| Concord Healthcare & Rehabilitation Center | 2.8 mi | ★★★★★ | 6 | 0 |
| Crest Pointe Rehabilitation And Healthcare Center | 3.6 mi | ★★★★★ | 10 | 0 |
| Complete Care At Shorrock | 3.8 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.