Complete Care At Prospect Heights Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hackensack, New Jersey.
- Location
- 336 Prospect Ave, Hackensack, New Jersey 07601
- CMS Provider Number
- 315460
- Inspections on file
- 24
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Complete Care At Prospect Heights Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required environmental standards in multiple resident-accessible areas. Dining/activity rooms on upper floors were documented at temperatures below the acceptable range, and a dining room that leadership described as decommissioned had no signage and remained accessible. In resident rooms, a loose pipe was found on the floor, privacy curtains were not properly hooked, and a ceiling vent had visible grayish buildup. A hallway linen cart was left partially uncovered with dried substances and stains on its cover. On two upper floors, hallways, rugs, walls, handrails, and dining rooms showed large dark stains, peeling wallpaper, and worn surfaces, with nursing and housekeeping leadership acknowledging that these conditions had persisted despite repeated cleaning and prior verbal reports. These findings conflicted with the facility’s own policy requiring a safe, clean, comfortable, and homelike environment in all resident areas.
The facility failed to provide sufficient CNA staffing to ensure timely and appropriate incontinence care for a resident who was cognitively intact, always incontinent of bladder and bowel, and dependent for toileting hygiene and transfers. On one unit, two CNAs were assigned to 28 residents, and a CNA reported having about 14 residents and not being finished with morning care. During an incontinence round, an RN/Unit Manager found the resident wearing double incontinence briefs that were saturated with urine, with wet pads and linens and a urine odor, despite no care plan entry or documentation that the resident had requested double briefs. Review of electronic CNA documentation showed toileting hygiene tasks were routinely signed off as completed, but on the day of observation only a single entry was recorded shortly after midnight, with no further documentation of incontinence care by the day shift, even though the resident was listed as incontinent and only two CNAs were scheduled on that floor.
Three residents with significant medical conditions did not have their weights collected and documented as ordered by physicians, with only one weight recorded for each or none after admission, and no explanation documented in the medical record. Staff interviews and job descriptions confirmed that policies and responsibilities for weight monitoring were in place, but these were not followed.
The facility failed to screen two EMTs and ensure they wore PPE while transporting a resident on a COVID unit. The EMTs were not informed of the outbreak or required to wear masks, contrary to facility policy. The Receptionist admitted to not screening them, and the DON confirmed the expectation for screening all entrants.
A facility failed to disinfect a multi-use glucometer with an EPA-registered disinfectant, using alcohol wipes instead, which increased the risk of blood-borne pathogen transmission among residents. Additionally, improper disposal of PPE was observed, with used PPE being discarded in hallway trash receptacles instead of inside isolation rooms, contrary to facility policy. These practices were inconsistent with infection control protocols, as confirmed by the DON and housekeeping staff.
A facility failed to maintain appropriate physician orders and labeling for a resident's oxygen use. The resident was observed using oxygen without an active order, and the oxygen tubing was unlabeled and improperly handled. A nurse confirmed the lack of proper labeling and contamination of the tubing, and it was noted that the last active order for oxygen had expired over a month ago.
The facility did not post the Nursing Home Resident Care Staffing Report in areas accessible to residents, as required by policy. Observations showed no postings on resident floors, and interviews with the DON and Administrator confirmed the absence of postings where residents lived, potentially preventing residents from knowing staffing levels.
A facility did not effectively implement and revise care plan interventions for a resident experiencing significant pain, leading to a decline in condition. Despite having orders for pain medication and a care plan indicating pain management strategies, the resident reported high pain levels on multiple occasions without appropriate intervention. The lack of adequate pain management and care plan revision resulted in a decline in the resident's functional abilities and overall well-being, contrary to the facility's pain management policy.
The facility did not consistently follow the care plan, evaluate pain, or ensure proper administration of pain medications for a resident experiencing pain from various conditions. Pain assessments were not always conducted or documented appropriately, and medication records showed discrepancies where reported pain levels were not matched with the administration of prescribed pain medication. Occupational Therapy notes indicated continuous complaints of pain and a decline in interventions due to pain and fatigue. Communication gaps between the Occupational Therapy team and nursing staff were identified, highlighting challenges in managing pain with only PRN medication. The facility's policy emphasized the need for an interdisciplinary approach to pain management, including both pharmacological and non-pharmacological interventions.
The facility failed to accurately encode a resident's wound in the MDS assessment. A resident admitted with diagnoses including Difficulty in Walking and Protein Calorie Malnutrition was documented as not having a pressure ulcer in the MDS assessment. However, records showed the resident had a sacral pressure ulcer, and preventative skin care orders were in place. The MDS Coordinator confirmed the miscoding by previous staff.
A resident with multiple medical conditions was found in a neglected state, with a soaked incontinence brief and fecal matter on their back, due to the facility's failure to provide adequate toileting assistance. The CNA responsible did not check or change the resident since the beginning of the shift, citing staff shortages. Facility policies requiring regular checks and immediate changes were not followed.
The facility failed to provide adequate staffing, resulting in a resident with multiple health issues being left in a soiled and wet condition for several hours. The resident's care plan and MDS indicated the need for assistance with ADLs and incontinence care, which were not met due to staffing shortages.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident-accessible areas. Surveyors observed that thermostats in the 3rd and 4th floor dining/activity rooms showed temperatures of approximately 67°F and 66.7°F, and a later temperature check in the 3rd floor dining room showed 64°F, below the facility’s own policy definition of comfortable and safe temperature levels and below the CMS temperature range referenced in state guidance. The 3rd floor dining room, which the LNHA stated was decommissioned and not in use, had no signage or notifications indicating it was closed, and the doors could be opened by surveyors, visitors, residents, and staff. Facility environmental temperature and safety rounds documentation did not include temperature measurements for any dining/activity areas on any floor. Additional environmental deficiencies were observed in resident rooms and common areas. In one resident room, a white pipe was found on the floor, which a CNA stated was likely from the metal cover under the sink. On a 6th floor hallway near a resident room, a linen cart was observed not fully covered, with whitish and blackish dried substances and a brownish stain on the cover; the Director of Recreation and a CNA acknowledged the cart should not be left open and that the white stain was from soap that had burst. In two separate resident rooms on the 4th floor, privacy curtains were hanging and not properly hooked on the rods, and in one of those rooms, a ceiling vent was observed with an accumulation of grayish substances upon entry. Surveyors also documented widespread issues with cleanliness and maintenance of floors, walls, and dining areas on the 5th and 6th floors. On the 5th floor, between specific rooms, the hallway rug was stained with a large dark brownish substance, handrails were scuffed and worn, and walls were stained with brown substances; wallpaper was peeling in at least one hallway area, and rugs throughout the 5th floor, including around the nursing station and near several rooms, had dark stains. The 5th floor dining room area had peeling wallpaper. The 5th floor RN/UM reported she had repeatedly raised these concerns with the LNHA, Maintenance Director, and DON for over a year and that shampooing every two weeks did not remove the stains. On the 6th floor, the main dining room had peeling wallpaper on the ceiling near the television and on the walls, and the rug area by the windows was stained with a brownish substance. These conditions were inconsistent with the facility’s Safe and Homelike Environment Policy, which requires a safe, clean, comfortable, and homelike environment in all resident-frequented areas, including hallways and dining/activity rooms.
Insufficient CNA Staffing Leads to Untimely Incontinence Care and Undocumented Double Brief Use
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to ensure timely and appropriate incontinence care, as evidenced by staffing levels and the condition of an incontinent resident. On one morning, the Nursing Home Resident Care Staffing Report showed a census of 118 residents on the 7 AM–3 PM shift with a CNA-to-resident ratio of 1:14.8. On the 5th floor, there were 28 residents and only two CNAs assigned. When interviewed, a CNA on that unit stated she had about 14 residents, described the assignment as hard, and reported she was not finished with morning care. On another day, the posted staffing report showed a census of 117 with 10 CNAs on the 7 AM–3 PM shift, for a ratio of 1 CNA to 11.7 residents. The facility’s own leadership later acknowledged that staffing concerns and at times not meeting New Jersey minimum staffing ratios were known issues. During an incontinence round on the 5th floor, the RN/Unit Manager confirmed that a resident was incontinent of both bladder and bowel and obtained the resident’s permission to check the incontinence brief. The RN/Unit Manager and surveyor observed that the resident was wearing double incontinence briefs that were wet with urine. The RN/Unit Manager also found that the resident’s pads, folded linen, and cloth-type chuck under the resident were wet beyond the pads, and there was a noticeable urine odor. The RN/Unit Manager stated she was unaware that the resident had requested double briefs and indicated that double briefs were not allowed unless specifically requested by the resident and included in the care plan. She further stated she was unsure whether this preference was in the care plan. The surveyor was unable to interview the CNA assigned to the resident at that time. Record review for this resident showed diagnoses including type 2 diabetes mellitus without complications, COPD unspecified, need for assistance with personal care, and difficulty in walking. The care plan identified a focus on potential impairment to skin integrity with an intervention to assist with toileting needs, but there was no care plan entry documenting a preference for double incontinence briefs or any documented evidence that the resident had requested them. The most recent quarterly MDS showed the resident was cognitively intact (BIMS 15/15), always incontinent of bladder and bowel, and dependent for toileting hygiene and toilet transfer, with no documented skin impairment. Review of CNA electronic documentation for toileting hygiene from 1/10/26 to 1/22/26 showed the task was checked off every shift as completed with the resident dependent and requiring assistance of two or more helpers. However, on 1/23/26, only one shift at 12:17 AM documented toileting hygiene, and there was no documentation by the 7 AM–3 PM shift or any evidence of incontinence care after 12:17 AM that day, despite the resident being listed on the facility’s list of incontinent residents and only two CNAs being scheduled on the 5th floor for that shift.
Failure to Obtain and Document Resident Weights per Physician Orders
Penalty
Summary
The facility failed to follow professional standards of clinical practice regarding the assessment and documentation of residents' weights and the implementation of physician orders. Specifically, three residents with various medical conditions, including urinary tract infection, congestive heart failure, hypertension, respiratory failure, COVID-19, pneumonia, anemia, and muscle weakness, had physician orders for weights to be collected on admission and then weekly for four weeks. However, for each of these residents, weights were either not collected as ordered or were only collected once, with no documentation in the progress notes explaining the omissions. Interviews with facility staff, including the Dietitian and Director of Nursing, revealed that there were established expectations and policies for weight monitoring and documentation, including procedures for documenting refusals or missed weights. Job descriptions for CNAs, LPNs, RNs, and the Dietitian outlined responsibilities related to weighing residents and documenting or reporting weight changes. Despite these policies and procedures, the required weights were not consistently obtained or documented, and there was no evidence in the medical record to explain the missed assessments.
Failure to Screen and Enforce PPE Use for EMTs
Penalty
Summary
The facility failed to properly screen outside vendors and ensure that Personal Protective Equipment (PPE) was worn on the COVID unit, specifically involving two Emergency Medical Technicians (EMTs) who were observed transporting a resident. The resident's electronic medical record indicated an admission date, but the report does not specify any medical history or condition at the time of the deficiency. During an observation, the EMTs were seen on the facility elevator without masks while transporting the resident to the third floor, which was under COVID precautions. Interviews revealed that the EMTs were not informed of the COVID outbreak, nor were they screened or instructed to wear masks on the affected units. The facility Receptionist admitted to not properly screening the EMTs, and the Director of Nursing (DON) confirmed the expectation that all individuals entering the facility should be screened according to the COVID outbreak protocol. The facility's policy for emergent infectious diseases required screening and temperature checks for all administrative staff, contractors, and visitors before entering the facility, which was not followed in this instance.
Infection Control Deficiencies in Glucometer Disinfection and PPE Disposal
Penalty
Summary
The facility failed to properly disinfect a multi-use glucometer with an EPA-registered disinfectant, as observed during a survey. A Licensed Practical Nurse (LPN) was seen using an alcohol wipe to clean the glucometer after using it on a resident, which is not in accordance with the facility's policy that requires the use of an EPA-registered disinfectant effective against HIV, Hepatitis C, and Hepatitis B. This practice was observed on the East medication cart, where the same glucometer was used for multiple residents, increasing the risk of transmitting blood-borne pathogens. The LPN confirmed that she had been educated to use alcohol pads for disinfection, which contradicts the facility's policy. Additionally, the facility did not ensure proper doffing and disposal of Personal Protective Equipment (PPE) to prevent infection spread. Observations revealed that a visitor exiting a resident's room on isolation precautions disposed of used PPE in hallway trash receptacles instead of inside the room. The facility's policy mandates that PPE should be disposed of in appropriate waste receptacles within the room to prevent contamination. The Director of Nursing (DON) confirmed that the expectation was to dispose of PPE inside the rooms, but the trash cans were placed in the hallway by housekeeping staff. The survey also noted that the facility had two rooms on isolation precautions, with signage and PPE equipment posted on the doors. However, there was inconsistency in the availability of trash receptacles for PPE disposal inside these rooms. One room had a large trash can near the door, while the other did not, leading to improper disposal practices. The Housekeeping Director stated that training was provided to staff on cleaning isolation rooms, but the placement of trash receptacles was not consistent with the facility's infection control policy.
Removal Plan
- Facility wide staff education on proper disinfection of multi-use glucometers
Failure to Maintain Proper Oxygen Orders and Labeling
Penalty
Summary
The facility failed to ensure that a resident had the appropriate physician orders for the use of oxygen and that the oxygen tubing was properly labeled. The electronic medical record for the resident showed no active order for oxygen use, yet the resident was observed using oxygen at 2 liters per minute from a wall delivery system. The oxygen tubing and water humidifier were unlabeled, and the tubing was improperly wrapped around the bed's side rail, with an oxygen mask left uncovered and dangling to the floor. A staff nurse administered medication to the resident without addressing the oxygen system. A Licensed Practical Nurse confirmed that the oxygen should be continuously administered via nasal cannula and acknowledged the lack of proper labeling and contamination of the dangling tubing. It was also confirmed that the resident did not have any active oxygen orders, with the last order having expired over a month prior.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Nursing Home Resident Care Staffing Report was posted in areas accessible to residents, as required by their policy. The policy, revised on 08/14/24, mandates that nurse staffing information be readily available in a readable format to residents and visitors at any time. However, an observation on 09/25/24 at 10:30 AM revealed that there was no staff posting on the third, fifth, and sixth floors where residents lived. During interviews, the Director of Nursing (DON) indicated that the posting should be on the clerk's desk downstairs and sometimes in the window next to activities, but both the DON and the Administrator confirmed that it was not available on the resident floors. This oversight had the potential to prevent residents from knowing the staffing levels provided for all 96 residents in the facility.
Inadequate Pain Management and Care Plan Revision
Penalty
Summary
The facility failed to implement and revise care plan interventions for Resident #1, who was experiencing pain resulting in a decline in condition. Despite the CP indicating pain related to a disease process and interventions to address pain symptoms, the facility did not adequately manage Resident #1's pain when it exceeded a Pain Scale (PS) of 3. Orders for pain medication were in place, but Resident #1 reported significant pain levels on multiple occasions, including a PS of 9 on 2/2/24, without appropriate intervention or revision of the care plan. Documentation revealed Resident #1's steady decline in skilled interventions due to pain and fatigue, with reports of significant pain levels in various body parts. The facility's failure to address Resident #1's pain adequately led to a decline in functional abilities and overall well-being. Despite reports of pain and weakness, there was no indication that the care plan was revised or that stronger pain management measures were considered, as required by the facility's policy on pain management and comprehensive care planning.
Inconsistent Pain Management and Documentation
Penalty
Summary
The facility failed to consistently follow the care plan, evaluate pain, and ensure proper administration of pain medications for Resident #1, who was experiencing pain related to various conditions including falls, difficulty in walking, and adult failure to thrive. Despite the care plan indicating the need for analgesia as per physician's orders, there were instances where pain assessments were not conducted or documented appropriately. The medication administration records revealed discrepancies where Resident #1 reported pain levels above the prescribed threshold, but there was no indication that the ordered pain medication was administered accordingly. Documentation from the Occupational Therapy Treatment Encounter Notes indicated Resident #1's continuous complaints of pain and decline in skilled interventions due to pain and fatigue. The Certified Occupational Therapy Aide (COTA) acknowledged the lack of communication to nursing regarding the resident's pain and emphasized the importance of documenting such interactions for proper care coordination. The facility's policy on pain management highlighted the need for comprehensive, person-centered care plans addressing individual pain management needs, including both pharmacological and non-pharmacological interventions. During interviews with the Occupational Therapist/Director of Rehab (OT/DOR), COTA, and LPNs, it was revealed that there were communication gaps regarding Resident #1's pain status and management. LPN #3 mentioned the challenges in managing Resident #1's pain with only PRN medication and the resident's distress during episodes of severe pain. The facility's policy emphasized the interdisciplinary approach to pain management, incorporating non-pharmacological interventions alongside pharmacological treatments tailored to each resident's specific pain needs.
Inaccurate MDS Assessment of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for one of the three residents reviewed for MDS accuracy. Specifically, Resident #1 was admitted with diagnoses including Difficulty in Walking, Adult Failure to Thrive, and Protein Calorie Malnutrition. The MDS assessment dated 12/10/23 indicated that the resident did not have a pressure ulcer. However, a review of the resident's Skin Integrity/Diagram (SID) dated 12/8/23 showed that the resident had a sacral pressure ulcer described as redness. Additionally, the Order Summary Report (OSR) dated 4/15/24 revealed an order for preventative skin care, including the application of barrier cream after cleansing with soap and water every shift and as needed after each incontinent episode, starting from 12/6/23. The Treatment Administration Record (TAR) for December 2023 confirmed that the barrier cream was applied to the resident's skin from 12/7/23. During interviews with the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the documentation on the SID, and the MDS Coordinator (MDSC) confirmed that the previous MDS staff, who no longer work at the facility, had miscoded the 12/10/23 assessment in Section M. The facility's policy titled MDS Completion and Submission Timeframes, dated 10/2019, indicated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. This discrepancy in the MDS assessment led to the deficiency noted in the report.
Failure to Provide Adequate Toileting Assistance
Penalty
Summary
The facility failed to provide adequate assistance in toileting services to a resident, leading to a deficiency. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, muscle weakness, and a need for assistance with personal care, was found in a severely neglected state. During a skin check, the resident was observed lying in a soaked and wet incontinence brief, with fecal matter on their back, and stained bed linens. The resident's care plan indicated a need for assistance with hygiene and comfort measures due to impaired mobility and incontinence, but these needs were not met. The CNA responsible for the resident admitted to not checking or changing the resident's incontinence underwear since the beginning of the shift, citing staff shortages as the reason for the oversight. The facility's policy requires residents to be checked for wetness every two hours and changed immediately if soiled, but this protocol was not followed. The facility's documentation and interviews with staff revealed that the third floor, where the resident was located, had three CNAs assigned to 27 residents on the day of the incident. The CNA job description and facility policies emphasize the importance of keeping residents dry and providing necessary perineal care to prevent skin breakdown and maintain hygiene. However, the failure to adhere to these policies resulted in the resident being left in an unsanitary and uncomfortable condition, highlighting a significant lapse in the standard of care provided by the facility.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, specifically Resident #2, who was admitted with diagnoses including Urinary Tract Infection, Metabolic Encephalopathy, Muscle Weakness, and required assistance with personal care. On 4/15/24, during a skin check at 10:36 am, Resident #2 was found lying in bed with a soaked and wet incontinent brief, and the bed sheets were stained with urine and feces. The resident's lower to mid-back had fecal matter, indicating that the resident had not been checked or changed since the beginning of the shift at 7:00 a.m. The CNA assigned to Resident #2 confirmed that she did not provide care until 10:36 a.m. due to being short-staffed that day. The third floor had 27 residents and only 3 CNAs on duty, which contributed to the inadequate care provided to Resident #2. The care plan for Resident #2, initiated on 4/9/24 and revised on 4/15/24, indicated that the resident had actual impairment to skin integrity related to impaired mobility, incontinence, and nutritional concerns. The Minimum Data Set (MDS) assessment dated 4/13/24 indicated that Resident #2's cognition was moderately impaired and required assistance with Activities of Daily Living (ADLs). The MDS also noted that the resident was incontinent of bowel and bladder. The CNA job description included specific functions such as making residents comfortable, keeping them dry, and assisting with bowel and bladder functions, which were not adequately performed due to staffing shortages. This deficiency highlights the facility's failure to provide sufficient nursing staff to meet the needs of its residents, as required by NJAC 8:39-27.1(a).
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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