Complete Care at Marcella

Inspectors wroteComplaint #3001244 Based on interviews, review of medical records, and review of other pertinent facility documents on 5/6/26, 5/7/26 and 5/12/2026, it was determined that the facility failed to maintain a safe environment and to provide adequate supervision for a resident (Resident #2) who was assessed to have poor safety awareness, impaired cognition, and was identified as an elopement and fall risk. Resident #2 was also identified having a history of fall and required supervision with ambulation (walking). The deficient practice was identified for 1 of 4 residents (Resident #2) reviewed and was evidenced by the following: The facility policy titled: Fall Prevention Program, with a revised date of 10/7/25, revealed that residents would receive individualized care that would minimize their risk of falls, and that interventions will be monitored for effectiveness. [...]

Inspectors wroteComplaint # 185832, 186185 Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to administer medications within the scheduled medication administration times. The deficient practice was identified for 2 of 2 residents (Resident # 12, # 159) reviewed for significant medication errors. The deficient practice was evidenced by the following: 1.) On 07/16/2025 at 10:16 AM, the surveyor observed Resident # 12 in bed in their room. At that time, he/she declined to be interviewed due to experiencing pain. The resident displayed facial grimacing as he/she spoke. A review of Resident # 12's Electronic Medical Record (EMR) under Orders revealed that Resident # 12 was prescribed Morphine Sulfate (medication used to treat pain) ER (Extended Release) 15 milligrams (mg) tablet to be given one time a day for Chronic Pain. [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to ensure infection control practices were followed for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident #92). On 7/16/2025 at 10:06 AM, during rounds the surveyor observed Resident #92 laying in bed in their room with the nasal cannula (a tube used to deliver oxygen through the nose). The tube was labeled 7/13/2025 and coiled directly on top of the oxygen concentrator (a medical device that delivers extra oxygen to the resident). The tube was not in a bag and exposed to air. On 7/17/2025 at 9:04 AM, during rounds the surveyor observed Resident #92 lying flat in bed. [...]

Inspectors wroteComplaint #: NJ00180123 Based on interviews, medical record review, and review of other pertinent facility documents on 1/21/2025 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents and to follow the Certified Nursing Assistant (CNA) job description and follow its policy titled Activities of Daily Living (ADLs). This deficient practice was identified for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for ADL documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses that included but were not limited to: moderate protein calorie malnutrition; muscle weakness (generalized); [...]

Inspectors wroteCOMPLAINT #NJ00174308 Based on interviews, review of medical records and other pertinent facility documentation on 06/07/24, it was determined that the facility failed to perform skin scrapings to confirm the presence of scabies (an infestation of the skin by a human itch mite). The deficient practice was identified for 2 of 4 residents (Resident #1 and Resident #4) sampled and was evidenced by the following: During a review of Resident #1's electronic medical record (EMR), a physician note, dated 02/22/24, at 08:53 A.M. revealed that one of the resident's chief complaints included a rash that had developed across his/her lower extremities, trunk and back. The note further revealed that Ivermectin (an oral medication effective in treating scabies) was ordered for Scabies. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/13/23 from 09:25 AM until 10:35 AM the surveyor, who were accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. A Food Service Worker (FSW) was observed with a hairnet on with the hair near her ears exposed. Another FSW was observed with a surgical mask on his face. His facial hair was exposed. The FSD stated that hairnets should cover all hair. He also stated that the FSW should be wearing a beard guard. 2. In the snack refrigerator there were five individual cartons of commercially prepared vanilla shakes with no use by date. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility records, it was determined that the facility failed to a.) ensure infection control practices were adhered to in a manner that would decrease the possibility of the spread of infection during wound care, and b.) medication administration. This deficient practice was observed with 1 of 2 residents (Resident# 5) reviewed for pressure ulcers, and for 1 of 2 nurses observed during the medication observation pass on 1 of 3 nursing units, (Second Floor). This deficient practice was evidenced by the following: a.) On 11/13/23 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #5 resting in bed in their room. On the wall outside of the resident's room door was an Enhanced Barrier Precaution sign and a plastic bin with three drawers containing disposable gloves and disposable gowns. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to provide an appropriately sized bed for 1 of 28 residents (Resident #44) reviewed for accommodation of needs and was evidenced by the following: On 11/13/23 at 11:10 AM, during initial tour of the facility, the surveyor observed Resident #44 resting in bed in their room. The resident was laying diagonally in bed, had both knees bent to keep their legs and feet on the mattress. The resident's feet were up against the foot board while the resident's head was propped on a pillow extending past the edge of the mattress. Resident #44 informed the surveyor that their legs hurt from being bent and that he/she is seven feet tall and in a short bed and is uncomfortable. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 2 residents (Resident #63) reviewed for smoking. This deficient practice was evidenced by the following: On 11/13/23 at 10:23 AM, during the tour of the facility, Resident #63 was identified by the Licensed Practical Nurse/Nurse Manager LPN/UM as a smoker. At that time the surveyor observed Resident #63 ambulating in his/her room. The resident stated that he/she went out to smoke four to five times a day. The surveyor reviewed the admission Record for Resident #63 which reflected that the resident was admitted with diagnoses that included diabetes (high blood sugar) and depression. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation it was determined the facility failed to develop a person-centered baseline care plan for a fall risk resident within 48 hours of admission to a facility. This deficient practice was identified in 1 of 28 residents reviewed for baseline care plans (Resident #185) and was evidenced by the following: On 11/13/23 at 11:15 AM, the surveyor reviewed facility documentation which revealed the resident left the facility against medical advice (AMA) on 03/07/23. Review of the admission Record indicated that the resident was admitted to the facility with medical diagnoses which included but were not limited to heart failure, diabetes (high blood sugar), difficulty in walking, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined the facility failed to 1. Obtain physician orders to change oxygen tubing on a resident who was ordered nasal cannula (a devices that delivers oxygen through a tube into the nose) oxygen and 2. Obtain physician orders for care of a Percutaneous endoscopic gastrostomy (PEG) tube (tube passed through abdominal wall into the stomach to provide a means of feeding) site for a resident. This was identified in 1 of 2 residents reviewed for PEG tubes (Resident #61) and 1 of 2 residents reviewed for oxygen (Resident #31 ) and was identified by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on observations, interviews, review of medical records (MR) and other pertinent facility documentation, it was determined that the facility failed to administer medications in accordance with the medication's cautionary statement, and manufacturer specifications. This deficient practice was identified for 1 of 2 nurses who administered medications to 2 of 4 (Residents #27 and #98) observed during medication pass and was evidenced by the following: On 11/15/2023 at 08:18 AM, the surveyor observed Licensed Professional Nurse (LPN) #1 who prepared seven medications, which included Potassium Chloride ER (extended release) tablet 10 Milliequivalents (meq) give one tablet by mouth one time a day for hypokalemia (deficiency of potassium in blood stream), for Resident #27. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to follow a physician's order for 1 of 2 residents (Resident #44) reviewed for pressure ulcers. This deficient practice was evidenced by: On 08/06/2021 at 8:25 AM, the surveyor observed Resident #44 lying in bed. With the resident's permission, the resident pulled the blankets off his/her feet to reveal he/she was wearing non-skid socks and his/her heels were resting directly on the mattress. There was no pillow or offloading device in the vicinity of the foot of the bed. On 08/09/2021 at 9:00 AM, the surveyor observed Resident #44 lying in bed. With the resident's permission, the resident pulled the blankets off his/her feet to reveal he/she was wearing non-skid socks and his/her heels were resting directly on the mattress. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 1 of 3 nurses, on 1 of 2 units (Unit 3), who administered medication to 1 of 5 residents. There were 2 medication errors out of 31 medication opportunities (Resident #50), which resulted in a medication error rate of 6%. This deficient practice was evidenced by the following: On 08/06/2021 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #50. The LPN dispensed seven oral (by mouth) medications, including a Biotin 5,000 mcg (microgram) capsule and one Gabapentin 100 mg (milligram) capsule. The LPN recorded the medications were administered in the electronic Medical Administration Record (eMAR). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care for residents, for Resident #8. This deficient practice was identified for 1 of 11 residents reviewed for Resident Assessment and was evidenced by the following: A review of the MDS section of the Electronic Medical Record (EMR) for Resident #8 revealed that the Quarterly MDS on 03/30/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/07/21, revealed that the 03/30/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the Annual Comprehensive Assessment as the next MDS assessment. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care for residents, for Residents #1, #2, #3, #4, #5, #6, #7, #9, #10 and #11. This deficient practice was identified for 10 of 11 residents reviewed for Resident Assessment and was evidenced by the following: A review of the MDS section of the Electronic Medical Record (EMR) for Resident #1 revealed that the Quarterly MDS on 03/22/21 was in progress. The facility provided the Centers for Medicare Services (CMS) Submission Final Validation Report, dated 04/05/21, that revealed the 03/22/21 Quarterly MDS was completed. The EMR did not reflect that the facility initiated the next quarterly MDS assessment. [...]