Adroit Care Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rahway, New Jersey.
- Location
- 1777 Lawrence Street, Rahway, New Jersey 07065
- CMS Provider Number
- 315198
- Inspections on file
- 22
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Adroit Care Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that personal refrigerators in multiple resident rooms lacked thermometers or temperature logs, had improper temperatures, and contained expired, undated, or unlabeled food items. Some units had visible debris, spilled food, or were warm to the touch, and one unit was frozen at 9 F. The LPN/UM said staff did not routinely monitor or document temperatures and that residents handled expiration checks and cleaning, while the DOM said CNAs were responsible for daily checks and cleaning. The facility policy required labeling, discarding expired food, and daily monitoring and weekly cleaning of resident room refrigerators.
Improper Disposal of Soiled Materials and Unclean Linen Storage: Surveyors observed soiled linen, PPE, and gloves discarded on top of a trash receptacle and on the floor in a room with EBP signage. For a resident with dementia, muscle weakness, and an unhealed stage 4 pressure ulcer, surveyors also found clean linens and incontinence supplies sitting on top of a trash bin cover. The CNA, LPN, DON, and IP all confirmed that PPE and linen were not being stored or discarded as required by facility practice.
Unlabeled Tube Feeding Bags: Two residents receiving continuous TF were observed with feeding bags that lacked required labels, including the resident name, room number, start time, and infusion rate. One resident had dysphagia, aphasia, gastrostomy status, and severely impaired cognition, while the other had gastrostomy status and received most calories through TF. Orders specified continuous pump feedings with set rates and start times, and the DON confirmed that TF bags should be labeled with resident information, formula, and rate.
Unlocked Medication Cart and Improper Insulin Storage: A surveyor observed a B-side medication cart left unlocked and unattended in a hallway, and an RN later locked it after being approached. The DON stated medication carts must be locked when not being attended to. The surveyor also found insulin lispro, insulin glargine, and an unopened Lantus vial box stored in a cart drawer instead of refrigerated, even though the manufacturer instructions required refrigeration until use; an LPN confirmed the insulin should be refrigerated.
Infection control failures were observed involving a resident with COPD who had oxygen therapy and nebulizer orders, where oxygen tubing was left hanging and the nebulizer mask was found open to air instead of stored in protective covering. A second resident on Contact Precautions for C. auris had a CNA enter the room without a gown, remove a basin, and then enter another resident's room; the DON and IP stated that nebulizers should be stored in a plastic bag and PPE should be worn before room entry.
A resident with vascular dementia and moderate cognitive impairment was allowed outside unescorted, contrary to their care plan requiring escort. The nurse failed to document the physician's order for an out on pass, and the care plan was not updated after the resident eloped, was found wandering on a highway, and experienced a syncopal episode requiring emergency care. Facility policies requiring timely care plan updates after incidents were not followed.
A resident with vascular dementia and moderate cognitive impairment was allowed by nursing staff to go outside, after which the resident left the premises unaccompanied and was later found by police. The incident was not reported to the NJDOH as required, and there was no physician's order in the medical record authorizing the resident to go out on pass unescorted at the time of the event.
A resident with vascular dementia and moderate cognitive impairment was allowed to leave the facility without a documented physician's order for an out on pass, resulting in the resident leaving the premises and requiring emergency care after a syncopal episode. Additionally, required psychiatric and psychological consults were not completed as ordered, with one consult delayed for months and the other not obtained at all.
A resident's family member, who was the primary contact and had full PHI access, requested the resident's medical records. The facility received the request and was informed by their contracted provider that more documentation was needed, but did not notify the family member of this requirement for about two weeks, resulting in a failure to provide the records within the required two-day timeframe.
The facility failed to maintain a clean and sanitary environment in two shower rooms, with issues such as tiles on the floor, brown stains, and improperly stored items. Housekeeping staff and the Director of Housekeeping acknowledged the problems, attributing some to water harshness. Facility policies emphasized the importance of sanitation and regular audits.
A facility failed to provide dignified ADL care by not ensuring privacy for a resident with moderately impaired cognition. A CNA was observed assisting the resident with a transfer and removing their pants without closing the door or pulling the privacy curtain, exposing the resident's lower body. The facility's policy requires maintaining privacy during such care.
A resident with quadriplegia and peripheral vascular disease had incomplete treatment records, with numerous blanks in the Treatment Administration Record (TAR) over several months. The resident expressed concerns about wound care not being completed when staffing was low. The DON confirmed that blanks indicate treatments may not have been documented or performed, contrary to facility policy requiring complete documentation.
The facility failed to remove expired Covid-19 vaccines from the medication room inventory. During a survey, a surveyor found expired Moderna Covid-19 vaccine syringes in a refrigerator, which the LPN confirmed should have been removed by the overnight shift. The ADON and IP also acknowledged the oversight, and the facility's policy requires monthly checks to ensure medications are not expired.
The facility failed to ensure proper disposal of PPE in rooms with Enhanced Barrier and Contact Precautions. PPE gowns were found discarded in residents' personal trash bins and on the floor, contrary to the facility's procedures requiring disposal in red biohazard bags. Staff interviews confirmed the expectation for correct disposal, and the facility's Infection Control Manual outlined these procedures.
Failure to Monitor and Sanitize Resident Personal Refrigerators
Penalty
Summary
The facility failed to ensure that food stored in residents’ personal refrigerators was maintained in a safe and sanitary manner. During a tour of rooms with personal refrigerators, surveyors found that several units did not have thermometers, no temperature logs were available, and some refrigerators had visible debris or spilled food inside. In one room, a thermometer was present but the unit read 50 F, and in another room the refrigerator was warm to the touch. One refrigerator was observed at 9 F with food frozen inside, and the resident’s family was reported to adjust the temperature control. Surveyors also found multiple expired or undated food items in the refrigerators. Examples included expired pudding, mixed fruit, turkey sandwiches, mustard, soda, sliced cheese, cream cheese, ketchup, dressing, sandwich meat, rum punch, lemon Jell-O, apple juice, and other sandwiches that were either expired or not labeled and dated. These findings were identified in all 6 resident rooms reviewed for personal refrigerator use. During interviews, the LPN/UM acknowledged that thermometers were not routinely placed in residents’ personal refrigerators and that staff did not monitor or document temperatures. The LPN/UM also stated that residents, rather than staff, checked expiration dates and cleaned the refrigerators. The DOM stated that CNAs were responsible for monitoring, cleaning, and discarding expired items, while the LNHA stated the facility was not responsible for residents’ personal refrigerators and that no specific policy existed. The facility policy reviewed by surveyors stated that food items were to be labeled, expired food discarded by nursing staff, refrigeration units monitored, and resident room refrigerators checked daily and cleaned weekly.
Improper Disposal of Soiled Materials and Unclean Linen Storage
Penalty
Summary
The facility failed to provide a clean environment by improperly disposing of soiled materials and PPE in a room with Enhanced Barrier Precautions (EBP) signage posted. During observation, surveyors saw soiled bed linen with other items wrapped inside and a blue disposable chuck placed on top of a garbage receptacle, and a disposable glove turned inside-out discarded on the floor. On a later observation in the same room, surveyors again saw a pair of disposable gloves turned inside-out on the floor. Staff interviews confirmed that soiled linen should be placed inside the trash receptacle and that gloves and other PPE should not be discarded on the floor or on top of the trash bin. The RN/IP stated that used PPE should be discarded in a red trash bin or a regular trash receptacle lined with a red bag if needed, and that hand hygiene should follow disposal. The facility also failed to keep clean bed linen and incontinence supplies maintained in sanitary condition for Resident #16, who was admitted with diagnoses including local infection of the skin and subcutaneous tissue, dementia, and muscle weakness, and whose MDS reflected an unhealed stage 4 pressure ulcer on the left hip. Surveyors observed a covered red plastic trash bin at the foot of the resident’s bed with folded blue disposable chuck, folded cream-colored incontinence brief, and several layers of folded linen and garments sitting directly on top of the trash bin cover. The resident’s care plan included a focus on the stage 4 pressure ulcer and a goal of showing no signs of infection to the site. The DON and IP both stated that clean linens should not be placed on top of the trash bin, and the IP stated that red trash bins were for soiled PPE of residents on EBP and that clean linens should be bagged and not left on top of trash bins.
Unlabeled Tube Feeding Bags
Penalty
Summary
The facility failed to ensure that residents receiving enteral feedings were provided appropriate care and services by not completing formula labels for tube feeding bags. This deficient practice was identified for 2 of 3 residents reviewed for tube feeding, including Resident #114 and Resident #49, both of whom were observed asleep in bed while receiving continuous tube feedings with unlabeled feeding bags. For Resident #114, the resident had diagnoses including dysphagia, aphasia, and gastrostomy status, and the quarterly MDS showed a BIMS score of 0 out of 15, indicating severely impaired cognition. The care plan identified the resident as requiring tube feeding related to dysphagia, failure to thrive, malnutrition, and risk for aspiration. The physician's order directed Peptamen 1.5 cal. via gastrostomy at 60 mL/hr by pump, with a total volume of 1000 mL per 24 hours, and required staff to document the feeding start time each shift and verify the infusion rate each shift. During observation, the TF bag was not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate. For Resident #49, the resident had gastrostomy status and the annual MDS indicated that 51% or more of total calories were received through tube feeding. The EMR included an order for Glucerna 1.2 at 75 mL/hr via pump, with a total volume of 1,550 mL and initiation at 5:00 PM until the total volume was infused. During observation, the TF bag was also not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate. The DON confirmed that TF bags should be labeled with the resident's information, date, time, formula, and rate, and the facility policy directed staff to fill in the label with the resident's name, room, start time, and rate.
Unlocked Medication Cart and Improper Insulin Storage
Penalty
Summary
The facility failed to store medications securely inside medication carts by leaving a B-side 2nd floor medication cart unlocked when it was unattended. During the initial tour, the surveyor observed the cart unlocked in the hallway with no medications on top and no residents, visitors, or staff present nearby. A nurse later came out of a resident room, approached the cart, and locked it. In interview, the RN confirmed responsibility for the cart and stated that medication carts need to be locked at all times, and the DON stated that nurses must lock medication carts if they are not behind them. The facility policy titled Medication Storage, reviewed on 1/28/2026, did not include keeping medication carts locked when not being attended to. The facility also failed to ensure proper temperature control for insulin stored on the 2nd floor central medication cart. The surveyor observed one multi-dose vial of insulin lispro 100 units, one insulin glargine 100 units/mL, and one unopened box of Lantus multi-dose vial 100 units in the top drawer of the cart, with the protective caps intact and the box unopened. The surveyor reviewed the manufacturer instructions, which stated the insulin should be refrigerated at 36 degrees F to 46 degrees F until time of use, and the second floor medication room had a refrigerator for medications. The LPN confirmed that the insulin vials should be refrigerated and confirmed the condition of the vials and unopened box. The facility policy titled Medication Storage-Insulin, last reviewed 1/28/26, stated that the facility follows manufacturer recommendations for proper storage and temperature controls of medications including insulin.
Infection Control Failures With Respiratory Equipment and Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed two infection control failures. For Resident #50, who was admitted with COPD and had an order for oxygen therapy and nebulizer treatments for shortness of breath, the surveyor found oxygen tubing hanging from the bedside table and, after opening the top drawer with the resident's permission, observed the resident's nebulizer with the mask left open to air rather than stored in protective covering between uses. The DON stated that when nebulizers were not in use they should be stored in a plastic bag. For Resident #75, who had a physician's order for Contact Precautions and a care plan focus related to C. auris after a positive swab, the surveyor observed contact precaution signage on the door instructing staff to put on a gown before room entry. At the same time, a CNA entered the room without a gown, removed a basin from the room, and then entered another resident's room. The CNA stated she removed the basin because the resident's water took too long to warm. The IP stated that PPE should be applied before entering the resident's room and that residents on contact precautions should have dedicated supplies that do not go in and out of the room.
Failure to Implement and Update Care Plan Following Resident Elopement
Penalty
Summary
The facility failed to implement and update a comprehensive care plan for a resident with vascular dementia and a mood disorder, who had a moderately impaired cognitive status as indicated by a BIMS score of 12 out of 15. The resident was allowed to sit outside unescorted after expressing a desire to do so, and the nurse verbally agreed and intended to obtain a physician's order for an out on pass, but failed to document the order or update the care plan. The resident subsequently left the facility grounds unaccompanied, was found wandering on a multi-lane highway by a passerby, and was later brought to a police precinct where the resident experienced a syncopal episode and required transfer to the emergency room. Review of the resident's care plan revealed it included an intervention for community pass with escort only, but the plan was not updated following the incident or after the resident's quarterly MDS assessment. The facility's policies required care plans to be reviewed and updated after significant incidents and changes in condition, but this was not done. Staff interviews confirmed that the care plan was not revised post-incident, and the required physician's order for the out on pass was not documented, resulting in a lack of communication and appropriate interventions for the resident's safety.
Failure to Report Resident Elopement to State Authorities
Penalty
Summary
The facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH) as required. A resident with vascular dementia and a moderately impaired cognitive status, as indicated by a BIMS score of 12, was observed by nursing staff preparing to go outside. The nurse allowed the resident to sit outside and documented that the physician was informed to obtain an out on pass order. However, the resident left the premises unaccompanied and was later found by police, who transported the resident to a precinct. While at the precinct, the resident experienced a syncopal episode and was transferred to the emergency room for evaluation. The facility's investigation concluded that the resident, who was alert and oriented, had verbalized a desire to go for a walk and sit outside, and an out on pass order was obtained and signed after the fact. However, a review of the medical record did not show a physician's order for the resident to go out on pass unescorted at the time of the incident. During interviews, facility leadership stated they did not report the elopement to NJDOH, believing it was unnecessary due to the out on pass order. The facility's policy requires reporting such incidents to state agencies within five working days, but this was not done.
Failure to Document Physician Orders and Complete Required Consultations
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice by not documenting a physician's order for a resident to leave the facility on pass and by not following physician's orders for psychiatric and psychological consultations. Specifically, a resident with vascular dementia and a moderately impaired cognitive status was allowed to go outside after the nurse verbally obtained, but did not document, a physician's order for an out on pass. The resident subsequently left the premises, was found by police, and experienced a syncopal episode requiring transfer to the emergency room. Review of the medical record confirmed that no physician's order for the out on pass was documented at the time of the incident. Additionally, the facility did not follow through on physician's orders for psychiatric and psychological consultations for the same resident. Although orders for both consults were present upon admission, the psychiatric consult was not completed until nearly three months later, after the resident's elopement, and there was no evidence that the psychological consult was ever obtained. The DON confirmed that the orders were not followed as written, and the facility's policies required both obtaining and documenting such orders in the medical record.
Delay in Providing Medical Records to Authorized Family Member
Penalty
Summary
The facility failed to provide a requested medical record for a discharged resident within two days of a written request, as required. The family member of a resident with severe cognitive impairment, as indicated by a BIMS score of 3 and diagnoses including Alzheimer's Disease, Dementia, Respiratory Disorder, and COPD, submitted a written request for the resident's medical records. The family member was listed as the primary contact and designated with full PHI access. The request was received by the facility and forwarded to the contracted provider, who responded the same day that additional documentation was needed to confirm the requestor's authority. Despite receiving this information, the facility did not promptly communicate the need for additional documentation to the family member. The Administrator waited approximately two weeks before informing the family of the requirement for further documentation, resulting in a delay that exceeded the two-day regulatory timeframe. The deficiency was identified through interviews, record reviews, and examination of facility documentation, and was specific to the handling of this single resident's record request.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two shower rooms, as observed by a surveyor. On multiple occasions, the surveyor noted various issues in the shower rooms, including tiles on the floor, hygienic products left in the whirlpool tub, brown stains on the walls and floor tiles, an empty can of aftershave, a leaking shower head in a plastic bag, a broken faucet, and improperly stored incontinence products. Additionally, the surveyor found clothing and tissues on the floor, and trash cans without bag linings. Interviews with housekeeping staff and the Director of Housekeeping revealed that housekeeping is responsible for cleaning the shower rooms, while CNAs are expected to clean up after residents. The Director of Housekeeping attributed the brown stains to the harshness of the water and mentioned that the Regional Director of Housekeeping had been notified for guidance. The Licensed Nursing Home Administrator confirmed the water's harshness as the cause of the stains and acknowledged that the shower area should have been cleaned. Facility policies emphasized the importance of sanitation in high-risk areas like bathrooms and the need for regular audits to ensure cleaning standards are met.
Failure to Ensure Privacy During ADL Care
Penalty
Summary
The facility failed to provide a resident's activities of daily living (ADL) care in a dignified manner, as observed by a surveyor. On November 7, 2024, a surveyor witnessed a Certified Nursing Assistant (CNA) assisting a resident in transferring from a wheelchair to a bed. During this process, the CNA removed the resident's pants, exposing the resident's lower body and incontinence briefs, without ensuring privacy by closing the door or pulling the privacy curtain. This incident occurred in the resident's private room, and the CNA acknowledged the oversight when questioned by the surveyor. The resident involved had a history of fractures in the humerus and ribs and was assessed with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. The facility's policy on Resident Rights, last reviewed in June 2024, mandates that residents be treated with respect and dignity, which includes ensuring privacy during ADL care. The Licensed Nursing Home Administrator, Regional Nurse, and Director of Nursing confirmed that the expectation is for staff to maintain privacy by closing the door or using the privacy curtain during such care.
Incomplete Treatment Records and Documentation Deficiency
Penalty
Summary
The facility failed to maintain complete treatment records with staff signatures for a resident, as required by professional standards of clinical practice. The resident, who was admitted with diagnoses including quadriplegia and peripheral vascular disease, was found to have numerous blanks in their Treatment Administration Record (TAR) over several months. These blanks were noted for various treatments to different parts of the resident's body, including the left and right toes, calf, lower leg, and buttock, indicating that the treatments may not have been administered or documented properly. During interviews, the resident expressed concerns that their wound care was not completed when there were only two nurses on the floor. The Director of Nursing confirmed that blanks on the TAR indicate that a nurse did not sign off on the treatment, leaving uncertainty about whether the treatment was performed. The facility's policy requires that all treatments be documented in the TAR, including the treatment ordered, frequency, location, date/time administered, and the staff member who performed the treatment. Any refusals should also be documented, and the physician should be informed.
Expired Vaccines Not Removed from Inventory
Penalty
Summary
The facility failed to ensure that expired vaccines were removed from active inventory upon expiration. This deficiency was identified in one of the two medication rooms during a survey conducted on the second floor medication room of the sub-acute unit. The surveyor, accompanied by the Licensed Practical Nurse Unit Manager (LPNUM #1), discovered a brown bag in the refrigerator containing five prefilled Intramuscular (IM) Moderna Covid-19 vaccine syringes, all of which had expired. LPNUM #1 confirmed that the overnight shift was responsible for checking expiration dates and acknowledged that the expired vaccines should not have been in the refrigerator. Further interviews with the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) confirmed the oversight, with both acknowledging that the expired vaccines should have been removed. The facility's policy on medication storage, which was last reviewed on an unspecified date, mandates that licensed nurses check medication storage at least monthly to ensure all medications and supplies are checked for labels and expiration dates. The policy also states that any medications nearing expiration should be removed before the expiration date. Despite this policy, the expired vaccines remained in the medication room, indicating a lapse in adherence to the facility's procedures.
Improper PPE Disposal in Precaution Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections, as evidenced by improper disposal of Personal Protective Equipment (PPE). During a survey, it was observed that PPE gowns were discarded inappropriately in residents' personal trash bins and on the floor in rooms marked with Enhanced Barrier Precautions and Contact Precautions signs. This was contrary to the facility's established procedures, which required PPE to be disposed of in a red biohazard bag and taken to the soiled trash room. Interviews with staff, including a Licensed Practical Nurse Unit Manager, a Certified Nursing Assistant, and the Infection Preventionist, confirmed that the facility's expectation was for PPE to be disposed of in a red bag and not in resident trash bins or on the floor. The facility's Infection Control Manual and job descriptions for nursing staff also outlined the correct procedures for PPE disposal, which were not followed. The Director of Nursing and other administrative staff acknowledged the improper disposal practices during the survey.
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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