Birchwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranford, New Jersey.
- Location
- 205 Birchwood Ave, Cranford, New Jersey 07016
- CMS Provider Number
- 315091
- Inspections on file
- 18
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Birchwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in the Memory Care Unit, including missing or broken furniture components, damaged surfaces, and unaddressed maintenance issues in both resident rooms and common areas. Staff interviews confirmed these problems and described a logbook system for reporting repairs, but the environment was not maintained in good repair as required by facility policy.
A resident with dementia and diabetes, who was at risk for nutritional problems, did not receive a physician-ordered Ensure Plus supplement at the scheduled time because it was not available on the medication cart. Staff interviews confirmed the supplement was not administered as ordered due to stocking issues, and the DON stated staff are expected to follow physician orders.
The facility was found to have deficiencies in food storage and kitchen equipment maintenance, potentially leading to foodborne illnesses. Observations included ice accumulation in the walk-in freezer, inconsistent temperature readings in refrigerators, and unclean kitchen equipment. Interviews with staff confirmed these issues, acknowledging the risk of foodborne illnesses and degraded food quality.
The facility failed to consistently document post-dialysis access site assessments for two residents with end-stage renal disease, despite orders to monitor for complications every shift. Observations and interviews revealed inconsistent documentation practices, with missing records over several months. The Director of Nursing acknowledged the documentation issues, and the facility was unable to provide additional evidence of assessments.
A resident with hypotension was prescribed Midodrine with instructions to hold the medication if SBP exceeded 130. Despite this, the medication was administered multiple times without adhering to the SBP parameter. The LPN responsible admitted to errors in the EHR system and was unaware of the need to document held medications. The consultant pharmacist's recommendations to reevaluate the medication were not followed, leading to continued administration outside prescribed parameters.
A surveyor observed infection control deficiencies during medication administration in an LTC facility. An RN failed to perform hand hygiene before and after administering medications, despite Enhanced Barrier Precautions signage. Additionally, a House Keeper did not follow proper handwashing procedures. The facility's policies align with CDC guidelines, but staff did not adhere to them.
The facility failed to maintain a sanitary and homelike environment, with surveyors observing dirty areas in hallways and an unsanitary shower room on the 400 wing. The porter and Director of Housekeeping acknowledged issues with floor maintenance, citing years of wax buildup. The shower room was found with used items left behind, and staff interviews revealed uncertainty about cleaning responsibilities and frequency. Despite some maintenance efforts, issues persisted.
The facility failed to ensure accurate MDS assessments for three residents. A resident with chronic MASD was inaccurately documented as having no skin conditions. Another resident with rectal cancer was not coded for cancer in the MDS, despite medical records indicating its presence. Additionally, a resident who suffered a fall resulting in a fracture was incorrectly reported as having no falls in the discharge MDS. These errors highlight a pattern of oversight in documenting residents' conditions.
A facility failed to create a comprehensive care plan for a resident prescribed an anticoagulant medication. The resident, diagnosed with Atrial Fibrillation, had a physician's order for Apixaban. However, no care plan was in place to address the medication needs. An LPN indicated that the Unit Manager should have completed the care plan, but it was unclear why it was not done. The issue was discussed with the Administrator and DON, but no further information was provided.
A resident admitted with conditions like spinal stenosis and diabetes was identified as high risk for skin breakdown, but the facility failed to document detailed skin assessments and implement a care plan. Despite noted discolorations, preventive interventions were not initiated, and required documentation was incomplete, as confirmed by facility staff interviews.
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Medical records showed that physicians did not sign the monthly orders for April, May, or June 2024. The Wing 2 Unit Manager and the DON confirmed that physicians should sign orders electronically, but this was not done.
Failure to Maintain Homelike Environment and Good Repair in Memory Care Unit
Penalty
Summary
The facility failed to provide a homelike environment in good repair for six residents residing on the Memory Care Unit. Observations revealed multiple deficiencies in resident rooms and common areas, including missing covers on air conditioner/heating units, broken drawers in closets and nightstands, missing or chipped laminate on windowsills and cabinets, partially detached privacy curtains, chipped and missing paint on overbed table stands, and missing baseboards. Additionally, common area issues included missing heating unit covers, torn vinyl on chair cushions, and dried substances on walls. These deficiencies were directly observed by surveyors during their inspection of the unit. Interviews with facility staff, including the Maintenance Director, LPN, CNA, and DON, confirmed the presence of these issues and described the process for reporting and addressing maintenance concerns through a logbook system. The facility's policy requires the maintenance department to keep the building and equipment in safe and operable condition at all times, and to maintain the building in good repair and free from hazards. The observed failures to maintain the environment in good repair had the potential to affect the psychosocial needs of the residents.
Failure to Administer Physician-Ordered Nutritional Supplement
Penalty
Summary
Nursing staff failed to follow physician dietary orders for a resident with dementia and type II diabetes who was identified as having a potential for nutritional problems. The resident's care plan included an intervention to provide an Ensure supplement as ordered, and physician orders specified Ensure Plus twice daily at 9:00 AM and 5:00 PM for protein calorie malnutrition. On the evening of 12/09/25, observation revealed that the resident was not provided the 5:00 PM Ensure Plus supplement with dinner. Interviews with staff indicated that the Ensure Plus supplement was not available on the medication cart at the time it was due. The unit manager obtained the supplement and gave it to the LPN, but the LPN confirmed that the supplement had not been administered because it was not on the cart. The LPN stated it was the nurse's responsibility to ensure the cart was stocked. The Director of Nursing stated that staff are expected to follow physician orders and administer supplements in a timely manner.
Deficiencies in Food Storage and Kitchen Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies related to food storage and kitchen equipment maintenance, which could potentially lead to foodborne illnesses. During the survey, it was observed that the walk-in freezer had sheets of ice on the floor and icicles hanging from the ceiling, condenser fans, and food boxes. Additionally, several boxes of opened food items, such as croissants, turkey burgers, and breaded eggplant, were not labeled with open or expiration dates and were unsealed, covered with snow, frost, and ice crystals. The walk-in refrigerator #1 had inconsistent temperature readings from different thermometers, and a box of bacon was found opened, unsealed, and unlabeled. Walk-in refrigerator #2 was out of service, and there was no plan for its repair, despite communication from the repair service. Further observations revealed that the temperatures of potentially hazardous foods in walk-in refrigerator #1 were above the safe range, with heavy cream and cottage cheese measuring 46.7 degrees F and 50.4 degrees F, respectively. The facility's kitchen equipment was also not maintained in a clean and sanitary manner. The microwave's interior ceiling was covered with multi-color splatter debris, the meat slicer was found with caked-on brown debris despite being covered with a plastic bag indicating it was clean, and the shelf under the griddle had sediment and debris. Interviews with the Food Service Director, kitchen supervisor, clinical dietary manager, and licensed nursing home administrator confirmed the issues with the freezer and refrigerator, acknowledging that these conditions could lead to foodborne illnesses and degrade food quality. The facility's policies on food safety, physical environment, and monitoring of cooler/freezer temperatures were reviewed, highlighting the need for proper labeling, dating, and maintenance of equipment to prevent contamination and ensure food safety.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to properly assess and document the condition of dialysis access sites for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident #55, who has end-stage renal disease and severe cognitive impairment, was observed refusing dialysis due to feeling unwell. Despite having orders to monitor the dialysis access site on the left arm for signs of complications every shift, the facility's records showed inconsistent documentation of these assessments over a two-month period. Similarly, Resident #146, also diagnosed with end-stage renal disease and severe cognitive impairment, had orders to monitor the dialysis access site for complications every shift. However, the nursing progress notes revealed missing documentation for post-dialysis access site assessments over a three-month period. The facility's policy required nurses to monitor and document the status of the resident's access site upon return from dialysis, but this was not consistently done. Interviews with the facility's staff, including the Director of Nursing and registered nurses, confirmed the lack of documentation for post-dialysis assessments. The Director of Nursing acknowledged the poor documentation practices, and the registered nurse admitted to the absence of required documentation in the electronic health records. Despite requests for additional documentation, the facility was unable to provide evidence of consistent post-dialysis assessments, leading to the deficiency finding.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring the accurate administration of Midodrine, a medication used to increase blood pressure, according to the physician's order for a resident with hypotension. The resident, who had severe impaired cognition, was prescribed Midodrine to be administered at bedtime with the condition to hold the medication if the systolic blood pressure (SBP) was greater than 130. However, the medication was administered multiple times over several months without adhering to the SBP parameter, despite the resident's blood pressure readings exceeding the prescribed limit on several occasions. The deficiency was identified through a review of the electronic medication administration records (eMARS) and interviews with facility staff. The LPN responsible for administering the medication admitted to making errors in the electronic health record (EHR) system, stating that they were unaware of the need to document when the medication was held and to notify the appropriate personnel. The LPN had been working with the EHR system for three years but was not familiar with the process of canceling a medication in the system when it was held. The facility's consultant pharmacist had noted the issue in the Medication Review Reports (MRR) for two consecutive months, recommending reevaluation of the resident's need for Midodrine. However, the recommendations were not followed up by the unit manager, leading to continued administration of the medication outside the prescribed parameters. The facility's policy on medication administration required obtaining and recording vital signs and holding medications for vital signs outside the physician's prescribed parameters, which was not adhered to in this case.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration, as observed by a surveyor. A Registered Nurse (RN) was seen preparing and administering medications to residents without performing hand hygiene before or after the process. This occurred despite the presence of Enhanced Barrier Precautions (EBP) signage, which required hand hygiene before entering and exiting rooms. The RN acknowledged the oversight when questioned by the surveyor. Additionally, a House Keeper (HK) was observed improperly washing hands by not following the facility's hand hygiene policy. The HK washed hands for only 12 seconds, turned off the faucet with bare hands, and dried hands on pants, contrary to the policy that requires using a towel to turn off the faucet and drying hands with a single-use towel. The Infection Preventionist (IP) confirmed that the HK had been educated on proper hand hygiene. The facility's policies on medication administration and hand hygiene were reviewed and found to be in line with CDC guidelines, which emphasize the importance of hand hygiene to prevent infection spread. The Director of Nursing (DON) acknowledged the expectation for staff to perform hand hygiene as per the guidelines, especially when dealing with residents on precautions.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for residents, as evidenced by observations of dark, dirty areas in the hallways and doorways of the 400 hallway over several days. The porter responsible for cleaning stated that he had not yet cleaned the 400 wing and was usually the only porter, with a floor technician working only on weekends. The Director of Housekeeping acknowledged the issue, attributing it to years of wax buildup and stated that the floors had only been waxed once in the past three years. She also admitted to not having seen a policy regarding floor maintenance. Additionally, the shower room on the 400 wing was found in an unsanitary condition with used towels, gloves, a clothing item, a used mask, and an opened adult brief left on a shower chair. Interviews with a CNA and an LPN revealed that CNAs were expected to clean up after showers, but there was uncertainty about how often the shower room was checked. The Director of Housekeeping and the Maintenance Director both acknowledged the poor condition of the shower room, with the Director of Housekeeping suggesting the need for new tiles and caulking. Despite some maintenance efforts, dark brown areas remained in the shower stall.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments of residents using the Minimum Data Set (MDS) assessment tool, as evidenced by deficiencies identified in three residents. Resident #94 was observed with chronic moisture-associated skin damage (MASD) in the sacral area, yet the MDS assessment on 7/14/24 inaccurately indicated no skin conditions were present. The MDS Coordinator acknowledged the error, noting that the MASD should have been documented. Resident #37, diagnosed with rectal cancer, had an MDS assessment on 5/17/24 that failed to reflect cancer as an active diagnosis, despite medical records and care plans indicating its presence. The MDS Coordinator admitted the oversight in coding the cancer diagnosis. Resident #586, who suffered a left femur fracture due to an unwitnessed fall, had a discharge MDS on 3/26/24 that incorrectly reported no falls since the prior assessment. Progress notes and a facility investigation confirmed the fall, yet the MDS did not reflect this incident. The MDS Coordinator was informed of the discrepancy and acknowledged the need to address the coding error. These inaccuracies in MDS assessments highlight a pattern of oversight in documenting residents' conditions accurately.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed an anticoagulant medication. During an observation, the resident confirmed taking an anticoagulant medication. A review of the resident's Electronic Medical Records showed that the resident was admitted with a diagnosis of Atrial Fibrillation and had a physician's order for Apixaban, an anticoagulant, to be taken orally every two days. However, the surveyor found no care plan addressing the resident's anticoagulant medication needs. An interview with an LPN revealed that the Unit Manager is responsible for completing care plans, and there should have been a care plan for the resident receiving anticoagulant medication. The LPN was unsure why the care plan was not created. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided.
Failure to Assess and Plan for High-Risk Skin Breakdown
Penalty
Summary
The facility failed to thoroughly assess a skin discoloration identified on an admission assessment and did not implement a care plan for a resident at high risk for skin breakdown. Resident #585 was admitted with conditions including spinal stenosis, muscle wasting, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) indicated the resident was frequently incontinent and required maximum assistance with activities of daily living. Despite being identified as at risk for pressure ulcers, no skin or ulcer injury treatments were documented. The admission assessment noted discolorations on the resident's groin and sacrum, but lacked details such as size and color. The Braden scale score indicated a high risk for skin breakdown, necessitating immediate prevention protocols and care plan documentation. However, the care plan did not include interventions to prevent skin deterioration. The Treatment Administration Record (TAR) lacked documentation of preventive skin care treatments, and a physician's order for weekly skin checks was not properly documented in the electronic medical record. Interviews with facility staff, including the wound care nurse, Director of Nursing (DON), and other nursing staff, revealed a lack of detailed documentation and care planning. The DON confirmed that the admission nurse should have provided a more descriptive assessment and initiated a care plan with preventive interventions. The facility's policy required a pressure risk injury assessment and a full body skin assessment upon admission, with findings documented in the medical record, but these protocols were not followed for Resident #585.
Failure to Sign Monthly Medication Orders
Penalty
Summary
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Specifically, the medical records for five residents showed that their physicians did not hand sign or electronically sign the monthly physician's orders for April, May, or June 2024. This deficiency was identified during a review of hybrid medical records for the residents. The Wing 2 Unit Manager and the Director of Nursing confirmed to the surveyor that physicians should be signing their monthly orders electronically, but this was not done for the specified months.
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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