Complete Care At Ocean Grove Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocean Grove, New Jersey.
- Location
- 160 S Main St, Ocean Grove, New Jersey 07756
- CMS Provider Number
- 315365
- Inspections on file
- 17
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Complete Care At Ocean Grove Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently document ADL bladder care for two residents, one with spinal stenosis and Parkinson’s disease and another with chronic pulmonary embolism and type 2 DM. Review of the electronic POC records for a specific month showed multiple blank entries for bladder documentation across various shifts, indicating care was not recorded as completed. A CNA and an LPN confirmed that facility expectations require ADL documentation to be completed before the end of each shift, and the DON acknowledged the blanks and reiterated that CNAs are expected to accurately and fully complete ADL logs in accordance with the facility’s ADL policy.
Surveyors found that kitchen staff failed to properly label, date, and store potentially hazardous foods, and did not maintain kitchen equipment in a clean and sanitary manner. Observations included spoiled produce in refrigerators, an ice machine with condensation, unidentified substances, and makeshift repairs, as well as an oven with greasy residue. Opened food items were not labeled or dated as required, and facility policies for cleaning and food safety were not consistently followed.
During incontinence rounds, two residents dependent on staff for ADLs were found wearing double incontinence briefs, both of which were wet. An LPN confirmed this was not appropriate practice. Both residents had significant medical conditions and were assessed as always or frequently incontinent, with care plans lacking specific interventions in one case. Facility policy and staff confirmed that double briefing was not acceptable.
The facility did not have an RN present for at least eight consecutive hours on one day, as required. An RN was scheduled but called out, and although the agency was contacted, an LPN was sent instead. The absence of an RN was not discovered until the next shift, resulting in a lapse in required RN coverage for resident care and assessments.
A resident's medical record was found to be incomplete when the facility could not provide the full Controlled Drug Administration Record (CDAR)/Declining Sheet for a prescribed medication, despite repeated requests and searches by the DON. Only a partial record was available, resulting in a deficiency for failure to maintain complete and accurate documentation as required.
The facility did not meet required CNA-to-resident staffing ratios on multiple day shifts over several weeks, with staffing levels consistently below state-mandated minimums for the number of residents present. This deficiency was identified through interviews and review of facility records, and had the potential to affect all residents.
Two residents in an LTC facility did not receive their medications at the scheduled times, as required by the facility's policy. Despite the late administration of medications for hypertension and pain, there was no documentation of notifying the residents' PCPs or evidence of harm. Interviews with nursing staff confirmed the expectation of timely medication administration and proper documentation, aligning with the facility's policy.
The facility staff failed to document ADL care for two residents as per policy. One resident, with muscle weakness, lacked documentation of necessary interventions like rolling and toileting over several days. Another resident, with severe cognitive impairment, also had missing documentation for bed mobility and toileting care. Staff interviews revealed CNAs were responsible for documenting care in the POC system by shift end, even if care was refused.
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY number for three residents. This omission was identified during a review of the NOMNC forms, and the Director of Social Services was unaware of the requirement.
The facility failed to protect residents from physical abuse, as evidenced by incidents where a resident with severe cognitive impairment hit another resident with a fly swatter, and another incident where a cognitively impaired resident kicked a cognitively intact resident. The facility conducted abuse training and had policies in place, but these incidents still occurred.
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency. Incidents involving a resident being hit with a fly swatter, a resident with a bruised wrist, and a resident with multiple bruises and an abrasion were either reported late or not reported at all. Staff interviews revealed a lack of awareness regarding the required reporting timeframes.
The facility failed to investigate injuries of unknown origin for a resident. Despite reporting the incidents to the DON, no skin audits, resident interviews, or camera footage reviews were conducted. The facility did not follow its policy for thorough investigations.
The facility staff failed to complete a baseline care plan within 48 hours for a resident admitted with diabetes mellitus, spinal stenosis, and quadriplegia. The resident, moderately cognitively impaired, did not have a care plan until 14 days post-admission, contrary to the facility's policy.
The facility failed to provide scheduled showers twice a week for two dependent residents due to staff shortages, despite the residents' preferences and cognitive awareness. Documentation and staff interviews confirmed the inconsistency in providing the scheduled showers.
The facility staff failed to maintain a medication error rate below five percent, as evidenced by two incidents where an LPN administered the incorrect dosage of acetaminophen to a resident and an RN held a dose of spironolactone without physician orders to do so.
The facility failed to ensure medical records were readily accessible for a resident admitted with hypertension, diabetes, and dementia. Despite multiple requests and attempts to retrieve the records from a previous EMR system, the facility was unable to provide the necessary medical information, including critical wound care documentation. This highlights a significant deficiency in maintaining and retrieving resident medical records.
The facility failed to ensure proper infection control practices: a hospitality aide did not wear an N-95 mask and eye protection in a COVID-19 positive room, a CNA doffed PPE outside a room with strict contact precautions, and an LPN cleaned a glucometer without gloves.
Failure to Consistently Document ADL Bladder Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to consistently document Activities of Daily Living (ADLs), specifically bladder care, for two residents. For one resident with spinal stenosis and Parkinson’s disease and a BIMS score of 8/15 indicating moderate cognitive impairment, review of the December 2025 Documentation Survey Report (POC) showed blank entries for bladder documentation on multiple shifts and dates, indicating the task was not documented as completed. For another resident with chronic pulmonary embolism and type 2 diabetes mellitus and a BIMS score of 15/15 indicating intact cognition, the December 2025 POC similarly contained numerous blank bladder documentation entries across day, evening, and night shifts, again indicating the task was not documented as completed. During interviews, a CNA stated that ADL care is documented on the POC and that the expectation is to complete documentation within two hours before the end of the shift, acknowledging that documentation serves as proof of care provided. An LPN stated that all documentation should be completed before staff leave the facility. When presented with the POC records for both residents, the DON acknowledged the blanks and stated that staff are expected to document accurately according to the numerical log and to complete ADL logs in their entirety so the facility can know and perform residents’ needs and expectations. Review of the facility’s ADL policy, implemented 09/01/24, stated that residents unable to carry out ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which the facility failed to follow as evidenced by the incomplete ADL documentation.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper labeling, dating, and storage of potentially hazardous foods, as well as inadequate cleaning and maintenance of kitchen equipment. During kitchen inspections, condensation and an unidentified yellow substance were found on the ice machine, which also had duct tape and a white bonding material applied to damaged areas. The Food Service Director (FSD) was unable to identify the yellow substance or provide a satisfactory explanation for the use of duct tape and bonding material. The oven was observed to have a greasy, brown substance on its inner surface, and the FSD acknowledged that the oven should be kept clean and free of such substances. Additionally, wilted and partially decomposed lettuce, wilted and yellow celery, and cucumbers with visible spoilage and leaking juice were found in the walk-in refrigerators. The FSD stated that produce is checked during meal preparation rather than daily, which contributed to spoiled items remaining in storage. Further observations revealed an opened, unlabeled, and undated box of sausage and a container of cottage cheese in the walk-in refrigerator, both of which lacked required labeling and dating. The FSD confirmed that these items should have been covered and labeled with opened or used-by dates to ensure food safety. Facility policies reviewed by surveyors required regular cleaning and sanitizing of the ice machine and ovens, as well as proper labeling and dating of food items, but these procedures were not consistently followed. The deficiencies were acknowledged by facility leadership during the survey.
Deficient Incontinence Care Due to Use of Double Briefs
Penalty
Summary
Surveyors identified a deficiency in incontinence care during rounds on one of two nursing units, where two residents who were dependent on staff for activities of daily living were found to be wearing double incontinence briefs. In both cases, a staff member exposed the front of the resident's brief, which was wet, and upon further inspection, a second, also wet, incontinence brief was discovered layered underneath. The staff member present acknowledged that applying two briefs was not appropriate. Both residents had significant medical histories, including congestive heart failure, type 2 diabetes mellitus, and acute respiratory failure, and were assessed as always or frequently incontinent and dependent on staff for toileting hygiene. The medical records and individualized care plans for these residents documented their incontinence and dependence on staff, but one care plan did not include specific interventions for incontinence. The facility's policy on incontinence care required appropriate treatment to prevent infections and restore continence to the extent possible. The surveyor confirmed with facility staff and policy that the use of double briefs was not acceptable practice, and the deficiency was cited based on these observations and record reviews.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least eight consecutive hours on one of the days reviewed. Specifically, review of the facility's Nurse Staffing Reports showed that there was no RN coverage for any shift on a particular day. During interviews, facility staff confirmed that an RN was scheduled but called out, and although the agency was contacted to provide a replacement, a Licensed Practical Nurse (LPN) was sent instead. The error was not identified until the next shift, resulting in a full day without RN coverage. The facility's policy requires sufficient staffing, including RNs, to provide nursing care in accordance with resident care plans. However, on the day in question, the absence of an RN meant that there was no RN available to assist with assessments and overall care of the residents, as confirmed by staff interviews. The deficiency was identified through document review and staff interviews, with staff acknowledging the oversight and the failure to ensure RN coverage as required by federal regulations.
Plan Of Correction
1. The facility failed to ensure there was a Registered Nurse working for at least 8 consecutive hours on 1 of 21 days reviewed. 2. All residents have the potential to be affected by this practice. 3. The Facility continues to actively fill all open Registered Nurse positions to comply with Federal Nursing Regulation to have 8 consecutive hours a day, 7 days a week. Staff requirements and facility policy were reviewed with Human Resources and the Staffing Coordinator, who were able to reiterate minimum staffing requirements. The facility will take the following measures to ensure this deficient practice does not occur. The facility will focus on recruitment and retention strategies as follows: identify vacant Registered Nurse positions daily and attempt to fill positions with current Registered Nurses staff or agency; work diligently with the Administrator, Director of Nursing, and Corporate Recruiter to advertise, recruit, and hire sufficient Registered Nurse staff. 4. The Staffing Coordinator will review schedules daily to ensure that at least 8 RN hours are scheduled and will review with the Director of Nursing. The Administrator or designee will audit the schedules weekly for 4 weeks and monthly for 2 months to ensure there is an RN scheduled for 8 consecutive hours 7 days a week. Results and audits will be reviewed at the monthly Quality Assurance Meeting for 3 consecutive meetings. Based upon the results of these audits, a decision will be made regarding the need to continue submission and reporting.
Incomplete Medical Record for Controlled Drug Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of four sampled residents. Specifically, the surveyor requested the complete Controlled Drug Administration Record (CDAR)/Declining Sheet for a resident's medication, but the facility was unable to provide the entire documentation. The only available record was a single sheet with a specific date issued, and despite further requests and searches by the Director of Nursing, the full CDAR/Declining Sheet could not be located. An email response confirmed that the document was still missing at the time of the survey. This deficiency was identified through observations, interviews, and review of medical records and facility documentation. The resident involved had multiple diagnoses and was receiving medication as ordered, but the lack of a complete CDAR/Declining Sheet meant that the facility did not have a full record of the administration of a controlled drug as required by federal and state regulations.
Plan Of Correction
1. Resident #2 was discharged from the facility. 2. All residents who have orders for medications that require a Controlled Drug Administration Record/Declining Sheet have the ability to be affected by this practice. 3. The Medical Record staff was re-educated on the procedure for maintaining accurate, complete, readily accessible, and systematically organized records by the Director of Nursing or designee. The Drug Administration Record Declining sheet will be reviewed for accuracy and placed in residents' charts. 4. The Director of Nursing/Designee will audit the Controlled Drug Administration Record/Declining Sheet on each cart weekly x 4 and monthly x 2. The results of the audit will be reviewed at the Monthly Quality Assurance Meeting for three months. Continuation of the audits, reporting, and frequency after three months will be determined by the QA Committee.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.
Plan Of Correction
1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications in accordance with the acceptable standard of nursing practice and its own policy on administering medications for two residents. Resident #1, who was admitted with diagnoses including hypertension and pain, had medication orders for Clonidine and Gabapentin to be administered at specific times. However, the Medication Administration Audit Report revealed that these medications were consistently administered late, with no documentation indicating that the resident's primary care physician was notified of these deviations. Despite the late administration, there was no documented evidence of harm to the resident. Similarly, Resident #2, admitted with hypertension and dermatitis, had medication orders for Cozaar and Hydroxyzine to be administered at specific times. The Medication Administration Audit Report showed that these medications were also administered late on multiple occasions. Again, there was no indication in the progress notes that the resident's primary care physician was informed of the late administration, and no documented evidence of harm was noted. Interviews with nursing staff, including a registered nurse and a unit manager, confirmed that medications were expected to be administered within one hour of the scheduled time. They also stated that if medications were not administered on time, the physician should be notified, and the incident documented in the medical records. The facility's policy on medication administration, dated October 2022, supports these expectations, emphasizing the importance of timely administration and proper documentation.
Failure to Document ADL Care for Residents
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to two residents, as per the facility's policy and protocol. For one resident, who was admitted with muscle weakness and required assistance with ADLs, the documentation survey report (DSR) did not indicate that necessary interventions such as rolling, turning, repositioning, and toileting were provided during specific shifts over several days in April 2024. This resident had intact cognition and required assistance due to impaired balance and musculoskeletal impairment, as noted in their care plan. Another resident, admitted with Parkinsonism, Alzheimer's Disease, and Dementia, required total assistance with ADLs due to severe cognitive impairment. The DSR for this resident also lacked documentation of bed mobility, turning, repositioning, and toileting care provided during various shifts in May and June 2024. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Unit Manager/Registered Nurse (UM/RN), revealed that CNAs were responsible for documenting ADL care in the Point of Care (POC) system by the end of each shift, even if care was refused. The facility's policy emphasized the importance of documenting all services provided to residents to facilitate communication among the interdisciplinary team.
Failure to Include Required Information on NOMNC Forms
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY (teletypewriters) number for three residents. This omission was identified during a review of the NOMNC forms for three residents, who were either discharged or remained in the facility for long-term care. Specifically, the NOMNC for Resident 23, who was admitted for therapy and discharged home, did not contain the name of the QIO or the TTY number. Similarly, the NOMNCs for Residents 188 and 189, who remained in the facility for long-term care, also lacked this required information. The NOMNC for Resident 188 was issued by phone to the resident's daughter, who handled all business matters, but still did not include the necessary details for filing an expedited appeal. The NOMNC for Resident 189 was issued without the QIO name or TTY number as well. During an interview, the Director of Social Services (DSS) stated she was unaware that the name of the QIO and the TTY number had to be included on the NOMNC. A review of the facility's policy, dated 2022, confirmed that the NOMNC should inform beneficiaries of their right to an expedited review by a QIO. This failure to include the required information could prevent Medicare beneficiaries with hearing impairments from being able to file an appeal in a timely manner.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving four residents. One incident involved a resident with severe cognitive impairment who entered another resident's room and hit her with a fly swatter. The resident who was hit did not sustain any injuries and did not believe the other resident intended to harm her. The staff had attempted a gradual dose reduction of the aggressive resident's psychotropic medication, which led to increased behaviors, and the medication was subsequently resumed at the original dose. Despite the use of a wander guard and staff supervision, the incident occurred, and there were no further incidents reported with this resident. Another incident involved a resident who was cognitively intact and was kicked in the leg by another resident who mistakenly entered her room. The cognitively impaired resident believed he was in his own room and became adamant about staying. The cognitively intact resident attempted to push the other resident out of her room, leading to the altercation. The facility's investigation noted a small purpuric area on the resident's leg as a result of the kick. The cognitively impaired resident was placed on half-hour behavior checks following the incident. Interviews with staff revealed that the facility conducted abuse training annually and in-services throughout the year. Staff were expected to report any concerns to the DON and ensure resident safety. The DON and Regional Administrator both emphasized the expectation for residents to be safe and have an abuse-free environment. The facility's policy on abuse, neglect, exploitation, or misappropriation required all reports of abuse to be thoroughly investigated and documented, with findings reported to relevant agencies.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency for three of six incidents reviewed. In one instance, a resident reported being hit by another resident with a fly swatter, but the incident was not reported to the New Jersey Department of Health (NJDOH) until the following day. In another case, a resident was found with a bruise on her wrist, which was reported to the Director of Nursing (DON) and the former Administrator, but the incident was not reported to NJDOH until three days later. Additionally, a resident was found with multiple bruises and an abrasion, but this incident was not reported to NJDOH at all. Interviews with staff revealed a lack of awareness regarding the requirement to report abuse within two hours if it involves serious bodily injury, or within 24 hours if it does not. The facility's policy on reporting abuse, neglect, exploitation, or misappropriation of resident property was not followed, as incidents were either reported late or not reported at all. The DON admitted to being unaware of the specific reporting timeframes, and the Regional Administrator confirmed that all incidents should be reported within the required two hours. The facility's failure to adhere to these reporting requirements resulted in deficiencies in their handling of abuse and injury incidents.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of an unknown origin for a resident. On one occasion, a resident was found with a bruise on the left wrist, and although the incident was reported to the Director of Nursing (DON) and the former Administrator, no skin audit or resident interviews were conducted. Additionally, the facility did not review camera footage or complete additional body audits. On another occasion, the same resident was found with a bruised finger, a small bruise near the right elbow, and an abrasion on the right elbow. Despite reporting the incident to the DON, no investigation was conducted to determine the cause of the injuries. The facility's policy requires thorough investigations of all reports of resident abuse, including injuries of unknown origin. This includes reviewing documentation, interviewing staff and residents, and observing the alleged victim. However, the facility did not follow these procedures in the cases mentioned. The DON admitted that they were still learning their new electronic medical record (EMR) system and were unsure where to document the incidents. The Regional Administrator also stated that he expected all incidents to be thoroughly investigated, which was not done in these cases.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility staff failed to complete a baseline care plan within 48 hours of admission for one resident. The resident, who was admitted with diagnoses of diabetes mellitus, spinal stenosis, and quadriplegia, was moderately cognitively impaired with a BIMS score of 12 out of 15. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission, the care plan for this resident was not completed until 14 days after admission. Both the Director of Nursing and a registered nurse confirmed the delay during interviews. The facility's policy, dated 10/02/23, mandates the development of a baseline care plan within 48 hours of a resident's admission.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers twice a week as scheduled for two residents, R21 and R51, who were dependent on staff assistance for activities of daily living (ADLs). R21, who was admitted with diagnoses including end-stage renal disease, COPD, hemiplegia, and diabetes mellitus, did not receive scheduled showers on multiple occasions in January and February 2024. Despite being cognitively intact and expressing a preference for showers over bed baths, R21 reported not receiving her scheduled showers due to staff shortages. This was confirmed by the facility's documentation and staff interviews. Similarly, R51, who was admitted with diagnoses of cerebral infarction and hemiplegia, also did not receive scheduled showers on several occasions. R51, who was also cognitively intact, expressed a preference for showers and reported inconsistencies in receiving them as scheduled. The facility's documentation and staff interviews corroborated these claims, indicating that staff shortages were a contributing factor. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) responsible for R21 and R51 confirmed that the residents were scheduled for showers on Mondays and Thursdays but did not always receive them due to staffing issues. The Director of Nursing (DON) acknowledged the problem and stated that residents were supposed to receive bed baths if showers could not be provided. However, the documentation showed that the scheduled showers were not consistently provided, leading to the deficiency.
Medication Administration Errors
Penalty
Summary
The facility staff failed to ensure the medication error rate was below five percent, as evidenced by two observed incidents involving residents R22 and R6. For R22, who has diagnoses including diabetes mellitus, bipolar disease, and schizophrenia, the physician ordered two 500 mg tablets of acetaminophen to be administered in the morning for pain. However, during a medication administration observation, LPN7 was seen administering only one tablet. LPN7 later confirmed the error, acknowledging that she might have given only one tablet despite the order for two. The Director of Nursing (DON) confirmed that all medications should be given as ordered by the physician. In the case of R6, who has diagnoses of hypertension and congestive heart failure, the physician ordered 25 mg of spironolactone to be administered in the morning for edema, with no parameters to hold the medication based on blood pressure readings. During a medication administration observation, RN5 held the medication, citing a low blood pressure reading of 91/53, despite the absence of any such directive in the physician's orders. The DON confirmed that the nurse should have contacted the physician if they felt the blood pressure was too low to administer the medication. RN6 also confirmed that there were no parameters for holding the spironolactone for R6.
Failure to Maintain and Retrieve Resident Medical Records
Penalty
Summary
The facility failed to ensure medical records were readily accessible for one resident (R137) out of a sample of 25. R137 was admitted with diagnoses including hypertension, diabetes, and dementia. Upon review, the facility's current electronic medical record (EMR) system did not contain any information for R137. The Director of Nursing (DON) confirmed that R137's records were not accessible because the facility was previously owned by a different company that used a different EMR system. Despite multiple requests and attempts to retrieve the records, the facility was unable to provide the necessary medical information for R137 in a timely manner. The survey team made several requests for specific medical records, including physician's orders, treatment records, medication administration records, progress notes, and wound care documentation. The facility's Registered Nurse Consultant (RNC) and Administrator made efforts to contact the previous owner and IT department to gain access to the records. However, these efforts were unsuccessful, and the survey team was not provided with the requested information within the expected timeframe. The facility eventually provided a computer tablet containing over 1800 pages of R137's medical record in a portable document format (pdf), but key documents such as wound treatment records and care plans were still missing. Interviews with the facility's staff and a family member of R137 revealed that the resident had a wound care appointment where maggots were found in the foot wound. The family member had a copy of the wound care report, but the facility did not have this report in R137's medical records. The facility's inability to access and provide complete medical records for R137, including critical wound care documentation, highlights a significant deficiency in maintaining and retrieving resident medical records as required by state and federal law.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff members. One hospitality aide entered a COVID-19 positive resident's room wearing a surgical mask instead of the required N-95 mask and eye protection. The aide was unaware of the need for these specific PPE items. Additionally, a certified nursing assistant doffed his gown outside of a resident's room who was on strict contact precautions for Methicillin Susceptible Staphylococcus Aureus (MSSA) in a wound, instead of inside the room as required. The CNA admitted to rushing and not following proper protocol. Furthermore, a licensed practical nurse cleaned a glucometer without wearing gloves after administering insulin to a resident with diabetes mellitus. The nurse stated that he had not considered the need to wear gloves during the cleaning process. The Director of Nursing confirmed that the expectation was for staff to use gloves when cleaning medical equipment. These lapses in protocol could lead to exposure to COVID-19 and bloodborne pathogens among residents and staff.
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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