Atrium Post Acute Care Of Wayne
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 1120 Alps Road, Wayne, New Jersey 07470
- CMS Provider Number
- 315335
- Inspections on file
- 14
- Latest survey
- February 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Atrium Post Acute Care Of Wayne during CMS and state inspections, most recent first.
The facility failed to ensure accurate MDS assessments for several residents, leading to potential unmet care needs. A resident was discharged home, but the MDS inaccurately indicated a return was anticipated. Another resident's MDS incorrectly documented ventilator use, despite the facility not admitting residents on ventilators. Additionally, a resident's MDS inaccurately coded bowel and bladder continence, and another resident's MDS incorrectly indicated Hospice treatment. Staff interviews and facility assessments confirmed these discrepancies.
A facility failed to complete and submit a discharge MDS tracking form within 14 days for a resident with multiple diagnoses, including clostridium difficile and pressure ulcers. The MDS Coordinator and DON acknowledged the requirement, but the discharge MDS was not completed in the required timeframe, contrary to facility policy and RAI manual standards.
A resident was readmitted to the facility with multiple diagnoses, including bipolar disorder, but the PASRR Level I screen incorrectly marked the bipolar diagnosis as 'no'. This error prevented a Level II screening, which is crucial for determining necessary services. Facility staff failed to review the PASRR for accuracy, and there was confusion about responsibility for ensuring accurate screenings.
The facility failed to initiate comprehensive care plans for two residents. One resident receiving IV medication and fluids did not have these needs addressed in their care plan. Another resident, who is Muslim, had dietary restrictions and caregiver preferences that were not included in their care plan. Interviews with staff confirmed these omissions, which were contrary to the facility's care plan policy.
A facility failed to revise a resident's care plan to address a contracture of the left hand. The resident, with severe cognitive impairment and multiple diagnoses, had a physician order for a hand splint to manage the contracture. However, the care plan did not initially include this intervention. Interviews with staff revealed that the contracture should have been addressed, and the care plan was not updated until later.
A resident with a left hand contracture did not receive the prescribed restorative services, including the use of a carrot hand splint, due to miscommunication among staff about responsibility for its application. Despite a physician's order, the splint was not applied, and the care plan initially failed to address the contracture. The resident, who was severely cognitively impaired, was at risk of worsened contracture due to this oversight.
A CNA failed to follow infection control procedures while distributing lunch trays, neglecting to sanitize hands before entering and after exiting rooms with Enhanced Barrier Precautions (EBP). Despite clear signage and prior training, the CNA was unaware of EBP protocols, increasing infection risk among residents.
The facility changed its name on the sign to Alps at [NAME] without obtaining the necessary licensure and certification approval. The administrator admitted they were in the application process but had not completed the CMS-855B form. Documents provided did not include the required approval, and the administrator confirmed the absence of an approval letter from the State Licensure agency.
The facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficiency was observed for four residents with various diagnoses, including Toxic Encephalopathy, Low Back Pain, Schizoaffective Disorder, and Anxiety Disorder. Interviews with the DON and RCNS RN confirmed the orders were not signed as required.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for five residents, which could potentially lead to unmet care needs. Resident 138 was discharged home, but the MDS inaccurately indicated a return was anticipated. Interviews with the Registered Nurse and MDS Coordinator confirmed the error, as the resident was not expected to return. Resident 293's MDS inaccurately documented the use of an invasive mechanical ventilator, despite the resident not using one since admission. Observations and interviews with staff confirmed the facility did not admit residents on ventilators, highlighting a discrepancy in the MDS coding. Resident 295's MDS inaccurately coded bowel and bladder continence, despite the resident having a foley catheter and colostomy. The MDS Coordinator acknowledged the need for accurate coding in such cases. Resident 299's MDS also incorrectly documented the use of a ventilator, similar to Resident 293, despite the resident only using a tracheostomy mask with oxygen. Interviews with staff and review of facility assessments confirmed the facility's policy against admitting residents on ventilators, indicating a pattern of inaccurate MDS coding. Resident 89's MDS inaccurately indicated receipt of Hospice treatment, which was never provided. The MDS Coordinator confirmed the error, and the Director of Nursing emphasized the expectation for accurate and timely MDS coding. The facility's policy on MDS completion, which mandates adherence to the Resident Assessment Instrument (RAI) manual standards, was not followed, leading to these inaccuracies in resident assessments.
Failure to Timely Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete and submit a discharge Minimum Data Set (MDS) tracking form within 14 days of a resident's discharge, as required by the Centers for Medicare and Medicaid Services (CMS) system. This deficiency was identified for one resident out of 37 sampled, referred to as Resident 7. The resident was admitted with diagnoses including clostridium difficile, pressure ulcers, chronic kidney disease, and diabetes. The resident was discharged, but the discharge MDS was not completed and transmitted within the required timeframe. Interviews with the MDS Coordinator and the Director of Nursing revealed that the discharge tracking MDS should have been opened and completed within 14 days of the resident's discharge. The facility's policy, reviewed in July 2024, mandates that MDSs be filled out accurately and timely according to the RAI manual standards. However, the review of the RAI Manual dated October 2024 confirmed that a Discharge Assessment-Return Not Anticipated must be completed within 14 days after the discharge date, which was not adhered to in this case.
Inaccurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASRR) for a resident who was readmitted from an acute care hospital. The resident had multiple diagnoses, including schizoaffective disorder and bipolar disorder, but the PASRR Level I screen incorrectly marked the bipolar diagnosis as 'no' instead of 'yes'. This error led to the resident not qualifying for a Level II screening, which is necessary to determine if special services are needed. The facility's policy requires a Level I screen for all applicants to Medicaid-certified nursing facilities and a Level II evaluation for those who test positive at Level I. Interviews with facility staff revealed a lack of review and verification of the PASRR's accuracy. The Social Services Director and Admission Coordinator admitted to not reviewing the PASRR for accuracy, with the Admission Coordinator only uploading it into the system. The Director of Nursing confirmed the inaccuracy of the PASRR and acknowledged the importance of a Level II screening for determining necessary services. However, there was confusion about who was responsible for ensuring the accuracy of the PASRR Level I and II screenings, indicating a gap in the facility's process for handling these assessments.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were initiated for two residents, R63 and R128, out of a sample of 37. R63, who was admitted with multiple diagnoses including diabetes mellitus and acute respiratory failure, was receiving intravenous (IV) medication and fluids. However, the care plan did not include any problems or interventions related to hydration or IV medication usage. Interviews with LPN1, the MDS Coordinator, and the Director of Nursing confirmed that a care plan should have been developed to guide staff on R63's care needs, but it was not in place. R128, who was admitted with a fracture and identified as Muslim, had specific religious and cultural dietary preferences that were not addressed in the care plan. Despite having an order for no pork or chicken, the care plan did not reflect these dietary restrictions or the need for a female caregiver, as required by her religious beliefs. Interviews with R128, a CNA, the Registered Dietician, and the Dietary Manager revealed that R128 often had to request alternative foods and that her care plan did not include her cultural and religious needs. The facility's policy on the care plan process, last reviewed in September 2024, stated that care plans should incorporate identified problems with appropriate interventions to maintain the resident's highest practicable well-being. However, the care plans for R63 and R128 did not meet these requirements, as they failed to address critical aspects of their care needs, leading to deficiencies in the facility's compliance with care planning standards.
Failure to Revise Care Plan for Resident's Contracture
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident, identified as R91, was revised to address a contracture of the left hand. R91 was admitted with multiple diagnoses, including a contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, and dysphagia. The resident's annual Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a functional limitation in the range of motion of the left upper extremity. Despite these conditions, the comprehensive care plan, which was initiated and revised on specific dates, did not address the contracture of the left hand. The deficiency was identified through a review of physician orders, which included a Restorative Nursing Program (RNP) order for a left carrot hand splint to manage the flexion contracture. Interviews with facility staff, including an LPN and the MDS Coordinator, revealed that the contracture should have been included in the care plan. The MDS Coordinator acknowledged that the care plan was not updated to include the contracture until a later date, and the nurse who took the RNP order should have updated the care plan accordingly.
Failure to Provide Restorative Services for Hand Contracture
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R91, who had a contracture in the left hand. Despite having a physician's order for a Restorative Nursing Program (RNP) to use a left carrot hand splint for four hours on and four hours off daily, the splint was not applied. Observations over several days confirmed that R91 did not have the carrot hand splint on, and it was not present in the room. Interviews with staff, including the Restorative Aide, Assistant Director of Therapy, CNA, LPN, RN, and the Director of Nursing, revealed a lack of clarity and responsibility regarding the application of the splint. The Restorative Aide believed it was the nurse's responsibility, while the LPN and RN indicated that therapy was supposed to apply the splint. The Director of Nursing acknowledged that the splint should have been applied when ordered to prevent further contracture. R91 was admitted with multiple diagnoses, including contracture of the left hand, diabetes mellitus, Alzheimer's disease, dementia, heart failure, hypertension, and dysphagia. The resident was severely cognitively impaired, with a BIMS score of zero out of 15, and had a functional limitation of the range of motion on the left upper extremity. The care plan did not initially address the contracture of the left hand, and the intervention for the carrot hand splint was only added after the deficiency was noted. The facility's policy indicated that restorative nursing programs should prevent the diminution of a resident's ability to perform range of motion exercises unless clinically unavoidable, which was not adhered to in this case.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection control procedures during the distribution of lunch trays on one of the floors, specifically the third-floor unit. Observations revealed that a Certified Nursing Assistant (CNA2) did not sanitize his hands before entering or after exiting rooms, including those with Enhanced Barrier Precautions (EBP) signage. Despite the signage indicating the need for hand sanitization upon entry and exit, CNA2 continued to pass trays without following these protocols. During an interview, CNA2 admitted to not being aware of the EBP and mistakenly believed he had hand sanitizer in his pocket, which he did not. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that proper hand hygiene and the use of personal protective equipment (PPE) are critical in preventing the spread of infections, especially for residents on EBP. The IP and DON emphasized that failure to follow these precautions increases the risk of infection among residents, who are already vulnerable due to their health conditions. The facility's policy and signage clearly outlined the necessary precautions, yet these were not adhered to by CNA2, despite having attended a handwashing and PPE in-service training.
Facility Name Change Without Approval
Penalty
Summary
The facility failed to ensure it received licensure and certification approval before changing the name on the facility's sign. The facility was originally licensed to operate as Atrium Post Acute Care of [NAME] with 209 long-term care beds. However, observations revealed that the sign at the facility's driveway had been changed to read Alps at [NAME], with a banner completely covering the original sign. This change was made without the necessary approval, as confirmed by the facility's administrator. During an interview, the administrator admitted that they were in the application process for the name change but had not yet completed the CMS-855B form, which is part of the approval process. The administrator provided several documents, including letters from an attorney and an application for a long-term care facility license, but none of these documents included the required approval for the name change. The administrator confirmed that they did not have an approval letter from the State Licensure agency, indicating that the name change was not officially sanctioned.
Failure to Ensure Monthly Physician Orders Signed and Dated
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficiency was observed for four residents. Resident #1, with diagnoses including Toxic Encephalopathy and Malignant Neoplasm of Breast and Ovary, had unsigned orders for January, February, and March 2024. Resident #2, diagnosed with conditions such as Low Back Pain and Narcolepsy, also had unsigned orders for December 2023, January, and February 2024. Resident #3, with Schizoaffective Disorder and Type 2 Diabetes Mellitus, had unsigned orders for the same months. Resident #4, diagnosed with Anxiety Disorder and Peripheral Vascular Diseases, had unsigned orders for October, November, and December 2023, as well as March 2024. During interviews, the Director of Nursing (DON) and the Regional Clinical Nursing Services (RCNS) Registered Nurse (RN) acknowledged that the physician orders were not signed and dated as required. The DON stated that all medication orders were signed electronically and should be signed every thirty days. The RCNS RN confirmed that physicians saw their residents but did not write their notes on the same day and was unable to provide documentation of signed orders. The facility's policies, which require physician orders and progress notes to be signed and dated every thirty days, were not followed, leading to this deficiency.
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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