Riverside Health And Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Trenton, New Jersey.
- Location
- 325 Jersey Street, Trenton, New Jersey 08611
- CMS Provider Number
- 315235
- Inspections on file
- 19
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Riverside Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
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 Social Worker Assistant did not receive required annual in-service training on abuse and neglect, as evidenced by a lack of documentation in her employee file and confirmation from both the Social Worker and Assistant Director of Nursing. The facility's policy mandates annual education for all staff, but records showed only initial orientation training for the SWA, resulting in noncompliance with regulatory requirements.
A resident with multiple medical conditions and intact cognition alleged verbal abuse by the ADON. Although staff reported the incident to the Social Worker, no immediate investigation was initiated, and the event was not reported to facility leadership, contrary to the facility's abuse policy.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by a surveyor. Egg salad sandwiches lacked a made-on date, and expired marshmallows and water were found in storage. Staff, including a Speech Therapist and an Administrator, were seen in the kitchen without required hair restraints, indicating a need for reeducation.
The facility's call bell system was found to be deficient, with issues including inaudible notifications and non-functioning devices, affecting all residents. Observations revealed that call bell activations did not register at the nurse's station, and visual notifications were obstructed. In one instance, a call bell did not function due to broken pins, as confirmed by the DOM, with residents present during testing.
Surveyors identified multiple deficiencies in the facility, including unclean and unsafe environments, non-functional equipment, and inadequate resident care. Observations included dirty washcloths, worn mattresses, non-working lights and televisions, missing furniture, and improper meal service. Staff interviews revealed a lack of communication and reporting, contributing to unresolved issues.
Facility staff failed to follow infection control practices during wound care and meal service. A resident on Enhanced Barrier Precautions did not receive proper gown use by the Unit Manager during wound care. Additionally, CNAs on the 4th floor did not perform or assist with hand hygiene during meal service. These actions were contrary to the facility's policies on Enhanced Barrier Precautions and hand hygiene.
A resident's privacy and personal property rights were violated when a housekeeper accessed their bedside drawer without permission. The resident, who is cognitively intact, expressed distress over the intrusion. Facility staff, including the DON and LNHA, confirmed that such actions were against policy, which emphasizes respect and dignity for residents.
A resident's call bell was repeatedly found on the floor, out of reach, despite their care plan and facility policy requiring it to be accessible. Staff interviews confirmed the expectation for call bells to be within reach, yet the deficiency persisted, as acknowledged by the facility's administration.
A resident with a history of stroke and dementia experienced a witnessed fall in the facility, but the investigation was incomplete. The assigned nurse failed to provide a statement, and there was no documentation in the progress notes. The facility's policy lacked specific guidance on conducting thorough investigations, leading to the deficiency.
The facility failed to accurately assess two residents in the MDS. One resident with a Wander guard was incorrectly coded as having no wander alarm, and another resident using continuous oxygen was incorrectly coded as not using oxygen. These errors were confirmed by the MDS Coordinator and other staff.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. One resident's care plan lacked specific details on mood impairment and medication use, while another resident's care plan did not address significant weight loss. The Registered Dietitian and Director of Nursing acknowledged the omissions, which were contrary to the facility's policy on comprehensive care plans.
A resident with severe cognitive impairment experienced a fall in the facility, which was witnessed by a CNA. Despite the incident, there was no documentation in the resident's medical record, violating the facility's protocol for documenting falls. The lack of documentation was confirmed by multiple staff members, including an LPN Supervisor and the DON.
Two residents with indwelling urinary catheters were not provided appropriate care, leading to potential infection risks. A resident's catheter bag was found on the floor and unsecured, with missing documentation for catheter care. Another resident's catheter bag was improperly positioned above the bladder and lacked a privacy cover. Staff interviews confirmed these practices were against facility policy.
The facility failed to properly store respiratory equipment for two residents, leaving nebulizer masks and nasal cannulas unsecured and exposed to air. One resident's equipment was found in an open drawer and another's on a nightstand and floor. Staff acknowledged that equipment should be stored in bags, as confirmed by the Infection Preventionist and Director of Nursing.
A facility failed to timely address a CP's recommendation to clarify a resident's medication order for liquid Colace, despite repeated notices. The ADON and DON acknowledged the delay, which contradicted the facility's policy for timely communication and response to CP recommendations.
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.
Failure to Provide Annual Abuse and Neglect Training to Social Services Staff
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation policy by not ensuring that all existing staff received annual education on abuse and neglect. Specifically, the Social Worker Assistant's (SWA) employee file only contained documentation of an in-service on resident neglect and abuse from her orientation in 2009, with no evidence of any additional or annual in-services on this topic. During interviews, the SWA could not recall the last time she received such training, and the Social Worker (SW) confirmed she had never provided or reviewed any in-services on abuse and neglect for the SWA. The Assistant Director of Nursing (ADON) stated that while she maintained in-service records for the nursing department, other department heads were responsible for their own staff, and she was unable to locate any recent training records for the SWA. The facility's undated Abuse, Neglect, and Exploitation policy requires that existing staff receive annual education through planned in-services. The SW's job description also assigns responsibility for checking the competence of social services personnel. Despite these requirements, there was no documentation of annual abuse and neglect training for the SWA, indicating a failure to follow facility policy and regulatory requirements for staff education on this critical topic.
Failure to Investigate Alleged Verbal Abuse and Implement Abuse Policy
Penalty
Summary
The facility failed to immediately initiate an investigation into an allegation of verbal abuse and did not implement its Abuse, Neglect and Exploitation policy as required. A resident with diagnoses including paraplegia, acute pyelonephritis, anxiety, and depression, and who was cognitively intact, was involved in an incident where the Assistant Director of Nursing (ADON) was alleged to have been verbally abusive. Documentation showed that the resident accused the ADON of speaking inappropriately to them. Despite this, there was no immediate investigation initiated at the time of the allegation. Interviews revealed that the Social Worker (SW) was informed by multiple staff members that there had been a verbal altercation between the resident and the ADON, and that the ADON later apologized to the resident. However, the SW did not follow up with either party or report the incident to the Administrator or Director of Nursing. The facility's policy required immediate investigation of any suspected or reported abuse, but this was not followed in this case.
Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the reach-in cooler, two egg salad sandwiches were found without a made-on date, only a use-by date, which the Dietary Director (DD) acknowledged should be discarded due to the risk of causing illness. Additionally, in the dry storage area, four bags of unopened marshmallows were found with an expired manufacturer's date, and the DD confirmed they should be discarded. Furthermore, in the overstock storage area, 70 cases of water were found with an expired manufacturer's date, and the DD noted that the Licensed Nursing Home Administrator (LNHA) was aware and working on obtaining a new supply. The surveyor also observed sanitation issues related to staff not wearing hair restraints in the kitchen area. The Speech Therapist (SP) and the Administrator of Pediatric Medical Daycare (APMC) were both seen without hairnets, despite acknowledging the requirement to wear them. The District Dietary Director (DDD) confirmed that staff should wear hair restraints and mentioned that the APMC frequently enters the kitchen without a hairnet, indicating a need for reeducation. The facility's policy on labeling food requires all products to be marked with a made-on and use-by date, which was not adhered to in the observed instances.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of the resident call bell system, which had the potential to affect all residents. During observations and interviews conducted in the presence of the Director of Maintenance (DOM), it was found that the call bell system's volume was not set to a level that could be heard, and the devices used to identify call bell notifications were not functioning properly. Specifically, in two separate rooms, the call bell light turned on when tested, but there was no audible notification, and the activation did not register at the nurse's station call bell annunciator. Additionally, visual notification of the activation was obstructed by a hallway wall. In another room, the call bell did not function at all due to broken pins in the call bell box, as confirmed by the DOM. Residents were present in the rooms during these tests, highlighting the immediate impact of the deficiency.
Deficiencies in Environmental Safety and Resident Care
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by several observations made by surveyors. On the Fourth Floor, a surveyor found dirty washcloths and a hairbrush in a central bath, a worn mattress in a resident's room, and a non-functional bathroom light and television in another resident's room. Interviews with staff revealed that these issues were known but not addressed, with the CNA and RN responsible for reporting such deficiencies to the unit manager, who in turn would use a computerized system to log maintenance requests. However, the system was not accessible to CNAs, and the issues remained unresolved. On the Third Floor, a surveyor noted a missing drawer in a resident's wardrobe, which had not been reported to maintenance. The Unit Manager was unaware of the missing drawer, and the Maintenance Director stated that room rounds were conducted every three to six months, with the last one in July 2024. The Director of Nursing confirmed that there should be no broken furniture in resident rooms, and the Licensed Nursing Home Administrator acknowledged the oversight after it was brought to their attention. On the Second Floor, a surveyor observed a trash can without a liner, disposable gloves in a whirlpool tub, and a full sharps bin that had not been emptied. Additionally, hair was found tangled in the wheels of medication carts, and residual stains and wrappers were present in the glove holder. During meal service observations, staff served residents on meal trays without removing items or inquiring about preferences, contrary to the facility's policy on providing a homelike environment and treating residents with dignity and respect.
Infection Control Deficiencies in Wound Care and Meal Service
Penalty
Summary
The facility staff failed to adhere to appropriate infection control practices in two specific instances. Firstly, during the provision of wound care to a resident with a sacral pressure ulcer, the Unit Manager did not wear a gown despite the resident being on Enhanced Barrier Precautions, which required gown and glove use for high-contact activities such as wound care. The absence of a bin containing personal protective equipment outside the resident's room was noted, and the Unit Manager acknowledged the oversight. The facility's policy on Enhanced Barrier Precautions, which mandates gown and glove use for residents with wounds or indwelling medical devices, was not followed. Secondly, during meal service on the 4th floor, three CNAs distributed meal trays to residents without performing hand hygiene beforehand, nor did they assist residents with hand hygiene before, during, or after the meal. Interviews with the CNAs, the Registered Nurse Unit Manager, the Infection Preventionist, and the Licensed Nursing Home Administrator confirmed that hand hygiene should have been performed by staff and assisted for residents. The facility's policies on hand hygiene and assistance with meals, which emphasize the importance of hand hygiene to prevent infection, were not adhered to.
Violation of Resident Privacy and Personal Property Rights
Penalty
Summary
The facility failed to maintain an environment that protected and valued a resident's private space and personal property, as observed during a survey. A housekeeper was seen wiping the inside of a resident's bedside drawer without permission, which was confirmed by the Registered Nurse Unit Manager (RN/UM#1) and the Housekeeping Director (HD) as inappropriate since the room was not scheduled for terminal cleaning. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed distress and did not give permission for the drawer to be accessed. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that residents have an expectation of privacy regarding their personal property. The facility's Environmental Services Operational Manual and Resident Rights policy emphasize treating residents with kindness, respect, and dignity, which was not upheld in this instance. The incident involved a resident with diagnoses including paranoid schizophrenia, anxiety disorder, and bipolar disorder, highlighting the importance of respecting their personal space and belongings.
Failure to Maintain Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call bell within reach for a resident, leading to a deficiency. During a survey, it was observed multiple times that the resident's call bell was on the floor under the bed, and the resident was unaware of its location. The resident had a BIMS score indicating intact cognition and was at risk for falls due to impaired balance and mobility. The resident's care plan specified that the call bell should be within reach at all times, yet this was not adhered to. Interviews with facility staff, including a CNA, RN, RN Unit Manager, and the DON, confirmed that call bells should be within reach and secured to the bed. The facility's policy also required staff to ensure call lights are accessible to residents. Despite these guidelines, the call bell was repeatedly found on the floor, indicating a failure to follow established procedures and policies, as acknowledged by the Licensed Nursing Home Administrator.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to maintain proper documentation and conduct a thorough investigation following a witnessed fall involving a resident. The incident occurred when a resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, and dementia, fell after their shoe came off while walking. The fall was witnessed by a certified nursing assistant, and the resident was found sitting on the floor with the back of their head having hit the wall. Despite the fall being witnessed, the facility did not complete a comprehensive investigation as required. The investigation was incomplete because the assigned nurse did not provide a statement detailing the fall, and there was no nurse's note in the electronic medical record progress notes regarding the incident. Interviews with the LPN Supervisor and LPN Unit Manager confirmed that the necessary documentation and witness statements were not gathered, and the Director of Nursing acknowledged the lack of a thorough investigation. Additionally, the facility's Accidents and Supervision policy did not offer specific guidance on conducting a thorough investigation, contributing to the deficiency.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the status of two residents in the Minimum Data Set (MDS), an essential assessment tool for facilitating care. For Resident #98, the surveyor observed a Wander guard on the resident's left ankle, which was ordered by a physician and documented in the Medication Administration Record. However, both the Quarterly and Annual MDS assessments incorrectly indicated that there was no wander/elopement alarm. The MDS Coordinator and the Director of Nursing confirmed the coding errors during interviews. For Resident #41, the surveyor observed the resident using oxygen via nasal cannula, which was consistent with the resident's medical history of Chronic Obstructive Pulmonary Disorder (COPD) and a physician order for continuous oxygen use. Despite this, the most recent Quarterly MDS assessment incorrectly coded the resident as not using oxygen. The MDS Coordinator and the Licensed Nursing Home Administrator acknowledged the error, confirming that the resident's oxygen use should have been accurately reflected in the MDS.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the care plan did not specify the focus areas related to their risk for mood impairment, use of psychotropic medications, anti-anxiety medications, and antidepressant medications. The care plan lacked details on what the mood impairment was related to and did not specify the medications involved. Additionally, the resident could not recall if the facility had ever discussed their care plan with them, indicating a lack of communication and involvement in the care planning process. For another resident, the facility failed to include a care plan focus area or interventions for significant weight loss, despite the resident experiencing a weight loss greater than 5% in a month or 10% in six months. The Registered Dietitian acknowledged that a focus should have been added to the care plan for the significant weight change, and the Director of Nursing confirmed that the dietitian should have been responsible for updating the care plan. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain thorough documentation following a witnessed fall, which is a deficiency in meeting professional standards of clinical practice. This issue was identified for one resident who experienced a fall without injury. The fall occurred when the resident's shoe came off while walking, causing them to fall and hit the back of their head against the wall. Despite the incident being witnessed by a certified nursing assistant, there was no documentation in the resident's medical record regarding the fall. The resident involved in the incident had a medical history that included cerebral infarction, hemiplegia, hemiparesis, and dementia. The resident's cognitive function was severely impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The lack of documentation was confirmed by multiple staff members, including a Licensed Practical Nurse Supervisor, a Registered Nurse, and a Licensed Nurse Unit Manager, all of whom acknowledged that the assigned nurse was responsible for entering the assessment into the progress notes. The facility's protocol required detailed documentation of falls, including vital signs, range of motion, and any injuries or changes in condition. However, the surveyor found that there was no progress note or electronic medical documentation from the assigned nurse detailing the fall. The Director of Nursing and the Licensed Nursing Home Administrator both acknowledged the absence of necessary documentation, which was a clear deviation from the facility's established protocols for assessing and documenting falls.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. For Resident #120, the catheter drainage bag was observed resting on the floor and unsecured to the bed, contrary to the physician's order to document catheter output every shift. The Treatment Administration Record for Resident #120 showed blank sections on multiple dates, indicating a lack of documentation for catheter care. During an interview, the Licensed Practical Nurse acknowledged that the bag should not be on the floor, and the Director of Nursing confirmed that the bag should be secured to the bed frame and not in contact with the floor for infection control reasons. Resident #21 was observed with a urinary catheter drainage bag laying on top of the bed without a privacy bag and visible from the hallway. The bag was also hooked onto the right arm of the resident's wheelchair, positioned above the bladder, which is against the facility's policy. The Treatment Administration Record for Resident #21 also showed blanks for monitoring Foley catheter output. Interviews with the Unit Manager and Infection Preventionist confirmed that the catheter bags should be below the bladder level and covered with privacy bags to prevent infection. The facility's policy on catheter care emphasizes the importance of maintaining the drainage bag below the bladder level and ensuring privacy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment, specifically nebulizer masks and nasal cannulas, in accordance with professional standards of practice. For Resident #72, a nebulizer mask was observed unsecured and exposed to air in an open drawer, and nebulizer tubing was found extending into a closed drawer without a date label. The Registered Nurse/Unit Manager acknowledged that the equipment should normally be stored in a bag, and the Infection Preventionist confirmed that all equipment should be stored in a bag with the resident's name and date on it. Similarly, for Resident #19, a nebulizer mask and nasal cannula were observed unsecured and exposed to air on a nightstand and hanging from an oxygen concentrator. The nasal cannula was also found on the floor and hanging from the back of the resident's chair. Resident #19 had a medical history of acute respiratory failure and chronic obstructive pulmonary disease (COPD), with orders for nebulization and continuous oxygen therapy. The Unit Manager and Infection Preventionist both stated that the equipment should be stored in bags when not in use, and the Director of Nursing confirmed that it should not be left open to air or on the floor.
Delayed Response to Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident admitted with Alzheimer's Disease and Protein-Calorie Malnutrition. The CP had recommended clarifying the resident's liquid Colace order to include specific concentration and dosage details. This recommendation was initially made on May 22, 2024, and reiterated on June 24, 2024, but was not acted upon until July 6, 2024, when the original order was discontinued and a new order was written. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for handling CP recommendations was not followed as intended. The ADON stated that recommendations are typically sent to the doctor for review and completed within a day or two, but could not recall why this particular recommendation was delayed. The DON acknowledged that the recommendation should have been completed sooner, despite the facility's policy stating that CP recommendations should be communicated and responded to in a timely fashion.
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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