Careone At Cresskill
Inspection history, citations, penalties and survey trends for this long-term care facility in Cresskill, New Jersey.
- Location
- 221 County Road, Cresskill, New Jersey 07626
- CMS Provider Number
- 315313
- Inspections on file
- 15
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Careone At Cresskill during CMS and state inspections, most recent first.
A facility failed to include the bed hold reserve payment amount in written emergency transfer notices for 3 residents who were hospitalized. The transfer letters stated that each resident was entitled to a 10-day bed-hold privilege, but they did not list the reserve payment amount and also referenced insurance the facility did not participate in. One resident had DM and HF, another had orthopedic aftercare and a humerus fracture, and a third had AFib and hypertensive heart disease with HF.
A resident with hydrocephalus, a prior subarachnoid hemorrhage, coordination deficits, dysphagia, and moderately impaired cognition was observed seated in a specialized w/c with the call bell wrapped around the bed side rail and not within reach. The resident could not locate the call bell when asked, and an LPN acknowledged the resident could not reach it and that it should not have been wrapped around the side rail; the resident also had limitations in both upper and lower extremities.
Failure to provide required Medicare non-coverage notice: A resident remained in the facility after signing a NOMNC ending Medicare A coverage, but the SNFABN was not provided in writing. The RN/MDSC stated the SNFABN was her responsibility and that it was usually given only after the resident decided to stay, while the LNHA later said another NOMNC should have been done but was not shown and that no SNFABN was issued because there was no financial liability.
Inadequate monitoring and inappropriate diagnosis for antipsychotic use: A resident with severe cognitive impairment and dementia-related behaviors received quetiapine and divalproex, but the MDS did not show an active diagnosis for the antipsychotic, the care plan did not list target behaviors, and behavior monitoring was not documented when the antipsychotic was started or increased. The psych APRN described restlessness in the evenings without aggression or psychotic symptoms, while the LPN, UM, and DON stated that target behaviors and monitoring should be documented and that restlessness and agitation were not appropriate diagnoses for the antipsychotic.
Failure to Transmit Completed MDS: A resident’s DRNA MDS was completed but not transmitted within the required timeframe. The RN/MDSC confirmed the MDS should have been sent and was unsure of the applicable deadline, and later stated there were no transmission reports because it had not been transmitted. The DON and LNHA were notified of the finding.
MDS assessments did not accurately code diagnoses related to psychotropic meds for four residents. The RN/MDSC said she reviewed psych notes, meds, and diagnoses for coding, but the MDSs still left Section I blank for antidepressant and antipsychotic indications even though records showed orders and psych consults for depression, anxiety, mood disorder, agitation, and adjustment disorder.
Incomplete psychotropic medication monthly documentation was found for a resident with hydrocephalus, subarachnoid hemorrhage, coordination problems, dysphagia, and moderately impaired cognition. The PMMN entries did not match the psychiatric consult note or eMAR, listed incorrect target behaviors such as depressed mood and psychosis instead of restlessness, and omitted required episode counts and a psychiatry consult date. The DON stated nurses were responsible for the notes and that the documentation should match the reviewed month and the resident’s monitored behavior.
Pressure ulcer treatment, documentation, and hand hygiene failures: A resident with severe cognitive impairment and facility-acquired heel and buttock pressure injuries had missing eTAR signatures for ordered wound care, no timely CP for the heel wound, and no CP for the buttock wound. During observed wound care, an LPN used a handwashing method that did not match policy, and a CNA returned room items to the treatment cart without disinfecting them. Staff confirmed the documentation gaps and improper hand hygiene process.
A resident with type 2 DM, gait and mobility impairment, and severely impaired cognition had multiple falls, but new interventions were not implemented and documented in the care plan in a timely manner after several of the events. Records showed delayed additions such as a med review, a directive not to leave the resident unattended in the shower, psych consult, and dycem to the wheelchair, while one fall had no new intervention documented and the care plan did not reflect the resident’s actual falls.
A resident with a PEG tube and severe cognitive impairment received enteral feeding at 50 ml/hr, but staff did not document the actual volume infused each shift. The eMAR showed a flush order for 125 ml q6h that was plotted three times daily instead of q6h, and the enteral feed order was not clarified despite staff signing that 1200 ml had been infused in 24 hours.
A facility failed to post an accurate NHRCSR daily for 2 of 5 observed days. Surveyors found a posted staffing report in the lobby that was dated the prior day and listed an incorrect resident census, and on another day the posted census of 75 did not match the midnight census of 74 confirmed by the Regional Nurse. The DON and LNHA acknowledged the discrepancy, and the facility policy required daily posting of staffing data including the resident census.
A resident with type 2 DM, gait and mobility abnormalities, and severe cognitive impairment did not receive a documented monthly medication regimen review from the pharmacy consultant for one month. The PC binder showed only the initial admission EPIC review, and the DON stated the resident was in the hospital when the PC visited that unit, leaving no documented February MRR.
Medication Administration Error Rate Exceeded Allowed Threshold: Surveyors observed an LPN preparing meds for a resident with cognitively intact status and active orders for PreserVision and Saccharomyces boulardii. The LPN selected multivitamin with minerals tablets instead of PreserVision capsules and Probiotic Acidophilus instead of the ordered probiotic, contributing to an 8% med administration error rate during the observed med pass.
Surveyors found medication labeling and storage deficiencies in two med carts. An unlabeled foil package of albuterol/ipratropium inhalation solution vials was stored in one cart without its original box, and a Humalog insulin pen in another cart had no date of first use or disposal date. The LPN and RN both confirmed the items should have been labeled or dated, and the facility policy required meds to be stored in the packaging in which they are received and opened multi-dose vials to be dated.
Inaccurate documentation of 1 to 1 observation: A resident with hypertensive heart disease and acute myeloblastic leukemia had a grievance-related schedule showing CNA coverage, but the CNA assignment sheet, care plan, and PN did not document any 1 to 1. Staff gave conflicting explanations about whether the 1 to 1 was for safety, suicidal ideation, or simply a temporary companion/customer service arrangement, and the LNHA stated there was no policy for 1 to 1 documentation.
A resident with hydrocephalus, prior subarachnoid hemorrhage, coordination problems, dysphagia, and moderately impaired cognition had no documented influenza vaccine consent, refusal, or ineligibility after the last recorded consent from the prior season. The EMR and paper chart showed the last flu vaccine was given previously, but there were no consent forms or documentation that the RR was contacted for later seasons. The LPN and RN/IPN confirmed the missing documentation, and the facility policy required annual flu vaccination documentation and refusal recording.
The facility failed to provide sufficient nursing staff and timely call bell responses, as reported by residents and confirmed by staff interviews. Residents experienced delays in assistance due to short staffing, particularly during the 3-11 and 11-7 shifts. The facility did not meet New Jersey's mandated staffing ratios, with CNAs responsible for up to 19 residents during the night shift. Grievance reports and staffing assignments further highlighted these deficiencies.
The facility was found deficient in infection control practices, including improper hand hygiene by two LPNs during medication administration, inadequate disinfection of equipment between residents by an LPN, and improper use of disinfecting wipes by an RN. Additionally, a Housekeeping staff member failed to wear full PPE, including eye protection, when entering the room of a COVID-19 positive resident, despite clear signage. These actions were contrary to the facility's policies and CDC guidelines.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in their care assessments. One resident's MDS was completed remotely without an in-person interview, inaccurately reflecting adequate hearing despite observed hearing difficulties. The second resident's MDS did not include a required cognitive interview, despite the resident being sometimes understood. These issues were acknowledged by facility management.
A Registered Nurse in a long-term care facility administered a 500 mg tablet of Ascorbic Acid instead of the prescribed two 250 mg tablets due to unavailability, without consulting the physician. This action was against the facility's policy, which requires medications to be administered as prescribed.
A resident experienced an allergic reaction and requested to be sent to the hospital, but the nurse on duty did not honor this request. Instead, the nurse administered Benadryl without a physician's order and failed to notify the DON or the resident's representative. The resident self-administered an epinephrine pen, which improved their condition. The facility's investigation found that the nurse did not follow proper procedures for medication administration and resident rights.
A resident with end-stage renal disease had medications scheduled during their dialysis sessions, leading to a deficiency in care. Despite the resident's dialysis schedule, medications were signed as administered at times when the resident was not present at the facility. The LPN and RN/UM acknowledged the need to adjust medication times, but the facility's policies did not address this issue, contributing to the deficiency.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident's medication was inaccurately documented, while another had unclear fluid restriction instructions. The facility's policy requires accurate documentation, but entries were not reviewed and updated, resulting in incomplete records.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice care, as required by CMS guidelines. The resident, with multiple diagnoses including Parkinsonism and dementia, was initially in hospice for end-stage polycystic kidney disease. The MDS Coordinator admitted the oversight, and facility management confirmed the SCSA was not completed.
Bed Hold Payment Amount Omitted From Transfer Notices
Penalty
Summary
The facility failed to include the bed hold reserve payment amount in the written emergency transfer notifications provided to resident representatives for 3 of 3 residents reviewed for hospitalization. For Resident #3, who had diagnoses including type 2 diabetes mellitus and heart failure and whose cognitive skills for daily decision making were modified independence, the record showed a transfer to a short-term general hospital. The letter to the resident’s representative stated that the resident was transferred for a higher level of care and that every resident was entitled to a ten-day bed-hold privilege, but it did not include the bed hold reserve payment amount and also referenced an insurance the facility did not participate in. For Resident #33, whose diagnoses included orthopedic aftercare and an unspecified fracture of the upper end of the right humerus and whose cognitive skills for daily decision making were intact, the record showed hospital transfers on two occasions. The letters to the resident and resident representative dated for those transfers stated that the resident was transferred for a higher level of care and that every resident was entitled to a ten-day bed-hold privilege, but they did not include the bed hold reserve payment amount. Those letters also included information related to an insurance that the facility did not participate in. For Resident #93, whose diagnoses included paroxysmal atrial fibrillation and hypertensive heart disease with heart failure, the record showed an unplanned discharge to a hospital. The Notice of Transfer to Acute Care Facility did not include any information reflecting the amount of reserve bed hold payment, and the admission agreement’s bed hold policy also did not reflect the amount of reserve bed hold payment. The facility’s Bed-Holds and Returns Policy referenced the reserve bed payment policy as indicated by the state plan, but it did not reflect any mention of bed hold reserve payment amounts or notification of reserve bed hold payment amounts with every acute transfer.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to ensure that one resident’s call bell was within reach and usable to accommodate the resident’s needs. During observation, the resident was seated in a specialized wheelchair in the room while the call bell was wrapped around the side rail of the bed and not accessible. When asked, the resident was unable to locate the call bell, and a CNA removed it from the side rail and placed it in the resident’s left hand under the blanket. The assigned LPN stated that the resident was unable to reach the call bell and acknowledged that it should not have been wrapped around the side rail. The resident had diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and dysphagia. The most recent MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition, and the LPN stated the resident had limitations to both upper and lower extremities. The facility’s documentation also reflected that the resident’s call bell arrangement was later assessed by OT, who noted the resident could retrieve and press the call bell and that it should be clipped to the wheelchair and positioned in the resident’s lap when seated.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to complete in writing the required beneficiary notice for Resident #106. The SNF Beneficiary Protection Notification review showed that the resident’s last covered Medicare A day was 10/5/25 and that the resident remained in the facility, with a Notice of Medicare Non-Coverage (NOMNC) signed by the resident on 10/2/25 indicating Medicare coverage for skilled nursing services would end on 10/5/25. The review also showed that a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was not provided. During the survey, the RN/MDS Coordinator stated that the NOMNC was prepared by the SW and that the SNFABN was her responsibility, and she said the SNFABN was sometimes given at the same time as the NOMNC but most often was provided once the resident or representative decided to stay at the facility. The resident had remained in the facility for five more days after signing the NOMNC, and the RN/MDS Coordinator later provided appeal paperwork showing the resident had appealed twice, while stating she was unsure whether another NOMNC had been done. The LNHA later stated that another NOMNC should have been done but was not presented to the surveyor, and also stated there was no financial liability, which was why no SNFABN was provided.
Inadequate monitoring and inappropriate diagnosis for antipsychotic use
Penalty
Summary
The facility failed to adequately monitor target behaviors for a psychotropic medication and failed to ensure an antipsychotic medication was ordered for an appropriate diagnosis for one resident. The resident had severe cognitive impairment with a BIMS score of 00 out of 15 and diagnoses that included type 2 diabetes mellitus and abnormalities of gait and mobility. The resident was observed lying in a bed low to the ground, and the resident representative stated the resident had fallen two times. The resident’s MDS showed receipt of an antipsychotic medication, but no active diagnosis was documented for the medication. The care plan included risk for adverse effects related to antipsychotic and anxiolytic use, but it did not include target behaviors to be monitored. The January eMAR/TAR showed quetiapine and divalproex orders, including quetiapine for agitation and mood disorder with behavior, and there was no other behavior monitoring documented for quetiapine or divalproex during that month. The February eMAR/TAR showed quetiapine ordered every 8 hours for mood disorder, later changed to target symptoms of restlessness and agitation, with behavior monitoring entries for paranoia and restlessness to exhaustion, but the medication was increased without any behavior monitoring documented. The psychiatric APRN documented that the resident had dementia with behavioral disturbance, mood disorder NOS, and delirium or sundowning, and noted the resident was cooperative with treatment and medications, frequently restless in the evenings, and without aggression, exit-seeking behaviors, or psychotic symptoms. The APRN increased quetiapine and instructed continued monitoring and documentation of moods and behaviors. During interviews, the LPN, UM, and DON stated that residents on antipsychotics should have target behaviors and behavior monitoring documented, and that the diagnosis of restlessness and agitation was not appropriate for an antipsychotic. The DON later stated that behavior monitoring had not been restarted after the resident returned from the hospital and that the order for restlessness and agitation should have been clarified.
Failure to Transmit Completed MDS
Penalty
Summary
The facility failed to complete and transmit the MDS within the required timeframe for Resident #80. The resident had a DRNA MDS with an ARD of 10/30/25 that was completed, but the surveyor found that it had not been accepted or transmitted. The RAI Manual cited in the report states that for a discharge MDS return not anticipated, the MDS completion date is the discharge date plus 14 calendar days, and the transmission date is the MDS completion date plus 14 calendar days. During the survey, the RN/MDS Coordinator confirmed that the DRNA MDS had been completed but not transmitted and stated that the 10/30/25 MDS should have been transmitted. She also stated she was unsure whether the completed MDS was required to be transmitted within seven or 14 days. Later, she stated there were no transmission reports for Resident #80 because the DRNA MDS was not transmitted. The LNHA and DON were notified of the findings, and the DON later stated that Resident #80's MDS was transmitted after the surveyor's inquiry.
MDS assessments did not accurately code psychotropic medication diagnoses
Penalty
Summary
The facility failed to accurately complete portions of the MDS for 4 of 22 residents reviewed, with the assessments not reflecting residents’ status as of the ARD. For Resident #7, the Admission/Medicare 5 Day MDS and Quarterly MDS showed a BIMS score of 12 out of 15 and captured antidepressant and antipsychotic medications in Section N, but Section I did not include diagnoses related to those psychotropic medications. The record showed diagnoses including metabolic encephalopathy and a right femur fracture, physician orders for olanzapine and paroxetine, and psychiatric consults stating to continue Paxil for depression/anxiety and Zyprexa for mood disorder, with target symptoms of restlessness and agitation. For Resident #33, the Significant Change MDS showed a BIMS score of 15 out of 15 and captured an antidepressant in Section N, but Section I did not include depression. The record showed diagnoses including orthopedic aftercare and an unspecified fracture of the upper end of the right humerus, a physician order for trazodone at bedtime for depression, and a psychiatric consult documenting adjustment disorder with depression and anxiety and continuing trazodone for depression. For Resident #54, the Admission/Medicare 5 Day MDS showed a BIMS score of 15 out of 15 and captured an antidepressant in Section N, but Section I did not include a diagnosis for the antidepressant. The record showed diagnoses including surgical aftercare following digestive system surgery and diverticulitis with perforation and abscess, along with orders for escitalopram and mirtazapine and a psychiatric consult diagnosing adjustment disorder with depression and changing antidepressant therapy. For Resident #99, the comprehensive MDS showed a BIMS score of 00 out of 15 and captured an antipsychotic in Section N, but Section I did not include an active diagnosis for the antipsychotic medication. The resident’s admission record listed type 2 diabetes mellitus and abnormalities of gait and mobility. During interview, the RN/MDS Coordinator stated she reviewed psychiatry notes, medications, and diagnoses and would code medications in Section N and diagnoses in Section I, and then acknowledged that the four MDSs were completed in error and that diagnoses for antidepressants and antipsychotics should have been coded.
Incomplete Psychotropic Medication Monthly Documentation
Penalty
Summary
The facility failed to thoroughly complete the psychoactive medication monthly note and failed to accurately document the target behavior being monitored for Resident #81, who was reviewed for unnecessary medications. Resident #81 was observed seated in a specialized wheelchair and watching a movie on a tablet, and the assigned LPN stated the resident was able to make needs known to staff. The resident’s record showed diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and dysphagia, and the most recent MDS reflected moderately impaired cognition with a BIMS score of 10 out of 15. The psychiatric follow-up notes stated that Depakote was to be continued for mood disorder NOS, with prior dose reduction having increased restlessness and later dose increase improving nighttime restlessness. The Psychoactive Medication Monthly Note for one review month documented the target behavior as depressed mood, but no corresponding number of episodes was recorded, and the date of last psychiatry consult was 11/28/25. Another monthly note documented the target behavior as psychosis, but again no corresponding number of episodes was recorded, and the date of last psychiatry consult was left blank. The DON stated that nurses were responsible for documenting the monthly psychotropic notes in the electronic medical record and that the note should match the eMAR and psychiatric consult note targeted behavior of restlessness. The DON also stated that the effective date should reflect the month being reviewed rather than the current month. The facility’s psychotropic medication use policy stated that residents should not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record, and that monitoring may include behavior flow sheets and MARs.
Pressure ulcer treatment, documentation, and hand hygiene failures
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident with significant cognitive impairment and multiple diagnoses including Alzheimer’s disease, generalized muscle weakness, gait abnormalities, and a history of falls. The resident’s record showed facility-acquired pressure ulcers involving the left heel and right buttock, with wound documentation reflecting a left heel deep tissue injury and a right buttock unstageable wound that later progressed to a stage 2 pressure injury. The wound nurse documented the wounds and notified the physician and resident representative, and physician orders were entered for heel and buttock wound care, air mattress use, and turning every 2 hours. The record review showed missing documentation of ordered wound treatments in the eTAR. There was no signed treatment for the left heel on one date, and no signed treatment for the right buttock on another date, and there was no nursing progress note showing the right buttock treatment was rendered. The care plan was also not developed in a timely manner for the left heel wound, being initiated 12 days after the wound was identified, and there was no care plan initiated for the right buttock pressure ulcer. Facility staff confirmed the eTAR should have been signed and that the care plan should have been started earlier, but could not explain why the right buttock care plan was absent. During direct observation of wound treatment, the surveyor observed the LPN perform handwashing by applying soap before wetting her hands, which was inconsistent with the facility’s hand hygiene policy requiring hands to be wet first. The surveyor also observed a CNA bring gloves, disinfectant, and ABHR into the resident’s room and then remove those items back to the treatment cart without disinfecting them. The LPN confirmed she did not know the correct handwashing sequence and stated that items brought into the resident’s room should not come out, and she confirmed the items were not disinfected before being returned to the cart.
Delayed fall interventions and care plan updates
Penalty
Summary
The facility failed to ensure that a new intervention was implemented and documented in the resident’s care plan in a timely manner after multiple falls for one resident reviewed for falls. Resident #99 was admitted with diagnoses including type 2 diabetes mellitus and abnormalities of gait and mobility, and the most recent cMDS showed a BIMS score of 00 out of 15, indicating severely impaired cognition. The resident was observed lying in a bed low to the ground, and the resident representative stated the resident had fallen two times. A review of five fall incidents showed that after the resident was found on the floor or had a fall, care plan interventions were added several days later in some instances. After the resident was observed laying on the floor in the lounge, the care plan was updated nine days later with a medication review. After the resident was found sitting on the shower floor, the care plan was updated five days later with an intervention not to leave the resident unattended in the shower. After another fall, the record showed no new intervention was implemented. After a later fall, a psych consult was added the next day, and after another fall involving a chair alarm and sliding to the floor, dycem to the wheelchair was added seven days later. The individualized care plan included a fall-risk focus area with interventions such as therapy, slow transfers, easy access to commonly used items, assistance with transfers and ambulation, call-for-help reinforcement, bed and chair alarms, medication review, psych eval, and dycem to the wheelchair. However, the care plan did not indicate that the resident had actual falls, and the intervention of not leaving the resident unattended was not included. Staff interviews reflected that the nurse documented the fall and risk management, and that the multidisciplinary team and leadership typically met the following day to decide on interventions, but the documented interventions for this resident were delayed after the falls.
Enteral Feeding Order and Documentation Not Properly Managed
Penalty
Summary
The facility failed to ensure that enteral feeding was provided and documented in accordance with standard of practice for a resident with a gastrostomy tube. Resident #12 was admitted with diagnoses including gastrostomy and Down syndrome, and the most recent MDS reflected a BIMS score of 00, indicating severe cognitive impairment. During observation, the resident was in bed with the head of bed elevated and receiving enteral feed via pump at 50 ml/hr; the pump showed 877 ml infused with 323 ml remaining. The resident’s eMAR included an enteral feed order for Jevity 1.2 at 50 ml/hr with a total nutrient amount of 1200 ml starting at 4 PM and running until 1200 ml had infused, but the nurses signed the feed as administered without documenting the actual total volume infused each shift. The record also showed a flush order for 125 ml every 6 hours, but it was plotted three times a day rather than every 6 hours, and the order did not specify what fluid was to be used. The LPN stated that the enteral feed was hung in the evening and finished when the total volume of 1200 ml was reached, and the DON stated that nurses signed off that 1200 ml were infused in 24 hours. The surveyor questioned how the resident could receive 1200 ml in 24 hours when the feed would need to be stopped for care, and the LNHA acknowledged the concern. The facility policy stated that adequate nutritional support through enteral nutrition is provided as ordered, but it did not contain information about documenting amount infused.
Inaccurate Daily Staffing Report Posting
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report daily for 2 of 5 days observed. On 3/12/26 at 8:19 AM, the surveyor observed a posted staffing report in the lobby dated 3/11/26 that listed the census as 74 for all shifts and showed a CNA-to-resident ratio of 1:8.2 for the 7:00 AM to 3:00 PM shift. The receptionist stated that visiting hours were from 8:00 AM to 8:00 PM, and the DON later confirmed that the facility census was 74. On 3/16/26 at 9:25 AM, the surveyor observed another posted staffing report dated 3/16/26 showing a census of 75 for the day, evening, and night shifts. However, a review of the Midnight Census report at 12:51 PM showed the census was 74, and the Regional Nurse confirmed that the census was 74. During meetings with the LNHA and DON on 3/17/26 and 3/19/26, the LNHA stated that the census was being reconciled and acknowledged that the posted NHRCSR should have reflected 74 instead of 75 on 3/16/26. The facility policy required daily posting of staffing data, including the resident census at the beginning of the shift, and the facility did not refute the findings.
Missing Monthly Pharmacy Medication Review
Penalty
Summary
The facility failed to ensure that Resident #99 received a monthly medication review from the pharmacy consultant for February 2026. Resident #99 was admitted with diagnoses including type 2 diabetes mellitus and abnormalities of gait and mobility, and the most recent cMDS showed a BIMS score of 00 out of 15, indicating severe cognitive impairment. The MDS also reflected that the resident received an antipsychotic medication. A review of the pharmacy consultant binder showed an EPIC review completed on 1/9/26 for the initial admission medication orders, but no other monthly medication review was documented during the resident’s stay. A progress note in the medical record showed that the pharmacy consultant completed a medication regimen review on 3/9/26, but there was no documented evidence of a review for February 2026. The DON stated that the pharmacy consultant reviewed residents on one unit on one day and returned another day for the other unit, and later stated that Resident #99 did not have a medication regimen review in February because the resident was in the hospital on the day the pharmacy consultant was at the facility. The LNHA did not provide additional information.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that medication administration error rates remained below 5 percent. During observation of medication passes involving 3 nurses and 3 residents, surveyors identified 2 errors out of 25 opportunities, resulting in an 8% medication administration error rate. The deficiency was identified during the medication pass of one resident, where an LPN prepared medications that did not match the active physician orders displayed on the eMAR. For that resident, the active orders included PreserVision capsule 1 cap by mouth twice daily and Probiotic oral cap (Saccharomyces boulardii) 1 cap by mouth once daily. The LPN selected and prepared a bottle labeled multivitamin with minerals tablets instead of PreserVision capsules, and a bottle labeled Probiotic Acidophilus capsules instead of the ordered probiotic. The resident’s EMR showed diagnoses including osteoarthritis and osteoporosis, and the cMDS reflected a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The consultant pharmacist stated that PreserVision and regular multivitamins with minerals were not confirmed to be interchangeable, and that Saccharomyces boulardii and Acidophilus were different types of probiotics.
Medication Labeling and Storage Deficiencies in Med Carts
Penalty
Summary
The facility failed to properly store and label medications in 2 of 4 medication carts observed during surveyor inspection. In the northwest med cart, the surveyor found a sealed foil package containing albuterol/ipratropium inhalation solution vials that did not have a pharmacy label, and no matching box for the medication was located in the cart. The LPN confirmed that the medication should have had a label or its original box and removed the foil pouch from the cart. In the northeast med cart, the surveyor observed a Humalog insulin pen inside a plastic bag with no date of first use or disposal date written on the bag or on the device label. The label showed the pen had been dispensed by the pharmacy on 1/27/26. The RN stated the insulin pen should have been dated when placed in the med cart and removed it from the cart. The facility policy stated medications are stored in the packaging in which they are received and that opened or accessed multi-dose vials are dated and discarded within 28 days unless the manufacturer specifies otherwise.
Inaccurate Documentation of 1 to 1 Observation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident reviewed. The record for the resident, who had diagnoses including hypertensive heart disease and acute myeloblastic leukemia, was reviewed in connection with a grievance about a 1 to 1 being late and another grievance about a call bell being unplugged. The grievance binder contained a schedule listing CNA coverage for the resident on multiple dates, but the North Station CNA assignment sheet did not show any resident assigned to a 1 to 1, and the resident’s comprehensive care plan and progress notes did not document that the resident was on a 1 to 1. During interviews, the LPN stated that a 1 to 1 would be used if a resident was not safe or tried to leave, and the UM stated it would be documented somewhere, likely in progress notes, and should be in the care plan. The DON stated that a 1 to 1 would be provided for suicidal ideation or self-harm and that if physically needed it should be in the care plan. Later, the UM stated the 1 to 1 may have been a temporary companion arrangement provided by the facility, while the DON stated the previous administration described it as customer service and unrelated to resident safety. The LNHA stated the facility did not have a policy regarding 1 to 1 documentation and did not provide additional information.
Failure to Document Influenza Vaccine Consent or Refusal
Penalty
Summary
The facility failed to offer an influenza vaccine or document a refusal or reason for ineligibility for one resident reviewed for unnecessary medications. The resident had diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and oropharyngeal dysphagia. The most recent MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition, and the resident was observed seated in a specialized wheelchair while watching a movie on a tablet. Review of the medical record showed the last influenza vaccine was administered on 10/26/23. The paper chart contained an Influenza and Pneumococcal Vaccine Consent and Tracking Form dated 10/24/23 showing telephone consent from the resident representative for that season, but there were no consent forms for 2024, 2025, or 2026. The record also did not contain documented evidence that the resident received or declined the influenza vaccine for those years. During the survey, the LPN confirmed that the EMR immunization record and paper consent matched the last consent obtained on 10/24/23. The RN/IPN stated that consent should be obtained and documented in the chart, but she could not locate documentation that the resident representative was contacted for consent for the influenza vaccine and stated there was no information showing the resident received the vaccine in 2024 or 2025. The facility policy stated that influenza vaccine is to be offered annually and that refusals must be documented in the resident's medical record.
Staffing Deficiencies and Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff and timely response to call bells, as evidenced by observations, interviews, and record reviews. During a resident council meeting, three residents reported that the 3-11 and 11-7 shifts were short-staffed, leading to delays in call bell responses. One resident mentioned waiting over 15 minutes for assistance, while another reported a delay of an hour. The facility's CASPER and PBJ reports indicated excessively low weekend staffing, which was confirmed by the surveyor's findings. Interviews with staff revealed that the facility did not meet the New Jersey mandated staffing ratios, particularly during the night shift. A Registered Nurse and Certified Nursing Aides (CNAs) reported being understaffed, with each CNA responsible for up to 19 residents, exceeding the state's requirement of 1 CNA per 14 residents during the night shift. The facility's grievance reports also documented complaints from residents about long wait times for call bell responses, further highlighting the staffing issues. The facility's policy on staffing and competency, as well as the Facility Assessment Tool, indicated that staffing plans should consider the needs of each unit and shift. However, the facility management acknowledged that they did not meet the staffing requirements, especially on weekends. The surveyor's review of the facility's staffing assignments confirmed the shortfall in staffing, particularly during the 11-7 shift, contributing to the delayed response to residents' needs.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, as observed during a survey. Two Licensed Practical Nurses (LPNs) did not perform hand hygiene after direct contact with residents and their environments during medication administration. One LPN was observed touching a resident and their immediate environment without washing hands before donning gloves. Another LPN failed to perform hand hygiene after administering medication and before exiting the resident's room. These actions were contrary to the facility's hand hygiene policy and CDC guidelines. Additionally, the facility did not follow appropriate infection control practices during medication and treatment pass observations. An LPN used the same vital signs equipment on two residents without disinfecting it between uses, and a Registered Nurse (RN) used disinfecting wipes that had been exposed to air for 15 minutes, failing to maintain the required contact time for effective disinfection. These practices were inconsistent with the facility's policies on equipment disinfection and the use of disinfecting wipes. The facility also failed to enforce isolation precautions for a resident on Transmission-Based Precautions. A Housekeeping staff member entered the room of a COVID-19 positive resident without wearing the required eye protection, despite signage indicating the need for full PPE. This oversight was acknowledged by the staff member and the facility's management, highlighting a lapse in adherence to the facility's PPE policy and CDC guidelines for preventing the spread of infection.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the assessment of their care needs. For the first resident, the MDS was completed remotely by a per-diem worker who did not conduct an in-person interview. The resident was observed to have difficulty hearing, especially when masks were worn, and was noted to have some confusion. Despite these observations, the MDS inaccurately reflected adequate hearing and severely impaired cognition without a proper assessment. The resident's care plan indicated hearing impairment, but this was not accurately captured in the MDS, leading to a discrepancy between the resident's documented needs and the assessment. The second resident's MDS also contained inaccuracies. The resident was coded as sometimes understood in the MDS, yet the required interview for cognitive patterns was not attempted. The MDS Coordinator acknowledged that the interview should have been conducted according to the RAI Manual guidelines. Despite the resident's ability to be sometimes understood, the failure to attempt the interview resulted in an incomplete assessment of the resident's cognitive status. Both cases highlight a lack of adherence to the RAI Manual's guidelines for conducting resident assessments. The facility's reliance on remote workers for MDS completion without in-person interviews and the failure to attempt required interviews for residents who are sometimes understood contributed to the inaccurate coding of the MDS. These deficiencies were acknowledged by the facility management during discussions with the survey team, but no additional information or corrective actions were provided at the time.
Failure to Follow Physician Orders in Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders during medication administration for a resident, as observed by a surveyor. A Registered Nurse (RN) administered a 500 mg tablet of Ascorbic Acid instead of the prescribed two 250 mg tablets due to the unavailability of the 250 mg tablets in the medication cart. The RN justified the substitution by stating that the total dose was the same, although the physician's order specifically required two 250 mg tablets. This action was contrary to the facility's policy, which mandates that medications be administered as prescribed. During the survey, the RN acknowledged the discrepancy and mentioned that she would check for the availability of the 250 mg tablets or contact the physician to amend the order. The Director of Nursing (DON) later confirmed that the appropriate action would have been to call the doctor. The facility's policy on administering medications, revised in April 2019, emphasizes the importance of administering medications safely, timely, and as prescribed, which was not followed in this instance.
Failure to Follow Resident's Care Plan During Allergic Reaction
Penalty
Summary
The facility failed to ensure that a resident's plan of care was followed during an acute change in condition, specifically when the resident experienced an allergic reaction. The resident, who had a history of allergies and was knowledgeable about their symptoms, reported to the nursing staff that they were experiencing an allergic reaction, characterized by shortness of breath, redness, and welts on their skin. Despite the resident's request to be sent to the hospital, the nurse on duty, RN#1, did not honor this request and instead administered Benadryl without obtaining a physician's order. The nurse attempted to contact the physician but did not receive a timely response. During this time, the resident self-administered an epinephrine pen from their personal belongings, which had a positive effect on their condition. However, the nurse proceeded to administer Benadryl without a physician's order and failed to notify the Director of Nursing (DON) or the resident's representative about the incident. The nurse documented the administration of the medication in the medical record but only obtained the physician's order for Benadryl hours later. The facility's investigation revealed that the nurse did not follow the appropriate procedures for medication administration and failed to respect the resident's right to be transferred to the hospital. The nurse's actions were not in line with the facility's policies on responding to changes in a resident's condition, administering medications, and respecting resident rights. The investigation concluded that there was no willful abuse or neglect, but the nurse's actions were not in accordance with professional standards of clinical practice.
Failure to Adjust Medication Schedule for Dialysis
Penalty
Summary
The facility failed to adjust a resident's medication schedule to accommodate their dialysis sessions, leading to a deficiency in care. The resident, who had end-stage renal disease and was dependent on dialysis, had a physician's order for dialysis every Monday, Wednesday, and Friday at 2:00 PM. Despite this schedule, the resident's medications were not adjusted accordingly, with several medications scheduled for administration at times when the resident was at dialysis. Observations and interviews revealed that the resident's medications were signed as administered at 4:30 PM and 5:00 PM, even though the resident was not present at the facility during these times due to dialysis. The Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) both acknowledged that medications should be scheduled around dialysis times and that any conflicts should be clarified with the physician. However, the Medication Administration Record (MAR) showed that medications were signed as administered at the scheduled times, despite the resident being at dialysis. The Director of Nursing (DON) confirmed that medications were administered when the resident returned from dialysis, but the facility's policy did not address adjusting medication times for dialysis sessions. The surveyor's review of the facility's policies revealed that they did not include guidance on accommodating medication schedules for dialysis, contributing to the deficiency. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue and indicated that staff education and a quality assurance performance improvement (QAPI) initiative were being implemented.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care. For Resident #4, the surveyor found discrepancies in the medication records. The resident was prescribed Valacyclovir for a specific period in June 2024, but the medication continued to appear in the Physician/Practitioner Progress Notes without a corresponding physician's order in the electronic Medication Administration Record (eMAR) for the months following the completion of the prescription. This inconsistency was not addressed until the surveyor brought it to the attention of the facility management, who then clarified that the medication had been discontinued. For Resident #66, the surveyor observed that the Licensed Practical Nurse (LPN) was administering medication with special instructions for fluid restriction. However, there was no clear accountability or documentation in the eMAR regarding how much fluid the resident was allowed per shift, despite the special instructions indicating a fluid restriction of 1 liter per day. The Registered Nurse/Unit Manager and the LPN were unable to explain how the fluid restriction was being managed, and it was later revealed that the order for fluid restriction had been discontinued, yet the special instructions remained in the resident's profile. The facility's Charting and Documentation Policy requires that all services, progress, and changes in a resident's condition be accurately documented in the medical record to facilitate communication among the care team. However, the survey revealed that electronic entries were not being reviewed and updated as required, leading to incomplete and inaccurate documentation. The facility management did not dispute these findings during the exit conference with the survey team.
Failure to Complete SCSA for Resident Revoking Hospice Care
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice care, as required by the CMS's RAI Manual. The resident, who was admitted with diagnoses including Parkinsonism, dementia, depression, and neuromuscular dysfunction of the bladder, was initially placed in hospice care for end-stage polycystic kidney disease. Despite the requirement to perform an SCSA within 14 days of the hospice care revocation, the facility did not complete this assessment. The MDS Coordinator acknowledged that the quarterly Minimum Data Set (qMDS) assessment conducted on January 13, 2024, should have been an SCSA. The deficiency was identified during a survey when the surveyor reviewed the resident's medical records and interviewed facility staff. The MDS Coordinator admitted the oversight, and the Licensed Nursing Home Administrator and Director of Nursing confirmed that the SCSA was not completed as required. The facility management did not dispute the findings during the exit conference with the survey team.
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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