Complete Care at Clark LLC

Inspectors wroteComplaint #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. [...]

Inspectors wroteBased on observation, interviews, record review, and facility documents, it was determined that the facility failed to ensure Licensed Practical Nurse's (LPN) followed the physician's order (PO) in accordance with professional standards of nursing practice for 1 of 6 residents (Resident #58) reviewed for unnecessary medications. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteCOMPLAINT #NJ00183738 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring; a.) timely administration and accurate documentation of a medication (Fluticasone-Salmeterol Inhalation Aerosol (Advair Inhaler) (a combination medication used to reduce inflammation and open airways) for one (1) of 12 residents, (Resident #173), reviewed for medication management for 14 out of 50 doses and b.) proper technique was performed for administration of an Insulin pen injector by one (1) of three (3) nurses who administered medications to one (1) of five (5) residents, (unsampled Resident #110), during the medication administration observation. The deficient practices were evidenced by the following: Reference: [...]

Inspectors wroteBased on interviews, employee file review, and review of other pertinent documents, it was determined that the facility failed to implement their abuse policy to ensure a criminal background check was completed for one (1) of ten (10) newly hired staff (Licensed Practical Nurse #1) reviewed for criminal background checks. This deficient practice was evidenced by the following: On 5/14/25, the surveyor reviewed ten (10) randomly selected new employee files which revealed the following: - LPN #1 had a date of hire (DOH) of 1/28/24. Review of the file revealed a physical dated 1/29/24, a criminal background check dated 10/10/22, and reference checks dated 1/9/24 and 1/19/24. On 5/14/25 at 2:10 PM, during a meeting with the survey team, the Regional Nurse Consultant (RNC) and the Regional Director of Operations (RDO) confirmed LPN #1 was onboarded (hired) by the facility on 1/28/24. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that preventative measures to prevent and promote healing of a facility acquired stage III (full thickness tissue loss) pressure ulcer to the coccyx (tailbone) were in place and consistently followed as well as follow facility policy and procedures for Prevention of Pressure Ulcers/Injuries. This deficient practice was identified for 1 of 5 residents (Resident # 27) who was assessed with intact skin on 10/5/23 and identified with a stage III pressure ulcer on 10/8/23 (3 days later). The wound required excisional debridement (removal of dead tissue using a blade or scalpel) on 10/23/23 and was assessed as worsening on 10/30/23. This deficient practice was evidenced by the following: [...]

Inspectors wrote2. The surveyor reviewed Resident #109's records. The resident was discharged from the facility and according to the Discharge Return not Anticipated MDS dated [DATE], the resident was assessed as being discharged to the hospital. A review of Resident #109's discharge summary and progress notes, dated 7/31/23, the resident was discharged to home/lesser care and was picked up by a family member. On 11/02/23 at 11:45 AM, the surveyor interviewed the MDSC, who stated that the MDS for Resident #109, dated 7/31/23, should have been accurately coded for discharge to home and not hospitalization. During an interview on 11/2/23 at 1:41 PM, the surveyor brought the above concerns to the attention of the Regional Director of Nursing, Director of Nursing and Administrator. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documentation, it was determined that the facility failed to (a.) ensure medication and treatment were administered in accordance with professional standards of clinical practice and (b.) monitor behavior for anti-psychotic, anti-anxiety, and anti-depressant medications. The deficient practice was identified for 7 of 29 residents (Residents #41, 68, 50, 67, 6, 33, and #54). The deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records for Resident #41 which revealed the following: Resident #41 had diagnoses which included but not limited to anxiety, dementia (memory loss) with behavioral disturbance and major depressive disorder. According to the Physician Orders (PO) on 11/20/22, Resident #41 had a PO to monitor for behaviors for antianxiety and antidepressant medications. [...]

Inspectors wroteComplaints NJ00167370; NJ00163024, NJ00157820; NJ00161456, NJ00166876. Based on interviews of facility staff, residents, and a resident representative (Residents #72, 63, 31, 61, 41) and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 29 (Resident # 57) residents reviewed. This deficient practice was evidenced as follows: According to the Resident Assessment Instrument Manual Version 3.0 of Centers for Medicaid and Medicare Services (CMS) guidelines, updated October 2019, a SCSA MDS is required within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, a SCSA/MDS must be completed. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed a) to complete a Tracking Record (Discharge) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, and b) electronically transmit an MDS, for 2 of 29 residents (Residents #23 and #68) reviewed for resident assessments. The deficient practice was evidenced by the following: 1. On 10/30/23 at 01:11 PM, the surveyor completed record review of Resident #23 specific to MDS assessment. The resident was admitted to the facility on [DATE]. The resident was discharged to home with Hospice Care on 8/2/23. The discharge MDS was not completed for 8/2/23. The discharge MDS was 75 days overdue. On 10/31/23 at 11:10 AM, the surveyor interviewed the facility MDS Coordinator who had been working in facility since 2018. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order for the administration of oxygen in accordance with professional standards of practice and according to facility policy. This deficient practice was observed for 1 of 1 resident (Resident #6) reviewed for respiratory care. The deficient practice was evidenced by the following: On 10/27/2023 at 12:08 PM, the surveyor observed Resident #6 sitting in the wheelchair. The resident received Oxygen (O2) at two liters per minute by way of a nasal cannula attached to an oxygen concentrator (a free-standing device used to deliver oxygen). The surveyor reviewed the hybrid medical record: The admission Record indicated that the resident had medical diagnoses that included but were not limited to chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in 4 of 6 medication carts and 1 of 3 medication room refrigerators inspected. This deficient practice was evidenced by the following: 1. On [DATE] at 10:20 AM, the surveyor inspected the first floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Xatmep (Methotrexate) oral solution (treats inflammatory conditions such as arthritis) with an opened date of [DATE] and was expired. The surveyor interviewed LPN#1 who stated that the medication belongs to a resident who was discharged from the facility. LPN#1 further stated that all medications belonging to a discharged resident should have been removed from the medication cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) implement mitigation strategies in accordance with the Center for Disease Control guidance to prevent the transmission of COVID-19; b.) ensure infection control practices were adhered during wound care as previously cited during last standard survey; and c.) ensure a clean tissue was used for optical drops to prevent cross contamination. These deficient practices were identified for 2 of 2 residents (Resident #86 and #154) newly admitted unvaccinated residents; 1 of 1 resident (Resident #354) during wound care; and 1 of 4 residents (Resident #203) during medication pass and evidenced by the following: 1. Reference: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to obtain a physician's order for a restorative nursing program and accurately document the continuation of the restorative nursing program services in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 1 residents reviewed for restorative nursing services (Resident #49). 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 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 pass on 12/16/21 and 12/20/21, the surveyor observed three nurses passing medications to four residents with 27 opportunities for error. There were two errors which calculated to a medication administration error rate of 7.41%. This deficient practice was identified for 2 of 3 nurses for 2 of 4 residents (Resident #64 and #33) and was evidenced by the following: 1. On 12/16/21 at 8:24 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor. [...]