Fountainview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakewood, New Jersey.
- Location
- 527 River Avenue, Lakewood, New Jersey 08701
- CMS Provider Number
- 315327
- Inspections on file
- 12
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fountainview Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including obstructive sleep apnea, did not have physician's orders in place for weekly CPAP tubing changes, machine cleaning, or daily filling of the water chamber with distilled water. Although staff reported performing these tasks, there was no documentation or orders to support this, as confirmed by interviews with the LPN, Unit Manager, and DON. Facility policy required such orders, but they were not present in the resident's record.
A resident with severe cognitive impairment was verbally abused and videotaped by a housekeeping aide during a medical appointment. The aide yelled and cursed at the resident, causing distress and confusion. The ENT staff intervened, and the facility's investigation confirmed the abuse, highlighting a failure in implementing the abuse prevention policy.
A facility failed to thoroughly investigate an incident where a Housekeeping Aide verbally abused and videotaped a resident with severe cognitive impairment during a doctor's appointment. The resident, diagnosed with bipolar disorder and schizoaffective disorder, appeared visibly upset and confused. The facility's investigation was inadequate, lacking interviews with all witnesses, including other residents escorted by the aide. This failure resulted in an Immediate Jeopardy situation.
The facility breached confidentiality by leaving residents' EMRs open during medication administration, exposing private information to potential onlookers. Both an RN and an LPN acknowledged the oversight, and the DON confirmed it violated HIPAA and resident privacy rights.
A facility failed to attempt alternative measures before installing bedrails for a resident with hemiplegia and hemiparesis. The resident's care plan required a left bedrail for safety, but no alternatives were explored prior to its use. Staff confirmed that assessments were completed without considering other options, and the DON acknowledged this oversight.
A resident with a DNR order was mistakenly given CPR due to the facility's failure to maintain a complete medical record. The resident's POLST form was not included in the official records, leading to the resident being treated as a full code. The Social Service Director kept relevant documentation in a separate file, unaware that it should have been part of the medical record.
A resident with severe cognitive impairment was video recorded without consent by a Housekeeping Aide at an ENT doctor's office. The resident appeared upset and confused, believing they had been kidnapped. The transport driver continued recording after taking the aide's phone. ENT staff witnessed the aide yelling and belittling the resident. The DON confirmed staff were trained not to record residents, indicating a breach of the resident's rights to dignity and privacy.
A resident with severe cognitive impairment was improperly restrained with a wheelchair lap seatbelt during a visit to an ENT office, without proper documentation or physician orders. The facility's policy requires a physician's written order for restraints, which was not obtained, leading to a violation of regulatory requirements.
A resident with severe cognitive impairment was allegedly sexually assaulted by an unidentified staff member. The facility was informed of the allegation by the ombudsman but failed to report it to the NJDOH or police, as required by their policy. The Director of Nursing believed reporting was unnecessary since the ombudsman had investigated and closed the case.
The facility failed to securely store medications during administration, as observed in two incidents. An RN left a medication cart unlocked and a vial of insulin unsecured, while an LPN also left a cart unlocked without supervision. The DON confirmed the policy requiring carts to be locked when out of sight.
A resident with multiple diagnoses, including COPD and diabetes, was transferred to a hospital for an emergency without the required New Jersey Universal Transfer Form (NJUTF) in their medical record. The Director of Nursing confirmed the absence of the NJUTF, which is against the facility's policy for emergency transfers.
Failure to Obtain Physician Orders for CPAP Maintenance
Penalty
Summary
The facility failed to obtain physician's orders for the weekly cleaning and tubing changes of a resident's CPAP machine, as well as for the daily filling of the CPAP machine's chamber with distilled water, from March 2025 through the resident's discharge. The deficiency was identified through interviews and record reviews, which revealed that although the facility's staff, including the Infection Preventionist and Unit Manager, stated that these tasks were performed by the night shift nurses, there were no corresponding physician's orders or documentation in the resident's medical record. The Medication Administration Records showed daily administration of the CPAP machine but did not include documentation for cleaning, tubing changes, or water chamber maintenance. The resident involved had multiple medical conditions, including obstructive sleep apnea, multiple rib fractures, a prosthetic heart valve, depression, and a history of falls, and required assistance with all activities of daily living. Interviews with the Unit Manager and Director of Nursing confirmed that physician's orders were required for CPAP maintenance tasks, but none were present in the record. The facility's policy also indicated that such procedures should be performed according to physician's orders and manufacturer instructions, but this was not followed in practice for the resident in question.
Verbal Abuse Incident Involving Resident and Housekeeping Aide
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a housekeeping aide (HA #1) and a resident with severe cognitive impairment. The resident, who had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety, was verbally abused and exploited by HA #1 during an appointment at an Ear, Nose, and Throat (ENT) doctor's office. HA #1 was observed yelling, cursing, and videotaping the resident, causing the resident to become visibly upset and confused, believing they were being kidnapped. The ENT staff witnessed the incident and reported that HA #1 was belittling and yelling at the resident without providing any reassurance of safety. The ENT office requested HA #1 to leave and contacted the facility to send a new escort for the resident. The facility's Director of Nursing (DON) was informed of the incident and advised the ENT office to call the police to have HA #1 removed. The facility's investigation confirmed the abuse, as HA #1's actions were captured on video, which was later deleted. The resident's medical records indicated a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The resident's care plan included interventions for cognitive deficits, such as verbalizing safety rules and engaging in appropriate social conversations. Despite these interventions, the resident was subjected to verbal abuse and exploitation, highlighting a failure in the facility's implementation of its abuse prevention policy.
Removal Plan
- HA #1 was terminated
- Resident #239 received a psychosocial evaluation
- All staff were in-serviced on the facility's abuse prevention and reporting policies
Inadequate Investigation of Verbal Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse and exploitation involving a Housekeeping Aide (HA #1) and a resident with severe cognitive impairment. The incident occurred during an Ear, Nose, and Throat (ENT) doctor's office appointment, where HA #1 was observed verbally abusing and videotaping the resident. The ENT staff reported that HA #1 was belittling and yelling at the resident, who appeared visibly upset and confused, believing they were being kidnapped. The facility's investigation was inadequate as it did not include statements from all witnesses, including other residents escorted by HA #1. The resident involved had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Upon returning from the doctor's office, the resident appeared calm and in no emotional distress, unable to recall the incident. However, the ENT's surveillance video confirmed HA #1's inappropriate behavior, including yelling, cursing, and videotaping the resident without consent. The facility's investigation concluded that the abuse allegation was substantiated, but it lacked thoroughness as it did not interview all relevant parties. The Director of Nursing (DON) received a call from the ENT's office about the incident, but the investigation did not include interviews with the ENT staff, the driver of the contracted transportation company, or other residents who had been escorted by HA #1. The facility's failure to conduct a comprehensive investigation and implement their abuse policy posed a likelihood of serious harm to all residents, resulting in an Immediate Jeopardy situation.
Removal Plan
- A complete investigation was initiated.
- The Licensed Nursing Home Administrator and Director of Nursing were educated on the facility's abuse policy, customer service, professionalism, and complete and thorough investigations.
- The Social Services Director was in-serviced on proper investigation of abuse including interviews of other residents.
- All staff were in-serviced on abuse.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records during medication administration, as observed in two instances. On March 5, 2025, at 11:27 AM, a Registered Nurse (RN) left the electronic medical records (EMR) of a resident open, making confidential information visible to anyone in the hallway outside the dining room. Similarly, at 1:02 PM, a Licensed Practical Nurse (LPN) left another resident's EMR open, exposing private medical information to potential onlookers. Both nurses acknowledged the oversight during interviews, with the RN expressing nervousness and the LPN recognizing the risk of exposure. The Director of Nursing confirmed that leaving computer screens open violates HIPAA and resident privacy rights, as outlined in the facility's Resident Rights policy.
Failure to Attempt Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of bedrails for a resident. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including hemiplegia and hemiparesis. The resident's comprehensive care plan indicated the need for a left bedrail for mobility and safety, but the Bed Rail Evaluation revealed that no alternatives were attempted prior to the placement of the bedrails. During observations and interviews, it was confirmed that the nursing staff completed the bedrail assessment but did not explore alternative options before implementing the use of the bedrail. The Director of Nursing acknowledged that the facility did not explore alternative options and allowed residents to use bedrails upon request. This practice was not in compliance with the requirement to try different approaches before using a bedrail.
Incomplete Medical Record Leads to CPR on DNR Resident
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident, identified as Resident #87. The resident was admitted with diagnoses including atherosclerosis of native arteries of bilateral legs, restless leg syndrome, and nerve pain. A critical incident occurred when the resident was found unresponsive, and CPR was initiated due to the absence of a Practitioner Orders for Life-Sustaining Treatment (POLST) form in the facility's records. The resident's power of attorney (POA) indicated that a POLST form had been signed, specifying a do not resuscitate (DNR) order, but the facility did not have a copy, leading to the resident being treated as a full code. The Social Service Director (SSD) confirmed during an interview that she maintained a soft file with all documentation related to the resident, including discussions with the POA about the POLST. However, this information was not included in the resident's official medical record, which should have been complete, accurately documented, and readily accessible. The facility's policy on medical records emphasized the need for accurate, current, and complete documentation, but the SSD was unaware of the requirement to include all relevant information in the medical record. This oversight resulted in a failure to comply with the facility's policy and applicable regulations.
Resident's Rights Violated by Unauthorized Video Recording
Penalty
Summary
The facility failed to protect a resident's rights when a staff member video recorded the resident without consent. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder. The resident was recorded by a Housekeeping Aide (HA #1) at an Ear, Nose, and Throat (ENT) doctor's office, where the resident appeared upset and confused, expressing a belief that they had been kidnapped by HA #1. The situation escalated when the transport driver took HA #1's cell phone and continued recording the resident. ENT staff members witnessed HA #1 yelling and belittling the resident while recording. The Director of Nursing (DON) confirmed that staff were prohibited from recording residents and had been trained on this policy. The incident was reported to the DON by ENT staff, highlighting a breach of the resident's rights to dignity and privacy.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a wheelchair lap seatbelt that restricted the resident's movement. The resident, who had diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder, was observed in a video recording at an ENT doctor's office with a lap seatbelt applied, preventing them from standing up independently. The resident's comprehensive care plan and physician orders did not include any mention of restraints or a wheelchair seatbelt, indicating a lack of proper documentation and authorization for the use of such restraints. Interviews with staff revealed that the seatbelt was applied by the transport driver, and the facility's Director of Nursing confirmed that the use of the lap seatbelt constituted a restraint. The facility's policy requires a physician's written order for the application of restraints, specifying the type, medical justification, duration, and conditions for use, none of which were present in this case. This oversight led to the resident being improperly restrained without the necessary documentation and authorization, violating the facility's policy and regulatory requirements.
Failure to Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the New Jersey Department of Health (NJDOH) as required by their policies and procedures. This deficiency was identified in the case of a resident who had been admitted with diagnoses including anxiety disorder, dementia with agitation, social phobia, and cognitive communication deficit. The resident, who had a severely impaired cognition with a BIMS score of 4 out of 15, was reported to have been sexually assaulted by an unidentified staff member approximately two weeks before their death. The facility was notified of the allegation by the ombudsman, but the Director of Nursing (DON) did not report the incident to the NJDOH or the police, believing it unnecessary since the ombudsman had investigated and closed the case. The facility's Abuse Prevention policy mandates that all occurrences of abuse, neglect, mistreatment, and other grievances be reported to the appropriate agencies, including the NJDOH and local police. The policy specifies that any suspected crime resulting in serious bodily injury must be reported immediately, and no later than two hours after forming the suspicion. In this case, the DON acknowledged the responsibility for reporting such allegations but failed to do so, keeping only a soft file of the investigation and educating staff on abuse. The failure to report the allegation as per the facility's policy and state regulations constitutes a significant deficiency in the facility's handling of abuse allegations.
Medication Storage Deficiency During Administration
Penalty
Summary
The facility failed to properly store medications safely and securely during medication administration, as observed in two separate incidents. In the first incident, a Registered Nurse (RN) left the medication cart unlocked in the hallway outside of the dining room and left a vial of insulin unsecured on top of the cart while administering medication to a resident. The RN admitted to being nervous and acknowledged that this was not her usual practice. In the second incident, a Licensed Practical Nurse (LPN) also left the medication cart unlocked in the hallway during medication administration, without keeping it in sight. The LPN recognized the risk of someone accessing the medications if the cart was left unlocked. The Director of Nursing (DON) confirmed that the facility's policy required medication carts to be locked when not in the nurse's line of sight during medication administration. The DON acknowledged that leaving the cart unlocked could allow unauthorized access to medications. The facility's Medication Administration policy, dated March 2017, specified that medication carts should be kept closed and locked when out of sight, with no medications left on top of the cart, and all sides inaccessible to residents or passersby.
Failure to Maintain Complete Medical Record for Emergency Transfer
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was sent out for an emergent hospitalization. Specifically, the New Jersey Universal Transfer Form (NJUTF) was not included in the medical record for the resident's transfer to the hospital. The resident, who had multiple diagnoses including benign neoplasm of cerebral meninges, hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes mellitus type 2, experienced an emergency situation where they were noted to be yelling "I can't breathe." The resident's vital signs were recorded, and a call was placed to the physician, resulting in an order to send the resident to the emergency room for evaluation and treatment. Emergency medical technicians arrived immediately, and the resident was transported to the hospital. Upon review, it was found that the NJUTF was missing from the resident's medical record for the transfer that occurred on the specified date. During interviews, the Director of Nursing (DON) confirmed the absence of the NJUTF and stated that they did not see the resident when they were transferred out. The facility's policy on emergency transfers requires the preparation of a transfer form to accompany the resident, which was not adhered to in this instance. This deficiency was identified during a complaint investigation and was based on interviews, record reviews, and other pertinent facility documentation.
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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