Our Ladys Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasantville, New Jersey.
- Location
- 1100 Clematis Ave, Pleasantville, New Jersey 08232
- CMS Provider Number
- 315054
- Inspections on file
- 19
- Latest survey
- December 31, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Our Ladys Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility was found deficient as two out of five kitchen exhaust hood grease baffles were missing interior channels, compromising fire protection. This issue was observed over the main 4-burner natural gas cooking appliance and confirmed through staff interviews, potentially affecting all residents.
The facility's fire alarm system was found to be deficient as the main entrance annunciator panel was in trouble mode due to a faulty CO detector module in the basement. This issue was identified by a technician, who noted that the module needed replacement to resolve the panel's boot cycling and supervisory status issues.
A facility was found to be in violation of electrical safety standards when a green extension cord was improperly used to power a 120-gallon holding tank circulating pump in the basement boiler location. This practice, confirmed by two individuals during an observation, did not comply with NFPA standards, which prohibit the use of extension cords as a substitute for fixed wiring. The deficiency had the potential to affect all residents and was noted during the Life Safety Code exit conference.
Surveyors observed multiple deficiencies in maintaining a clean and safe environment in the facility. A resident's bathroom had a loose toilet paper dispenser and stains, while another resident's room had a disconnected bed rail. The smoking area was littered with cigarettes, and nourishment rooms had various issues, including unlabeled substances, rust, and improperly stored items. Staff acknowledged these problems, and efforts to address them were noted.
The facility failed to properly store and label medications in medication carts, as observed by surveyors. Loose tablets were found in multiple carts, and undated insulin vials were noted. An LPN acknowledged the need for dating insulin vials and corrected the storage of Heparin. The facility's policies require orderly storage and dating of insulin vials, which were not adhered to.
The facility failed to ensure emergency illumination operated automatically along the means of egress, as required by NFPA 101:2012. In the C-hall dining room, a single wall switch controlled all ceiling lights, affecting 25 residents. This was confirmed by U.S. FOIA representatives during an observation.
The facility failed to ensure fire-rated doors to hazardous areas were self-closing and properly sealed, affecting 25 residents. Observations revealed gaps in kitchen doors and a door to the dining room that wouldn't close due to air pressure, compromising fire safety.
Access to a fire extinguisher in the E-hall exit/egress corridor was obstructed by a desk, computer monitor, and a 3-tier paper tray, potentially affecting approximately 75 residents. This deficiency was confirmed by U.S. FOIA representatives during an interview.
A facility failed to ensure a resident's call device was within reach while the resident was in bed, despite the resident's diagnosis of Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region. The call device was observed on the floor, outside the resident's reach, on two occasions. The facility's policy requires a call bell system to be accessible for residents to call for assistance.
The facility failed to maintain complete medication records and follow physician orders for two residents. One resident's treatment with Medihoney was not properly documented, with missing nurse initials on the TAR. Another resident received Midodrine HCL despite physician orders to hold the medication if SBP was greater than 135. Interviews with nursing staff confirmed these documentation and administration errors, highlighting deficiencies in adherence to medication policies.
A resident with cognitive intactness but physical limitations was found with long, sharp nails due to the facility's failure to provide necessary nail care. Despite the resident's inability to perform ADLs independently, the CNA did not trim the nails, and the LPN noted a previous refusal of care. Facility policies on nail care and ADLs were not adequately followed, resulting in this deficiency.
A facility failed to adjust medication administration times for a resident undergoing hemodialysis, resulting in missed doses of prescribed hypertension medications. Despite the care plan's directive to coordinate with the physician or dialysis center, the resident did not receive clonidine and isosorb dinitrate-hydralazine on multiple occasions due to being off the unit for dialysis. The LPN and Nurse Manager acknowledged the oversight and the need to clarify medication orders with the physician.
The facility failed to ensure regular face-to-face visits and documentation by physicians for several residents, as required by policy. Residents with various medical conditions, including hypertension and diabetes, had inconsistent or missing progress notes from attending physicians, with gaps in documentation spanning several months. The facility's policy required monthly visits and documentation, but these were not consistently followed.
A facility failed to ensure staff wore appropriate PPE when entering a room under Contact Precautions. A nurse entered a resident's room, diagnosed with a multi-drug resistant organism, wearing gloves but no gown, despite signage indicating the requirement. The facility's policy mandates gown use in such situations, and the incident highlights a lapse in adherence to infection control protocols.
The facility failed to meet the required CNA staffing ratios for 12 out of 14 day shifts, as mandated by New Jersey law. Despite the facility's policy claiming adequate staffing, the 'Nurse Staffing Report' showed consistent understaffing, with the number of CNAs falling short of the required number. Interviews with the Staffing Coordinator and DON revealed awareness of the requirements, yet they incorrectly stated compliance.
The facility did not meet mandatory nurse staffing requirements for two days in early December 2024, falling short by 33 and 9 hours, respectively. Despite claims from the Staffing Coordinator, DON, and Licensed Nursing Home Administrator that staffing was adequate based on census and resident acuities, the facility's policy to maintain adequate staffing was not fulfilled.
A facility failed to obtain a physician-ordered blood test for a resident with multiple diagnoses, leading to a delayed discovery of an abnormally high white blood cell count. The oversight occurred because the order was not entered into the EMR, and the facility's policies lacked pertinent information about lab orders.
Deficiency in Kitchen Exhaust Hood Grease Baffles
Penalty
Summary
The facility failed to ensure that two out of five exhaust hood grease baffles were fully operational, which is necessary to protect against grease and fire from entering above the exhaust hood system in accordance with NFPA 96. During an observation, it was noted that the interior channels of the #1 and #5 baffles were missing, providing no protection in those areas. The #1 grease baffle was specifically observed over the main 4-burner natural gas cooking appliance. This deficiency was confirmed through interviews conducted shortly after the observation, and it was noted that this practice had the potential to affect all residents.
Plan Of Correction
K-0324 (F) Cooking Facilities 1. Replacement of the 2 of the 5 kitchen hood grease baffles identified as missing; the interior channels of the #1 and #5 baffle were ordered and installed on 1/9/2025. 2. All other areas have been inspected and comply. All resident areas are free from hazard and all systems are operating as designed. 3. The Maintenance Director provided education with the Maintenance staff to confirm proper gap penetration in kitchen equipment on 1/10/2025. 4. Every quarter for a year, the Maintenance Director or designee will review random areas for excess penetrations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *photo of replacement of kitchen baffles attached*
Fire Alarm System Deficiency Due to Faulty CO Detector Module
Penalty
Summary
The facility failed to ensure that all components of the fire alarm system were fully operational in accordance with NFPA 70 and 72. During an observation, it was noted that the main entrance fire alarm annunciator panel was in trouble mode, indicating a disconnection in Zone-4 and a trouble with the basement CO detector. A document from the facility vendor dated 12/13/24 revealed that a technician identified a faulty module for the CO detector, which was causing the panel to boot cycle and not return to normal supervisory status. The panel was left in supervisory mode until the necessary monitoring module and programmer could be obtained to correct the issue. This deficiency was acknowledged during the Life Safety Code exit conference.
Plan Of Correction
K-0345 (E) NFPA 101- Testing and Maintenance 1. [R] has restored functionality to the fire alarm system by installing a new module on 1/14/2025. The system was always functioning, and all residents areas are free from hazard. 2. All testing and maintenance paperwork has been completed and inspected on 1/14/2025. 3. The Maintenance Director provided education with Maintenance staff to confirm proper repairs on paperwork once deficiencies are found on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee review paperwork for proper paperwork and deficiency free reporting. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *Invoice of service installation of fire alarm system module attached*
Improper Use of Extension Cord in Facility
Penalty
Summary
The facility failed to comply with electrical safety standards as outlined in NFPA 101, NFPA 70, and NFPA 99. During an observation in the basement boiler location, it was found that a green extension cord was improperly used to supply power to a 120-gallon holding tank circulating pump. This extension cord was plugged into a duplex wall outlet, which is a violation of the requirement that extension cords should not be used as a substitute for fixed wiring. This practice was identified as a deficiency because it did not meet the conditions specified in the relevant NFPA standards, which prohibit the use of extension cords beyond temporary installation. The deficiency was confirmed through an interview with two individuals present during the observation. The improper use of the extension cord had the potential to affect all residents in the facility, as it was not in compliance with the safety standards designed to prevent electrical hazards. The issue was formally communicated to the responsible party during the Life Safety Code exit conference.
Plan Of Correction
K-0920 (E) Power Cords and Extensions. 1. The extension cord plugged into a circulator pump for the hot water system has been removed and replaced with a permanent circuit on 1/10/2025. All residents are free from hazard. 2. All areas are free from extension cords and have been inspected by 1/10/2025. 3. The Maintenance Director provided education with Maintenance staff regarding the need to maintain proper electrical connected with approved electrical connections. 4. Every quarter for a year the Maintenance Director or designee will check surge protectors throughout the facility to maintain logs of what they are used for. This information will then be entered on a log and will be presented to the monthly QAPI meeting quarterly for one year. *extension cord was replaced with permanent circuit to the circulator pump- see attached photo*
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made by surveyors. In one instance, a resident's bathroom had a crooked and loose toilet paper dispenser, stains on the floor near the window, and stains on the wall outside the bathroom door. Another resident's room was found with a disconnected bed rail and a bed remote control left on the floor. Additionally, the smoking area grounds were littered with discarded cigarettes, and an outdoor bench was cracked. Further observations revealed issues in the nourishment rooms across various units. In one unit, a water bottle with an unlabeled blue substance and an open sponge were found under the sink, while the ice machine had white stains and rust. Paper cups were improperly stored facing up, exposing them to germs. Another unit had a kitchen cabinet in poor condition with missing knobs and paperclips used to open doors, along with peeling paint. In yet another unit, cabinets were nailed shut, and there was visible dirt, dust, and a dead bug in the open cabinets. Interviews with staff, including registered nurses, the Director of Housekeeping, and the Maintenance Director, confirmed awareness of these issues. The staff acknowledged that personal items and cleaning supplies were improperly stored, and that the nourishment rooms required cleaning and maintenance. The Licensed Nursing Home Administrator also recognized the need for appropriate storage solutions and replacements for the damaged cabinets, indicating ongoing efforts to address these deficiencies.
Plan Of Correction
F584 Homelike Environment What corrective action will be accomplished for those residents affected by the deficient practice? The following residents were identified as being affected by the deficient practice: resident #11, resident #319, and resident #20. Resident #11 toilet paper dispenser in the bathroom was secured to the wall. The bedroom walls were repainted, and the floor was stripped and buffed. Resident #319 NJ EX Order 26 on the left side was immediately reconnected to NJ Ex Order 26.4. The bed remote control was immediately picked up, wiped clean, tested to be in working condition and placed within residents reach. Resident #20 room was immediately swept and mopped discarding the medication cup, straw and liquid on the floor. The unidentified tablet was discarded via drug buster. The clean left bedside were put away per residents request. The following areas were identified as being affected by the deficient practice: The cigarettes on the ground in the grass and sidewalk area of the designated smoking area were discarded. The cracked outdoor bench in the courtyard was removed and discarded. The pillowcases in room B8 bathroom window were removed. The window was checked by maintenance and is in good working order. Room B4 (A) wall was repainted. The water bottle with blue substance and sponge were immediately removed from Unit C/D nourishment room. The white stains on the ice machine were removed and the rust was removed off the rack. The stack of 3 paper cups observed facing up and open to room air were discarded. The nourishment room cabinet On Unit G/H was discarded and a new cabinet was installed. Cabinet doorknobs were placed on the Unit B nourishment room cabinet doors under the counter. The tied plastic bag with a mop head in it was immediately removed and discarded. The open bag of clothes on the chair was removed. The inside of the upper cabinets in Unit E/F nourishment room were cleaned. The bottom cabinets on Unit E/F nourishment room were replaced. The counter tops in Unit E/F nourishment room were cleaned. Six tied bags of clothes on the counters in Unit E/F nourishment room were removed. The missing paint around the soap dispenser in Unit E/F nourishment room was repainted. The layer of dirt and debris behind the sink in Unit E/F nourishment room was cleaned. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A facility audit was conducted to identify rooms/areas with the following: Resident bathroom toilet paper dispensers were audited for secure placement. The condition of resident bedroom walls and floors were audited. Resident bed rails were audited to ensure proper placement. Unit ice machines were audited for descaling and cleanliness. Unit nourishment rooms were audited for repairs. Nourishment rooms were audited for employee personal belongings. Resident wearing briefs were identified and asked regarding their preference of storing incontinence products. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Housekeeping Director began re-education on January 6, 2025, to the housekeeping staff reviewing the following: Resident room cleaning procedures. Nourishment room cleaning procedures. Smoking area cleaning procedures. The Housekeeping Director or Designee will conduct random audits of the following areas: Resident rooms for cleanliness of floors and walls by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment rooms for cleanliness of counter tops, cabinets and sinks by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Smoking area for cleanliness and removal of cigarettes by rounding and visually observing the smoking area 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Director of Maintenance began re-education on January 6, 2025, to the maintenance staff reviewing the following: Resident room repairs and preventative maintenance. Resident bathroom repairs and preventative maintenance. Nourishment room repairs and preventative maintenance. Equipment repairs and preventative maintenance ie. Bed rails, ice machines. The Director of Maintenance and or Designee will conduct random audits of the following areas: Resident rooms for identified maintenance repairs by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Resident bathrooms for identified maintenance repairs by rounding and visually observing 5 resident bathrooms 5 days a week x4 weeks, then 3 bathrooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment room for identified maintenance repairs by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Bed rails to ensure proper placement on the bed frame by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. All Unit Ice machines to ensure descaling and tray maintenance by rounding and visually observing the ice machines 5 days a week x4 weeks and then 3 days a week x4 weeks. The Unit Managers began re-education on January 6, 2025, to the nursing staff on proper storage location of personal items and resident preference of location to store incontinent products. The Unit Managers and or Designee will conduct random audits for employee personal belongings by rounding and visually observing nourishment rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Unit Managers and or Designee will conduct random audits of residents who use incontinence products for proper storage in rooms by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. How will the corrective action be monitored to ensure the deficient practice will not recur? The Director of Housekeeping and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Director of Maintenance and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Unit Managers and/or designee will report all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in medication carts, as observed during a survey. On multiple occasions, surveyors found loose tablets in the drawers of medication carts across different halls, indicating a lack of adherence to the facility's medication storage policy. Specifically, on one occasion, two loose tablets were found in a medication cart drawer, and undated multi-use vials of Insulin Lispro and Lantus were observed. Additionally, loose vials of Heparin were improperly stored with insulins, which was acknowledged by an LPN who then corrected the storage. Further inspections revealed similar issues with loose tablets in other medication carts, with one LPN unsure about the frequency of cart cleaning, attributing the issue to the night shift. The facility's policies on medication storage and administration were reviewed, highlighting the requirement for medications to be stored in an orderly manner and for insulin vials to be dated upon opening. These observations indicate a failure to maintain medication storage areas in a clean, safe, and sanitary manner, as required by the facility's policies.
Plan Of Correction
F761- Label/Store Drugs and Biologicals What corrective action will be accomplished for those residents affected by the deficient practice? Destroy all loose pills in the drug buster that were found in D-Hall, B-Hall, A-Hall, G-Hall medication carts, the undated Lantus multi-dose vial and the undated Lispro. Place Heparin vial in the proper box labeled Heparin. Educated USFOIA (b) (6) assigned in A-hall, B-Hall, D-Hall, G-Hall medication carts on the Policy for Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug busters if found. Educated USO assigned in D-Hall cart the Policy on Medication Labeling of Multi-dose Vial. Given specific instructions on proper labeling expiration date of Lantus multi-dose vial once opened. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Unit Managers audited medication carts on their units and no further concerns were noted. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Nurse Educator began education on December 17, 2025 to RN/LPN's on staff of policy on Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug buster if found. Policy on Medication Labeling of Multi-dose Vial will be provided. Given specific instructions on proper labeling of multi-dose vials once opened. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by the Nursing Administration for loose pills in med carts, expiration labels on multi dose vials, and proper storage of Heparin Vials, weekly x4, monthly x3. The results of the audits will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Failure to Provide Automatic Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination that would operate automatically along the means of egress, as required by NFPA 101:2012 Edition, Sections 19.2.8 and 7.8.1.3* (2). This deficiency was identified during an observation and interview conducted on December 30, 2024, in the presence of U.S. FOIA representatives. Specifically, it was observed that in the C-hall occupied dining room, a single wall light switch controlled all eight ceiling light fixtures, which did not comply with the requirement for emergency illumination to operate automatically. This issue was noted in one of four areas and had the potential to affect 25 residents. The findings were confirmed by the U.S. FOIA representatives at the time of observation and were communicated to the facility during the Life Safety Code survey exit conference on December 31, 2024.
Plan Of Correction
K-0281 (E) NFPA 101- Illumination of Means of Egress 1. The facility is scheduled on January 24, 2025, to install emergency lighting in the dining room to illuminate the discharge path. The room has ambient lighting, and all residents were free from hazards. 2. All remaining egress path lights have been inspected and found at least one light that is on constant power. Fixtures have been tested and are in full operation as of 1/10/2025. All resident areas are free from hazards and all systems are operating as designed. 3. Education is completed with Maintenance staff to confirm proper function and maintenance of all egress path lighting on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee reviews random exit path lights for function. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *emergency lighting was installed in the dining room- see attached photo*
Deficient Fire-Rated Door Compliance in Hazardous Areas
Penalty
Summary
The facility failed to ensure that fire-rated doors to hazardous areas were self-closing, properly labeled, and separated by smoke-resisting partitions as required by NFPA 101, 2012 Edition. This deficiency was observed in two of six doors located at the back of the facility, potentially affecting 25 residents in the identified area. Specifically, an observation at 10:10 AM revealed that the set of wooden doors to the kitchen had a gap of approximately 1/2-inch to 3/4-inch when in the closed position, compromising the fire barrier's integrity. Additionally, at 10:21 AM, it was observed that the blue door from the kitchen to the resident dining room would not fully close and latch due to positive air pressure from the kitchen, causing the door to remain open by approximately 6 inches. These observations were confirmed in an interview with the involved staff members. The deficiency was communicated to the facility during the Life Safety Code exit conference.
Plan Of Correction
K-0321 (E) NFPA 101- Hazardous Areas Enclosure 1. Replacement of kitchen-rated doors were ordered on January 14, 2025 with installation prior to compliance date of February 11, 2025. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All hazardous enclosure doors have been inspected, and confirmation of latching and free from gaps completed on 1/10/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee will review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. * See attached quote and receipt of payment for kitchen rated doors* * See attached photo of kitchen double door replacement*
Obstructed Access to Fire Extinguisher
Penalty
Summary
The facility failed to ensure that fire extinguishers were readily accessible and ready for use, as required by NFPA 101, 2012 Edition, Section 19.3.5.12, 9.7.4.1, and NFPA 10, 2010 Edition, Section 5.5.5.3(a). During an observation at 11:11 AM, it was noted that access to a fire extinguisher in the E-hall exit/egress corridor was obstructed by a desk, computer monitor, and a 3-tier paper tray. This deficiency had the potential to affect approximately 75 residents. The observation was confirmed in an interview at 11:15 AM with the U.S. FOIA representatives. The issue was communicated to the U.S. FOIA (b) (6) during the Life Safety Code exit conference.
Plan Of Correction
K-0355 (E) Fire Extinguishers 1. The Fire Extinguisher compromised by the desk has been corrected by having the desk removed on 1/10/2025. All resident areas are free from hazard. 2. All Fire Extinguishers in the facility have been reinspected and are ready for use, and the staff inspect the extinguisher areas to prevent this from happening in the future. All resident areas are free from hazard and all systems are operating as designed as of 1/10/2025. 3. The Maintenance Director provided education with Maintenance staff regarding monitoring Fire Extinguishers by Maintenance Staff on 1/10/2025. 4. Every quarter for a year, the Maintenance Director or designee will check Fire Extinguishers throughout the facility to ensure they are ready for use. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *desk was removed clearing access to fire extinguisher-see attached photo*
Failure to Ensure Resident's Call Device Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the resident's call device was within reach while the resident was in bed. This deficiency was identified for a resident diagnosed with Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region, which is an infection of the bone. On two separate occasions, the surveyor observed the resident's call device on the floor, outside of the resident's reach. The facility's policy, effective since March 2020, states that a call bell system is utilized to allow residents to call for staff assistance. Despite this policy, the resident's call device was not accessible, indicating a failure to accommodate the resident's needs and preferences as required.
Plan Of Correction
F558- Reasonable Accommodations What corrective action will be accomplished for those residents affected by the deficient practice? Unit Manager ensured resident's call bell was placed in close proximity to the resident #320 on 12/16/2024 and 12/20/2024. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. Unit Managers completed an audit and if a call bell was not in close proximity of the resident, the call bell was moved toward the resident. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Call bell policy was reviewed. Clinical staff were educated on the importance of ensuring residents' call bells are in reach of residents. Unit managers will monitor call bells to ensure they are in close proximity of residents. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing or designee will complete an audit of the location of resident call bells to ensure they are in close proximity of the resident. The Audit will be completed once a week for 30 days, then monthly x3. The results of the audit will be reviewed at the monthly QAPI team chaired by the facility administrator.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete medication records with staff signatures according to professional standards of clinical practice for Resident #23. The resident, who had diagnoses including dementia and arthritis, was observed on a pressure-relieving mattress. A review of the Treatment Administration Record (TAR) revealed blank areas where nurses' initials should have been, indicating the completion of treatment with Medihoney, a topical cream ordered for daily application to a sacral wound. The blanks were noted on specific dates in December 2024, and interviews with nursing staff confirmed that there should not be blanks on the TAR, as it either indicated a failure to sign or a failure to complete the treatment. The facility also failed to follow physician orders regarding medication administration for Resident #51, who had diagnoses including hypertension, end-stage renal disease, and schizophrenia. The resident had a physician order for Midodrine HCL to be administered with specific parameters to hold the medication if the systolic blood pressure (SBP) was greater than 135. However, the electronic Medication Administration Record (eMAR) showed that the medication was administered on several occasions when the SBP exceeded 135, contrary to the physician's order. Interviews with LPNs revealed that the medication was documented as administered, and one LPN admitted to possible incorrect documentation without providing further explanation. The facility's policy on administering medications, revised in March 2020, states that medications must be administered safely, timely, and as prescribed, including adherence to any required time frames. The Director of Nursing acknowledged the issues with medication administration and documentation, confirming that Midodrine should be held for SBP greater than 135. The surveyor noted these deficiencies in the facility's adherence to medication administration policies and procedures.
Plan Of Correction
F658- Services Provided Meet Professional Standards What corrective action will be accomplished for those residents affected by the deficient practice? A statement was obtained by the Director of Nursing from the nurse who completed the treatment for resident #23. Statement indicated the residents treatment was completed. Resident #23 Treatment administration record could not be retroactively updated to include the initial of the nurse who completed the treatment. The Medical Director was made aware of the residents parameters on the medication administration record for Midodrine. The Medical Director provided no new orders. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Treatment Administration Records were reviewed by Unit Managers for residents and no concerns or blanks were identified. Unit Managers reviewed charts for residents on Midodrine and no concerns were noted for blood pressure. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Medication administration policy was reviewed. Nurses were educated on the importance of documenting treatments on the treatment administration records. Nurses were also educated by the Educator on monitoring and following medication parameters. Unit Managers or designee will monitor Treatment and Medication Administration records to ensure nurses are documenting and following medication parameters. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing will monitor Treatment/Medication Administration Records once a week for 30 days, then monthly x 3 to ensure nurses are documenting or following parameters. The results of the audit will be reviewed at the monthly QAPI team chaired by the facility administrator.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was unable to perform activities of daily living (ADLs) independently. This deficiency was identified during a survey when Resident #122 was observed with long, squared nails with sharp edges. The resident, who had a history of type II diabetes mellitus, anxiety disorder, muscle weakness, and lack of coordination, was cognitively intact but required supervision or assistance with personal hygiene. Despite the resident's inability to cut their own nails due to arm shakiness, the Certified Nursing Assistant (CNA) admitted to not providing nail care, even though it was part of his responsibilities. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that nail care was recognized as important for infection control and hygiene. However, the LPN noted that the resident was confused and had refused nail care on a previous occasion, although the resident was generally calm and cooperative. The facility's policies on nail care and ADLs emphasized the importance of routine cleaning and inspection of nails, yet these were not adequately followed for Resident #122, leading to the observed deficiency.
Plan Of Correction
F677- ADL Care Provided for Dependent Residents What corrective action will be accomplished for those residents affected by the deficient practice? Resident #122 was provided with ex order 26.4 by the caretaker on 12/18/2024. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. The Unit Managers checked all residents for nail care and if nail care was required, the resident care team provided nail care. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Policy for resident hygiene was reviewed. Clinical staff were educated on the importance of providing routine hygiene practices for residents. Unit managers or designee will monitor resident hygiene routine to ensure care is being provided. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing or designee will audit residents' nails to ensure they have been provided with nail care. The audit will be conducted once a week for one month, then monthly x3. The results of the audit will be reviewed at the facility QAPI meeting x3 months.
Failure to Adjust Medication Times for Dialysis Schedule
Penalty
Summary
The facility failed to ensure that medication administration times were adjusted to accommodate a resident's hemodialysis schedule, as per professional standards of practice. This deficiency was identified for a resident with a primary diagnosis of anemia and end-stage renal disease, who required hemodialysis three times a week. The resident's care plan included an intervention to confer with the physician or dialysis center regarding changes in medication administration times as needed. However, the review of the electronic Medication Administration Record (eMAR) indicated that the resident did not receive prescribed medications, clonidine and isosorb dinitrate-hydralazine, on several occasions because the resident was off the unit for dialysis. The Licensed Practical Nurse (LPN) familiar with the resident confirmed that the resident was not receiving these medications while at dialysis and acknowledged the need to clarify the orders with the physician. The Nurse Manager also confirmed that the resident should be receiving the medications as ordered and intended to speak with the doctor to adjust the medication times to align with the dialysis schedule. The facility's policy on hemodialysis, revised in June 2024, stated that medication times might be altered based on dialysis times, but this was not adhered to in practice.
Plan Of Correction
F698- Dialysis What corrective action will be accomplished for those residents affected by the deficient practice? Nurse Manager spoke to the Primary Care Physician clarified and changed Resident #43 medication times of NU EX Order 26.4 (b) and NJ Ex Order 26.4(b)(1) to coincide with NJ Ex Order 26. hours and days. Educated RN/LPN assigned to Resident #43 on the Policy for NJ Exec Order 26.451 Given specific instructions on scheduling meds to coincide with resident dialysis hours and days. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on hemodialysis have the potential to be affected. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Dialysis Policy was reviewed. Nurse Educator conducted education to RN/LPN/Unit Manager/Nursing Supervisor on the Policy for Dialysis. Education on specific instructions regarding scheduling medications to coincide with resident dialysis hours and days. Unit Managers or designee will monitor dialysis residents medication orders to ensure times are scheduled around Dialysis days and hours. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on medication schedules coinciding with dialysis hours and days. The audits will be completed weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Deficiency in Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was observed in four residents who were reviewed for physician visits. The facility's policy required that physicians make rounds every day and document in the electronic medical record (EMR), with an expectation for a history and physical (H&P) within 24 hours of admission and monthly physician visit progress notes. However, the records for these residents showed inconsistencies and gaps in documentation by the attending physician. Resident #51, admitted with multiple diagnoses including hypertension and schizophrenia, had no progress notes from the attending physician from May to December 2024. The nurse practitioner (NP) documented visits, but there was no evidence of alternating monthly visits between the physician and NP. Similarly, Resident #52, with diagnoses including hypertension and anxiety disorder, had only a few documented visits by the attending physician and physician assistant (PA)/NP, with missing progress notes for several months. Resident #119, who had a tracheostomy and was cognitively intact, also lacked progress notes from the attending physician for several months. The NP documented visits sporadically, but there was no consistent alternation of visits. Resident #122, with type II diabetes mellitus and anxiety disorder, had NP visit progress notes but no documentation from the attending physician for several months. The Director of Nursing (DON) confirmed the expectation for physician visits and documentation, but the surveyor noted the deficiencies in the facility's adherence to these requirements.
Plan Of Correction
F712- Physician Visits What corrective action will be accomplished for those residents affected by the deficient practice? The Director of Nursing and Director of Clinical Services spoke with the Medical Director and advised of policy on Physician Visits. The Medical Records for identified residents could not be retroactively updated to include physician visits. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. Managers audited clinical records and contacted physicians with any findings. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Policy for Physician Visits was reviewed. The Director of Clinical Services, Director of Nursing and or the Medical Director began education on January 8th, 2025 to the primary physicians on staff of the policy on Physician Visits. Unit Managers will monitor resident records to ensure physicians are making visits at appropriate intervals. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on Physicians Visits/Frequency/Timeliness, weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Failure to Use Appropriate PPE in Contact Precaution Room
Penalty
Summary
The facility failed to adhere to appropriate infection control practices by not ensuring that staff wore a personal-protective gown while entering a room under Contact Precautions. This deficiency was observed in the case of a resident diagnosed with Methicillin Resistant Staphylococcus Aureus Infection, a multi-drug resistant organism. During the survey, a registered nurse was seen entering the resident's room wearing gloves but not a gown, despite the presence of a sign outside the room indicating the requirement for both gloves and a gown under Contact Precautions. The nurse justified her actions by stating she was not providing direct care, only shutting off a pump alarm. However, the facility's policy on Transmission-Based Precautions, revised in April 2024, clearly states that a gown should be worn whenever there is potential contact with the resident or contaminated surfaces. The Infection Preventionist confirmed the resident was on Contact Precautions, and the Director of Nursing acknowledged the need for staff education on the proper protocol for entering rooms under such precautions.
Plan Of Correction
F880- Infection Control What corrective action will be accomplished for those residents affected by the deficient practice? Educated RN #1 on the Policy for Transmission Based Precautions. With emphasis on wearing proper PPE when entering room and providing care on Resident #320 on NJ Ex Order 26.4(b)(1) Precautions. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on Contact Isolation Precautions have the potential to be affected by this alleged deficient practice. Unit managers checked other residents on Contact Precautions, and no concerns were identified. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The policy on Infection Prevention and Control was reviewed. Nurse Educator began education on December 16, 2024 to RN/LPN/CNAs/Therapists on policy for Transmission Based Precautions. The staff members were educated on the importance of wearing proper PPE when entering and giving care for resident on Contact Isolation Precaution. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on wearing proper PPE when entering and giving care for residents on Contact Isolation Precautions. Audits will be conducted weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratios for 12 out of 14 day shifts, as mandated by the State of New Jersey. According to the New Jersey Department of Health memo dated 01/28/2021, the law requires one Certified Nurse Aide (CNA) for every eight residents during the day shift. However, the facility's 'Nurse Staffing Report' for the period from 12/01/2024 to 12/14/2024 showed that the facility was consistently understaffed. For instance, on 12/01/24, there were only 13 CNAs for 178 residents, whereas at least 22 CNAs were required. Similar deficiencies were noted on other days, with the number of CNAs consistently falling short of the required number. Interviews conducted on 12/20/24 with the Staffing Coordinator and the Director of Nursing revealed that both were aware of the minimum staffing ratio requirements. Despite this awareness, they stated that the facility was meeting the requirements, which contradicts the documented staffing levels. The facility's policy titled 'Staffing', revised in 4/2024, claims that adequate staffing is provided to meet the care and service needs of the residents, yet the documented staffing levels indicate otherwise.
Plan Of Correction
S560 Staffing Levels What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the week of December 1, 2024. Specifically, on December 1, 2024, the facility provided 480 actual staffing hours, which was 33 hours short of the required 513 hours. Similarly, on December 2, 2024, the facility provided 504 actual staffing hours, falling short by 9 hours. This deficiency was identified through a review of the Supplementary Nurse Staffing Report for the weeks of December 1, 2024, to December 14, 2024. Interviews conducted on December 20, 2024, with the Staffing Coordinator, Director of Nursing (DON), and the Licensed Nursing Home Administrator revealed differing perspectives on staffing adequacy. The Staffing Coordinator indicated reliance on the facility census for scheduling, while the DON asserted that registered nurses were available 24/7 and that staffing requirements were met. The Licensed Nursing Home Administrator emphasized staffing based on resident acuities, claiming the facility was correctly staffed. Despite these assertions, the facility's policy, revised in April 2024, stated that adequate staffing should be maintained to meet resident care needs, which was not achieved on the specified days.
Plan Of Correction
S1680- Mandatory Nurse Staffing What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for professional nurses and certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review professional nurse and certified nurse aides staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.
Failure to Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to provide the needed care and services in accordance with professional standards of practice by not obtaining a laboratory diagnostic, specifically a blood test, as ordered by the physician for the next day. This deficiency was discovered for a resident who had multiple diagnoses, including a fracture, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The physician had ordered a complete blood count (CBC) test for the next morning, but the order was not entered into the Electronic Medical Record (EMR), and the test was not conducted on the specified date. The resident's next CBC test was conducted two days later, revealing an abnormally high white blood cell count, which led to the resident being sent to the emergency room. Interviews with the Unit Managers and the Licensed Nursing Home Administrator confirmed that the physician's order should have been added to the EMR. The Director of Nursing acknowledged that the nurse forgot to enter the order. The facility's policies on physician orders and lab draws did not contain pertinent information about laboratory orders, contributing to the oversight.
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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