River Front Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pennsauken, New Jersey.
- Location
- 5101 North Park Drive, Pennsauken, New Jersey 08109
- CMS Provider Number
- 315225
- Inspections on file
- 24
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at River Front Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Facility staff restricted cognitively intact residents' access to outdoor areas and limited smoking opportunities, allowing only three supervised smoke breaks per day with a maximum of two cigarettes per session. Both smokers and non-smokers were unable to access the patio at their leisure, and staff cited safety concerns as the reason for these restrictions. Residents expressed dissatisfaction with the lack of individualized consideration for their preferences and the inability to go outside or smoke according to their own routines.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment, with observations of dirty and damaged equipment, unclean and sticky floors, broken furniture, missing or damaged window screens, and inadequate cleaning of shower rooms and vents. Residents and staff confirmed these issues, and review of facility policies and logs showed a lack of effective cleaning and maintenance systems.
Surveyors found that kitchen vents, an ice machine, and equipment were not kept clean or in good repair, with black buildup on vents, rusted prep tables, missing food cart latches, and uncleanable surfaces. Staff were unclear about cleaning responsibilities, and cleaning schedules lacked assignments for key areas, potentially affecting nearly all residents receiving facility-prepared meals.
The facility did not maintain an effective pest control program, as evidenced by repeated observations and reports of flies, cockroaches, water bugs, and ants throughout all units. Both residents and staff confirmed ongoing pest issues, and pest control logs documented frequent sightings. Despite weekly visits from a pest control company, pests remained a persistent problem in common areas and resident rooms.
The facility did not report allegations of potential exploitation, abuse, and injuries of unknown origin to the State Agency within the required timeframe for four residents, including cases involving financial exploitation by a family member, a bruise of unknown origin, and a verbal altercation between two residents. Facility leadership confirmed awareness of the delays and acknowledged that reporting was not completed as required by policy.
The facility did not conduct timely or thorough investigations into allegations of financial exploitation and possible abuse involving two residents with severe cognitive impairment. In both cases, required steps such as interviewing involved staff and promptly initiating investigations were not followed, despite the facility's policy and awareness of the incidents.
A resident with multiple cardiac conditions was prescribed a Life Vest, but the care plan failed to address essential aspects such as device cleanliness, personal hygiene, alarm response, and physician notification, despite facility policy requiring these interventions. Staff interviews indicated unclear responsibility for care plan completion and missing documentation of these specific needs.
Surveyors found that multiple resident rooms had stained ceiling tiles, debris in heater vents, chipped paint, wall holes, rusted fixtures, and other cleanliness issues. The DM and LNHA confirmed these conditions did not provide a homelike environment, and the facility could not provide evidence of required weekly environmental rounds.
The facility failed to maintain sufficient CNA staffing levels, leading to long wait times for residents. Despite a staffing plan of 1 CNA to 8 residents during the day, the facility often had significantly fewer CNAs than required. This issue persisted over multiple weeks, with some shifts having less than half the needed staff. Interviews with the Staffing Coordinator and DON revealed awareness of the requirements, yet the facility consistently fell short of meeting them.
The facility failed to act on the consultant pharmacist's recommendations to discontinue unnecessary medications for two residents. Despite physician agreement, the medications remained active, indicating a breakdown in the medication regimen review process. Interviews with staff revealed that physicians are responsible for handling recommendations, but there was a lack of follow-through in discontinuing the medications.
Surveyors identified deficiencies in food handling and temperature monitoring at the facility. A dented can of mushrooms was improperly stored, and wet nesting of pans was observed, indicating sanitation issues. Additionally, freezer temperatures in the PAV1 and PAV3 pantries were not monitored due to the absence of thermometers, which staff were unaware were required.
The facility failed to maintain a clean and sanitary environment, with surveyors observing sticky floors, debris, and stains in rooms and hallways. A resident's IV pole was found covered with dried enteral feed formula over several days, despite housekeeping being responsible for cleaning. Interviews revealed discrepancies between the facility's cleaning policy and actual practices, with daily cleaning tasks not being adequately performed.
A facility failed to ensure the dignified transport of a non-ambulatory resident, as observed by a surveyor. A staff member was seen pulling a resident in a Geri-chair from behind, rather than pushing it forward, which did not promote the resident's dignity. The resident had severe cognitive impairment and physical impairments. The facility's policy emphasizes treating residents with dignity, but during an interview, the administration acknowledged the proper transport method should involve moving the resident forward.
A facility failed to implement a comprehensive care plan for a resident with a tracheostomy and chronic respiratory failure. Despite physician orders and documented needs for oxygen therapy and tracheostomy care, these were not included in the care plan. The RN/UM admitted responsibility for the oversight during a survey.
The facility failed to obtain physician orders for the hospital transfer of two residents, despite their medical conditions necessitating emergency care. One resident with Conversion Disorder was unresponsive, and another with spinal cord injury experienced shortness of breath. Both were transferred without documented physician orders, as confirmed by the DON.
A resident with a feeding tube did not have their piston set changed as per physician orders, which required a change every 24 hours. Despite documentation indicating compliance, the piston set had not been changed for two days. Interviews with the RN/UM and DON confirmed the importance of daily changes to prevent infection, highlighting a deficiency in infection control practices.
A resident using oxygen therapy at night did not have a required physician order, as observed by a surveyor. The facility's policy mandates a physician order for oxygen use, but the EMR lacked such an order for the resident, despite staff acknowledging the requirement. Interviews with staff confirmed the policy, yet the deficiency persisted.
A facility failed to complete the dialysis communication book for a resident with chronic kidney disease, who attended dialysis sessions three times a week. The facility's policy required a communication form to be filled out by the facility nurse and the dialysis center, but the surveyor found that on multiple occasions, either the facility or the dialysis center did not complete their respective portions. The resident's LPN and RN/UM confirmed the incomplete forms, and the DON stated that nurses were responsible for ensuring the form was completed and reviewed.
The facility failed to manage medications properly, resulting in expired and discontinued medications being administered and stored. An LPN administered expired pantoprazole to a resident, and pre-signed a narcotic count record, violating policy. Additionally, expired Fentanyl patches were found in the automated dispensing system, despite daily checks. The DON and Consultant Pharmacist confirmed these practices were against protocol.
The facility's QAPI committee failed to effectively monitor and address expired medications on medication carts. Despite identifying the issue in February 2024, the facility did not implement a systematic process for checking carts three times weekly. The QAPI plan outlined goals and responsible team members, but no data collection forms were available to demonstrate compliance. The DON admitted the plan did not work, and the facility could not provide data to support the reported 77% compliance rate.
The facility failed to properly store medical supplies and ensure laundry staff used appropriate PPE. Medical supplies were found stored under a sink, risking contamination, and a bag of IV fluid was improperly stored. Laundry staff did not wear required PPE while handling soiled laundry, and hand hygiene was not performed. The Infection Preventionist and Director of Environmental Services were unaware of relevant policies, contributing to these deficiencies.
Failure to Honor Resident Rights to Outdoor Access and Self-Determination in Smoking Practices
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence, self-determination, and communication by restricting access to outdoor areas and limiting smoking opportunities for residents, including those who were cognitively intact and assessed as safe to smoke without supervision. Facility policy required that residents be informed of smoking policies and that their preferences and abilities be assessed, but in practice, residents were only permitted to smoke three times daily for twenty minutes each, with a maximum of two cigarettes per session. These sessions were strictly supervised by activity staff, and the outdoor patio area was locked outside of these designated times, preventing residents from accessing the area at their leisure. Multiple residents, both smokers and non-smokers, expressed dissatisfaction with these restrictions. Cognitively intact residents who were assessed as not requiring supervision for smoking reported that they would like more frequent access to smoke breaks, the ability to smoke more cigarettes per session, and the opportunity to smoke after dinner or before bed. Non-smoking residents were also limited in their access to the outdoor patio, only being allowed outside twice daily during scheduled activities, with no option to go out at other times. Staff interviews confirmed that the patio was kept locked and that residents could only go outside when accompanied by staff, citing safety concerns such as the risk of falls. Review of facility records and interviews revealed that these restrictions were not individualized based on resident assessments or preferences, but rather applied uniformly to all residents regardless of their cognitive status or ability to safely access the outdoor area. The activity calendar did not include any outdoor activities, further limiting residents' opportunities for outdoor access. The facility's actions were inconsistent with its own policies and regulatory requirements to promote resident rights, dignity, and quality of life.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment across all three floors. Observations included broken room number signs, unidentified spills and unclean walls, sticky and grimy floors, holes in walls, damaged furniture, and missing or damaged window screens. Equipment such as wheelchairs, electric wheelchairs, and Geri chairs were found to be dirty, with worn or missing padding and exposed hardware. Air conditioning units were noted to be rusty, broken, or emitting little cool air, and ceiling vents and door frames were dirty, rusty, or missing covers. Shower rooms lacked proper cleaning, with dirty tables and heavy grime buildup, and some areas had no vent covers. Trash and debris were observed throughout the facility, and there were strong urine odors in certain hallways. Interviews with residents and staff confirmed these environmental concerns. Residents reported that equipment, bathrooms, and shower rooms were dirty, walls needed cleaning, and there were issues with pests such as flies and ants. Some residents noted that floors were often sticky and that window screens were broken. Staff, including the Environmental Director and Maintenance Director, acknowledged the lack of established cleaning systems and confirmed the presence of the documented issues during facility tours. The Environmental Director stated that prior to their arrival, there was no system in place for cleaning rooms, floors, or halls, and the Maintenance Director, new to the facility, recognized the need for improvements. Review of facility policies and logs revealed that while there were policies for maintenance rounds and cleaning, implementation was lacking. Cleaning schedules and logs were either undated, lacked specificity, or indicated infrequent cleaning (e.g., wheelchairs cleaned every three months). Maintenance logs did not address the specific issues observed. The facility's failure to adhere to its own policies and to maintain a sanitary, comfortable, and homelike environment resulted in the cited deficiencies.
Deficient Kitchen Cleanliness and Equipment Maintenance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to cleanliness and equipment maintenance. During an inspection, it was observed that two out of three insulated food carts failed to latch properly, and a third cart was missing a latch on one door. Several ceiling vents, including those near the prep table and above the oven/stove, had a heavy buildup of a black substance. The vent on the outside of the ice machine also had a black substance that transferred onto the surveyor's finger when touched. The tray line table was missing rollers and had a piece of cardboard taped to its side with tattered duct tape, creating an uncleanable surface. Additionally, the prep table behind the plate warmer had significant rust on its legs, shelf, and edges, and a portable stand fan near the oven was found without a front cover, with exposed blades covered in dust and grime. Interviews with the Dietary Director and the Regional Food Service Director revealed uncertainty regarding responsibility for cleaning the vents and maintaining equipment. Review of the cleaning schedule showed no assigned tasks for cleaning the vents, ice machine, or floor fan. There was no evidence that the need for repairs to the insulated food carts had been identified prior to the survey. Furthermore, a policy and procedure for kitchen cleaning was not provided before the survey exit. These failures had the potential to affect 149 of 153 residents who received meals prepared in the facility kitchen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of flies, cockroaches, water bugs, and ants throughout the building. Pest control logs indicated repeated reports of flies and cockroaches/water bugs on all three units over a three-month period. During multiple facility tours, surveyors observed numerous flies on all floors and a large dead roach in a resident room entry. Residents unanimously reported ongoing issues with flies and water bugs in both common areas and individual rooms, with some also noting the presence of ants around the nurse's desk. Staff interviews confirmed recent sightings of these pests and acknowledged that pest sightings were documented in pest control books on each unit. The Director of Housekeeping and Laundry, along with the President of Environmental Services, confirmed the ongoing pest issues and stated that the pest control company visited weekly, basing their services on reported sightings. Despite these measures, pests continued to be observed by both staff and residents, and the problem was described as persistent and bothersome. The Administrator stated her expectation that the facility should be free of pests, but the ongoing presence of flies, water bugs, and ants indicated that the pest control program was not effective in preventing or addressing infestations.
Failure to Timely Report Allegations of Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure timely reporting of allegations of potential exploitation and/or abuse to the State Agency for four residents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy in several instances, as evidenced by record reviews and staff interviews. For one resident with dementia and a history of falls, concerns regarding potential financial exploitation by family members were known to the facility since June, but were not reported to the State Agency or local police until months later, during the surveyors' investigation. The resident was severely cognitively impaired and unable to manage her own finances, with her responsible party refusing to provide information about the resident's assets. Multiple attempts were made by the facility to obtain this information, and involuntary discharge notices were issued due to non-payment, but the potential exploitation was not reported until prompted by surveyors. In another case, a resident with severe cognitive impairment was found with a bruise of unknown origin. The injury was identified and documented, but the incident was not reported to the State Agency until almost 24 hours later, exceeding the required two-hour reporting window. Additionally, a verbal altercation between two severely cognitively impaired residents was not reported to the State Agency until nearly 12 hours after the incident. In all cases, facility leadership confirmed that the incidents were reported late and acknowledged that they should have been reported within the required timeframe.
Failure to Investigate Allegations of Exploitation and Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of potential exploitation and abuse involving two residents. For the first resident, who had dementia and a history of falls and was severely cognitively impaired, concerns about possible financial exploitation by a family member were known to the Administrator as early as June. Despite repeated attempts by staff to contact the responsible party and ongoing concerns about the resident's assets, no investigation was initiated until surveyors requested information in September. The facility's own policy required prompt and comprehensive investigation of such allegations, but this was not followed. In the second case, another resident with dementia, cerebral ischemia, and COPD, and who was also severely cognitively impaired, was found with bruising and discoloration to the right hand after an incident involving a CNA. The progress notes indicated that the resident had refused care and allegedly swung a backscratcher at the CNA, after which the CNA removed the object from the resident's hand. The facility's investigation into the injury did not include interviews with staff present during the incident, as required by policy, to determine whether abuse had occurred. Interviews with facility leadership confirmed that the required investigations were not conducted in either case. The President of Clinical and the Regional Nurse Consultant acknowledged that both the potential financial exploitation and the injury of unknown origin should have been thoroughly investigated according to facility policy, but this did not occur until prompted by surveyors.
Failure to Develop Comprehensive Care Plan for Resident Using Life Vest
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed a Life Vest, a wearable defibrillator, as part of their treatment for multiple cardiac conditions including hemiplegia, hypertensive heart disease with heart failure, chronic atrial fibrillation, and chronic diastolic congestive heart failure. Although physician orders specified daily battery changes and monitoring of the device for function and placement, the care plan only addressed general cardiovascular status and dietary recommendations, omitting critical aspects related to the Life Vest. Specifically, the care plan did not include interventions for maintaining the cleanliness of the Life Vest, ensuring personal hygiene while using the device, responding to device alarms, or instructions on when to notify the physician. Review of facility policy indicated these elements were required, including daily inspection for cleanliness and fit, assistance with hygiene, and protocols for responding to both non-emergency and emergency alarms. Interviews with staff revealed a lack of clarity regarding responsibility for completing the care plan and an absence of documentation addressing these specific needs.
Failure to Maintain Clean and Homelike Environment in Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and homelike environment for residents on two of three units, specifically Pavilion 2 and Pavilion 3. During tours of these units, multiple resident rooms were found with brown stains on ceiling tiles, a build-up of dust and unknown debris in heater vents, chipped paint on walls and heaters, holes in the walls, rust on electrical outlet covers, rust spots on bathroom floors, and tape around heaters. These environmental deficiencies were directly observed by surveyors during their inspection. Interviews with the Director of Maintenance (DM) revealed that maintenance staff were responsible for addressing these issues, and that environmental rounds were supposed to be conducted weekly by the DM, Housekeeping Director (HD), nursing staff, and the Licensed Nursing Home Administrator (LNHA). However, the DM stated he was not aware of the specific deficiencies prior to the survey, and the facility was unable to provide evidence that weekly environmental rounds had been completed, aside from work order sheets. The DM and LNHA acknowledged the findings and confirmed that these conditions did not create a homelike environment for residents.
Deficient CNA Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by multiple deficiencies in Certified Nurse Aide (CNA) staffing levels. The facility's assessment outlined a staffing approach of 1 CNA to 8 residents during the day, 1 to 10 in the evening, and 1 to 14 at night. However, during a resident council meeting, residents reported long wait times due to understaffing, particularly at night. The New Jersey Department of Health's Nurse Staffing Report confirmed these deficiencies, showing that the facility consistently failed to meet the required CNA staffing levels across various shifts and dates. The report detailed specific instances where the facility provided significantly fewer CNAs than required. For example, on several occasions, the facility had only 12 to 16 CNAs for 160 to 170 residents during the day shift, where at least 20 to 21 CNAs were needed. This pattern of understaffing was observed over multiple weeks, with some shifts having less than half the required number of CNAs. Additionally, the facility was also deficient in total staff for residents on some overnight and evening shifts, further exacerbating the issue of inadequate care. Interviews with the facility's Staffing Coordinator and Director of Nursing revealed an awareness of the staffing requirements, yet the facility struggled to meet these standards consistently. The Staffing Coordinator believed they were meeting the minimum requirements most of the time, despite evidence to the contrary. The Director of Nursing provided details on the staffing pattern for nurses across different pavilions, which also indicated a shortfall in meeting the necessary staffing levels to ensure adequate care for all residents.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to consistently and timely follow through on recommendations made by the consultant pharmacist during the monthly medication regimen review for two residents. The consultant pharmacist recommended discontinuing certain medications that had not been used for over 60 days, but these recommendations were not acted upon by the attending physicians, despite their agreement to do so. This deficiency was identified for two residents who were reviewed for unnecessary medications. For one resident, the consultant pharmacist recommended discontinuing the PRN Dicyclomine medication, as it had not been used for over 60 days. The attending physician agreed with this recommendation and signed off on it, but the medication order remained active, and the resident's medication administration record showed no discontinuation of the drug. Similarly, for another resident, the consultant pharmacist recommended re-evaluating the need for Lasix, a diuretic, as the resident had been on it since the previous year. The attending physician agreed to this recommendation, but there was no documentation in the resident's progress notes indicating that the medication was discontinued. Interviews with facility staff, including a Licensed Practical Nurse/Unit Manager and the Director of Nursing, revealed a breakdown in the process of implementing the consultant pharmacist's recommendations. The staff indicated that while physicians are responsible for handling and agreeing to the recommendations, there was a lack of follow-through in discontinuing the medications as agreed. The Director of Nursing acknowledged the breakdown in the medication regimen review process and the need for improvement.
Deficiencies in Food Handling and Temperature Monitoring
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by surveyors. In the dry storage room, a can of mushrooms with a significant dent on the seam was found, which was then removed to the designated dented can area by the Food Service Director (FSD). Additionally, a stack of five deep/full pans was found wet nested, with a clear, watery substance on the bottom surface of the pans, indicating improper drying and storage. The FSD removed these pans for rewashing and sanitizing. Furthermore, the facility did not monitor freezer temperatures in the pantries, as required. In the PAV1 pantry, the temperature log only recorded refrigerator temperatures, and there was no internal thermometer in the freezer. The Unit Manager/Licensed Practical Nurse (UM/LPN) was unaware of the need for a thermometer and monitoring of freezer temperatures. Similarly, in the PAV3 pantry, no freezer temperatures were recorded, and no internal thermometer was present. The LPN/UM acknowledged the oversight and the need for a thermometer.
Deficiencies in Facility Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by observations on two of its units, Pavilion 2 and Pavilion 3. During the initial and subsequent tours, surveyors noted several deficiencies, including sticky floors, debris, hair knots, dark marks, and stains in various rooms and hallways. A family member reported that the rooms were not being cleaned properly, with floors only being mopped without prior sweeping, and toilets not being cleaned. Interviews with the Director of Environmental Services and Laundry (DEVS) and housekeeping staff revealed discrepancies between the facility's cleaning policy and actual practices, with daily cleaning tasks not being adequately performed. Additionally, the facility failed to properly clean and maintain IV poles, as observed in the case of a resident who was receiving tube feeding. The IV pole base was consistently found to be covered with a dried tan/brown substance resembling enteral feed formula over multiple days. Despite the facility's policy that housekeeping staff are responsible for cleaning IV poles weekly or as needed, the IV pole in the resident's room remained uncleaned for several days. Interviews with housekeeping staff and the DEVS confirmed that the responsibility for cleaning IV poles lay with housekeeping, yet the task was not completed. The facility's failure to adhere to its cleaning policies and maintain a sanitary environment was confirmed through interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). They acknowledged that housekeeping and environmental services were responsible for cleaning IV poles and addressing spills. The report highlights significant lapses in the facility's cleaning protocols, contributing to an unsanitary environment for residents.
Failure to Ensure Dignified Transport of Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure the dignified transport of a non-ambulatory resident, which was identified during a survey. A surveyor observed a staff member transporting a resident in a Geri-chair by pulling it from behind, rather than pushing it forward, as they moved from the dining/activity room past the nursing station. This method of transport did not promote the dignity and respect of the resident, as it is generally expected that residents should be transported facing forward to maintain their dignity and allow them to see where they are going. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 3/15, and had impairments in both the lower and upper extremities. The facility's policy on resident rights emphasizes the importance of treating all residents with dignity and respect, regardless of their condition. However, during an interview with the facility administration, including the DON and LNHA, it was acknowledged that the proper method of transport should involve moving the resident forward, aligning with the direction of movement for both the staff and the resident.
Failure to Implement Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with significant respiratory needs. The resident, who had a tracheostomy and required continuous oxygen therapy, was observed without a care plan addressing their respiratory care. Despite having physician orders for tracheostomy care and the need for oxygen therapy, suctioning, and tracheostomy care documented in the Minimum Data Set, these were not reflected in the resident's care plan. During an interview, the Registered Nurse/Unit Manager acknowledged the absence of a care plan for the resident's respiratory care, stating it was her responsibility to ensure one was in place. This oversight was identified during a survey, highlighting a deficiency in meeting the resident's medical and nursing needs through a comprehensive care plan.
Failure to Obtain Physician Orders for Hospital Transfers
Penalty
Summary
The facility failed to ensure that a physician order was obtained for the transfer of two residents to the hospital, which is a requirement according to the facility's policy. Resident #126, who was admitted with a diagnosis of Conversion Disorder with Seizures or Convulsions, was found unresponsive with eyes rolled up, prompting a call to 911 and subsequent transfer to the hospital. However, a review of the Electronic Medical Record (EMR) revealed that there was no physician order documented for this transfer. The Director of Nursing (DON) confirmed during an interview that an order should have been in place. Similarly, Resident #137, who had diagnoses including injury of the cervical spinal cord, muscle weakness, and difficulty walking, was observed with shortness of breath and pale skin. The Nurse Practitioner (NP) was contacted and ordered the resident to be sent to the hospital via 911. Despite this, the Medication Review Report for August 2024 did not show a physician's order for the transfer. The DON acknowledged the absence of the required order in the resident's medical record, confirming the deficiency.
Failure to Change Piston Set for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of a piston set for a resident with a feeding tube. The resident, who was admitted with conditions including Multiple Sclerosis, a Gastrostomy (G Tube), and Dysphagia, required the piston set to be changed every 24 hours as per the physician's order. However, during an observation on August 5, 2024, it was noted that the piston set had not been changed since August 3, 2024, despite documentation indicating otherwise. This discrepancy was confirmed through interviews with the Registered Nurse/Unit Manager and the Director of Nursing, who both acknowledged the importance of changing the piston set daily to prevent infection. The facility's policy on enteral tubes, revised in June 2024, mandates that the syringe and bag be changed every 24 hours to maintain infection control. The failure to change the piston set as required was documented in the Treatment Administration Record, where signatures falsely indicated compliance with the order. The Registered Nurse/Unit Manager and the Director of Nursing both emphasized the risk of introducing bacteria into the resident's gastrointestinal system if the piston set is not changed as prescribed. This oversight in following the physician's order and facility policy resulted in a deficiency related to infection control practices.
Lack of Physician Order for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident using oxygen therapy at night had a physician order, which is a requirement according to the facility's policy. During an initial tour, a surveyor observed oxygen tubing next to the resident's bed, which was not dated, and there was no oxygen sign outside the room. The resident confirmed using oxygen at night. A review of the Electronic Medical Record (EMR) showed that the resident was admitted with diagnoses including hypertensive heart disease and had been using oxygen since admission. However, the Order Summary Report did not include a physician order for oxygen use at bedtime. Interviews with facility staff, including an LPN, RN/UM, and the Director of Nursing, confirmed that a physician order is required for oxygen use, except in emergencies. Despite this, the RN/UM acknowledged the absence of a physician order for the resident's oxygen use, even though the resident reported using it nightly and nurses documented pulse oximetry readings while on oxygen. The facility's policy and staff statements highlighted the need for a physician order, but this was not adhered to in the case of the resident in question.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication book for a resident who required dialysis services. The resident, who had chronic kidney disease and was dependent on renal dialysis, attended dialysis sessions three times a week. The facility's policy required a communication form to be filled out by the facility nurse with the resident's vital signs and by the dialysis center with treatment details. However, the surveyor found that on multiple occasions, either the facility or the dialysis center did not complete their respective portions of the communication form. The resident's Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) confirmed the incomplete forms, acknowledging that the communication book was not consistently filled out as required. The Director of Nursing (DON) stated that the nurses were responsible for ensuring the form was completed and reviewed upon the resident's return from dialysis. Despite this, the surveyor identified that the communication process between the facility and the dialysis center was not adequately maintained, leading to incomplete documentation for the resident's dialysis care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper management of medications, leading to several deficiencies. During a medication cart inspection, it was discovered that a discontinued and expired medication, pantoprazole, was still present in the active inventory and had been administered to a resident. The medication was ordered for the treatment of GERD and had been discontinued months prior, yet remained in the cart until the surveyor's inquiry. The Licensed Practical Nurse (LPN) involved admitted to not checking the expiration date, and the Consultant Pharmacist and Director of Nursing (DON) confirmed that staff should verify expiration dates before administration. Additionally, the facility did not maintain accurate accountability for controlled substances. The surveyor found that an LPN had pre-signed the Narcotic Count Record for a shift he had not yet completed, which is against the facility's policy. The purpose of the narcotic count is to ensure that both incoming and outgoing nurses agree on the count's accuracy, and pre-signing undermines this process. The DON and Consultant Pharmacist both emphasized that pre-signing is unacceptable and that the count should be verified at the time of the shift change. Furthermore, expired controlled medications were not removed from the automated medication dispensing system. During a cycle count, it was found that expired Fentanyl patches were still present in the system, despite daily cycle counts being performed by the Registered Nurse Supervisor and Infection Preventionist. The DON acknowledged that the expired medications should have been identified and removed during these counts, and the Consultant Pharmacist reiterated that expired medications should not be present in the system.
Failure in QAPI Process for Monitoring Expired Medications
Penalty
Summary
The facility's Quality Assessment and Performance Improvement (QAPI) committee failed to effectively utilize the Facility Performance Improvement Plan (PIP) to monitor and address the issue of expired medications on medication carts. Despite identifying expired medications as a major concern in February 2024 through pharmacy reports, the facility did not implement a systematic process to measure and utilize data for checking medication carts three times weekly. The QAPI plan outlined goals such as removing expired medications and educating LPNs on checking carts, with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and LPNs identified as responsible team members. However, the plan's implementation was ongoing, and no data collection forms were available to demonstrate compliance or progress. During the survey, it was revealed that the facility did not have any data collected for the expired medication QAPI plan for February or April 2024. The DON admitted to the surveyors that the QAPI plan did not work, and they were in the process of developing a new one. The facility also could not provide data to support the reported 77% compliance rate mentioned in the April 2024 QAPI plan, with the DON suggesting that the data might have come from the monthly consultant pharmacist visit. This lack of data collection and monitoring indicates a failure in the facility's QAPI process to address and rectify the issue of expired medications effectively.
Infection Control Deficiencies in Medical Supply Storage and Laundry Handling
Penalty
Summary
The facility was found to have deficiencies in the storage and maintenance of medical supplies and the use of personal protective equipment (PPE) by laundry staff. During an inspection of the Pavilion Three Medication Storage Room, it was observed that several medical supplies, including enema kits, heel booties, and wound treatment supplies, were improperly stored beneath a handwashing sink. The Licensed Practical Nurse Unit Manager (LPN/UM) was unaware of the supplies being stored there and acknowledged the risk of contamination. Similarly, in the Pavilion Two Medication Room, a bag of intravenous fluid solution was found with its packaging previously opened, which could compromise its effectiveness. The Infection Preventionist (IP) and Central Supply Director (CSD) confirmed that storing items under the sink was against facility rules due to contamination risks, and the Director of Nursing (DON) emphasized the unsanitary nature of such storage practices. In the laundry area, a staff member was observed not wearing the required PPE while handling soiled laundry. The staff member wore a surgical mask improperly and gloves but did not wear an apron or gown as required by the facility's Linen Handling Policy. The staff member admitted to not wearing the apron initially and failed to perform hand hygiene after removing gloves. The Infection Preventionist was not familiar with the laundry policy regarding soiled linens, and the Director of Environmental Services and Laundry (DEVS) stated that staff should wear gowns, gloves, and masks, although he had never seen anyone wear an apron. The facility's failure to adhere to proper infection prevention and control practices was evident in both the medication storage and laundry handling processes. The lack of awareness and enforcement of policies by staff and management contributed to these deficiencies, posing potential risks of contamination and infection.
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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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