Careone At Middletown
Inspection history, citations, penalties and survey trends for this long-term care facility in Atlantic Highlands, New Jersey.
- Location
- 1040 State Route 36, Atlantic Highlands, New Jersey 07716
- CMS Provider Number
- 315087
- Inspections on file
- 12
- Latest survey
- January 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Careone At Middletown during CMS and state inspections, most recent first.
The facility failed to maintain a sanitary kitchen environment and properly functioning equipment, potentially leading to contamination. Observations included soiled exhaust hood baffles, inadequate handwashing water temperature, and unprotected tray lids under a soiled table. The Food Service Director confirmed the lack of a cleaning schedule.
The facility's call bell system was found to be deficient, as it failed to send activation signals to the nurse's station in several rooms. Observations revealed issues such as an ERROR CONNECTIVITY signal and an unplugged annunciator, which were identified during a survey with maintenance staff present.
The facility failed to update and maintain accurate activity care plans for two residents, leading to deficiencies in their care. One resident, who primarily speaks Spanish, had no activities or language-appropriate materials, and the CNA was unaware of their preferences. Another resident's care plan was outdated, with no recent evaluation or documentation of activity participation. The facility's policy requires regular assessments and updates, but the interdisciplinary team did not review or update the care plans, resulting in a lack of personalized and culturally appropriate activities.
The facility failed to provide appropriate activities for a non-English speaking resident and did not complete a yearly activity assessment for another resident. A resident who spoke only Spanish was left without activities or language-appropriate materials, while another resident's activity preferences were not documented or offered. The facility's policies on activity documentation and resident engagement were not followed, leading to deficiencies in meeting residents' needs.
The facility failed to maintain a system for inspecting emergency crash carts (ECC) for expiration dates and placement. Surveyors found incomplete checklists and expired items in the ECCs across three resident sections. Staff acknowledged the absence of a policy or procedure for inspections, leading to confusion about responsibilities. Despite creating a new checklist, it still lacked necessary instructions.
The facility failed to maintain infection control standards, as a CNA entered a resident's room on Contact Precautions without PPE, and another CNA did not perform hand hygiene after delivering a meal tray to a resident on Enhanced Barrier Precautions. Additionally, a urinary drainage bag was observed on the floor, contrary to infection control policies. Staff interviews confirmed these lapses in protocol adherence.
A resident with a history of acute kidney failure and other conditions was prescribed Midodrine HCL for hypotension, with instructions to hold the medication if systolic blood pressure (SBP) exceeded 120. Despite this, the medication was administered multiple times when the resident's SBP was above the threshold. Interviews with nursing staff confirmed the oversight, acknowledging that the medication should have been held according to the physician's orders.
A resident with severe cognitive impairment and dependent on staff for personal hygiene was observed with long, thick facial hair over several days, indicating a lack of grooming care. The CNA assigned was unaware of her responsibility to shave the resident, and the Unit Manager failed to supervise and ensure proper care. The deficiency was addressed only after another CNA took initiative, highlighting the need for better staff training and supervision.
A facility failed to implement a baseline care plan within 48 hours of admission for a resident with spinal stenosis, heart disease, and diabetes. The resident had a moderate depression score, but no care plan was initiated to address this. The DSS acknowledged the lack of documentation for a psychological services referral and the absence of a mood care plan, despite facility policy requiring such plans to be developed promptly.
A resident with a history of depression and intact cognition attempted self-harm using a call bell cord, which was found wrapped around their neck. The CNA discovered the resident unresponsive and untied the cord, after which the resident regained consciousness. The facility failed to conduct a psychological assessment and provide adequate supervision, contributing to the incident.
A facility's DSS failed to document and track psychological referrals for a resident with moderate depression, as revealed during a survey. Despite the resident's mood score indicating a need for psychological assessment, no formal referral documentation was provided. Interviews highlighted a lack of formal tracking and documentation of psychological services, contrary to the DSS's job responsibilities.
A facility failed to thoroughly investigate an abuse allegation involving a resident with cognitive impairment and multiple health issues. The resident, who required substantial assistance, reported being pushed after a fall and was sent to the hospital. The facility's policy requires comprehensive investigations, including interviews with involved parties, but the investigation was incomplete, as acknowledged by the Administrator.
A facility failed to maintain complete medical records for a resident by not documenting psychological assessment attempts and missing weight records. The resident, admitted with spinal stenosis, heart disease, and diabetes, had an intact cognition and moderate depression. The psychologist's attempts to assess the resident were not documented, and weekly weights were missing, contrary to facility policy. This deficiency was identified during a survey review.
The facility failed to meet New Jersey's mandatory staffing ratios during day shifts over a three-week period, with insufficient CNAs on 9 out of 21 days. The required ratio of one CNA to every eight residents was not met, with staffing levels ranging from 6 to 9 CNAs instead of the required 10 for the resident population.
The facility did not meet the mandatory nurse staffing levels for two days during a two-week period, as required by N.J.A.C. 8:39-25.2(b)(1)&(2). On two separate days, the facility was short by 2.25 and 4 hours, respectively, in providing the necessary nursing services. This deficiency was noted in response to specific complaints.
Deficient Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and properly functioning equipment, which could potentially lead to contamination or the spread of foodborne illness. During a kitchen tour, the surveyor observed that the metal baffles inside the exhaust hood were visibly soiled with black debris, grease, and grime. Additionally, the nozzles of the fire suppression system were covered in a grease-like substance. The Food Service Director (FSD) confirmed these findings and admitted to not having a cleaning schedule in place for the baffles. Furthermore, the surveyor noted that the only handwashing sink in the kitchen dispensed water at a temperature of 74 degrees Fahrenheit, which is below the required range of 90 to 110 degrees Fahrenheit for effective handwashing. The FSD acknowledged that cold water would not effectively remove bacteria. Additionally, insulated tray lids were found stacked with the food-covering side open and unprotected under a visibly soiled stainless steel table. The facility's cleaning policy, which was undated, stated that surfaces must be cleaned with a sanitizing agent and that grid panels in the fire suppression hood should be cleaned monthly, indicating a lack of adherence to these guidelines.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure that the resident call bell system was properly functioning, which had the potential to affect all residents. During observations and interviews conducted between January 8 and January 10, 2025, in the presence of the Maintenance Assistant, Regional Director of Maintenance, and Senior Regional Director of Maintenance, it was found that the call bell system in several rooms did not send activation signals to the nurse's station. Specifically, on January 9, 2025, the call bell in one room showed an ERROR CONNECTIVITY signal at the nurse's station on unit 3. Further investigation revealed that the annunciator cord was not fully inserted. Additionally, another room's call bell failed to send a signal because the annunciator at the nurse's station was unplugged and not powered on. These issues were brought to the attention of the facility's Administrator during the Life Safety Code exit conference.
Deficiencies in Resident Activity Care Plans
Penalty
Summary
The facility failed to update and maintain accurate care plans for activities for two residents, leading to deficiencies in their care. Resident #26, who primarily speaks Spanish, was observed without any activities or Spanish language materials in their room. The CNA assigned to Resident #26 was unable to communicate effectively with the resident due to the language barrier and was unaware of the resident's activity preferences. The electronic medical record indicated that the resident required an interpreter, yet the care plan inaccurately documented the resident's language as English and did not include any Spanish activities. The Activities Director was unable to provide evidence of any sensory programs or activities tailored to the resident's cognitive status and language needs. Resident #24's care plan was outdated and had not been revised since 2020, despite changes in the resident's condition and preferences. The activity calendar on the unit did not include all times and locations of activities, and there was no documentation of Resident #24's participation in activities. The resident's care plan indicated a preference for independent activities, but there was no recent evaluation or update to reflect the resident's current interests or participation levels. The Activities Director acknowledged the lack of documentation regarding the resident's activity attendance and preferences. The facility's policy on comprehensive person-centered care plans requires regular assessments and updates to reflect residents' strengths, needs, and preferences. However, the interdisciplinary team failed to review and update the care plans for both residents, resulting in a lack of personalized and culturally appropriate activities. The Director of Nursing acknowledged the oversight in Resident #24's care plan review and revision, and the facility had no additional information to provide regarding the deficiencies.
Deficient Activity Program and Documentation
Penalty
Summary
The facility failed to ensure that activity assessments accurately reflected the needs of all residents, particularly for a non-English speaking resident and another resident whose yearly activity assessment was incomplete. Resident #26, who primarily speaks Spanish, was observed multiple times without engaging in any activities and without the presence of activity staff. The resident's care plan inaccurately documented that the resident spoke English, and there were no activities provided in Spanish or tailored to the resident's cognitive status. The Activity Director admitted to not having any sensory type programs for cognitively impaired residents and could not provide documentation of activities offered in the resident's native language. Resident #24 was observed in their room or in the day room watching television, with no active engagement in activities. The resident's care plan indicated a preference for independent activities, but there was no documentation of the resident being invited to participate in activities of interest, such as music events. The facility's activity evaluation for this resident was outdated and incomplete, and there was no consistent documentation of the resident's participation or refusal of activities. The facility's policies on activity programs and documentation were not adhered to, as evidenced by the lack of documentation for resident participation in activities and the absence of tailored activities for residents with specific needs. The Activity Director acknowledged the deficiencies in documentation and the lack of tailored activities for residents with cognitive impairments or language barriers. The facility administration was unable to provide additional information to address these concerns.
Failure to Inspect Emergency Crash Carts
Penalty
Summary
The facility failed to ensure a system was in place to inspect the emergency crash carts (ECC) for expiration dates and placement, as observed by surveyors across three resident sections. During the inspection, it was found that the ECCs were locked, but the checklists on top of the carts were incomplete and lacked instructions. Items such as the AED, suction machine, IV kit, and others were not documented as checked. Additionally, a resuscitation bag was observed hanging on the ECC, which was not included in the checklist. The Licensed Practical Nurse Infection Preventionist (LPN IP) and other staff members acknowledged the absence of a policy or procedure for inspecting the ECCs, and there was confusion about who was responsible for checking expiration dates. Further observations revealed that the ECCs contained expired items, such as a resuscitation bag and IV insertion kits. The Licensed Nursing Home Administrator (LNHA) and Registered Nurse (RN) Supervisor confirmed the lack of a policy and procedure for staff to follow when checking the ECCs. The facility administration was informed of these concerns, and although a new ECC checklist was created, it still did not include inspection of the resuscitation bag. The deficiency was identified as a failure to maintain a proper system for inspecting and ensuring the readiness of emergency equipment.
Infection Control Deficiencies in PPE Usage and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control standards, as evidenced by multiple observations and interviews. A Certified Nursing Assistant (CNA) was observed entering the room of a resident on Contact Precautions without wearing the required personal protective equipment (PPE), such as a gown and gloves, despite clear signage indicating the necessity of such precautions. The CNA admitted to not wearing PPE because she was only delivering a lunch tray and not providing direct care, although the facility's policy required PPE to be worn at all times in such rooms. The Licensed Practical Nurse/Unit Manager (LPN/UM) and the Infection Preventionist (IP) confirmed the importance of PPE usage in these situations. Another deficiency was noted with a resident who had an indwelling urinary catheter. The surveyor observed the resident's urinary drainage bag resting on the floor, which is against the facility's infection control policy that requires the bag to be secured to the bedframe to prevent contamination. The CNA and LPN acknowledged the error and stated that the bag should not have been on the floor. The facility's policy clearly states that catheter tubing and drainage bags must be kept off the floor to prevent infection. Additionally, a CNA was observed failing to perform hand hygiene after delivering a meal tray to a resident on Enhanced Barrier Precautions. Despite signage instructing staff to wash hands before entering and exiting the room, the CNA did not comply. The Infection Control Nurse confirmed that all staff had been educated on infection control prevention, yet the CNA did not follow the protocol. These observations indicate a lapse in adherence to established infection control procedures, as confirmed by interviews with facility staff.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for a resident, leading to a deficiency. The resident, who had a history of acute kidney failure, repeated falls, and muscle weakness, was prescribed Midodrine HCL to manage hypotension, with specific instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120. However, the electronic Medication Administration Record (eMAR) indicated that the medication was administered on multiple occasions when the resident's SBP was above the prescribed threshold, contrary to the physician's orders. Interviews with nursing staff, including an LPN and a Unit Manager, confirmed that the protocol was to check vital signs before administering the medication and to hold it if the SBP was greater than 120. Despite this, the medication was not held as required, and the staff acknowledged the oversight. The facility's policy on administering medications emphasized adherence to prescriber orders, yet this was not followed in the case of the resident, leading to the deficiency noted by the surveyors.
Failure to Provide Adequate Grooming for Dependent Resident
Penalty
Summary
The facility failed to provide necessary grooming services for a resident who was dependent on staff for activities of daily living. The deficiency was observed in a resident who had been admitted with severe cognitive impairment and required total staff assistance for personal hygiene. Over several days, the resident was observed with long, thick facial hair, indicating a lack of grooming care. Despite being dependent on staff, the resident remained in bed for extended periods without receiving adequate grooming or personal hygiene care. The Certified Nursing Assistant (CNA) assigned to the resident was unaware that she could shave the resident, despite the facility's policy indicating that CNAs are responsible for such tasks. The Unit Manager and other staff members failed to notice or address the resident's grooming needs, resulting in the resident remaining unshaven for several days. The lack of supervision and communication among staff contributed to the oversight in providing necessary grooming care. The facility's policy on shaving and activities of daily living was not effectively communicated or enforced among the staff, leading to the resident's unmet grooming needs. The CNA's lack of awareness and the Unit Manager's failure to supervise and ensure proper care were significant factors in the deficiency. The resident's condition improved only after another CNA took the initiative to address the grooming issue, highlighting the need for better staff training and supervision.
Failure to Implement Baseline Care Plan for Resident's Immediate Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident, which included the necessary healthcare information to address the resident's immediate needs. The resident was admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated the resident had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and a moderate depression score of 10 on the Resident Mood Interview. However, no BCP was initiated to address the resident's mood. The Director of Social Services (DSS) acknowledged the responsibility to assess the mood section of the MDS and stated that a referral for psychological services was made, but could not provide documentation of the referral or services provided. The DSS admitted that a mood care plan should have been initiated due to the high mood score. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including therapy and social services, but this was not done for the resident in question.
Plan Of Correction
1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. 1) Resident #1 NU Ex Order 26.4(b)(1) at the facility. On 1/22/2024 the Assistant Director of Nursing /FE (ADON/FE) completed an audit of all new admissions in the last 30 days to ensure a baseline care plan was initiated within 48 hours of admission and included person-centered care planning. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. 2) All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. 3) On 12/27/2024 the Assistant Director of Nursing/Facility Educator (ADON/FE) immediately provided in-service education to all nurses including shift supervisors and unit managers on the procedure for developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident including, but not limited to a) initial goals based on the physician orders; b) physicians orders; c) dietary orders; d) therapy orders; e) social services; f) PASARR recommendation, if applicable. On 1/22/2025 The ADON/FE provided in-service education to the [R] and U.S. FOIA (b) (6) regarding the process of developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident. The Unit Manager or designee will review all new admission records daily to ensure a baseline care plan has been initiated within 48 hours of admission. This review will continue on an ongoing basis. On 1/22/2025 the ADON/FE provided in-service education to the [R] the [R] and U.S. FOIA (b) (6) on the importance of a personalized care plan for depression as well as psychology consult for any resident with a PHQ9 over the score of 10, which notes signs and symptoms of depression. The Director of Social Services and ADON/FE have created a formal record for tracking all referrals made to a psychologist. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. 4) The Director of Nursing or designee will conduct audits of 100% of newly admitted residents to ensure a baseline care plan has been implemented within 48 hours of admission. The audits will continue daily on an ongoing basis to ensure compliance. The results of the audits will be reported to the Administrator and the Quality Assurance Performance Improvement (QAPI) Committee monthly x 3 months, then quarterly x 3 quarters. The Director of Social Services or designee will conduct audits of all residents who have referrals for psychology consults. The audits will be conducted weekly x 3 weeks, then monthly x 3 months, then quarterly x 3 quarters. The results of the audits will be provided to the Administrator and QAPI Committee monthly x 3 months then quarterly x 3 quarters. The QAPI Committee will review and determine need for further audits. The QAPI Committee meets on a monthly basis.
Failure to Prevent Self-Harm Incident
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident who was found with ligature marks around the neck. The incident involved a resident who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes. The resident had an intact cognition with a BIMS score of 15 out of 15 but was noted to be moderately depressed with a score of 10 on the Resident Mood Interview. Despite these indicators, there was no psychological assessment documented in the medical record. The incident report revealed that the resident had intentionally used the call bell cord, which had been disconnected from the wall, to attempt self-harm. On the morning of the incident, a CNA responded to the resident's call bell, which was ringing, and found the resident unresponsive with the call bell cord wrapped around their neck. The CNA untied the cord and called for help, after which the resident regained responsiveness. The Administrator was informed of the incident and noted that the call bell cord had been unplugged, which could occur inadvertently due to bed adjustments. However, the Administrator could not recall if the resident sustained any injuries, and no psychological assessment was completed prior to the incident, indicating a lack of adequate monitoring and supervision for the resident's mental health needs.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents who had physicians orders for a referral for psychology assessment to ensure the consult was completed. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with referrals for psychology consults have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) and the facility Administrator conducted in-service education to the psychology provider on the process for psychology consults. The practitioner has been advised of the implementation of a tracking form for all psych referrals to ensure compliance. The ADON/FE educated the psychology provider on the process of documenting refusal of referrals in the electronic medical record. The ADON/FE provided in-service education to all nurses on the implementation of a tracking form for all psychology referrals to ensure compliance. The ADON/FE provided in-service education to all staff on the process of keeping residents free from hazards and providing the necessary monitoring and supervision for those individuals who may have signs or symptoms of depression. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Nursing or designee will conduct audits of the psychology referral book to ensure all referrals for psychology or psychiatry consults are completed timely and documented. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of all audits will be provided monthly x 3 months to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.
Failure to Document and Track Psychological Referrals
Penalty
Summary
The Director of Social Services (DSS) at the facility failed to develop and implement policies and procedures for identifying and addressing the medically related social and emotional needs of a resident. This deficiency was identified during a survey when it was found that a resident, who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes, had a mood score indicating moderate depression. Despite this, there was no documentation of a referral for a psychological assessment or evidence that such an assessment was completed. The DSS claimed to have verbally referred the resident for psychological services, but no written documentation was provided to support this claim. Interviews with the DSS, the psychologist, and the facility's administrator revealed a lack of formal tracking and documentation of psychological referrals and assessments. The DSS admitted that there was no formal system in place to track whether residents identified as needing psychological assessments received them or if the services were effective. The facility's administrator acknowledged the expectation that concerns identified in screenings should be followed up with documented referrals, but was unaware of the lack of formal tracking until the survey. The facility's job description for the DSS required the development and implementation of policies to address residents' social and emotional needs, which was not fulfilled in this case.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Director of Social Services immediately conducted an audit of 100% of all residents to determine if their NJ Ex Order 26.4(b) (1) interview indicated a score of or greater, indicating the resident was NJ Ex Order 26.4(b)(1). The Director of Social Services identified 13 residents who had a score of or greater in section of the MDS and made a referral to the NJ Ex Order 26.4(b)(1) provider to ensure a NJ Ex Order 26.4(b)(1) assessment was conducted. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with a Resident Mood Interview (RMI) of 10 or greater have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024 the Administrator provided in-service education to the U.S. FOIA (b) (6) with regards to the Directors responsibility which includes but is not limited to procedures for the identification of medically related social and emotional needs for residents and assisting residents in obtaining needed services from outside entities as needed. The Director of Social Services is the designated staff person who acts as the primary contact and coordinator for the contracted providers for psychiatry and psychology services. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of 5 residents weekly to review the score of the Resident Mood Interview (RMI). Residents with a RMI equal to or greater than 10 will be referred by the Director of Social Services to the contracted psychology provider for consult. The audits will be conducted weekly x 3 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who no longer resides at the facility. The resident, who had a history of anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and the presence of an artificial eye, was found on the floor beside their bed with their head under their wheelchair. The resident required substantial maximal assistance with activities of daily living and transfers and had some cognitive impairment. After a fall, the resident was sent to the hospital, where they reported being pushed, prompting an investigation by hospital social workers. However, the facility did not complete a thorough investigation as required by their policy. The facility's policy mandates that all reports of abuse, neglect, exploitation, or misappropriation are thoroughly investigated and documented. The investigation should include interviews with the person reporting the incident, any witnesses, the resident or their representative, and staff members who had contact with the resident. Despite this, the facility's investigation was incomplete, as acknowledged by the Administrator, who only became aware of the allegation after gathering documentation. The Director of Social Services, who was not employed at the time of the incident, stated that she would typically collect statements from the resident making the allegation but did not speak with other residents. The facility's failure to adhere to its policy resulted in an incomplete investigation of the abuse allegation.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 NJ Ex Order 26.4(b)(1) at the facility. The Administrator immediately conducted an audit of all reportable events in 2024 involving allegations of NEXTER to ensure the allegation was thoroughly investigated. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents who report an allegation of abuse have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/26/2024 the facility Administrator (LNHA) conducted in-service education with the U.S. FOIA (b) (6), the U.S. FOIA (b) (6), and Unit Managers (UM) on the policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating. Education included but was not limited to all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies & thoroughly investigated by facility management. On 12/26/2024 the FE/ADON conducted in-service education to line staff on the procedure for reporting allegations of abuse. On 12/26/2024 the Director Of Social Services conducted an audit of all grievances from 2024 to ensure all grievances were investigated and there were no allegations of abuse or mistreatment. There were no untoward findings. The LNHA is the designated individual at the Facility to investigate all allegations of Abuse, Neglect, Exploitation or Misappropriation. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of all reported resident concerns or grievances to ensure allegations are immediately reported to the Administrator for a full and thorough investigation. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.
Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurately documented and complete medical records for a resident, as evidenced by the absence of documentation for psychological assessment attempts and missing weight records. The resident, who was not present at the facility during the survey, had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated an intact cognition and moderate depression. However, the psychologist's attempts to assess the resident were not documented, despite the psychologist stating that she had tried to see the resident multiple times but found him sleeping. Additionally, the facility did not document the resident's weekly weights for two consecutive weeks following admission, as required by the facility's policy. The Registered Dietician confirmed the missing weights and stated that new admissions should be weighed weekly for four weeks. The facility's policies on weight assessment and documentation were reviewed, revealing that all services and changes in the resident's condition should be documented to facilitate communication among the interdisciplinary team. The lack of documentation for both the psychological assessment attempts and the resident's weights led to the identification of this deficiency.
Plan Of Correction
1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 [R] NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents with referrals for J Ex Order 26.4(b)(1) assessment to ensure the assessment was completed timely. There were no untoward findings. The Dietician conducted an audit of all residents residing in the facility to ensure NJ Ex Order 26.4(b) (1) were obtained and entered in the electronic medical record for all new admissions. No residents had untoward effects related to this practice. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses on the importance of ensuring the contracted vendor for psychology services documented attempts for psychological assessments on residents. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses, Certified Nursing Assistants (CNAs), and the U.S. FOIA (6) (6) on the procedure for documenting weights for new admissions. Weights will be obtained for all new admissions, on the date of admission to the facility. The Dietician or designee will review the admission weight the day after admission, to ensure it is documented in the electronic medical record. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Unit Manager or designee will conduct audits of residents with psychology/psychiatry referrals to ensure the provider documents attempts to complete the psychological assessment. The audits will be conducted on 5 residents per week x 3 weeks, then 5 residents per month x 3 months, then 5 residents per quarter x 3 quarters to ensure compliance. The dietitian or designee will conduct audits of residents' admission weights to ensure proper completion. These results will be monitored weekly. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.
Deficient Staffing Ratios in Day Shifts
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts over a three-week period from December 1, 2024, to December 21, 2024. The deficiency was identified in 9 out of 21 day shifts, where the number of Certified Nurse Aides (CNAs) was insufficient to meet the mandated ratio of one CNA to every eight residents. This staffing shortfall was documented in several instances, with the number of CNAs ranging from 6 to 9, while the required number was at least 10 for the resident population during those shifts. The specific dates and staffing levels were as follows: On December 1, 4, 8, 9, 13, 14, 15, 16, and 21, the facility had fewer CNAs than required for the number of residents present. For example, on December 1, there were 7 CNAs for 79 residents, and on December 15, there were only 6 CNAs for 83 residents. These instances demonstrate a consistent failure to comply with the staffing requirements, which are crucial for ensuring adequate care and supervision of residents.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur: The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change: The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.
Nurse Staffing Deficiency Identified
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the weeks of 12/08/2024 and 12/21/2024. Specifically, on 12/08/2024, the facility provided 240 actual staffing hours, falling short by 2.25 hours from the required 242.25 hours. Similarly, on 12/15/2024, the facility provided 240 actual staffing hours, which was 4 hours less than the required 244 hours. This deficiency was identified based on the review of Nurse Staffing Reports and was associated with complaint numbers NJ00168416 and NJ00181485.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
