Complete Care at Brakeley Park

In the surveyor’s words

From the most serious findings on record at Complete Care at Brakeley Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 5, 2024

  Based 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. […]

• Actual harm, isolatedF689Oct 10, 2023

  Complaint #: 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. […]

• No harm, potential for more than minimal, widespreadF804May 16, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2025

  Repeat 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. […]

• No harm, potential for more than minimal, patternF755May 16, 2025

  Based 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. […]