Atlas Rehabilitation Healthcare At Daughters Of Mo
Inspection history, citations, penalties and survey trends for this long-term care facility in Clifton, New Jersey.
- Location
- 155 Hazel Street, Clifton, New Jersey 07011
- CMS Provider Number
- 315021
- Inspections on file
- 18
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Atlas Rehabilitation Healthcare At Daughters Of Mo during CMS and state inspections, most recent first.
Surveyors found that two residents received inappropriate incontinence care, including the use of double briefs without proper documentation or care plan updates, and that meal trays were not delivered in a timely manner due to insufficient staffing and lack of clear policy. Staff interviews revealed inconsistent practices and a lack of awareness regarding resident preferences and care plan requirements.
Surveyors identified that two residents had incomplete CNA documentation logs and care plans that were not updated to reflect their current incontinence status and care preferences. One resident's ADL records had multiple blank entries, and another resident's care plan was only updated to include the use of double briefs after surveyor inquiry, despite the resident being observed with double briefs. The DON confirmed the missing documentation and the need for care plan updates.
The facility failed to complete and transmit MDS assessments within the required 14 days for multiple residents, as identified by surveyors through interviews and record reviews. The MDSC/RN confirmed the delays, citing workload issues, and the facility relied on the RAI manual for guidelines without a separate policy. Meetings with the LNHA and DON did not yield additional information or corrective actions.
The facility failed to ensure physicians reviewed residents' care, including medications and treatments, and documented progress notes at each visit. This deficiency affected 14 residents, with overdue physician orders and missing progress notes. Interviews confirmed ongoing issues with physician services, despite facility policies requiring regular visits and documentation.
A facility failed to ensure a resident's privacy and dignity during medication administration. An LPN administered medications and checked a resident's blood pressure in the dining area, contrary to the facility's Resident Rights Policy. The resident's preference for this setting was not documented in their care plan, leading to a deficiency.
A facility failed to verify the credentials of a newly hired Social Worker (SW) upon hire. The SW's license was found to be inactive with reinstatement pending, and this was only verified after a surveyor's inquiry. The LNHA acknowledged a user error during the license renewal process and stated that HR should have verified the license upon hire, as per the facility's Hiring Policy.
A facility failed to provide written bed hold notices to a resident or their representative during multiple hospitalizations. The resident, with a complex medical history including dementia and COPD, was hospitalized for issues like catheter malfunction and ESBL. Despite policy requirements, no bed hold notifications were documented for the specified dates, as confirmed by facility staff.
A resident experienced significant cognitive decline and weight gain, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. The MDS Coordinator acknowledged the oversight but could not provide documentation or justification for the decision not to conduct the assessment, resulting in a deficiency.
The facility inaccurately coded the MDS for two residents, leading to discrepancies in assessments. One resident's weight was incorrectly recorded, and another's discharge location was misreported. The errors were acknowledged by staff but highlighted the absence of a specific MDS policy.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with a history of falls did not have an individualized care plan, another with multiple diagnoses had an incomplete plan for ADLs, and a third with a left arm splint lacked documented interventions. Additionally, a resident at risk for skin breakdown had a care plan missing necessary interventions. These oversights highlight the need for improved care planning processes.
A facility failed to conduct routine and accurate monthly Psychoactive Reviews for a cognitively impaired resident on psychotropic medications. The behavior monitoring records showed inconsistencies, and the PR did not account for all medications or documented behaviors. The facility's policy required comprehensive reviews, which were not adhered to, leading to incomplete monitoring.
A facility failed to update a resident's care plan with necessary interventions after falls and did not conduct quarterly fall risk assessments as required. The resident experienced several falls, and the care plan lacked previous interventions. Staff interviews revealed confusion about responsibilities for updating care plans and conducting assessments, contributing to inadequate supervision and increased accident risk.
A facility failed to administer the correct total volume of enteral tube feeding for a resident with a gastrostomy, as per physician's orders. The resident, with a history of stroke, dementia, and diabetes, was prescribed a specific volume of Diabetisource 1.2, but documentation showed significantly lower volumes were infused over several days. Interviews revealed confusion among nursing staff regarding documentation, leading to discrepancies in the Medication Administration Record.
A resident with a history of pneumonia was found with improperly stored nebulizer equipment, and the facility lacked an individualized care plan and necessary orders for equipment maintenance. The Unit Manager confirmed the absence of a care plan and order for weekly nebulizer changes, contrary to facility policy.
The facility failed to adjust medication schedules for two residents requiring dialysis, leading to missed doses and duplicate orders. One resident had duplicate blood sugar check orders, while another had eye drops scheduled during dialysis sessions. The facility's Hemodialysis Policy was not followed, resulting in deficiencies in care.
The facility failed to post accurate daily staffing information on two occasions, with outdated and incorrect Nursing Home Resident Care Staffing Reports observed by surveyors. Staff interviews and policy reviews confirmed the deficiencies, as the reports were not updated at the beginning of each shift as required.
A resident with dietary restrictions due to hypertension and diabetes did not receive meals according to their preferences, despite selecting items from a menu. The resident, who was cognitively intact, frequently received incorrect meals, such as turkey meatloaf instead of roasted chicken. The Food Service Director confirmed the resident's selections were not honored, and the facility's investigation cited unclear writing as the cause, despite clear indications on the menu.
The facility failed to maintain complete and accurate medical records, with late entries for physician visits, missing consent documentation for vaccinations and psychoactive medications, and incomplete bowel and bladder management records. These deficiencies were identified for several residents, highlighting significant oversights in care documentation and consent processes.
The facility failed to follow proper infection control practices, including hand hygiene and PPE use, as observed with a CNA and RN/UM. An LPN left a disinfecting wipes container open, compromising its effectiveness. Additionally, a resident on transmission-based precautions for COVID-19 lacked proper signage and documentation, indicating a failure to adhere to facility policies.
A resident with multiple serious health conditions was observed to be dehydrated, but the LPN on duty failed to promptly notify the physician or escalate the issue according to facility policy. Despite an initial attempt to contact the physician, no further action was taken until after the resident's death, and the required communication with supervisory staff and the Medical Director did not occur.
Deficient Incontinence Care and Delayed Meal Delivery
Penalty
Summary
Surveyors identified deficiencies related to the provision of incontinence care and timely meal delivery for residents. On the observed unit, there was only one CNA present to distribute breakfast trays, resulting in meal trays being left unattended and not delivered to residents within the expected timeframe. The DON confirmed that meal trays should be delivered within 5 to 10 minutes of arrival to keep food warm, but observations showed that the last tray was not delivered until significantly later. Staff interviews revealed that the lack of a written policy and reliance on verbal communication contributed to inconsistent meal delivery practices. Incontinence care deficiencies were also observed for two residents. One resident, who was cognitively impaired and required extensive assistance with ADLs, was found to be wearing double incontinence briefs, a practice not documented in the care plan and not in line with facility expectations unless specifically requested and documented. The CNA responsible stated that the double briefs were applied at the resident's request, but the RN and LPNS were unaware of this and confirmed it was not standard practice. The resident's care plan did not reflect this preference, and the DON stated that such preferences should be documented, especially for residents who are cognitively intact. A second resident was also found with double incontinence briefs, with staff unable to confirm who applied them and the care plan not reflecting this intervention until after surveyor inquiry. The resident was moderately cognitively impaired and had a history of urinary incontinence. The DON stated that double briefs should only be used if requested by the resident and documented in the care plan, and that this practice increases the risk of skin impairment and urinary tract infection. Facility policies reviewed did not provide clear guidance on the use of double incontinence briefs or the process for meal tray distribution, contributing to the observed deficiencies.
Incomplete Medical Records and Inaccurate Care Plans Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by missing documentation in the Certified Nursing Aide (CNA) accountability logs and care plans that were not updated to reflect current resident needs. For one resident with moderate cognitive impairment and incontinence, the CNA documentation logs for activities of daily living (ADLs) had multiple blank entries for specific dates in October, despite the expectation that CNAs document every shift. The Director of Nursing (DON) confirmed that the ADL log was the required care log for CNAs and acknowledged the missing documentation when notified by surveyors. For another resident with a history of stroke, hemiplegia, and urinary incontinence, the care plan was not revised to accurately reflect the resident's incontinence status and preference for extra protection until after surveyor inquiry. The CNA documentation for this resident also had blank entries for several shifts in October. Additionally, the resident was observed wearing double incontinent briefs, a preference that was only added to the care plan on the day of the survey after being brought to the attention of the DON. The DON confirmed that the care plan had not been updated to reflect the resident's current needs prior to the surveyor's inquiry.
Repeated Deficiency in Timely MDS Completion
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set Assessment (MDS) within the required 14 days for 14 out of 38 residents reviewed. This deficiency was identified through interviews and record reviews conducted by surveyors. The MDS Coordinator/Registered Nurse (MDSC/RN) was unable to immediately provide the facility's protocol for completing MDS assessments and later confirmed that the assessments for several residents were completed beyond the required timeframe. The facility relied on the Resident Assessment Instrument (RAI) manual for guidelines but did not have a separate policy for MDS completion. Surveyor #1 found that the comprehensive MDS (cMDS) for five residents were completed late, with completion dates highlighted in red in the electronic medical records. The MDSC/RN confirmed that these assessments were not completed within the 14-day requirement. Similarly, Surveyor #2 identified late completion of MDS for six residents, with the MDSC/RN attributing the delays to the workload and being the only one handling subacute assessments. Surveyor #3 also noted late completion of MDS for three residents, and the facility's policy was found to be based on the RAI manual's current requirements. The survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services to discuss the findings. Despite the facility's reliance on the RAI manual, the MDS assessments were not completed within the required timeframes, leading to repeated deficiencies. The facility did not provide additional information or corrective actions during the survey team's meetings.
Deficiency in Physician Services and Documentation
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total program of care, including medications and treatments, and wrote, signed, and dated progress notes at each required visit. This deficiency was identified for 14 out of 35 residents reviewed for physician services. For instance, Resident #18's medical records showed no evidence of progress notes or assessments by Physician #1 from July 2024 through February 2025. Similarly, Resident #175's records lacked documentation from Physician #2 from November 2024 through February 2025, despite the resident being on contact precautions for ESBL in urine. The survey revealed that several residents' monthly physician orders were overdue for signing by their respective physicians. For example, Resident #10's physician had not signed the monthly physician orders for several months, and Resident #13's physician failed to conduct face-to-face visits or write progress notes for multiple months. Additionally, Resident #50's physician did not sign orders or conduct visits for several months, indicating a pattern of non-compliance with required physician services. Interviews with facility staff, including the Licensed Nursing Home Administrator and the Director of Nursing, confirmed ongoing issues with physician services, including the signing of orders and writing of visit notes. The facility's policy required physicians to visit residents monthly for the first 90 days and every 60 days thereafter, with orders to be signed off monthly. However, the survey findings highlighted significant lapses in adherence to these policies, affecting the quality of care provided to the residents.
Failure to Ensure Privacy and Dignity During Medication Administration
Penalty
Summary
The facility failed to treat a resident with respect and dignity during medication administration, as observed by a surveyor. During a medication pass, an LPN prepared and administered medications to a resident in the dining area while the resident was eating breakfast with other residents present. The LPN also checked the resident's blood pressure in the same setting. When questioned, the LPN stated that it was the resident's preference to receive medications in the dining room, but this preference was not documented in the resident's care plan. Further investigation revealed that the resident's care plan did not include any documentation of a behavior of swaying hands or a preference for taking medications in the dining room. The resident's cognitive status was assessed as intact, with no documented behaviors or mood disturbances. The facility's Resident Rights Policy emphasizes the importance of treating residents with respect and dignity, but the lack of documentation and adherence to the resident's care plan led to a deficiency in this area.
Failure to Verify Social Worker's License Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of a newly hired licensed staff member, a Social Worker (SW), were verified upon hire. During a review of ten randomly selected new employee files, it was discovered that the SW's license was not present in her employee file. Upon inquiry, the Regional Nurse indicated that the SW worked full-time and mentioned a pending status on her license. The License Nursing Home Administrator (LNHA) later provided documentation showing that the SW's license was inactive and reinstatement was pending, which was only verified after the surveyor's inquiry. The LNHA acknowledged that the SW's license had erroneously expired due to a user error during the renewal process, where the SW may have selected inactivate instead of renew. The LNHA stated that the Human Resources (HR) department should have verified and printed the license upon hire. The facility's Hiring Policy mandates that the HR Director is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. However, there was no documented evidence that the SW's license was verified before her hire date, indicating a lapse in the facility's hiring procedures.
Failure to Provide Bed Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide written notification of bed hold policies to a resident or their representative during instances of hospitalization. This deficiency was identified for a resident who had multiple unplanned discharges to the hospital on three separate occasions. Despite the facility's policy requiring that bed hold notices be provided within 24 hours of an emergency transfer, there was no documented evidence that such notifications were given for the dates in question. The absence of these notifications was confirmed through a review of the facility's bed hold notification binders for the years 2024 and 2025, which did not contain any notices for the specified dates. The resident involved had a complex medical history, including diagnoses of urinary tract infection, ESBL resistance, dementia, anxiety disorders, malnutrition, and chronic obstructive pulmonary disease. The resident experienced unplanned discharges to the hospital due to issues such as suprapubic catheter malfunction and ESBL of the urine. Despite these hospitalizations, the facility did not provide the required written bed hold notices, as confirmed by the Licensed Nursing Home Administrator and the Director of Nursing during the survey process.
Failure to Complete SCSA for Resident with Significant Changes
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced significant changes in cognitive status and weight. According to the CMS's RAI Version 3.0 Manual, an SCSA must be completed within 14 days of determining a significant change from baseline, especially when the resident's condition is not expected to return to baseline within two weeks. The resident in question had a cognitive decline from a BIMS score of 13 to 5 over two quarterly MDS assessments and experienced an 11% weight gain over three months, which met the criteria for an SCSA. The surveyor's review of the resident's medical records revealed no documented evidence that the Interdisciplinary Team (IDT) met and decided that an SCSA was unnecessary despite the significant changes in the resident's status. The MDS Coordinator/Registered Nurse acknowledged that an SCSA should have been completed but was unable to provide documentation supporting the decision not to proceed with it. The facility's failure to document the IDT's decision and the lack of an SCSA for the resident's significant changes in cognitive status and weight gain constituted a deficiency. During interviews, the MDS Coordinator stated that the team believed the resident's cognitive status fluctuated and did not warrant a significant change assessment. However, there was no documentation to support this claim, and the MDS Coordinator admitted that the BIMS scores for the two quarters might not have been accurate. The facility's inability to provide documentation or a valid explanation for not conducting an SCSA highlighted a lapse in following the required assessment protocols.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their assessments. For one resident, the quarterly MDS indicated a weight of 163 lbs, which did not match the dietary assessment documentation that recorded a weight of 180 lbs on the same date. This resident had a history of significant weight gain, which was unplanned and considered significant. The MDS Coordinator/Registered Nurse acknowledged the discrepancy but did not provide a separate policy for MDS coding. The Licensed Nursing Home Administrator and Director of Nursing were informed of the findings but did not provide additional information. For another resident, the discharge return not anticipated (drna) MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while the progress notes and unit manager confirmed the resident was discharged home with family. The MDS Coordinator/Registered Nurse confirmed the coding error upon review. The Director of Nursing acknowledged the error and stated it was corrected after the surveyor's inquiry. The facility lacked a policy regarding MDS, contributing to these inaccuracies.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #111, who had a history of falls and was at risk due to conditions like diabetes and hypertension, did not have an individualized care plan that included all relevant focus areas and interventions. The care plan was mistakenly canceled when the resident was hospitalized, and upon return, a new care plan was not properly initiated, leaving out important interventions that were previously in place. Resident #172, who had multiple diagnoses including stroke, dementia, and diabetes, was found to have an incomplete and non-individualized care plan for activities of daily living (ADLs). The care plan lacked specific interventions tailored to the resident's needs, despite the resident being dependent on staff for all ADLs and having significant cognitive impairments. This oversight was acknowledged by the facility's Director of Nursing (DON), who noted the need for re-education of staff to ensure care plans are completed. Resident #180, admitted for rehabilitation with a left arm splint, did not have documented evidence of the splint in their care plan, nor were there any interventions for its care. This omission was only addressed after the surveyor's inquiry. Similarly, Resident #442, who had severe cognitive impairment and was at risk for skin breakdown due to incontinence, had a care plan that lacked interventions related to their risk factors and diabetes management. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these were not adequately implemented for the residents reviewed.
Deficient Psychoactive Review and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that the monthly Psychoactive Review (PR) for behavior monitoring was conducted routinely and accurately for a resident, as required by professional standards and facility policy. The resident, who was cognitively impaired with a BIMS score of 3 out of 15, was on psychotropic medications including Quetiapine and Trazodone. However, the behavior monitoring records for December 2024 and January 2025 showed inconsistencies, with several shifts either left blank or not accurately reflecting the resident's behaviors. The PR dated February 1, 2025, only reviewed Trazodone and did not account for other psychotropic medications or documented behaviors from previous months. The facility's policy required a comprehensive review of psychotropic medication use, including evaluation of the resident's signs and symptoms. Despite this, the PR did not reflect the documented behaviors in the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), nor was there evidence of routine PRs being conducted. During meetings with the survey team, the facility's Regional Director of Clinical Services acknowledged the deficiency, noting that only one PR summary was completed. The facility's policy on psychotropic medication use, which mandates monthly reviews, was not adhered to, leading to incomplete and inaccurate behavior monitoring for the resident. The surveyor's findings highlighted a failure to meet the standards of clinical practice and facility policy in monitoring and reviewing psychotropic medication use.
Failure to Update Care Plan and Conduct Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that a resident's current active care plan contained the necessary interventions implemented after each fall to prevent additional falls. This deficiency was identified for a resident who had experienced several falls, including an unwitnessed fall in October 2024. The resident's care plan, initiated in November 2024, only included one intervention to maintain a clutter-free environment, despite previous falls and interventions being documented in a completed care plan that was not transferred to the current active care plan. Additionally, the facility did not conduct fall risk assessments quarterly as required by their policy. The resident's fall risk assessments were not completed for several quarters, including April 2024, July 2024, and January 2025. The assessments that were conducted were either incomplete or not done quarterly, as evidenced by assessments being dated on the same day as the resident's falls. This lack of consistent assessment and documentation contributed to the failure to update the resident's care plan with appropriate interventions. Interviews with facility staff, including the LPN, Unit Manager, and MDS Coordinator, revealed confusion and inconsistency in the process of updating care plans and conducting fall risk assessments. The MDS Coordinator admitted to canceling the care plan by accident when the resident was hospitalized, and there was uncertainty about who was responsible for initiating and updating assessments. The facility's policies on fall prevention and care plans were not followed, leading to inadequate supervision and increased risk of accidents for the resident.
Failure to Administer Correct Enteral Feeding Volume
Penalty
Summary
The facility failed to monitor and administer the correct total volume of enteral tube feeding as per the physician's orders for a resident with a gastrostomy. The resident, who had a history of cerebral infarction, dementia, type 2 diabetes mellitus, and was NPO, was prescribed Diabetisource 1.2 to be administered via feeding tube at 55 ml/hr, with a total volume of 1100 ml to be infused. However, documentation in the Medication Administration Record (MAR) revealed that for six out of eleven days, the total volume infused was significantly less than the prescribed amount, with volumes ranging from 450 ml to 500 ml. The deficiency was identified through observation, interviews, and record reviews. The Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) confirmed that the enteral feeding should be administered according to the physician's orders and documented in the MAR. However, the RN/UM could not explain the discrepancy in the documented volumes. The Director of Nursing (DON) later stated that some nurses were confused about the volume to document, leading to incorrect entries. The facility's policy required verification of physician orders and accurate documentation of the amount and type of enteral feeding administered, which was not adhered to in this case.
Deficient Respiratory Care and Incomplete Care Plan
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident, as evidenced by the lack of an individualized care plan and necessary orders for nebulizer equipment maintenance. During an observation, a resident was found with a nebulizer machine on the bedside table, but the mask was improperly stored in a drawer instead of a plastic bag. The resident, who had a history of pneumonia and was on antibiotics, confirmed that they had not placed the mask back in the bag. The facility's records showed no orders for changing the nebulizer mask or tubing, and the care plan lacked specific goals or interventions for respiratory care. Interviews with the Unit Manager and Licensed Practical Nurse revealed that the facility's practice was to change nebulizer tubing and masks weekly, but there was no documented order for this procedure for the resident in question. The Unit Manager acknowledged the absence of a care plan and order for the nebulizer equipment change, admitting that the care plan was incomplete. The Director of Nursing and the Licensed Nursing Home Administrator were informed of these deficiencies, which were not in compliance with the facility's nebulizer therapy policy and comprehensive person-centered care plan requirements.
Failure to Adjust Medication Schedules for Dialysis Residents
Penalty
Summary
The facility failed to ensure that the medication administration and blood sugar monitoring for two residents requiring dialysis were adjusted to accommodate their dialysis schedules. Resident #77, who has diabetes mellitus and end-stage renal disease, had duplicate orders for blood sugar checks, with one scheduled early in the morning and another before meals and at bedtime. The electronic Medication Administration Record (eMAR) showed inconsistencies in the documentation of blood sugar checks, with some entries marked as 'X' or 'NA' without explanation. The Registered Nurse (RN) and Unit Manager acknowledged the issue but did not address it until after the surveyor's inquiry. Resident #121, also diagnosed with end-stage renal disease, had a physician's order to adjust medication and treatment timing to accommodate dialysis sessions. However, the Brimonidine Tartrate eye drops were scheduled for administration at times when the resident was at dialysis, leading to missed doses. The Licensed Practical Nurse (LPN) confirmed that medication schedules should be adjusted around dialysis sessions, but this was not done for Resident #121. The Director of Nursing (DON) acknowledged the oversight and stated that the order should have been clarified by the nursing staff. The facility's Hemodialysis Policy requires that care and treatment be consistent with professional standards, physician orders, and the resident's care plan. However, the facility did not adhere to this policy, resulting in deficiencies in the care provided to residents requiring dialysis. The survey team discussed these concerns with the facility's administration, but no additional information was provided to address the deficiencies at the time of the survey.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to post the accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily in a prominent place within the facility, as required. On two separate occasions, surveyors observed that the NHRCSR was not updated correctly. On the first occasion, the report dated 2/6/25 was still posted on 2/7/25, and the receptionist admitted to waiting for the Staffing Coordinator to provide the updated numbers. The Staffing Coordinator confirmed that the report was not printed correctly for 2/7/25. The facility's policy requires the staffing sheet to be posted at the beginning of each shift, which was not adhered to in this instance. On another occasion, the NHRCSR posted on 2/10/25 was for the previous day, 2/9/25, and contained incorrect census information. The Staffing Coordinator provided a Nursing Daily Staffing Sheet with handwritten notes indicating discrepancies in the census for the days leading up to 2/9/25. The facility's policy mandates that the staffing sheet be posted at the beginning of each shift, but this was not followed, resulting in outdated and incorrect information being displayed. These deficiencies were confirmed through interviews with staff and a review of the facility's policy.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preferences, as evidenced by the case of a resident who consistently did not receive the meals they requested. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed concerns about not receiving the food items they selected from the menu. Despite discussing these issues with the kitchen staff and the registered dietician, the problem persisted. The resident, who had a no concentrated sweets diet due to hypertension and type 2 diabetes, often received meals that did not match their selections, such as receiving turkey meatloaf instead of the requested roasted chicken. During the survey, it was observed that the resident was served a meal that did not include the requested items, and there was no meal ticket on the table to verify the order. The Food Service Director confirmed that the resident had selected roasted chicken on their menu, but the meal ticket listed turkey meatloaf instead. The director could not explain why the resident received the incorrect meal and acknowledged that the resident's food preferences should be honored. The facility's policy on nutritional management indicated that residents' goals and preferences should be reflected in their care plans, but this was not adhered to in this case. The issue was brought to the attention of the Licensed Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, who were informed of the resident's unmet food preferences. The facility's investigation revealed that unclear writing on the menu led to the dietary staff's confusion. However, the surveyor noted that the resident's menu clearly showed the crossed-out item, indicating the resident's choice. The facility's policy emphasized the importance of interviewing residents to ensure their preferences are met, which was not effectively implemented in this instance.
Deficiencies in Medical Record Maintenance and Consent Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents, leading to deficiencies in care documentation and consent processes. For one resident, the physician's visit notes were entered late, covering a period from September 2024 to January 2025, which was not in compliance with the expected timeline for documentation. This issue was brought to the attention of the facility's administration, who acknowledged the requirement for timely documentation of physician visits. Another resident's medical records lacked documentation of consent for influenza and pneumococcal vaccinations, as well as psychoactive medication use. The facility staff were unable to locate the necessary consent forms during the survey, and it was later discovered that these documents were left in a copying machine. The absence of documented consent and education regarding vaccinations and psychoactive medications was a significant oversight in the resident's care plan. Additionally, the facility failed to document bowel and bladder management for a resident, with numerous missing entries in the CNA Intervention/Task Report sheets. This lack of documentation was confirmed by multiple staff members, who acknowledged the importance of monitoring and recording such information to prevent health complications. The facility's incontinence policy emphasized the need for appropriate treatment and services based on comprehensive assessments, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following hand hygiene protocols and improper use of personal protective equipment (PPE). A Certified Nursing Aide (CNA) was observed with a surgical mask not covering her nose and mouth, and she did not perform hand hygiene before and after touching her mask or donning and doffing gloves. Additionally, the CNA stored gloves in her pocket, which is against facility policy. A Registered Nurse/Unit Manager (RN/UM) also failed to perform hand hygiene before and after glove use. These actions were contrary to the guidelines set by the CDC and the facility's own policies. Further deficiencies were noted during a medication administration pass, where a Licensed Practical Nurse (LPN) left the disinfecting wipes container open, which could compromise the effectiveness of the wipes. The LPN acknowledged the oversight but did not correct it during the medication pass. This practice was not in line with the facility's Safety Data Sheet instructions, which require the container to be closed when not in use. Additionally, the facility did not properly implement transmission-based precautions (TBP) for a resident who was COVID-19 positive. There was no signage outside the resident's room to indicate TBP, and the sign was mistakenly placed inside the door. The resident's Medication Administration Record (MAR) was not signed for TBP for two shifts, and the Progress Notes did not reflect the resident's TBP status. These oversights indicate a failure to follow the facility's policy on TBP, which requires clear signage and documentation to prevent the spread of infection.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure immediate physician notification and adherence to its policy regarding changes in a resident's condition. A resident with multiple complex diagnoses, including Parkinson's Disease, Alzheimer's Disease, multiple myeloma, type 2 diabetes, aortic insufficiency, and dementia, was observed by their responsible party to appear dehydrated. The LPN on duty assessed the resident, noted poor skin turgor, and attempted to contact the resident's physician by phone but was unable to leave a message. No further attempts to reach the physician were documented until several hours later, after the resident had expired. The LPN did not escalate the issue to the Nursing Supervisor or Medical Director as required by facility policy. Interviews with staff revealed that the expectation was for nurses to report any significant changes in a resident's condition to the Nursing Supervisor and, if unable to reach the primary physician, to contact the Medical Director. The Assistant Director of Nursing confirmed that the process for physician notification was not followed in this case. Review of the facility's policy indicated that circumstances requiring a change in treatment, such as new symptoms or the need for new interventions, necessitate prompt physician notification, which did not occur for this resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
