Meadowbrook Respiratory And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Matawan, New Jersey.
- Location
- 38 Freneau Avenue, Matawan, New Jersey 07747
- CMS Provider Number
- 315463
- Inspections on file
- 19
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Meadowbrook Respiratory And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities experienced deficiencies in wound care when staff failed to follow WCP recommendations for wound cleansing and did not update physician orders to reflect changes in treatment. Additionally, a skin tear on the resident's wrist was not treated for several days due to a delay in obtaining a treatment order. Documentation of wound measurements was inconsistent, and staff could not explain the discrepancies or delays.
A resident with anxiety and depression was prescribed Valium as needed and fluoxetine daily, but staff failed to document behavior monitoring or the use of non-drug interventions prior to administering Valium, despite pharmacy recommendations and facility policy. Staff interviews and record reviews confirmed the lack of required documentation and monitoring.
A resident with hypertension and congestive heart failure received clonidine HCl outside of physician-ordered parameters on multiple occasions, as documented in the MAR. Despite orders to hold the medication if systolic blood pressure was below 130 or heart rate below 60, nursing staff administered the medication when these conditions were not met. Both the LPN and DON confirmed the medication was given outside of the prescribed parameters, contrary to facility policy.
Two residents were found living in rooms with significant, unfinished wall damage, including unpainted spackled patches and multiple long holes, which had persisted for weeks to months. Despite a computerized maintenance work order system and regular audits by staff, these repairs were not completed in a timely manner, resulting in a failure to provide a clean, comfortable, and homelike environment.
Surveyors found that kitchen equipment, including ovens and stove tops, was not cleaned according to policy, with visible grease, food debris, and residue present. The area above a knife block was also unclean, and the walk-in freezer contained open, undated food items and a tray with unclear labeling. The DODS and facility leadership acknowledged these sanitation and food storage deficiencies.
Surveyors identified that two residents did not receive care in accordance with professional standards: one resident did not have all prescribed doses of topical lidocaine documented as administered, and another had a PIC dressing that was not labeled or dated, with incomplete documentation of dressing changes. Interviews with LPN, DON, and Infection Preventionist confirmed that required documentation and procedures were not followed, as outlined in facility policy.
A resident with severe cognitive impairment sustained a head laceration after falling from a wheelchair and required hospital treatment with staples. The facility did not provide documentation that the incident was reported to the NJDOH as required.
Two residents with severe cognitive impairment and dependence on staff for ADLs and transfers did not receive consistent accommodation for their activity needs and preferences. Despite care plans requiring staff assistance and scheduled activity visits, documentation showed long gaps without recorded activities, and interviews confirmed that activities were not consistently provided or documented for these residents.
A resident with chronic respiratory failure and a tracheostomy activated the call bell for suctioning, but staff did not respond promptly despite the alarm being active and visible. The resident continued to cough until a respiratory therapist arrived several minutes later to provide suctioning, after the surveyor intervened. Staff interviews and facility policy confirmed that call bells, especially for urgent needs, should be answered immediately.
Failure to Follow Wound Care Recommendations and Delayed Treatment Orders
Penalty
Summary
The facility failed to follow wound care practitioner (WCP) treatment recommendations and did not document accurate wound measurements for a resident with significant medical conditions, including peripheral vascular disease, atherosclerotic cardiovascular disease, and cellulitis. After a new wound was identified on the resident's right lower leg, the WCP recommended cleansing the wound with Dakin's solution, applying calcium alginate, and covering with ABD and kling. However, the facility instead ordered and implemented cleansing with normal saline solution (NSS), contrary to the WCP's recommendations. Additionally, subsequent changes in the WCP's treatment recommendations were not reflected in updated physician orders, and the facility continued to use outdated treatments. There were also discrepancies in wound measurements documented by nursing staff and the WCP, with no explanation provided for these inconsistencies. In a separate incident, the same resident developed a skin tear on the left wrist. Although the physician and wound care team were notified and recommendations were made to cleanse the area with NSS and apply a xeroform dressing, no treatment order was entered or implemented for eight days after the wound was identified. The delay in obtaining and implementing a treatment order was confirmed by review of the treatment administration record and interviews with facility staff, who could not provide an explanation for the delay. Facility policies required immediate transcription and implementation of wound care orders, as well as accurate and complete documentation of wound assessments and treatments. Despite these policies, the facility did not ensure timely and accurate execution of wound care recommendations and orders, nor did it maintain consistent and accurate documentation regarding wound measurements and treatments provided.
Failure to Monitor and Document Non-Drug Interventions for Psychoactive Medication Use
Penalty
Summary
The facility failed to act upon consultant pharmacy recommendations regarding the monitoring and administration of as-needed psychoactive medications for a resident with diagnoses including malnutrition, major depression, respiratory failure, and anxiety disorder. The resident was prescribed Valium as needed for anxiety and fluoxetine for depression. The care plan required monitoring and documentation of target behaviors and symptoms related to the use of these medications, as well as the use of non-drug interventions prior to administering Valium. However, a review of the Medication Administration Records over several months showed no evidence of behavior monitoring, and progress notes did not document any non-drug interventions attempted before administering Valium. Interviews with staff, including an LPN and the DON, revealed that behavior monitoring was expected to be documented on the MAR, but in this case, it was not done. The DON acknowledged that behavior monitoring and non-drug interventions were missed for this resident. The facility's own policy required the use of non-pharmacological approaches and monitoring for efficacy and adverse consequences of psychotropic medications, but these procedures were not followed for the resident in question.
Blood Pressure Medication Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered according to physician-ordered parameters for a resident with hypertension and congestive heart failure. The physician's order specified that clonidine hydrochloride should be held if the systolic blood pressure was less than 130 or if the heart rate was less than 60. Despite these clear parameters, the medication was repeatedly administered when the resident's blood pressure and/or heart rate were below the specified thresholds, as documented in the Medication Administration Record for multiple dates in April and May. The resident had a moderately impaired cognition, as indicated by a BIMS score of 8 out of 15, and was being treated for hypertension related to congestive heart failure. Interviews with nursing staff, including an LPN and the DON, confirmed that the medication was given outside of the prescribed parameters and acknowledged that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed, including adherence to any parameters set by the prescriber. The deficiency was identified through review of medical records, staff interviews, and facility policy, all of which confirmed that the medication administration did not comply with the physician's orders.
Failure to Maintain Homelike Environment Due to Unfinished Wall Repairs
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by observations on one of three nursing units. During the initial tour, one resident was found resting in bed with a wall behind them that had a large, unpainted, and unfinished spackled patch, which the resident reported had been present for at least a couple of months and expressed dislike for its appearance. In another room, a resident was observed sitting in a wheelchair with a wall behind their bed that had dried spackle and was severely damaged with multiple long holes, which the resident stated had been in that condition for about three weeks. Interviews with staff, including an LPN, the Director of Maintenance, and the Licensed Nursing Home Administrator, confirmed the use of a computerized maintenance work order system that notifies maintenance staff of needed repairs and that the facility conducts twice-weekly audits of resident rooms. Despite these systems, the wall repairs in the residents' rooms remained incomplete for extended periods, contrary to the facility's policy to maintain a homelike environment and provide timely housekeeping and maintenance services.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple instances of unsanitary conditions and improper food storage in the facility's kitchen. During a kitchen tour with the Director of Dietary Services (DODS), both convection ovens were found to be soiled with baked-on residue, and the six-burner and four-burner stove tops and ovens were covered with cooked-on grease, sediment, and food debris. The catch trays in these ovens were lined with foil that was also covered in burnt liquid and food debris. The DODS acknowledged that these items were not cleaned according to facility policy. Additionally, a wall above a mounted knife block had a sticky, colored substance, and while the knives themselves were clean, the area above the block had not been cleaned as required. Further inspection of the walk-in freezer revealed open and undated boxes of carrots and beef burgers, which the DODS acknowledged were susceptible to freezer burn and should have been sealed and dated. A metal tray containing an unidentified food item was also found, covered with torn plastic wrap and foil, with unclear dating. The DODS was unable to explain the labeling or the presence of the tray. The facility's sanitation policy requires all food service areas to be maintained in a clean and sanitary manner, but these observations demonstrated non-compliance with those standards. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged the surveyor's concerns during the exit interview.
Failure to Adhere to Medication Administration and Catheter Care Standards
Penalty
Summary
The facility failed to administer medication according to physician's orders and did not ensure proper care and documentation for a midline catheter site, as required by professional standards. For one resident with a diagnosis including malignant neoplasm of the left renal pelvis and urinary retention, the medical record review showed that several doses of lidocaine hydrochloride gel, ordered for topical application twice daily, were not signed off as administered on the Medication Administration Record (MAR). Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that the absence of documentation indicated the medication was not given, and there was no alternative documentation to support administration of the missed doses. In another case, a resident with chronic respiratory failure, anoxic brain damage, and neurogenic bladder had a peripherally inserted catheter (PIC) in the left forearm. Observation revealed the dressing was not labeled or dated as required. Review of the Treatment Administration Record (TAR) showed that the dressing change and site check orders were not consistently documented, with missing signatures on the TAR and an undated dressing at the time of observation. The Infection Preventionist and DON both stated that dressings should be dated to prevent infection and ensure proper treatment completion. Facility policies reviewed by the surveyor required that medications be documented as administered or withheld, and that IV dressings be labeled with the date and time of change. The failures identified were confirmed through interviews and record reviews, with staff acknowledging the lack of documentation and adherence to policy in both medication administration and catheter site care.
Failure to Report Resident Injury to State Authorities
Penalty
Summary
A facility failed to report an injury involving a severely cognitively impaired resident to the New Jersey Department of Health (NJDOH). The resident, who had diagnoses including Alzheimer's Disease, dementia, and hypertension, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. According to the medical record and incident report, the resident was found face down on the floor after falling from a wheelchair while reaching for candy, resulting in a head laceration. The resident was transferred to the hospital, where they received seven staples to the forehead for the injury. Review of the incident report and facility documentation did not show evidence that the NJDOH had been notified of the incident, as required. During interviews, facility staff stated that the incident had been investigated and reported to the NJDOH by a previous administrator, but no documentation was provided to confirm this. The surveyor did not receive any additional documentation indicating that the NJDOH had been contacted regarding the incident.
Failure to Accommodate Resident Activity Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences related to activities for two residents with severe cognitive impairment and dependence on staff for activities of daily living and transfers. Both residents had care plans indicating a need for staff assistance to participate in activities, cognitive stimulation, and social interaction, with interventions specifying that all staff should assist and invite them to scheduled activities. However, documentation revealed that one resident had not had a documented activity since early January, and the other since early September, despite scheduled activity visits. Interviews with the activities director confirmed that activities for bedbound residents were only completed 2-3 times a week and that documentation was often lacking due to time constraints. Additionally, an interview with one resident and a family member confirmed that the resident had not left the room to participate in scheduled activities, nor were any activities provided in the room. The activities director acknowledged the importance of activities for socialization and engagement but admitted that documentation was inconsistent and that there should be some form of documentation for activity encounters. No further documentation was provided to support that the scheduled activity visits actually occurred for the two residents in question.
Delayed Response to Call Bell for Resident with Tracheostomy
Penalty
Summary
A deficiency was identified when staff failed to answer a resident's call bell in a timely manner. The resident, who had chronic respiratory failure, a tracheostomy, and was dependent on a ventilator, was observed in bed with a call light within reach. The resident activated the call light and later began coughing, stating a need for suctioning. Despite the call light being on and the alarm sounding at the nurses' station, staff did not respond immediately. The surveyor observed a nurse and other staff in the hallway, with the call light indicator visible, but no one entered the room until prompted by the surveyor. The respiratory therapist arrived several minutes later to provide suctioning, after which the resident reported relief. Interviews with staff confirmed that call bells should be answered immediately or as soon as possible, especially in urgent situations. The facility's policy requires calls for assistance to be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately. The delay in responding to the resident's call bell, particularly given the resident's respiratory needs, constituted a failure to provide appropriate and timely care as per facility policy and physician orders.
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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