Whiting Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whiting, New Jersey.
- Location
- 3000 Hilltop Road, Whiting, New Jersey 08759
- CMS Provider Number
- 315293
- Inspections on file
- 19
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Whiting Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance was transferred by a single CNA using a pull sheet, rather than the required equipment and staffing. During the transfer, the shower stretcher moved away, causing the resident to fall and sustain a left upper extremity fracture. The resident had multiple medical conditions and was fully dependent for transfers, with care plans and facility policies clearly indicating the need for two-person mechanical lift transfers. Staff interviews confirmed these requirements were standard practice.
A resident with dementia and behavioral issues was physically abused when an LPN used personal pepper spray on them during an episode of agitation, causing chemical conjunctivitis and pain. Surveillance footage showed the resident was left on the floor without medical assistance and later dragged back to their room by staff, with no care provided until emergency services arrived. Staff interviews confirmed the inappropriateness of the action, and facility policy at the time did not address weapons or pepper spray.
A cognitively impaired resident with a history of exit-seeking eloped from the facility due to inadequate supervision, lack of specific care plan interventions, and failure to follow protocols for monitoring and documentation. Staff did not notice the resident was missing until notified by an external caller, and post-incident checks of security systems were not performed. The required social services assessment was also not completed after the elopement.
The facility failed to perform quarterly smoking assessments for three residents who were active smokers, as required by their policy. One resident with moderate cognitive impairment had not been assessed for five months, another resident with intact cognition was overdue for an assessment by 63 days, and a third resident identified as an unsafe smoker had no further evaluations after the initial assessment. Conflicting information about responsibility for assessments indicated a lack of clarity within the facility.
The facility failed to ensure timely face-to-face visits by the attending physician for residents, as required by regulations. Several residents with serious conditions, such as dementia and bipolar disorder, were not seen by the physician within the mandated timeframes. Instead, APNs conducted visits and documented notes in the EMR, as confirmed by staff interviews.
The facility failed to maintain proper sanitation and food handling practices. A meat slicer was found uncovered with food debris, and pans were improperly air-dried, leading to wet nesting. In the pantry, a freezer had a thick ice buildup with debris, and staff were unaware of maintenance responsibilities.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing over residents while feeding them, contrary to the facility's policy requiring staff to sit at eye level. This was confirmed by the LNHA and DON, and observed on one unit where both an IP and a CNA did not adhere to the policy.
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. Staff were observed standing while assisting residents with meals, contrary to facility policy, and meals were served on trays, detracting from a homelike setting. The Licensed Nursing Home Administrator acknowledged these practices as inappropriate.
A resident with chronic kidney disease and hypotension did not receive Midodrine as prescribed when their systolic blood pressure (SBP) was below 100 mmHg, and received it when SBP was above 100 mmHg, contrary to physician's orders. The facility's Medication Pass policy lacked specific instructions for following hold parameters, leading to this deficiency.
A resident with a contracture in the right upper extremity was not provided with necessary assistive devices to maintain or improve range of motion. Despite recommendations for a handroll, the resident was observed without any such device, and the care plan lacked specific interventions for the contracture. Interviews with staff revealed inconsistencies in care and communication gaps regarding the resident's needs.
A resident with an indwelling urinary catheter was observed with the tubing dragging on the floor, contrary to infection control protocols. The resident, diagnosed with urinary tract infection and neuromuscular dysfunction of the bladder, had a care plan to keep the drainage bag off the floor, which was not followed. Staff interviews confirmed the tubing should not touch the ground, highlighting a deficiency in maintaining proper catheter care.
A facility failed to implement infection control measures for a resident with COPD by improperly storing a nebulizer mask. The mask was observed face down on personal belongings and undated, and later found exposed in a side table drawer. The resident had a history of COPD and was cognitively intact. The facility's policy did not address nebulizer care, and both the LPN and DON acknowledged the mask should have been bagged and labeled.
A facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. The resident, who had been receiving dialysis for five years, had missing entries for vital signs and other pertinent information on several dates. The LPN confirmed that the communication forms should be completed by the nursing staff before dialysis, but this was not consistently done. Interviews with the DON and LNHA revealed that the facility's process involved using a communication book, but the policy was not consistently followed.
A facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. The resident, admitted with palliative care, depression, and sacral wounds, was identified as being on hospice care. The LPN/Unit Manager could not provide a complete Hospice Communication Book, only showing billing and symptom management documents. The facility's policy requires documented communication with hospice providers, which was not adequately maintained.
Multiple residents with cognitive and mental health conditions were subjected to physical and verbal abuse by another resident with a history of aggression and by an LPN. Despite recommendations for one-on-one supervision and behavior tracking, the facility did not consistently implement these interventions or revise care plans in response to ongoing aggressive behaviors and medication refusals. Staff-to-resident abuse was substantiated through witness statements and incident reports, with the LPN continuing to provide care after the first incident before being suspended and terminated.
Two residents with significant behavioral and medical diagnoses were involved in separate incidents where one was involuntarily secluded in a dayroom and another threw a knife and made threats toward staff and others. In both cases, the facility did not conduct or document thorough investigations as required by its abuse prevention policy, nor did it ensure the safety of all residents and staff involved.
The facility failed to prevent and address multiple incidents of physical and verbal abuse involving residents with behavioral health needs and staff, resulting in repeated aggression, injuries, and substantiated staff-to-resident abuse. Despite recommendations for one-on-one supervision and behavioral tracking, there was inconsistent implementation and documentation of these interventions, and staff were not always aware of required protocols. The facility did not consistently notify medical providers of medication refusals or behavioral incidents, and delays in reporting and investigating abuse were noted.
A resident with Huntington's disease and asthma, who was cognitively intact, was placed in a dayroom by a CNA, who then closed and blocked the door, preventing the resident from leaving despite repeated requests. The CNA sat outside the door to monitor the resident, and the incident was confirmed by interviews and surveillance footage. This action constituted involuntary seclusion and was not in accordance with facility policies on restraints and abuse prevention.
A resident with a history of TBI and dementia fell from a geriatric chair, sustained a forehead hematoma, and subsequently declined, exhibiting decreased alertness and inability to swallow. Facility staff did not complete or document required neurological assessments or monitor for delayed complications as per policy, and the incident was not properly recorded in the medical record or fall investigation documentation.
A resident with traumatic brain injury and severe dementia experienced multiple falls, including head injuries, due to inadequate supervision and ineffective interventions. Despite repeated incidents, the care plan was not consistently updated, root causes were not always documented, and increased monitoring was not implemented as required by facility policy. Staff interviews revealed that supervision was insufficient, particularly during mealtimes when one CNA was responsible for several high-fall-risk residents.
The facility did not complete or document required annual performance evaluations for all CNAs, with personnel files missing evaluations for one or more years. Staff interviews revealed confusion about who was responsible for conducting these reviews, and neither the ADON nor HR Director could locate the necessary documentation or policy.
The facility did not report allegations of abuse and threats in a timely manner to NJDOH as required by policy and regulation. In one case, a resident with dementia and a history of inappropriate behaviors was observed touching another resident inappropriately, but the incident was not reported to NJDOH within the required timeframe. In another case, a resident with schizophrenia and anxiety disorder displayed threatening behavior, and there was no evidence this was reported. Interviews confirmed that staff were aware of reporting requirements, but these were not consistently followed.
The facility did not ensure RN coverage for at least eight consecutive hours on a specific day, as confirmed by staffing records and staff interviews. This lapse was contrary to the facility's stated policy and regulatory requirements, potentially affecting all residents.
A resident with dementia and other conditions was involved in an altercation, leading to a room change. The facility failed to notify the resident's POA about the change and did not document the notification, violating resident rights. Interviews with staff confirmed the requirement for family notification and documentation, but the facility lacked a specific policy on room changes.
A resident with dementia, depression, and anxiety experienced a fall, but the LTC facility failed to update the care plan with new interventions as required. Despite being at risk for falls, the care plan had not been revised since January, and staff interviews confirmed the oversight. Facility policy mandates updates after significant changes, but this was not followed.
Failure to Follow Transfer Protocols Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for transfers was not safely or properly transferred according to their care plan. The resident, who required a mechanical lift and two staff members for transfers, was instead moved by a single CNA using a pull sheet from the bed to a shower stretcher. During this transfer, the shower stretcher moved away from the bed, causing the resident to fall to the floor and sustain a left upper extremity humeral fracture. The incident was witnessed after a nurse heard yelling and found the resident on the floor, with the CNA present in the room. The resident involved had multiple medical diagnoses, including heart disease, end stage renal disease, diabetes, and osteoporosis, and was assessed as being completely dependent on staff for transfers. The resident's care plan specifically required the use of a mechanical lift and two-person assistance for all transfers. Documentation in the facility's records, including the Minimum Data Set and assignment sheets, confirmed these requirements. Other staff interviews confirmed that the standard procedure for mechanical lift transfers was to have two staff members present, and that this information was clearly communicated to CNAs through assignment sheets and the electronic medical record. Despite these established protocols, the CNA involved in the incident did not follow the resident's care plan and attempted the transfer alone, without the mechanical lift or a second staff member. The facility's policies also required two staff for mechanical lift transfers. The failure to adhere to these procedures directly resulted in the resident's fall and injury.
Resident Abused with Pepper Spray by LPN; Left Without Care
Penalty
Summary
A moderately cognitively impaired resident with a history of dementia, severe mood disturbances, and major depressive disorder was subjected to physical abuse by a staff member. The resident, who had a care plan addressing aggressive and combative behaviors, was observed at the nurse's station exhibiting agitation, including grabbing and throwing equipment. In response, an LPN retrieved pepper spray from her personal belongings and sprayed the resident in the face multiple times, resulting in the resident collapsing to the floor, holding their eyes, and appearing to be in pain and distress. The resident was later treated for chemical conjunctivitis and pain to the left eye at the emergency room. Surveillance footage reviewed by facility leadership and law enforcement showed that after being sprayed, the resident was left on the floor without medical assistance as staff walked away. The resident attempted to crawl to an adjacent room while disoriented, at which point a CNA and the LPN dragged the resident by their clothing back to their room and left, again without providing care. No one else entered the resident's room until police and emergency medical services arrived. Interviews with staff confirmed that the use of pepper spray was not appropriate and that staff had been educated on abuse and the prohibition of such actions after the incident. Facility policy at the time prohibited physical abuse and required that law enforcement be called if a resident became violent or uncontrollable, but there was no explicit policy regarding weapons or pepper spray. The actions and inactions of the staff directly resulted in harm to the resident and constituted a failure to protect the resident from abuse and neglect.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking behavior eloped from the facility. The resident, diagnosed with unspecified dementia, schizophrenia, and schizoaffective disorder, was independent with ambulation and had a BIMS score indicating severe cognitive impairment. The resident's care plan included interventions such as a wander guard, frequent monitoring of whereabouts, and documentation of wandering behavior, but there was no evidence of specific interventions to monitor the resident's whereabouts or to distract from wandering or exit-seeking behaviors. On the day of the incident, staff did not notice the resident was missing until notified by an external caller, and the resident was later returned by police without injury. Following the elopement, it was found that the facility did not test the wander guard system or egress doors immediately after the incident. The Director of Maintenance was not asked to check the doors or wander guard system post-incident, and only continued with routine weekly checks. Staff interviews revealed that no alarms were heard at the time of the elopement, and camera footage did not capture the resident exiting the facility. The Director of Nursing and Assistant Director of Nursing did not conduct a thorough root-cause analysis, as they did not interview all relevant staff or test the security systems after the event. Documentation of frequent monitoring and behavior logs, as required by the care plan, was not found in the resident's medical record. Additionally, the facility's elopement drill protocol required a social services assessment for emotional distress after an elopement, but this was not completed or documented for the resident. Staff were unclear about the meaning and documentation of "frequent monitoring," and there was no formal process or set time for such monitoring. The lack of specific interventions, inadequate supervision, failure to follow protocols, and insufficient documentation contributed to the resident's ability to elope undetected, resulting in a deficiency that placed the resident and others at risk.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to consistently perform quarterly smoking assessments for residents designated as active smokers, as required by their policy. This deficiency was observed in three residents. Resident #30, who has moderate cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, had not received a quarterly smoking assessment since August 2024, despite being an active smoker. The resident's care plan did not address the need for quarterly smoking assessments, and the last assessment was overdue by approximately five months. Resident #127, who has intact cognition and diagnoses including traumatic subdural hemorrhage and seizures, was observed smoking without staff supervision. The resident's smoking safety evaluation was overdue by 63 days, with the last assessment due in November 2024. The facility's corporate activity director and nursing staff provided conflicting information about who was responsible for completing smoking assessments, indicating a lack of clarity and communication within the facility. Resident #58, who is cognitively intact and has multiple diagnoses including metabolic encephalopathy and major depressive disorder, was identified as an unsafe smoker. However, no further smoking evaluations were conducted after the initial assessment in August 2024. The facility's smoking policy requires quarterly re-evaluations of a resident's ability to smoke safely, but this was not adhered to, contributing to the deficiency.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at the required intervals. Specifically, the attending physician did not see residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficiency was identified for 8 out of 35 sampled residents, including those with serious conditions such as dementia, bipolar disorder, and chronic obstructive pulmonary disease. For instance, Resident #139, admitted with dementia and anxiety disorder, was not seen by the attending physician from June 2024 to January 2025. Similarly, Resident #79, with bipolar disorder and neuropathy, had no documented visits by the attending physician since July 2024. Other residents, such as Resident #59 with bipolar disorder and non-Alzheimer's dementia, and Resident #120 with cauda equina syndrome and obstructive uropathy, also lacked timely physician visits. Interviews with facility staff, including LPNs and the Medical Director, revealed that the facility relied on Advanced Practice Nurses (APNs) to conduct visits and document notes in the Electronic Medical Record (EMR). The Medical Director confirmed that they typically see patients in the hospital and do not write physician notes, leaving this task to the APNs. The facility's policy, revised in April 2013, mandates compliance with OBRA regulations, which were not adhered to in this case.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. During an inspection, a meat slicer was found uncovered and exposed to air, with unidentified food debris and a white slimy substance present on the table behind the blade guard. The Food Service Director (FSD) confirmed that the slicer was cleaned and sanitized, but it was not covered when not in use, exposing it to potential contamination. Additionally, a stack of deep 1/4 pans was observed to be wet, indicating improper air drying before stacking, a practice known as wet nesting, which can promote bacterial growth. In the North Pantry/Nourishment room, a thick buildup of ice was observed at the bottom of the freezer, containing a white plastic spoon, pieces of napkin, aluminum foil, and Styrofoam. Bagged ice packs were stored alongside resident food, and the Licensed Practical Nurse/Unit Manager (LPN/UM) was unaware of who was responsible for the freezer's maintenance. The facility's policy on sanitization and cleanliness was reviewed, highlighting the need for proper air drying of equipment and utensils to prevent cross-contamination.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity while being assisted with meals. This deficiency was observed on one of the facility's units, where staff members were seen standing over residents while feeding them, rather than sitting at eye level as required by the facility's feeding assistance guidance. On one occasion, the Infection Preventionist was observed standing over a resident seated in a Geri chair while assisting with a meal, and admitted to the surveyor that they did not have a chair to sit on. On another occasion, a Certified Nursing Assistant (CNA) was observed standing while assisting two different residents with their meals, despite a chair being available for use. The Licensed Nursing Home Administrator and Director of Nursing confirmed during an interview that staff are supposed to sit while assisting residents with meals, aligning with the facility's policy. The facility's policy, titled 'Feeding Assistance Guidance,' explicitly states that staff should sit facing the resident at eye level. This practice was not followed, leading to the deficiency being cited under NJAC8:39-4.1(a)(12).
Deficiency in Dignity and Homelike Environment During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. On multiple occasions, staff members, including the Infection Preventionist and a Certified Nursing Assistant, were observed standing while assisting residents with their meals, rather than sitting at eye level as per facility policy. This practice was noted in both the [NAME] wing and South wing, affecting residents seated in Geri chairs. Despite the availability of chairs, staff continued to stand, which was acknowledged as inappropriate by the Licensed Nursing Home Administrator during an interview. Additionally, the facility did not remove food from trays when serving meals in the dining room, which detracted from creating a homelike environment. This was observed on several occasions in the South Unit dining room, where residents were served their meals directly on trays. The Licensed Nursing Home Administrator admitted that serving meals on trays was a longstanding practice, despite it not aligning with the goal of providing a homelike dining experience. The facility's policy on feeding assistance, which advises staff to sit facing residents at eye level, was not adhered to, contributing to the deficiency.
Failure to Follow Medication Hold Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following the hold parameters for administering a blood pressure medication, Midodrine, to a resident with chronic kidney disease and hypotension. The resident, who was moderately cognitively impaired and dependent on renal dialysis, had a physician's order specifying that Midodrine should be administered when the systolic blood pressure (SBP) was less than 100 mmHg. However, the Medication Administration Records (MAR) for November and December 2024, and January 2025, revealed multiple instances where the resident's SBP was below 100 mmHg, yet Midodrine was not administered. Conversely, there were also instances where Midodrine was given when the SBP was above 100 mmHg, contrary to the physician's order. Interviews with the nursing staff, including an LPN and a Unit Manager, confirmed that the nurses did not follow the physician's hold order parameters for Midodrine on multiple occasions. The Director of Nursing acknowledged that the nurses should have adhered to the physician's orders. Additionally, the facility's Medication Pass policy did not include specific instructions for following physician's orders regarding medication hold parameters, contributing to the oversight in medication administration for the resident.
Failure to Provide Appropriate Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a contracture, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, identified as having a contracture in the right upper extremity, was observed multiple times without any assistive devices such as a splint or handroll, which are typically used to prevent further decrease in ROM. Despite the resident's family being informed that an appropriate device would be provided, no such device was observed during the surveyor's visits. The resident's medical records indicated a history of cerebral infarction and major depression, with a moderately impaired cognitive status. The care plan for the resident included monitoring for signs of immobility and providing gentle ROM exercises, but it lacked specific interventions for the contracture of the right hand. Additionally, there were no active physician orders addressing the contracture, and previous therapy recommendations for wearing a handroll were not being followed. Interviews with facility staff revealed a lack of consistent application of assistive devices and a gap in communication regarding the resident's care needs. The head therapist confirmed that the resident had not been on therapy since early 2024, and the discharge recommendations for wearing a handroll were not implemented. The Director of Nursing outlined general interventions for residents with contractures, but these were not reflected in the resident's care plan or observed in practice.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. During an observation, the surveyor noted that the tubing of the urinary collection bag was dragging on the ground as the resident self-ambulated in a wheelchair. The resident, who had a diagnosis of urinary tract infection, dementia, and neuromuscular dysfunction of the bladder, was cognitively intact with a BIMS score of 14/15. The resident's care plan included interventions to keep the drainage bag off the floor and covered for dignity, but these were not followed. Interviews with facility staff, including the Infection Preventionist, LPNs, and the Director of Nursing, confirmed that the urinary collection tubing should never touch the ground due to infection control concerns. The facility's Foley Catheter Care policy stated that the drainage bag must not touch the floor, but it did not explicitly mention the tubing. The deficiency was identified as a failure to adhere to infection control protocols, as the tubing was observed on the floor, posing a risk of cross-contamination and infection.
Improper Storage of Respiratory Equipment for Resident with COPD
Penalty
Summary
The facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for a resident with COPD. During an initial tour, a surveyor observed a nebulizer mask belonging to the resident placed face down inside the bedside on top of personal belongings, such as a book and a mirror, and the mask was undated. Subsequent observations revealed the nebulizer mask was consistently stored improperly, either inside a side table drawer or on top of the side table, exposed and undated. The resident, who was cognitively intact, had a history of COPD and was admitted with other diagnoses, including atrial fibrillation. The facility's documentation showed that the resident had a physician's order for Albuterol Sulfate Inhalation Nebulization Solution, which was discontinued in August 2024. Despite this, the nebulizer mask was not stored according to infection control protocols. The resident's care plan included interventions for COPD, such as the administration of bronchodilators as ordered. However, the facility's Oxygen Administration policy did not address the care or storage of nebulizers. Both the resident's LPN and the DON acknowledged that the nebulizer mask should have been bagged and labeled when not in use.
Failure to Ensure Consistent Communication with Dialysis Facility
Penalty
Summary
The facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. This deficiency was identified for a resident who had been receiving dialysis treatment for approximately five years due to end-stage renal disease and other related conditions. The resident attended dialysis four days a week, and the facility's policy required the use of a communication book to document vital signs and other pertinent information before the resident's departure for dialysis. Upon review, it was found that the facility did not consistently document necessary information on the dialysis communication forms. Specifically, there were missing entries for vital signs, access site status, and any problems or complaints on several dates. The Licensed Practical Nurse (LPN) responsible for the resident confirmed that the top portion of the communication form should be completed by the facility's nursing staff before the resident's dialysis treatment. However, this was not consistently done, leading to incomplete communication records. Interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) revealed that the facility's process involved using a communication book for documenting and communicating with the dialysis center. The DON acknowledged that the nursing staff was responsible for ensuring the completion of the communication forms before the resident's departure for dialysis. Despite this, the facility's policy was not consistently followed, resulting in incomplete documentation and communication with the dialysis center.
Failure to Maintain Hospice Communication Record
Penalty
Summary
The facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. During an initial tour, the surveyor observed the resident in their room and identified them as receiving hospice care. The resident was admitted with diagnoses including palliative care, depression, and sacral wounds. The most recent Minimum Data Set indicated the resident was on hospice care, and their comprehensive care plan included coordination with hospice and notification of any changes in condition or medication. During an interview, the LPN/Unit Manager was unable to provide a complete Hospice Communication Book for the resident, only presenting two documents related to billing and symptom management. The facility's hospice program policy requires communication with the hospice provider to ensure resident needs are met 24/7, but the documentation was insufficient. This lack of documentation and communication with hospice providers led to the identified deficiency.
Failure to Protect Residents from Abuse by Peer and Staff
Penalty
Summary
The facility failed to protect multiple residents from physical and verbal abuse by both another resident and a staff member. One resident with a history of mental illness, aggressive behavior, and non-compliance with psychotropic medication physically assaulted two other residents on separate occasions. Despite documented recommendations for one-on-one supervision and behavior tracking, there was no evidence that these interventions were consistently implemented or that the care plan was revised in response to ongoing aggressive behaviors and repeated medication refusals. The facility did not provide documentation that the physician was notified or that behavior tracking was forwarded as recommended, and staff interviews revealed a lack of awareness regarding supervision requirements. Additionally, two residents were subjected to physical and verbal abuse by an LPN on two separate occasions. Witness statements and incident reports confirmed that the LPN pushed one resident and yelled at them, and on another occasion, used expletives and physically struck another resident's hand while attempting to take a binder away. The incidents were witnessed by other staff, and the LPN continued to provide care after the first incident before being suspended and subsequently terminated following the second incident. The facility's own investigation substantiated the staff-to-resident abuse. The residents involved had varying degrees of cognitive impairment and medical conditions, including dementia, anxiety disorder, depression, and chronic illnesses. The facility's failure to implement and maintain appropriate interventions, revise care plans, and ensure staff adherence to abuse prevention policies resulted in actual harm to the residents and placed them in situations of immediate jeopardy.
Removal Plan
- Educate the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on investigating allegations of abuse
- Review and revise policies
- Educate staff on abuse
Failure to Investigate Abuse Allegations and Threats
Penalty
Summary
The facility failed to ensure residents' safety by not conducting thorough and complete investigations into allegations of abuse and threats involving two residents. In one incident, a resident with Huntington's disease, muscle weakness, gait instability, and anxiety disorder, who was cognitively intact, reported being placed in a dayroom against their wishes during the night shift. The resident stated that a CNA, following a nurse's instructions, placed them in the dayroom with the door closed and sat outside the door, preventing the resident from leaving. The resident expressed fear and distress during the incident, and the facility's documentation confirmed that the resident was kept in the room against their wishes. However, the facility could not provide evidence of a comprehensive investigation, including interviews with all involved staff and assessment of resident safety. In a separate incident, another resident with schizophrenia and anxiety disorder was observed by an LPN throwing a knife into the hallway and making ongoing verbal and physical threats toward staff and other residents. Despite the seriousness of the behavior, the facility was unable to provide documentation that a thorough investigation was conducted to ensure the safety of other residents and staff. There was no evidence that the incident was fully investigated or that appropriate steps were taken to assess the situation and prevent further harm. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention requires protection of residents from abuse and the maintenance of a culture of compassion and caring, particularly for those with behavioral or emotional problems. In both incidents, the facility failed to implement its own policy and procedures, as there was a lack of documented evidence of complete investigations and follow-up actions to ensure resident safety following the reported events.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to ensure the safety and well-being of residents by not adequately preventing or addressing incidents of physical and verbal abuse, as well as not following its own policies regarding abuse prevention, physical restraints, and behavioral management. Multiple residents with cognitive and behavioral health diagnoses, including schizophrenia and dementia, were involved in repeated altercations and aggressive incidents. One resident with schizophrenia exhibited ongoing aggressive and violent behaviors towards both staff and other residents, including physical assaults, threats, and property damage. Despite recommendations from psychiatric consultants and outreach programs for one-on-one supervision and behavioral tracking, there was no consistent documentation that these interventions were implemented or that the physician was notified of ongoing medication refusals. The resident continued to refuse medications and engaged in multiple aggressive episodes, some resulting in injuries to other residents and staff, without evidence of timely or adequate intervention by facility leadership. In addition to resident-to-resident aggression, the report documents substantiated incidents of staff-to-resident abuse. An LPN was witnessed pushing and yelling at a resident and using inappropriate language and physical force with another resident. These incidents were observed by other staff members, and the involved LPN continued to provide care after the initial incident before being suspended and ultimately terminated. The facility's documentation revealed delays in reporting and investigating these abuse allegations, and there was a lack of immediate protective measures for the affected residents. Interviews with staff indicated that some were unaware of required supervision protocols, and there was confusion regarding the implementation and discontinuation of one-on-one supervision for residents with behavioral issues. The facility did not provide evidence that all recommended safety measures, such as consistent one-on-one supervision, behavioral tracking, and timely notification of psychiatric and medical providers, were followed. There was also a lack of documentation regarding the rationale for discontinuing supervision and the communication of behavioral incidents to appropriate authorities. The failure to implement and document these interventions contributed to repeated episodes of aggression, injury, and abuse among residents and staff, in violation of facility policies and regulatory requirements.
Involuntary Seclusion of Resident in Dayroom by CNA
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) placed a resident in the dayroom, closed and blocked the door, and sat outside to prevent the resident from leaving, despite the resident's repeated requests to exit. The resident reported feeling terrified and begged to be let out, but the CNA did not allow it. The incident was corroborated by interviews, surveillance footage, and statements from both the resident and staff, which confirmed that the resident was kept in the dayroom against their wishes. The resident involved had a diagnosis of Huntington's disease and asthma, and was assessed as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. The event occurred during the night shift, when the resident was found in the hallway and redirected to the dayroom by the CNA, following instructions from a nurse to keep the door closed due to fall risk concerns. The CNA remained outside the door, monitoring the resident and others in the dayroom, but did not permit the resident to leave when requested. Facility documentation, including the Reportable Event Record and investigative summaries, confirmed that the resident was involuntarily secluded in the dayroom. The facility's own policies on physical restraints and abuse prevention were not followed, as these policies prohibit involuntary seclusion and require the protection of residents' rights to freedom from such practices. The incident was reported, and the CNA involved was suspended following the event.
Failure to Assess and Monitor Resident After Fall Resulting in Hematoma
Penalty
Summary
The facility failed to assess and monitor for delayed complications after a resident fell from a geriatric chair in the day room and sustained a hematoma. The facility did not follow its own policy, which required observation for delayed complications for approximately 48 hours after a fall and documentation of findings in the medical record. There was no evidence in the resident's electronic medical record that a neurological assessment was completed or that the facility's fall assessment policy was implemented after the incident. The nursing progress notes lacked documentation of the resident's status following the fall, and the fall investigation packet did not include a neurological assessment. The resident involved had a history of traumatic brain injury, unspecified dementia with behavioral disturbances, and was severely impaired in decision making. After the fall, the resident exhibited a decline, including inability to swallow, drooling, decreased alertness, and bruising on the forehead, as observed by family members and staff. Interviews with staff and the medical director confirmed that the required assessments and monitoring were not documented or performed according to policy, and the director of nursing acknowledged the expectation for neurological assessments and documentation following such incidents.
Failure to Provide Adequate Supervision and Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident with a history of traumatic brain injury and severe dementia. The resident was dependent on staff for all activities of daily living and exhibited behavioral symptoms, including attempts to get out of bed, wheelchair, and geriatric chair. Despite multiple falls, including incidents where the resident sustained head injuries and required emergency treatment, the facility did not consistently document the root causes of the falls or update the care plan with new interventions after each event. Review of the facility's fall management policy indicated that staff were required to identify and implement interventions based on the resident's specific risks and to re-evaluate and modify interventions if falls recurred. However, after several falls, the care plan was not promptly updated with new or different interventions, and there was no evidence that increased monitoring was implemented as documented. Staff interviews revealed that supervision in the day room was insufficient, especially during mealtimes when one CNA was responsible for feeding and monitoring multiple high-fall-risk residents. Interviews with nursing staff and management confirmed that falls were discussed in meetings, but the interdisciplinary team did not consistently meet after each fall to re-evaluate interventions. The staff acknowledged that the interventions in place were not effective in preventing further falls for the resident, and there was a delay in increasing supervision or changing the approach despite repeated incidents.
Failure to Complete and Document Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct and document annual performance evaluations for all Certified Nursing Assistants (CNAs) as required. Review of personnel files for five CNAs revealed missing or outdated Performance Evaluations for Non-Exempt Employees (PENEE), with some files lacking evaluations for one or more years. Interviews with CNAs confirmed that annual reviews had not been completed in the past year or more. Additionally, the facility was unable to provide documentation or evidence of completed evaluations for the required periods. Further interviews with facility staff, including the Unit Manager, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources (HR) Director, revealed confusion regarding responsibility for completing the annual evaluations. The Unit Manager admitted to not completing the reviews in recent years and was unsure who was responsible. The DON stated that direct managers were supposed to complete the reviews, coordinated through HR, but the ADON and HR Director could not locate the necessary documentation or a performance review policy. This lack of clarity and documentation led to the identified deficiency.
Failure to Timely Report Abuse Allegations and Threats
Penalty
Summary
The facility failed to report allegations of abuse in a timely manner to the New Jersey Department of Health (NJDOH) and did not follow its own policy on abuse, neglect, exploitation, and misappropriation prevention. Specifically, an incident occurred in which one resident with dementia and a history of sexually inappropriate behaviors was observed by a CNA touching another resident, also with dementia and severely impaired cognition, inappropriately while both were fully clothed. The incident was reported to the nurse immediately, but the facility did not notify NJDOH until more than two hours after the event, which was not in accordance with federal requirements or facility policy. Documentation showed the incident occurred at 8:30 p.m. and was reported to NJDOH at 12:30 p.m. the following day. Additionally, another resident with schizophrenia and anxiety disorder was reported by an LPN to have thrown a knife into the hallway and continued to display verbal and physical threats toward staff and other residents. The facility could not provide evidence that these verbal threats were reported to NJDOH as required. Interviews with the DON confirmed that all allegations of abuse, including resident-to-resident abuse and threats, should be reported to NJDOH within two hours, but this was not consistently done. The Administrator also indicated a misunderstanding of what incidents were reportable, further contributing to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours on 08/29/23, as required by regulation. Review of the Nurse Staffing Report for that date showed no RN coverage for the required period. The Unit Secretary/Staffing Coordinator, responsible for scheduling, confirmed that RN coverage is typically arranged for eight hours daily but could not recall the reason for the lapse on the specified date. The Director of Nursing acknowledged the expectation for federal compliance. This deficiency had the potential to affect all 157 residents in the facility, as the absence of RN coverage was not in accordance with the facility's stated staffing policy and regulatory requirements.
Failure to Notify POA of Room Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) about a room change and did not document this notification in the progress notes, violating Mandatory Resident Rights. This deficiency was identified during a review of a resident who had been involved in a physical altercation with another resident, leading to a room change. The resident, who had a history of unspecified dementia, major depressive disorder, and hypertension, was assessed with a moderately impaired cognitive status. Despite the facility's protocol requiring family notification and documentation in such cases, there was no record of the POA being informed about the room change. Interviews with facility staff, including the Licensed Practical Nurse Unit Manager (LPN UM) and the Licensed Nursing Home Administrator (LNHA), confirmed that family notification should occur before a room change and be documented in the resident's progress notes. The Director of Nursing (DON) and LNHA emphasized the importance of this practice as a resident's right. However, the facility lacked a specific policy on room changes and notification, as revealed by the DON, who provided a document titled Subchapter 4: Mandatory Resident Rights, which outlines the resident's right to be notified of room changes.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement care plan interventions for a resident following a fall, as required by their policy. The resident, who was admitted with diagnoses including dementia, depression, and anxiety disorder, had a fall on September 8, 2024. Despite being identified as at risk for falls, the resident's care plan had not been updated with new interventions since January 29, 2024. This oversight was confirmed during interviews with the Licensed Practical Nurse Unit Manager (LPN UM) and the Director of Nursing (DON), who acknowledged that the care plan should have been updated within 24 to 48 hours after the incident. The facility's policy on comprehensive person-centered care plans mandates that care plans be revised when there is a significant change in a resident's condition, such as a fall. However, the care plan for the resident in question was not updated after the fall, and no new interventions were added. The DON confirmed that interventions are typically discussed during falls huddle meetings, but in this case, the care plan remained unchanged, contrary to the facility's policy and expectations.
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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