Hamilton Grove Healthcare And Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, New Jersey.
- Location
- 2300 Hamilton Ave, Hamilton, New Jersey 08619
- CMS Provider Number
- 315423
- Inspections on file
- 20
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Hamilton Grove Healthcare And Rehabilitation, Llc during CMS and state inspections, most recent first.
Air mattress settings were not matched to resident weight for multiple residents with pressure injury risk, impaired mobility, incontinence, and cognitive impairment. Surveyors observed mattresses set at incorrect weights, including settings far above or below the residents’ documented weights, and one resident had no active air mattress order even though the mattress remained in use. Staff confirmed the mattresses were intended for pressure prevention and that the setting should correspond to the resident’s weight.
A resident with bipolar disorder, chronic pain syndrome, edema, neuralgia, and neuritis, and with a BIMS of 15/15, was observed being transported backwards in a recliner chair from the hallway to the lounge area. The CNA acknowledged residents should be moved forward facing, and the LPN/UM, DON, and LNHA all stated that pulling a resident backwards was not appropriate and was a dignity issue.
Failure to follow up on a psychiatrist’s recommended GDR for quetiapine. A resident with major depressive disorder, PTSD, and paranoid schizophrenia was receiving antipsychotic medication, and the psych note recommended reducing Seroquel from 50 mg HS to 25 mg HS for 7 days, then discontinuing it. The MAR showed the medication continued as ordered, but the chart lacked documentation that the PCP or resident representative addressed the recommendation, and the consultant pharmacist also noted the need for follow-up.
Missing Pre-Employment Background Check: The facility failed to complete a criminal background check before an CNA began work, despite policies stating that all prospective employees must be screened and may not start until required checks are completed and approved. Surveyors found no evidence of a background check in the employee file, and the LNHA could not provide additional information when the finding was presented.
A resident was discharged from the facility, but the MDS record did not include a discharge assessment. Survey review found the last MDS on file was a quarterly assessment, and the MDS Coordinator confirmed the discharge MDS was missed. The LNHA later acknowledged that no discharge MDS had been completed for the resident at discharge.
Failure to revise the care plan for a resident receiving enteral tube feeding. The resident had dysphagia, a gastrostomy tube, GERD, and severe cognitive impairment, and the chart showed NPO orders plus enteral feeding orders. The ICCP included aspiration risk and tube feeding focus areas, but staff acknowledged the care plan was not updated when the diet changed from PO to NPO and tube feedings began.
An LPN signed a smoking-related physician order as completed on multiple shifts for a resident who was identified as a smoker, but later could not explain the entries and stated she never saw the resident smoke. The resident had anxiety disorder and schizoaffective disorder, bipolar type, was cognitively intact on MDS, and had a care plan and smoking evaluation indicating supervision with smoking and staff control of cigarettes and a lighter. The RN/UM and DON confirmed that if the MAR was signed, the cigarettes should have been given.
A resident who was dependent for toileting was found soaked with urine and later soiled with urine and feces, with staff confirming the resident should not have been left in that condition and that no overnight incontinence care was documented. Another resident with dementia and dependence for ADLs was observed with long, unclean fingernails despite an order for nails to be kept clean, trimmed, and filed; a CNA admitted the nail care was not done, and an LPN had signed it as completed.
An LPN performed tracheostomy care for a resident with a trach, severe cognitive impairment, and orders for trach care every shift, but did not use the sterile gloves provided in the trach care kit and instead handled sterile supplies with bare hands and nonsterile gloves. The LPN placed nonsterile items on the draped bedside table and used nonsterile exam gloves during parts of the procedure, despite the facility policy requiring sterile gloves and aseptic technique for trach care. The UM and DON stated that sterile gloves from the kit should be used and that nonsterile items should not be placed on the sterile field.
The facility failed to complete annual performance evaluations for CNAs. Surveyors requested the records for five randomly selected CNAs, but the LNHA and HRD could not provide any performance reviews. The HRD stated the CNAs were unionized and that the facility had no policy for performance evaluations, despite the facility policy requiring personnel files to include performance evaluations.
Medication Left Unattended at Resident Bedside: A resident with glaucoma, bilateral ocular hypertension, end stage renal disease, intact cognition, and highly impaired vision was observed with two unidentified tablets left in a medication cup on the overbed table after the RN had signed the MAR showing 1400 meds were administered. The LPN/UM and RN both acknowledged that meds should not be left at the resident's bedside and that the nurse should remain with the resident to ensure the medications are taken.
Medication Error Rate Exceeded Threshold: Surveyors observed two LPNs administer incorrect constipation medications to two residents during med pass, resulting in a 7.14% medication error rate. One resident ordered sennosides-docusate sodium 8.6-50 mg received Geri-Kot (Senokot) 8.6 mg, and another resident ordered senna plus 8.6-50 mg received Senokot 8.6 mg. Staff acknowledged the errors and stated the meds were not the same and that the 5 rights and three checks were not followed.
A cognitively impaired resident with dysphagia was ordered a pureed diet with nectar-thick liquids and had a care plan identifying aspiration risk and the need for thickened liquids. A family member brought in a smoothie from outside and, after asking an RN about it, was told the resident was supposed to receive nectar-thick liquids; however, the RN did not verify whether the smoothie was given, did not document any follow-up, and did not notify the physician. No incident report was completed, and the care plan was not updated with interventions regarding outside food, contrary to facility policy requiring reporting and physician notification of incidents.
A resident with severe cognitive impairment was mistakenly given another resident's medications by an agency LPN who failed to verify the resident's identity and did not report the error. The error was not documented, and the facility only learned of the incident after the resident was hospitalized for nausea, vomiting, and an upper GI bleed. The incident was not reported or documented by the nurse, and staff were unaware until notified by the hospital.
A resident in an LTC facility was involved in a sexual encounter with an LPN, which was witnessed by a CNA. Despite the resident's cognitive intactness and fear expressed during the incident, the facility failed to report the event to authorities, citing it as consensual. The facility's investigation was incomplete, and the incident was not documented in the resident's medical records, leading to an Immediate Jeopardy situation.
A facility failed to report an allegation of sexual abuse involving a resident and an LPN to the NJDOH. The incident was considered consensual by the resident, who had intact cognition and various medical conditions. Despite the facility's policy requiring such incidents to be reported, the DON and LNHA did not notify authorities, leading to a deficiency finding.
A resident with an indwelling catheter did not receive scheduled urology and nephrology consultations due to oversight in a LTC facility. The Unit Manager/LPN was unaware of the orders due to absence, and the ADON admitted the orders were missed during an in-house transfer. There was no facility policy for admitting residents or transcribing physician's orders, contributing to the deficiency.
The facility failed to provide the required 12 hours of in-service training for CNAs, with none of the reviewed CNAs meeting the mandated hours. Additionally, two CNAs did not receive abuse prevention training. The deficiency was attributed to a lack of policy and oversight due to staffing changes, as acknowledged by the DON.
A facility failed to thoroughly investigate an alleged incident of sexual abuse between a resident and an LPN. The resident, with intact cognition, reported consensual oral sex with the LPN, which was witnessed by another staff member. The facility did not complete an incident report, notify the resident's physician promptly, or document the investigation thoroughly, including missing interviews with the resident's roommate and written statements from witnesses.
A resident was observed without heel booties, contrary to physician orders for continuous use to prevent skin breakdown. The LPN acknowledged the oversight, and the DON confirmed the requirement for booties when in a recliner. The facility's policy mandates adherence to physician orders for such devices.
A resident was observed smoking without a required smoking apron, contrary to their care plan, while supervised by the Director of Activity. The resident's care plan and smoking evaluation indicated the need for a smoking apron and assistance with lighting cigarettes. The Registered Nurse Unit Manager and DON acknowledged the oversight, noting the care plan should have been updated to reflect the resident's current needs.
The facility failed to ensure timely physician visits and documentation for two residents with severe cognitive impairments. One resident had no physician notes since admission, and another had no notes since January, despite a readmission. The LPN and DON confirmed the lack of documentation, and the Medical Director acknowledged the oversight.
A resident with severe cognitive impairment and multiple diagnoses developed several pressure injuries, but the facility failed to update the care plan with new interventions. Despite documentation of the injuries and communication among staff, the care plan was not revised to address the resident's wound care needs, as required by facility policy.
A facility failed to document a registered nurse's assessment of a reported injury for a resident with severe cognitive impairment receiving hospice care. An LPN noted a mark on the resident's forearm, informed the shift supervisor, and attempted to contact the NP, but no further documentation was made. The RN shift supervisor observed the resident but did not document his findings, leading to a deficiency.
Air mattress settings were not matched to resident weight
Penalty
Summary
The facility failed to provide preventive care consistent with professional standards of practice for residents at risk for pressure injuries and failed to ensure that air mattresses were accurately set according to resident weight. Surveyors observed multiple residents in bed with air mattress settings that did not match their documented weights, including settings of 330 pounds, 180-230 pounds, 325 pounds, 80 pounds, and 540 pounds. The report identified this deficient practice for four residents who had orders or care plan interventions related to pressure prevention or skin breakdown. One resident had diagnoses including hemiplegia, hemiparesis, muscle weakness, and cognitive communication deficit, with severe cognitive impairment on the MDS and a care plan addressing risk for skin breakdown, incontinence, and impaired mobility. The resident had an order for an air mattress for pressure prevention and a documented weight of 210.8 pounds, yet the mattress was observed set at 330 pounds on one occasion and 180-230 pounds on another. A nurse confirmed the resident had the air mattress because of pressure ulcer risk. Another resident had diagnoses including bed confinement status, chronic pain syndrome, and dementia, with severe cognitive impairment on the MDS, impaired extremities, and an indicator for pressure injury. The resident’s care plan addressed risk for skin breakdown related to incontinence and decreased mobility, and included an air mattress and pressure relieving mattress. The resident had a documented weight of 147.2 pounds and a new right lateral foot arterial ulcer was noted in the wound assessment record, while the air mattress was observed set at 180-230 pounds. A nurse stated the mattress setting was adjusted to the resident’s weight and that the setting determines the amount of air in the mattress to relieve pressure. A third resident with diagnoses including unspecified symptoms involving cognitive function and awareness and nontraumatic intracerebral hemorrhage had severe cognitive impairment, was at risk for pressure injury, and had a care plan for impaired mobility and incontinence with an air mattress intervention. The resident’s documented weight was 147.2 pounds, but the mattress was observed set at 325 pounds on one occasion and 80 pounds on another. A fourth resident with muscle weakness, muscle wasting, and chronic pain syndrome had a care plan for decreased mobility and risk for skin breakdown with an air mattress intervention, but the order for the air mattress had been discontinued and no active order was listed. Despite this, the mattress was observed set at 540 pounds, and the UM stated the setting should be adjusted by weight and that nurses should be signing out an order for placement and function of the air mattress.
Resident Transported Backwards in a Recliner Chair
Penalty
Summary
The facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner. During an initial tour of the unit, a surveyor observed a CNA transport Resident #45 in a recliner chair facing backwards from the hallway near the resident's room to the lounge area across from the nursing station. The resident's EMR showed diagnoses including bipolar disorder, chronic pain syndrome, localized edema, neuralgia, and neuritis. The most recent quarterly MDS dated 2/27/26 indicated a BIMS score of 15 out of 15, showing cognitively intact cognition, and also showed the resident required a wheelchair for transfers. The resident's comprehensive care plan included interventions for falls risk, knee pain, arthritis, ambulatory dysfunction, and antidepressant use, including assistance with transfers as needed and escort/transport to activities as needed. When interviewed, the CNA stated residents should be transported forward facing and acknowledged she should have turned the resident around. The LPN/UM stated residents should be pushed forward and not pulled backwards because it was a dignity issue. The DON and LNHA also acknowledged that staff should not have pulled the resident backwards down the hallway, and the facility policy stated residents are to be treated with courtesy, consideration, and respect for dignity and individuality.
Failure to Follow Up on Recommended GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to follow up on a psychiatrist’s recommendation for a gradual dose reduction (GDR) of quetiapine for one resident who was receiving antipsychotic medication. The resident had diagnoses including major depressive disorder, PTSD, and paranoid schizophrenia, and the quarterly MDS dated 1/16/2026 showed a BIMS score of 00 out of 15, indicating cognition could not be assessed. The resident was observed sitting in a reclining area in the hallway near the nursing station and had a splint on the left hand/wrist. The psychiatric progress note dated 1/5/2026 documented an assessment/plan recommending discontinuation of the current Seroquel order and starting Seroquel 25 mg at bedtime for 7 days, then discontinuing it, with the note stating that a dose reduction was recommended. The note also stated that recommendations were discussed with facility staff, who would await approval from the PCP and then obtain consent from the appropriate decision-maker. The physician order summary showed quetiapine 50 mg at bedtime for schizophrenia, with the order dated 10/8/2025 and a discontinue date of 2/2/2026. The January and February 2026 MARs showed the quetiapine order was administered as ordered from 1/6/2026 through 2/2/2026. Review of the progress notes did not show documentation that the GDR was addressed by the PCP or the resident representative, and the same GDR recommendation appeared again in the psychiatric progress note dated 2/3/2026. The consultant pharmacist’s monthly report dated 1/13/2026 also noted the psych consult recommendation for GDR and requested follow-up documentation. Facility staff, including the RN/UM and DON, acknowledged during interview that they would expect documentation showing the recommendation was addressed, but no such documentation was present in the record reviewed.
Missing Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its abuse policy by not completing a criminal background check before the first day of work for 1 of 96 employees, Employee #4, a CNA. Employee #4 had a date of hire of 2/28/25 and first day of work of 2/28/25, and the reviewed file contained no evidence of a background check completed before employment began. During the survey, the team reviewed newly hired employee files since the last survey and identified this missing background check. On 3/13/26 at 2:02 PM, the survey team presented the finding to the LNHA, DON, Regional Nurse Consultant, and the President of Clinical Services, and the LNHA could not provide additional information regarding the finding. The facility’s Resident Abuse/Neglect Policy and Procedure stated that all prospective employees are carefully screened, including background checks, and that all staff are screened upon hire. The Hiring and Recruitment policy also stated that employees may not begin work until required screening procedures are completed and approved, and referenced NJAC 8:39-9.3(b).
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment for one resident who was discharged from the facility on 11/3/25. Survey review on 3/11/26 found that the resident’s electronic medical record showed the discharge had occurred, but the last MDS on file was a quarterly assessment and there was no discharge assessment completed. The MDS Coordinator confirmed that the resident was discharged and that a discharge MDS should have been completed, stating that the assessment was missed. The LNHA later acknowledged that no discharge MDS assessment had been completed for the resident when discharged.
Failure to Revise Care Plan for Resident Receiving Tube Feeding
Penalty
Summary
The facility failed to revise an individual comprehensive care plan for a resident receiving enteral tube feeding. Resident #1 was admitted with diagnoses including dysphagia, gastrostomy, and gastro-esophageal reflux disease without esophagitis. The most recent comprehensive MDS dated 12/30/25 showed a BIMS score of 00 out of 15, indicating severely impaired cognition, and section K noted the resident had a feeding tube on admission. The individualized comprehensive care plan contained a focus area for aspiration risk related to dysphagia and another focus area for receiving enteral feedings to meet nutrition and hydration needs, with interventions such as administering feedings as ordered, monitoring for intolerance, checking residuals as ordered, administering flushes as ordered, and maintaining NPO status. The medical record also included physician orders for NPO diet and enteral feeding one time a day with a total volume of 1400 ml. During interview, the LPN/UM stated care plans were updated every 3 months, annually, and as needed with changes in the resident's plan of care, and acknowledged the care plan should have been updated when the resident's diet changed from PO to NPO. The DON confirmed the care plan should have been updated when the diet order changed and tube feedings were started, and stated it was the responsibility of the unit manager, DON, and nursing team to update care plans. The LNHA also acknowledged that a care plan should be updated when there were any changes in the resident's care.
Failure to Follow Smoking Order Documentation
Penalty
Summary
The facility failed to ensure nursing staff followed a physician order and acceptable standards of clinical practice for Resident #142, who was identified as a smoker. The resident was admitted with diagnoses including anxiety disorder and schizoaffective disorder, bipolar type, and had a quarterly MDS dated 2/25/2026 showing a BIMS score of 15/15, indicating cognitive intactness. The care plan included a focus that the resident required supervision with smoking because the resident chose to smoke despite the possible ill effects. The smoking evaluation also indicated the resident smoked, and the physician order directed that cigarettes and a lighter be kept by staff and that 5 cigarettes be given on the 7-3 and 3-11 shifts every day. Review of the February and March 2026 MARs showed an LPN signed the smoking order as completed on multiple day shifts, including 3/12/2026. During interview, the LPN stated she was the resident’s assigned nurse, said she never saw the resident smoke, and could not explain why she signed the order as completed. The RN/UM stated the resident was periodically a smoker and that if the MAR was signed as done, it meant it should have been done. The DON stated that if nurses signed the MARs indicating cigarettes were given, they should have been giving them and should not sign if they were not. The facility policy on documentation stated that clinical documentation is used to enhance continuity of care and show what must be carried out to monitor outcomes of care.
Failure to Provide Timely Incontinence Care and Nail Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident who was observed with a completely saturated incontinence brief and urine stains on the top sheet. During incontinence rounds, the resident was found soaked with urine, and later was also observed soiled with urine and feces, with urine and feces stains on the bed padding and fitted sheet. Staff interviews confirmed the resident should not have been left in that condition, and the last documented incontinence care had been completed the prior evening with no documentation of care during the overnight shift. The resident had diagnoses including type 2 diabetes, muscle weakness, difficulty walking, depression, anxiety disorder, and hypertension, and the MDS indicated severe cognitive impairment and dependence for toileting. The resident’s care plan identified a risk for skin breakdown and included interventions to offer or assist with toileting during care, before and after meals and activities, at bedtime, and to provide prompt incontinence care. The RN/UM, LPNs, and CNA involved stated that the resident should not have been left saturated and that the condition could lead to skin breakdown. The DON stated the expectation was for all shifts to round on residents, change residents if soiled at least two times each shift and as needed, and that no resident should be saturated and soiled like that. The facility also failed to provide nail care during ADL care for another resident. During an initial tour, the resident was observed with long fingernails on both hands and a black substance under two nails. The resident had diagnoses including unspecified dementia, Alzheimer’s disease, and hemiplegia and hemiparesis following cerebral infarction, and the MDS showed moderate cognitive impairment and dependence for ADL care. The care plan noted the resident could be combative during ADL care, and the physician’s order required nails to be clean, trimmed, and filed as needed. A CNA stated nail care was part of morning care but admitted it was not done because the resident was resistant, and the nurse later acknowledged the nail care had been signed as completed even though the resident’s nails remained long and unclean.
Tracheostomy Care Performed Without Sterile Technique
Penalty
Summary
The facility failed to ensure tracheostomy care was completed using sterile technique for one resident who had diagnoses including autistic disorder, aphagia, unspecified asthma, and COPD with acute exacerbation. The resident’s MDS indicated severe cognitive impairment, rare or no understanding, dependence on staff for activities of daily living, and a need for tracheostomy care. The care plan identified the resident as at risk for complications related to having a tracheostomy and directed staff to perform tracheostomy care every shift. During direct observation, an LPN performed tracheostomy care and was seen placing nonsterile items on a draped bedside table, opening a tracheostomy care kit, opening sterile gauze and a disposable inner cannula, and emptying sterile saline into the open gauze packet. The LPN then reached into the packet with bare hands to remove the sterile gauze and placed it into the kit basin. Although sterile gloves were present in the kit, the LPN did not use them during the preparation. The LPN later used nonsterile exam gloves to wipe the tracheostomy site, removed and discarded the inner cannula, and then continued care using nonsterile gloves and newly opened sterile gauze to dry the site before placing a new inner cannula and sterile slit-gauze at the tracheostomy site. The resident had physician orders for tracheostomy care every shift, oxygen via trach collar every shift, and suctioning as needed for increased secretions. In interviews, the LPN stated tracheostomy care required aseptic technique and that the sterile gloves in the kit should be used, but did not remember whether those gloves were used. The UM and DON both stated that sterile gloves from the tracheostomy care kit should be used and that nonsterile items should not be placed on the sterile field. The facility’s tracheostomy care policy required hand hygiene, gathering sterile equipment, putting on sterile gloves, and using aseptic technique to cleanse the stoma site.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to evaluate the performance of Certified Nursing Assistants (CNAs) on an annual basis. During review of records and facility documents, the surveyor requested the education and performance reviews for five randomly selected CNAs, but no performance evaluations were provided. The Licensed Nursing Home Administrator could not provide the evaluations when asked, and the Human Resources Director also could not provide them. The Human Resources Director stated that there were no performance evaluations for the last year for CNAs because they are unionized, and that the facility had no policy for performance evaluations. Review of the facility’s Hiring and Recruitment policy, last reviewed in 8/2025, showed that personnel files were to contain performance evaluations and be maintained in accordance with state and federal requirements, including NJAC 8:39-43.17(b).
Medication Left Unattended at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were administered according to standards of practice for one resident. On 3/6/26 at 1:30 PM, the surveyor observed the resident lying in bed, awake, and eating lunch with a medication cup containing two unidentified tablets on the overbed table. The Licensed Practical Nurse/Unit Manager acknowledged the cup contained one pink tablet and one white tablet. The resident stated they thought they had taken all of their medications. The LPN/UM stated the nurse should stay with the resident during medication administration to ensure all medications were taken and that medications should never be left at the resident's bedside. At 1:45 PM the same day, the Registered Nurse stated the resident had told her they were going to swallow the medications and acknowledged that medication should never be left unattended at the resident's bedside. Review of the EMR showed the resident had diagnoses including primary open-angle glaucoma, bilateral ocular hypertension, and end stage renal disease, with a BIMS score of 15/15 and highly impaired vision. The March 2026 MAR showed the RN signed for all 1400 medications as administered, including Abilify 10 mg and nephro vitamins 0.8 mg, despite the observed tablets remaining in the medication cup.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below 5%, with surveyors observing 2 medication errors during 28 doses administered by 2 nurses, resulting in a 7.14% error rate. On 3/11/26, an LPN on the Klockner Unit administered Geri-Kot (Senokot) 8.6 mg one tablet to Resident #2 even though the order was for sennosides-docusate sodium 8.6-50 mg one tablet daily for constipation. The resident’s record showed diagnoses including anemia, joint pain, and constipation. The LPN stated that Senokot was the only product available at the facility and acknowledged administering it. The RN/UM later stated the nurse should have performed the three checks and that the LPN did not follow the five rights during medication administration. Also on 3/11/26, an LPN on another unit administered Geri-Kot (Senokot) 8.6 mg two tablets to Resident #197 when the order was for senna plus 8.6-50 mg, two tablets by mouth two times a day. The resident’s record showed diagnoses including muscle weakness and essential hypertension. The LPN confirmed giving Senokot and stated that senna plus and Senokot were the same and both had 8.6 mg. The LPN/UM stated the nurses were expected to perform three checks and review physician orders before administration, and the DON stated Senna and Senokot were different medications and that the nurses should have held the medication if it was not available. The facility policy required medications to be administered safely and effectively and directed staff to review the 5 rights at each step of medication administration.
Failure to Ensure Ordered Nectar-Thick Liquids and Follow-Up on Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident consistently received nectar-thick liquids as ordered and to implement interventions to prevent the resident from receiving liquids inconsistent with the prescribed diet. The resident had diagnoses including metabolic encephalopathy, dysphagia (oral phase), and unspecified dementia with severely impaired cognitive skills for daily decision making, as documented on the quarterly MDS. Physician orders specified a regular diet with pureed texture and nectar (mildly thick) liquids, and the care plan identified a risk for aspiration related to dementia and the resident’s preference not to be assisted during meals, with interventions including monitoring for aspiration signs and providing thickened liquids as ordered. On a documented date, the resident’s family member brought an outside smoothie into the facility and asked RN #1 if it was acceptable to give it to the resident. RN #1 informed the family member that the resident was supposed to receive nectar-thick liquids, but the family member stated that the smoothie looked acceptable and that the resident would only have a taste. The progress note recorded that the smoothie cup contained approximately 45 cc (1.5 oz) of smoothie and that RN #1 did not witness the smoothie being given to the resident. There was no documentation that RN #1 followed up with the family member to determine whether the smoothie was actually given or how much was consumed. The record review and interviews further showed that there was no incident/accident report completed for this event, and no documentation that the physician was notified of the potential administration of an inappropriate fluid consistency, despite facility policy requiring all incidents and accidents to be reported to the nursing supervisor and the attending physician. The DON and UM acknowledged that the family member should have been educated, the physician notified, and the care plan updated with new interventions related to outside food, but these actions were not taken. The facility also did not implement measures to prevent recurrence of similar incidents involving outside food inconsistent with ordered diet and fluid thickness.
Significant Medication Error Due to Failure to Verify Resident Identity and Report Incident
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's medications to a resident with severe cognitive impairment. The resident, who had a history of traumatic subdural hemorrhage, dysphagia, pleural effusion, metabolic encephalopathy, anemia, and was severely cognitively impaired, received medications including Rivaroxaban, Nifedipine, Flomax, and Insulin Lispro that were not prescribed for him. The nurse did not verify the resident's identity prior to administration, as required by facility policy, and did not report the error to the supervisor or the primary care physician. Following the administration of the incorrect medications, the resident developed nausea and vomiting and was subsequently hospitalized for an upper gastrointestinal bleed. The medication error was not documented in the resident's medical record or medication administration record. The facility only became aware of the incident after being notified by the hospital several days later, as the nurse involved did not report the error or document it in any facility records. Interviews with facility staff revealed that neither the CNA nor the unit manager were aware of the medication error at the time it occurred. The nurse responsible for the error was not available for interview, and the facility's investigation began only after external notification. The lack of immediate reporting and documentation of the medication error, as well as failure to follow established medication administration protocols, contributed to the deficiency.
Failure to Report and Investigate Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, specifically a Licensed Practical Nurse (LPN). The incident involved a resident who was cognitively intact and had a history of major depressive disorder and anxiety. The resident reported engaging in a sexual act with the LPN in their room, which was witnessed by a Certified Nursing Assistant (CNA). The resident expressed fear during the encounter, indicating a lack of consent, yet the facility did not report the incident to the appropriate authorities. The Director of Nursing (DON) and other facility staff were informed of the incident but failed to take immediate and appropriate action. The DON did not report the incident to the state health department or law enforcement, citing the resident's claim of consensuality as the reason. The facility's investigation was incomplete, and the incident was not documented in the resident's medical records. The facility's policies on abuse and neglect were not followed, as the incident was not reported within the required timeframe. Interviews with staff revealed a lack of understanding of the facility's abuse reporting procedures. The Licensed Nursing Home Administrator (LNHA) and other staff members were unsure about the necessity of reporting the incident, leading to a delay in addressing the situation. The facility's failure to report and investigate the incident properly resulted in an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's abuse prevention and response protocols.
Removal Plan
- LPN#1 was removed from the facility
- Resident #59 was assessed
- The resident's physician was notified
- The incident was reported to the New Jersey Department of Health
- The abuse and neglect policy was updated
- The police were called
- All staff were educated on the facility abuse policies and procedures
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to report an allegation of sexual abuse involving a resident and a staff member to the New Jersey Department of Health (NJDOH) as required. The incident involved Resident #59, who had a Brief Interview of Mental Status (BIMS) score indicating intact cognition and was diagnosed with conditions including diabetes, respiratory disease, anxiety disorder, and depression. On 10/15/24, a staff member observed Resident #59 in a compromising position with an LPN. During an investigation, the resident admitted to performing oral sex on the LPN, stating that the encounter was consensual but inappropriate. Despite the resident's request for privacy and the belief that the encounter was consensual, the facility did not report the incident to the NJDOH or the police. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the incident should have been reported within two hours of the allegation, as per federal regulations and the facility's policy. The facility's policy on abuse and neglect clearly states that any form of abuse, including sexual abuse, should be reported to the appropriate authorities. The failure to report the incident was identified as a deficiency during the survey, as the facility did not adhere to the required protocols for reporting suspected abuse, neglect, or theft.
Failure to Schedule Required Consultations for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident #55, from the time of admission on 8/28/24 until the surveyor's inquiry. The resident, who had an indwelling catheter, was observed without a urinary drainage bag while in a wheelchair, although it was noted that a leg bag was used when the resident was out of bed. The resident's comprehensive care plan highlighted a risk for urinary tract infection related to catheter use, and physician's orders included catheter care every shift and follow-up consultations with urology and nephrology. However, the facility did not schedule the required consultations. The Unit Manager/LPN, responsible for checking physician's orders and setting up consults, was unaware of these orders due to personal reasons that kept her away from work in September. The Assistant Director of Nursing (ADON) acknowledged that the orders for the consults were missed during an in-house transfer of the resident, and there was no facility policy for admitting residents or transcribing physician's orders, leading to the oversight.
Deficiency in CNA In-Service Training and Abuse Prevention Education
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of mandatory in-service training, as evidenced by a review of five CNA files. The surveyor found that none of the five CNAs had completed the necessary training hours for the current 12-month period. Specifically, the CNAs had completed between 5.5 and 8.25 hours of training, falling short of the mandated 12 hours. Additionally, two of the CNAs did not receive abuse prevention training, which is a critical component of their education. The deficiency was further highlighted during interviews with facility staff. The Director of Nursing (DON) acknowledged that the facility lacked a policy related to CNA education and that there was a gap in ensuring CNAs received their training due to staffing changes. The previous educator responsible for the training had been on leave and subsequently left the role, leading to a lapse in oversight. The DON and the Licensed Nursing Home Administrator (LNHA) were identified as responsible for ensuring staff completed their education, but the facility's documentation did not adequately quantify the training hours completed.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of sexual abuse involving a staff member and a resident. The incident involved a resident with intact cognition, as indicated by a BIMS score of 15 out of 15, and diagnoses including diabetes, respiratory disease, anxiety disorder, and depression. The resident reported engaging in oral sex with an LPN in their room, which was witnessed by another staff member. Despite the resident's claim that the act was consensual, the facility did not complete an incident report or notify the resident's primary physician promptly. The investigation conducted by the facility was incomplete and lacked thorough documentation. Interviews were conducted with six alert and oriented residents on the LPN's assignment, but did not include the resident's alert and oriented roommate. There was no documentation of an assessment of the resident after the incident, and no evidence that non-alert and oriented residents were assessed for inappropriate sexual contact. Additionally, there were no written statements from the witness or others involved in the incident. The facility's policies on abuse and neglect, as well as risk management, were not followed. The policies require that an incident report be completed, the attending physician be notified, and all interviews and statements be documented in writing. The Director of Nursing acknowledged that the attending physician should have been notified at the time of the incident and that proper documentation was necessary. The failure to adhere to these policies resulted in a deficient practice in handling the alleged incident of sexual abuse.
Failure to Apply Heel Booties as Ordered
Penalty
Summary
The facility failed to ensure that heel booties were consistently applied to Resident #72 to prevent skin breakdown. During an observation, the surveyor noted that the resident was sitting in a reclining chair wearing only socks, with no heel booties, despite physician orders requiring heel booties to be worn at all times. The resident's medical record indicated severe cognitive impairment and no existing pressure ulcers, with a care plan intervention for booties to be worn for skin protection. The LPN responsible for Resident #72 confirmed that the booties were not on the resident and acknowledged signing the Treatment Administration Record as if the order had been completed. The Director of Nursing stated that both nurses and certified nursing assistants are responsible for ensuring heel booties are applied, and confirmed that booties should be worn when the resident is in a recliner. The facility's policy mandates the application of splints and similar devices as per physician's orders, which was not adhered to in this instance.
Failure to Follow Smoking Safety Protocols for Resident
Penalty
Summary
The facility failed to ensure that a resident's care plan and smoking evaluation were followed, leading to a deficiency in providing adequate supervision and safety measures for a resident who smoked. The surveyor observed a resident in a wheelchair smoking outside with supervision from the Director of Activity (DOA), who lit the resident's cigarette. However, the resident was not using a smoking apron, which was required according to their care plan. The DOA mentioned that the resident did not use a smoking apron because they did well without it, despite the care plan's directive. The resident's electronic medical record and smoking evaluation indicated that the resident required a smoking apron and assistance with lighting cigarettes. The Registered Nurse Unit Manager confirmed that the resident's care plan included the use of a smoking apron and acknowledged that it should have been used each time the resident smoked. The Director of Nursing (DON) stated that the resident did not need a smoking apron and that the care plan should have been updated. The facility's smoking policy required that care plans be kept current and updated as needed, which was not adhered to in this case.
Failure to Conduct Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the attending physician conducted face-to-face visits and wrote progress notes for residents as required by regulations. Specifically, two residents were not seen by their attending physicians within the mandated timeframes. Resident #28, who was admitted with diagnoses including metabolic encephalopathy and unspecified dementia, had no history and physical or physician progress notes documented since their admission in February 2024. Similarly, Resident #167, admitted with metabolic encephalopathy and dementia, had no attending physician progress notes since January 2024, despite being readmitted in July 2024. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyor. The Licensed Practical Nurse/Unit Manager and the Director of Nursing confirmed the absence of required documentation for both residents. The facility's policy, which mandates physician visits every thirty days for the first ninety days and at least every sixty days thereafter, was not adhered to. The Medical Director acknowledged the oversight, stating that the attending physicians should see residents within 72 hours of admission, which was not the case for the residents in question.
Failure to Update Care Plan for Resident with Pressure Injuries
Penalty
Summary
The facility failed to update and revise the care plan for a resident, identified as Resident #3, who was admitted with multiple diagnoses including acute embolism, thrombosis, atherosclerotic heart disease, hypertension, metabolic encephalopathy, dementia, anxiety disorder, osteoarthritis, mood disorder, and depression. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for activities of daily living. Despite these conditions, the care plan was not updated to reflect new interventions for pressure injuries that developed over time. The resident's admission observation documented several skin issues, including a pressure ulcer and deep tissue injuries. Weekly wound notes from the wound physician detailed the progression of these injuries, including a pressure injury on the right heel that evolved from unstageable to stage 3, and additional deep tissue pressure injuries and stage 3 pressure injuries on various parts of the body. Despite these documented changes, the care plan did not include new interventions for these specific pressure injuries. Interviews with facility staff, including the RN Unit Manager and the DON, revealed that while new wounds were documented in nurses' notes and communicated to relevant parties, the care plan was not revised accordingly. The facility's policy required that care plans be updated with any changes in the resident's condition, but this was not adhered to in the case of Resident #3. The DON acknowledged the oversight, confirming that the care plan was not updated to address the resident's wound care needs.
Failure to Document RN Assessment of Injury
Penalty
Summary
The facility failed to adhere to acceptable standards of nursing practice by not documenting a registered nurse's assessment of a reported injury of unknown origin for one resident. The incident involved a resident who was receiving hospice services and had severe cognitive impairment due to dementia, Parkinson's Disease, and Type II diabetes. On a specific date, a Licensed Practical Nurse (LPN) was informed by a family member about a mark on the resident's right inner forearm. The LPN notified the shift supervisor and attempted to contact the Nurse Practitioner (NP) but was unable to reach them. However, there was no further documentation regarding the mark in the resident's medical records. The Assistant Director of Nursing (ADON) stated that any report of a bruise or injury should trigger the abuse protocol, which includes a nursing assessment. The Nurse Practitioner confirmed that she did not observe any skin issues during her visit a week after the incident. The shift supervisor at the time, an RN, admitted to observing the resident's skin but did not document his findings, stating he got distracted. He mentioned that he did not see any bruise, blister, or raised area and would have investigated further if he had observed an injury. The lack of documentation and follow-up assessment by a registered nurse led to the deficiency identified by the surveyors.
Latest citations in New Jersey
A resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
