Spring Grove Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Providence, New Jersey.
- Location
- 144 Gales Drive, New Providence, New Jersey 07974
- CMS Provider Number
- 315005
- Inspections on file
- 21
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Spring Grove Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed ripped linen cart covers, damaged linen cart shelving, and clean linens and gowns stored in carts parked in hallways near resident rooms and precaution areas. They also found grayish, whitish, blackish, and brownish-grayish substances on ceiling vents in a resident toilet room and the South unit central bath, along with chipped paint and exposed wallboard in several resident rooms. The DON, LED, LNHA, and Maintenance Director were present for some observations and acknowledged the conditions.
A nurse administered meds to a resident while the resident was seated on the toilet in the lavatory, rather than waiting until the resident was in a more appropriate setting. The resident had dementia with a BIMS score of 0, and the care plan did not address med administration in the lavatory. The DON stated this was not appropriate, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
A resident with COPD, muscle weakness, difficulty walking, and need for assistance with personal care had orders for duloxetine for depression, trazodone for insomnia, and PRN clonazepam for insomnia/anxiety. The chart lacked documented behavior monitoring for the psychotropic meds, the cMDS did not identify an active diagnosis for the antianxiety and antidepressant meds, and the record did not clearly document an indication for insomnia. The LPN/UM confirmed behavior monitoring should be in the eMAR, and the DON stated the clonazepam order and behavior monitoring were clarified after the surveyor’s inquiry.
Inaccurate MDS coding affected two residents. One resident’s MDS omitted active diagnoses such as HTN, anxiety, depression, and DJD despite physician documentation and ongoing use of related meds, while another resident’s MDS failed to reflect repeated refusal of psychotropic meds documented on the eMAR. The RN/MDSC acknowledged both assessments were inaccurate.
Medication administration was documented before the meds were actually given for two residents during a med pass observation. An RN marked the eMAR as meds were prepared and checked them off as administered before entering the rooms, then gave the meds afterward. One resident had severe cognitive impairment with dementia and difficulty walking, and the other had moderate cognitive impairment with type 2 diabetes and GERD. The facility policy stated meds should be initialed on the MAR after each med is given and before moving to the next resident.
A resident with a Stage 3 sacral/coccyx pressure ulcer and multiple chronic conditions, including quadriplegia and DM2, had daily wound care that was not documented on the eTAR for one day. The surveyor also found that a wound care consultant recommended changing the treatment to collagen powder, but there was no contemporaneous documentation that nursing notified the physician or that the physician reviewed, accepted, or declined the recommendation, and the original Triad paste order remained in place.
Missing Nephrostomy Order and Outdated Catheter Care Plan: A resident returned from the hospital with a nephrostomy tube in place, but the chart had no active MD order for nephrostomy management or care at the time of review. In a separate case, another resident’s Foley had been discontinued, yet the care plan still listed an indwelling urinary catheter and UTI-related focus instead of reflecting the current incontinent status.
Surveyors found respiratory care deficiencies involving two residents. One resident receiving O2 at 2 L/min had tubing repeatedly observed on the floor and an undated humidification bottle, despite an order to date and label the equipment and change tubing weekly. Another resident’s neb/O2 tubing was hanging to the floor, with a mask stored in a drawer outside a bag and no dates on the equipment; the resident could not recall whether a neb treatment had been given that day. Facility policy required dated, labeled, and properly stored respiratory equipment.
A resident with OA and chronic pain had PRN pain meds ordered, but the facility did not consistently monitor and document pain levels or administer pain medication according to the physician’s orders. Ibuprofen was given when the resident’s pain score was 1 even though it was ordered for moderate pain of 3 or more, while other PRN pain orders lacked clear pain-scale instructions. The RNS stated the orders were confusing, and the resident said staff dispensed what was ordered by the doctor and that they were not aware of naproxen being prescribed.
Failure to Post Accurate Daily Staffing Reports: Surveyors observed that the NHRCSR was not accurately posted at the front desk before the start of the shift on 2 of 5 days reviewed. On one occasion, the report was dated the prior day and no current report was posted; on another, an incorrectly dated report was displayed and the census did not match the DON’s later staffing information. Interviews showed the SC/HR was responsible for preparing the sheets and the receptionist was expected to post them in the morning, but the reports were not posted accurately when surveyors entered the facility.
The facility failed to complete and accurately document behavioral health monitoring for two residents receiving psychotropic medications. One resident with psychosis, depression, and dementia-related behaviors had multiple missing shift entries and staff used NO and other markings instead of the required side effect codes. Another resident with major depressive disorder, dementia, psychosis, and anxiety had blank behavior-monitoring shifts and inconsistent use of the facility’s required coding system for behavior and side effect documentation.
An LPN was observed preparing meds for a resident when ordered enoxaparin could not be found. The LPN checked the eMAR, documented the med as on order and awaiting delivery, and stated they would wait two days before calling the pharmacy. The resident had an active daily order for enoxaparin for DVT prophylaxis, and the eMAR showed the dose was not administered on two occasions. The DON later stated the LPN should have notified the physician right away, checked backup supply, or arranged immediate pharmacy delivery.
A facility failed to act on CP medication regimen review recommendations for three residents. Issues included unaddressed PRN psychotropic and pain-med orders, lack of stop dates and rationale for PRN insomnia meds, failure to clarify pain scales for PRN analgesics, and an acetaminophen liquid dose that was difficult to measure. Nursing staff acknowledged some of the orders were confusing, and one resident received PRN tramadol even when the documented pain score was 0.
Medication labeling and storage deficiencies were identified in the North unit med storage room and med carts. Surveyors found expired Iodoform packing strips, an opened acetaminophen ER container with no expiration date, a clonazepam blister pack missing a resident label and name but identified by an LPN as belonging to a resident, and an OTC acetaminophen bottle with no expiration date. Staff, including the DON, confirmed the items should have been discarded.
Staff failed to verify a resident's identity before discussing medical information during a care conference, resulting in confidential health details being disclosed in the presence of the wrong resident. The error was discovered when a family member recognized the mistake, leading to a breach of privacy and noncompliance with facility policy.
A resident in a LTC facility sustained an ankle injury during rehabilitation therapy, but there was a delay in notifying nursing staff and assessing the injury. The resident experienced severe pain and swelling, but was not assessed by a nurse until two days later, leading to a delayed diagnosis of a non-displaced fracture. The incident highlighted a communication breakdown between the rehabilitation and nursing departments, as well as a failure to follow documentation policies.
Surveyors observed that the facility failed to provide timely incontinence care to residents, with multiple instances of residents wearing two saturated briefs, contrary to policy. Residents with severe cognitive impairments and those requiring assistance for personal hygiene were not checked and changed every two hours as required. Additionally, a cognitively intact resident reported not receiving incontinence care throughout the day, leading to saturated clothing and equipment.
The facility failed to ensure call bells were within reach for six residents, all with severe cognitive impairments and requiring assistance for ADLs. Observations showed call bells were often on the floor or under beds, contrary to care plans and facility policy. Staff acknowledged the oversight, confirming call bells should be accessible.
The facility failed to issue the required SNF ABN and/or NOMNC for three residents regarding insurance termination. Two residents who stayed in the facility after Medicare Part A coverage ended did not receive the SNF ABN, and a resident discharged to a lesser level of care did not receive a NOMNC. The Administrator cited a change in social service staff as a possible cause.
A facility failed to discontinue a treatment order for a healed wound and did not follow a physician's treatment order for a resident with a history of heart disease and hypertension. Despite the wound being healed, the treatment was still signed off daily. The resident reported not receiving treatments, and inspection confirmed no dressing or gauze was applied. The RN Supervisor and DON were informed of these issues.
A resident with acute respiratory failure and other conditions was not provided with continuous oxygen therapy as prescribed. On two occasions, the resident was found without the oxygen concentrator in use, and when it was used, the oxygen flow was set incorrectly. The RN acknowledged the oversight and corrected the settings, but the facility's policy on verifying physician orders was not followed.
A facility failed to identify psychoactive medication irregularities for a resident with severe cognitive impairment. Despite recommendations for gradual dose reductions of Lexapro and Seroquel by an APN-C, the Consultant Pharmacist did not identify these irregularities during monthly reviews. The physician's notes lacked rationale for not following the recommendations, and there was no documented discussion with the resident's family. The Director of Nursing confirmed the oversight, highlighting a communication breakdown between the CP, nursing staff, and physician.
A resident with Alzheimer's disease, requiring total assistance, fell from bed while being cared for by a single CNA, despite needing a two-person assist. The CNA, newly hired and oriented on safety, acted alone due to insufficient help, resulting in the resident sustaining a forehead abrasion. The CNA was later discharged for policy violation.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment during environmental tours of the North, [NAME], and South units. Surveyors observed multiple linen carts with ripped covers and damaged shelving while clean linens and gowns were stored inside them, including carts parked in hallways between resident rooms and near rooms with posted isolation or precaution signs. The DON and LED were present for some of these observations and confirmed that the items inside the carts were considered clean linens and gowns, while the LNHA later stated the linen carts were brand new. Surveyors also observed environmental cleanliness concerns in resident areas. In one resident room, the toilet room ceiling vent had grayish and whitish substances, and two residents were in their beds in the room at the time. In the South unit central bath, the LNHA accompanied the surveyor and observed ceiling air vents in multiple shower cubicles with grayish, blackish, and brownish-grayish substances. When asked about the material in the vents, the LNHA stated it was not dust and later said it was aesthetic and needed to be painted. Additional observations on the South unit found chipped paint and exposed wallboard behind the bed near the window in three resident rooms, with chipped paint also noted on windowsills in two of those rooms. The Maintenance Director acknowledged the concerns and stated that his rounds did not routinely include resident rooms, and that repairs were addressed through staff submissions in the electronic maintenance system. The facility’s Homelike Environment policy stated that residents are provided with a safe, clean, comfortable, and homelike environment, and the laundry and linen policy stated that clean linen should remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts.
Medication Administered While Resident Was on Toilet
Penalty
Summary
The facility failed to treat a resident with respect and dignity during medication administration when the Registered Nurse administered medications while the resident was seated on the toilet in the lavatory. During observation, the nurse prepared the medications, entered the resident’s room, noted the resident was receiving care in the lavatory, and then entered the lavatory to give the medications while the resident remained on the toilet before returning to the med cart. When asked if this was common practice, the nurse stated they had known the resident for a long time and that the resident liked to get medications right away. Resident #43 was admitted with diagnoses including acute embolism and thrombosis, dementia, and difficulty walking. The resident’s comprehensive MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. Review of the resident’s comprehensive care plan did not include any focus, goal, or intervention for administering medications while the resident was in the lavatory or seated on a toilet. The DON later stated that it was not appropriate to administer medications to a resident while seated on a toilet, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
Psychotropic Medication Monitoring and Indication Not Adequately Documented
Penalty
Summary
The facility failed to adequately monitor target behavior for psychotropic medications and failed to ensure that an antianxiety medication was ordered for an appropriate diagnosis or indication for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including COPD, muscle weakness, difficulty walking, and need for assistance with personal care. The March 2026 eMAR showed orders for duloxetine 30 mg daily for depression, trazodone 50 mg at bedtime for insomnia, and clonazepam 0.5 mg every 14 hours PRN for insomnia/anxiety. The record contained no behavior monitoring documented for duloxetine, trazodone, or clonazepam during March. The resident’s most recent cMDS showed a BIMS score of 13/15, indicating intact cognition, and reflected receipt of an antianxiety and antidepressant medication, but did not identify an active diagnosis for those medications. The care plan included focus areas for antianxiety medication use and depression/anxiety related to admission to the nursing facility, with interventions to administer medications as ordered and monitor/document side effects and effectiveness, but it did not document target behaviors for the psychotropic medications. The late entry H&P and physician progress notes documented COPD and anxiety/depression, but there was no documented indication for insomnia in the progress notes. A psychiatric DNP note listed clinical signs and target symptoms of anxiety and depression and included clonazepam, duloxetine, melatonin, and trazodone as psychotropic medications being monitored. During interview, the LPN/UM stated that diagnosis and indication should be based on physician documentation and confirmed behavior monitoring should be in the eMAR, while the DON later stated the clonazepam order was clarified and behavior monitoring was entered after the surveyor’s inquiry.
Inaccurate MDS Coding for Active Diagnoses and Medication Refusal
Penalty
Summary
The facility failed to accurately complete portions of the MDS for 2 of 23 residents reviewed, resulting in assessments that did not reflect the residents’ status as of the ARD. For one resident admitted with COPD, muscle weakness, difficulty walking, and need for assistance with personal care, the March 2026 cMDS with an ARD of 3/5/26 showed a BIMS score of 13 and indicated use of antianxiety, antidepressant, and pain medications, but did not include active diagnoses such as HTN, anxiety, depression, or DJD even though the resident was receiving medications for those conditions and physician documentation reflected those diagnoses. Survey review showed the resident’s MAR included nifedipine for HTN, duloxetine for depression, trazodone for insomnia, clonazepam PRN for insomnia, and tramadol PRN for pain, with multiple administrations documented during the assessment period. The resident’s care plan included focus areas for anxiety, depression, and pain, and the physician H&P and progress notes documented HTN, DJD, and anxiety/depression. The RN/MDSC stated she used physician H&P, physician notes, hospital records, and nursing notes to complete Section I, but acknowledged the MDS was inaccurate and that the active diagnoses should have been included. For the second resident, the quarterly MDS with an ARD of 3/5/26 reflected cognitive impairment consistent with dementia and metabolic encephalopathy, but Section N was not coded accurately to reflect medication refusal. The resident had diagnoses including dementia, major depressive disorder, psychosis, Parkinson’s disease, hemiplegia, aphasia, diabetes, atrial fibrillation, HTN, CKD, and anemia, and the care plan addressed psychosis, depression, dementia-related behaviors, and psychotropic medication use. The eMAR showed repeated refusals of mirtazapine and quetiapine over the seven days before the assessment, yet the MDS did not capture this pattern; the RN/MDSC stated the section had been completed by the SW and acknowledged the assessment was not accurate.
Medication Administration Documented Before Administration
Penalty
Summary
The facility failed to correctly document medication administration during a medication pass observation for 2 of 4 residents observed. The surveyor observed the RN preparing medications for two residents and marking the eMAR as medications were placed into a dose cup, then checking a box indicating the medications had been administered before entering the residents’ rooms. The RN then administered the medications and moved on to the next resident. When asked whether it was common practice to sign for medication administration before the medications were given, the RN stated, “not really, I just hit the button.” Resident #43 had diagnoses including acute embolism and thrombosis, dementia, and difficulty walking, and the cMDS reflected a BIMS score of 0 out of 15, indicating severe cognitive impairment. Resident #69 had diagnoses including type 2 diabetes and GERD, and the quarterly MDS reflected a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The eMARs for both residents showed scheduled medications were documented as received during the observation, and the facility policy stated the individual administering the medication initials the MAR after giving each medication and before administering the next one.
Missing Wound Care Documentation and Unfollowed Consultant Recommendation
Penalty
Summary
The facility failed to ensure that a resident with a Stage 3 pressure ulcer received care and services consistent with professional standards of practice. The resident had diagnoses including quadriplegia, type 2 diabetes mellitus, muscle wasting and atrophy, hypertension, depression, neuromuscular dysfunction of the bladder, hyperlipidemia, anemia, thyrotoxicosis with diffuse goiter, cervical disc disorder with myelopathy, and arthropathy. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and the care plan identified a Stage 3 sacral pressure ulcer related to immobility and incontinence with interventions that included ordered treatments, monitoring, documentation, and use of a low air loss mattress. The surveyor found that the ordered daily wound care treatment was not documented on the eTAR for one day, and there was no progress note, weekly skin assessment, or other documentation confirming that the treatment had been completed on that date. Although a weekly skin check was listed as complete, there was no documentation specific to the wound care treatment itself. The LPN told the surveyor that the resident was seen by wound care weekly and that wound care was completed daily to the sacrum, and later the DON stated that the nurse probably forgot to sign the eTAR. A typed and signed statement from the nurse, created after the surveyor’s inquiry, stated that the wound treatment had been provided before medication pass but was not signed in the eTAR. The surveyor also found that a wound care consultant evaluated the Stage 3 coccyx wound and recommended changing treatment to collagen powder because the wound was stable and showed granulation tissue with no signs of infection. However, there was no documentation that nursing notified the physician of the recommendation, and no contemporaneous documentation showed that the physician reviewed, accepted, or declined the change in treatment. The existing physician order for Triad paste with border dressing remained unchanged. Later notes entered after the surveyor’s inquiry stated that the doctor opted not to change the dressing, but no prior physician documentation or rationale was present before those late entries.
Missing Nephrostomy Order and Outdated Catheter Care Plan
Penalty
Summary
The facility failed to ensure that an active physician order was in place for the management, care, and monitoring of a nephrostomy tube when a resident returned from the hospital. The resident was observed in bed with a nephrostomy drainage bag in place and functioning, and the resident stated the tube was being used for urine drainage. Record review showed diagnoses including obstructive and reflux uropathy, renal agenesis, urinary calculus, and status involving artificial openings of the urinary tract. The resident’s MDS indicated the presence of an indwelling catheter including a nephrostomy tube, and the care plan included interventions for nephrostomy care, drainage, dressing, monitoring urine, and monitoring the insertion site for infection. The admission summary documented that the resident was readmitted from the hospital with a nephrostomy tube attached to a urine drainage bag at the left lower back, and that admission orders were verified with the physician. However, review of the physician orders and eTAR showed no active physician order for the nephrostomy tube or nephrostomy care at the time of survey review. The record showed that prior nephrostomy orders had existed before the resident’s most recent hospitalization, but no active order had been entered after the resident returned from the hospital. The facility also failed to ensure that the comprehensive care plan accurately reflected the current status of another resident’s urinary catheter after the device was discontinued. The resident had diagnoses including ESBL in urine, was frequently incontinent of bowel and bladder, and the most recent cMDS indicated no indwelling catheter. A physician progress note documented an order to remove the Foley catheter, and a nursing note documented that the Foley was removed with 400 mL output. Although the eTAR later showed catheter care and Foley maintenance orders discontinued, the care plan still reflected an indwelling urinary catheter related to neurogenic bladder and a UTI focus, and it was not revised to reflect that the catheter had been discontinued.
Respiratory Equipment Not Maintained or Labeled Properly
Penalty
Summary
The facility failed to maintain necessary respiratory care and services and failed to follow physician orders for two residents receiving oxygen and nebulizer-related respiratory support. For one resident, surveyors observed oxygen tubing connected to nasal cannula oxygen at 2 L/min laying on the floor while the resident sat in a common area. The tubing was observed on the floor again later, and the humidification bottle was undated. An LPN and later an RNS both confirmed the tubing should not be touching the floor and that the humidification bottle should be dated, but the tubing was only moved off the floor and not replaced. That resident’s record showed diagnoses including a left femur fracture, orthopedic aftercare, and unspecified dementia, with a BIMS score of 3 indicating severe cognitive impairment. The resident had an order for oxygen at 2 L/min via nasal cannula to maintain SpO2 above 90%, and an order to change oxygen tubing, humidifier, and clean the filter weekly on Wednesday night shift and as needed, with tubing and humidifier bottle to be dated and labeled. Surveyors observed the oxygen tubing on the floor again on a later date while the resident was participating in an activity, and the RNS again removed the tubing from the floor without disposing of it or replacing it. For the second resident, surveyors observed oxygen tubing connected to a nebulizer machine hanging to the floor and looped into a drawer, with a mask stored in the drawer not contained in a bag and neither the tubing nor mask labeled with a date of use. On a later observation, the same conditions remained, and the resident stated they could not recall whether they had received a nebulizer treatment that day. The resident’s record showed orders for two medications administered by nebulizer and a care plan directing respiratory treatments and inhalants as ordered and keeping respiratory equipment clean with disposable equipment changed per facility policy. The facility policy required nebulizer equipment to be stored in a plastic bag with the resident’s name and date and tubing changed every seven days or per protocol.
Pain Medication Given Without Clear Pain Scale Documentation
Penalty
Summary
Facility failed to provide safe, appropriate pain management for a resident with intact cognition and diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, malignant neoplasm of endometrium, and bilateral primary osteoarthritis of the knees. The resident’s MDS indicated occasional pain with a pain score of 2 (mild), and the care plan addressed back pain, hand and wrist pain probably due to OA, and chronic pain and/or potential for pain related to arthritis. The physician order summary included an order to monitor for pain every shift and document a pain scale every shift, along with PRN orders for acetaminophen, ibuprofen, and naproxen. During record review, the ibuprofen order was written for moderate pain of 3 or more, but the medication administration record showed ibuprofen was given when the resident’s pain level was 1. The surveyor also found that the acetaminophen and naproxen orders did not specify a pain scale for administration, and the care plan did not include an intervention stating that the resident would tell staff which pain medication to give. Nursing progress notes for the relevant dates did not document that the resident verbalized which pain medication was preferred. In interview, the RNS stated she would ask the resident what the pain was on a 1-10 scale, but also stated the orders for Tylenol and naproxen needed clarification because they did not indicate a pain scale. She further stated she could not explain why ibuprofen was given with a pain scale of 1 and said she would not give it that way. The resident stated they used Motrin for finger pain, were not aware of any other pain medications ordered, did not take naproxen because it was not prescribed, and did not tell nurses which pain medication to give.
Failure to Post Accurate Daily Staffing Reports
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report (NHRCSR) showing licensed nurse staffing, CNA staffing, and resident census was posted before the start of the current shift on 2 of 5 days reviewed during the annual recertification survey. On 3/24/26 at 8:55 AM, surveyors observed a staffing report posted at the front desk that was dated 3/23/26 and reflected a census of 100 for the day shift, and there was no NHRCSR posted for 3/24/26. The LNHA later provided a 3/24/26 staffing report showing a census of 100 with 2 RNs, 3 LPNs, and 13 CNAs. On 3/27/26 at 8:07 AM, surveyors again observed an incorrectly dated staffing report posted at the front desk, dated 3/26/26 with a census of 100. The LNHA stated the Human Resources/Staffing Coordinator was responsible for posting, and later provided a 3/27/26 report showing a census of 100 with 3 RNs, 4 LPNs, and 14 CNAs, while the DON had earlier provided staffing with a census of 98. The LNHA later acknowledged that two discharges before midnight were not reflected on the 3/27/26 report. Interviews with the DON, Regional Human Resources, receptionist, and LNHA showed the process was for the staffing sheets to be prepared in advance and posted in the morning, but the reports observed by surveyors were not accurately posted at the front desk at the time of entry. The facility policy stated daily staffing numbers are posted for every shift, and another policy stated the number of unlicensed nursing personnel is posted within 2 hours of the beginning of each shift, while the regulation required posting at the beginning of each shift.
Incomplete behavioral health monitoring and inaccurate psychotropic documentation
Penalty
Summary
The facility failed to ensure the implementation and accurate documentation of behavioral health monitoring for 2 of 5 residents reviewed for unnecessary medications. Resident #4 was observed seated in a wheelchair in the hallway and was noted to be confused at baseline, with no behavioral concerns observed during the surveyor’s observations. The resident’s care plan included psychosis, depression, dementia-related behaviors, and psychotropic medication monitoring, with directions to administer medications as ordered and monitor and document side effects and effectiveness each shift. For Resident #4, review of the eMAR and eTAR showed incomplete behavior monitoring documentation, including nine missing night shift entries and two missing day shift entries. The record also showed that staff were not using the facility’s required side effect coding system as ordered; instead of entering code 15 for side effect not seen and code 13 for side effect noted, nurses documented NO, placed markings above initials, or entered information in the wrong column. A nurse told the surveyor that monitoring for mood, behaviors, and medication refusal was completed each shift and documented on the eTAR. Resident #9 had diagnoses including major depressive disorder, dementia, psychosis, and anxiety disorder, and was receiving Seroquel and sertraline with orders to monitor behaviors. The resident was observed self-propelling in a wheelchair and later seated in the day room, smiling but not verbally responding. The March 2026 Behavior Monitoring Record showed four blank shifts for behavior monitoring, X and O markings where monitoring was not completed, and use of markings and NO entries instead of the required codes. Two shifts were also left blank for anti-psychotic side effect monitoring, and the DON and LNHA confirmed that behavior monitoring was not fully completed and that staff were not consistently following the facility’s designated coding system for side effect documentation.
Unavailable Ordered Medication During Med Pass
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when a medication ordered for a resident was unavailable during medication administration. During a med pass observation, an LPN preparing medications for Resident #21 stated that enoxaparin could not be located. The LPN accessed the eMAR, saw that the medication was listed as on order from the pharmacy, and documented that it was awaiting delivery. When asked about the procedure for an ordered medication that had not arrived, the LPN stated that if it did not come within two days they would call the pharmacy, and only then might call the resident’s doctor. Resident #21 was admitted with diagnoses including displaced bicondylar fracture, essential hypertension, and difficulty walking. The resident’s cMDS showed a BIMS score of 14 out of 15, indicating intact cognition. The resident had an order for enoxaparin sodium injection 30 mg/0.3 mL subcutaneously daily for DVT prophylaxis, and the eMAR showed documentation on two dates indicating the medication was not administered. The DON later stated that the LPN should have notified the physician right away and obtained further instructions, checked the backup supply, or called the pharmacy for immediate delivery. The facility policy stated that medications are administered in accordance with prescriber orders, but it did not address missing or undelivered medications.
Failure to Act on CP Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on Consultant Pharmacist (CP) recommendations for 3 of 23 residents whose medication regimens were reviewed. The deficiency involved failure to follow irregularity reporting guidelines in the facility’s policies and procedures, including failure to address CP recommendations within the required timeframe and failure to document prescriber responses for identified medication irregularities. For one resident with COPD, muscle weakness, difficulty walking, and intact cognition, the CP recommended clarifying clonazepam, identifying a stop date for PRN use beyond 14 days, and clarifying the pain severity scale for PRN tramadol. The record showed PRN clonazepam, trazodone, melatonin, and tramadol orders, including tramadol being administered on days when the documented pain level was 0. The surveyor also found that the CP recommendation to identify a stop date and document rationale for PRN insomnia medications was not acted upon, and the recommendation to clarify the pain scale for tramadol was not followed. For another resident with hemiplegia/hemiparesis, intracranial hemorrhage, essential hypertension, severe cognitive impairment, and a tracheostomy with mechanical ventilation, the CP recommended changing PRN acetaminophen liquid from 650 mg to 640 mg because the ordered 20.3 mL dose was difficult to measure. The recommendation was signed by nursing staff, but the survey found no timely follow-up on the recommendation in the record. For a third resident with diabetes, chronic kidney disease, endometrial cancer, osteoarthritis, and intact cognition, the CP recommended that if more than one pain medication was used, the facility should include continuity of pain scales across each order and address all choices 1-10. The resident’s orders for acetaminophen, ibuprofen, and naproxen did not include consistent pain-scale parameters, and nursing staff acknowledged the orders were confusing. The facility policy stated that a licensed pharmacist reviews each resident’s medication regimen at least monthly and that irregularities are to be addressed within 30 days of receipt.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly store and label medications and biologicals in accordance with accepted professional principles and the facility’s medication labeling and storage policy. During inspection of the North Nursing Unit med storage room, the surveyor observed a container of Iodoform packing strips with an expiration date of 2/2026 and a container of acetaminophen ER 650 mg that had been opened but had no expiration date. The RN/UM confirmed that the expired medication and packing strips should have been discarded. During inspection of the North nursing unit med carts, the surveyor and staff identified additional labeling problems. A blister pack of clonazepam 1 mg tablets in the narcotic count was missing a medication label and did not include a resident name, although LPN #1 identified it as belonging to Resident #72 and the back of the bingo card showed clonazepam 1 mg tablets with a use-by date. The pack contained 27 tablets, matching the declining inventory sheet. In a separate med cart, a bottle of acetaminophen 325 mg OTC had no expiration date. LPN #1 and LPN #2 each confirmed the items should have been discarded, and the DON stated that all medications should be labeled with the resident’s name and that missing labels or expired medications should be discarded and the pharmacy contacted.
Failure to Safeguard Resident Medical Information During Care Conference
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information and did not follow its own Resident Rights policy. During an interdisciplinary team (IDT) meeting intended to update a resident's family member on their progress, staff mistakenly brought the wrong resident to the meeting. The Unit Manager began reading the intended resident's medication information aloud with the incorrect resident present. The error was identified when the family member on the phone noted that the resident present did not sound like their family member. Upon checking the identification band, staff confirmed that the wrong resident was present, and the meeting was stopped. The resident whose information was disclosed had diagnoses including muscle wasting and atrophy, type 2 diabetes, and chronic lymphocytic leukemia, and was cognitively intact according to assessment records. The facility's Licensed Nursing Home Administrator confirmed that staff did not verify the resident's identity before discussing medical information, which resulted in a breach of privacy and confidentiality. Facility policy and federal standards require verification of resident identity to protect sensitive health information, but this protocol was not followed in this instance.
Delayed Care and Communication Breakdown Following Resident Injury
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who sustained an injury during rehabilitation therapy. On the day of the incident, the resident twisted their ankle while using a rollator during a physical therapy session. Although the Physical Therapy Assistant (PTA) applied ice and a bandage as a precautionary measure, there was no immediate notification to the nursing staff or physician about the injury. The resident did not initially express significant pain, and the PTA assumed the resident would inform the nursing staff, which did not occur. The following day, the resident was observed to have swelling and reported severe pain in the injured ankle during a physical therapy session. Despite this, there was no documentation in the Nursing Progress Notes regarding the resident's pain or injury on that day. The resident's pain was not assessed by a Registered Nurse until two days after the injury, at which point an x-ray was ordered, revealing a non-displaced fracture of the medial malleolus. The delay in assessment and treatment resulted in a lack of pain management and delayed diagnosis of the fracture. Interviews with facility staff revealed a breakdown in communication between the rehabilitation and nursing departments. The facility's policies required immediate notification of nursing staff following an injury, which did not occur in this case. The nursing staff was unaware of the incident until two days later, leading to a delay in the resident receiving appropriate care and pain management. The facility's documentation policies were not followed, as evidenced by the lack of entries in the Nursing Progress Notes and the Medication Administration Record, which contradicted the physical therapy notes.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed by surveyors on two units. Multiple residents were found wearing two incontinence briefs, both saturated with urine, which is against facility policy. This practice was observed in several residents, including those with severe cognitive impairments and those requiring assistance for personal hygiene. The use of double briefs was noted to potentially cause skin breakdown, as stated by the registered nurses involved in the observations. Specific instances included residents with severe cognitive impairments, such as dementia and Parkinson's disease, who were found with saturated briefs and bedding. These residents were dependent on staff for personal hygiene and required regular incontinence care, which was not provided as per their individualized care plans. The facility's policy was to check and change residents approximately every two hours, but this was not adhered to, leading to the observed deficiencies. Additionally, a resident with intact cognition reported not receiving incontinence care after being transferred to a wheelchair in the morning, remaining in soiled briefs until the evening. This resident's request for two briefs was due to the lack of timely care, resulting in saturated clothing and equipment. The facility's policy and staff statements confirmed that incontinence care should be provided every two hours, yet this was not consistently practiced, leading to the deficiencies noted by the surveyors.
Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, which was identified for six residents during the survey. Observations revealed that the call bells for these residents were either on the floor, under the bed, or otherwise not accessible to the residents. This deficiency was noted during multiple observations over several days, indicating a pattern of neglect in ensuring that residents could summon assistance when needed. The residents involved in this deficiency had severe cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores, and required staff assistance for activities of daily living (ADLs). Their individualized care plans included interventions to ensure the call bell was within reach and to remind residents to use it for assistance. Despite these documented interventions, the call bells were consistently found out of reach, compromising the residents' ability to request help. Staff members, including CNAs and RNs, acknowledged the oversight when shown the misplaced call bells and confirmed that the call bells should have been within reach. The facility's policy on answering call lights emphasized the importance of timely responses to residents' needs, yet this policy was not adhered to, as evidenced by the surveyor's findings. The Director of Nursing confirmed the expectation that call bells should always be accessible to residents.
Failure to Provide Required Insurance Termination Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or the Notice of Medicare Non-coverage (NOMNC) for three residents who were reviewed for facility change notifications regarding insurance termination. Specifically, the facility did not provide the SNF ABN form to two residents who elected to stay in the facility after their Medicare Part A coverage ended. Additionally, the facility failed to provide a NOMNC form to a resident who was discharged to home or a lesser level of care. The deficiency was identified during a survey when the facility presented a list of residents discharged within six months who were required to receive Beneficiary Notices. The surveyor found that the facility did not comply with the notification requirements for the three residents reviewed. The Administrator attributed the errors to a change in social service staff responsible for providing these notifications, but no further information was provided.
Failure to Discontinue Healed Wound Treatment and Follow Physician Orders
Penalty
Summary
The facility failed to discontinue a treatment order for a healed wound and did not follow a physician's treatment order for a resident. The resident, who was alert and able to communicate their needs, had a history of atherosclerotic heart disease, congestive heart failure, and hypertension. The Minimum Data Set assessment indicated no cognitive deficits. The October 2024 Order Summary Report included orders to clean the resident's toe web spaces and apply gauze daily, as well as to cleanse a deep tissue injury on the right buttock and apply a foam cover daily. However, the Wound Assessment Report from September 2024 noted that the right buttock wound had resolved. Despite the wound being healed, the Treatment Administration Record showed that the nurse continued to sign off on the treatment order for the right buttock daily. During an interview, the RN Supervisor confirmed that the treatment orders were still being signed even though the wound had healed. Additionally, the resident stated they were not receiving any wound treatments, and upon inspection, the RN Supervisor confirmed there was no dressing on the right buttock or gauze between the toes. The Director of Nursing was informed of these concerns regarding the physician treatment orders.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease, and dementia. On two separate occasions, the resident was observed without the prescribed continuous oxygen therapy. Initially, the oxygen concentrator was not in use, despite a sign indicating the need for continuous oxygen. The RN assigned to the resident's care acknowledged the oversight and activated the concentrator, setting it to 2.5 liters per minute (lpm), which was above the prescribed 2 lpm. The following day, the resident was again found without the oxygen concentrator in use. The RN, upon entering the room, realized the mistake and corrected it by turning on the concentrator and setting it to the correct 2 lpm. The facility's policy on oxygen administration, which requires verification of physician orders, was not adhered to, leading to these deficiencies. The RN confirmed the discrepancy between the physician's order and the actual oxygen administration, acknowledging the failure to follow the prescribed order.
Failure to Identify Psychoactive Medication Irregularities
Penalty
Summary
The facility failed to identify psychoactive medication irregularities during the monthly Medication Record Review (MRR) conducted by the Consultant Pharmacist (CP) for a resident. The resident, who was admitted with diagnoses including unspecified dementia, obsessive-compulsive disorder, anxiety, and major depressive disorder, was observed to be frequently drowsy and asleep during the survey. Despite recommendations from an Advanced Practical Nurse/Board Certified Psychiatric Nurse Practitioner (APN-C) for gradual dose reductions (GDR) of Lexapro and Seroquel, the CP did not identify these irregularities in the medication regimen. The resident's medical records showed that the APN-C recommended a decrease in Lexapro and Seroquel doses, but the physician's progress notes did not reflect any rationale for not following these recommendations. Additionally, there was no documented discussion with the resident's family regarding the risks and benefits of the dose reductions. The CP's recommendations from May to September did not address the irregularities between the APN-C's recommendations and the physician's notes. During discussions with the survey team, the Director of Nursing (DON) confirmed that the physician was aware of the GDR recommendations but did not document discussions with the family, which was cited as the reason for not implementing the GDR. The CP also failed to communicate effectively with the nursing staff and physician regarding the medication irregularities, as required by the facility's policies and the Consultant Pharmacist Provider Agreement.
Resident Fall Due to Inadequate Assistance
Penalty
Summary
The facility failed to ensure a resident with Alzheimer's disease remained free from accident hazards, leading to a fall incident. The resident, who was severely cognitively impaired and required total assistance with care, including a two-person assist and the use of a Hoyer lift, fell from the bed while being cared for by a single CNA. The incident occurred when the CNA was providing care alone, despite the resident's care plan indicating the need for two-person assistance. The CNA was lowering the bed and had turned the resident on their side when the resident rolled out of bed onto a floor mat, sustaining an abrasion on the forehead. The CNA involved in the incident was newly hired and had received orientation on resident safety. However, during the incident, the CNA proceeded to provide care without waiting for additional assistance, citing a lack of help as the reason for acting alone. The resident's spouse witnessed the fall and called for help, leading to the involvement of an LPN who assessed the resident. The CNA was subsequently suspended and discharged for violating company policy and code of conduct.
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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