St Mary's Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherry Hill, New Jersey.
- Location
- 220 St Mary's Drive, Cherry Hill, New Jersey 08003
- CMS Provider Number
- 315060
- Inspections on file
- 17
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Mary's Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
Two residents with complex medical needs did not receive prescribed medications and nutritional treatments as ordered, and providers were not notified in a timely manner. Documentation in the MAR showed missed and refused doses, but there was no evidence in progress notes that providers were informed, as required by facility policy. Staff interviews confirmed that provider notification and documentation were expected but not completed.
The facility failed to accommodate dietary preferences for several residents, as evidenced by missing or incorrect food items on meal trays. A resident on a specific diet did not receive their ordered items, and another resident reported not receiving requested beverages. The Dietary Department's policy was not followed, leading to unmet resident preferences and inadequate communication among staff.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by surveyors. Issues included expired hot dog rolls and cucumber salad, unlabeled pizza dough, and open containers of food thickener and flour. Additionally, an unlabeled plate of food and outdated blueberries were found in unit pantry refrigerators. These practices were not in compliance with the facility's food storage and dietary policies.
The facility's Arbitration Agreement failed to inform residents or their representatives of their right not to sign as a condition of admission or continued care. The agreement also lacked language allowing communication with officials, as confirmed by the LNHA and Admissions Director.
The facility did not properly test and maintain battery-operated smoke detectors in resident rooms, as required by NFPA 101. Documentation lacked details such as make, model, and battery type, and only included monthly checkmarks. The manufacturer's manual required weekly testing, which was not documented. This affected all 114 smoke detectors, potentially impacting all residents.
The facility failed to conduct fire drills with varying activation types and times as required by NFPA 101: 2012 Edition. The fire drill reports lacked specificity regarding the method of alarm transmission, and six out of twelve drills were conducted on a Saturday without varying times for the first shift. This deficiency had the potential to affect all residents.
The facility's emergency generator annunciator panel was found to be malfunctioning, as the test lamp button did not work and no alarm condition lights functioned, despite the generator running. This issue was identified during an observation and had the potential to affect all residents.
The facility failed to keep an exit stairway free of storage, as required by NFPA 101. During an observation, two chairs were found obstructing the path of egress in the physical therapy stairway, potentially affecting 50 residents. A U.S. FOIA representative confirmed that nothing should be stored in stairway exits.
The facility failed to ensure that an electrical outlet next to a water source in the Physical Therapy room was equipped with GFCI protection, as required by NFPA 70 and NFPA 99. This deficiency, observed during an inspection, had the potential to affect ten residents.
The facility failed to maintain a clean and safe environment, as observed by a surveyor. Linen was found unfolded and piled on a linen cart handle, and soiled utility rooms had overflowing linens and untied trash bags on the floor. The Infection Preventionist and LNHA acknowledged the issues, with the LNHA noting that soiled utility rooms are checked twice during the day shift, but additional checks were requested.
A resident with a history of falls and severe cognitive impairment experienced multiple falls without thorough investigation or documentation. Incident reports lacked witness statements, vital signs, and clarity on whether falls were witnessed. Staff interviews confirmed inconsistencies in following facility policy, and the Director of Nursing acknowledged the deficiencies.
A facility staff member failed to wear a gown during high-contact activities for a resident under Enhanced Barrier Precautions, despite the requirement outlined in the resident's care plan and facility policy. The CNA was observed providing incontinence care with only gloves and a mask, which was confirmed by the UM/LPN, Infection Preventionist, and DON. The facility's policy mandates gown and glove use during such activities to prevent the spread of MDROs.
The facility failed to maintain the required minimum CNA-to-resident ratios as mandated by New Jersey law. Multiple instances of insufficient staffing were identified across several weeks in 2023 and 2024, with the facility consistently falling short of the required number of CNAs during the day shift. Despite the facility's policy to provide sufficient staffing, the documented levels did not meet the state-mandated ratios, as confirmed by interviews with the Staffing Coordinator and the DON.
Failure to Notify Providers of Unadministered and Refused Medications
Penalty
Summary
The facility failed to notify providers in a timely manner when prescribed treatments and medications were not administered as ordered for two residents. For one resident with severe cognitive impairment and multiple complex diagnoses, including epilepsy and cancer, there were several missed doses of phenobarbital documented in the Medication Administration Record (MAR) over multiple dates. The MAR indicated missed doses using a chart code, and progress notes showed that the medication was on order and not yet delivered. However, there was no documentation that the provider was notified of these missed doses until several weeks later, and for some missed doses, no provider notification was documented at all. For another resident with moderate cognitive impairment and multiple medical and psychiatric conditions, including anorexia nervosa, malnutrition, and gastrointestinal disorders, there were missed and refused doses of intravenous nutritional support (Clinimix and Clinolipid) documented in the MAR. The chart codes indicated both unadministered and refused doses, but there was no documentation in the progress notes that a provider was notified of these events. Interviews with staff, including a unit manager and the Director of Nursing (DON), confirmed that provider notification and documentation were expected but not completed or recorded in these cases. Facility policy required that the attending physician or nurse practitioner be notified of changes in condition or when medical intervention was warranted, and that such notifications be documented in the medical record. The DON and other staff acknowledged that the medical record should reflect all care provided, including provider notifications, and that the lack of documentation was not consistent with facility policy. Interviews with providers did not confirm that they had been notified of the missed or refused medications, further supporting the finding that timely provider notification and documentation did not occur.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate resident preferences with specific food items as documented on meal tickets for four out of six sampled residents. Resident #2, who was cognitively intact and on a specific diet due to medical conditions, reported not receiving their food preferences. The Dietician confirmed that Resident #2's lunch tray did not contain the ordered items and communicated this issue to relevant staff. However, the Food Service Director acknowledged that the resident's request for sugar packets was not fully met, and there was no documentation of staff education to prevent recurrence. Resident #1 also reported not receiving requested items like coffee with creamer and sugar, and tea during meals, which was a common complaint in Resident Council Meetings. The Licensed Nursing Home Administrator was aware of a tray being delivered to the wrong room, indicating a lapse in communication and coordination among staff. Additionally, Resident #5 did not receive the ordered two juices and garlic spinach, as confirmed by the Unit Manager and the Certified Nursing Assistant, who admitted to being sidetracked and not fulfilling the resident's request. The Dietary Department's policy required that meal trays be provided as ordered, with routine checks by the Food Services Manager or supervisor. However, the facility's failure to adhere to these policies resulted in residents not receiving their dietary preferences, as evidenced by the surveyor's observations and interviews with staff and residents. The deficiency highlights a lack of effective communication and documentation within the dietary department, impacting the residents' rights to receive meals according to their preferences.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the kitchen's walk-in refrigerator, 15 bags of hot dog rolls were found with a received by date of 11/11/24, and an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. Both items were acknowledged by the Dietary Director (DD) and were discarded. Additionally, in the walk-in freezer, an opened clear plastic bag with pizza dough was found without a label or date, which the DD also discarded. In the prep area, large containers of food thickener and flour were left open and exposed to air, which the DD subsequently closed. Further observations included an unlabeled, covered plate with fish, pork, and fries in a unit pantry refrigerator, which was removed by a Nurse Manager. Another observation in a different pantry refrigerator revealed a plastic container of fresh blueberries dated 11/23/2024, with some appearing dry. The Nurse Manager was unaware of the expiration date for fresh fruit and removed the blueberries. The facility's policies on food storage, freezer management, and dietary practices were reviewed, indicating that the observed practices were not in compliance with the established guidelines.
Plan Of Correction
Plan of Correction F812 Level F Completion Date: 1/15/2025 Corrective Action: Items that were outdated (hotdog rolls and cucumber salad were discarded). Pizza dough was discarded. Open containers in work area were closed. Personal resident food in pantry (blueberries) were discarded. ID Other Residents: Residents who require nutrition from the Dietary Department or who have personal food brought into the facility. Systemic Change: In-service Labeling, Dating and Discarding Food to the Dietary Department by the Dietary Director completed by 1/15/2025. In-service Resident Food Brought into the Facility to Dietary and Nursing Department by the Dietary Director completed by 1/15/2025. Daily rounds will be completed by the dietary staff in the kitchen and pantry to monitor for outdated items and dispose of them per policy. Monitoring: Audit - Labeling and Dating of Items will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by the Dietary Director. Audit Nursing Pantry Refrigerator will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in Arbitration Agreement Language
Penalty
Summary
The facility failed to include explicit language in their Arbitration Agreement to inform residents or their representatives of their right not to sign the agreement as a condition of admission or continued care. This deficiency was identified through a review of the facility's admission packet, which included an Arbitration Agreement titled 'Voluntary, Binding Arbitration.' The agreement did not contain any language explicitly stating that signing was not a requirement for admission or continued care. Additionally, the agreement lacked language allowing residents or others to communicate with federal, state, or local officials, including representatives of the Office of the State Long Term Care Ombudsman. During interviews, the Licensed Nursing Home Administrator (LNHA) and the Admissions Director confirmed the absence of such language in the arbitration agreement. The LNHA acknowledged that the agreement did not explicitly state that signing was not a condition for admission or continued care. Furthermore, the LNHA confirmed that the agreement did not allow for communication with federal, state, or local officials, although an Ombudsman notification form was included in the admission agreement. This oversight has the potential to affect all residents who signed the binding arbitration clause.
Plan Of Correction
1/15/25 Plan of Correction F847 Level F Completion Date: 1/15/2025 Corrective Action: Admissions Agreement changed to reflect appropriate language in regards to Voluntary Binding Arbitration. Admissions Agreement now will state THIS AGREEMENT IS OPTIONAL FOR RESIDENTS AND FACILITY. ADMISSION TO THE FACILITY IS NOT CONDITIONAL UPON A RESIDENT'S WILLINGNESS TO ENTER INTO THIS AGREEMENT. Appropriate officials and departments for the New Jersey Department of Health and Human Services Division of Aging and Long-Term Care Ombudsman contact information added to Admissions Agreement. Added information will be available to those individuals who have previously signed admissions agreements prior to the above changes being made. ID Other Residents: Any resident or Responsible Party who sign an Admission Agreement. Systemic Change: In-service Updated Admissions Agreement to the Admissions Department by the LNHA completed by 1/15/2025. Monitoring: Audit - Admissions Agreement will be completed on the following schedule: (4) weekly x 2 weeks then (4) monthly x 2 months then (4) quarterly x 1 quarter by the Admissions Coordinator. Results of the audits will be brought to QA/QAPI on a quarterly basis x 3 quarters.
Failure to Maintain Smoke Detectors
Penalty
Summary
The facility failed to ensure proper testing and maintenance of battery-operated smoke detectors in resident rooms, as required by the NFPA 101 Life Safety Code: 2012 Edition. This deficiency was identified during an interview and documentation review, which revealed that the facility's preventative maintenance logs lacked detailed information about the smoke detectors, such as make, model, installation date, and battery type. The logs only contained a checkmark for each room every month, without any further details. Additionally, the manufacturer's user manual indicated that the smoke detectors should be tested at least once a week, a requirement that was not reflected in the facility's documentation. This oversight affected all 114 documented battery-operated smoke detectors in the facility, potentially impacting all residents. The findings were communicated to the U.S. FOIA (b)(6) during the Life Safety Code exit conference.
Plan Of Correction
Plan of Correction K0347 Level F Completion Date: 1/15/2025 Corrective Action: 10 year maintenance free battery operated smoke detectors were tested in all resident rooms on 12/12/24 and operational as designed. ID Other Residents: Any resident within the facility Systemic Change: In-service Monitoring Smoke Detectors to the Maintenance Department by the Maintenance Director completed on 12/20/24. Smoke Detectors will be tested monthly and a log maintained by the Maintenance Department. Monitoring: Audit - Smoke Detectors will be completed on the following schedule: (10) quarterly x 3 quarter by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Inadequate Fire Drill Procedures
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Sections 19.7.1.4 through 19.7.1.7. This deficiency was identified during a document review and interview on December 3, 2024, in the presence of the U.S. FOIA (b)(6). The review revealed that the facility's fire drill reports did not specify the method used for the simulation of alarm transmission signals. Additionally, six out of twelve drills were conducted on a Saturday, and the times for the first shift drills were not varied, which is a requirement for ensuring staff preparedness under different conditions. The lack of specificity in the fire drill reports and the failure to vary drill times and activation types had the potential to affect all residents in the facility. The findings were verified by the [R] at the time of the record review, and the U.S. FOIA (b)(6) confirmed the inadequacies in the documentation and execution of the fire drills. These issues were discussed at the Life Safety Code exit conference on December 4, 2024.
Plan Of Correction
Plan of Correction K0712 Level F Completion Date: 1/15/2025 Corrective Action: - Additional 12/24 Fire Drill will be performed during the day shift and not on a weekend. - Additional 12/24 Fire Drill will reflect type of signal. ID Other Residents: - All residents within the facility have the potential to be affected. Systemic Change: - In-service Fire Drill Testing, Scheduling, Monitoring to the Maintenance Department by the Maintenance Director on 2/2/24. - Fire Drills will be performed during the evening and night shifts and not on the weekend to ensure fire drill training is completed on all shifts. - Supervision log will be utilized to ensure fire drills are completed timely, note signal type and vary for the appropriate shift and time. Monitoring: - Audit - Fire Drill will be completed on the following schedule: (3) quarterly x 3 quarters by the Maintenance Director/Designee. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Emergency Generator Annunciator Panel Malfunction
Penalty
Summary
The facility failed to ensure that the emergency generator annunciator was fully functional and operating in normal mode, as required by NFPA 99: 2012 Edition, Section 6.4.1.1.17 and 6.4.1.1.17.5. During an observation at 11:32 AM, it was noted that the generator annunciator panel's test lamp button did not work when activated. Although the generator produced a green light on the annunciator panel indicating it was running, no other alarm condition lights functioned at the time of observation. This deficiency was identified for the only generator annunciator panel in the facility and had the potential to affect all residents. The findings were communicated to the relevant personnel at the Life Safety Code exit conference.
Plan Of Correction
K0916 Level F Completion Date: 1/15/2025 Corrective Action: The generator was inspected and found to be functioning as designed and a new annunciator control board ordered for Generator Annunciator Panel. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Annunciator Panel Monitoring and Resident Safety to the Maintenance Department by the Maintenance Director completed by 12/20/2024. Monitoring: Audit - Annunciator Panel will be completed on the following schedule: every quarter x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Obstruction in Exit Stairway
Penalty
Summary
The facility failed to maintain one of its six exit stairways free of storage, as required by NFPA 101: 2012 Edition, Sections 19.2.2.3, 19.2.2.4, and 7.2. During an observation conducted on December 4, 2024, in the presence of a U.S. FOIA representative, it was noted that two chairs were obstructing the path of egress in the physical therapy stairway. One chair was located on the middle landing, and another was on the lower level of the exit/egress stairs leading to the public way. This deficiency had the potential to affect 50 residents. In an interview at the time of the observation, the U.S. FOIA representative acknowledged that nothing should be stored in the stairway exits at any time. The findings were communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
1/15/25 Plan of Correction K0225 Level E Completion Date: 1/15/2025 Corrective Action: - 2 chairs removed from therapy stairwell. - Other stairwells were checked and no obstruction noted. ID Other Residents: - Any resident within the facility have the potential to be affected. Systemic Change: - In-service Stairwells Free of Obstruction to the Maintenance and Therapy Departments by the Maintenance Director completed on 12/20/24. Monitoring: - Audit - Obstruction in Stairwell will be completed on the following schedule: (4) quarterly x 3 quarter by the Maintenance Director. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Equip Electrical Outlet with GFCI Protection
Penalty
Summary
The facility failed to ensure that one of ten electrical outlets located next to a water source was equipped with Ground-Fault Circuit Interrupter (GFCI) protection, as required by NFPA 70 and NFPA 99. This deficiency was observed on December 4, 2024, during an inspection in the Physical Therapy room. At 11:50 AM, it was noted that a device was plugged into a standard duplex wall outlet instead of the required GFCI outlet for wet locations. This oversight had the potential to affect ten residents. The finding was confirmed by the U.S. FOIA (b)(6) at the time of observation and was communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
Plan of Correction K0912 Level F Completion Date: 1/15/2025 Corrective Action: Existing outlet was removed and replaced with GFCI outlet. Facility wide inspection has been completed for GFCI outlets. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Testing and Inspection of GFCI Outlets to the Maintenance Department by the Maintenance Director on 12/20/2024. Facility wide inspection of installed GFCI. Monitoring: Audit - GFCI Outlet will be completed on the following schedule: (4) quarterly x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by observations made by a surveyor. On December 3, 2024, in the St. [NAME] hallway, linen including towels and blankets were found unfolded and piled onto the outside handle of the linen cart. Additionally, in the St. [NAME] Soiled Utility room, linens were observed overflowing and not bagged from the receptacle, with two trash bags placed on top of the trash receptacle. In the St. Mary's soiled utility room, linens in untied trash bags were left on the floor. During an interview on December 4, 2024, the Infection Preventionist acknowledged that soiled utility rooms should not be piled up and confirmed that she ensures nothing is on the floor. On December 5, 2024, the Licensed Nursing Home Administrator (LNHA) stated that soiled utility rooms are checked twice during the day shift, but additional checks by housekeeping were requested. The LNHA confirmed that trash bags should be in receptacles and not on the floor.
Plan Of Correction
Plan of Correction F584 Level D Completion Date: 1/15/2025 Corrective Action: Linen found outside of the linen cart was placed in soiled laundry. Linens in the Soiled Utility Room were tied, taken off the floor and placed in the receptacle. Soiled linen was removed from Soiled Utility Room. ID Other Residents: Any resident within the facility Systemic Change: In-service Proper Storage of Linens will be given to the Nursing Department and Laundry by Nurse Educator completed by 1/15/2025. In-service Proper Disposal of Soiled Linens will be given to the Nursing Staff and Laundry by Nurse Educator completed by 1/15/2025. Soiled linens will be collected by laundry service 3 xs daily on the morning shift and 2 xs daily on the evening shift. Additional laundry disposal bins will be purchased to handle the amount of soiled linen that is created. Monitoring: Audit - Clean and Soiled Linen will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xos 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Audit Soiled Utility Room Linen Disposal will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xos 3 quarters.
Inadequate Fall Investigation and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and conduct thorough investigations for a resident who experienced repeated falls. The surveyor reviewed incident reports for falls that occurred on three separate occasions. The reports lacked essential details such as statements from witnesses, vital signs, and whether the falls were witnessed or unwitnessed. The facility's policy required these elements to be included in the incident reports, but they were missing in the cases reviewed. The resident involved had a history of repeated falls and was admitted with diagnoses including cardiomegaly and hypomagnesemia. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). Despite these conditions, the incident reports did not include comprehensive assessments or documentation of the resident's condition following the falls, such as vital signs or any potential injuries. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the documentation process. Staff confirmed that statements from witnesses and detailed assessments were not consistently obtained or recorded. The Director of Nursing acknowledged the deficiencies in the incident reports and confirmed that the facility's policy was not followed, as the reports lacked signatures, titles, and complete information about the incidents.
Plan Of Correction
Plan of Correction F610 Level D Completion Date: 1/15/2025 Corrective Action: Resident #347 incident report dated 26 was reviewed and reinvestigated by Nursing Administration. Statements were obtained by nursing staff involved in care of resident during incident. Post incident follow up was rewritten. ID Other Residents: Any resident within the facility who has an incident that requires an investigation. Systemic Change: In-service How to Complete a Thorough Investigation to the Nursing Department by Nursing Administration by 1/15/2025. In-service What to Include in an Incident Report: to the Nursing Department by Nursing Administration by 1/15/2025. Statements will be obtained for all unwitnessed incidents by those individuals who interacted with resident within the timeframe of the incident. Monitoring: Audit - Incident Reports and Investigations will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration by 1/15/2025. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to appropriate infection control practices by not wearing a gown during high-contact activities in a resident's room who was under Enhanced Barrier Precautions. This deficiency was identified for a resident reviewed for respiratory care. The resident's electronic medical record indicated an order for Enhanced Barrier Precautions every shift for catheter/wound care, requiring staff to wear a gown and gloves during high-contact activities such as dressing, bathing, transfers, linen changes, providing hygiene, brief changes, toileting assistance, indwelling medical device care, and wound care. During an observation, a Certified Nurse Aide (CNA) was seen providing incontinence care to the resident without wearing a gown, despite wearing gloves and a mask. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the CNA's failure to wear a gown during the care. The Infection Preventionist and the Director of Nursing (DON) both confirmed that staff are expected to wear a gown and gloves when providing incontinence care to residents under Enhanced Barrier Precautions. The facility's policy on Enhanced Barrier Precautions, dated March 2024, also outlined the requirement for gown and glove use during high-contact resident care activities to reduce the transmission of multiple-drug resistant organisms.
Plan Of Correction
Plan of Correction F880 Level E Completion Date: 1/15/2025 Corrective Action: 1:1 in-service provided to CNA #1 regarding appropriate PPE when providing care to a resident on Enhanced Barrier Precautions. ID Other Residents: Any resident within the facility who requires care. Systemic Change: In-service Enhanced Barrier Precautions and Proper PPE will be given facility to the Nursing Department by Infection Preventionist will be completed by 1/15/2025. Personal Protective Equipment (PPE) will be made available in clean work rooms as well as in each resident room who is identified on Enhanced Barrier Precautions (EBP). Monitoring: Audit - PPE for Enhanced Barrier Precautions will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the facility's Nurse Staffing Report (AAS-11) and interviews with facility staff. The report highlighted multiple instances where the facility did not meet the staffing requirements for Certified Nurse Aides (CNAs) during the day shift across several weeks in 2023 and 2024. For example, during the week of October 29, 2023, to November 4, 2023, the facility was deficient in CNA staffing on four out of seven day shifts, with the number of CNAs ranging from 13 to 21, while at least 25 were required for the number of residents present. Further deficiencies were noted in subsequent periods, including April 28, 2024, to May 11, 2024, where the facility was deficient on 11 out of 14 day shifts. The number of CNAs ranged from 16 to 21, while at least 25 were required for the resident count. Similar patterns of insufficient staffing were observed in August and November 2024, with the facility consistently failing to meet the mandated staffing ratios. These deficiencies were confirmed through interviews with the Staffing Coordinator and the Director of Nursing, both of whom claimed that the facility met the staffing requirements despite evidence to the contrary. The facility's policy titled "Staffing," revised in March 2020, stated that the facility would provide sufficient numbers of staff with the necessary skills and competency to care for all residents. However, the documented staffing levels did not align with this policy, as the facility repeatedly failed to meet the minimum staffing requirements based on the residents' needs and the state-mandated ratios. This discrepancy between policy and practice contributed to the identified deficiency in staffing levels.
Plan Of Correction
Plan of Correction S560 Completion Date: 1/15/2025 Corrective Action: - No residents were identified - Staffing levels were reviewed for all deficient dates listed - Additional staff were recruited to meet the minimum staffing standards moving forward ID Other Residents: - Potential to affect all residents residing within the facility Systemic Change: - Bonuses are offered for double shifts, extra shifts, and weekends - Perfect attendance bonuses are offered on a weekly basis - In-service Lateness and Attendance Policy - Usage of Staffing Agencies to supplement staffing needs - Offering of Certified Nursing Assistant Courses within the facility - Referral Program promoted for staff - Sign on bonuses to assist with staff recruitment - Employee Appreciation parties - In-service State Mandated Staffing Levels: to the Nursing Department by Nursing Administration by 1/15/2025 - Additional shifts will be made available to meet staffing levels for Certified Nursing Assistants - Licensed staff will supplement Certified Nursing Assistant positions if the need arises that staffing levels go below the state required minimum Monitoring: - Nursing Administration will conduct weekly CNA staffing schedule audits - Nursing Administration will report findings to the Administrator - Results of the audits will be brought to QA/QAPI on a quarter basis for 3 quarters.
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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