Complete Care at Brakeley Park

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable on 1 of 2 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 5/14/24 at 11:30 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Regional Food Service Director (RFSD). At 11:51 AM, the surveyor and RFSD observed the first food truck arrived on the 1st floor unit. The surveyor and RFSD observed the first lunch tray being served at 11:55 AM, at that time a test tray of a regular diet and regular consistency was identified by the surveyor and RFSD, this tray was removed from the food truck and placed at the nurse's station by the RFSD. [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 5/12/25 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour. 1. In the dry storage area, the surveyor observed two 28 ounce (oz) opened bags of whole wheat bread and one 16oz opened bag hamburger buns. All items were missing open and use by labels. FSD stated all items once opened need to be properly labeled and dated. 2. In the three-door standing freezer the surveyor observed an opened bag of vegetable burgers without an opened and use by label. 3. On top of the standing two door oven, the surveyor observed a grease like substance. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to 1. ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 (two) of 4 (four) residents (Resident #94 and Resident #170) observed during the medication observation pass and 2. failed to clarify a PO for an enteral feeding resident. This deficient practice was identified in 1 (one) of 2 (two) residents (resident #68). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations and interviews on 05/15/2025 in the presence of the Maintenance Director (MD), it was determined that the facility failed to ensure that the call bell light above the room could be seen, and the volume of the resident call bell system was set to a level to be heard. This deficient practice had the potential to affect 57 residents and was evidenced by the following: An observation at 12:55 PM revealed that when testing the call bell for resident room [ROOM NUMBER], there was no audible notification of the call bell activation at the nurse's station. In an interview at the time, 2 staff members at the nurse's station were asked how they would be notified of a call bell activation. The infection control nurse (ICN) stated that they would hear and see it at the call bell annunciator. The surveyor asked if they could tell if there were any currently active calls. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications. This deficient practice was identified for 1 (one) of 5 residents (Resident #25) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 5/12/25 at 10:41 AM, the surveyor observed Resident #25 lying in bed, awake, unable to answer the surveyor's inquiry. On 5/14/25 at 10:25 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #25, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 (two) of the 10 residents (Residents #25 and #41) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 5/12/25 at 10:41 AM, the surveyor observed Resident #25 lying in bed, awake. The surveyor observed that the call light was not within the resident's reach. It was hanging on the upper left side of the resident's bed, beside the light switch and behind the tapestry. On 5/14/25 at 10:25 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #25, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified for 1 (one) of 2 (two) residents (Resident #320) who were reviewed for urinary catheter use and bowel and bladder incontinence. This deficient practice was evidenced by the following: On 5/12/25 at 10:12 AM, the surveyor observed Resident #320 lying in bed awake, with their catheter bag hanging from the bed frame. The catheter bag was not in a privacy bag and was visible from the hallway. On 5/13/25 at 9:37 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #320, which revealed the following: [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review of medical records, and pertinent facility documentation, it was determined that the facility failed to ensure that the physician's orders were followed according to the standard of clinical practice. This deficient practice was identified for one of the residents (Resident #81) who was reviewed for respiratory care. This deficient practice was evidenced by the following: On 5/12/25 at 10:28 AM, the surveyor observed Resident #81 sitting in a wheelchair wearing a nasal cannula (NC - plastic prongs attached to a tube, inserted into the nostrils which oxygen flows) connected to the oxygen (O2) concentrator (a device that supplies oxygen) at 3 (three) lpm (liters per minute). On 5/13/25 at 8:56 AM, the surveyor observed the resident out of bed to the wheelchair on O2 via NC at 3 lpm connected to the O2 concentrator. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication reviews for 1 of 6 Residents, (Resident #68). The deficient practice was evidenced by the following: On 5/12/25 at 10:50 AM, the surveyor observed Resident #68 in bed with eyes closed and a tube feeding (TF) machine (enteral nutrition or tube feeding is a method of supplying nutrition through a feeding tube. This tube goes directly into the stomach or small intestine, bypassing the mouth and esophagus next to the resident's bed) at bedside. On 5/12/24 at 11:50 AM, the surveyor reviewed Resident #68's hybrid (paper and electronic) medical chart which revealed the following: [...]

Inspectors wroteBased on observation, interview, review of medical records, and pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for nasal cannula (a device that delivers oxygen) storage and care. This deficient practice was identified for one of the residents (Resident #81) who was reviewed for respiratory care. This deficient practice was evidenced by the following: On 5/12/25 at 10:28 AM, the surveyor observed Resident #81 sitting in a wheelchair wearing a nasal cannula (NC - a plastic prongs attached to a tube, inserted into the nostrils which oxygen flows) connected to the oxygen concentrator (a device that supplies oxygen) at 3 (three) lpm (liters per minute). On 5/13/25 at 9:03 AM, the surveyor observed the resident's nasal cannula lying on the floor beside their wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that on 09/24/24 the facility failed to: (a) ensure a lip plate and a Kennedy cup was provided to a resident during a meal service, (b) follow this intervention as deemed necessary in the resident's Comprehensive Care Plan (CCP), and (c) provide supervision or assistance in feeding the resident. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for need of feeding assistance and was evidenced as follows: According to Resident #2's admission Record (AR), Resident #2 had the following diagnoses but not limited to Dementia without Behavioral Disturbance, Dysphagia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Hypertensive Chronic Kidney Disease, Muscle Weakness, and Lack of Coordination. [...]

Inspectors wroteComplaint: NJ00176533 Based on observation, interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to obtain appropriate physician's orders (POs) for WanderGaurd (WG) (a small, wearable device designed to alert caregivers and/or restrict access when residents have wandered beyond a designated area), follow the facility's policy titled Physician Orders, and follow the facility's Nurse Manager job description for 1 of 2 residents (Resident #1) reviewed for standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on interview, review of facility records, and other pertinent facility documents on [DATE], it was determined that the facility failed to initiate life saving measures for a resident who was found unresponsive and was designated by the facility as a full code (Initiate Cardiopulmonary Resuscitation if the heart stops and respirations cease), as well as failed to follow the facility policy titled; Cardiopulmonary Resuscitation (CPR) and failed to call emergency services/911. This deficient practice was identified for 1 of 2 residents who were reviewed for in-facility deaths and were deemed a full code status (Resident #112). On [DATE] at 6:05 AM, Resident #112 was found by Licensed Practical Nurse (LPN #1) with no pulse or respirations. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to consistently demonstrate and communicate their response to the residents for the issues/concerns presented during the monthly resident council meetings for September 2023, October 2023 and November 2023. This deficient practice was evidenced by the following. On 12/28/23 at 9:00 AM, the surveyor requested the Resident Council meeting minutes. 1.) A review of the Resident Council Meeting minutes from 9/25/23 included the following: The date, location, time, facilitators, prior minutes reviewed was marked accepted as written, discussion of old/unfinished business to include resolution referred to the department response form, and discussion of new business. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) provide ongoing assessment for complications upon return from the hemodialysis (HD) center and b.) failure to monitor vascular access site for 1 of 1 resident (Resident #35) reviewed for dialysis care. The deficient practice was evidenced by the following: On 1/4/24 at 9:35 AM, the surveyor observed Resident #35 sitting in the wheelchair, awake and able to answer the surveyor's inquiry. On 1/4/24 at 9:45 AM, the Licensed Practical Nurse (LPN #1) stated that Resident #35 goes to the HD clinic every Monday, Tuesday, and Wednesday. The LPN #1 stated that an assessment of the resident's vital signs and an assessment of the HD access site before leaving for the HD clinic and upon return from the HD clinic was documented in the electronic treatment administration record. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 4 of 27 residents (Resident #115, 79, 35, 51) reviewed. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above which revealed the residents' primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition, electronic signatures under the physician's orders in the electronic medical record were inconsistant for the following residents: 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 1/3/24, the surveyors observed three (3) nurses administer medications to four (4) residents. There were thirty-three (33) opportunities, and five (5) errors were observed, which calculated a medication administration error rate of 15.1%. This deficient practice was identified for three (3) of three (3) unsampled residents and one (1) sampled resident #38, who were administered medications by three (3) of three (3) nurses who were observed. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently treat residents in a dignified manner during a meal service. This deficient practice was identified during an interview for one (1) of seven (7) residents in attendance of the 1/3/24, resident council meeting and was evidenced by the following. On 01/03/24 at 10:00 AM, the surveyor conducted the group meeting with seven residents. During the meeting, Resident #102 informed the surveyor that he/she had no use of his/her left arm. The resident verbalized being upset that his/her meal trays were at times, delivered on his/her bedside meal tray table, without removal of the urinal which was placed on the left side of the tray table and without disinfecting the table. The resident was unable to move the urinal him/her self due to the non-use of the left arm. [...]

Inspectors wrote2. On 01/03/24 at 10:00 AM, the surveyor conducted the group meeting with seven residents. During the meeting, Resident #102 informed the surveyor that he/she had no use of his/her left arm. The resident verbalized being upset that his/her meal trays were at times, delivered on his/her bedside meal tray table, without removal of the urinal and without disinfecting the table. The resident admitted to not informing the staff as he/she felt that they should have known his/her condition. The surveyor reviewed the medical records for Resident #102. [...]

Inspectors wroteBased on observation, interview, record review, and other pertinent facility documents, it was determined that the facility failed to a) follow the physician's order and b) carry out the recommendation of another consultant for Uro (Urology) Gynecology consult for one (1) of two (2) residents, Resident #51, reviewed for catheter use according to adherence to accepted standards of clinical practice, as evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that: a) oxygen care and services were provided according to the standard of clinical practice and b) the physician orders were followed for one (1) of two (2) residents (Resident #38) reviewed for respiratory care. This deficient practice was evidenced by the following: On 12/27/23 at 11:59 AM, the surveyor observed Resident #38 asleep, with oxygen (O2) at 2 LPM (liters per minute) via nasal cannula (N/C) attached to a concentrator (a medical device that produces oxygen). On 12/29/23 at 11:36 AM, the surveyor observed the resident in bed watching TV (television) with O2 at 2 LPM via N/C attached to the concentrator. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store, label, and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 12/27/23 at 09:36 AM, the surveyor in the presence of the Food Service Director (FSD) and District Manager (DM) observed the following during the kitchen tour: 1. In the dry storage area, the surveyor observed: a. One, 28oz box of cream of wheat, the box was opened without an open or use by date label. b. Two, 5 lb. bags of egg noodles, both opened without an open or use by date label. c. One, 3lb bag of penne pasta, opened with an open date, but the date was unclear. The FSD nor the DM could accurately say what the date was on the label. d. One, 3 lb. [...]

Inspectors wroteComplaint #: NJ165331, NJ167363, NJ168017 This deficient practice was evidence as follow: Based on interviews, medical records reviews, and review of other pertinent facility documentation on 10/5/2023 and 10/10/2023, it was determined that the facility failed to ensure that an avoidable accident was prevented because care plan interventions were not followed during the transfer from the bed to a shower chair for Resident #2. The resident was transferred out of bed by 2 Certified Nurses Aides ( CNA) who failed to use the mechanical lift hoyer device as indicated in the plan of care. The staff could not place the resident in the shower chair and had to lower Resident #2 to the floor on his/her knees that resulted in noticible injuries to those areas. Resident #2 was sent to the Hospital emergency room and was found to have 2 closed fractures to both legs. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a Physician Order (PO) for a self-releasing seatbelt. This deficient practice was identified for one of 21 residents reviewed, (Resident #9) for professional standards of clinical practice and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to collaborate as a multidisciplinary team and implement appropriate interventions for a resident with a history of significant weight loss. This deficient practice was identified for one of six residents reviewed, (Resident #42) for nutrition and was evidenced by the following: On 10/12/21 at 9:30 AM, the surveyor observed Resident #42 sitting upright in bed with a carton of 2 % milk in front of him/her. The surveyor attempted to interview the resident. The resident was able to tell the surveyor his/her name and stated, yes when the surveyor asked the resident if he/she had been sent to the hospital. On 10/13/21 at 12:25 PM, the surveyor observed the resident seated in a wheelchair in his/her room with a lunch tray in front of him/her. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to provide foods of resident preferred palatable temperatures. This deficient practice was identified on one of two nursing units during monitoring refrigerator temperatures, during an interview with one anonymous resident, with 5 of 5 residents who attended resident council meeting, and during a surveyor food temperature monitoring on one of two nursing units. The deficient practice was evidenced by the following: On 10/12/21 at 10:15 AM, the surveyor interviewed an alert and oriented resident on the second floor who wished to remain anonymous who stated that food that was supposed to be served cold was served warm. The resident gave the example that he/she received a salad one time that was warm. [...]