Livingston Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, New Jersey.
- Location
- 348 E Cedar Street, Livingston, New Jersey 07039
- CMS Provider Number
- 315526
- Inspections on file
- 18
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Livingston Post Acute Care during CMS and state inspections, most recent first.
A resident admitted for IV antibiotic therapy for osteomyelitis did not receive four consecutive doses of prescribed Cefazolin due to medication unavailability and IV access issues. Facility staff did not document timely notification to the physician about the missed doses, and the medical record lacked evidence of physician awareness or alternative orders during the period of missed therapy.
The facility failed to meet the required staffing ratios as per New Jersey law, with deficiencies noted on several day shifts. From August 11 to August 24, 2024, the facility was short of CNAs on five day shifts, affecting the care of all residents. A similar deficiency was noted on one day shift in December 2024, highlighting ongoing staffing issues.
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation, as observed by a surveyor. Unlabeled and undated food items were found in a refrigerator and on carts, and the sanitizing solution in the 3-compartment sink was absent. A box fan with dust was blowing on utensils, and there was dust on the utensil rack and discolored vents and ceiling tiles. The log book for the sink was falsified, and facility policies on food storage and sanitization were not followed.
The facility failed to include a staffing contingency plan in its Facility Assessment (FA) and did not meet its own staffing requirements. The FA lacked necessary details in the staffing plan and policies, despite CMS updates. Staffing reports showed consistent shortfalls in nurse aide numbers, failing to meet the required 16-18 aides per shift.
The facility did not provide a designated dining room for residents, as required by regulations and policy. Instead, room tray services were offered, despite the facility being approved for communal dining on the first floor. During a resident council meeting, four residents expressed a desire for communal dining, which was not being provided. The facility's policy stated that residents' dining preferences should be accommodated, but this was not adhered to.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in care management. A resident's MDS did not reflect antibiotic administration, and there were discrepancies in respiratory therapy documentation. Another resident's MDS was inaccurately coded as a Significant Change in Status Assessment without proper documentation, and a third resident's pain assessment interview was conducted outside the required period. These inaccuracies reflect a failure to adhere to federal guidelines.
The facility failed to maintain adequate staffing levels and timely call bell responses, affecting several residents. Observations showed CNA to resident ratios exceeding state requirements, leading to delayed assistance. Residents reported long wait times, particularly during night shifts, with some needing to call family members for help. Call bell audits revealed response times up to 25 minutes, and a resident council meeting confirmed average wait times of at least 20 minutes.
The facility failed to administer oxygen therapy according to physician orders, improperly stored respiratory equipment, and did not obtain necessary physician orders for oxygen therapy. Observations included residents receiving incorrect oxygen levels, nebulizer masks exposed to contamination, and oxygen tubing not dated or stored properly. These deficiencies were acknowledged by facility management.
The facility exhibited multiple infection control deficiencies, including improper hand hygiene by a CNA, incorrect PPE use by staff, and contamination of clean linen. Additionally, a nurse used the same tissue for both eyes during medication administration, posing an infection risk. These actions were contrary to the facility's policies and CDC guidelines.
A resident with moderate cognitive impairment reported a fall and leg pain, but the facility failed to notify the resident's representative and physician immediately. The incident was not documented, and the physician was only informed after the resident was found in pain. The facility's policy on timely notification was not followed.
A resident with severe cognitive impairment and medical conditions was discharged from a facility without a physician's order and without documented confirmation from the home care service agency that they could provide necessary post-discharge care. The Social Worker Director sent a referral to the agency, but there was no evidence of acceptance. The resident was later taken to the hospital after the agency could not accept the referral.
A facility failed to document a discharge summary for a resident with severe cognitive impairment who was discharged home. The resident's medical record lacked a discharge summary, despite the facility's policy requiring it to include a recapitulation of the resident's stay and a final summary of their status. The facility administration did not provide additional information or confirm the presence of the summary in the electronic medical record.
A facility failed to provide adequate pain management for a resident with moderate cognitive impairment and lower back pain. Despite physician orders for Acetaminophen, there was no documented evidence of routine pain assessments from June through July 2024, and the resident's care plan lacked a pain management plan. Interviews revealed inconsistencies in pain assessment practices, with staff acknowledging that assessments should be documented every shift, but this was not done. The facility's policy required regular pain assessments, which were not followed, leading to the deficiency.
The facility failed to monitor and document a resident's condition post-fall, did not follow a physician's order for urinary catheter output documentation, and administered the wrong form of medication. A resident experienced two falls with inadequate neurocheck documentation. Another resident's catheter output was not consistently recorded, and low output was not reported to a physician. Additionally, a nurse administered a tablet instead of a prescribed capsule, contrary to facility policy.
A resident with a history of chronic conditions developed a new heel wound after admission, but the LTC facility failed to provide timely treatment and accurate documentation. The eTAR showed inconsistent entries, and the wound care policy lacked specific guidance. The facility did not provide additional policies when requested.
A facility failed to provide appropriate care for a resident with decreased range of motion and mobility, leading to a deficiency in maintaining and preventing further decline. The resident's care plan did not address impairments in both upper and lower extremities, and there was no evidence of services or interventions provided. Observations revealed contractures without assistive devices, and the facility could not provide evidence of required quarterly rehab screens.
The facility failed to monitor and document weights for two residents, leading to a deficiency in maintaining adequate nutrition and hydration. One resident experienced significant weight loss without physician notification, while another had missing weight records and duplicate orders for gastrostomy tube flushes. Staff interviews revealed a lack of communication and responsibility in addressing weight changes.
The facility failed to maintain proper dialysis communication records and provide care in accordance with professional standards for two residents requiring dialysis services. For one resident, the Dialysis Center Communication Record was inconsistently filled out, and there was no documentation of the assessment of the dialysis access site post-treatment. Another resident experienced deficiencies in care, with missing dialysis communication forms and incomplete CNA documentation for meal consumption. The facility's policies did not adequately address record-keeping or meal provision for dialysis residents.
The facility failed to post daily staffing information for two out of five days during a survey. The Nursing Home Resident Care Staffing Report was not updated for the current day shift on two occasions. The DON acknowledged the issue, and the Staffing Coordinator confirmed her responsibility to post the information daily, as per facility policy.
A facility failed to address Consultant Pharmacist recommendations for a resident with dementia and hypertension, who was prescribed Lorazepam for agitation and anxiety. Despite recommendations to specify a duration for the PRN medication, there was no follow-up with physicians or hospice, and no documentation by the primary physician or nurse practitioner about the resident's psychotropic medication regimen. The Director of Nursing acknowledged the oversight, which was contrary to the facility's policy requiring timely follow-up on such recommendations.
A surveyor observed a medication storage deficiency where two vials of Acetylcysteine were left unattended on a medication cart. The responsible nurse admitted to leaving the vials while attending to a resident, which was against the facility's policy requiring secure storage of medications. The facility's policy mandates that all drugs be stored in locked compartments and only accessible to authorized personnel.
The facility failed to maintain accurate and accessible medical records for two residents. One resident's advance directives were inconsistently documented, while another resident's pulmonary consultation plan was not properly communicated or documented. The facility's electronic medical records policy did not address these documentation issues.
The facility failed to offer or document the pneumococcal vaccine for three residents, despite their medical conditions and cognitive status. Resident #43, with multiple health issues, had no record of vaccine offer or ineligibility. Resident #62, with moderate cognitive impairment, was noted in the MDS as having declined the vaccine, but this was not documented in the EMR. Resident #148, with COPD and other conditions, was not documented as having been offered the vaccine. The facility's policy to assess and offer vaccines was not adhered to.
Failure to Administer IV Antibiotics and Notify Physician of Missed Doses
Penalty
Summary
A deficiency occurred when a resident admitted with end stage renal disease, Parkinson's Disease, type 2 diabetes, and osteomyelitis did not receive ordered intravenous (IV) antibiotic therapy as prescribed. The resident was admitted for the primary purpose of receiving IV Cefazolin to treat a bone infection. Despite physician orders for daily administration of Cefazolin, the resident did not receive four consecutive doses following admission, with the first dose not administered until several days later. The facility's policy required nursing staff to contact the pharmacy, attempt to obtain the medication from available sources, and notify the physician if a medication was unavailable. Documentation in the resident's medical record indicated that the antibiotic was not on hand and that there were difficulties establishing IV access, including unsuccessful attempts to start a line and delays in obtaining a midline due to the need for renal clearance. However, there was no documentation that the resident's physician was notified of the missed doses or the unavailability of the medication during this period, nor was there evidence of alternative orders or instructions from the physician regarding the missed therapy. Interviews with facility leadership confirmed that the expectation was for the physician to be informed of missed medication doses and for this communication to be documented in the resident's record. The record review and staff interviews revealed that the physician was not made aware of the missed doses until several days after the initial missed administrations, and the medical record did not reflect timely notification or a plan to address the missed antibiotic therapy.
Staffing Ratio Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels in nursing homes. During the investigation of complaints NJ00179449, NJ00179546, and NJ00181407, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on several day shifts. For the period from August 11, 2024, to August 24, 2024, the facility was deficient in staffing on five out of fourteen day shifts. For instance, on August 11, 2024, there were only 15 CNAs for 130 residents, whereas at least 16 were required. Similar deficiencies were noted on August 21, 22, 23, and 24, 2024, where the number of CNAs was consistently below the required ratio. Additionally, a review of staffing levels for the two weeks prior to the complaint survey, from December 22, 2024, to January 4, 2025, revealed a deficiency on one day shift. On December 22, 2024, the facility had 14 CNAs for 120 residents, falling short of the required 15 CNAs. These staffing deficiencies had the potential to affect all residents in the facility, as adequate staffing is crucial for ensuring proper care and safety for residents.
Plan Of Correction
No residents were identified as having been affected. All residents have the potential to be affected. Will add a certified nursing aide to all shifts that did not meet the requirement to be in compliance with staffing ratio of 1:8 during daytime hours, 1:10 for afternoon, and 1:14 for overnight. When an employee calls out coverage to be obtained by nursing supervisor and Director of Nursing. Director of Nursing, Staffing Coordinator and Administrator will meet daily during the week to review recruitment efforts, staffing for next day, and staffing for upcoming week. Trends identified from these meetings will be presented during monthly QAPI meeting. The facility has implemented a multifaceted approach for recruitment and retention of employees, which includes increased utilization of PRN/Per diem staff (Staff hired without any set hours, usually staff who have another job and pickup extra shifts when the need arises), Multimedia advertisements, Partnership with schools, Pick-up shift bonuses, Text message campaigns. Flyers placed around the buildings and on social media. The facility continues to utilize a recruitment company to do paid campaigns with Indeed, and other social media platforms to recruit nursing staff. Daily update emails and weekly meetings help to identify trends in hiring and review all new hires and where candidates stand in the hiring process. Targeted advertising in place to attract licensed nurses and aides. Employee engagement is led by management team/department heads to facilitate staff engagement and reduce employee turnover. Exit interviews being held to determine why staff are leaving. Referral bonus in place for any staff who refer a friend who gets hired, new hire bonus in place and paid out over a year of hire to ensure that employees stay in the position.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation in accordance with professional standards, as observed by the surveyor. During a tour of the kitchen, the surveyor noted several deficiencies, including unlabeled and undated food items in a refrigerator and on wheeled carts. The refrigerator contained packages of waffles, a bowl of salad, and a pan of pasta, all without labels or dates, and debris was found at the bottom of the refrigerator. Additionally, food items on the carts were mostly unlabeled and undated, with only two items properly marked. The surveyor also observed issues with the facility's sanitation practices. DA#2 was seen washing pans in a 3-compartment sink, but the sanitizing solution in the third compartment was not present, as indicated by a test strip showing a result of zero. The test strips used did not have an expiration date, and DA#2 was not aware of the proper use of the sanitizing solution. Furthermore, a box fan with dust accumulation was blowing air on utensils, and there was an accumulation of dust on the utensil rack, as well as discolored air vents and ceiling tiles. The facility's documentation and staff training were also found lacking. The log book for the 3-compartment sink was initially missing and later found, showing entries with DA#2's initials for days he did not work. The LNHA confirmed that no other staff shared the same initials, indicating falsification of records. The facility's policies on food storage and sanitization were not adhered to, contributing to the observed deficiencies.
Deficiency in Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included the necessary resources to establish policies and procedures for a staffing contingency plan, as required by CMS updates. This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unable to provide a comprehensive Facility Assessment (FA) that included a staffing contingency plan. The FA, dated July 23, 2024, lacked details in Part 3, Section 3.2 Staffing Plan, and Section 3.5 Policies and Procedures, which are essential for managing staffing during both regular operations and emergencies. Despite the LNHA's awareness of the CMS updates effective from August 8, 2024, the FA did not reflect these requirements. Additionally, the facility did not meet its own staffing plan as outlined in the FA. The FA indicated a need for 16-18 nurse aides to meet resident needs at any given time. However, staffing reports for the weeks of September 1-7 and September 8-14, 2024, showed that the facility consistently fell short of this requirement. Specifically, nurse aide staffing was below the minimum of 16 on multiple occasions across day, evening, and night shifts. The surveyor, upon reviewing these discrepancies with the LNHA, DON, Regional Nurse Consultant (RNC), and Infection Preventionist (IP), noted the absence of a staffing contingency plan as per the CMS update and the Quality Safety Oversight memo. The facility did not provide any additional documentation to address these concerns.
Facility Fails to Provide Designated Dining Room for Residents
Penalty
Summary
The facility failed to provide a designated dining room for residents, as required by federal regulations, the approved floor plan, and facility policy. This deficiency was identified during a survey conducted by surveyors who met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA admitted that since her tenure began, there had been no physical dining area, resulting in the absence of communal dining services for the 126 residents. Instead, the facility offered room tray services. The surveyors noted that the facility was approved for communal dining on the first floor, according to the submitted floor plan, but this service was not being provided. Further investigation revealed that during a resident council meeting, four residents expressed a desire for communal dining, which was not being offered. The facility's Accommodation of Needs Policy, updated in April 2024, stated that residents' individual needs and preferences should be accommodated, including their dining preferences. However, the facility failed to adhere to this policy by not providing a communal dining option. The survey team communicated these concerns to the facility management, but no additional information was provided during the exit conference.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For Resident #148, the MDS did not reflect the administration of antibiotics, despite documentation in the electronic Medication Administration Record (eMAR) indicating that Cephalexin was given. Additionally, there was a discrepancy in the recorded minutes and days of respiratory therapy, as the MDS showed different values than those documented in the resident's records. The Registered Nurse/MDS Coordinator (RN/MDSC) acknowledged the discrepancies but did not provide a satisfactory explanation. Resident #62's MDS was inaccurately coded as a Significant Change in Status Assessment (SCSA) without proper documentation to support a significant change in the resident's condition. The resident's cognitive status was assessed as moderately impaired, but there was no evidence of a significant change that warranted the SCSA. Furthermore, the MDS inaccurately indicated that the resident had declined a pneumococcal vaccine, with no supporting documentation in the medical record. For Resident #209, the Quarterly MDS was completed with an incorrect timeline for the pain assessment interview, which was conducted outside the required look-back period. The RN/MDSC was unable to provide a clear response regarding the timing of the assessment. These inaccuracies in MDS coding reflect a failure to adhere to federal guidelines, impacting the accuracy of resident assessments and care planning.
Inadequate Staffing and Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely response to call bells, affecting seven residents. Observations revealed that the Certified Nursing Aide (CNA) to resident ratio exceeded the mandated New Jersey staffing law requirement of 1:8, with ratios of 1:8.6 and 1:9 on different days. This staffing inadequacy contributed to delayed responses to residents' call bells, as reported by several residents. Resident #83, who had intact cognition and required assistance with toileting hygiene, reported long wait times for call bell responses, particularly during the night shift. The resident had to call a family member to get assistance after the call bell was not answered, and the staff only responded after the family member contacted the facility. Similar issues were reported by Resident #100, who had a sacral pressure ulcer and other medical conditions, and Resident #36, who experienced long wait times during night shifts. The facility's call bell audits showed response times ranging from 4 to 25 minutes, with some instances of staff re-education when longer wait times were noted. However, the audits were infrequent and did not cover all shifts adequately. During a resident council meeting, four residents reported average call bell response times of at least 20 minutes. The facility's policy stated that calls for assistance should be answered as soon as possible, but this was not consistently achieved, as evidenced by the surveyor's observations and resident reports.
Deficiencies in Respiratory Care and Infection Control Practices
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident who was observed receiving 4 liters per minute (LPM) of oxygen via nasal cannula, despite the physician's order specifying 2 LPM. The discrepancy was confirmed by the Unit Manager/LPN, who was unaware of who changed the oxygen setting. This oversight was acknowledged by the Director of Nursing as a human error. Another resident was observed with a nebulizer mask improperly stored, exposing it to environmental contamination. The resident's care plan lacked documentation on the proper storage of respiratory equipment. Additionally, a pulmonary consultation's recommendations were not communicated to the primary care physician, and there was no documentation of the physician's agreement or disagreement with the recommendations. The Assistant Director of Nursing/Infection Preventionist confirmed the need for proper documentation and storage practices. Further observations revealed that several residents had oxygen tubing and nebulizer masks that were not dated or stored in bags when not in use, contrary to infection control measures. One resident was found to be on oxygen therapy without a physician's order, and the facility's policy did not provide guidance on dating or storing respiratory equipment. These deficiencies were acknowledged by the facility management during meetings with the survey team.
Infection Control Deficiencies in PPE Use and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations during a survey. Several staff members, including a Certified Nursing Aide (CNA), were observed not performing hand hygiene after glove removal, which is a critical step in preventing the spread of infection. The CNA admitted to not performing hand hygiene due to the absence of alcohol-based hand rub (ABHR) in the resident's room, despite having received prior education on hand hygiene and PPE use. Additionally, improper use of personal protective equipment (PPE) was noted among staff members. A CNA was observed with a surgical mask improperly worn below the nose and mouth while assisting a resident, and another CNA failed to wear a PPE gown during high-contact care activities with a resident on Enhanced Barrier Precautions (EBP). These actions were contrary to the facility's infection control policies and CDC guidelines, which require proper PPE use to prevent the spread of multidrug-resistant organisms (MDROs). Further deficiencies were observed in the handling of clean linen and medication administration. A linen cart, considered clean, was found to contain food items, which is against the facility's policy for maintaining hygienically clean linen. During a medication pass, a nurse used the same tissue to wipe both eyes of a resident after administering eye drops, which was acknowledged as an infection risk by the nurse and the unit manager. These observations highlight lapses in maintaining infection control standards during routine care activities.
Failure to Notify Resident's Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative and physician of a change in condition in a timely manner. The resident, who had moderate cognitive impairment, reported to the nursing staff that they had fallen the previous day and were experiencing leg pain. However, there was no documentation of the fall, and the resident's representative and physician were not immediately informed of the incident. The resident was later found crying in pain, and only then was the physician notified, and an x-ray was ordered. Attempts to contact the resident's representative were made, but no immediate notification was documented. The facility's policy on accidents and incidents requires immediate notification of the resident's physician and family, which was not adhered to in this case. The Licensed Practical Nurse involved could not recall if the resident's representative was notified and had to refer to her notes. The facility management acknowledged the lapse in following their process for notifying the resident's representative and physician. The survey team reviewed the facility's policy and found it was not followed, leading to the deficiency.
Failure to Ensure Safe Discharge Due to Lack of Physician's Order and Home Care Referral Confirmation
Penalty
Summary
The facility failed to ensure a safe discharge for a resident by not obtaining a physician's order for discharge and not documenting the acceptance of a referral for home care services. The resident, who had severe cognitive impairment and medical conditions including a pressure ulcer, was discharged without confirmation from the home care service agency that they could provide the necessary post-discharge care. The Social Worker Director (SWD) stated that the referral was sent to Home Care Service Agency #1 (HCSA#1), but there was no documented evidence of acceptance or approval from the agency. The discharge planning process was initiated at the time of the resident's admission, involving the resident's representative and the facility's interdisciplinary team. However, the facility's documentation did not include a physician's order for discharge, and the SWD did not receive or document confirmation from HCSA#1 that they could accept the referral. The SWD later learned that HCSA#1 could not take the resident and had referred them to another agency, HCSA#2, but by that time, the resident had already been taken to the hospital by their representative. The facility's policies required that a discharge summary and post-discharge plan be developed, including arrangements for follow-up care and services. Despite these requirements, the facility did not provide evidence that the home care referral was accepted or that a physician's discharge order was obtained. The lack of documentation and communication between the facility and the home care agency contributed to the failure to ensure a safe discharge for the resident.
Failure to Document Discharge Summary for Resident
Penalty
Summary
The facility failed to document a discharge summary for a resident who was reviewed for discharge. The resident, identified as having severe cognitive impairment with a BIMS score of 03 out of 15, was admitted with medical diagnoses including a pressure ulcer of the sacral region, abnormal posture, and cognitive communication deficit. The resident had a planned discharge to home/community, but upon review, the hybrid medical record did not contain a discharge summary. During the survey, the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse Consultant, and Regional LNHA were informed of the missing discharge summary. The facility's policy requires a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status, which was not present in this case. Despite the facility's policy and the surveyor's request for confirmation, the facility administration did not provide additional information or confirm the presence of a discharge summary in the electronic medical record.
Inadequate Pain Management for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate pain management for a moderately impaired resident, identified as Resident #209, who was admitted with diagnoses including lower back pain, hypertension, and metabolic encephalopathy. The resident's Quarterly Minimum Data Set indicated moderate cognitive impairment. Despite having physician orders for pain management with Acetaminophen, there was no documented evidence of routine pain assessments from June through July 2024, and the resident's care plan did not include a plan for pain management. Interviews with the Director of Nursing (DON) and other nursing staff revealed inconsistencies in the facility's pain assessment practices. The DON stated that pain assessments were conducted upon admission and every shift, but acknowledged that documentation was not always required. The Unit Manager and Licensed Practical Nurses confirmed that pain assessments should be documented every shift, but this was not consistently done for Resident #209. The facility's policy required pain assessments to be conducted and documented regularly, but this was not adhered to in practice. The facility's Pain Assessment and Management policy outlined the need for consistent pain assessment and documentation, especially for acute or worsening chronic pain. However, the facility failed to follow these guidelines, resulting in a lack of documented pain assessments for Resident #209. The survey team highlighted these deficiencies to the facility management, who acknowledged the oversight and confirmed that the pain assessment would be reinstated in the resident's orders.
Deficiencies in Monitoring, Documentation, and Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of a resident's condition following falls. Resident #148 experienced two falls, one on 8/29/24 and another on 9/04/24, with the latter resulting in skin tears and a hospital visit for a CT scan. Despite the nurse practitioner's note indicating the resident was on neurochecks, there was no documented evidence of such monitoring post-fall, except on the day of the incidents. The Director of Nursing acknowledged the expectation for nurses to document every shift for three days post-incident, which was not adhered to in this case. Another deficiency involved the failure to follow a physician's order regarding urinary catheter output documentation for Resident #358. The resident had a history of urinary tract infection and obstructive uropathy, with a physician's order to document catheter output every shift. However, the electronic Treatment Administration Record showed multiple instances of missing or low urine output documentation, with no evidence of physician notification or actions taken for low output. The Assistant Director of Nursing confirmed the expectation for nurses to document output every shift and notify physicians of low output, which was not met. The third deficiency was observed during medication administration for Resident #260, where a Registered Nurse administered a tablet form of Docusate Sodium instead of the prescribed capsule form. The nurse acknowledged the error upon questioning and stated the procedure would be to contact the physician for an order change. The facility's policy requires medications to be administered as prescribed, which was not followed in this instance. The Unit Manager and Consultant Pharmacist both confirmed that the correct dosage form should be administered or the order changed if necessary.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. The deficiency was identified for a resident who developed a new wound on the right heel after being admitted to the facility. The resident, who was cognitively intact and had a history of chronic kidney disease, heart failure, hypertension, diabetes mellitus, and osteoarthritis, reported the new wound to the surveyor. The facility's records indicated that the wound was first noted on 9/09/24, and treatment with Medihoney was ordered, but there was a lack of documentation and timely initiation of treatment. The surveyor found discrepancies in the facility's documentation practices. The electronic Treatment Administration Record (eTAR) showed inconsistent entries for skin evaluations, with one entry marked as 'n' instead of the required numerical codes. The Director of Nursing (DON) was unable to explain the discrepancy initially but later clarified that 'n' indicated no wound or change. Additionally, there was no documentation in the nurse's progress notes about the new wound, and the wound treatment order was missing for the period between 9/09/24 and 9/11/24. The facility's wound care policy was reviewed and found to be lacking in specific guidance on wound assessments and documentation. The surveyor noted that the policy required documentation of any change in the resident's condition, but this was not adequately followed. Despite requests for additional policies related to wound care and skin assessments, the facility did not provide any further information. The surveyor's findings highlighted the facility's failure to maintain accurate and timely documentation and to follow established protocols for wound care.
Failure to Address Resident's Range of Motion Impairments
Penalty
Summary
The facility failed to provide appropriate care for a resident with decreased range of motion (ROM) and mobility, leading to a deficiency in maintaining and preventing further decline in the resident's condition. The resident, who was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had impairments in both upper and lower extremities. Despite these impairments, the resident's personalized care plan did not address these issues, and there was no documented evidence of services or interventions provided to address the impairments. Observations and interviews revealed that the resident had bilateral upper and lower extremities contractures, and no assistive devices or splints were provided since the resident's admission. The Director of Rehabilitation (DoR) and other staff members were unable to provide evidence of quarterly rehab screens for the resident, which were supposed to be part of the facility's process. Additionally, the therapy screen forms for other residents were incomplete, lacking necessary details such as the names of the occupational therapy staff and whether evaluations were recommended. The facility's policy on range of motion devices did not include information about passive range of motion (PROM), and there was no policy provided regarding PROM. The surveyor's inquiries revealed that the resident was not included in the therapy screen list, and the facility management could not provide evidence of quarterly rehab screens for the resident. The lack of a comprehensive care plan and failure to provide necessary interventions and documentation contributed to the deficiency identified by the surveyors.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' weights, leading to a deficiency in maintaining adequate nutrition and hydration. For Resident #2, the facility did not perform or document monthly weights and re-weighs as required. Despite a significant weight loss of 32.8 pounds within a month, there was no evidence that the physician was notified. The resident's medical records showed a history of various health conditions, including diabetes, chronic kidney disease, and heart failure, which necessitated careful nutritional monitoring. The dietitian noted the weight loss but did not communicate it to the physician, and the Unit Manager failed to enter the re-weighs into the electronic medical records. For Resident #67, the facility did not clarify duplicate physician orders for gastrostomy tube flushes, which were transcribed and signed off by nurses without correction. The resident, who was dependent on tube feeding due to severe cognitive impairment and other health issues, had missing weight records for certain months, and the facility did not follow the physician's order for monthly weight checks. The dietitian documented missing weights but did not follow up on them, and the Unit Manager acknowledged that weights were not taken or documented as required. The facility's policy on weight assessment and intervention was not adhered to, as evidenced by the lack of proper weight monitoring and physician notification for significant weight changes. The surveyor's interviews with staff revealed a lack of communication and responsibility in documenting and addressing weight changes, contributing to the deficiency in providing adequate nutrition and hydration to the residents.
Deficiencies in Dialysis Care and Documentation
Penalty
Summary
The facility failed to maintain proper dialysis communication records and provide care in accordance with professional standards for two residents requiring dialysis services. For Resident #98, the Dialysis Center Communication Record (DCCR) was inconsistently filled out, with several dates showing incomplete documentation. The facility's policy did not address the protocol for completing the communication form, and the Licensed Practical Nurse (LPN) confirmed that the expectation was for the record to be fully completed upon the resident's return from dialysis. Additionally, there was no documentation of the assessment of the dialysis access site post-treatment for several dates. Resident #458, who had severe cognitive impairment and multiple health issues including chronic kidney disease and diabetes, also experienced deficiencies in care. The facility failed to provide dialysis communication forms for this resident, and there were no progress notes for several dates when the resident was sent to or returned from dialysis. Furthermore, the Certified Nurse Aide (CNA) documentation for the resident's eating and percentage consumed was largely incomplete, with 84 out of 90 entries left blank. This lack of documentation did not reflect the resident's meal consumption or the assistance provided during meals. The facility's policies on dialysis communication and activities of daily living did not adequately address the record-keeping requirements or the provision of meals and snacks for dialysis residents. The surveyor's interviews with staff revealed inconsistencies in the understanding and implementation of these policies, contributing to the deficiencies observed in the care of Residents #98 and #458.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on two out of five days during the survey. On two separate occasions, the Nursing Home Resident Care Staffing Report (NHRCSR) was not updated for the current day shift. Specifically, on the morning of 9/16/24, the NHRCSR posted was dated for the previous day, 9/15/24, and similarly, on 9/17/24, the report was dated for 9/16/24. This oversight was observed by the surveyor upon entry into the facility on both days. The Director of Nursing (DON) acknowledged the issue when notified by the surveyor, stating that the Staffing Coordinator (SC) was responsible for posting the NHRCSR. The SC confirmed her responsibility and recognized the importance of posting the staffing information daily to inform residents and their families about the staffing levels. The facility's policy, updated in 4/2024, mandates that direct care daily staffing numbers be posted for every shift. Despite the acknowledgment of the deficiency, the facility management did not provide additional information or refute the findings during the exit conference.
Failure to Address Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident reviewed for unnecessary medications. The resident, who had diagnoses including unspecified dementia with psychotic disturbance and hypertension, was observed to be alert and verbally responsive but had moderate cognitive impairment. The resident had a physician's order for Lorazepam to be given as needed for agitation and anxiety, and a care plan involving the use of antipsychotic medication Seroquel. However, there were no psychiatry consultant notes after February 2024, and the resident's representative had requested that the primary physician manage the medication regimen. The CP reports from June, July, and August 2024 recommended specifying a duration for the PRN psychoactive medication Lorazepam unless a clinical rationale was documented by the physician. Despite these recommendations, there was no documentation of follow-up with physicians or hospice regarding the CP's suggestions. The Director of Nursing (DON) acknowledged reviewing the August 2024 CP report and the Medication Administration Record (MAR) but had not yet followed up with the physician or hospice. The facility's policy on psychotropic medication use and medication regimen reviews required timely follow-up on CP recommendations, with documentation of any actions taken. However, the surveyor found that the facility did not adhere to these policies, as there was no documentation by the primary physician or nurse practitioner about reviewing the resident's psychotropic medication regimen. The DON stated that the Assistant Directors of Nursing (ADONs) were responsible for reviewing CP recommendation reports, with an expectation of follow-up within two weeks, but this was not done in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and appropriately, as observed by a surveyor during an initial tour. On the third floor, a medication cart was found with two vials of Acetylcysteine left unattended on top. The nurse responsible for the cart admitted to leaving the vials there while attending to a resident, intending to return them to the refrigerator. This action was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. The surveyor confirmed with the Consultant Pharmacist that medications should never be left unattended or unsecured. The Director of Nursing also acknowledged that medications should not be left on top of the cart unattended. The facility's policy, last updated in April 2024, clearly states that drugs and biologicals must be stored in a safe, secure, and orderly manner, under proper conditions. Despite this policy, the facility did not provide any further pertinent information to address the observed deficiency.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For the first resident, there was a discrepancy in the documentation of their advance directives. Although the resident's medical records, including the POLST and care plan, indicated a DNR status, the physician's progress notes did not accurately reflect this. The facility's management acknowledged the inconsistency but did not provide additional information or policies addressing medical record accuracy. For the second resident, the facility did not properly document or follow up on a pulmonary consultation. The pulmonologist recommended a treatment plan that included duoneb and monitoring of oxygen saturation, but this plan was not communicated to or agreed upon by the primary care physician or nurse practitioner. The DON later revealed that the pulmonologist verbally advised against the plan, but this was not documented. Additionally, there were errors in the nurse practitioner's notes, which were not corrected until after the surveyor's inquiry. The facility's policy on electronic medical records did not address the issues of accuracy or documentation, contributing to the deficiencies observed. The survey team met with facility management multiple times, but no further information or corrective actions were provided to address the documentation issues identified during the survey.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer or document the administration or ineligibility of the pneumococcal vaccine for three residents. Resident #43, who was cognitively intact, had multiple medical conditions including metabolic encephalopathy, multiple myeloma, type 2 diabetes, hypertension, morbid obesity, anemia, and asthma. Despite these conditions, there was no documentation in the resident's medical record indicating that the pneumococcal vaccine was offered, declined, or that the resident was ineligible. The Licensed Nursing Home Administrator (LNHA) was unable to provide documentation to support the claim that the resident was not eligible for the vaccine. Resident #62, who had moderate cognitive impairment, was documented in the Minimum Data Set (MDS) as having been offered and declined the pneumococcal vaccine. However, there was no documentation in the electronic medical record (EMR) or paper chart to support this, nor were there any physician orders for the vaccine. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the lack of documentation and was unable to provide further information on the resident's vaccination status. Resident #148, who was cognitively intact and had conditions such as essential hypertension, anemia in chronic kidney disease, and chronic obstructive pulmonary disease (COPD), was not documented as having been offered the pneumococcal vaccine. There was no evidence in the medical records that the vaccine was offered, declined, or that education about the vaccine was provided. The ADON/IP confirmed the absence of documentation and stated that the vaccine should have been offered. The facility's policy required that all residents be assessed for vaccine eligibility and offered the vaccine unless contraindicated, but this was not followed in these cases.
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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