The Center For Rehab & Nursing Washington Township
Inspection history, citations, penalties and survey trends for this long-term care facility in Sewell, New Jersey.
- Location
- 535 Egg Harbor Road, Sewell, New Jersey 08080
- CMS Provider Number
- 315231
- Inspections on file
- 19
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at The Center For Rehab & Nursing Washington Township during CMS and state inspections, most recent first.
Failure to Investigate Abuse Allegation: A cognitively impaired resident alleged that a nightshift CNA punched them, but the CNA who heard the allegation told an LPN and then did not report it further when the LPN said he did not want to get involved. The DON and LNHA were unaware of the allegation when interviewed, and no investigation had been started at that time. The resident had severe cognitive impairment and later stated they had received punches and that the incident should have been reported sooner.
Unsanitary dish handling and pantry conditions: A surveyor found dirty cups and a bowl with debris still present before meal service, and debris transferred from the cups onto a paper towel during inspection. In multiple pantry areas, the surveyor observed exposed glycerin swab sticks in a freezer, sticky debris on the floor and trash can lid, splatters on walls and pipes, loose trash and particles on the floor, and debris in steam trays. The FSD stated dishes must be thoroughly cleaned and that the swab sticks should not have been stored in the freezer, while the HKD said there was no formal pantry cleaning schedule.
A resident with chronic shoulder pain, osteoarthritis, and intact cognition received PRN oxycodone for documented pain scores that did not match the order for severe pain. MAR review showed repeated administrations at pain levels below severe, while the Consultant Pharmacist noted the mismatch multiple times and staff did not document action taken. Interviews showed staff understood severe pain as 7-10, but the DON stated there was no policy defining pain scale levels and the pain medication order did not include numeric pain guidance.
A cognitively impaired resident with a history of depression, anxiety, and severe cognitive impairment told a CNA that a night-shift CNA had punched them in the ribs. The CNA reported the allegation only to an LPN, who allegedly said he did not want to get involved, and the CNA did not escalate the report further, leaving the allegation undocumented in the record. When later interviewed, the resident stated they had received a couple of punches from a staff member and that the CNA knew who it was. Other staff described the resident as confused but not prone to false accusations. Facility leadership stated that all abuse allegations must be immediately reported up the chain of command for investigation and that accused staff should be removed from duty, but they were unaware of this allegation until informed by surveyors, indicating the facility’s abuse reporting policy was not followed.
Homelike Environment Not Maintained: Surveyors observed a cracked bedroom window, patched walls, stained ceiling tiles, cracks above doorways, debris on a shower bed, and stored items on the shower room floor on the 200 Unit, along with stained ceiling tiles on the hallway leading to the 300 Unit. The MD said several repairs were ongoing, including a delayed window replacement, and the HKD stated shower rooms were cleaned daily by housekeeping and after each resident use by nursing staff, but the shower room condition was not consistent with infection control standards or a homelike environment.
A cognitively impaired resident alleged that a staff member punched him/her in the side/back, but the allegation was not escalated after a CNA told an LPN and no further report was made. The resident had severe cognitive impairment on MDS, and staff interviews showed they knew abuse allegations should be reported immediately through the chain of command to the DON and LNHA. The facility’s policy required abuse allegations to be reported to the state within 2 hours, but the allegation was not reported to NJDOH within that timeframe.
Incomplete and Non-Specific Care Plan: A resident with spine fusion, bacterial pneumonia, osteomyelitis, and moderately impaired cognition had an ICCP that was not comprehensive or individualized. The plan listed vague or incomplete focuses such as infection, feeding tube use, impaired vision, hydration risk, toileting assistance, ADL deficits, falls, pain, and several medication-related therapies, but many entries lacked resident-specific details and included only generic interventions.
A resident with ESRD, dialysis dependence, and type 2 DM had ordered HD on M/W/F at 7:15 AM, plus insulin lispro, sevelamer, and timolol. The care plan did not address coordinating meds with dialysis, and MAR review showed multiple doses documented as not administered during dialysis times. Staff stated dialysis residents’ meds should be scheduled before or after dialysis, and the DON said the meds should be sequenced to when the resident was in the facility with MD approval.
A resident with atrial fibrillation, HTN, disorientation, and moderately impaired cognition had orders for Cardizem CD and Metoprolol, but the MAR showed multiple Code 9 entries for missed doses without a corresponding progress note explaining why the meds were not given. Staff, including an LPN, LPN/UM, and DON, stated that Code 9 should be accompanied by documentation of the reason the medication was withheld or not administered.
Failure to Report and Investigate Alleged Resident Abuse: A cognitively impaired resident told a CNA that a nightshift CNA punched the resident in the ribs, but the CNA only reported it to an LPN who said he did not want to get involved and no further report was made. The DON and LNHA later said they were unaware of the allegation, even though facility policy required abuse allegations to be reported to administration, investigated, and the resident protected during the investigation.
A resident with a sacral wound did not receive timely wound care due to a failure to transcribe a verbal order into the facility's system. The wound worsened, leading to hospital admission for debridement. Interviews confirmed that facility procedures for wound care orders were not followed, contributing to the deficiency.
The facility failed to provide a homelike environment by not ensuring adequate access to clean linens for residents. A surveyor observed a shortage of washcloths and towels in the 500 Unit, affecting 30 residents. Staff interviews revealed that linens were delivered late, and there were frequent complaints about the lack of linens. The DON and LNHA acknowledged the issue, with the DON attributing it to improperly labeled bins leading to discarded linens.
A facility failed to update a resident's care plan after a new wound was identified. The resident, admitted with conditions like anemia and muscle weakness, developed a skin tear in the sacral area. Although documented in progress notes, the care plan was not revised to include interventions for the wound. Interviews revealed a lack of understanding and adherence to the facility's policy on care plan updates.
A facility failed to secure a treatment cart and properly label a wound dressing during care for a resident. An RN left the treatment cart unlocked and unattended while performing wound care, and applied a dressing without initialing, dating, or timing it. Interviews confirmed the importance of these actions for safety and compliance with facility policies.
The facility was found deficient in food safety and storage practices, with observations of undated and expired food items, and incomplete temperature logs in the kitchen. The Dietary Director acknowledged the issues, which included expired bread and undated juice containers, contrary to the facility's food service policy.
A facility staff member failed to follow infection control practices by returning an opened pack of unused 4x4 gauze to the treatment cart after wound care, instead of discarding it. This was observed by a surveyor and confirmed by the RN involved, as well as the Infection Preventionist and DON, who reiterated the importance of discarding unused supplies to prevent cross-contamination.
The facility's wireless call bell system failed to alert staff effectively, leading to delayed responses to residents' needs. A resident with a fracture and other conditions reported a 50-minute delay in response, while another with COPD and anemia experienced similar issues. Staff interviews revealed that the system did not ring to work areas, requiring visual monitoring in hallways. The DON and LNHA confirmed the lack of a centralized alert system.
A facility failed to provide adequate nursing staff, resulting in delayed incontinence care for a resident. The resident was found with a saturated brief, and the CNA responsible had an excessive workload, including 13 residents needing significant assistance. Staffing records showed consistent deficiencies in meeting mandated ratios, impacting care quality. The DON acknowledged the shortfall, and the facility's staffing policy aimed to meet required ratios but fell short.
The facility failed to maintain safe food handling and sanitation practices, as observed in the kitchen and five pantries. Open food items were found in the walk-in freezer, and several pantries had issues such as missing thermometers, debris, and unlabeled resident food. Staff interviews revealed miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas.
The facility failed to maintain a sanitary environment by not properly disposing of garbage in the dumpster area. Observations revealed debris and trash bags on the ground, contrary to the facility's policy. The FSD, FM, and LNHA acknowledged the issue, emphasizing the responsibility of maintenance, housekeeping, and dietary staff to keep the area clean to prevent pest infestations.
The facility failed to provide a dignified dining experience in one dining area, where two residents seated at the same table were not served their meals simultaneously. This led to one resident taking food from another's plate. The Registered Dietician and DON confirmed that meals should be served at the same time to maintain dignity, as per facility policies.
A facility failed to document a resident's life-sustaining treatment preference on the physician's orders. The resident, admitted with multiple diagnoses and an intact cognitive status, had no documented code status in their medical record. Interviews with staff revealed that the code status should have been determined upon admission, as per facility policy, but this process was not followed.
A facility failed to report an allegation of staff-to-resident abuse to the NJDOH and the Office of the Ombudsman in a timely manner. A resident with dementia and other conditions was allegedly emotionally abused by a CNA, as reported by the resident's family. The DON and staff did not follow proper reporting procedures, resulting in incomplete documentation and incorrect faxing of the report. The facility's policy requires immediate reporting of abuse allegations, which was not adhered to in this case.
A facility failed to conduct a thorough investigation into an alleged staff-to-resident abuse incident. A resident's family reported emotional abuse by a CNA, but the facility's investigation lacked comprehensive interviews and documentation, including missing statements from the involved CNA and the resident's roommate. The facility's policy requires thorough investigations, which was not adhered to in this case.
A facility failed to update a resident's care plan after the resident developed contractures. Despite therapy recommendations for daily range of motion (ROM) exercises, the resident's care plan did not reflect these needs. Interviews with staff revealed that the resident's contractures were not included in the care plan, and there were no physician orders or CNA instructions for ROM exercises. The Director of Nursing confirmed that the care plan should have been revised to include these details.
A resident with severe cognitive impairment and physical limitations did not receive proper nail care, resulting in a long, jagged fingernail on a contracted hand. Despite the care plan's directives and facility policy, staff were unclear about their responsibilities, leading to a lapse in care. Interviews revealed inconsistencies in understanding who was responsible for nail care, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses was not provided with meaningful activities reflecting their preferences. Despite a care plan indicating a preference for group activities, there was no documentation of participation or refusal in the past six months. On the survey day, the resident was found in bed during a scheduled activity, and the activity staff did not conduct the planned event. Staff interviews revealed a lack of coordination and documentation regarding the resident's activity participation.
A resident with multiple health issues, including a risk for skin integrity alteration, was found with an undocumented bandage on their forearm. The facility failed to notify the physician, obtain a treatment order, and document the injury, contrary to their policies. Staff interviews confirmed the lack of documentation and investigation.
A resident with severe cognitive impairment and a history of falls was observed without required floor mats on multiple occasions, despite physician orders and care plan interventions. Staff interviews confirmed the expectation for floor mats to be in place, but the facility lacked a policy and did not document the order in the treatment administration record.
A resident requiring CPAP therapy upon admission did not receive it until several days later due to communication failures and procedural oversights. The CPAP equipment was improperly stored, and the therapy was not included in the resident's care plan, contrary to facility policies.
The facility did not ensure the daily Nursing Home Resident Care Staffing Report was posted in an accessible location for residents and the public. The report was only available at the receptionist's desk in the front lobby, requiring a pass code for access to nursing units. The Director of Nursing and Licensed Nursing Home Administrator were unaware of the requirement for the report to be accessible without request, and the Staffing Coordinator confirmed limited posting locations. The facility's staffing policy lacked details on the required daily posting.
A resident with pressure ulcers received wound care from an LPN who failed to follow proper hand hygiene protocols. The LPN did not consistently wash hands or use ABHR between glove changes, washing hands for only eight seconds instead of the required twenty. This deficiency was confirmed through interviews with the LPN, Infection Preventionist, and DON, highlighting a significant infection control concern.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to initiate and complete a thorough investigation after a cognitively impaired resident alleged staff-to-resident physical abuse. Resident #123 had diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms involving cognitive functions and awareness, and the quarterly MDS dated 11/15/25 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. The resident’s care plan addressed cognitive loss, a right to a safe environment free from abuse, and resistive/noncompliant behaviors related to cognitive impairment. According to CNA #1’s statement and interview, Resident #123 reported that a nightshift CNA punched the resident in the ribs on 1/23/26 at 9:15 AM. CNA #1 stated she immediately told LPN #1, but he said he did not want to get involved. CNA #1 then did not report the allegation to anyone else. The resident later told the surveyor that they had received “a couple punches” and identified that CNA #1 probably knew who the perpetrator was. The resident also stated that the incident happened less than a month ago and that it would have been better if it had been reported earlier. When interviewed, the DON and LNHA stated they were not aware of the allegation and that an investigation had not yet been started at the time the surveyor raised the issue. The facility’s records reviewed by the surveyor did not include any abuse allegation in the progress notes from 1/20/26 through 2/3/26. Staff interviews showed that personnel understood allegations of abuse should be reported immediately through the chain of command, but that did not occur in this case. The report states the facility’s failure to implement its abuse policy by immediately investigating the allegation placed Resident #123 and all residents at risk for abuse and resulted in an Immediate Jeopardy situation.
Unsanitary dish handling and pantry conditions
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. During a spot-check of dishes in the large dining area before meal service, three 8 oz blue coffee cups and one black bowl were observed with debris inside. When the surveyor inspected the dishes with a paper towel, brown debris transferred from the coffee cups onto the towel, showing the items were not clean for service. Additional observations in multiple pantry areas showed unsanitary conditions and improper storage. In the 200 Unit pantry, an open package of lemon-flavored glycerin swab sticks was found exposed in the freezer, along with brown sticky debris, an open sugar packet, an open straw, and a trash can lid with brown sticky debris and loose trash exposed. In the 400 Unit pantry, the walls had splatters of brown debris and the steam trays contained white debris. In the 500 Unit pantry, the walls and pipes had splatters of brown debris, the floor had loose paper and particles, and there was a loose plastic cup, additional paper, white debris, a cabinet with brown sticky debris, and steam table trays with white debris. The Food Service Director stated that dishes should be thoroughly cleaned and that the glycerin swab sticks should not have been stored in the freezer. The Housekeeping Director stated housekeeping was responsible for cleaning pantry floors, walls, and trash, but there was no formal cleaning schedule for the pantries.
Pain Medication Administered Outside Ordered Pain Levels
Penalty
Summary
The facility failed to consistently administer pain medication according to the physician’s order and Consultant Pharmacist recommendations for one resident with chronic bilateral shoulder pain and osteoarthritis. The resident also had diagnoses of dementia with mild cognitive impairment, major depressive disorder, and anxiety disorder, and had a BIMS score of 15 out of 15, indicating intact cognition. The care plan identified oxycodone therapy for severe pain, and the physician order directed oxycodone 5 mg by mouth every 8 hours as needed for severe pain. Review of the MARs showed multiple administrations of oxycodone when the documented pain scores were 0, 2, 3, 4, 5, or 6, rather than severe pain. The Consultant Pharmacist repeatedly noted that documented pain levels of 0, 2, 3, and 4 did not match the PRN oxycodone indication of severe pain, and later noted that the resident had no PRN order covering moderate pain and that oxycodone had been administered for pain levels of 0 and 6. These recommendations were initialed by staff, but no action taken was documented in the reports reviewed. During interviews, an LPN stated that severe pain was 7 and above and commented that the order did not include a numeric pain scale related to severe pain. Another LPN stated that severe pain was 7 to 10 and that mild, moderate, and severe pain levels were expected to be included in pain medication orders. The DON stated there was no policy addressing pain levels with associated numerical ratings, and also stated that pain medication orders should define mild, moderate, and severe pain levels. Facility policy related to pain medication did not address or define pain scale levels.
Failure to Report and Act on Resident’s Allegation of Staff Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. The resident had multiple diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and cognitive impairment, with a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan included interventions related to cognitive loss, the right to be free from abuse, and approaches for resistive or noncompliant behavior. Progress notes from 1/20/26 through 2/3/26 contained no documentation of any abuse allegation. During an interview, a CNA reported that approximately a week prior, the resident told her that a night-shift CNA had punched the resident in the ribs. The CNA stated she immediately informed an LPN, who allegedly responded that he did not want to get involved, and the CNA did not report the allegation to anyone else. The CNA believed the alleged perpetrator was another CNA who worked overnight and had previously received a written warning related to resident care. When interviewed, the resident initially had difficulty recalling the incident but then stated they had received a couple of punches from a staff member and indicated that the CNA probably knew who the perpetrator was. Other staff described the resident as confused but not known to make false accusations. Facility leadership, including the DON and LNHA, stated that staff were required to immediately report any abuse allegations to a supervisor so an investigation could be initiated and that staff accused of abuse should be suspended to protect residents. They reported being unaware of the allegation until informed by the surveyor and confirmed that the CNA should have reported the allegation beyond the LPN. Review of the facility’s Abuse Prevention Program policy showed requirements to protect residents from abuse, train staff on identification and reporting of abuse, and identify, assess, investigate, and report all possible incidents of abuse, which were not followed when the initial allegation from the resident was not promptly and fully reported or acted upon.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike environment that was clean, safe, and sanitary on the 200 and 300 units. On the 200 Unit, the surveyor observed a cracked bedroom window in one room that allowed air to pass through, multiple patched areas on the walls, a brown-stained drop ceiling tile in the hallway, cracks above the shower room and nursing supplies room entrance doors, white debris on a shower bed, and stored items on the shower room floor including uncovered pillows, plastic-wrapped pillows, a black metal device, and an air-pressure mattress pad. The surveyor also observed a piece of wall paint ripped away near the sink by the soap dispenser in the shower room. On the hallway leading to the 300 Unit, the surveyor observed two brown-stained drop ceiling tiles with white material coming through them. The Maintenance Director stated that the cracks above doorways were recurring settled cracks, that the spackling in the room and hallways was related to planned painting, that wall damage in the shower room resulted from relocating hand sanitizer dispensers, and that repairs had been underway for one to two months. He also stated that a replacement window for the room had been ordered six months earlier but was delayed due to financial approval and partial vendor payment, and that the delivered window had incorrect measurements. The Housekeeping Director stated that housekeeping cleaned shower rooms daily and nursing staff cleaned them after each resident use, and the report stated the shower room condition was not consistent with infection control standards and did not meet the requirements for a homelike environment.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report within two hours to the NJDOH an allegation of abuse after a cognitively impaired resident reported that a staff member punched him/her in the ribs/side/back. Resident #123 had diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms involving cognitive functions and awareness, and the quarterly MDS dated 11/15/25 showed a BIMS score of 7 out of 15, indicating severely impaired cognition. The care plan addressed cognitive loss, dignity and respect, and resistive/noncompliant behavior related to cognitive impairment. According to CNA #1’s written statement and interview, the resident reported the allegation to her on 1/23/26 at 9:15 AM. CNA #1 stated she immediately told LPN #1, but he said he did not want to get involved, and she did not report the allegation to anyone else. The resident later told the surveyor that CNA #1 knew about the incident and that, if it had been reported earlier, it would have been better. Other staff interviewed stated that allegations of abuse should be reported immediately through the chain of command to the supervisor, DON, and LNHA. The DON and LNHA stated they were unaware of the allegation until the surveyor informed them during the investigation, and they verified that CNA #1 should have reported it to a supervisor. The facility’s Abuse Investigation and Reporting policy stated that alleged abuse must be reported immediately, but not later than two hours if the allegation involves abuse, and that the Administrator or designee reports to the state licensing/certification agency. The deficiency was based on the facility’s failure to ensure the allegation was reported to NJDOH within the required timeframe.
Incomplete and Non-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for one resident reviewed for care plans. The resident had diagnoses including fusion of the spine, bacterial pneumonia, and osteomyelitis of the vertebra, and the comprehensive MDS dated 11/16/25 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. The resident was also taking an antibiotic medication. On 1/29/26, the resident was observed sitting in the room and stated being on a long-term antibiotic and having no concerns. Review of the individualized comprehensive care plan showed multiple incomplete and nonspecific focuses and interventions. The care plan listed an incomplete focus of infection without identifying the type of infection and included only one intervention to administer medication per physician order. Additional care plan entries were also incomplete, including need for feeding tube/potential for complication of feeding tube use, impaired vision, risk for alteration in hydration, toileting assistance, ADL self-care deficit, risk for falls, pain, anticoagulant therapy, anticonvulsant therapy, endocrine system, and diuretic therapy. Several of these entries lacked resident-specific details, and some interventions were limited to generic statements such as diet type, total dependence for toileting, extensive assist with ADLs and bed mobility, and administering pain medication per physician orders.
Missed Medication Administration During Dialysis Schedule
Penalty
Summary
The facility failed to adjust medication administration times to accommodate a resident’s scheduled dialysis treatments. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus, and the comprehensive MDS indicated intact cognition with a BIMS score of 15 out of 15 and that the resident received dialysis treatments. The individualized care plan identified the resident’s need for dialysis related to renal failure, but it did not include interventions to coordinate the medication schedule with dialysis times. The resident was ordered hemodialysis by wheelchair on Monday, Wednesday, and Friday with pickup at 7:15 AM, along with insulin lispro with meals, sevelamer with meals, and timolol eye drops twice daily. Review of the January and February 2026 MARs showed multiple instances in which these medications were documented as not administered during the resident’s dialysis dates and times. Staff interviews confirmed that dialysis residents’ medications were supposed to be scheduled before or after dialysis so doses would not be missed, and that if a medication time conflicted with dialysis, the nurse should notify the supervisor, ADON, or physician to have the schedule adjusted. The DON stated the medications should be sequenced to when the resident was in the facility with physician approval, but the MARs showed the medications were still documented as not administered during dialysis times.
Missing Documentation for Withheld Medications
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when the facility failed to document a rationale for medications that were not administered for one resident. The resident had diagnoses including atrial fibrillation, hypertension, and disorientation, and the admission MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition. The care plan identified cardiac disease related to hypertension, atrial fibrillation, and congestive heart failure, with interventions to administer medications per physician orders. The resident had physician orders for Cardizem CD 120 mg daily and Metoprolol Succinate ER 50 mg daily for hypertension. The MAR showed Code 9 entries for both medications on multiple dates, and for Metoprolol on additional dates. The corresponding progress notes did not include a rationale for why the medications were not administered. Staff interviews confirmed that Code 9 was used when a medication was not available, refused, or possibly held for low blood pressure, and that a progress note should be written to explain why the medication was not given. The DON acknowledged that a progress note should have been written when Code 9 was used and stated the facility did not have a policy reflecting the specific codes used during medication administration.
Failure to Report and Investigate Alleged Resident Abuse
Penalty
Summary
The LNHA failed to ensure staff and facility leadership followed the abuse reporting and investigation policies after a cognitively impaired resident alleged that a nightshift CNA punched the resident in the ribs. The report states that the resident, Resident #123, told CNA #1 about the alleged physical abuse, and CNA #1 then told LPN #1, who said he did not want to get involved. CNA #1 did not report the allegation to anyone else after that response. The surveyor interviewed Resident #123, who initially said they could not recall the incident, then stated, "I can't honestly say, too much time has gone by, but I did get a couple punches from her." CNA #1 later provided a written statement confirming that the resident reported the allegation on 1/23/26 at 9:15 AM and that she reported it to LPN #1, but no further report was made. The DON and LNHA stated they were unaware of the allegation when interviewed and acknowledged that abuse allegations were supposed to be reported immediately so an investigation could begin and the accused staff member could be suspended to protect residents. The facility's abuse policies required all allegations of abuse to be reported to administration, thoroughly investigated, and reported within required timeframes. The Abuse Prevention Program and Abuse Investigation and Reporting policies both stated that administration would identify and assess possible abuse incidents, investigate and report allegations, and protect residents during investigations. The LNHA stated his responsibilities included managing the facility, ensuring staff education was completed, and ensuring policies and procedures were followed, but the allegation involving Resident #123 was not reported to administration and no investigation was initiated when the allegation was first made.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to obtain a Physician's Order for a wound care recommendation, which resulted in the worsening of a pressure ulcer for a resident. The resident, who was cognitively intact and admitted with conditions including anemia, depression, and muscle weakness, developed a skin alteration in the sacral region. Despite a verbal order for wound care being received by an LPN, it was not transcribed into the facility's electronic system, Point Click Care (PCC), as required by the facility's policy. Consequently, there was no documented wound care order in place from the time the skin alteration was identified until the wound worsened. The resident's sacral wound was initially identified on 01/23/2025, and a wound consult on 01/28/2025 noted the wound's size and condition. However, the wound care recommendations were not implemented, and the wound progressed in size by 02/04/2025. The resident complained of pain in the sacral area, and although the dressing was changed, there was no evidence of consistent wound care being provided. It was not until 02/05/2025 that a formal wound care order was documented, but by then, the resident required hospital admission for wound debridement. Interviews with the LPN, DON, and the resident's Physician confirmed that the facility's procedures for wound care orders were not followed. The LPN admitted to not entering the verbal order into PCC, and the DON acknowledged that the absence of a treatment order could lead to the worsening of the wound. The Physician emphasized the importance of immediate implementation of wound care orders to prevent deterioration. The facility's policies on wound care and documentation were not adhered to, contributing to the deficiency.
Facility Fails to Provide Adequate Linens for Resident Care
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not providing adequate access to clean linens. During a tour of the 500 Unit, the surveyor observed a significant shortage of washcloths and towels in the linen rooms, with only a few washcloths available for 30 residents. Interviews with staff, including a housekeeper and a CNA, revealed that linens were delivered late, and there were frequent complaints from residents about the lack of linens. The CNA reported having to cut bath blankets to provide care due to the shortage of washcloths and towels. The Director of Nursing acknowledged the issue, attributing it to improperly labeled bins in the soiled linen room, which led to staff discarding linens. The Housekeeping Director also recognized that the PAR levels for linens were low and needed adjustment. The Licensed Nursing Home Administrator was aware of the linen shortage and had ordered more linens, but the problem persisted, as evidenced by the surveyor's observations and staff interviews. The deficiency was further corroborated by Resident Council Meeting Minutes, which documented ongoing resident complaints about the lack of linens.
Failure to Update Care Plan for Resident's New Wound
Penalty
Summary
The facility failed to update and revise a resident's care plan for a newly identified wound. Resident #4, who was admitted with diagnoses including anemia, depression, and muscle weakness, was found to have a skin tear in the sacral area on 01/23/2025. Despite the wound being documented in the progress notes and wound care recommendations being provided, the care plan was not updated to reflect this new condition. The care plan initially noted the resident was at risk for skin integrity issues due to fragile skin and immobility, but it did not include interventions for the actual wound. During interviews, the Resource Nurse/Registered Nurse was unable to explain the importance of the care plan or who was responsible for updating it. The Director of Nursing confirmed that the care plan should have been updated with the new wound information and that the interdisciplinary team is responsible for such updates. The facility's policy requires care plans to be revised as new information about residents becomes available, but this was not followed in the case of Resident #4.
Failure to Secure Treatment Cart and Properly Label Wound Dressing
Penalty
Summary
The facility failed to ensure that the treatment cart was secured during a wound care observation and did not adhere to professional standards of clinical practice by not initialing, dating, and timing a dressing before applying it to a resident. During the observation, a Registered Nurse (RN) parked the treatment cart outside the resident's room, performed hand hygiene, donned clean gloves, and gathered supplies before entering the room to perform wound care. The treatment cart was left unlocked and unattended, out of the RN's line of sight, while the RN was in the resident's room. No residents were observed in the hallway near the treatment cart at that time. After completing the wound care, the RN applied a clean dressing to the resident's wound without initialing, dating, or timing it. Interviews with the RN, Resource Nurse, and Director of Nursing (DON) confirmed the importance of locking treatment carts to prevent residents from accessing potentially harmful items and the necessity of initialing, dating, and timing dressings to inform staff of the last dressing change. The facility's policies on Storage of Medications and Wound Care were not followed, as they require compartments containing drugs and biologicals to be locked when not in use and dressings to be initialed, dated, and timed before application. These deficiencies were identified for one resident observed for wound care.
Deficiency in Food Safety and Storage Practices
Penalty
Summary
The facility failed to ensure proper food safety and storage practices, as evidenced by several observations during a survey. The surveyor, along with the Dietary Director (DD), noted that food items in the kitchen were not properly dated, and some were past their use-by dates. Specifically, an unopened loaf of rye bread and an opened gluten-free bread were found with expired use-by dates, and a bag of English muffins lacked any labeling or expiration date. Additionally, the temperature log for the walk-in refrigerator was incomplete, with a missing entry for the PM temperature on a specific date. Further inspection of the walk-in refrigerator revealed undated opened juice containers, including a pitcher of orange juice and two bottles of cranberry juice. The DD acknowledged that all food and juice items should have been dated upon opening and agreed that expired items should have been discarded. The facility's food service policy mandates that food be clearly marked with the date it should be consumed or discarded, and the DD's job description includes monitoring food preparation and storage to ensure compliance with health and sanitation regulations.
Infection Control Breach During Wound Care
Penalty
Summary
The facility staff failed to maintain appropriate infection control practices during a wound care observation. Specifically, a Registered Nurse (RN) completed a wound care treatment and improperly returned an opened pack of unused 4x4 gauze to the treatment cart instead of discarding it. This action was observed by a surveyor and confirmed during an interview with the RN, who acknowledged that the opened gauze should have been discarded to prevent cross-contamination. Further interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the facility's policy requires unused treatment supplies to be discarded after use. Both the IP and DON emphasized the importance of not returning opened supplies to the treatment cart to prevent the potential spread of infection. The facility's policy, revised in January 2025, outlines the need for an Infection Control Program to prevent disease transmission, which was not adhered to in this instance.
Deficient Call Bell System Delays Resident Assistance
Penalty
Summary
The facility failed to ensure that their wireless call bell system effectively communicated calls directly to the staff, resulting in delayed responses to residents' needs. Resident #1, who was admitted with a fracture, sarcoidosis, and hypertension, reported that it took staff 50 minutes to respond to their call light. The surveyor confirmed this delay by observing the call bell light still on without an audible sound after 14 minutes. Resident #1 mentioned that this was a recurring issue and had been reported to the nurse. Resident #3, with chronic obstructive pulmonary disease, anemia, and hyperlipidemia, also experienced delays in call light responses. The resident stated that staff sometimes never responded to the call light, and this issue was reported to the charge nurse. Similarly, Resident #7, who had diabetes, morbid obesity, and a history of falls, reported that staff took more than ten minutes to respond to call bells, particularly during the evening shift. Interviews with staff, including CNAs, LPNs, and RNs, revealed that the call bell system did not ring to staff work areas, and staff had to visually monitor the lights in the hallways. The system's design required staff to be present in the hallways to notice the call lights, as there was no centralized alert system. The Director of Nursing and the Licensed Nursing Home Administrator confirmed the lack of a centralized call bell system, and the facility's policy emphasized the need for prompt responses to call bells.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by the inability to provide timely incontinence care to a resident. On a specific day, a resident was observed lying in bed with a saturated incontinence brief that had leaked onto the cloth underpad. The resident's family member noted that the resident was usually washed, dressed, and in their wheelchair by that time. The assigned LPN and CNAs confirmed the saturated condition of the brief. The CNA responsible for the resident explained that she had to prioritize getting rehabilitation residents ready for therapy, which delayed her usual morning routine with the resident. The staffing issues were further highlighted by the CNA's workload, which included 13 residents, many of whom required total assistance with activities of daily living (ADLs) and feeding. The facility's staffing records revealed consistent deficiencies in CNA staffing over several weeks, failing to meet the New Jersey mandated staffing ratios. The Director of Nursing acknowledged the staffing shortfall and confirmed that the CNA should not have been assigned 13 residents, as it exceeded the mandated ratio of one CNA for every eight residents on the day shift. The facility's staffing policy, revised in December 2023, outlined the requirement to meet federal, state, and local staffing requirements, including specific staff-to-resident ratios. Despite efforts to manage staffing levels based on census and resident care needs, the facility consistently fell short of the required staffing ratios, impacting the quality of care provided to residents. The surveyor's interviews with the staffing coordinator and DON revealed attempts to address staffing challenges, but the facility continued to experience deficiencies in meeting the mandated staffing levels.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by the surveyor in the kitchen and five pantries designated for resident food. In the walk-in freezer, a box of French toast and a box of veggie burgers were found open to the air, which the Food Service Director acknowledged should have been closed and wrapped. Additionally, the 200-unit pantry's freezer lacked a thermometer and had dark dust-like debris, while the 100-unit pantry's freezer also had debris and the microwave contained dried food particles. The 300-unit pantry's freezer was missing a thermometer, had ice buildup, and contained an unlabeled pint of ice cream with ice buildup on the container. Further observations revealed that the 400-unit locked pantry had a stainless-steel sink with dried food particles and dust-like debris, and the water machine outside had white debris on the grate. The 500-unit locked pantry had food particles outside the microwave and liquid on the refrigerator's bottom tray. Interviews with staff, including the Housekeeping Supervisor and Food Service Director, indicated miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas, including the stainless sinks, refrigerators, and freezers. The facility's policy required all foods in refrigerators or freezers to be covered, labeled, and dated, and for refrigerators to have working thermometers, but no policy was provided for cleaning the pantry area.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly disposing of garbage and refuse in the dumpster area. During an initial kitchen tour, the surveyor observed debris, trash, and leaves around the enclosed dumpster area, which included four blue dumpsters and one black dumpster for used oil. Five black trash bags were found lying directly on the ground next to the first dumpster, and one black trash bag was lying next to the third dumpster. The trash company driver stated that he had moved the bags to access the dumpster, and the Food Service Director (FSD) acknowledged that there should be no debris or trash bags outside the dumpster area. The FSD indicated that maintenance, housekeeping, and dietary staff were responsible for cleaning the area to prevent pest or rodent infestations. Further interviews revealed that both maintenance and dietary staff were responsible for keeping the dumpster area clean, as confirmed by the Facility Manager (FM). The Licensed Nursing Home Administrator (LNHA), along with the Director of Nursing (DON) and the survey team, also stated that leaving trash bags on the ground was unacceptable. The facility's policy on garbage disposal, reviewed and revised in March 2024, mandates that containers and dumpsters be kept covered when not being loaded and that the surrounding area be kept clean to minimize debris accumulation and insect or rodent attraction. The policy also specifies that garbage should not accumulate or be left outside the dumpster.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents, as observed in one of the six dining areas, specifically the activities room. During the observation, two residents were seated at the same table, but only one had received their lunch tray. The delay in serving the second resident led to the resident taking food from the other resident's plate. This incident was witnessed by a surveyor and involved intervention by an LPN. The Registered Dietician and the Director of Nursing both acknowledged that residents seated at the same table should be served simultaneously to maintain dignity and respect. The facility's policies on Dining Room Services and Resident Rights emphasize treating residents with dignity and respect during mealtimes. However, the failure to serve meals simultaneously resulted in a breach of these policies. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that the resident who was not served on time usually ate in the main dining room, but due to its unavailability, was rerouted to the activities room, leading to the oversight. This deficiency was identified as a failure to honor the residents' rights to a dignified existence and self-determination.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document a resident's life-sustaining treatment preference on the physician's orders, which was identified during a survey. The deficiency was noted for a resident who was admitted with multiple diagnoses, including heart failure and chronic kidney disease. Despite having an intact cognitive status, as indicated by a BIMS score of 13 out of 15, there was no documented evidence of the resident's code status in their medical record. This oversight was confirmed by a Registered Nurse (RN) who acknowledged the absence of the code status in the electronic medical record and expressed uncertainty about how it was missed. Interviews with facility staff, including the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), revealed that the resident's code status should have been determined upon admission as part of the facility's admission process. The facility's policy required the Social Services Director or designee to inquire about any written advance directives prior to or upon admission. However, the process was not followed, resulting in the lack of a documented code status for the resident. The DON explained that if a Provider Orders for Life-Sustaining Treatment (POLST) form was not available upon admission, it should be confirmed during a care conference with the Interdisciplinary Team (IDT), and a physician order should be written accordingly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman in a timely manner, as required by state and federal regulations and the facility's own policy. This deficiency was identified during a review of a case involving a resident with multiple diagnoses, including dementia and major depressive disorder, who was alleged to have experienced emotional abuse by a Certified Nursing Assistant (CNA). The incident was reported by the resident's family member, who claimed that the CNA was rude and asked them to leave the room during care, leading to the CNA walking out when the family refused. The Director of Nursing (DON) and other staff members failed to follow proper procedures for reporting the incident. The Reportable Event Record/Report (RER/R) was not completed correctly, as it lacked the date and time the incident was reported to the NJDOH. Additionally, the RER/R was faxed to an incorrect number, and there was no evidence that the NJDOH received the report. The facility also did not provide documentation that the Office of the Ombudsman was notified of the incident. The DON admitted to human error in the reporting process and was unsure of the specific time frame required for reporting such incidents. The facility's policy mandates that all allegations of abuse must be reported immediately, or within two hours if the incident involves abuse, and within 24 hours if it does not involve abuse or serious bodily injury. The policy also requires that the findings of abuse investigations be reported to the appropriate agencies. However, the facility failed to adhere to these requirements, as evidenced by the lack of timely notification to the NJDOH and the Office of the Ombudsman, and the absence of a completed investigation report submitted within the required time frame.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of staff-to-resident abuse, as required by their policy. The incident involved a resident with intact cognition, who was reported by their family to have experienced emotional abuse by a CNA. The family alleged that the CNA was rude and did not provide timely care, which left the resident tearful. Despite the family’s report, the facility did not document a comprehensive investigation, including interviews with all potential witnesses such as the resident's roommate. The facility's documentation was incomplete, as evidenced by the absence of a statement from the CNA involved, despite it being referenced in the investigation report. The Director of Nursing (DON) acknowledged the missing statement and attempted to rectify this by contacting the CNA after the event. However, the investigation did not include interviews with the resident, the resident's roommate, or other staff members who might have witnessed the incident, which was contrary to the facility's policy. The facility's policy mandates a thorough investigation of abuse allegations, including interviews with all relevant parties and documentation of findings. However, the investigation into this incident was insufficient, as it lacked comprehensive interviews and documentation. The failure to adhere to the policy resulted in an incomplete understanding of the events and potentially compromised the resident's right to be free from abuse and neglect.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan after the resident developed contractures. The deficiency was identified during a survey when a resident was observed with a contracted left hand. The resident's medical record indicated diagnoses of unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. The Minimum Data Set (MDS) assessment revealed impaired range of motion (ROM) in both upper and lower extremities, but the resident's Individualized Comprehensive Care Plan (ICCP) did not reflect these impairments or include interventions to address or prevent further reduction in ROM. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Rehab (DOR), revealed that the resident had been seen by Occupational Therapy (OT) and Physical Therapy (PT) earlier in the year. The therapies had provided education to staff on the importance of ROM exercises, and recommendations were made for daily ROM exercises to be incorporated into the resident's care. However, the ICCP was not updated to include these recommendations, and there were no physician orders or CNA instructions for ROM exercises in the resident's records. Further interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that contractures should be included in the resident's care plan to ensure proper care. The DON acknowledged that the ICCP should have been revised to include the resident's contractures and therapy recommendations. The facility's policies on ROM exercises and comprehensive care plans emphasized the need for ongoing assessments and updates to care plans as residents' conditions change, which was not adhered to in this case.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was unable to perform activities of daily living (ADL) due to severe cognitive impairment and physical limitations. The resident, diagnosed with unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was observed with a contracted left hand and a long, jagged fingernail on the left middle finger. The resident's care plan included interventions for nail care, specifying that nails should be checked and trimmed on bath days and as necessary. However, there was no documentation of the resident refusing nail care, and the facility staff were unclear about their responsibilities regarding nail care. Interviews with facility staff revealed inconsistencies in understanding who was responsible for nail care. A CNA stated that activities staff were responsible, while the Activities Director indicated that their staff only painted nails and did not trim them. The DON confirmed that CNAs were responsible for filing nails and should notify a nurse if a resident refused care. Despite these protocols, the resident's left-hand fingernails remained untrimmed, indicating a lapse in care. The facility's policy on nail care emphasized the importance of regular cleaning and trimming to prevent injury, yet this was not adhered to, as evidenced by the resident's condition.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities that reflected the preferences of a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was dependent on staff for all activities of daily living. The resident's care plan indicated a preference for group activities, yet there was no documentation of the resident's participation or refusal of activities in the past six months. On the day of the survey, the resident was observed lying in bed during a scheduled activity time, and the activity staff did not show up to conduct the planned activity. The Activities Director admitted to not being present for the activity and acknowledged that the resident would benefit from attending activities for social stimulation. Despite the resident expressing a desire to attend an activity when asked, there was no prior documentation of refusals or attempts to engage the resident in activities. Interviews with staff revealed a lack of coordination and communication regarding the resident's participation in activities. CNAs and LPNs were unclear about their responsibilities in encouraging and documenting the resident's involvement in activities. The facility's policy emphasized the importance of tailoring activities to residents' interests and maintaining records of participation, but these practices were not followed, leading to the deficiency.
Failure to Document and Report Resident's Skin Injury
Penalty
Summary
The facility failed to notify the physician of an injury sustained by a resident, obtain a physician's order for a wound treatment, and document a skin assessment in accordance with the facility policy and professional standards of nursing practice. This deficiency was identified for a resident who was observed with a bandage on their right lower forearm, which was not dated, and a dried red substance on their pillow. The resident reported that the bandage was applied by an unknown staff member after they scratched themselves. The resident's medical record review revealed multiple diagnoses, including repeated falls, multiple fractures, cancer, chronic obstructive pulmonary disease, and a pressure ulcer. The resident's comprehensive care plan indicated a risk for skin integrity alteration due to impaired mobility, with interventions including weekly body audits and reporting changes to the medical doctor. However, there was no documented evidence of the resident's forearm skin alteration in the progress notes or skin assessments. Interviews with facility staff, including a CNA, RN, and the DON, confirmed that the bandage was not documented, and no wound investigation or treatment order was obtained. The facility's policies on accidents, incidents, and documentation require prompt investigation, documentation, and communication of changes in a resident's condition, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that floor mats were in place for a resident who was at risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed on multiple occasions without floor mats on either side of the bed, despite having physician orders and care plan interventions for floor mats to be placed on both sides of the bed. The resident had a history of rolling out of bed and sustaining a head injury, which was documented in the progress notes and incident report. Interviews with facility staff, including a hospice aide, certified nursing assistant, licensed practical nurses, and the director of nursing, confirmed that floor mats should have been in place while the resident was in bed to prevent injury from falls. The facility was unable to provide a policy related to the use of floor mats, and the treatment administration record for the relevant month did not include the physician order for the floor mat, indicating a lapse in following the prescribed care plan and physician orders.
Failure to Provide and Manage CPAP Therapy for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required a CPAP machine upon admission. The resident, who had a history of obstructive sleep apnea among other medical conditions, did not receive CPAP therapy until several days after admission, despite the need being documented in the Admission Notification form and physician's progress notes. The delay in providing the CPAP was due to a breakdown in communication and procedure, as the Admission Notification form did not reach the admitting nurse, and the discharge summary did not include the CPAP requirement. Additionally, the facility did not store the CPAP equipment according to professional standards. The CPAP mask was observed on multiple occasions to be improperly stored, either uncovered on the nightstand or hanging and touching the floor. This improper storage was confirmed by nursing staff, who acknowledged that the mask should be cleaned and stored in a bag when not in use. Furthermore, the resident's comprehensive care plan did not include the CPAP therapy, which is a critical component of the resident's care needs. The omission was confirmed by the nursing staff and the Director of Nursing, who stated that the CPAP should have been included in the care plan to ensure all staff were aware of the resident's needs. The facility's policies on Durable Medical Equipment and comprehensive care planning were not adhered to in this case.
Failure to Post Daily Staffing Report Accessibly
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in a location that was readily accessible to both residents and the general public. This deficiency was observed across all five nursing units. On a specific date, the surveyor noted that the staffing report was only posted on the receptionist's desk in the front main lobby, which required a pass code to access the nursing units. During a subsequent inquiry, the Director of Nursing stated that the report was posted at both facility entrances, but the Licensed Nursing Home Administrator was unaware of the requirement for the report to be accessible without request. The Staffing Coordinator confirmed that the report was only posted in the front and rehab lobbies, not on the nursing units. Additionally, the facility's staffing policy, reviewed in December 2023, did not include details about the required daily posting of the staffing report.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during a wound treatment for a resident. The resident, who had a history of osteomyelitis, diabetes mellitus with chronic kidney disease, muscle weakness, and pressure ulcers, was observed receiving wound care from an LPN. The LPN did not consistently perform hand hygiene between glove changes, which is a critical step in preventing infection. Specifically, the LPN did not wash hands or use alcohol-based hand rub (ABHR) after doffing gloves and before donning new ones, which is against the facility's hand hygiene policy. The resident's medical record indicated the presence of a Stage 4 pressure ulcer on the sacral region and a Stage 2 pressure ulcer, both of which required specific wound care treatments as per physician orders. During the wound care observation, the LPN was seen preparing and applying treatments such as Medihoney and Santyl without following proper hand hygiene protocols. The LPN washed hands for only eight seconds on two occasions, which is below the required minimum of twenty seconds as per the facility's policy. Interviews with the LPN, the Infection Preventionist, and the Director of Nursing confirmed the deficiency in hand hygiene practices. The facility's policy mandates hand washing for at least twenty seconds, especially after removing gloves and before handling clean or soiled dressings. The failure to adhere to these protocols was identified as a significant infection control concern, as it could lead to cross-contamination and compromise resident safety.
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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