Redbank Center For Rehabilitation And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Bank, New Jersey.
- Location
- 100 Chapin Avenue, Red Bank, New Jersey 07701
- CMS Provider Number
- 315286
- Inspections on file
- 13
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Redbank Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to provide activities according to care plans for five residents, affecting their social and mental status. Residents with severe cognitive impairments and physical dependencies were not invited to or engaged in activities, despite care plans indicating the need for scheduled and one-on-one activities. Documentation of activities was inconsistent, and staff were unaware of residents' specific needs, such as broken equipment or language barriers.
A cook in the facility's kitchen failed to change gloves and wash hands after touching his face and contaminated items, then proceeded to handle food directly with the same gloves. Despite being alerted by the Dietary Manager, the cook continued to use his gloved hands improperly, violating the facility's handwashing policy and potentially risking the spread of infection among 132 residents.
The facility failed to follow infection control Enhanced Barrier Precautions (EBP) for two residents and did not handle medications properly for another. Staff did not consistently sanitize hands or use appropriate PPE when entering rooms with EBP signage. An LPN did not wear a gown while administering tube feeding to a resident on EBP, and isolation supplies were not readily available. Additionally, an LPN improperly handled medication by picking up a pill with an ungloved hand. These deficiencies put residents at risk of infection.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential unmet care needs. One resident's MDS inaccurately documented no oxygen therapy or tracheostomy care, despite evidence to the contrary. Another resident's discharge MDS was incorrectly coded, indicating discharge to a hospital instead of a private home. A third resident's MDS failed to reflect existing pressure areas and risk for further ulcers, despite documented skin assessments. These inaccuracies were confirmed through interviews with facility staff.
The facility failed to conduct timely PASARR screenings for two residents with psychiatric diagnoses. One resident was admitted without a psychiatric diagnosis, but later diagnosed with schizoaffective disorder, and no new PASARR Level I screen was completed. Another resident had a positive Level I PASARR screening for mental illness, but the required Level II screening was delayed. The facility's policy mandates reporting and evaluation of such issues by Social Services.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed needs for vision impairment, oxygen use, and protective boots. Despite documented diagnoses and physician orders, care plans lacked necessary interventions, and staff were unaware of these needs. This deficiency highlights a lack of communication and documentation in the facility's care planning process.
A resident with multiple health conditions, including quadriplegia and incontinence, was found to be double briefed on several occasions, contrary to facility policy. Staff confirmed that this practice could lead to skin breakdown and pressure sores. The resident's care plan required pericare after each incontinent episode and immediate changing of wet briefs, which was not followed.
The facility failed to follow physician orders for two residents, leading to risks of skin breakdown and infection. One resident did not receive prescribed heel protector and Multipodus boots, while another had discrepancies in PICC line dressing changes. Staff interviews revealed communication and documentation issues, resulting in non-compliance with care protocols.
A resident with a history of bronchiectasis and acute respiratory failure was not administered oxygen at the physician-prescribed dose of 2 LPM. Observations showed the resident receiving higher doses of 5 LPM and 3.5 LPM. An LPN confirmed the incorrect settings and adjusted them. The DON emphasized the importance of following oxygen orders, as high settings could be problematic for residents with certain conditions.
A resident receiving dialysis three times a week did not receive adequate care, as the facility failed to document vital signs before dialysis and did not provide meals or snacks before early morning sessions. The dialysis communication forms were inconsistently filled out, and staff interviews revealed confusion about responsibilities. The facility's policy for coordinating with the dietary department and maintaining communication with the dialysis center was not effectively implemented.
A facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for a resident with anxiety and depression. The resident's Clonazepam order lacked an end date, and the medication was administered multiple times despite a psychiatric evaluation showing no acute issues. The DON confirmed the oversight, acknowledging the regulatory requirement for an end date.
A resident received medications incorrectly, including late administration of gabapentin, incorrect dosage of estradiol, and discontinued calcium acetate, leading to a medication error rate above 5%. The LPN involved confirmed the errors, and the facility's policy requires adherence to prescribed orders and timing.
Medication carts on multiple floors were left unlocked and unattended by staff, posing a potential risk to resident safety. An RN and an LPN admitted to leaving carts unsecured, contrary to facility policy and expectations. Observations confirmed these lapses, with residents in proximity to the carts.
The facility failed to maintain complete medical records for two residents, leading to deficiencies in documentation related to a death in the facility and a discharge to the community. For one resident, the EMR lacked details about the death, including notifications and a physician's order to release the body. For another resident, the EMR was missing progress notes for the discharge date, and the LPN responsible forgot to document the discharge. The facility's policy requires comprehensive documentation for transfers and discharges, which was not followed.
Failure to Provide Activities According to Care Plans
Penalty
Summary
The facility failed to provide activities according to assessments and care plans for five residents, potentially affecting their social and mental status. Resident 5, who had severe cognitive impairment and was dependent on staff for transfers, expressed a desire to participate in activities but was not invited to any. Despite a comprehensive care plan indicating the need for scheduled activities compatible with her needs, she did not attend any activities in January or February. The Activity Director acknowledged that Resident 5 had not been invited to activities she enjoyed, such as music or dancing, and the Recreation Aid attempted to involve her but faced challenges in getting her up for activities. Resident 87, who was rarely understood and required one-on-one bedside activities, did not attend any activities in January or February. Although room visits were documented, the logs did not specify the activities conducted. Observations revealed that Resident 87 was often lying in bed without any engagement, and family members noted that he enjoyed music but was not involved in activities. The Activity Director and Recreation Aid admitted to inconsistencies in providing and documenting activities for Resident 87. Similarly, Resident 92, who had severe cognitive impairment and a tracheostomy, did not participate in any activities outside his room. Although room visits were recorded, the documentation lacked details on the activities performed. Observations showed that Resident 92 was frequently in bed without engagement, and family members reported that his Geri-chair was broken, preventing him from attending activities. The Activity Director was unaware of the broken chair and the resident's tracheostomy, leading to inaccurate documentation of activities. Residents 112 and 121 also experienced similar issues, with inadequate documentation and lack of engagement in activities, despite their care plans indicating the need for one-on-one visits and activities compatible with their preferences.
Improper Hand Hygiene and Glove Use in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use by kitchen staff, which could lead to the spread of infection and foodborne illness among residents. During an observation, a cook was seen touching his face and nose with gloved hands and then serving food without changing gloves. The cook handled food items directly with his gloved hands, including fried fish filets, sandwiches, and chicken strips, without using utensils. Additionally, the cook used visibly soiled oven mitts over his gloves to handle hot pans and continued serving food without changing gloves or washing hands. The Dietary Manager was informed of the issue and observed the cook's actions, confirming the failure to change gloves. Despite being provided with serving utensils, the cook continued to use his gloved hands to touch food, his pants, and his face. The facility's policy on handwashing requires staff to wash hands before working, after touching any part of the body, and between working with foods, which was not followed in this instance. This deficiency affected 132 of 141 residents consuming food in the facility.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to infection control Enhanced Barrier Precautions (EBP) for two residents, R92 and R107, and did not handle medications properly for resident R101. Observations revealed that staff, including a Certified Nurse Aide (CNA) and Licensed Practical Nurses (LPNs), did not consistently sanitize their hands or use appropriate personal protective equipment (PPE) such as gowns and gloves when entering rooms with EBP signage. Specifically, CNA2 did not sanitize her hands when passing meal trays to rooms with EBP signage, and LPN5 and LPN6 did not follow proper hand hygiene or PPE protocols when providing care to R92, who had a tracheostomy and was on EBP. For resident R107, who had a feeding tube and was on EBP, LPN5 did not wear a gown while administering tube feeding, contrary to the facility's infection preventionist's guidance that a gown should be worn during such high-contact procedures. The facility's Director of Nursing (DON) also confirmed that the expectation was for staff to use EBP, including wearing gowns and gloves when handling feeding tubes. Additionally, the facility failed to ensure that isolation supplies, such as face shields and goggles, were readily available on the third floor, where several residents with tracheostomies were located. In the case of resident R101, an LPN was observed picking up a pill that had fallen onto the medication cart with an ungloved hand and placing it back into the medication cup, which was then administered to the resident. This action was against the facility's policy, which required a no-touch technique for medication administration. The infection preventionist and DON both stated that gloves should be worn if touching medications, and hand hygiene should be performed before putting on gloves. These deficiencies in infection control practices put all residents at risk of infection.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to potential unmet care needs. Resident 107's MDS inaccurately documented that the resident did not receive oxygen therapy or tracheostomy care, despite records and observations indicating otherwise. The resident had a tracheostomy tube with oxygen flowing at 4 liters per minute, and the care plan noted the tracheostomy related to impaired breathing mechanics. Interviews with the Regional Nurse and Director of Nursing confirmed the expectation for accurate MDS coding, which was not met in this case. Resident 129's discharge MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while in reality, the resident was discharged to a private home with home health services. This discrepancy was confirmed through interviews with a Licensed Practical Nurse and the Regional Nurse, who acknowledged the coding error. The resident's actual discharge location was either her mother's or grandmother's home, not a hospital. Resident 92's admission MDS failed to reflect existing pressure areas and the risk for further pressure ulcers. The resident had a documented history of quadriplegia, hypertension, and sepsis, with skin assessments revealing redness and a pressure area on the sacrum. Despite this, the MDS did not indicate any unhealed pressure ulcers or risk for pressure ulcers. The Regional Nurse verified the inaccuracies, noting that the MDS should have included the pressure area on the sacrum and buttock, as well as the risk for further pressure areas. The facility's policy and the Resident Assessment Instrument Manual emphasize the importance of accurate and timely MDS completion, which was not adhered to in these cases.
Failure to Conduct Timely PASARR Screenings for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) for a resident (R20) when a psychiatric diagnosis of schizoaffective disorder was identified. Initially, R20 was admitted without a psychiatric diagnosis, and the hospital's PASARR Level I Screen documented no major mental illness. However, the facility later entered a diagnosis of schizoaffective disorder into the electronic medical record (EMR) without conducting a new PASARR Level I screen. Interviews with the Regional Nurse and the Director of Nursing confirmed that a new PASARR Level I screening should have been completed following the addition of the new psychiatric diagnosis. Another resident (R101) was admitted with a history of mental and behavioral disorders and had a positive Level I PASARR screening for mental illness, indicating the need for a Level II screening. Despite this, the facility did not ensure a Level II screening was conducted in a timely manner. The Social Services Director acknowledged the positive screening and stated that the facility was working to schedule the Level II screening. The Assistant Director of Nursing confirmed that the Level II screening was only requested after the surveyor's inquiry. The facility's policy requires that any issues identified in the PASARR process be reported to the Director of Social Services for further evaluation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which led to deficiencies in addressing their specific needs. One resident, who was admitted with end-stage renal disease and heart failure, had impaired vision documented in their Minimum Data Set (MDS) but lacked a care plan addressing this issue. Despite having an order for an ophthalmology consult due to blurry vision, the care plan did not include interventions for vision impairment, which was confirmed by interviews with the resident and staff. Another resident, who had been hospitalized and returned with a diagnosis of bronchiectasis and acute respiratory failure, required supplemental oxygen. However, their care plan did not document the need for oxygen, even though orders were in place for oxygen delivery. Observations and interviews revealed discrepancies in the oxygen settings, and staff were unaware of the care plan details, indicating a lack of communication and documentation. The third resident had impaired range of motion and was at risk for pressure sores, requiring heel protector boots and Multipodus boots. Despite physician orders for these interventions, the care plan did not include them, and staff were not informed of the need for these boots. Interviews with staff highlighted a lack of responsibility in updating care plans and ensuring that interventions were communicated to those providing direct care. The facility's policies required comprehensive care plans based on thorough assessments, but these were not followed, leading to potential impacts on resident care.
Improper Incontinence Care Due to Double Briefing
Penalty
Summary
The facility failed to provide proper incontinence care for a resident, identified as R92, who was found to be double briefed on multiple occasions. R92, who was admitted with multiple serious health conditions including quadriplegia and incontinence, was dependent on staff for all activities of daily living. The resident's care plan specified that pericare should be performed after every incontinent episode, and briefs should be changed immediately when wet or soiled. However, observations revealed that R92 was double briefed, with the inner brief soaked with urine, which was confirmed by both a family member and facility staff. Interviews with facility staff, including an LPN and CNA, confirmed that double briefing was against facility policy and could lead to skin breakdown and pressure sores. The Director of Nursing also stated that no residents should be double briefed unless requested, and R92 had not made such a request. The facility's policy on incontinence care emphasized the importance of checking residents for incontinence every two hours and changing briefs immediately when wet, which was not adhered to in R92's case.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for two residents, R121 and R89, which put them at risk for skin breakdown and infection. R121 was admitted with multiple fractures and was at risk for pressure sores. Physician orders required R121 to wear heel protector boots while in bed and Multipodus boots when out of bed. However, observations over several days revealed that R121 was not wearing the boots as ordered, and the care plan did not include interventions for the boots. Interviews with staff indicated a lack of communication and documentation regarding the need for the boots, leading to their non-use. R89, who had a PICC line and was diagnosed with conditions including diabetes and MRSA, was observed with a bandage dated 02/14/25, despite orders for weekly dressing changes. The Medication Administration Record showed discrepancies in the dressing change schedule, and interviews revealed confusion about the orders and documentation errors. The facility's policy required verification of physician orders and proper documentation, which was not followed, resulting in the bandage not being changed as required. The deficiencies in both cases were due to failures in communication, documentation, and adherence to physician orders and facility policies. These lapses in care placed the residents at risk for adverse outcomes, such as skin breakdown and infection, due to the non-implementation of prescribed interventions and care protocols.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed dose for a resident, identified as R56, who was reviewed for respiratory care. R56 had a history of bronchiectasis and acute respiratory failure with hypercapnia. The physician's order, dated 01/06/25, specified that R56 should receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. However, observations revealed discrepancies in the oxygen administration. On 02/23/25, R56 was observed receiving oxygen at 5 LPM, and on 02/24/25, the setting was at 3.5 LPM, both of which were higher than the prescribed dose. During an interview, an LPN confirmed the incorrect setting and adjusted the oxygen concentrator to the correct 2 LPM. The Director of Nursing (DON) stated that she expected oxygen orders to be followed, noting that high oxygen settings could be problematic for residents with conditions like COPD. The facility's policy on oxygen administration required staff to verify physician orders and ensure the proper flow of oxygen. The failure to adhere to the prescribed oxygen dose had the potential to cause respiratory distress for the resident.
Inadequate Dialysis Care and Communication for Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as R13, who required dialysis three times a week. R13 was admitted with diagnoses including end-stage renal disease and heart failure. The care plan for R13 included interventions such as taking vital signs before and after dialysis and addressing the risk of altered weight status due to edema and fluid fluctuations. However, the facility did not consistently document vital signs before dialysis, and there was no record of meals or snacks being provided before dialysis sessions, which could affect the resident's nutritional status. The facility's dialysis communication process was also inadequate. The Dialysis binder, which contained communication forms for each dialysis day, was not properly filled out. Of the 19 forms reviewed, 15 lacked documentation of pre-dialysis vital signs, and none recorded any meal or snack provided. Additionally, 17 forms did not have boxes checked regarding medications taken or changes since the last dialysis treatment. Interviews with staff revealed confusion about who was responsible for filling out the forms, and it was noted that dietary staff did not send food for residents to eat before early morning dialysis sessions. The facility's policy required communication with the dialysis center through a communication book and coordination with the dietary department to provide meals or snacks as needed. However, this policy was not effectively implemented, as evidenced by the lack of documentation and communication regarding R13's care. Interviews with various staff members, including LPNs, the Unit Manager, and the Director of Nursing, highlighted inconsistencies in the process and a lack of clarity about responsibilities, contributing to the deficiency in providing safe and appropriate dialysis care for R13.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were not prescribed beyond 14 days without documented rationale for a resident reviewed for unnecessary medications. The resident, who was admitted with diagnoses including depression, anxiety, and end-stage renal disease, had an order for Clonazepam 2MG to be administered as needed for anxiety. This order, which started on February 13, 2024, did not have an end date, contrary to regulatory requirements. The resident's medical records indicated that the medication was administered on multiple occasions in February 2025. Despite a psychiatric evaluation noting no acute behavioral issues or concerns, the facility did not document a rationale for continuing the PRN medication beyond the 14-day limit. The Director of Nursing confirmed the oversight, acknowledging the absence of an end date for the PRN medication, which is a requirement under the regulation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as evidenced by several errors involving a resident identified as R101. R101, who was admitted with diagnoses including hypothyroidism and failure to thrive, had specific medication orders for estradiol, gabapentin, and calcium acetate. During an observation, an LPN administered gabapentin 1 hour and 39 minutes after the scheduled time, gave only one tablet of estradiol instead of the prescribed two, and administered calcium acetate despite it being discontinued. These actions were contrary to the facility's policy, which mandates medication administration within one hour before or after the scheduled time and as per the physician's orders. Interviews with the LPN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed the deviations from the prescribed medication orders. The LPN acknowledged the late administration of gabapentin and the incorrect dosage of estradiol, and was unaware of the discontinuation of calcium acetate. The ADON and DON reiterated the expectation for medications to be administered as ordered and within the specified time frame. The facility's policy on medication administration, reviewed in December 2024, outlines the procedure for verifying and administering medications, emphasizing adherence to physician orders and time frames.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were securely locked when unattended, as observed on multiple occasions across different floors. On the third floor, a registered nurse (RN1) left a medication cart unlocked several times while attending to residents, with residents in close proximity to the cart. This occurred between 11:25 AM and 1:00 PM, during which RN1 admitted to leaving the cart unlocked and acknowledged the potential risk of residents accessing medications. Additionally, on the fourth floor, a medication cart was found unlocked and unattended near the nursing station, with residents nearby, and the unit manager confirmed the cart was not secure. Further observations on the second floor revealed another unattended and unlocked medication cart, which was subsequently locked by the Assistant Director of Nursing (ADON). Interviews with staff, including the ADON, Licensed Practical Nurse (LPN) 11, and the Director of Nursing (DON), confirmed the expectation that medication carts should be locked when unattended. The facility's policy on medication storage, revised in May 2024, also mandates that medication carts be locked or attended by authorized personnel. These lapses in securing medication carts posed a potential risk to resident safety.
Incomplete Documentation for Resident Death and Discharge
Penalty
Summary
The facility failed to maintain complete medical records for two residents, R127 and R129, which led to deficiencies in documentation related to a death in the facility and a discharge to the community. For R127, the electronic medical record (EMR) lacked documentation regarding the circumstances of the resident's death, including how it was discovered, who was notified, and the absence of a physician's order to release the body to the funeral home. Interviews revealed that the LPN on duty forgot to document the death after working a double shift, and the RN who pronounced the death did not document it either, assuming the floor nurse would handle it. For R129, the EMR was missing progress notes for the date of discharge, and the last note did not address the discharge. The LPN responsible for the discharge forgot to document it, including details about the resident's destination and whether discharge instructions or medications were provided. The facility's policy requires comprehensive documentation for transfers and discharges, including reasons for the action, notifications, and a summary of the resident's condition, which was not adhered to in these cases. The lack of documentation for both residents could lead to staff being unaware of the reasons for the residents' absence, whether proper notifications were made, and potential legal issues. The facility's failure to follow its own policy on documentation of transfers and discharges contributed to these deficiencies, as highlighted by the absence of critical information in the residents' medical records.
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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