Runnells Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Berkeley Heights, New Jersey.
- Location
- 40 Watchung Way, Berkeley Heights, New Jersey 07922
- CMS Provider Number
- 315009
- Inspections on file
- 21
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Runnells Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
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.
A resident with multiple medical conditions was admitted and had medications reconciled by an LPN/UM who failed to verify that all pages of a multi-page medication list belonged to the correct individual, resulting in transcription of another resident’s psychotropic and cardiac medications into the new admission’s EMR and MAR. These incorrect medications, including furosemide, lithium ER, trazodone, clonazepam, and risperidone, were then administered over several days until the resident’s representative questioned the accuracy of the list and reported that the resident was not completing sentences. Review of records and staff interviews confirmed that the medications actually belonged to another resident and that the provider had been given inaccurate information when admission orders were obtained.
A resident with paraplegia, generalized weakness, incontinence, and a urinary catheter was transferred to a hospital for altered mental status, hypotension, diarrhea, and later admitted with septic shock, where the resident was identified as having Candida auris (CA). The IP stated the facility had the ability, PPE, and staff education to care for residents requiring Enhanced Barrier Precautions for CA. However, the DON and Admissions Director reported that, based on an internal corporate clinical capabilities list and an upper management decision that the facility was “not a C. Auris facility,” the resident was not allowed to return after hospitalization, resulting in a deficiency related to failing to ensure the transfer/discharge met the resident’s needs and preferences.
Surveyors identified that staff failed to consistently document care and services provided to two residents with severe cognitive impairment, including required behavior monitoring and two-hour safety rounds, as outlined in their care plans. Electronic records showed numerous missing entries for behavior and elimination monitoring, and facility leadership confirmed that these interventions were not documented as required by policy.
A resident with severe cognitive impairment was found with unexplained bruising on the right eye and arm. The facility investigated the incident but did not report it to the NJDOH as required, and failed to update the care plan to address the use of aspirin, the new bruising, or the resident's dementia. Facility policies for reporting and care planning were not followed.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss, but the facility failed to ensure accurate weight documentation and consistent monitoring of food intake. Weight records were incomplete or inaccessible in the eMR, and most shifts lacked documentation of meal consumption, despite care plan and policy requirements. Staff interviews confirmed that re-weights and intake monitoring were not properly recorded or available for review.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their medical records. One resident's use of antidepressant medication was not reflected, and another resident's multiple falls were not documented in the MDS. The errors were acknowledged by the facility's staff, who indicated that corrections would be made.
The facility failed to ensure that the primary physician conducted face-to-face visits and wrote progress notes at least once every sixty days for a resident with anxiety and depressive disorders. Instead, the NP conducted all visits within the specified period, with no documented evidence of the primary physician's involvement.
The facility failed to adequately monitor and document the target behaviors, interventions, and outcomes for a resident on psychotropic medications, leading to an incident of resident-to-resident abuse. The nursing staff did not understand how to properly use the Behavior Monitoring for Medication (BMFM) system, resulting in incorrect documentation.
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.
Significant Medication Error from Incorrect Medication Reconciliation
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors during the admission and medication reconciliation process. A resident identified as having diagnoses including influenza, depression, cerebral infarction, hyperlipidemia, hypertension, and cardiac arrhythmia was admitted to the facility. An LPN/Unit Manager (LPN/UM) was responsible for reviewing the admission packet and reconciling the resident’s medications. While transcribing the medication list, which was on multiple pages, the LPN/UM did not verify that each page belonged to the correct resident and mistakenly used another resident’s medication list. As a result, medications prescribed for a different resident were entered into this resident’s electronic medical record and medication administration record (MAR). Review of the January MAR and order summary report for the admitted resident showed that several medications not ordered for this resident by the transferring facility were listed and administered. These included furosemide 20 mg daily, lithium carbonate ER 450 mg daily, trazodone 100 mg at bedtime, clonazepam 0.5 mg twice daily, and risperidone 3 mg twice daily. The transferring facility’s medication list for this resident did not contain any of these medications. Further review of records showed that these medications actually belonged to another resident with diagnoses including schizoaffective disorder, heart failure, and hypertension. The LPN/UM’s written statement confirmed that she failed to verify that each page of the multi-page medication list was for the correct resident, which led to entering the wrong medications and providing inaccurate information to the provider when obtaining verbal orders. The MAR documented that the wrong medications were administered over multiple days. Clonazepam and risperidone were given starting on the day of admission and continued on subsequent days; trazodone was administered at bedtime on several consecutive nights; and furosemide and lithium were administered daily on multiple mornings. The error was discovered only after the resident’s representative informed facility staff that the medications on the list were not accurate and reported that the resident was not completing sentences. The facility’s investigation, interviews with staff, and review of the medical record confirmed that the medication reconciliation process was not performed correctly, that the LPN/UM used another resident’s medication list, and that the attending physician had been provided with incorrect medication information when admission orders were obtained.
Removal Plan
- Assess and monitor the resident for any adverse reaction, including vital signs and level of consciousness; initiate and maintain neurological checks until the resident is sent out for further evaluation.
- Initiate an investigation into the incident and suspend the identified LPN/UM pending the outcome of the investigation.
- Audit all new admissions and re-admissions (including discharged medication reconciliation records) to ensure accuracy, proper transcription, physician orders, and compliance with the facility's admission protocol.
- Provide re-education for licensed nursing staff on the facility's admission process, medication reconciliation requirements, nurse accountability, and resident identification procedures.
- Educate licensed nursing staff on a protocol requiring two-nurse verification for transcription and review of hospital discharge medication lists and use of two resident identifiers prior to medication transcription and administration.
Failure to Readmit Resident With Candida auris Despite Facility Capability
Penalty
Summary
The deficiency involves the facility’s failure to allow a cognitively intact resident with an infectious diagnosis requiring Enhanced Barrier Precautions to return from the hospital, despite the facility’s ability to provide the necessary care. The resident had multiple diagnoses including compartment syndrome, paraplegia, generalized muscle weakness, and a need for assistance with personal care, and was frequently bowel incontinent with a urinary catheter. The resident was transferred to an acute care hospital for altered mental status, hypotension, and diarrhea, and was subsequently admitted for septic shock. While hospitalized, the resident was identified as positive for Candida auris (CA). The facility’s Infection Preventionist reported that cultures for CA were negative and stated that the facility had the ability to care for residents with CA, including having adequate PPE and staff education for contact isolation. Despite this, the DON stated that the facility was notified that the resident was positive for CA and that, based on an internal facility document and a decision made by upper management, the facility was “not a C. Auris facility” and therefore did not accept residents with CA. The DON described CA as highly contagious and cited this as the reason for not accepting the resident back. The Admissions Director reported that a family member informed her of the CA diagnosis and that she told the family the facility generally did not accept residents with CA, referencing a corporate-supplied clinical capabilities list that specified which conditions the facility could and could not manage. The facility’s refusal to readmit the resident, despite the Infection Preventionist’s statement that the facility could care for residents with CA and had appropriate resources, led to the identified deficiency related to ensuring transfers/discharges meet resident needs and preferences and preparing for a safe transfer/discharge.
Failure to Document Care and Services per Professional Standards
Penalty
Summary
The facility failed to ensure that staff consistently documented care and services provided to residents in accordance with professional standards, as required by the Nurse Practice Act and facility policy. Specifically, for two of three residents reviewed for accident/incident, there were significant gaps in documentation related to behavior monitoring and implementation of care plan interventions. For one resident with Alzheimer's disease, dementia, and diabetes, the care plan required monitoring for wandering behaviors and safety rounds every two hours. However, electronic documentation revealed numerous shifts with missing entries for behavior monitoring, and the Assistant Director of Nursing (ADON) confirmed that the required two-hour monitoring was not documented anywhere. Another resident, admitted with dementia and behavioral disturbances, was identified as high risk for falls and required two-hour rounding at night and toileting assistance prior to bed. Review of the electronic documentation system showed multiple shifts with missing entries for bowel and bladder elimination monitoring, as well as behavior monitoring. The ADON acknowledged that there was no documentation to support that the individualized care plan interventions were implemented for this resident. The facility's own policy required documentation of all pertinent psychosocial, medical, and nursing observations, including the plan of care and resident response. Despite this, the survey found repeated instances where required documentation was missing, and facility leadership could not provide evidence that care plan interventions were carried out as documented. This failure to maintain complete and accurate records constituted a deficiency in meeting professional standards of quality.
Failure to Report Injury of Unknown Origin and Update Care Plan
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey State Department of Health (NJDOH) and did not fully implement its policy for accidents and incidents by neglecting to thoroughly update the care plan after the event. A resident with severe cognitive impairment and dependent functional status was observed with unilateral bruising on the right eye and right arm. The incident was documented in the medical record, and witness statements were collected, but the event was not reported to the state as required. The Assistant Director of Nursing (ADON) confirmed that no reportable event was filed with the NJDOH, despite the facility investigating the bruises as being of unknown origin. The facility's investigation attributed the bruising to the resident's use of aspirin and underlying dementia, but did not establish a definitive root cause. Additionally, the care plan was not updated to include interventions related to the use of anticoagulants, the new bruising, or the resident's dementia diagnosis. The interdisciplinary team met to discuss the incident, but the care plan lacked specific focus and interventions addressing the identified issues. The facility's own policies required individualized interventions and reporting of such incidents, which were not followed in this case.
Failure to Accurately Monitor and Document Resident Weight and Food Intake
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight and to monitor the resident's food intake as required by the care plan. The resident, who had diagnoses including Alzheimer's disease, dementia with psychotic disturbances, and type 2 diabetes, was noted to have severely impaired cognition and behavioral symptoms. The resident's weight records showed a decline from 162 lbs to 147 lbs over several months, with one weight entry being crossed off by the Registered Dietician (RD) due to concerns about its accuracy. The RD did not document re-weights in the electronic medical record (eMR), and the re-weight information was not accessible to other staff, as it was kept in the RD's office and not entered into the eMR. Interviews with staff revealed that weights were obtained by CNAs and entered into a weight binder, with the RD providing lists of residents needing re-weights. However, the Assistant Director of Nursing (ADON) confirmed that these records were not part of the official medical record, and that weights and re-weights should have been available in the eMR for review by ancillary providers. This lack of documentation meant that weight variances were not thoroughly investigated or accessible to all relevant staff. Additionally, the care plan for the resident included monitoring oral intake as needed, but review of the electronic point-of-care system (POCS) showed significant gaps in documentation. For two consecutive months, the majority of shifts lacked documentation of the percentage of meals consumed by the resident, with only a small fraction of shifts having this information recorded. Facility policies required CNAs to monitor and document dietary intake for each meal, but this was not consistently done, contributing to the deficiency.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For Resident #200, the MDS did not reflect the use of an antidepressant medication, despite the resident's admission record and physician's orders indicating the use of Sertraline HCL for depression. The MDS Coordinator acknowledged this as a data entry error and stated that the MDS assessment would be corrected. The facility's policy requires the MDS Coordinator to ensure appropriate edits are made before transmitting MDS data, which was not followed in this case. For Resident #655, the MDS did not accurately reflect multiple falls that occurred within the assessment period. The resident's medical records and incident reports documented falls on several occasions, but the quarterly MDS indicated no falls. The MDS Coordinator stated that the MDS Nurse responsible for completing that section should have included the data. The facility's policy mandates that all MDS assessments be completed and transmitted accurately, which was not adhered to in this instance. Both deficiencies highlight a failure in the facility's process for ensuring accurate MDS coding, which is crucial for the management of resident care. The inaccuracies in the MDS assessments for both residents were acknowledged by the facility's staff, who indicated that corrections would be made following the surveyor's findings.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for one resident who had diagnoses including generalized anxiety disorder and major depressive disorder. The review of the resident's medical records revealed that the primary physician did not visit and examine the resident at least every 60 days, as required. Instead, the Nurse Practitioner (NP) conducted all the visits within the specified period, with no documented evidence of the primary physician's involvement. Interviews with the VP of Clinical Services and the Director of Nursing (DON) confirmed that the primary physician should have conducted face-to-face visits at least every 60 days when alternating with an NP. The NP also confirmed that she visited the residents monthly and that the primary physician was required to visit quarterly. Despite these acknowledgments, there was no additional information provided by the facility to demonstrate compliance with the required physician visit schedule. The facility's policy also stipulated that after the first ninety days, the primary physician's visits should not exceed every sixty days, which was not adhered to in this case.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and their outcomes for the use of psychotropic medications in accordance with facility policy. This deficiency was identified for one resident who was involved in a resident-to-resident interaction that resulted in abuse. The incident occurred when a Licensed Practical Nurse (LPN) witnessed the resident strike another resident twice in the face. The resident had a history of unspecified dementia with behavioral disturbances and major depressive disorder, and was on medications including Ativan and Depakote for anxiety and mood stabilization, respectively. The review of the resident's medical records and electronic Medication Administration Record (eMAR) for June and July 2023 revealed that behaviors were documented without specifying whether they were for anxiousness or explosive aggressive behavior. Additionally, the documentation lacked details on the number of episodes, non-pharmacological interventions, and the outcomes of these interventions. This was a significant oversight as the facility's policy required detailed behavior monitoring to manage problematic behaviors appropriately. Interviews with the Director of Nursing (DON) and the President of Clinical Services confirmed that the nurses did not understand how to properly use the Behavior Monitoring for Medication (BMFM) system. The DON acknowledged that the order was for behavior monitoring, not just the administration of medication, and that the documentation on the BMFM was incorrect. This lack of proper documentation and understanding among the nursing staff contributed to the failure in adequately monitoring and managing the resident's behaviors, leading to the incident of resident-to-resident abuse.
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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