Complete Care at Clark LLC

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 6, 2023

  Based 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). […]

• No harm, potential for more than minimal, patternF658May 15, 2025

  Based 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and… […]

• No harm, potential for more than minimal, patternF755May 15, 2025

  COMPLAINT #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… […]

• No harm, potential for more than minimal, patternF641Nov 6, 2023

  2. 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. […]

• No harm, potential for more than minimal, patternF658Nov 6, 2023

  4. The surveyor reviewed the medical records for Resident #67 which revealed the following: Resident #67 had diagnoses which included anxiety disorder, psychosis, and major depressive disorder. According to the PO, Resident #67 had POs to monitor for behaviors for antipsychotic and antianxiety medications. The September 2023 eBMR for each shift in the month of September 2023 revealed blanks on the record where the nurses did not sign that behavior monitoring occurred for anxiety and psychosis for 13 of 90 opportunities. The October 2023 eBMR for each shift in the month of October 2023 revealed blanks on the record where the nurses did not sign that behavior monitoring occurred for anxiety and psychosis for 18 of 93 opportunities. […]