Accelerate Skilled Nursing And Rehab Piscataway
Inspection history, citations, penalties and survey trends for this long-term care facility in Piscataway, New Jersey.
- Location
- 10 Sterling Drive, Piscataway, New Jersey 08854
- CMS Provider Number
- 315522
- Inspections on file
- 15
- Latest survey
- November 10, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Accelerate Skilled Nursing And Rehab Piscataway during CMS and state inspections, most recent first.
A cognitively impaired resident with severe medical conditions was found unresponsive on an outdoor patio during a heat wave, having been left unsupervised despite requiring staff assistance for mobility and daily activities. The resident suffered a life-threatening heat stroke and required emergency medical treatment. Facility staff interviews and documentation revealed lapses in supervision and failure to follow protocols for resident safety and heat precautions.
A resident with severe cognitive impairment and multiple medical conditions was found unresponsive with a high fever after being outside on the patio during a heat wave, accompanied by a private companion. Staff provided emergency care and transferred the resident to the hospital, where heat stroke was diagnosed. Despite facility policy and regulatory requirements, the incident was not reported to the state health department within the required timeframe, as facility leadership did not consider it an allegation of neglect.
A resident with severe cognitive impairment and multiple medical conditions was found unresponsive on the patio with a high fever after being left outside for an extended period. Facility staff failed to thoroughly investigate the incident, as the initial investigation did not include a statement from the companion present at the time, and there were inconsistencies in staff accounts regarding supervision responsibilities. The incomplete investigation did not meet the facility's policy requirements for addressing alleged neglect.
The facility did not provide timely access to medical records for three residents or their legal representatives, despite multiple requests and in accordance with facility policy. Delays were attributed to changes in the process for handling record requests and incomplete fulfillment of requests, as confirmed by staff interviews and documentation.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
The facility failed to store potentially hazardous foods properly and maintain a sanitary kitchen environment, leading to the risk of foodborne illness. Observations included soiled surfaces, expired cheese in the refrigerator, and undated sugar in storage, indicating non-compliance with facility policies.
The facility did not document monthly inspections of the sprinkler system's gauges as required by NFPA 25, potentially affecting all 74 residents. This deficiency was confirmed during an interview with a staff member who acknowledged the lack of documentation.
The facility was found to have unsealed penetrations in smoke barriers in multiple rooms, with blue wires extending through 1-inch holes. A staff member confirmed the facility was unaware of these gaps. Additionally, there was no documented evidence of the required four-year testing or maintenance of smoke dampers, and a staff member was unaware of this missing documentation.
The facility did not conduct fire drills at least quarterly per shift as required by NFPA 101 Life Safety Code. A review of the facility's records showed no evidence of fire drills for April and May 2024, which was confirmed by a staff member. This deficiency had the potential to affect all 74 residents.
The facility failed to maintain its generator according to NFPA 110 standards, neglecting weekly visual inspections and checks of the battery electrolyte levels and gravity. This deficiency, confirmed by missing documentation, potentially affected all 74 residents by compromising emergency power reliability.
The facility failed to implement its Abuse Prohibition policy by not timely reviewing a newly hired employee's criminal background, which later revealed offenses, and by not conducting reference checks for eight newly hired employees. The dietary aide worked several shifts before being suspended and terminated after the offenses were discovered. The DON acknowledged that reference checks had not been consistently performed prior to the employment of a new Scheduler.
A resident with pressure ulcers did not receive recommended darco boots in a timely manner due to communication lapses within the facility. Despite the resident's ability to communicate needs, the Director of Rehab was not informed of the prescription until nearly a month later, and the boots ordered were initially the wrong size. The facility's procedures for documenting and communicating consult recommendations were not followed, leading to a deficiency in care.
The facility failed to follow CDC hand hygiene guidelines, with issues observed in the kitchen setup, improper handwashing by staff, and inadequate cleaning of medical devices. A nurse used a glucometer on two residents without cleaning it between uses, and staff were seen washing hands incorrectly. A phlebotomist improperly transported a urine specimen. These actions indicate a lack of adherence to infection control protocols.
The facility failed to offer COVID-19 vaccinations to three residents, despite their previous vaccination history. The DON indicated that vaccines are offered based on residents' preferences and history, but documentation did not reflect that additional vaccines were offered. The facility's policy requires documenting vaccination status and offering vaccines as per the schedule, which was not followed for these residents.
Three residents experienced undignified treatment and lack of responsiveness from staff. A CNA refused to assist a resident due to perceived aggression, a resident post-lung surgery was denied timely pain medication, and another resident's request for mailing assistance was ignored. These incidents reflect a failure to uphold residents' rights and proper care planning.
A resident's care plan for preventative skin care was not implemented consistently, with lapses in documentation and execution from January to June 2024. Prescribed treatment with Z-guard paste was not administered timely, and Clonazepam was given late on multiple occasions due to staffing shortages. The DON confirmed these deficiencies, highlighting issues in documentation and medication administration protocols.
The facility failed to provide timely incontinence care to residents, as observed by surveyors. Four residents were found with saturated or soiled incontinence briefs, indicating a lack of regular care. One resident, with severe cognitive impairment, had no care plan for incontinence. Another resident, who was alert, reported not having a diaper change since the previous night. The facility's policy requires incontinence rounds every two hours, but this was not consistently done.
A resident's MDS inaccurately indicated that the pneumococcal vaccine was offered and declined, but no documentation was found in the medical records. The DON stated that vaccine information should be documented, but the MDS Coordinator could not find the resident's details and later corrected the MDS to show the vaccine was not offered.
A resident with chronic obstructive lung disorder and other conditions was observed receiving oxygen therapy at incorrect flow rates on multiple occasions. The physician's order specified a continuous flow rate of 2 LPM, but the resident was seen receiving 3 LPM and later 4.5 LPM. The nurse responsible for monitoring the flow rate confirmed the discrepancy and suggested it might have been accidentally adjusted.
A facility failed to administer medications without error, resulting in a 12% error rate. A nurse improperly administered insulin to two residents by not following the manufacturer's instructions for insulin pen-injectors, affecting the dosage accuracy. The errors involved incorrect priming and insufficient holding time after injection.
The facility failed to offer or document the administration or refusal of the pneumococcal vaccine for two residents, leading to a deficiency in immunization practices. One resident with severe cognitive impairment and another with intact cognitive functioning were not properly documented regarding their pneumococcal vaccine status. The facility's policy required documentation of vaccine history, education, and refusal, but these steps were not followed.
A facility failed to report an injury of unknown origin involving a resident who had an unwitnessed fall, resulting in a small abrasion and complaints of neck pain. The resident, who was cognitively intact and dependent on assistance for daily activities, was admitted to the hospital for encephalopathy. Despite the facility's policies requiring timely reporting of such incidents, no report was filed with the NJDOH, and the Director of Nursing could not provide evidence of prior documentation of the resident's spastic movements.
The facility failed to maintain sufficient staffing levels, resulting in delayed medication administration for residents. During a specific week, the facility did not meet the required staff-to-resident ratios, leading to late administration of medications such as Quetiapine and Clonazepam. The Director of Nursing attributed these delays to short staffing due to a mass exit of staff.
The facility failed to meet the required staffing ratios for CNAs and total staff across various shifts, as mandated by New Jersey state law. Over multiple weeks, the facility consistently had fewer CNAs and total staff than required, with specific instances of significant shortfalls in staffing levels. The Director of Nursing was aware of the staffing criteria, yet the facility continued to operate below the mandated levels.
The facility failed to ensure that 9 out of 10 newly hired employees received the required health examinations within the specified time frame. These employees did not receive an examination by a physician or advanced practice nurse within two weeks of employment, nor did they receive a nursing assessment on their first day to defer the examination. The DON could not provide evidence of compliance, and no policy for new hire health examinations was available.
The facility did not administer the mandatory two-step Mantoux tuberculin skin test to 7 out of 10 newly hired employees before their first day of employment. The DON could not provide evidence of the required testing, and the facility lacked a policy for new employee screening.
Failure to Supervise Cognitively Impaired Resident Results in Heat Stroke
Penalty
Summary
A cognitively impaired resident with multiple complex medical conditions, including dementia, multiple sclerosis, encephalopathy, and a history of falls and strokes, was found unresponsive on an outdoor patio during a period of extreme heat. The resident had a severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required staff assistance for activities of daily living and mobility. Facility records and staff interviews confirmed that the resident could not ambulate independently and required one-person assistance for ambulation. On the day of the incident, the resident was last seen in the dayroom by assigned staff, but was later discovered outside on the patio by a companion, unresponsive and exposed to direct sunlight. The companion immediately alerted a nurse, who found the resident unconscious with a temperature of 103.8°F and a heart rate of 124 bpm. The resident was brought inside, treated for heat stroke, and subsequently transferred to the emergency room for further evaluation and care. Interviews with staff revealed inconsistencies regarding supervision in the dayroom and the process by which the resident accessed the patio, with staff unable to account for the resident's movement outside or provide clear oversight during the critical period. Facility policies required supervision of cognitively impaired residents and specific precautions during periods of extreme heat, including staff monitoring and prevention of heat-related illness. However, documentation and interviews indicated lapses in supervision and failure to ensure the resident's safety, as no staff observed or prevented the resident from being outside unsupervised during hazardous weather conditions. The lack of effective oversight and adherence to established protocols resulted in the resident suffering a life-threatening heat stroke, constituting neglect.
Removal Plan
- Resident was assessed and transferred to emergency room for evaluation.
- Resident returned to the facility and was placed on monitoring.
- The nurse and CNA who were assigned to Resident were in-serviced on resident safety and protection from neglect.
- Resident was placed on one-to-one supervision.
- All cognitively impaired residents were placed on monitoring.
- The LNHA, DON, and ADON reviewed the abuse and neglect policy, taking residents outside the facility, hot weather, enhanced supervision, and nursing round policies with no revisions made.
- The DON, ADON, LNHA provided the nurses and CNAs with training on the abuse and neglect policy, resident supervision, protection of resident from neglect, and resident safety.
- The DON, ADON, and LNHA provided non-clinical staff training on abuse and neglect and residents' rights to be free from neglect.
Failure to Timely Report Alleged Neglect Following Resident Heat Stroke
Penalty
Summary
The facility failed to report an allegation of neglect within two hours to the New Jersey Department of Health (NJDOH) after an incident involving a resident with multiple complex medical conditions, including multiple sclerosis, encephalopathy, dementia, and a history of falls and strokes. The resident, who had severely impaired cognition and required staff assistance for activities of daily living, was found outside on the patio during a heat wave, accompanied by a private companion. The resident became drowsy, unresponsive, and was found to have a high fever (103.8°F) and tachycardia. Staff provided cooling measures, administered Tylenol, and transferred the resident to the hospital as ordered by the physician. Interviews and documentation revealed that staff were unclear about how the resident ended up on the patio and whether appropriate supervision was maintained. The resident's family had previously indicated that the resident should not be outside unless accompanied by the companion. The incident investigation noted that staff did not observe the resident being taken outside and that there was typically a CNA assigned to oversee residents in the dayroom and patio area. The resident was ultimately diagnosed in the emergency room with heat stroke and transient alteration of awareness. Despite the circumstances suggesting possible neglect, the facility administration, including the DON and LNHA, decided not to report the incident to NJDOH, believing it did not constitute neglect. This decision was made even though the facility's own policy required the identification and investigation of all possible incidents of abuse, neglect, or mistreatment. The failure to report the incident as required constituted the identified deficiency.
Failure to Thoroughly Investigate Resident Heat Stroke Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who suffered heat stroke after being left outside on the patio, resulting in a life-threatening situation. The resident, who had multiple complex medical diagnoses including multiple sclerosis, encephalopathy, dementia, and severe cognitive impairment, required staff assistance for mobility and activities of daily living. On the day of the incident, the resident was found unresponsive on the patio with a temperature of 103.8°F and was subsequently transferred to the emergency room for evaluation and treatment. The investigation conducted by the facility was incomplete, as it did not include a statement from the resident's companion who was present at the time of the incident. Interviews with staff revealed inconsistencies regarding supervision in the dayroom and on the patio, with some staff unaware of how the resident ended up outside. The companion later reported that upon arrival, they found the resident alone on the patio, unresponsive and exposed to direct sunlight, and had to seek help from nursing staff. Documentation showed that the resident was outside for approximately 30-40 minutes before being discovered in distress. Facility records indicated that CNAs were assigned to supervise the dayroom in 30-minute rotations, but there was confusion about who was responsible for the resident at the time. The facility's investigation relied only on statements from the nurse and CNA involved, omitting the companion's account until later interviews by the surveyor. The facility's policy required thorough investigation of all possible incidents of neglect, but the lack of a complete investigation and failure to obtain all relevant statements constituted a deficiency in responding to and investigating alleged violations.
Delayed Provision of Medical Records to Residents and Representatives
Penalty
Summary
The facility failed to provide timely access to medical records for residents or their legal representatives, as required by its own policy. The policy specified that access to view documents must be provided within 24 hours of a request, and copies must be provided within two working days. For three sampled residents, multiple requests for medical records were either delayed or not fulfilled within the required timeframe. In one case, a legal representative made several requests for records, but the facility had not received or processed these requests for specific dates. In another instance, a family member submitted both in-person and certified requests for records, but did not receive the requested information. For a third resident, multiple requests were made over several months, and the records were not provided until several months after the initial requests. Interviews with facility staff revealed that changes in the process for handling medical record requests, such as forwarding requests to a paralegal, may have contributed to the delays. Staff confirmed receipt of some records but acknowledged that requests for certain dates had not been fulfilled. Documentation and correspondence reviewed during the survey supported the findings that the facility did not meet its policy requirements for timely provision of medical records to residents or their legal representatives.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain a sanitary kitchen environment, leading to the risk of foodborne illness. During an inspection, the surveyor observed several deficiencies in the kitchen area. The shelf holding the water dispenser was soiled with brown and white debris, and the drip tray underneath the water dispenser spout had a buildup of dried brown substance. The boiler handle and oven knobs were covered in cream and brown debris, respectively, which could be easily lifted with a pen. Additionally, four of the seven sprinklers above the cooktop area were soiled with a brown grease-like substance. In the food preparation area, a white cutting board was found with multiple deep scratches, which could harbor bacteria. In the walk-in refrigerator, a bag of shredded cheddar cheese was observed with a use-by date that had already passed, and the Food Service Director acknowledged it should have been removed. Furthermore, in the dry storage room, a plastic bin containing white sugar was undated, contrary to the facility's policy. These observations indicate a failure to adhere to the facility's cleaning schedule and use-by dating guidelines, as outlined in their policies.
Plan Of Correction
1. Corrective Action of Areas Affected: The shelf holding the water dispenser, drip tray, boiler handle, oven knobs, sprinkler heads, and convection oven knobs have been cleaned. The cutting board has been replaced, the shredded cheese discarded and sugar bin dated. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Administrator conducted a detailed Sanitation Audit to identify any additional concerns which have been corrected. All Dietary staff have been re-inserviced on Sanitation detail, dating the sugar and other bins, revised Cleaning Schedule, and the policy on Use By Dating. 3. Systemic Changes to Prevent Future Occurrences: The Administrator and Director of Food Service reviewed the facility's Cleaning Schedule and added in any of the specific items noted under #1 above not already included on it. Sanitation Audits are being conducted weekly by either the Director of Food Service or the Administrator. 4. Monitoring of Corrective Action: The Director of Food Service will submit a report weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Document Monthly Sprinkler Gauge Inspections
Penalty
Summary
The facility failed to comply with the NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, specifically regarding the inspection of sprinkler system gauges. A review of the facility's records showed that there was no documentation of monthly inspections of the gauges for the wet sprinkler system. This deficiency was confirmed during an interview with a staff member, who acknowledged the absence of the required documentation. This oversight had the potential to affect all 74 residents at the facility.
Plan Of Correction
1. Corrective Action of Areas Affected: The Director of Maintenance has completed the required monthly sprinkler gauge inspection for December. The US FOIA (b) (6) has been in-serviced on the need to ensure this inspection occurs on a monthly basis. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance is responsible to ensure the sprinkler gauge is inspected on a monthly basis and provide the report to the Administrator. 3. Systemic Changes to Prevent Future Occurrences: Sprinkler gauge inspection has been placed on a monthly Preventive Maintenance inspection by the Director of Maintenance. 4. Monitoring of Corrective Action: The Director of Maintenance will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Unsealed Smoke Barriers and Missing Smoke Damper Documentation
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, which is a requirement under the NFPA 101 Life Safety Code (2012 Edition). During an observation, a 1-inch unsealed hole with blue wires extending through it was found in the smoke barrier inside Room 320, as well as in Rooms 220 and 218. This deficiency was confirmed by a staff member during the observation, who stated that the facility was unaware of these unsealed gaps and penetrations. Additionally, the facility lacked documented evidence of a four-year testing or maintenance of its smoke dampers, as required. During an interview, a staff member was not aware of the missing documentation, indicating a lapse in the facility's maintenance and documentation processes.
Plan Of Correction
1. Corrective Action of Areas Affected: The penetrations in rooms 218, 220 and 320 have been sealed. The required 4 year testing on the smoke dampers has been completed. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance/Designee has conducted an inspection in 100% of all resident rooms for additional penetrations and any additional ones found have been sealed. 3. Systemic Changes to Prevent Future Occurrences: Inspection for penetrations in smoke barriers has been placed on a monthly preventative maintenance inspection by the Director of Maintenance/Designee. The Maintenance Director will submit this monthly inspection to the Administrator. 4. Monitoring of Corrective Action: The Director of Maintenance will submit a report monthly to the Administrator who will forward it x 3 months to the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Conduct Quarterly Fire Drills
Penalty
Summary
The facility failed to conduct fire drills at least quarterly per shift, as required by NFPA 101 Life Safety Code (2012 Edition), Section 19.7.1. This deficiency was identified through a review of the facility's "Fire Drill Reports," which showed no documented evidence of fire drills being conducted for April 2024 and May 2024. During an interview, a staff member confirmed the absence of fire drill reports for these months. This failure had the potential to affect all 74 residents in the facility.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concern related to the previous April and May fire drills not being completed. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Administrator and Director of Maintenance ensure that all fire drills are completed monthly on a shift rotating basis including weekend requirement. 3. Systemic Changes to Prevent Future Occurrences: The Administrator reviews compliance with fire drill requirements prior to the end of each month to ensure the rotating schedule is followed.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), Section 8. Specifically, the facility did not conduct weekly visual inspections of the generator, nor did it check the generator's battery electrolyte levels and gravity as required. This lack of maintenance and testing was identified through a review of the facility's generator documentation, which showed no evidence of the required weekly inspections or checks. During an interview, a staff member confirmed the absence of this documentation, indicating that the facility could not locate the missing records. These deficient practices had the potential to affect all 74 residents in the facility. The failure to perform these essential maintenance tasks could compromise the generator's ability to provide emergency power, which is critical for the safety and well-being of the residents. The report does not mention any specific incidents or adverse outcomes resulting from this deficiency, but it highlights the potential risk to the residents due to the facility's non-compliance with the established standards.
Plan Of Correction
4. Monitoring of Corrective Action: The Administrator will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations. 1. Corrective Action of Areas Affected: The Director of Maintenance is completing the required weekly generator tests as well as the weekly checks of the battery electrolyte levels. Monthly checks of the battery specific gravity on the generator is being completed by the US FOIA (5)(6) has been in-serviced of the need to conduct these required inspections. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Maintenance and Administrator have reviewed all other required generator tests/inspections to ensure all are routinely completed as required. Systemic Changes to Prevent Future Occurrences: The Administrator is now responsible to ensure all generator tests/inspections are completed as required by reviewing the documentation submitted by the Maintenance Director. Monitoring of Corrective Action: The Director of Maintenance will submit a weekly report on the generator test and battery electrolyte level weekly x 4 then monthly x 2. The Director of Maintenance will also submit a monthly report regarding the generator battery specific gravity x 3 months. The Administrator will submit a report monthly x 3 months at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Timely Review Background Checks and Conduct Reference Checks
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy by not reviewing a newly hired employee's criminal background investigation (CBI) report in a timely manner. Employee #4, a dietary aide, was hired without a complete review of their CBI, which later revealed two felony offenses for burglary and three misdemeanor offenses, including two for theft, from 2014 to 2016. The CBI search for New Jersey was conducted before the hire date and showed no offenses, but the searches for other states and county offenses were completed after the hire date, revealing the offenses. The employee worked several shifts before being suspended and eventually terminated after the offenses were discovered. Additionally, the facility did not conduct reference checks for eight out of ten newly hired employees reviewed. There was no documentation indicating that reference checks were attempted for these employees. The Director of Nursing acknowledged that reference checks had not been consistently performed prior to the employment of a new Scheduler three months ago. The facility's policies require screening potential employees for a history of misappropriation of property and checking at least two professional references prior to hire, which were not adhered to in these cases.
Plan Of Correction
1. Corrective Action of Areas Affected: Employee #4 was previously [R] and references have been obtained for employee #1, 3, 4, 5, 6, 7, 8, 9. The facility cannot retroactively obtain any background checks or references on any employee no longer employed with the facility. The [R] re-inserviced on ensuring references and criminal background checks are obtained in accordance with Federal/State regulations in order to fully protect residents from potential abuse. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. An audit of all current in-house employee files has been conducted to verify background checks and references have been obtained and any items missing have been obtained. 3. Systemic Changes to Prevent Future Occurrences: A new hire checklist has been implemented to include background checks and reference checks prior to employment. The Staffing Coordinator/HR is verifying items are obtained prior to employees beginning Orientation. 4. Monitoring of Corrective Action: The Staffing Coordinator/HR will complete a weekly audit of new employee hires to verify references and background checks have been completed x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Delay in Providing Specialty Device for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide a specialty device, darco boots, in a timely manner for a resident with pressure ulcers. The resident, who had a history of acute osteomyelitis, paraplegia, peripheral vascular disease, and type 2 diabetes with diabetic neuropathy, was observed waiting for the darco boots recommended by a wound consult physician. Despite the resident's intact cognition and ability to communicate needs, the boots were not provided promptly, leading to a deficiency in care. The delay in providing the darco boots was due to a breakdown in communication and procedure within the facility. The Director of Rehab was not informed of the prescription for the darco boots until nearly a month after it was issued, due to the prescription not being communicated by the nursing staff. The usual procedure required a nurse to notify the Director of Rehab of such prescriptions, but this did not occur. Additionally, the resident was instructed to continue using PRAFO boots until the darco boots arrived, but the delay in obtaining the correct size further prolonged the issue. The Interim Director of Nursing acknowledged procedural lapses, including the failure to verify recommendations from the wound consult and the lack of communication regarding the prescription. The facility's policy required that consult recommendations be documented and communicated to the attending physician, but this process was not followed. The prescription was scanned into the electronic system, but the Director of Rehab was unaware of it until the resident inquired about the boots, highlighting a significant gap in the facility's communication and follow-up procedures.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #14 received the [R]. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit for residents with orders for darco boots to validate the boots have been obtained as per orders. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing/designee has re-educated licensed nursing staff on the process for reviewing wound consultations and verifying new orders are followed. 4. Monitoring of Corrective Action: The Director of Nursing/designee will review charts for residents with pressure injuries to validate that treatments are being completed as per order and specialty devices utilized weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly at the Quality Assurance Improvement Meetings for review and recommendations.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to CDC guidelines for hand hygiene, as evidenced by several observations. In the kitchen, handwashing sinks were located on one side of the wall, while paper towel dispensers were on the opposite side, leading to water drips on food preparation surfaces. This setup was confirmed by the Food Service Director. Additionally, during a medication pass, a Registered Nurse used the same glucometer on two residents without cleaning it between uses, contrary to the facility's procedure and manufacturer's instructions, which require disinfection before and after each use. Further observations revealed improper hand hygiene practices among staff. A Nursing Assistant was seen washing her hands without lathering soap and turning off the faucet with bare hands. Similarly, a Certified Nursing Assistant handled soiled linens, removed gloves, and washed hands improperly by not lathering soap for the recommended duration and using the same paper towel to turn off the faucet. An agency RN failed to use soap when washing hands after handling a trash can lid and cleaning a spill, citing a lack of soap, which was later found to be available. The facility's policy requires washing hands with soap for 20 seconds outside the stream of water and using a clean towel to turn off the faucet. Additionally, a Phlebotomist was observed carrying a urine specimen in a wet bag through the facility while wearing gloves, which is against the facility's protocol. The Phlebotomist acknowledged the need to place the contaminated bag into a clean one for proper transport. The Director of Nursing confirmed the necessity of appropriate hand hygiene and the correct handling of specimens. These observations highlight the facility's failure to implement effective infection prevention and control measures as per their policies and CDC guidelines.
Plan Of Correction
1/17/25 1. Corrective Action of Areas Affected: The facility completed re-inservicing, competency training, and observations on the specific nurses related to [R]cleaning and hand hygiene for residents #46 and #48. 2. Other Areas Affected: The Director of Nursing/designee has conducted re-inservicing, competency training, and observations for nurses, CNAs, and Dietary on proper hand hygiene techniques. The Director of Nursing/designee has conducted re-inservicing, competency training, and observations for licensed nursing staff related to glucometer cleaning. 3. Systemic Changes to Prevent Future Occurrences: Licensed nurses, CNA's, and Dietary staff have been re-educated by the Director of Nursing/designee on hand hygiene policies and procedures. Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the manufacturers recommendations for cleaning of the glucometers after each use. 4. Monitoring of Corrective Action: The Director of Nursing/designee will observe 5 staff members' hand hygiene techniques weekly x4, then monthly x2. The Director of Nursing/designee will observe 5 nurses on the cleaning technique of glucometers after use weekly x4, then monthly x2. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.
Failure to Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to offer a COVID-19 immunization to three residents, which was identified during a survey. Resident #41, who was admitted with a urinary tract infection and had intact cognitive functioning, had previously received COVID-19 vaccines but was not offered an additional vaccine as per the facility's records. Similarly, Resident #9, admitted with hypothyroidism and type 2 diabetes, and Resident #55, admitted with severe malnutrition and diabetes, had received previous COVID-19 vaccinations but were not offered further doses according to the facility's documentation. The Director of Nursing (DON) stated that COVID-19 vaccines are offered based on residents' preferences and vaccination history, and that acceptance, refusal, and education are documented in the electronic medical record (EMR) or hard chart. However, upon review, there was no documentation indicating that these residents were offered additional vaccines. Furthermore, the DON was unsure if education was provided after vaccine refusals, as required by the facility's policy. The facility's policy mandates documenting vaccination status upon admission and offering vaccines according to the manufacturer's schedule, but this was not adhered to for the residents in question.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #9, #14 and #55 were educated by the licensed nurse regarding the NJ Ex Order 26.461 and consents and have been offered and administered as ordered. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit on current residents to validate that the COVID-19 vaccinations were offered. If any eligible resident did not receive the COVID-19 vaccination, the physician has been notified, orders placed and consents obtained. 3. Systemic Changes to Prevent Future Occurrences: Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the policy for the COVID-19 vaccination. 4. Monitoring of Corrective Action: The Director of Nursing/designee will conduct weekly audits x4, then monthly x2 on new admissions to validate that the COVID-19 vaccinations were offered. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.
Failure to Maintain Resident Dignity and Responsiveness
Penalty
Summary
The facility failed to maintain the dignity of three residents during the survey. In the first instance, a CNA refused to assist a resident, citing the resident's aggressive behavior, and communicated this in a loud and undignified manner to the resident's representative. The CNA did not recognize the undignified nature of her response. In the second instance, a resident who had undergone lung surgery and was diagnosed with Parkinson's Disease was left without pain medication for an extended period after activating the call light. The resident had to personally seek assistance from a nurse, who responded inappropriately by expressing reluctance to work due to tiredness. Additionally, the resident's care plan did not address post-surgical care needs. In the third instance, a resident approached a CNA at the nursing station for assistance with mailing an envelope. The CNA did not respond to the resident's request, citing a lack of knowledge about where to find the necessary supplies. The resident eventually received assistance from another staff member. These incidents highlight a failure to uphold the residents' rights to dignity and proper communication, as well as a lack of appropriate care planning and responsiveness to residents' needs.
Plan Of Correction
1/13/25 1. Corrective Action of Areas Affected: The concerns for residents #62, #34 and #35 were addressed. CNAs #1 and #2 were re-educated on resident rights, customer service, and addressing residents concerns in a proper manner. The [R] for resident #34 was re-educated in these areas and also received [R]. Resident #34 care plan was updated to address [R]. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. Interviewable residents or family members/Responsible Party's of non-interviewable residents, have been interviewed to identify and immediately address other potential resident rights concerns. 3. Systemic Changes to Prevent Future Occurrences: Licensed nurses and CNAs have been re-inserviced on Resident Rights and Customer Service. Managers function as resident Partners by frequently visiting residents. Partners have been re-educated on the various specific Resident Rights under the Federal/State regulations. They have conducted Resident Rights inquiries with all interviewable residents or family/Responsible Party of non-interviewable residents regarding potential resident rights violations and any concerns have been addressed through the facility's Grievance process. 4. Monitoring of Corrective Action: The resident "Partners" will interview a minimum of 5 alert residents or family members/Responsible Party of cognitively impaired residents weekly x4 weeks, then monthly x2 months. Results of the audits/Grievances will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Deficiencies in Skin Care and Medication Administration
Penalty
Summary
The facility failed to implement a resident's care plan for preventative skin care treatment against pressure ulcers from January to June 2024. The care plan included routine and as-needed skin care, which was not consistently documented in the Activities of Daily Living (ADL) log. The Treatment Administration Record (TAR) did not include an order for preventative skin care until June 25, 2024. The Director of Nursing (DON) confirmed that the preventative skin treatment was not reflected in the January 2024 log, indicating a lapse in the documentation and execution of the care plan. Additionally, the facility did not provide prescribed treatment with Z-guard paste in a timely and consistent manner. A skin evaluation on February 10, 2024, revealed a new stage 2 pressure ulcer on the resident's buttocks, but subsequent evaluations did not document any skin issues until June 23, 2024, when a nurse noted a small opening in the sacral area. The Nurse Practitioner ordered Z-guard paste to be applied twice daily, but the TAR showed missed administrations on several dates in June and July 2024. The facility also failed to administer Clonazepam as scheduled, with delays in administration noted on multiple occasions in June and July 2024. The DON acknowledged the late administration of medications, attributing it to staffing shortages. The facility's policy requires medication orders to be documented in the resident's medical record, but the report indicates inconsistencies in following this protocol, contributing to the deficiencies observed.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #76 is NJ Ex Order 26.461 in the facility. 2. Other Areas Affected: All residents have the potential to be affected by this practice. 3. Systemic Changes to Prevent Future Occurrences: A) DON/Designee has re-educated the nursing staff on the importance of adhering to care plans, timely receiving and medication administration, and the prevention and treatment of pressure ulcers. Medication pass observations have been conducted for licensed staff. An initial audit has been completed by the DON/Designee of admissions in the last 30 days to verify care plans are current, accurate, and reflect the resident's individual needs regarding skin care and pressure ulcer prevention. B) DON/Designee has re-educated nursing staff on proper medication administration procedures, including medication timing and documentation. Residents with new orders for medications for the past 5 days have been reviewed during clinical meetings to verify medication was received and administered timely. 4. Monitoring of Corrective Action: A) DON/Designee to audit 5 care plans per week x 4 weeks then monthly x 2 for accurate reflection of residents' skin care and pressure ulcer prevention needs. B) DON/Designee to audit 5 resident medication administration records per week x 4 weeks then monthly x 2 to verify timely and consistent administration of medications. Results of all audits to be reviewed monthly at the facility's Quality Assurance Improvement Meetings.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed by surveyors on the 2nd-floor unit. Four residents were found with saturated or soiled incontinence briefs, indicating a lack of regular care. Resident #66, with severe cognitive impairment, was found with a saturated pull-up and no care plan addressing incontinence. Resident #44, who was alert and oriented, reported not having a diaper change since the previous night, despite being dependent on staff for ADL care. Resident #49, with severe cognitive impairment, was found with a soiled brief containing urine and feces. Resident #29, also with severe cognitive impairment, was found with a saturated brief, and CNA #2 acknowledged that incontinence rounds should occur every two hours. The facility's policy on Activities of Daily Living (ADLs) requires that care plans address ADL needs and goals, including incontinence care. However, the observations revealed that the facility did not adhere to this policy, as evidenced by the lack of timely incontinence care for the residents. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that incontinence rounds should be conducted every two hours, but this was not consistently done, leading to the deficiencies observed by the surveyors.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #66, #44, #49, and #29 are having their [R] Ex Order 26.4b1 provided as per their plan of care. 2. Other Areas Affected: All residents who are incontinent have the potential to be affected by this practice. 3. Systemic Changes to Prevent Future Occurrences: DON/Designee has re-educated the nursing staff on incontinence care and documentation requirements. This information is included in the staff and agency Orientation program as well. An initial audit of incontinent residents has been completed by DON/Designee for care plan completion and compliance with identified toileting program. 4. Monitoring of Corrective Action: DON/Designee will conduct weekly observation audits x 4 then monthly x 2 of 5 incontinent residents on various shifts to verify incontinence care has been provided as per their plan of care. Results of the audits to be reviewed monthly at the facility's monthly Quality Assurance Improvement Meetings.
Inaccurate MDS Completion for Resident's Pneumococcal Vaccine Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident, who was admitted with a diagnosis including a urinary tract infection, had a quarterly MDS indicating intact cognitive functioning and that the pneumococcal vaccine was offered and declined. However, upon review, there was no documentation in the electronic medical record or hard chart regarding the pneumococcal vaccine. This discrepancy was identified during a surveyor's review of the resident's records. The Director of Nursing (DON) stated that vaccine acceptance, refusal, and education are documented in the resident's records, but this was not found for the resident in question. The MDS Coordinator, upon being questioned, was unable to locate the resident's information and later admitted that the MDS needed correction to reflect that the pneumococcal vaccine was not offered. The facility's policy on pneumococcal vaccination requires documentation of vaccination history and education, which was not adhered to in this case.
Plan Of Correction
1. Corrective Action of Areas Affected: The MDS Coordinator has reviewed and corrected the MDS for Resident #41 to accurately reflect the [R] status. 2. Other Areas Affected: All residents have the potential to be affected by the deficient practice. 3. Systemic Changes to Prevent Future Occurrences: DON/Designee has re-educated the MDS department on the accurate documentation of vaccine offerings, acceptances, and refusals. An initial house wide audit has been completed for accurate reflection of pneumococcal vaccination status in the MDS assessment. 4. Monitoring of Corrective Action: DON/Designee to conduct monthly audits x 4 of MDS assessments completed during that month for MDS accuracy of pneumococcal vaccination. Results of the audits to be reviewed at the facility's monthly Quality Assurance Improvement Meetings.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with congestive heart failure, chronic obstructive lung disorder, and anemia. The resident was observed receiving oxygen therapy at incorrect flow rates on multiple occasions. Initially, the resident was seen receiving oxygen at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Later, the resident was observed receiving oxygen at 4.5 LPM, which was also incorrect. The resident's assigned nurse confirmed that the physician's order specified a continuous flow rate of 2 LPM via a nasal cannula. The nurse acknowledged responsibility for setting and monitoring the oxygen flow rate and suggested that someone might have accidentally adjusted it. The facility's procedure required staff to verify the physician's order before setting the flow rate, but this was not adhered to, leading to the deficiency.
Plan Of Correction
1. Corrective Action of Areas Affected: For resident #6, orders have been updated to check the Ex Order26.451 being administered every shift by the nurse. 2. Other Areas Affected: All residents requiring oxygen have the potential to be affected by the deficient practice. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing/designee has re-educated the licensed nursing staff on the oxygen administration policy. The Director of Nursing/designee has conducted an initial audit for residents with physician orders for oxygen to validate oxygen is being administered as per MD order. 4. Monitoring of Corrective Action: The Director of Nursing/designee will complete random observations of residents with oxygen orders to verify oxygen is being administered as per the MD order weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly at the Quality Assurance Improvement Meetings for review and recommendations.
Medication Administration Errors with Insulin Pen-Injectors
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%. During an observation, a surveyor noted that three errors occurred out of 25 opportunities, involving two residents and one nurse. The errors were related to the improper administration of insulin using pen-injectors. The nurse did not follow the manufacturer's specifications for priming the pen-injector and holding it in place for the required time, which could affect the insulin dosage. For Resident #46, the nurse primed the insulin pen-injector incorrectly by holding it in a slanted downward position instead of upright, as required by the manufacturer's instructions. The nurse also failed to hold the pen-injector in place for the recommended five seconds after injection, potentially leading to an inaccurate dose. The resident had a physician's order for insulin lispro to be administered according to a sliding scale based on blood sugar results. Similarly, for Resident #38, the nurse repeated the same errors with both insulin lispro and insulin glargine pen-injectors. The nurse did not hold the pen-injectors upright during priming and removed them from the skin too quickly after injection. The resident had orders for both types of insulin, with specific dosages to be administered based on blood sugar levels and at scheduled times. These deficiencies were acknowledged by the facility's Interim Director of Nursing and Regional Clinical Nurse, who confirmed the importance of following the manufacturer's instructions for insulin administration.
Plan Of Correction
1. Corrective Action of Areas Affected: Facility cannot retroactively fix the procedure for administration for resident #38 and #46. RN#1 has been re-inserviced on the process for administration. 2. Other Areas Affected: All residents receiving insulin have the potential to be affected by this deficient practice. 3. Systemic Changes to Prevent Future Occurrences: Licensed nursing staff have been re-educated on medication administration policies and procedures, including insulin administration. The Director of Nursing/designee has completed medication administration competencies for licensed nursing staff related to insulin administration. 4. Monitoring of Corrective Action: The Director of Nursing/designee will randomly monitor licensed nursing staff for proper priming of insulin pens and administration of insulin to residents weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer or document the administration or refusal of the pneumococcal vaccine for two residents, leading to a deficiency in immunization practices. Resident #58, who was admitted with dementia and diabetes mellitus, had a severe cognitive impairment with a BIMS score of 7 out of 15. The facility's records did not indicate whether the pneumococcal vaccine was up to date, and there was no documentation of the vaccine being offered or declined. The Director of Nursing (DON) confirmed that the vaccine had not been administered or offered, and no declination form was available. Resident #41, who had intact cognitive functioning with a BIMS score of 13, was also not properly documented regarding the pneumococcal vaccine. Although the resident's MDS indicated the vaccine was offered and declined, there was no documentation in the electronic medical record or hard chart. The DON was unable to confirm if education about the vaccine was provided after the refusal. The facility's policy required documentation of vaccine history, education, and refusal, but these steps were not followed for the residents in question.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #58 and #41 were educated by the licensed nurse regarding the NJ Ex Order 26.4b1 and consents, and NJ Ex Order 26.4b1 have been offered and administered as ordered. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit on current residents to validate that the pneumococcal vaccinations were offered. If an eligible resident did not receive the pneumococcal vaccinations, the physician has been notified, orders placed, and consents obtained. 3. Systemic Changes to Prevent Future Occurrences: Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the policies for the pneumococcal vaccinations. 4. Monitoring of Corrective Action: The Director of Nursing/designee will conduct weekly audits on x4, then monthly x2 on all new admissions to validate that the pneumococcal consents and vaccinations were offered. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey State Department of Health (NJDOH) for an incident involving a resident on 6/4/24. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had multiple diagnoses including legal blindness, contractures, and spinal stenosis. The resident was dependent on assistance for daily activities and had an unwitnessed fall, resulting in a small abrasion on the forehead and complaints of neck pain and a headache. The resident was subsequently sent to the hospital and admitted for encephalopathy. Despite the incident, no report was filed with the NJDOH, and the facility's Director of Nursing (DON) was unable to provide evidence of prior documentation of the resident's spastic movements, which were observed but not care planned. The facility's policies on abuse prohibition and accidents/incidents require that injuries of unknown source be reported to the appropriate state and local authorities within 24 hours if they do not result in serious bodily injury. However, the DON confirmed that no report was filed for the unwitnessed injury of unknown origin. The investigation report lacked a conclusion and did not include a statement from the resident, who was incoherent at the time of the incident. The facility's failure to report the incident and document the resident's condition prior to the fall contributed to the deficiency identified by the surveyors.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #75 is [R] in the facility. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Director of Nursing and Administrator have reviewed incidents of unknown origin retroactive to 6/1/24 and verified other incidents have been reported as required. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing and Administrator are reviewing incidents, including those of unknown origin at daily Clinical Meeting to verify incidents meeting reporting criteria are reported to the appropriate agencies. The Director of Nursing and Administrator report events as per guidelines and have been re-inserviced by the Market Clinical Advisor on reporting incidents of unknown origin. 4. Monitoring of Corrective Action: The Director of Nursing or designee will complete an audit of incidents weekly x4 weeks, then monthly x2 months to verify incidents meeting reporting criteria are reported to the appropriate agencies. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Staffing Shortages Lead to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient staffing levels to administer medications in a timely manner, as required by physician orders. This deficiency was identified during a complaint investigation for one of two residents reviewed for Activities of Daily Living (ADL). The report highlights that the facility did not meet the minimum staffing requirements set by New Jersey law, which mandates specific staff-to-resident ratios for different shifts. During the week of June 23 to June 29, 2024, the facility was found to be deficient in Certified Nurse Aide (CNA) staffing on several day shifts and in total staff on one evening shift. This staffing shortfall contributed to delays in medication administration for residents. The Medication Administration Audit Report (MAAR) for the same week revealed multiple instances of delayed medication administration. For example, on June 25, 2024, medications such as Quetiapine and Clonazepam were administered several hours later than scheduled. Similarly, on June 29, 2024, medications including Quetiapine, Fluoxetine, Macrobid, and Keppra were administered late. The Director of Nursing acknowledged that these delays were due to short staffing caused by a mass exit of staff. The facility's policies, including the Staffing Center Plan and Facility Assessment, were reviewed but did not provide further information on how staffing levels were determined to meet patient needs.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility is scheduling sufficient staff in order to administer medications in a timely manner, and to meet staffing ratios. 2. Other Areas Affected: The Administrator reviewed CNA staffing ratio compliance from 12/3/24- 12/9/24 to determine if any other shifts did not meet minimum requirements. 3. Systemic Changes to Prevent Future Occurrences: The [R] has been re-educated on the staffing requirements and CNA ratios. 4. Monitoring of Corrective Action: A weekly audit will be conducted by the NHA/designee to determine if the CNA to resident ratio is being met for the next 30 days and verify that sufficient licensed staff were scheduled to administer medications timely. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.
Deficiency in Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report. The report highlighted multiple instances where the facility did not meet the staffing requirements for certified nurse aides (CNAs) and total staff across various shifts. Specifically, the facility was found to be deficient in CNA staffing for residents on several day shifts, as well as in total staff for residents on some evening and overnight shifts. The deficiency was observed over multiple weeks, with specific dates and staffing numbers provided. For example, on certain days, the facility had significantly fewer CNAs than required for the number of residents present. This pattern of insufficient staffing was consistent across different weeks, indicating a systemic issue rather than isolated incidents. The report detailed specific instances where the number of CNAs and total staff fell short of the mandated ratios, such as having only 2.1 CNAs for 57 residents on a day shift when at least 7 CNAs were required. The Director of Nursing was aware of the staffing ratio criteria, as discussed with the surveyor. However, the facility continued to operate below the required staffing levels, leading to the noted deficiencies. The report does not mention any corrective actions or plans to address these staffing issues, focusing solely on the observed deficiencies and the facility's failure to comply with state staffing mandates.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concerns related to not meeting the minimum CNA staffing requirements. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. On a daily basis, the Staffing Coordinator, Administrator and Director of Nursing review staffing patterns for the current and upcoming days and strategize accordingly in order to start each shift at or above the minimum CNA requirements to the fullest extent possible. 3. Systemic Changes to Prevent Future Occurrences: The facility has implemented a weekly Staffing Committee including the Staffing Coordinator, Director of Nursing, Administrator and Corporate Recruiters and have initiated recruitment/retention strategies for all staff with special focus on nurses and CNAs. Strategies include establishing relationships with local CNA schools, competitors salary analysis, addressing absenteeism, employee recognition/retention, and agency utilization. 4. Monitoring of Corrective Action: The Administrator will submit a report weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Deficiency in New Hire Health Examinations
Penalty
Summary
The facility failed to comply with the mandatory infection control and sanitation requirement by not ensuring that newly hired employees received a health examination within the required time frame. Specifically, 9 out of 10 new employees did not receive an examination by a physician or advanced practice nurse within two weeks prior to their first day of employment or upon employment. Additionally, these employees did not receive a nursing assessment by a registered professional nurse on their first day of employment, which would have allowed for a deferral of the examination for up to 30 days. The Director of Nursing was unable to provide evidence of the required health examinations for these employees, and no facility policy and procedures for new hire health examinations were available to the surveyor.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concerns related to new hires no longer employed by the facility who did not receive a NJ Ex Order 26.4b1 in accordance to Federal/State regulations. The Staffing Coordinator/HR was re-inserviced on ensuring new hires obtain a health history/physical in accordance with federal and State regulations. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The facility conducted an audit of all employee files to verify the required health history/physical is present. Those identified in need will be obtained. 3. Systemic Changes to Prevent Future Occurrences: A new hire checklist has been implemented including health history/physical and other necessary information required upon employment. The Staffing Coordinator/HR is ensuring the required health history/physical has been obtained prior to employees beginning Orientation. 4. Monitoring of Corrective Action: The Staffing Coordinator/HR will complete an audit weekly x4 weeks, then monthly x2 months of new hires to verify the required health history/physical has been obtained prior to employees beginning Orientation. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Administer Required Tuberculin Skin Tests to New Employees
Penalty
Summary
The facility failed to comply with mandatory infection control and sanitation requirements by not administering a two-step Mantoux tuberculin skin test to 7 out of 10 newly hired employees before their first day of employment. This deficiency was identified during a record review and interview conducted by a surveyor. The Director of Nursing (DON) was unable to provide evidence of the required testing for these employees. Additionally, the facility did not have a policy in place for the screening of new employees as per the relevant executive order.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concerns related to new hires no longer employed by the facility who did not receive the required [R] in accordance to Federal/State regulations. The Staffing Coordinator/HR was re-inserviced on ensuring all new hires obtain a [R] in accordance with federal and State regulations. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current employee files to verify the required tuberculosis screening has been completed. Documentation was not present on all employees, and their PPD has been properly administered. 3. Systemic Changes to Prevent Future Occurrences: A new hire checklist has been implemented including tuberculosis screening and other necessary information required upon employment. The Staffing Coordinator/HR is ensuring the required tuberculosis screening has been completed prior to employees beginning Orientation. 4. Monitoring of Corrective Action: The Staffing Coordinator/HR will conduct weekly audits x4 weeks, then monthly x2 months of new hires to verify the required tuberculosis screening has been completed prior to employees beginning Orientation. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Latest citations in New Jersey
A resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
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