Reformed Church Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Old Bridge, New Jersey.
- Location
- 1990 Route 18 North, Old Bridge, New Jersey 08857
- CMS Provider Number
- 315417
- Inspections on file
- 14
- Latest survey
- December 11, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Reformed Church Home during CMS and state inspections, most recent first.
The facility failed to meet the required CNA staffing ratios for three day shifts, having only 10 CNAs for 89 to 90 residents instead of the mandated 11. The staffing coordinator acknowledged the difficulty in covering call-outs despite efforts to fill vacancies with per diem staff and agencies.
The facility failed to maintain the integrity of smoke barrier partitions, with three out of twelve smoke barriers having penetrations that compromised their fire resistance rating. Observations revealed holes with wires and cables running through smoke barrier walls on multiple floors, potentially affecting all 88 residents.
The facility failed to maintain proper emergency communication systems in two of its four elevators. During testing, the emergency phones in elevators #1 and #2 malfunctioned, disconnecting calls prematurely and lacking pre-recorded messages. This issue had the potential to impact the safety of 88 residents.
The facility failed to ensure a fire-rated door to a hazardous area was properly separated by smoke-resisting partitions. The basement Activities room door did not self-close due to the removal of its automatic closure mechanism. Inside, combustible items were observed, and the room exceeded the size threshold for requiring proper fire separation.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced a fall resulting in injuries due to the facility's failure to follow the fall prevention interventions outlined in their care plan. The interventions, which included keeping the bed in the lowest position and placing a thick floor mat next to the bed, were not in place at the time of the incident. An agency CNA unfamiliar with the resident's needs was responsible for their care at the time.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for three of the fourteen day shifts reviewed. Specifically, on three separate days, the facility had only 10 Certified Nurse Aides (CNAs) for 89 to 90 residents during the day shift, whereas the state requirement was at least 11 CNAs. This deficiency was identified through a review of staffing records for the period from November 17, 2024, to November 30, 2024. During an interview, the staffing coordinator acknowledged awareness of the CNA staffing ratios and admitted that while the facility usually meets these ratios, covering call-outs can be challenging. The facility's staffing policy, reviewed on December 11, 2024, outlines that the staffing coordinator is responsible for filling vacancies, initially attempting to cover shifts with per diem staff and, if unsuccessful, reaching out to agencies. Despite these procedures, the facility was unable to meet the mandated staffing levels on the specified days.
Plan Of Correction
To ensure all residents have access to the care they need, Reformed Church Home has cross-trained our nursing staff to perform CNA duties during the day shift in emergencies. All residents have the potential to be affected by the staffing shortage. In addition to using our nurse managers to perform direct care, we have also contracted with additional staffing agencies to provide temporary CNAs in the event of shortages. Overtime is offered to existing staff since we are usually trying to fill vacancies due to illness. The facility has taken multiple steps to address the CNA concern. Efforts are made to stay ahead of the pay scale and to have Reformed Church Home at the top of the wage scale. Reformed Church Home is also offering an additional health family plan which is lower in cost than our traditional plans. The hope again is that we will be able to attract more CNAs with families due to our competitive rates and enhanced health coverage for families. We have also partnered with the CNA school, Above and Beyond in Colonia NJ to provide guidance and graduating CNAs job opportunities. We have also contracted with additional staffing agencies to provide temporary CNAs in the event of shortages. We have also petitioned 6 visas for CNAs from United Methodist Healthcare Recruitment out of Chicago. To ensure the deficient practice does not recur, the Director of Nursing and Staffing Coordinator will review daily/weekly staffing levels daily to ensure compliance with the required ratios. A quarterly report will be made at the QA committee.
Smoke Barrier Integrity Compromised
Penalty
Summary
The facility failed to maintain the integrity of smoke barrier partitions in accordance with NFPA 101:2012 Edition, Sections 19.3.6.2.3, 8.5.6, 8.5.6.2, and 8.5.6.3. During observations conducted on December 5 and December 9, 2024, in the presence of Facility Management, it was found that three out of twelve smoke barriers had penetrations that compromised their fire resistance rating. Specifically, on the third floor above the ceiling tiles by the 1-1/2 hour fire-rated double corridor doors leading into the "A-Wing," two approximately 1-inch diameter holes with wires running through the smoke barrier wall were observed. Further observations revealed additional deficiencies on the second and first floors. On the second floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors leading into the "A-Wing," a 1-1/2 inch diameter hole with nine black wires running through the smoke barrier wall was noted. On the first floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors next to the Social Services office, two 1-1/2 inch diameter holes with one BX electrical cable and a 1/2-inch diameter white plastic tubing running through one penetration were found. These deficiencies had the potential to affect all 88 residents in the facility.
Plan Of Correction
Immediate Corrective Action: **Inspection of Fire-Rated Barriers and Doors:** A comprehensive inspection of all fire-rated barriers, including walls and ceilings around fire doors, will be conducted immediately to identify any penetrations that lack proper fire blocking. Areas of focus will include penetrations above fire doors, walls with ducts, pipes, cables, or conduits passing through, and other vulnerable areas in the building. **Sealing Penetrations:** All identified penetrations that lack appropriate fire-blocking will be immediately sealed using approved fire-resistant materials. These materials will include fire-rated caulk, intumescent sealants, or other materials that meet NFPA 101 and NFPA 80 requirements for fire blocking. The materials used will be selected based on NFPA guidelines to ensure that they provide an effective barrier against fire and smoke. **Verification of Fire Blocking:** Once penetrations have been sealed, the Maintenance Director will perform a follow-up inspection to verify that all fire-blocking measures are properly implemented and meet required safety standards. Any issues found during this inspection will be corrected immediately. **Systematic Changes to Prevent Recurrence:** **Contractor Instructions and Oversight:** Moving forward, any contractors who perform work involving penetrations in fire-rated walls, ceilings, or around fire doors will be instructed as follows: Contractors will be required to ensure that all penetrations made during their work are properly fire-blocked in accordance with NFPA 101 and NFPA 80 standards. Contractor contracts will include a clause requiring compliance with all fire safety and building code regulations, including sealing all penetrations with fire-resistant materials. A checklist for contractors will be developed to ensure they have followed fire-blocking protocols before finalizing any work that involves penetrations in fire-rated barriers. **Maintenance Staff Oversight:** Maintenance staff will be tasked with monitoring and inspecting any penetrations made by contractors during construction, repair, or maintenance projects. Maintenance staff will perform follow-up inspections to ensure that any penetrations made by contractors are sealed correctly and fire-blocked immediately. If any deficiencies are found, the Maintenance Director will ensure that the issue is addressed before the area is considered fully operational or before the contractor leaves the job site. **Ongoing Inspections of Fire-Barriers:** The facility's maintenance team will develop a schedule for quarterly inspections of all fire-rated barriers, including doors, walls, and ceilings, to ensure that no unsealed penetrations have been made. Any new penetrations, whether by contractors or facility staff, will be immediately sealed with appropriate fire-blocking materials, and will be included in the inspection schedule for verification. **Fire Safety Training for Staff and Contractors:** Maintenance staff will receive additional training to ensure they are fully knowledgeable about the proper methods for sealing penetrations in fire-rated barriers and identifying potential fire-blocking deficiencies. Contractors will receive orientation or written instructions regarding the facility's fire safety protocols related to penetrations and fire-blocking. This will be reinforced during contractor onboarding before starting any project that involves fire-rated walls. **Follow-Up Monitoring and Compliance:** **Follow-Up Inspections:** A follow-up inspection will be performed within 30 days of completing the immediate corrective actions to verify that all fire-blocking has been implemented properly and that the facility remains in compliance with K372. The inspection will be performed by the Maintenance Director to confirm that all fire-rated barriers are intact and that all penetrations are properly sealed. **Quarterly Audits:** A quarterly fire-safety audit will be conducted to ensure continued compliance. This will include: - A review of all areas where penetrations have occurred. - Verification that all penetrations are properly fire-blocked and meet fire-safety codes. - Auditing the contractor checklist and documentation to ensure that all work completed by contractors adheres to fire safety regulations. **Ongoing Documentation:** Documentation will be maintained for all inspections, corrections, and training sessions. This includes: - Logs of contractor instructions regarding fire-blocking requirements. - Maintenance inspection records and follow-up reports. - Audit results and corrective actions taken. **Responsible Parties:** - **Maintenance Director:** Oversees inspections, repairs, and ensures all penetrations are properly sealed. Also responsible for ensuring maintenance staff follow procedures. - **Contractors:** Responsible for ensuring compliance with fire safety regulations and properly sealing penetrations made during work. **Completion Date for Corrective Action:** All immediate corrective actions, including sealing penetrations and inspecting fire-rated barriers, will be completed by 12/27/24. Ongoing monitoring and quarterly audits will begin immediately and continue per the established schedule. The results will be discussed in the facility's quarterly safety committee meetings.
Elevator Emergency Communication Deficiency
Penalty
Summary
The facility failed to maintain emergency communications in proper working condition for two of the four elevators tested, as observed during a survey conducted on December 5, 2024, and December 9, 2024. During the inspection, it was found that the emergency communication telephones in elevators #1 and #2 were not functioning correctly. In elevator #1, when the emergency communication button was pressed, the operator answered, but no words were exchanged, and the call disconnected automatically within approximately 20 seconds. A second test confirmed that the phone did not function properly, as it lacked a pre-recorded message. Similarly, in elevator #2, the emergency communication phone also malfunctioned. When tested, the operator answered and requested the caller to hold, but the call disconnected automatically within approximately 20 seconds. These deficiencies were confirmed by the facility's representative during the observations and were reported during the Life Safety Code survey exit. The malfunctioning emergency communication systems in these elevators had the potential to affect the safety of 88 residents in the facility.
Plan Of Correction
The facility must ensure that all elevator systems, including emergency communication devices (e.g., emergency phones in elevators), are properly maintained and functioning to ensure the safety and well-being of residents and staff. **Immediate Corrective Action:** **Inspection of All Elevators:** An immediate inspection of all elevator emergency communication systems (phones) was conducted to assess functionality. This inspection was performed by the facility's maintenance team and qualified elevator service provider to ensure that all emergency phones are working. The inspection focused on: - Ensuring each emergency phone connects to a 24-hour monitoring service or can directly communicate with emergency personnel. - Verifying that phones are in working condition with clear audio and uninterrupted functionality. **Immediate Repair or Replacement:** Any non-functional or damaged emergency phones was repaired or replaced immediately to ensure they met operational requirements. All phones that are out of service will be marked as "out of order" until repaired and will not be used until fully functional. **Test All Emergency Phones:** Once repairs or replacements were made, each elevator emergency phone was tested for connectivity to emergency services, ensuring they work properly in the event of an emergency. **Systematic Changes to Prevent Recurrence:** **Scheduled Inspections and Preventive Maintenance:** A monthly inspection will be established for all elevator emergency phones. The inspection will include: - Functionality testing to ensure clear, immediate communication with emergency personnel. - Visual inspection to check for physical damage or wear. These inspections will be documented, and the results will be reviewed by the Maintenance Director. **Documentation and Record-Keeping:** A logbook will be created and maintained to record each inspection and test result, including: - Date and time of inspection. - Description of any identified issues. - Actions taken (repair, replacement, etc.). - Confirmation that repairs have been completed and phones are operational. **Training of Maintenance Staff:** Maintenance personnel will receive training on the proper testing and repair of elevator emergency phones, including how to ensure they are properly connected to emergency services. **Follow-Up Monitoring and Compliance:** **Ongoing Monitoring:** To ensure long-term compliance, the monthly inspection schedule will be adhered to and documented. **Responsible Parties:** Maintenance Director: Responsible for overseeing the inspection, repair, and maintenance of all elevator emergency communication systems. Oversees all safety systems, including elevator emergency phones, ensuring compliance with fire safety codes. **Completion Date for Corrective Action:** All immediate corrective actions, including repairs and testing of emergency phones, was completed. Monthly inspections and preventive maintenance will commence immediately after the corrective actions have been implemented and will continue regularly. The results of the inspections will be discussed at the quarterly safety committee meetings.
Failure to Maintain Fire Safety in Hazardous Area
Penalty
Summary
The facility failed to ensure that one of eight fire-rated doors to hazardous areas was properly separated by smoke-resisting partitions, as required by NFPA 101, 2012 Edition. During an observation on December 5, 2024, at approximately 9:20 AM, it was noted that the basement level Activities room door did not close to the frame when tested. The automatic door closure mechanism had been removed, preventing the door from self-closing into its frame. This deficiency was confirmed by the surveyor and facility representatives during the Life Safety Code survey exit on December 9, 2024. Inside the Activities room, the surveyor observed several combustible items, including cardboard boxes and activity crafts, which posed a potential fire hazard. The room was measured to be 91.875 square feet, exceeding the 50 square feet threshold for requiring proper fire separation. The presence of these combustible materials, combined with the lack of a functioning self-closing door, constituted a failure to comply with the necessary fire safety standards, as outlined in the relevant sections of NFPA 101.
Plan Of Correction
12/31/24 Immediate Corrective Action: Inspection of all self-closing doors: A comprehensive inspection of all self-closing doors in hazardous areas (boiler rooms, electrical rooms, storage rooms, etc.) was conducted immediately by our maintenance team. Repairs or replacements: Any self-closing doors that are not functioning properly will be repaired or replaced immediately. This includes ensuring that the doors close automatically without obstruction and maintain the required fire-resistance rating. Basement activity storage door new closure was placed. See photo for reference. Identification of Non-Compliant Doors: We will identify and tag any doors that are not compliant and make necessary repairs, ensuring all doors in hazardous areas meet the required standards for self-closing and fire resistance. Systematic Changes to Prevent Recurrence: Routine Inspections and Testing: An annual inspection and testing program will be implemented for all self-closing fire-rated doors in hazardous areas. The program will include: - Verifying the proper operation of the door-closing mechanism. - Ensuring that doors are not obstructed and can close fully. - Checking that fire-rated doors are not damaged. The results of each inspection will be documented and kept on file for review. Long-Term Sustainability: Documentation and Tracking: A detailed log of all self-closing doors will be created, listing the location of each door, its inspection dates, and any repair or maintenance actions taken. Monitoring and Follow-Up: Ongoing Compliance: The facility will schedule annual internal inspections of self-closing doors in hazardous areas to ensure continued compliance. Reports will be reviewed by the facility's fire safety officer and any identified issues will be addressed promptly. The results of the findings will be addressed at the first quarter safety committee meeting and the first quarter QA meeting. Responsible Party: Maintenance Director: Oversees the inspection, repair, and ongoing monitoring of self-closing doors.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to follow fall prevention interventions as outlined in the individual comprehensive care plan (ICCP) for a resident identified as being at high risk for falls. The resident, who was admitted with diagnoses including Parkinson's disease and dementia, was observed in a reclining chair without the thick cushioned fall mat that was supposed to be placed next to their bed as per the care plan. The resident's ICCP included specific interventions such as keeping the bed in the lowest position and placing a thick floor mat and landing strips next to the bed. However, during an incident, these interventions were not in place, leading to the resident sustaining a hematoma and laceration after a fall. The investigation revealed that the bed was not in the lowest position at the time of the fall, and the floor mats were not in place, contrary to the care plan. The CNA responsible for the resident at the time was an agency staff member unfamiliar with the resident's specific needs. The Director of Nursing acknowledged that the care plan was not followed, and the Registered Nurse/Unit Manager emphasized the importance of adhering to the care plan to ensure the best outcomes for residents. The facility's policy required that interventions be implemented for residents with a high fall risk score, but this was not adhered to in this case.
Plan Of Correction
The root cause for this deficient practice was the nurse failed to properly oversee the agency aide assigned to resident #44 to ensure the appropriate interventions were in place when the resident was in bed. The nurse was re-educated on her responsibility to oversee the care provided by a CNA and to ensure the residents under her care have the appropriate safety interventions in place. All residents who are severely cognitively impaired, have a fall risk score above 10, and who have fall interventions of a low bed and floor mats, have the potential to be affected by this deficient practice. Residents Fall Risk Scores, BIMS scores, and Care Plans will be reviewed to identify residents at risk to ensure the information provided on the Resident Care Needs form is accurate. The unit managers/nursing supervisors will be educated on checking the daily staffing sheet to identify any agency staff assigned in the facility and will ensure they have received the Resident Care Needs form, which was created to easily and quickly be able to identify the care needs of residents. Licensed nursing staff will be re-educated on their responsibility to provide supervision and oversight to any CNA providing care to a resident under their care and to ensure all safety interventions are in place. A weekly Agency Staff Supervision form will be in the staffing office with the daily staffing sheets. The unit managers/nursing supervisors will complete this form daily. The form will be reviewed by the DON weekly x 12 weeks, then monthly x3 months to ensure agency staff have received the necessary information to provide safe resident care. The results of the reviews will be presented at the quarterly quality assurance meetings for the March and June meetings.
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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