Holly Manor Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mendham, New Jersey.
- Location
- 84 Cold Hill Road, Mendham, New Jersey 07945
- CMS Provider Number
- 315143
- Inspections on file
- 14
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holly Manor Center during CMS and state inspections, most recent first.
The facility failed to maintain proper kitchen sanitation practices, resulting in a repeat deficiency. Expired food items were found in the dry storage and chef preparation areas, and a lack of labeling was noted in the walk-in refrigerator. Additionally, a blackish dust-like substance was observed on the refrigerator's fan grate. The facility's policies on food storage and equipment maintenance were not followed, as confirmed by the FSD and LNHA.
The facility failed to maintain a sanitary environment by not keeping the dumpster and surrounding area free of garbage and debris. During a tour, the surveyor observed garbage debris, including food wrappers, cups, gloves, paper products, and medication cups, around the dumpster. The Food Service Director acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator confirmed that the garbage area should be kept free of debris, as per the facility's trash removal policy.
The facility failed to document the receipt of Schedule II controlled substances on DEA 222 Forms and did not follow physician orders for a resident's blood pressure medication. The forms lacked necessary details, and the resident's blood pressure was not recorded before administering Cozaar, despite instructions to hold the medication if systolic blood pressure was below 110. These deficiencies were confirmed by the DON and an LPN during the survey.
A facility failed to ensure the Consultant Pharmacist identified and reported irregularities in medication management for a resident. The CP did not notice that a nurse was not documenting the resident's blood pressure when administering Cozaar, which was prescribed with a parameter to hold if the systolic BP was below 110. This oversight occurred multiple times over several months, despite the facility's policy requiring the CP to communicate potential or actual problems related to medication therapy.
The facility failed to monitor, document, and evaluate the use of psychoactive medications for four residents. Observations and record reviews revealed a lack of documentation for target behaviors and side effects, incomplete AIMS assessments, and care plans missing specific interventions. Staff interviews confirmed inadequate monitoring practices, contrary to the facility's policy requiring non-pharmacological approaches and psychotropic medication evaluations.
The facility failed to follow infection control practices for linen handling and storage. Clean linens were observed uncovered in the laundry room, and pillows were stacked to the ceiling in the linen room, posing a fire hazard. The IP could not confirm the cleanliness of various items found on the floor, contrary to the facility's linen handling policy.
A facility failed to implement a comprehensive care plan for a resident who frequently refused care and was combative. Despite the resident's medical history of cerebral infarction and mood disorders, the care plan did not address their refusal of care. Staff interviews confirmed the resident's behavior, and the facility's policy required documentation of such refusals, which was not present.
The facility failed to properly label, dispose, and secure medications in multiple medication carts and a refrigerator. An LPN acknowledged an undated Lantus insulin pen was improperly stored, and a refrigerator was unlocked with Vancomycin IV bags. Further inspections revealed undated insulin pens, opened Xalatan eye drops without dates, expired medications, and undated blood glucose test strips. Staff acknowledged these deficiencies.
A facility failed to maintain accurate medical records when an RD did not sign a nutrition note for a resident on an altered consistency diet for dysphagia. The note, dated over a month prior, remained in draft status, and the RD confirmed it was not signed upon completion. The LNHA acknowledged that all clinical documentation should be signed at the time of service, as per facility policy.
Improper Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, leading to a repeat deficiency. During a kitchen tour, the surveyor, accompanied by the Food Service Director (FSD), observed several issues. In the dry storage area, an opened bottle of maple syrup and a container of cooking oil were found with use-by dates that had already passed. In the walk-in refrigerator, an opened container of fat-free Italian dressing lacked a label with open and use-by dates, and a blackish dust-like substance was observed on the fan grate. Additionally, on the chef preparation table, an opened container of red wine vinegar was found with a use-by date that had expired. The facility's policies on food storage and equipment maintenance were reviewed, revealing that all foods should be labeled, dated, and stored properly, and equipment should be routinely cleaned and maintained. The FSD acknowledged that the items should have been discarded according to their use-by dates, and the fan grate required immediate cleaning. The Licensed Nursing Home Administrator (LNHA) confirmed that all items in the kitchen should be discarded by their use-by dates. Despite these policies, the facility failed to adhere to them, resulting in the observed deficiencies.
Failure to Maintain Sanitary Garbage Area
Penalty
Summary
The facility failed to maintain a sanitary environment by not keeping the dumpster and surrounding area free of garbage and debris. During a tour conducted by the surveyor in the presence of the Food Service Director (FSD), it was observed that the designated garbage area had garbage debris, including food wrappers, cups, gloves, paper products, and medication cups, scattered around the dumpster. The FSD acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Clinical Lead (RCL) were informed of these findings, and the LNHA confirmed that the garbage area should be kept free of debris. The facility's policy on trash removal, which was provided to the surveyor, stated that the trash container is scheduled to be cleaned on a regular cleaning cycle or when visibly soiled. However, no further information was provided by the facility staff during the exit conference.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by the incomplete documentation on DEA 222 Forms for Schedule II controlled substances. The forms, which are used to order controlled substances, were not filled out in Part 5 by the purchaser, which should include the quantity and date received. This deficiency was noted for six orders of controlled substances, including Fentanyl patches, Oxycodone tablets, and Morphine Sulfate, where the necessary documentation was missing despite the presence of supplier packing slips. Additionally, the facility did not adhere to physician orders for the administration of blood pressure medication for a resident with hypertension, congestive heart failure, and hyperlipidemia. The resident's medical record indicated a prescription for Cozaar, with instructions to hold the medication if the systolic blood pressure was below 110. However, the electronic Medication Administration Record (eMAR) showed that the medication was administered multiple times without documenting the resident's blood pressure, making it impossible to verify compliance with the physician's order. The surveyor's review, in the presence of the Director of Nursing and a Licensed Practical Nurse, confirmed these deficiencies. The LPN acknowledged the omission of blood pressure documentation, which was necessary to ensure the safe administration of the medication. The facility's policies on controlled drug management and medication administration were not followed, as evidenced by the lack of proper documentation and monitoring of vital signs prior to medication administration.
Consultant Pharmacist Fails to Identify Medication Administration Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in medication management for a resident. Specifically, the CP did not identify that the facility nurse was not documenting the resident's blood pressure (BP) when administering Cozaar, a medication prescribed with a parameter to hold if the systolic BP was below 110. This oversight was noted for one resident, who was admitted with diagnoses including hypertension, congestive heart failure, and hyperlipidemia. The resident's medical records showed that Cozaar was administered multiple times across December 2024, January 2025, and February 2025 without the required BP documentation. The deficiency was identified during a survey when the surveyor reviewed the resident's electronic Medication Administration Record (eMAR) and found numerous instances where the medication was administered without BP documentation. The Licensed Practical Nurse (LPN) acknowledged the omission and stated that it was the CP's responsibility to identify such issues during monthly medication reviews. Despite the facility's policy requiring the CP to communicate potential or actual problems related to medication therapy, the CP failed to report this irregularity. The Director of Nursing (DON) confirmed the CP's responsibility in this matter, and no additional information was provided by the facility's administrative staff during the surveyor's inquiry.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications for four residents. This deficiency was identified through observations, interviews, and record reviews. For Resident #93, the facility did not document the target behaviors of screaming, hitting, and refusing care, nor did it monitor side effects and target behaviors with the use of psychotropic medications. The resident's care plan lacked specific target behaviors and non-pharmacological interventions, and there was no Abnormal Involuntary Movement Scale (AIMS) assessment conducted as per the facility's policy. Resident #68 was observed to be receiving antipsychotic medication without documentation of target behaviors and potential side effects. The resident's care plan did not include specific target behaviors or non-pharmacological interventions. An AIMS assessment was incomplete, and there was no routine monitoring of psychotropic medication use as required by the facility's policy. Similarly, Resident #4's records showed a lack of documentation for target behaviors and side effects, and the care plan did not reflect specific interventions for psychotropic medication use. Although some AIMS assessments were conducted, they were not done quarterly as required. For Resident #45, the facility did not document target behaviors and potential side effects after an increase in risperidone dosage. The care plan did not include specific target behaviors or non-pharmacological interventions. An AIMS assessment was incomplete, and there was no routine monitoring of psychotropic medication use. Interviews with staff revealed that side effects were only documented if observed, and there was no documentation of targeted behavior monitoring. The facility's policy required the use of non-pharmacological approaches and completion of psychotropic medication evaluations, which were not consistently followed.
Infection Control Deficiency in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices in the handling and storage of linens. During an inspection, a surveyor and the Infection Preventionist (IP) observed a cart full of linens in the laundry room, some of which were not covered with plastic. The housekeeping staff indicated that these linens were clean and ready for transport, but could not explain why some were uncovered. Additionally, in the linen room, pillows were stacked almost to the ceiling, posing a fire hazard, and some were uncovered. There were also heel boots on top of the pillows, and a pile of clothes, luggage, and a floor mat on the floor, with the IP unable to confirm if these items were clean. The facility's policy on linen handling, which requires clean linens to be covered and stored separately from soiled items, was not followed.
Failure to Implement Comprehensive Care Plan for Resident Refusing Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was refusing care. The deficiency was identified during a survey when a resident was observed screaming and yelling in their native language, with a family member present. Interviews with staff, including an LPN and a CNA, revealed that the resident frequently refused care, was combative, and only responded to a family member. The resident's medical records indicated a history of cerebral infarction, mood disorders, and moderate cognitive impairment, with regular administration of antipsychotic and antidepressant medications. Despite these behaviors and medical conditions, the care plan did not address the resident's refusal of care. The surveyor's review of the resident's records showed that the care plan focused on the risk of complications from psychotropic drugs but failed to include interventions for the resident's refusal of care. The facility's policy on person-centered care plans required documentation of services not provided due to the patient's exercise of rights, including the right to refuse treatment. Interviews with the Unit Manager/RN confirmed the absence of a care plan addressing the resident's refusal of care. The deficiency was discussed with the facility's administration, but no additional information was provided to address the concern.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label, dispose, and secure medications in four out of six medication carts and one out of three medication refrigerators inspected. During the inspection of the subacute medication cart, an unopened and undated Lantus insulin pen with a pharmacy date was found stored improperly. Additionally, an unlocked medication refrigerator contained two Vancomycin IV bags. The Licensed Practical Nurse present acknowledged the insulin pen should have been dated and the refrigerator should have been locked. Further inspections revealed additional issues with medication management. In the South medication cart #1, two unopened and undated Lantus insulin pens and two opened bottles of Xalatan eye drops without an opened date were found. The Registered Nurse acknowledged the insulin pens should have been refrigerated and the eye drops dated. In the South medication cart #2, an expired Xalatan eye drop was found, and the LPN confirmed it should have been removed. Lastly, the North medication cart #2 contained an opened bottle of blood glucose test strips without an opened date, which the RN acknowledged should have been dated.
Failure to Sign Nutrition Note by RD
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards, as evidenced by the Registered Dietitian (RD) not signing a nutrition note at the time of assessment for a resident. This deficiency was identified during a survey when the surveyor observed and interviewed a resident who had been in the facility for about three months and was on an altered consistency diet for dysphagia. The resident was unsure when the RD had last assessed them. A review of the resident's electronic medical record revealed a nutrition consult note dated over a month prior, which was still labeled as a draft and had not been signed by the RD. During the investigation, the RD confirmed that they had written the nutrition consult note but had not signed it upon completion, resulting in the note remaining in draft status. The Licensed Nursing Home Administrator (LNHA) acknowledged that all clinical documentation should be signed at the time of service. The facility's policy on Medical Nutrition Therapy, revised in 2017, states that the RD is responsible for completing a comprehensive assessment annually or as indicated by the resident's clinical condition. Despite this policy, the lack of a signed nutrition note indicated a failure to adhere to these standards, as no other staff member had alerted the RD to the oversight until the surveyor's investigation.
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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