Alaris Health At Belgrove
Inspection history, citations, penalties and survey trends for this long-term care facility in Kearny, New Jersey.
- Location
- 195 Belgrove Drive, Kearny, New Jersey 07032
- CMS Provider Number
- 315366
- Inspections on file
- 20
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alaris Health At Belgrove during CMS and state inspections, most recent first.
Staff did not consistently document completion of physician-ordered treatments on the TAR, specifically failing to record that the call bell was within reach for three residents with various medical conditions. Facility leadership and nursing staff confirmed that required documentation was missing, despite facility policy mandating that all care and treatments be properly recorded.
A facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident, with staff unfamiliar with the equipment's use. Additionally, oxygen concentrator filters for three residents were found unclean, despite documentation indicating otherwise. These deficiencies highlight a failure in ensuring the availability of critical medical supplies and equipment maintenance.
A facility failed to meet delayed egress locking requirements when an exit door did not sound an audible alarm after 15 seconds of pressure was applied. This issue had the potential to affect staff and 12 residents. A staff member confirmed the finding and stated the facility was unaware of the malfunction.
A facility failed to maintain the fire resistance rating of stairwells as required by NFPA 101. A door in a five-story stairwell lacked the necessary latching fire exit hardware and was instead secured by a magnetic locking device. The facility was unaware of the requirement for latching hardware, and the issue had the potential to affect 40 residents.
The facility failed to maintain smoke and heat detectors according to NFPA standards, as observed in the elevator equipment room where the devices were hanging from wires and not securely attached. This issue had the potential to affect 120 residents, and the responsible individual was unaware of the deficiency.
The facility's sprinkler system was found to have two unsupervised outside screw and yoke (OS&Y) valves, which could prevent staff from knowing if the system was impaired. The domestic and sprinkler riser water line shared the same main water line from the city, and the main water riser room was located in a corporate office storage room. This deficiency had the potential to affect 88 residents.
The facility failed to provide residents with transfer notices that included appeal rights information. Nine residents transferred to hospitals for various medical reasons did not receive notices with necessary appeal details, such as contact information for the entity handling appeals. Interviews with staff confirmed the omission, as they believed compliance was met through other means.
The facility failed to provide residents with bed hold notices that included the cost per day, affecting nine residents transferred to hospitals for various medical reasons. The facility's policies did not specify the daily rate, and the Administrator acknowledged the omission, believing it was justified since residents were always allowed to return.
The facility failed to ensure residents with severely impaired cognition understood binding arbitration agreements before signing. Four residents with low BIMS scores signed agreements without the cognitive capacity to comprehend them. In some cases, family members or friends, who lacked legal authority, provided verbal consent for the residents to sign. The facility's staff confirmed the residents' inability to understand the agreements, and the Administrator acknowledged the deficiency.
The facility failed to maintain a functional Antibiotic Stewardship Program, as it did not document whether infections met the McGeer criteria for appropriate antibiotic treatment over a four-month period. Despite having a policy emphasizing the importance of antibiotic stewardship, the facility did not ensure that unit managers completed and submitted the necessary documentation, potentially leading to unnecessary antibiotic prescriptions.
A facility failed to update a resident's advanced directive from full code to DNR in the medical records, despite the resident's documented wishes on a POLST form. The resident, with moderately impaired cognition, expressed a desire not to be resuscitated, but the EMR and paper chart continued to indicate a full code status. Staff interviews confirmed the discrepancy, highlighting a failure to align the medical records with the resident's expressed wishes.
A facility failed to provide a written summary of a baseline care plan to a resident and their family within 48 hours of admission, despite completing the care plan on time. Interviews revealed that the Social Services Director did not document the provision of the care plan, and the Director of Nursing confirmed the expectation for a written summary to be given. The facility's policy requires a baseline care plan and summary to be provided within 48 hours, which was not followed.
A facility failed to develop a care plan with specific goals and interventions for a resident using antipsychotic medication. The resident, with diagnoses of hallucinations and schizoaffective disorder, had an order for Quetiapine Fumarate. Despite a Care Area Assessment trigger, the care plan lacked necessary goals and interventions. The MDS Coordinator acknowledged the oversight, which was against the facility's policy requiring measurable objectives for psychotropic medication use.
The facility failed to properly store medications, with loose tablets and capsules found in medication carts for the 300 hall rooms. LPNs were responsible for destroying these unsecured medications but could not determine their ownership. Interviews revealed that it was the responsibility of all nurses to ensure medication carts were clean and that loose pills should be disposed of in the drug buster solution, as per facility policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a dialysis resident, risking cross-contamination. The resident, with end-stage renal disease, had no EBP order or PPE signage, and staff did not use gowns during care. Despite facility policy requiring EBP for residents with indwelling devices, staff misunderstood CDC guidelines, leading to this deficiency.
Failure to Document Physician-Ordered Treatments on TAR
Penalty
Summary
Facility staff failed to document the completion of physician-ordered treatments on the Treatment Administration Record (TAR) for three residents. Specifically, there were blank entries for the order to keep the call bell within reach every shift, as required by physician orders and facility policy. These omissions were identified during a review of the TARs for multiple months, where specific shifts lacked documentation that the call bell was within reach for each resident. The residents involved had various medical conditions, including acute pyelonephritis, depression, hypertension, chronic kidney disease, restless legs syndrome, type 2 diabetes, major depressive disorder, hyperglycemia, encephalopathy, transient ischemic attack, cerebral infarction, acute kidney failure, hyperlipidemia, and COPD. Their cognitive and functional statuses ranged from cognitively intact and independent to severely impaired and requiring assistance with activities of daily living. Despite these needs, the required documentation confirming that the call bell was within reach was not consistently completed by staff. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), confirmed that staff did not sign off on the TAR as required by physician orders and facility policy. Nursing staff interviewed acknowledged that they either forgot to document or were unaware of the need to sign off, despite performing the required checks. The facility's Clinical Charting and Documentation Policy required that all services provided be documented, including the name and title of the individual providing care, but this standard was not met in the cited instances.
Deficiencies in Emergency Equipment and Oxygen Filter Maintenance
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, identified as Resident #86. During the survey, it was observed that the required emergency supplies, such as an obturator and appropriately sized inner cannulas, were not available at the resident's bedside or in the supply room. The primary nurses responsible for the care of the resident were not familiar with the obturator or its use, indicating a lack of training and awareness among the staff. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents, identified as Resident #33, Resident #44, and Resident #60. Observations revealed that the concentrator inlet filters for these residents were covered with a gray/white substance, indicating they had not been cleaned as required. The Maintenance Director, who was responsible for cleaning the filters, admitted that the filters had not been cleaned until the day of the survey, despite documentation suggesting otherwise. These deficiencies highlight a failure in the facility's processes to ensure the availability of critical medical supplies and the maintenance of equipment necessary for resident care. The lack of emergency tracheostomy equipment and unclean oxygen concentrator filters posed significant risks to the residents' health and safety.
Plan Of Correction
Resident #86 was provided with the proper emergency equipment at his bedside and nursing staff were educated and competencies were completed. Resident #86 is the only resident currently in Alaris Health at Belgrove with [R]. On 12/3/24 upon receiving notification of the Immediate Jeopardy situation, the Director of Nursing in serviced LPN3 and RN1 assigned to work 3-11 shift on the first floor where Resident #86 resides on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. Director of Nursing and/or Infection Preventionist also inserviced the LPN4 and RN2 assigned to the 1st floor for 12/3/24 11-7 shift on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. This was completed prior to start of the shift. Director of Nursing and/or Infection Preventionist repeated this process for RN3, LPN2 and RN4 assigned to the first floor on 7-3 shift 12/4/24 prior to the start of their shift. Starting on 12/4/24, this education and competency will then be completed on all nurses in the facility. Any nurse caring for Resident #86 will be inserviced prior to the start of their shift. Any nurse that is on leave or vacation will receive this education and competency on their first shift upon return. This education and competency will be incorporated in the orientation process for all new hires starting on 12/4/24. The [R] for residents #33, #44, and #60 were cleaned by the Director of Maintenance and replaced back on the [R]. All residents with tracheostomies and all residents that use oxygen supplementation via oxygen concentrators are potentially affected. Nursing Supervisor will check the supplies in Resident #86 room and any residents with tracheostomy q shift for the next 3 months to assure that all required supplies are present in the room. For Resident #86 these supplies include Tracheostomy Care Kit, Ambubag, Suction Machine, Suction Kit, Normal Saline Bottles, Sterile Water Bottles, Drain Gauze, Sterile Gauze, Inner Cannulas (#6), Tracheostomy Set for Emergency Use (includes outer cannula, inner cannula, obturator, trachea ties, size #5), Corrugated Tubing, Yankeauer Suction Catheter, Velcro Trach Ties, Suction Connecting Tubes, Aerosol Drainage Bag w/ Y-Adaptor and Straight Adaptor. Central Supply Coordinator will maintain a weekly inventory of trach supplies. Inventory will be submitted to the Director of Nursing on a weekly basis for review. Director of Nursing will instruct Central Supply Coordinator on a weekly basis of any supplies that need to be ordered. If a potential admission is identified requiring trach supplies, the Director of Nursing will identify supplies needed and assure supplies are available in building prior to admission. Director of nursing or designee will inservice nurses upon hire and annually on tracheostomy care and care of the tracheostomy in an emergency. Director of nursing or designee inserviced the maintenance department on properly cleaning oxygen concentrators filters. Policy of care of the oxygen concentrator was revised to clean filters weekly by the maintenance department. QAPI was implemented to not only address immediate rectification, but also to maintain an ongoing system to ensure proper trach care and supplies present for residents who need. Within this QAPI there will be continued education with all nurses on Trach Care, Emergency Trach Care and supplies needed. The Director of Nursing, Infection Preventionist and/or designee will conduct 5 observations per week of nurses performing trach care and reviewing emergency trach care and supplies starting 12/9/24. Any nurses noted with deviation from standard of practice will be immediately reinserviced and have a successful competency completed prior to being able to care for a resident with a trach. Maintenance director or designee will audit 5 oxygen concentrators weekly to assure they are properly cleaned. Results of these audits will be reported to the Administrator on a weekly basis for review for the next 3 months. QAPI meeting will be held on a monthly basis to ensure proper procedures regarding cleaning of the concentrator filters, trach care, emergency trach care and availability of proper supplies are in place and followed for the next 2 months and quarterly thereafter for the next year.
Removal Plan
- All nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration.
- A nursing supervisor will check the supplies in Resident #86's room to assure all required supplies are present in the room.
- Central supply will maintain inventory of tracheostomy supplies.
- The DON will assure tracheostomy supplies are available prior to admission.
Delayed Egress Lock Failure
Penalty
Summary
The facility failed to meet the delayed egress locking requirements as specified in the NFPA 101 Life Safety Code (2012 Edition). During an observation, it was noted that an exit door between rooms 101 and 118 did not sound an audible alarm after 15 seconds of pressure was applied, as required. The signage on the door indicated that the locks would unlock after 15 seconds and an alarm would sound, but this did not occur. This deficiency had the potential to affect staff and 12 residents. During an interview conducted at the time of the observation, a staff member confirmed the finding and stated that the facility was unaware that the delayed egress lock was not functioning properly.
Plan Of Correction
The delayed egress door for exit between rooms 101 and 118 was repaired to initiate an audible alarm after 15 seconds of pressure is applied to the door. All residents have the potential to be affected by this deficient practice. The Maintenance Director checked all delayed egress doors in the building to assure all had audible alarm after 15 seconds of pressure is applied to the door. All doors were found to be in working order. The Maintenance Director will make monthly rounds to ensure all delayed egress door initiates an audible alarm after 15 seconds of pressure is applied to the door. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Deficiency in Stairwell Fire Resistance Rating
Penalty
Summary
The facility failed to maintain the fire resistance rating of stairwells as required by the NFPA 101 Life Safety Code. During an observation, a door opening into a five-story stairwell was found to lack the necessary latching fire exit hardware. Instead, the door was secured closed by a magnetic locking device. This deficiency was identified during an observation and interview, where it was confirmed that the facility was unaware of the requirement for latching hardware to secure the door in the frame. The magnetic locking device was designed to release upon activation of the fire alarm, allowing the door to swing freely into the exit stairwell. This issue had the potential to affect 40 residents.
Plan Of Correction
The proper latching fire exit hardware was installed on the stairwell lower-level annex door. All residents have the potential to be affected. The Maintenance Director audited all stairwell exit doors to assure they had a proper latching fire exit hardware. All other stairwell doors were found with proper latching hardware. The Maintenance Director will make monthly rounds to ensure the proper latching fire exit hardware is installed on all doors. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Deficient Installation of Fire Detection Devices
Penalty
Summary
The facility failed to maintain smoke detectors and heat detectors in accordance with NFPA 101, NFPA 70, and NFPA 72 standards. During an observation, it was found that the smoke detector and heat detector in the elevator equipment room were not securely attached to their device bases and were hanging from the wires. This deficiency was identified during an observation on December 3rd, 2024, at 11:45 AM. The issue had the potential to affect 120 residents. During an interview at the time of the observation, the responsible individual was not aware of the deficient installation.
Plan Of Correction
The smoke detector and heat detector devices were secured to the device base in the elevator equipment room. All residents have the potential to be affected. The Maintenance Director audited all smoke and heat detector devices in the building to assure they were secured to the device base. No additional issues were identified. The Maintenance Director will make monthly rounds to ensure all smoke and heat detector devices are properly secured to the device base. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Unsupervised Sprinkler System Valves
Penalty
Summary
The facility failed to ensure that the sprinkler system was electronically supervised in accordance with NFPA 101, 2012 Edition, Section 19.3.5.1 and section 9.7. During an observation, it was found that the domestic and sprinkler riser water line shared the same main water line from the city. The sprinkler system's water line had two unsupervised outside screw and yoke (OS&Y) valves. Without supervisory devices on these OS&Y valves, the nursing home staff would not be alerted if the sprinkler system was impaired, such as if the water flow was cut off. This deficiency had the potential to affect 88 residents. The main water riser room for both the nursing home and corporate offices was located in a corporate office storage room. During an interview, it was confirmed that the unsupervised OS&Y valves were on the water line for the facility's sprinkler system.
Plan Of Correction
Two tamper switches and two fire sprinkler control valve signs on the OS&Y valves coming from the street were installed. All residents have the potential to be affected. The Maintenance Director will make monthly rounds to ensure all the automatic sprinkler system supervisory attachments are properly installed. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Failure to Provide Appeal Information in Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with written transfer or discharge notices that included the option to appeal the transfer or discharge. This deficiency was identified for nine residents who were transferred to hospitals for various medical reasons, such as dehydration, urinary tract infections, and altered mental status. The notices provided to these residents did not contain essential appeal information, including the contact name, telephone number, or address of the entity to which appeals could be directed. The review of the facility's documentation revealed that the Notice of Emergency Transfer forms lacked the necessary details about the residents' rights to appeal the transfer decisions. For instance, the forms did not include the name, address, and telephone number of the entity that receives appeal requests, nor did they provide information on how to obtain and complete an appeal form. This omission was consistent across all reviewed cases, indicating a systemic issue in the facility's discharge process. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the current forms used for discharge notices did not include the required appeal rights information. The staff believed that the facility was compliant with regulations because residents were given the bed hold policy upon admission and were always allowed to return to the facility. However, the forms used were not in alignment with the guidance provided by the New Jersey Department of Health, which mandates the inclusion of specific contact information for appeal processes.
Plan Of Correction
1/7/25 The Emergency [R] Notice letter was updated to include the appeal information required before NJ Ex Order 26.4(b)(1). Residents R21, R27, R75, R9, R60, R69, R71, R91, R86 were previously provided an Emergency Letter of [R] prior to their discharge. All residents have returned from their NJ Ex Order 26.4(b)(1) stay. All residents discharged/transferred to the hospital have the potential to be affected. The Emergency [R] Notice letter was revised by the Administrator to include more detailed appeal information. The Administrator inserviced the [R] and all facility social workers on the regulatory requirements for the appeal information for Emergency Transfer Notification (ETN) to the resident, the resident's representative and the NJ Long Term Care Ombudsman's office. The Social Service Director will submit the Emergency Transfer Notifications to the Administrator on a monthly basis to assure the appeal information is in the letter. Administrator will audit this on a monthly basis. The Director of Social Services will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Provide Complete Bed Hold Notices
Penalty
Summary
The facility failed to provide residents and their representatives with a written bed hold notice that included the cost per day information, which is necessary for informed consent. This deficiency was identified for nine residents who were transferred to a hospital for various medical reasons, such as severe lethargy, low blood sugar, altered mental status, and respiratory distress. The bed hold notices issued to these residents or their representatives only indicated the length of the bed hold but omitted the daily cost, which is a requirement under Medicaid guidelines. The facility's policy on temporary discharge and bed hold did not specify the daily rate or cost per day for holding a resident's bed during their absence. This omission was consistent across multiple documents, including the facility's Temporary Discharge (Bed-Hold) policy and the Admission Agreement. The lack of this critical information in the bed hold notices and facility policies meant that residents and their representatives were not fully informed about the financial implications of holding a bed during a hospital transfer. During an interview, the facility's Administrator and President of Operations acknowledged that the bed hold notices did not include the reserve bed payment policy. They believed that since residents were given the bed hold policy upon admission and were always allowed to return to the facility, the omission was justified. However, this belief did not align with the regulatory requirements, which mandate that the cost per day must be clearly communicated to ensure informed consent.
Plan Of Correction
Bed hold letter was revised reflecting cost for services for future issued bed hold letters. No corrective measures were done for residents R21, R27, R75, R9, R60, R69, R71, R91, and R86 as residents were issued bed hold letters and have already returned to the facility from their acute care stay. All residents issued bed hold letters have the potential to be affected. U.S. FOIA (b) (6) was in serviced by Administrator on the revised bed hold letter that now includes the bed hold cost. Director of Admission will present all future acute discharged residents and/or responsible parties with the revised bed hold letter. The Administrator will audit 5 residents weekly to ensure the revised letter reflecting bed hold cost was issued. Director of Admissions or designee will review all issued bed hold letters weekly for 3 months then monthly. Results of these audits will be provided to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by Director of Admission or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign binding arbitration agreements. This deficiency was identified for four residents who were assessed to have severely impaired cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. Resident 71 had a BIMS score of six, while Residents 84, 75, and 44 each had a BIMS score of one, all indicating severe cognitive impairment. Despite this, these residents signed arbitration agreements without the necessary cognitive capacity to understand the terms. In the case of Resident 71, the resident's niece was present during the signing but did not have power of attorney. The niece understood the agreement but chose not to sign it herself, allowing the resident to sign instead. For Resident 84, the Admissions Coordinator communicated with the resident's grandson over the phone, who explained the agreement in Spanish to the resident. However, the Admissions Coordinator could not verify the resident's understanding due to the language barrier. Resident 75's daughter, who did not have power of attorney, explained the agreement to her mother in Spanish and permitted her to sign it. Resident 44, who had no legal representative or family, signed the agreement after a friend, contacted by phone, gave verbal consent. Interviews with the Admissions Director and Admissions Coordinator confirmed that these residents lacked the cognitive ability to comprehend the agreements they signed. The facility's Administrator acknowledged that it was unacceptable for residents to sign arbitration agreements without understanding them and stated that such instances should be considered refusals if the resident or their representative did not wish to sign.
Plan Of Correction
1/7/25 The [R] Agreements for R71, R84, R75 and R44 were rescinded. A facility wide audit was completed on all signed [R] Agreements in comparison to Brief Interview for Mental Status (BIMS) Assessment score and were corrected. All residents have the potential to be affected by this deficient practice. The Administrator inserviced the Admissions Department on the proper procedure for conducting Arbitration Agreements in accordance to their Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will audit 3 new admissions per month for accurate Arbitration Agreements signature in accordance to Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will report the results of these audits to the Administrator on a monthly basis. The Minimum Data Set (MDS) Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Failure in Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program that adhered to the McGeer criteria for antibiotic usage over a four-month period. During this time, the facility did not adequately document whether infections met the criteria for appropriate antibiotic treatment. Specifically, in January 2024, only one McGeer surveillance form was completed despite 36 facility-acquired infections being documented. In February, no McGeer forms were filled out for 24 documented infections. Similarly, in March, no forms were completed for 18 infections, and in April, only two forms were filled out for 23 infections. This lack of documentation meant that it was unclear if the infections met the criteria for antibiotic treatment. Interviews with facility staff revealed that the unit managers were responsible for completing the McGeer criteria forms for each facility-acquired infection. However, the Infection Preventionist (IP) nurse noted that these forms were not submitted regularly during the months in question. The Director of Nursing (DON) expected the unit managers to complete and forward these forms to the IP nurse for review. The facility's policy on Antibiotic Stewardship emphasized the importance of appropriate antibiotic use to prevent drug-resistant bacteria, increased hospitalizations, higher mortality, and escalating costs. Despite this policy, the facility's failure to document and review infections according to the McGeer criteria potentially led to unnecessary antibiotic prescriptions.
Plan Of Correction
No residents were identified to be affected by the deficient practice. All residents have the potential to be affected by the deficient practice. All nurses and the Infection Preventionist nurse were in-serviced by the Director of Nursing on completing and submitting the Revised McGeer Criteria for Infection Surveillance Checklist. A Revised McGeer Criteria for Infection Surveillance Checklist is to be completed for each facility acquired infection by unit managers or designee. The Infection Preventionist nurse will ensure a Revised McGeer Criteria for Infection Surveillance Checklist is collected and reviewed for each facility acquired infection. The Director of Nursing will audit the Antibiotic Stewardship Program monthly to ensure a Revised McGeer Criteria for Infection Surveillance Checklist is completed for each facility acquired infection. Results of these audits will be reported to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by the DON or designee to the QAPI committee. Evaluation by the committee will determine the continuing frequency of audits.
Failure to Update Resident's Advanced Directive
Penalty
Summary
The facility failed to update a resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) status. This deficiency was identified for one of nine residents reviewed for advanced directives. The resident, who had a moderately impaired cognitive status, expressed their wish not to be resuscitated if found without vital signs. However, the electronic medical record (EMR) and the paper chart continued to reflect a full code status, contrary to the resident's documented wishes on the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Social Service Director (SSD), revealed discrepancies between the resident's documented wishes and the information in the medical records. The SSD and the Administrator acknowledged that the resident's POLST form, signed by both the resident and their physician, indicated a DNR status, but the EMR and paper chart were not updated accordingly. This oversight had the potential to result in the resident receiving unwanted cardiopulmonary resuscitation (CPR).
Plan Of Correction
1/7/25 Resident #66 medical records were immediately updated to reflect NEX Ord order. All residents with Advance Directives could have the potential to be affected. U.S. FOIA (b) (6) and licensed nursing staff were in-serviced by Administrator or designee on updating Medical Records and Physician Orders with any changes with Advance Directives/POLST. Director of Social Services will present Advance Directive/POLST updates to the team during Morning meeting on a daily basis, and nursing will ensure orders are updated accordingly. Director Of Nursing will conduct audits on a sample of 10 residents per month to ensure that medical records reflect the most updated Advance Directive orders. Director of Social Services or designee will review all resident medical records to ensure Advance Directives are updated weekly for 3 months, then monthly thereafter. Results of these audits will be provided to the Administrator on a monthly basis. Director of Nursing and Director of Social Services will report results of all audits at the quarterly QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. This deficiency was identified for one resident, who was admitted with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, obstructive and reflux uropathy, and dementia. The resident's care plan was completed within the required timeframe, addressing various risks and needs, but the written summary was not provided to the resident or their family member. Interviews with facility staff revealed that the Social Services Director did not document the provision of the baseline care plan to residents or their representatives. The Director of Nursing confirmed the expectation that a written summary should be given within 48 hours of admission. The facility's policy mandates the development of a baseline care plan within 48 hours and the provision of a written summary to the resident and/or their representative, which was not adhered to in this case.
Plan Of Correction
A written summary of the baseline care plan was provided to R203 and [R] representative. All residents have the ability to be affected by this practice. The Administrator inserviced the Interdisciplinary Team members to provide a written summary of the baseline care plan to the resident or resident representative within 48 hours of admission to the facility. The MDS Coordinator will audit 5 admissions per month to ensure a written summary of the baseline care plan was provided to the resident or resident representative. Results of these audits will be provided to the Administrator on a monthly basis. The MDS Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Develop Care Plan for Antipsychotic Use
Penalty
Summary
The facility failed to develop a care plan with resident-specific goals and interventions for the use of antipsychotic medications for one resident. This resident, identified as R69, was admitted with diagnoses including hallucinations and schizoaffective disorder and had an order for Quetiapine Fumarate, an antipsychotic medication. Despite the presence of a Care Area Assessment trigger for psychotropic medication use, the care plan did not include specific goals or interventions related to the use of these medications. During an interview, the MDS Coordinator acknowledged that the care plan for R69 was not updated with the necessary goals and interventions for psychotropic medications. The facility's policy requires that the use of psychotropic medications be reflected in the resident's care plan with measurable objectives. However, the MDS Coordinator mistakenly believed that a goal related to behaviors was sufficient, as the medication was ordered due to behaviors. This oversight was contrary to the facility's policy, which mandates a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident.
Plan Of Correction
The care plan for resident #69 for [R] use was implemented. Unit managers on each unit reviewed all residents on antipsychotic medication to ensure care plans are in place. Those that did not have were implemented. All residents on antipsychotic medication are potentially affected. Director of Nursing inserviced unit managers on care planning all residents with orders for antipsychotic medication. Unit managers or designee will review new admission charts daily for antipsychotic medication and will review residents with new or changes in antipsychotic orders and will implement the care plan. Director of Nursing or designee will review 5 residents on antipsychotic medication weekly to assure care plan is in place and will report all findings to Administrator on a monthly basis. All findings will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of Nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to properly store medications, as evidenced by the presence of loose tablets and capsules in the medication carts for the 300 hall rooms. During an observation, surveyors found four loose tablets and one loose capsule in one medication cart, and ten and a half loose tablets in another cart. These medications were unsecured and not properly accounted for, increasing the potential for drug diversion. Licensed Practical Nurses (LPNs) 5 and 7 were responsible for destroying the unsecured medications using the drug buster solution, but they were unable to determine the ownership of the medications. Interviews with LPN5, LPN7, and the Director of Nurses (DON) revealed that it was the responsibility of all nurses to ensure medication carts were clean and that any loose pills should be disposed of in the drug buster solution. The facility's policy on the disposal and destruction of medication indicated that non-controlled medications, which are expired, refused, or adulterated, should be destroyed by nurses without the need for a second nurse. The policy also outlined the procedure for disposing of unused medications during medication pass. However, the presence of loose medications in the carts indicated a failure to adhere to these procedures.
Plan Of Correction
No residents were affected by this deficient practice. All loose medication were disposed of properly. LPN5 and LPN7 were unable to determine who the medications belonged. Both nurses were inserviced on proper handling of medication cards and the responsibility of keeping their medication carts clean and free of loose medications. All residents with medication orders are potentially affected. Director of Nursing or designee inserviced all nurses on the responsibility of maintaining cleanliness of the medication cart and proper disposal of medication. Inservice will be completed upon hire and annually thereafter. All nurses are to check assigned medication cart on their shift. The unit manager or designee will check med carts once per week to assure compliance with proper medication storage. Unit Managers will check med carts once per week to assure compliance with proper medication storage. The findings of these audits will be reported to the Director of Nursing on a monthly basis. All monthly audits will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident receiving dialysis, which could lead to cross-contamination among vulnerable residents. The resident, identified as R12, was admitted with end-stage renal disease and was receiving dialysis. Despite the resident's care plan and physician orders indicating the need for monitoring and reporting signs of infection, there was no order for EBP, and no signage or personal protective equipment (PPE) was available outside the resident's room. Observations and interviews revealed that staff did not use gowns when providing care to R12, and there was a lack of understanding among staff about the necessity of EBP for dialysis patients. The Director of Nursing and other staff members believed that EBP was not required according to CDC guidelines, despite the facility's policy indicating that residents with indwelling medical devices should be under EBP. This oversight in implementing EBP for R12, who had a dialysis shunt accessed multiple times a week, was a deficiency in infection prevention and control measures.
Plan Of Correction
NJ Ex Order 26.4(b)(1) per facility policy was initiated on 12/5/24 for Resident 12. All dialysis residents with access sites are potentially affected. All staff were inserviced by Infection Preventionist Nurse to ensure all dialysis residents with access sites have enhanced barrier precautions per facility policy. All dialysis residents with access sites will be placed on enhanced barrier precautions per facility policy. Unit Manager and/or designee will be responsible to assure residents with dialysis access sites are identified and have physicians order for enhanced barrier precautions on admission and with status changes. Infection Preventionist and/or designee will make rounds weekly on dialysis patients to assure compliance with enhanced barrier precautions. Results of these audits will be reported to the Administrator on a monthly basis. The Infection Preventionist will report the results of these audits quarterly during the QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
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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