Avalon Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, New Jersey.
- Location
- 1059 Edinburg Road, Hamilton, New Jersey 08690
- CMS Provider Number
- 315223
- Inspections on file
- 19
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Avalon Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that residents were seen by their attending physician or NP at the required intervals, nor that progress notes were consistently documented in the EMR. Several residents, including those with severe cognitive impairment and complex medical needs, lacked physician notes for extended periods, and staff confirmed that expected documentation and visits were missing. Facility policy required timely visits and documentation, but these requirements were not met for multiple residents.
A resident with dementia and diabetes was repeatedly observed in bed without the required fall mat in place, despite a care plan and physician order mandating its use. Nursing staff confirmed the fall mat should have been on the floor whenever the resident was in bed, but it was found leaning against the wall on multiple occasions.
A resident with ESRD and multiple comorbidities repeatedly missed scheduled medications, supplements, and blood glucose monitoring because administration times conflicted with dialysis appointments. Nursing staff documented missed doses due to the resident being out for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule, contrary to facility policy and professional standards.
A resident with hypertension and heart failure did not receive 14 doses of a prescribed antihypertensive medication due to unavailability, with missed doses documented in the MAR and no evidence that the physician was notified. The resident was later transferred to the hospital for uncontrolled hypertension and diagnosed with a hypertensive emergency. Nursing staff confirmed the medication was not available, and facility leadership was unaware of the issue until the survey.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive an initial comprehensive visit from a physician within the required 30-day period after admission. Review of records and staff interviews confirmed that only a "HISTORY AND PHYSICAL" by an APN was available, with no timely physician documentation, in violation of both federal regulations and facility policy.
Staff did not consistently document care provided to a resident in the Point of Care (POC) system, leaving multiple blank entries across several shifts. Interviews confirmed that CNAs are expected to record all ADLs in the POC, and that missing documentation means the policy was not followed. The facility's policy requires complete documentation of care, but this was not done for the resident in question.
The facility did not meet the required CNA-to-resident staffing ratios for 14 consecutive day shifts, consistently scheduling fewer CNAs than mandated by state law for the number of residents present. This deficiency was identified through review of staffing records and interviews, and had the potential to affect all residents.
A resident with respiratory failure and COPD did not receive prescribed continuous oxygen therapy when the oxygen concentrator was found off, resulting in the resident being unresponsive with low oxygen saturation. The care plan lacked documentation of oxygen supplementation, and staff did not ensure the concentrator was operating as ordered.
A resident with severe cognitive impairment required assistance with bathing and dressing but frequently refused care, leading to family concerns about hygiene. Although staff were aware of the refusals and communicated with the family, the facility failed to document the grievance or follow its policy for investigating and responding to complaints, and the Administrator was not informed.
A resident with respiratory diagnoses and an order for oxygen therapy did not have their care plan updated to reflect the use of oxygen, despite documentation in the medical record and physician orders. Staff interviews confirmed that the care plan should have been revised to include this intervention, in accordance with facility policy.
A resident with severe cognitive impairment and multiple respiratory diagnoses was found to be receiving oxygen at 3 L/min instead of the physician-ordered 2 L/min. The discrepancy was identified when the nasal cannula was observed out of the nostrils and the concentrator set incorrectly. Staff interviews revealed that the oxygen flow rate was not checked as required by facility policy, resulting in a failure to follow the physician's order.
A resident in a long-term care facility reported being pushed by a CNA, causing hot coffee to spill on them. Despite the resident's cognitive intactness and clear report of the incident, the facility failed to investigate or report the abuse in a timely manner, allowing the CNA to continue working. This failure to follow the facility's abuse prevention policy resulted in Immediate Jeopardy.
Two residents suffered burns due to inadequate supervision and safety measures while handling hot liquids. One resident experienced burns on two occasions while heating coffee in an unlocked nutritional room, and another resident sustained a burn while transporting coffee from the dining room. Both residents had intact cognition, but the facility failed to enforce safety policies, leading to these incidents.
The facility failed to secure a medication cart and remove expired items from a storage room. An unlocked cart was left unattended at a nurses' station, and several expired medical supplies were found in a storage room. The RN responsible was unaware of the unlocked cart, and the Unit Manager missed the expired items during routine checks.
The facility failed to accurately complete Medicare Part A forms for a resident and two residents, omitting essential information such as TTY numbers, QIO names, and facility contact details. The facility's policy lacked instructions on completing these forms, leading to deficiencies in notifying residents about their Medicare coverage and potential liabilities.
A resident, who was cognitively intact, was involved in an altercation with a CNA, resulting in a coffee spill. The resident alleged that the CNA pushed him, causing the spill. Despite the facility's policy requiring immediate reporting of such incidents, the alleged abuse was not reported to the state agency or Ombudsman within the required timeframe. The DON and Administrator confirmed the incident was not reported, citing an internal conclusion of the investigation.
A resident accused a CNA of pushing him, causing hot coffee to spill on his lap. The facility failed to conduct a thorough investigation, as required by policy, leading to a deficiency finding. The Director of Nursing initially dismissed the need for further investigation but later acknowledged the oversight.
A facility failed to ensure the PASARR Level I screen was completed correctly for a resident with schizoaffective disorder. The resident was admitted with a diagnosis of schizoaffective disorder and a BIMS score indicating moderately impaired cognition. However, the PASARR form incorrectly stated there was no major mental illness, which was acknowledged by the Social Services Director. This oversight potentially failed to identify necessary specialized services and appropriate placement.
A resident with major depressive disorder and other health issues did not have an activity care plan reflecting their preference for one-to-one activities. Despite being cognitively intact and dependent on staff for daily activities, the resident's care plan did not include their desire for individualized activities, as revealed through staff interviews and record reviews.
A resident with a complex medical history sustained a second-degree coffee burn while transporting hot coffee in a wheelchair. The facility failed to update the resident's care plan to include necessary interventions, such as reminders for the resident to seek assistance and staff education on cooling hot liquids. Interviews with staff confirmed the oversight, which did not align with the facility's policy on revising care plans as resident conditions change.
A resident with multiple diagnoses, including anoxic brain injury and diabetes, was not weighed according to physician orders, leading to unmonitored weight changes. The facility failed to document weights on several occasions, and the RD was not informed of any weight issues due to the lack of documentation. The Unit Manager's abrupt leave contributed to the oversight, and the facility's policy on weight documentation was not followed.
A resident on Enhanced Barrier Precautions due to an open wound was not provided care with the appropriate PPE by staff. A CNA and an LPN were observed not wearing gowns while providing direct care, despite clear signage and available PPE. The LPN admitted to forgetting the gown in a rush to administer pain medication.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by their attending physician or nurse practitioner at the required intervals, and that appropriate progress notes were documented in the electronic medical record (EMR). For four residents reviewed, there were significant gaps in physician documentation and visits. One resident with severe cognitive impairment and multiple diagnoses, including diabetes and asthma, had no progress notes from the attending physician for a ten-month period. Another resident, also severely cognitively impaired, lacked both a history and physical (H&P) note upon initial admission and re-admission, as well as progress notes from the attending physician for several months. A third resident, who was cognitively intact and had diagnoses of low back pain and anemia, had an H&P and a single progress note from the attending physician, but there were no physician or nurse practitioner notes for several consecutive months, nor evidence of consistent alternating monthly visits as required. This resident also experienced two hospitalizations, after which the expected H&P documentation upon re-admission was missing. The fourth resident, with moderately impaired cognition and diagnoses including anxiety disorder and anemia, had an H&P and a progress note from the physician, but no further notes from either the physician or nurse practitioner for multiple months, and no evidence of the required visit schedule being followed. Interviews with nursing staff and review of facility policy confirmed that the expectation was for physicians to see new admissions within 24-48 hours, complete H&P documentation, and make regular progress notes during rounds. However, staff were unable to locate the required documentation in the EMR for the residents reviewed, and confirmed that the expected physician visits and notes were not present for extended periods. The facility's policy aligned with state and federal regulations, but was not followed in practice for these residents.
Failure to Follow Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the resident's care plan and physician orders. Specifically, a resident with diagnoses including unspecified dementia and Type 2 Diabetes Mellitus with chronic kidney disease was observed multiple times in bed without the required fall mat in place. The care plan and physician order both specified that a fall mat should be positioned on the exit side of the bed at all times when the resident was in bed. However, on several occasions, the fall mat was observed leaning against the wall rather than on the floor as required. Interviews with nursing staff, including an RN and the DON, confirmed that the fall mat should have been in place whenever the resident was in bed, in accordance with the physician's order. The RN stated that the mat was not on the floor due to a broken bed, but could not explain why this prevented the use of the fall mat. The DON and LPN/Unit Manager both affirmed that the fall mat was necessary for resident safety and should be used as ordered. The deficiency was identified through observations, interviews, and review of the resident's medical record and care plan.
Failure to Adjust Medication and Supplement Administration for Dialysis Schedule
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident requiring dialysis by not adjusting medication administration times, nourishment supplementation, and monitoring to accommodate the resident's scheduled dialysis sessions. The resident, who had multiple diagnoses including end stage renal disease (ESRD), diabetes, heart failure, and was dependent on hemodialysis, had medication and supplement orders that conflicted with the times the resident was out of the facility for dialysis. Despite the resident's dialysis schedule being known (Tuesday, Thursday, and Saturday afternoons), there were no physician orders specifying alternative administration times for these days, and medications and supplements were repeatedly not administered as ordered on at least nine dialysis days during the resident's stay. Review of the electronic medication administration record (EMAR) and nursing progress notes revealed that medications such as Hydralazine, Novolog, Coreg, Gabapentin, Prosource, and Nepro, as well as blood glucose monitoring, were not given at scheduled times because the resident was out of the facility for dialysis. Documentation codes and nursing notes indicated the reason for missed doses was the resident's absence for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule. The facility's own policies required that medication administration times be determined by resident need and benefit, and that staff be educated on timing and administration of medications, particularly before and after dialysis. Interviews with nursing staff, the unit manager, the DON, and the administrator confirmed that nurses were expected to review and adjust medication orders with the physician for residents attending dialysis, and that documentation should not simply state that medications were missed due to dialysis. The DON acknowledged that the physician should have been notified to obtain appropriate orders and that the EMAR should not reflect missed medications for scheduled dialysis absences. The deficiency was identified through review of records, interviews, and facility policy, and was specific to one resident reviewed for dialysis services.
Failure to Administer Antihypertensive Medication Resulting in Hospital Transfer
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension and heart failure did not receive 14 doses of a physician-ordered antihypertensive medication, Entresto, over several days. The medication was documented as not administered or unavailable on multiple occasions, with corresponding entries in the Medication Administration Record (MAR) and progress notes. Despite the repeated lack of administration, there was no documentation that the physician was notified about the unavailability of the medication, and the medication was not obtained from the pharmacy or backup supply in a timely manner. The resident subsequently experienced uncontrolled hypertension, presenting with symptoms such as dizziness, generalized weakness, and markedly elevated blood pressure, which led to an emergency hospital transfer. Hospital records indicated a diagnosis of hypertensive emergency, and the medical team questioned compliance with prescribed medications, noting the absence of an exact substitute for Entresto. Interviews with nursing staff confirmed that the medication was not available and not administered, and that there was no documentation of physician notification regarding the missed doses. Further review revealed inconsistencies in MAR documentation, such as doses being marked as administered when the medication was not available, and the use of codes without corresponding physician orders. The Director of Nursing and other facility leadership acknowledged that medication should not be checked off as administered if not given and that the physician should be contacted if a medication is unavailable for several days. However, there was no evidence that the facility conducted a timely review or investigation of the incident prior to the survey, and leadership was unaware of the missed medication administration until informed by surveyors.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Complete Timely Initial Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of a resident conducted an initial comprehensive visit within the required 30-day time period after admission. Review of the electronic medical record and progress notes revealed that the initial physician visit for the resident was not completed within 30 days of admission, as required by federal regulations. The only available documentation was a "HISTORY AND PHYSICAL" signed by an advanced practice nurse, with no further documentation from the physician since the resident's arrival. Interviews with facility staff confirmed that there were no additional physician notes available for the resident during the required timeframe. The facility's own policy, which aligns with federal requirements, states that the attending physician must visit patients at least once every 30 days for the first 90 days following admission. This policy was not followed in the case of the resident identified in the report.
Plan Of Correction
1. Resident #2's initial comprehensive physician visit was completed on 01/07/2024, and as recently as 6/11/25, no negative concerns were identified. 2. All residents have the potential to be affected by this practice. An audit was completed of all current residents to ensure that physician visits occurred within the required time frame. Any inconsistencies were addressed immediately. 3. The facility's admission process has been updated to include a physician visit tracker that flags any upcoming 30-day deadlines for new admissions. U.S. FOIA (b) (6) educated Ex Order 26. 4B1 and medical staff, on facility policy regarding the timeliness of physician visits. 4. The DON or designee will monitor all new admissions weekly for 4 weeks, followed by a monthly audit for 3 months to ensure a physician visit occurs in accordance with facility policy and reported to the Committee for review and action. The QAPI Committee, including the NHA, DON, Medical Director, and Admissions Coordinator, will evaluate trends and determine whether additional interventions or education are needed.
Failure to Document Resident Care in Point of Care System
Penalty
Summary
Facility staff failed to consistently document care provided to a resident in the "Documentation Survey Report v2 (DSR)" and did not follow the facility's policy on Point of Care (POC) documentation. Specifically, for one resident, there were multiple instances where documentation was missing for care provided across several dates and shifts. The electronic medical record review revealed blank spaces in the POC documentation, indicating that care was either not provided or not recorded as required. Interviews with staff, including LPNs and other facility personnel, confirmed that the expectation is for CNAs to document all activities of daily living (ADLs) in the POC system for every shift. Staff stated that refusals of care should be documented in both the care plan and progress notes, and that blank spaces in the POC indicate a failure to document. The staff also acknowledged that the facility's policy was not followed, as documentation was missing for the identified periods. The facility's policy requires CNAs to document resident care in accordance with each resident's individualized plan of care, including self-performance and support for ADLs such as toileting and personal hygiene, as well as bowel and bladder continence. The lack of documentation for the resident in question was confirmed by both record review and staff interviews, establishing that the required documentation was not completed as per policy and regulatory requirements.
Plan Of Correction
1. Resident #2 was assessed that NJ Ex Order 26. 4B1 was provided by licensed nursing staff. The residents continue to receive appropriate care per the plan of care. 2. All residents have the potential to be affected by incomplete or inconsistent documentation by not documenting that incontinent care was provided. A facility-wide audit was completed to ensure POC is completed for all current residents. Any inconsistencies were addressed immediately, and all charts were updated accordingly. 3. All Certified Nursing Assistants were re-educated on the facility's policy titled "Point of Care (POC) Documentation," with emphasis on timely and complete documentation of care tasks, including incontinence care and toileting hygiene. Education will be completed on orientation and as part of annual competencies. 4. The Director of Nursing (DON) or designee will conduct daily audits of POC documentation prior to CNA end of shift for all residents for 5 consecutive days, followed by weekly audits for 3 weeks, and then monthly audits for 3 months. Results of the audits will be documented and reviewed during the facility’s monthly QAPI (Quality Assurance and Performance Improvement). The QAPI Committee, comprised of the NHA, DON, Infection Preventionist, and Medical Director, will oversee the effectiveness of these interventions and recommend additional actions if necessary.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during a 14-day review period. According to the findings, the facility was required to have at least one CNA for every eight residents on the day shift. However, for each of the 14 day shifts reviewed, the number of CNAs scheduled was consistently below the required minimum. For example, on multiple days, only 15 or 16 CNAs were present for 141 to 145 residents, when at least 18 CNAs were needed to meet the mandated ratio. This deficiency was identified through interviews and a review of facility staffing documents. The shortfall in CNA staffing was present on every day shift reviewed within the specified two-week period, affecting all residents in the facility. The report does not provide specific details about individual residents or their medical conditions, but it notes that the deficient practice had the potential to affect all residents due to the facility's failure to comply with state staffing requirements.
Plan Of Correction
1. Corrective Action for Residents Found to Have Been Affected: All staffing coordinators, unit managers, and scheduling personnel were re-educated on state staffing mandates and compliance tracking by the DON on 06/20/2025. 2. Identification of Other Residents Who May Be Affected: All residents in the facility during the day shift may have been affected by insufficient CNA staffing. 3. Measures and Systemic Changes to Prevent Recurrence: Staffing Recruitment: The facility has entered a new collective bargaining agreement as of 06/01/2025 with its union to increase wages $2.00 per hour. Daily Staffing Audits: The Director of Nursing (DON) or designee will review staffing ratios daily by shift and maintain a record to ensure compliance. Recruitment Campaign: A CNA recruitment initiative was launched including sign-on bonuses, referral incentives, job fairs, and outreach to local training programs including tuition sponsorship of nursing assistants, which has had successful outcomes. Through the sponsorship of Nursing Assistant training programs, the facility has successfully recruited and retained nursing assistants who received their Certified Nursing Assistant certification. A new recruiter started on 06/09/2025 who is actively engaging applicants through social media and on-the-spot interviews including weekends. Daily weekday meetings are held to discuss recruitment efforts. Retention Campaign: An employee survey was conducted of 95% of all staff, and results were received to facilitate feedback on actionable insights that help the facility understand, predict, and improve employee satisfaction and engagement to improve staff retention. Additionally, the facility has deployed human resource software through Retain. This software plays a proactive role in keeping employees engaged, utilized, and aligned with organizational goals. It minimizes turnover by addressing the root causes of attrition—overwork, disengagement, lack of growth, and misalignment between employee goals and business needs. Additionally, the facility has an active Employee of the Month program as well as team-building events to foster camaraderie and employee satisfaction. 4. Monitoring of Corrective Actions to Ensure Effectiveness: QAPI Oversight: Staffing ratio compliance will be tracked as a monthly Quality Assurance Performance Improvement (QAPI) indicator and results forwarded to the facility’s QAPI committee. Weekly Review: The DON will present a weekly staffing compliance summary to the Administrator for validation by 06/24/2025 for 30 days. 30-Day Audit: A 30-day audit (ending 07/24/2025) of CNA staffing ratios will be completed and submitted to the QAPI Committee for review and validation.
Failure to Provide Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure, pneumonia, and COPD did not receive care in accordance with physician orders and professional standards. The resident was admitted with an order for continuous oxygen at 5 liters per minute via nasal cannula, but the care plan did not mention oxygen supplementation. On the morning in question, the resident was found unresponsive, diaphoretic, and with blue nailbeds; the pulse oximeter showed an oxygen saturation of 50%. The oxygen concentrator was discovered to be off, though it was plugged in, and had to be turned on by the LPN. The resident required two-person assistance for repositioning and was reportedly unable to reach the concentrator, which was located at the bedside. Staff interviews revealed that the LPN received a report from the previous shift indicating no changes overnight, and the CNA observed the resident with oxygen tubing in place during morning rounds. However, the oxygen concentrator was not operating at the time the resident was found unresponsive. Facility policy required nursing staff to follow physician orders and document care accordingly, but the care plan lacked documentation of the oxygen order, and the facility's oxygen administration policy did not include guidelines for concentrator use. This series of actions and omissions resulted in the resident not receiving prescribed oxygen therapy.
Failure to Address Family Grievance Regarding Resident Hygiene
Penalty
Summary
The facility failed to properly address a family member's concern regarding a resident's bathing and changing of clothes. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1/15, and required supervision and assistance with bathing and dressing. Documentation showed that the resident frequently refused showers and changes of clothing, and staff reported that the resident would only accept care from a specific CNA. Despite these refusals, the family expressed concerns about the resident's hygiene, which were communicated to the Social Worker (SW). The SW informed the family that efforts were being made to resolve the issue, including working with the CNA to assist the resident. However, the SW did not document the conversation with the family, and the Administrator, who served as the facility's grievance officer, was not made aware of the family's concern. The facility's grievance policy required that all grievances be investigated, documented, and responded to in writing, with findings reported to the Administrator within five working days. This process was not followed in this case. Interviews with various staff members, including the Unit Manager, LPN, CNA, and DON, confirmed that the resident often refused showers and changes of clothing, and that refusals were to be documented and communicated. However, there was a lack of documentation regarding the family’s grievance and the facility’s response, and the required notification and investigation procedures outlined in the facility’s grievance policy were not followed. This resulted in the facility failing to honor the resident's right to have grievances addressed without discrimination or reprisal.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, pneumonia, and COPD, was admitted and re-admitted to the facility on multiple occasions. Despite physician orders and progress notes indicating the resident was receiving oxygen at 5 liters per minute via nasal cannula, the care plan did not reflect the use of oxygen. The omission was confirmed during interviews with the Unit Manager, Director of Nursing, and Licensed Nursing Home Administrator, all of whom acknowledged that the care plan should have been updated to include oxygen therapy upon the resident's admission or return to the facility. A review of the facility's policy on comprehensive person-centered care plans indicated that care plans are to be revised as information about the resident and their condition changes. However, the care plan for this resident did not include any mention of oxygen use, despite clear documentation in the medical record and physician orders. The failure to update the care plan was identified through observation, record review, and staff interviews during the survey.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute and chronic respiratory failure, hypoxia, hypercapnia, and COPD was observed receiving oxygen at a rate of 3 liters per minute via nasal cannula, despite a physician's order specifying 2 liters per minute. The surveyor and unit manager found the nasal cannula out of the resident's nostrils and the oxygen concentrator set at 3 liters per minute. The unit manager confirmed the discrepancy after checking the physician's order and adjusted the oxygen flow to the correct rate. The resident's pulse oximeter reading was 99% at the time of observation. Further interviews revealed that the LPN had seen the resident earlier with the nasal cannula in place but did not check the oxygen flow rate. The CNA reported that the oxygen concentrator appeared to be working during rounds. The facility's policy requires nursing staff to follow physician orders and verify oxygen administration procedures, including checking the flow rate. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported that the CNA pushed them, causing hot coffee to spill on their lap. This incident was not properly investigated or reported by the facility, leading to a situation of Immediate Jeopardy. The incident occurred when the resident was in the nutrition room heating up food and coffee. The CNA entered the room to get ice for other residents, and a confrontation ensued. The resident accused the CNA of pushing them, which resulted in the coffee spill. Despite the resident's report of physical abuse, the facility did not suspend the CNA or report the incident to the appropriate authorities in a timely manner. The facility's policy on abuse prevention was not followed, as the incident was not reported within the required two-hour timeframe, and the CNA continued to work for several days after the allegation. The Director of Nursing (DON) acknowledged the failure to act appropriately and confirmed that the incident should have been reported and the CNA suspended immediately.
Removal Plan
- Suspending CNA #1 pending investigation
- Notifying the New Jersey Department of Health of the allegation of abuse
- Educating all staff on the facility abuse policy
Inadequate Supervision and Safety Measures for Hot Liquids
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents handling hot liquids, resulting in multiple burn incidents. Resident #13 suffered burns on two occasions while attempting to heat coffee in a microwave located in an unlocked nutritional room. On the first occasion, Resident #13 experienced a first-degree burn on the pelvic area after an altercation with another resident. On the second occasion, Resident #13 sustained more severe burns, including second-degree burns on the left thigh and penis, when a door bumped into their wheelchair, causing the hot coffee to spill. Resident #40 also suffered a second-degree burn while attempting to transport hot coffee from the dining room to their room. The resident placed the coffee cup inside their wheelchair, which led to the spill and subsequent burn. The incident occurred despite the facility's policy that hot beverages should be served with a lid to prevent spills. Both residents involved had intact cognition, as indicated by their BIMS scores, and were capable of making decisions regarding their activities of daily living. However, the facility's lack of supervision and failure to implement adequate safety measures for handling hot liquids contributed to these incidents. The facility's policies and procedures were not effectively enforced, leading to these preventable accidents.
Removal Plan
- Resident education and care plans updated as indicated.
- The interdisciplinary care team met to discuss hot beverages policy, microwave use, and reviewed trends surrounding hot beverage spills.
- Microwaves were removed from the common area by Maintenance staff/designee.
- The resident council president and residents were made aware by unit managers/interdisciplinary team that microwaves were removed from common areas by maintenance staff/designee and that requests should be made to staff for reheating of food and beverages.
- The resident council/food committee was held. Residents were educated on hot beverage safety and the removal of microwaves from common areas. The residents were educated that dietary staff would reheat meals and beverages upon request to minimize the risk of injury and validate appropriate beverage temps before resident consumption and/or transporting of hot beverages.
- Staff education was initiated and remained ongoing.
- Education on monitoring during meals and during resident transport of hot beverages to assist in minimizing the risk of potential injury and following plan of care.
- Staff were educated to request reheating of meals and beverages from dietary staff. Education to dietary staff regarding reheating food and beverages per policy and facility-initiated process.
- A review was completed of resident incidents with identified residents reviewed. Care plans were in place, and no further variances were noted.
- Kitchen audits related to test trays remain ongoing. Variances addressed as indicated.
Medication Security and Expired Items Deficiency
Penalty
Summary
The facility failed to ensure the security of one of its medication carts and did not remove expired supplements and blood equipment from a medication storage room. An unlocked medication cart was observed at the nurses' station between the 800 and 700 halls. During this time, two staff members were in the office with their backs to the window, and the cart was not in their line of sight. Several staff members and two unidentified residents passed by the unlocked cart, and a CNA accessed it for a straw. The RN responsible for the cart was unaware it was unlocked and reported the incident to the Unit Manager. In the medication storage room between the 700 and 800 halls, several expired items were found, including intravenous catheters, a nutritional supplement, specimen collection instruments, and a viral access spike. The Unit Manager, who usually checks the room twice a week, admitted to missing these expired items during her last inspection. The facility's policy requires that expired medications and biologicals be returned or destroyed, and that all compartments containing medications be locked when not in use.
Inaccurate Completion of Medicare Beneficiary Notices
Penalty
Summary
The facility failed to accurately complete the Medicare Part A form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one resident and the CMS Skilled Facility Nursing Advanced Beneficiary Notice (SNFABN) CMS-10055 form for two residents. For Resident 6, the NOMNC form was missing the TTY number, which is essential for residents who are hard of hearing or deaf to assist them in filing an appeal. Additionally, the form did not include the name of the Quality Improvement Organization (QIO), which is responsible for reviewing appeal information. The SNFABN form issued to Resident 6 by phone was also incomplete, lacking the facility's telephone number and providing insufficient information in the sections for care, reason Medicare might not pay, and cost. Similarly, for Resident 79, the SNFABN form was completed in the same inadequate manner, missing the facility's phone number and providing vague descriptions in the care, reason Medicare might not pay, and cost sections. The facility's policy on Medicare Advance Beneficiary and Medicare Non-Coverage Notices did not provide instructions on how to complete these forms. The 2018 instructions for the SNFABN form and the undated instructions for the NOMNC form specify the necessary information that should be included, such as the facility's contact details and clear, understandable language for the beneficiary.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident, identified as R13, to the state agency within the required two-hour timeframe. R13, who was cognitively intact with a BIMS score of 14 out of 15, was involved in an altercation with a Certified Nursing Assistant (CNA1) in the nourishment room. During the incident, R13 reportedly blocked the entranceway and threatened to pour coffee on CNA1. In the ensuing struggle, R13 spilled coffee on himself and later alleged that CNA1 pushed him, causing the spill. Despite these allegations, the incident was not reported to the state agency or the Ombudsman as required by the facility's policy. The Director of Nursing (DON) and the Administrator confirmed that the incident was not reported, with the DON stating that the staff concluded the investigation internally and did not find it necessary to notify the state agency. However, upon reviewing the statements where R13 reported alleged physical abuse, the DON acknowledged that the incident should have been reported within two hours of staff's knowledge. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or exploitation to the Administrator and relevant authorities, which was not adhered to in this case.
Inadequate Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident, identified as R13, who was cognitively intact with a BIMS score of 14 out of 15. The incident occurred when R13 was in the nourishment room heating coffee, and a CNA entered the room to get ice. R13 accused the CNA of pushing him, causing hot coffee to spill on his lap. The CNA provided a written statement indicating that R13 blocked her path and threatened her, leading her to squeeze past him, which she claimed resulted in the coffee spill. The investigation into the incident was inadequate, as it lacked comprehensive interviews and documentation. The facility's policy required thorough investigation procedures, including interviews with all involved parties and witnesses, which were not fully conducted. The Director of Nursing initially decided not to pursue the investigation further, citing R13's tendency to fabricate stories, but later acknowledged the need to restart the investigation. Interviews with staff and the resident revealed inconsistencies in the accounts of the incident. The CNA denied returning to the nourishment room a second time, contrary to her written statement. The resident, R13, maintained that the CNA pushed him, causing the spill. The facility's failure to adhere to its abuse investigation policy and the lack of a comprehensive investigation placed R13 at risk and resulted in a deficiency finding.
Failure to Complete PASARR Screening Correctly
Penalty
Summary
The facility failed to ensure the Pre-Admission Screen and Resident Review (PASARR) Level I screen was completed correctly prior to the admission of a resident diagnosed with schizoaffective disorder. The resident, identified as R112, was admitted to the facility from the hospital with a diagnosis of schizoaffective disorder and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. Despite this, the PASARR Level I screen submitted by the hospital case worker incorrectly indicated that the resident did not have a diagnosis or evidence of a major mental illness disorder. During an interview, the Social Services Director acknowledged that the PASARR form was filled out incorrectly by the hospital and confirmed that the resident had a long-standing diagnosis of schizophrenia. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process, which was not adhered to in this case. This oversight created a potential failure to identify the specialized or rehabilitative services needed by the resident and whether the placement in the facility was appropriate.
Failure to Develop Activity Care Plan for Resident
Penalty
Summary
The facility failed to develop an activity care plan for a resident, identified as R49, which included the resident's preference for one-to-one activities. This oversight was identified during a review of the resident's records and interviews with facility staff. R49 was admitted with several diagnoses, including major depressive disorder, and was noted to be cognitively intact but dependent on staff for all activities of daily living. The resident's admission activities assessment indicated a preference for one-to-one activities rather than group activities, but this preference was not reflected in the care plan. Interviews with facility staff, including an LPN and the Activity Director, revealed a lack of awareness and follow-through regarding the resident's activity preferences. The LPN was unsure if the resident was on the list for one-to-one visits, and the Activity Director, who was new to the position, admitted to not having developed a care plan that reflected the resident's desires. The facility's policy on comprehensive person-centered care plans was not adhered to, as the care plan did not describe the services needed to maintain the resident's well-being.
Failure to Revise Care Plan After Resident Sustains Coffee Burn
Penalty
Summary
The facility failed to revise the care plan for a resident who sustained a second-degree coffee burn while attempting to transport hot coffee from the dining room to his room. The resident, who had a medical history including diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarct, was not provided with an updated care plan to reflect the incident and the necessary interventions to prevent recurrence. The care plan, last revised in 2014, did not include reminders for the resident to ask for assistance when carrying hot items or the staff education to ensure hot liquids were cooled before being offered to residents. Interviews with facility staff, including an LPN and the DON, confirmed that the care plan should have been updated to include these interventions. The facility's policy on care plans, which mandates ongoing assessments and revisions as resident conditions change, was not adhered to in this case. The failure to update the care plan posed a potential risk to resident safety, as it did not reflect the necessary precautions to prevent similar incidents in the future.
Failure to Document Resident Weights as Ordered
Penalty
Summary
The facility failed to provide quality care in accordance with physician orders for a resident, identified as R78, by not adhering to the prescribed schedule for weighing the resident. R78 was admitted with several diagnoses, including anoxic brain injury and type II diabetes mellitus, and had a feeding tube providing the majority of daily calories. The care plan required weekly weights for four weeks, then monthly weights, to monitor for unplanned weight loss. However, the facility did not document weights as ordered, with missing entries for several dates in May and June. This lack of documentation meant that significant weight changes were not communicated to the Registered Dietitian (RD), who was unaware of any issues due to the absence of recorded weights. Interviews revealed that the RD was not notified of any weight changes because the weights had not been entered into the system. The Unit Manager responsible for documenting weights had left abruptly, leaving work undone, which contributed to the lack of documentation. A Licensed Practical Nurse (LPN) stated that weekly weights were supposed to be recorded by the Unit Manager, and any significant weight differences should have been reported. The facility's policy required weights to be recorded in the medical record, which was not followed, leading to the deficiency.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions. The resident, who was admitted with multiple diagnoses including aftercare for hip replacement surgery, hemiplegia, hemiparesis, diabetes, major depressive disorder, seizures, and cerebral infarct, had an open area on the right buttocks. This condition necessitated Enhanced Barrier Precautions, as indicated by signage outside the resident's room, which instructed staff to perform hand hygiene and don gloves and gowns while providing direct care. During an observation, a Certified Nursing Assistant (CNA) was seen providing a bed bath to the resident without wearing a gown, and a Licensed Practical Nurse (LPN) entered the room to administer pain medication and assist with the bed bath, also without donning a gown. The LPN later admitted to forgetting to wear a gown in the rush to provide timely pain relief. The incident was noted by another LPN, who confirmed the failure to adhere to the PPE requirements. The Infection Preventionist was informed of the incident and conducted a staff in-service on Enhanced Barrier Precautions.
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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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