Buckingham At Norwood, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwood, New Jersey.
- Location
- 100 Mcclellan Street, Norwood, New Jersey 07648
- CMS Provider Number
- 315290
- Inspections on file
- 19
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Buckingham At Norwood, The during CMS and state inspections, most recent first.
Medication administration and documentation errors affected several residents. One resident’s insulin was frequently given outside the ordered time window, another resident’s routine pain meds were often late, and two residents receiving controlled meds had MAR and controlled substance record discrepancies, including missing signatures, lack of documented effectiveness, and entries showing the wrong tramadol strength being signed out.
A resident at risk for falls was repeatedly found with the call device on the floor under the bed and out of reach while the resident was in the doorway or lying in bed. The resident said they did not know where the call device was and needed it for help. The record showed altered mental status, difficulty walking, dementia, and a fall risk care plan that included providing a working and reachable call device; the facility policy stated the call light should be accessible when in bed.
A resident with dementia, difficulty walking, unsteadiness on feet, and a prior R femur fracture sustained an unwitnessed fall and was found on the bathroom floor with blood on the face and floor. Although a post-fall assessment was documented later that day, no further shift-by-shift assessments or neuro checks were documented for the required 72-hour period, despite the DON confirming the facility policy required ongoing observation and documentation after an unwitnessed fall.
A resident with DM2, obesity, HTN, and moderate cognitive impairment was ordered to be weighed daily with provider notification for significant weight gain, but the record showed weights were missed on most days over a 59-day period. The EHR documented only a few weights, there was no documentation that the weights were discussed with the provider, and the RN and DON confirmed the daily weight order was not followed.
A resident with hemiplegia, dementia, severe cognitive impairment, and hospice services had a PRN oxygen order written as 2-6 LPM via NC for SOB. Survey review found the order was not clarified to a specific LPM, and the RN/UM and DON acknowledged that oxygen orders should specify a set flow rate rather than a range.
The facility failed to notify CMS and receive authorization for a facility name change. Surveyors observed the outside sign using the Excelcare name, and the LNHA stated the name change had been sent to the state but not completed through CMS. The DON’s business card and the Facility Assessment also used the Excelcare name, and a letter showed written notice to the Assistant Commissioner about new management, but no CMS approval was provided.
A non-certified Nursing Aide was assigned independent resident care duties without completing required training and competency evaluations. Despite being hired as a Hospitality Aide, the aide provided direct care, including bathing and feeding, without proper oversight or documentation of training completion. Interviews revealed a lack of oversight and documentation regarding the aide's training and competency.
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly QAPI meetings, potentially affecting all 156 residents. The LNHA could not confirm when the Regional Infection Preventionist Nurse (RIPN) began as the IP. The DON provided attendance sheets showing the IP's absence, confirmed by the RIPN. The LNHA admitted non-compliance with the requirement for the IP to be dedicated solely to the IPCP, and the QAPI Plan lacked information on the committee's composition.
The facility failed to complete reference checks for five out of eight newly hired staff members, including RNs and CNAs, before their start date. The HRRD confirmed the oversight, despite the facility's policy requiring reference checks as part of the new hire process.
The facility failed to follow physician orders for medication administration, resulting in multiple medication errors. Residents received medications despite vital signs being outside prescribed parameters, and medications were left at the bedside for a resident's representative to administer, contrary to policy.
A facility failed to properly store and label medications, as observed in a resident's room and across multiple medication carts and storage rooms. Unordered medications were found in a resident's room, and medication carts contained undated and unidentified medications. Additionally, discrepancies in refrigerator temperature logs were noted. The facility's policy lacked guidelines for dating opened medications and handling loose or unlabeled medications.
A facility failed to provide timely breakfast service and maintain privacy during a medical consultation. One resident waited for their breakfast tray while others were served, and an eye doctor attempted to conduct an examination in a dining area, prompting intervention by the RN/UM. These actions violated the facility's policies on meal service and resident rights.
The facility failed to submit MDS assessments within the required timeframe for three residents, as identified during a survey. The assessments, crucial for managing resident care, were completed late for residents with severe cognitive impairments and other health conditions. The MDS Coordinator acknowledged the delay in completing these assessments.
The facility failed to accurately document the vaccination status of two residents in the MDS, leading to discrepancies between the MDS records and the residents' consent forms. The MDS inaccurately indicated that vaccines were not offered, while consent forms showed that the residents' representatives had refused the vaccines. This deficiency was confirmed through interviews with facility staff.
A facility's IDT failed to involve a resident in their care planning and discharge process, leading to a deficiency. The resident, who was independent with activities of daily living, expressed a desire to be discharged but was not invited to care plan meetings. The facility's documentation did not reflect the resident's participation in care planning or any follow-up actions for discharge, despite the resident's expressed wishes.
A facility failed to conduct routine weekly skin checks for a resident, leading to a delay in identifying ulcers on the resident's right foot. The resident, who had multiple medical conditions and required assistance with daily activities, was found with wounds that had serosanguineous drainage. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds, which were eventually treated after the resident was sent to the hospital for further evaluation.
Two residents receiving respiratory care experienced deficiencies in equipment storage and infection control. One resident's nebulizer mask was improperly stored, while another resident's contact precaution status was outdated, leading to improper PPE use by staff. Facility policies on nebulizer therapy and transmission-based precautions were not followed.
The facility failed to provide sufficient nursing staff and timely incontinence care, as observed during a survey. Staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly on weekends. Two residents were found with soaking wet diapers, indicating a failure to adhere to the facility's incontinence policy. Despite being informed, the facility management did not refute the findings.
The facility failed to post accurate daily Nursing Home Resident Care Staffing Reports, with discrepancies noted in CNA numbers and census figures. The Unit Clerk, covering for the Staffing Coordinator, used previous day's data to estimate current staffing, leading to inaccuracies. Management was informed but did not refute the findings.
A resident with Alzheimer's Disease did not receive their prescribed Seroquel 12.5 mg at the scheduled time due to the medication's unavailability in the med cart. The LPN acknowledged the issue and contacted the pharmacy for an urgent delivery. The medication was eventually administered later in the day. The deficiency was reported to the facility's administration.
A resident with chronic kidney disease was prescribed Vancomycin for suspected C-diff infection, but lab tests were negative. Despite this, the antibiotic was continued without documented justification, violating the facility's Antibiotic Stewardship Program Policy. Late entries in the medical record were made after surveyor inquiry, indicating a lack of proper documentation and reassessment.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to accurately document and administer medications in accordance with physician orders for multiple residents. One resident with diagnoses including type 2 diabetes, dementia, and chronic kidney disease had insulin orders for scheduled administration at specific times, but the medication administration record and audit summary showed numerous doses were given more than one hour after the ordered time. The surveyor observed one insulin dose administered at 9:17 AM for an 8:00 AM order, and the DON acknowledged that nurses should have administered insulin within an hour of the ordered time. Another resident with rheumatoid arthritis and osteoarthritis had scheduled pain medications ordered for morning, midday, and evening administration. Survey observations and staff interviews showed routine medication passes were running late, and the facility’s audit report documented numerous late administrations of the resident’s pain medications during the month reviewed. The surveyor also found that some medications scheduled for the beginning of the morning shift were frequently documented as being administered after 2 PM. The LPNs and RN interviewed stated it was difficult to complete the medication pass within the 2-hour window, and the DON confirmed the late administration had become routine and that the physician had not been made aware of the late doses. For a resident receiving alprazolam, the controlled substance removal record and the MAR did not match. The surveyor found doses signed out on the controlled substance record without corresponding MAR documentation on some dates, and on another date the MAR lacked documentation of effectiveness as required by the care plan. The DON acknowledged that the expected process was to sign the controlled substance record when the medication was removed and to sign the MAR right after administration, and also acknowledged that effectiveness should have been documented. For another resident receiving tramadol, the MAR and controlled substance administration records contained multiple discrepancies. Several MAR entries were left blank and unsigned, and the controlled substance records repeatedly showed nurses signing out tramadol 50 mg when the resident’s order was for tramadol 25 mg. The surveyor and DON reviewed multiple dates in February and March where the controlled substance records reflected the wrong strength being documented as dispensed, while the MAR showed the 25 mg dose as administered. The DON stated the records reflected that tramadol 50 mg was administered instead of tramadol 25 mg, and the facility’s records did not show documentation of disposal or a second nurse witness for split tablets.
Call Device Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call device was positioned within reach of a resident who was at risk for falls. Resident #59 was observed standing in the doorway of the room and told the surveyor that help was needed because water had spilled in the room, but the resident did not know where the call device was. The call device was observed on the floor under the bed near the roommate's bed. The same resident was later observed lying in bed on two additional occasions, and each time the call device was again found on the floor under the bed near the roommate's bed. The resident stated they did not know where the call device was and said it was important to have it in case it was needed. The resident's record showed diagnoses of altered mental status, difficulty walking, and dementia, and the care plan included a fall risk intervention for providing a working and reachable call device. The facility's policy stated the call light should be accessible to the resident when in bed.
Failure to Continue Post-Fall Assessments
Penalty
Summary
The facility failed to continue assessing a resident after an unwitnessed fall to determine whether there were any adverse effects from the event. Resident #80 had diagnoses that included a fracture of the right femur, dementia, difficulty walking, and unsteadiness on feet. The resident’s annual MDS reflected moderate cognitive impairment, wheelchair use for mobility, and a need for assistance with transfers. The resident was found on the bathroom floor with blood on the face and floor and was unable to provide details about what occurred. A nursing note documented a post-fall assessment later that day, but the EHR did not show any further follow-up assessments after that entry. The DON confirmed the facility’s fall prevention policy required the nurse assigned to the resident to document observations every shift for 72 hours after an unwitnessed fall, including neurological checks and assessment of the resident’s status, and confirmed those ongoing assessments were not documented after the initial post-fall note.
Failure to Follow Daily Weight Order
Penalty
Summary
The facility failed to monitor the nutritional status of Resident #137 by not following a physician’s order to weigh the resident daily and notify the provider if the resident gained more than 3 lbs. in 24 hours or more than 5 lbs. in one week. The resident was admitted with diagnoses including type 2 diabetes, obesity, essential hypertension, and urinary retention, and the annual MDS dated 2/20/26 reflected moderate cognitive impairment. On 3/26/26, the surveyor observed the resident in bed, awake and responsive, with the call bell within reach. A review of the medical record showed that a weight was not obtained on 50 of 59 days in February and March 2026 as required by the physician’s order. The EHR reflected weights documented on only a limited number of dates, including 2/5/26, 2/8/26, 2/14/26, 2/15/26, 2/17/26, 2/18/26, 2/28/26, 3/8/26, and 3/29/26, and the record did not show that these weights were discussed with the provider during March or April 2026. The resident stated he could not recall being weighed by staff, and the RN confirmed the order for daily weights and acknowledged that weights should be assessed and documented according to physician orders. The DON also confirmed that the weights were not obtained and documented per the order on 50 of 59 days.
Unclear PRN Oxygen Order Not Clarified
Penalty
Summary
The facility failed to clarify an oxygen therapy order for Resident #16, who had diagnoses including hemiplegia and dementia and was assessed as having severe cognitive impairment with a BIMS score of 5 out of 15. The resident also had an order indicating hospice services. A physician's order dated 10/13/25 directed oxygen at 2-6 liters per minute via nasal cannula as needed for shortness of breath, but the order did not specify a single liter flow rate. Review of the March and April 2026 TAR showed the resident had not needed PRN oxygen therapy. During surveyor interview, the RN Unit Manager stated oxygen therapy orders should have a specified LPM and acknowledged the nurses should clarify the physician's order because it should not be written as a range. The RN/UM also stated there may be oxygen therapy recommendations for a range of LPM, especially for hospice residents, but agreed the order needed clarification with the physician. The DON later stated the expectation was for an oxygen therapy order to have a specific LPM and not a range, and confirmed the RN/UM clarified the order with the physician after surveyor inquiry.
Failure to Obtain CMS Approval for Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in facility name in accordance with 42 CFR 424.516. During surveyor observation on 3/26/26 at 8:55 AM, the sign outside the facility identified the building as Excelcare at [NAME] rather than [NAME] at [NAME]. When interviewed later that morning, the LNHA stated that the facility was now owned by Excelcare and that a request for the name change had been sent to the state, but the change had not yet been completed through CMS. Additional documents reviewed by the surveyor reflected the Excelcare name on the DON’s business card and on the cover pages of the Facility Assessment. On 3/27/26, the LNHA provided a letter dated February 28, 2025 showing written notification to the Assistant Commissioner regarding an agreement for new management. The survey team met with the LNHA and DON to discuss the use of the ExcelCare at [NAME] facility name without CMS approval, and no further information or documentation was provided to refute the findings.
Failure to Ensure Nursing Aide Competency Before Independent Assignments
Penalty
Summary
The facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies before being assigned independent resident care duties. NA #1 was hired as a Hospitality Aide and began independent resident care assignments shortly after, without completing the necessary training and competency evaluations. This oversight was identified for one of nine NAs reviewed, who provided direct care to residents across all five nursing units. NA #1 was hired on June 17, 2024, and began independent assignments on July 3, 2024, before being enrolled in a state-approved Nurse Aide Training and Competency Evaluation Program (NATCEP) on July 15, 2024. Despite being enrolled, NA #1 worked 69 shifts without evidence of completing the required skills and competencies. The facility's job descriptions for Hospitality Aides and Nursing Assistants clearly outlined the responsibilities and limitations, yet NA #1 was assigned tasks beyond their training, such as bathing, toileting, and feeding residents. Interviews with facility staff revealed a lack of oversight and documentation regarding NA #1's training and competency. The Director of Nursing and Human Resources staff were unable to provide evidence of NA #1's completed training or competency evaluations. Additionally, NA #1's school confirmed that they did not complete the program, further highlighting the facility's failure to ensure that all NAs were adequately trained before providing direct care to residents.
Removal Plan
- NA #1 was removed from employee schedule
- Staff education on hiring Hospitality Aides and the process for hiring and scheduling Nursing Aides
- DON reviewed all current NA onboarding requirements
- DON reviewed all NAs to confirm they had the required competency skills
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly Quality Assurance Performance Improvement (QAPI) meetings, which had the potential to affect all 156 residents currently living in the facility. During an entrance conference, the Licensed Nursing Home Administrator (LNHA) was unable to confirm when the Regional Infection Preventionist Nurse (RIPN) began serving as the facility's IP. The Director of Nursing (DON) provided QAPI attendance sheets for the last three quarters, which showed that the IP did not attend the meetings on 5/29/24, 7/23/24, and 10/22/24. The RIPN confirmed the absence of an IP in these meetings. The LNHA acknowledged that the facility did not comply with the requirement for the designated IP to be dedicated solely to the Infection Prevention Control Program (IPCP). The QAPI Plan provided by the LNHA lacked information on the composition of the QAPI Committee. During a QAPI interview, the LNHA stated that the DON reported on infection control in the absence of the IP. The facility did not provide additional information or refute the findings during the exit conference.
Incomplete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for five out of eight newly hired staff members before their employment start date. This deficiency was identified during a review of eight randomly selected new employee files, where it was found that several staff members, including Registered Nurses and Certified Nursing Assistants, had incomplete or missing reference checks. Specifically, two RNs had only one reference check each, while three CNAs had no reference checks in their files. The Human Resources Regional Director (HRRD) acknowledged that the facility's process involved asking staff to provide additional references if initial contacts were unreachable, and personal references were required if there was no work history. However, the HRRD confirmed that reference background checks were not completed for the five newly hired staff. The facility's policy on the new hire process emphasized the importance of completing reference checks, but this step was not adhered to, leading to the deficiency.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding medication administration for several residents, leading to multiple instances of medication errors. For Resident #28, the facility did not follow the physician's order to hold hydralazine when the blood pressure was below 140, resulting in the medication being administered on several occasions despite the blood pressure being below the specified threshold. Similarly, Resident #131 received Humalog insulin even when their blood sugar levels were below the prescribed parameter of 110, indicating a failure to follow the physician's orders. Resident #117, who had severe cognitive impairment, was administered Midodrine despite having a systolic blood pressure greater than 140, contrary to the physician's order to hold the medication under such conditions. This pattern of not adhering to medication parameters was also observed with Resident #140, who received Midodrine when their systolic blood pressure was above the prescribed limit of 120. Additionally, Resident #142 was given Amlodipine and Losartan despite their blood pressure and heart rate being outside the parameters set by the physician. Furthermore, Resident #144 was found with a cup of medications left at the bedside, which were intended to be administered by the resident's representative. This practice was not in line with the facility's medication administration policy, which requires medications to be administered by licensed nurses or authorized staff. The facility's failure to ensure medications were administered according to physician orders and professional standards of practice was evident across multiple instances and residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications for one resident and ensure that medications were stored and labeled appropriately for two medication carts and two medication storage rooms across four nursing units. This was observed when a surveyor found three containers of medications, including L-Lysine, Vitamin D3, and Vitamin B12, in a resident's room without proper storage or orders in the electronic Medication Administration Record (eMAR). The Licensed Practical Nurse (LPN) was unaware of these medications being at the bedside and confirmed there were no orders for them, acknowledging that medications should not be left or stored in the resident's room. Further deficiencies were noted during inspections of medication carts and storage rooms. On one unit, a foil package of Budesonide nebulizer solution was found without a documented date of opening, and loose unidentified tablets were discovered in the medication cart. Similarly, on another unit, a box of Ipratropium/Albuterol nebulizer solution was found with an open foil packet lacking a documented opening date, along with a loose unidentified tablet. The med nurse was unable to identify the tablets and confirmed the absence of opening dates on the foil packages. The surveyor also noted discrepancies in the temperature logs of medication refrigerators, with one refrigerator showing a temperature of 30 degrees Fahrenheit, while the log recorded 40 degrees Fahrenheit. The facility's Medication Storage Policy, revised in October 2023, was reviewed and found to lack specific guidelines regarding the dating of opened medications and the handling of loose, unlabeled, or unidentifiable medications. The Consultant Pharmacist confirmed that opened foil packs should be dated and that the normal refrigerator temperature should be between 36 to 46 degrees Fahrenheit. The surveyor discussed these concerns with facility management, who acknowledged the need for proper medication storage and labeling.
Deficiencies in Meal Service and Privacy During Medical Consultation
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the 2 South dining area by not serving breakfast in a timely manner. On the morning of 10/31/24, a surveyor observed that one resident, identified as Resident #25, was seated without a breakfast tray while other residents had already received theirs. The breakfast tray for Resident #25 was on a food truck, but the Certified Nursing Aide (CNA) was occupied feeding another resident. The Quality Assurance Corporate Aide (QACA) eventually served the tray after the surveyor's inquiry, indicating a delay in service. Additionally, four residents had to wait 30 minutes for their breakfast trays, which were only served after the arrival of the second food truck. In a separate incident in the 1 South dining area, a lack of privacy was observed during a medical consultation. An eye doctor attempted to conduct an eye examination on Resident #67 in the dining room immediately after the resident finished their meal. The Registered Nurse/Unit Manager (RN/UM) intervened, instructing the doctor to conduct the consultation in the resident's room, as it was inappropriate to perform such procedures in a communal dining area. The facility's policies on serving meals and respecting resident rights were reviewed, revealing that meals should be served promptly and residents have the right to privacy and dignity. The surveyor's findings highlighted deficiencies in adhering to these policies, as evidenced by the delayed meal service and the lack of privacy during a medical consultation.
Late Submission of MDS Assessments for Three Residents
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessments within the required timeframe for three residents. The MDS is a critical assessment tool used to manage the care of residents, and according to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it must be completed no later than 13 days after a resident's entry date. However, the assessments for three residents were completed late, exceeding the 13-day requirement. This deficiency was identified during a surveyor's review of the residents' records and interviews with facility staff. Resident #125 was admitted with a diagnosis of encephalopathy and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The comprehensive MDS (cMDS) for this resident was completed more than 13 days after admission. Similarly, Resident #132, admitted with unspecified dementia and other mental health issues, had a cMDS completed late, with a BIMS score showing severely impaired cognition. Resident #212, diagnosed with rhabdomyolysis, also had a cMDS completed beyond the required timeframe, with a BIMS score indicating moderate cognitive impairment. The MDS Coordinator/Registered Nurse acknowledged the delay in completing these assessments during an interview with the surveyor.
Inaccurate MDS Documentation for Resident Vaccination Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in the Minimum Data Set (MDS), which is a critical assessment tool used for managing care in compliance with federal guidelines. For Resident #125, the MDS inaccurately documented the resident's vaccination status. The comprehensive MDS indicated that the resident had not received the influenza and pneumococcal vaccines, citing reasons such as 'not offered' and 'not eligible-medical contraindication.' However, a review of the resident's consent forms showed that the resident's representative had explicitly refused consent for these vaccinations. This discrepancy highlights a failure in accurately recording the resident's vaccination status in the MDS. Similarly, for Resident #212, the MDS inaccurately reflected that the pneumococcal vaccine was not received because it was 'not offered,' despite the resident's representative having refused consent for the vaccine. The surveyor's interview with the Regional Infection Preventionist Nurse and the MDS Coordinator/Registered Nurse confirmed the incorrect MDS coding. The facility's failure to accurately document the vaccination status in the MDS assessments for these residents constitutes a deficiency in maintaining accurate and compliant resident records.
Failure to Involve Resident in Care Planning and Discharge Process
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to ensure that the care plan for a resident was revised to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The deficiency was identified during a survey when a resident expressed concerns about their discharge plans. The resident, who had been in the facility for several months for rehabilitation therapy, was independent with activities of daily living and did not have a place to stay outside the facility. Despite expressing a desire to be discharged, the resident was not involved in the care planning process, and there was no documentation of the resident being invited to care plan meetings. The resident's medical records revealed that they had a history of atherosclerotic heart disease, hypertension, schizophrenia, and type 2 diabetes mellitus. A quarterly MDS assessment indicated that the resident was cognitively intact. However, the facility's documentation did not show that the resident was invited to participate in care plan meetings or that their wishes regarding discharge were considered. The social worker (SW) responsible for the resident's care planning did not document any follow-up actions or referrals for the resident's discharge planning, despite the resident's expressed desire to leave the facility. The facility's policies on discharge planning and comprehensive care plans require that residents be involved in their care planning and that any decisions regarding discharge be documented. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation of the resident's participation in care planning and the absence of referrals for discharge. The facility's failure to involve the resident in their care planning and to document the discharge planning process led to the identified deficiency.
Failure to Conduct Routine Skin Checks Leads to Delayed Wound Identification
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policies. This deficiency was identified during a review of a facility-reported event involving a resident who was found with ulcers on the right foot. The investigation revealed that weekly skin checks had not been completed for two weeks prior to the identification of the wounds, which were noted with serosanguineous drainage. The resident was subsequently examined by a nurse practitioner, who ordered x-rays, intravenous antibiotics, and various consults before the resident was sent to the hospital emergency room for further evaluation. The resident, who had a history of quadriplegia, major depressive disorder, contractures, peripheral vascular disease, neuromuscular dysfunction of the bladder, and hypertension, was cognitively intact and required assistance with activities of daily living. The facility's records indicated that there was only one documented skin evaluation for the month of August, despite a physician's order for weekly skin assessments. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds. Interviews with facility staff, including the LPN who cared for the resident, revealed that the resident was generally cooperative with care but occasionally refused it. The LPN relied on CNAs to notify them of any skin impairments during daily care, but the weekly skin assessments were not consistently documented. The Director of Nursing and the Licensed Nursing Home Administrator, who were not part of the administration at the time of the incident, were unable to provide additional information regarding the investigation conducted by the previous administration.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure proper storage and handling of respiratory equipment for two residents receiving respiratory care. One resident, who was cognitively intact and admitted for rehabilitation, had a nebulizer mask that was not stored in a plastic bag as required by facility policy. The nebulizer mask was observed on top of a nightstand, which was confirmed by the resident and a Licensed Practical Nurse (LPN) as improper storage. The resident's medical records indicated a history of asthma, heart failure, and hypertension, and the resident received respiratory therapy for 225 minutes over a seven-day period. Another resident, who had a tracheostomy and was on contact precautions for MRSA, was observed with a nebulizer mask not stored properly. The resident's room had a contact precaution sign, but a Recreation Aide (RA) entered without wearing personal protective equipment (PPE) and did not perform hand hygiene upon exiting. The LPN later clarified that the resident's contact precaution status was outdated, and the sign should have been for Enhanced Barrier Precautions (EBP) instead. The resident's medical records showed a history of intracerebral hemorrhage, chronic respiratory failure, and tracheostomy status, with respiratory therapy provided for 375 minutes over a seven-day period. The facility's policies on nebulizer therapy and transmission-based precautions were not followed, leading to improper storage of respiratory equipment and failure to adhere to infection control measures. The facility's Infection Preventionist Nurse confirmed the deficiencies and acknowledged that the nebulizer masks should have been stored in bags when not in use. Additionally, the RA's failure to follow posted signs for contact precautions was noted, although it was later clarified that the resident was not actively infected with MRSA.
Inadequate Staffing and Incontinence Care Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely incontinence care for residents, as observed during a survey. On multiple occasions, the staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly during weekend shifts. For instance, on a specific day, the Penthouse unit had only one CNA for 18 residents, and similar staffing issues were noted across other units. This staffing shortage was confirmed by interviews with staff and review of the Nursing Home Resident Care Staffing Report (NHRCSR), which showed high staff-to-resident ratios, especially during night shifts. The deficiency was further evidenced by the condition of two residents during an incontinence care tour. Resident #67 was found with a strong smell of urine emanating from their room, and upon inspection, was discovered to be wearing double diapers, which were soaking wet, along with the incontinence pads and bed sheets. The CNA attending to Resident #67 confirmed being the only CNA on duty for the shift. Similarly, Resident #214 was found with a soaking wet diaper, and the CNA responsible for their care also reported being the sole CNA for the unit, managing 37 residents. Interviews with the nursing staff revealed that the issue of insufficient staffing, particularly on night shifts and weekends, was a recurring problem. The facility's incontinence policy, which mandates appropriate treatment and services for incontinent residents, was not adhered to, as evidenced by the condition of the residents. Despite being informed of these issues, the facility management did not provide additional information or refute the findings during the exit conference.
Inaccurate Staffing Reports in LTC Facility
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily for three out of seven days, which could affect the knowledge of staff availability for resident care. On multiple occasions, discrepancies were noted between the posted staffing reports and the actual staffing levels. For instance, on one day, the posted report indicated 13 CNAs for the day shift, while the actual schedule showed only 11 CNAs. Additionally, the census numbers on the posted reports did not match the actual census numbers provided by the Registered Nurse Supervisor. The inaccuracies in the staffing reports were attributed to the process used by the Unit Clerk, who was temporarily covering for the full-time Staffing Coordinator. The Unit Clerk was using the previous day's staffing information to estimate the current day's staffing levels, leading to discrepancies. Furthermore, the Unit Clerk incorrectly counted two noncertified nursing aides (NAs) as equivalent to one CNA, which contributed to the inaccurate staffing numbers. The facility's management, including the Licensed Nursing Home Administrator and the Director of Nursing, were informed of these discrepancies. The Regional Clinical Operation acknowledged that the posted NHRCSR should be accurate and not estimated. Despite being aware of the issues, the facility did not provide additional information or refute the findings during the exit conference with the survey team.
Medication Unavailability Leads to Delayed Administration
Penalty
Summary
The facility failed to administer medication to a resident due to the unavailability of the prescribed drug. During a medication administration observation, an LPN was unable to provide Seroquel 12.5 mg to a resident diagnosed with Alzheimer's Disease, as the medication was not available in the medication cart. The LPN acknowledged the absence of the medication and informed the surveyor that she would contact the pharmacy for an urgent delivery. The resident's medical record indicated a severely impaired cognitive status with a BIMS score of 07 out of 15. The electronic Medication Administration Record (eMAR) showed that the Seroquel was not administered at the scheduled time but was given later in the day once it became available. The last delivery of the medication was recorded on 10/24/24, indicating a lapse in ensuring the medication was restocked in a timely manner. The deficiency was reported to the Director of Nursing, the Licensed Nursing Home Administrator, and the Regional Director of Operations.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. The resident, who was admitted with chronic kidney disease and a urinary tract infection, was prescribed Vancomycin for suspected Clostridium difficile (C-diff) infection. However, a lab test conducted after the initiation of Vancomycin treatment returned negative for C-diff toxins. Despite this, the antibiotic treatment was continued without documented justification for its necessity, as required by the facility's Antibiotic Stewardship Program Policy. The surveyor's investigation revealed that the physician's progress notes justifying the continued use of Vancomycin were entered as late entries after the surveyor's inquiry. The Regional Infection Preventionist Nurse confirmed that there was no documented reason for continuing the antibiotic in the resident's medical record or the facility's antibiotic stewardship documentation. The facility's policy mandates reassessment of empiric antibiotics after 2-3 days, but this was not adhered to, leading to the administration of an unnecessary medication.
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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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