Cranford Park Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranford, New Jersey.
- Location
- 600 Lincoln Park East, Cranford, New Jersey 07016
- CMS Provider Number
- 315390
- Inspections on file
- 17
- Latest survey
- October 31, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Cranford Park Care during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with observations including soiled and damaged carpets, dust and debris accumulation, broken exposed pipes, leaking and stained air conditioner covers, missing window treatments, and unsanitary kitchen and dumbwaiter areas. Facility staff were unaware of some issues and could not provide documentation of recent environmental rounds.
The facility did not consistently document ADL care, including personal hygiene and toilet use, for three dependent residents with cognitive impairment. Multiple days and shifts lacked required entries in the electronic medical record, despite staff and policy requirements that all care be documented. Staff interviews confirmed that documentation was incomplete and that all care provided should have been recorded.
A resident with severe cognitive impairment and multiple diagnoses required maximum assistance with eating, as documented in the MDS and care conference notes. However, the care plan was not updated to reflect this need, contrary to facility policy requiring timely care plan revisions when a resident's condition changes.
The facility failed to submit their PBJ Report to CMS for FY Quarter 1 2024 on time. The LNHA relied on a third party for submission but could not provide proof of submission. The facility's policy did not specify the timeframe or responsible party for the submission.
The facility failed to submit MDS assessments within the required 14-day period for seven residents, with delays ranging from several weeks to over a month. The MDS Coordinator cited the need for additional time to complete assessments as the reason for the delays. Facility management did not respond to the survey team's concerns.
The facility failed to accurately code the MDS for five residents, leading to discrepancies in their medical records, including incorrect discharge information, vaccination status, and missing assessment interviews. These issues were confirmed by the MDS Coordinator and other staff during interviews with the surveyor.
A facility failed to implement a timely intervention recommended by the wound physician for a resident with a stage four sacral wound. Despite multiple recommendations for a wound VAC starting from February, the facility did not apply it until late March due to a lack of communication and follow-up. The delay was acknowledged by the DON and the wound doctor, who agreed that better documentation and communication were needed.
The facility failed to implement and revise the care plan for a resident with limited range of motion, resulting in the resident not receiving the prescribed splints to prevent contracture. The interdisciplinary care plan meetings did not document the use of medical devices, and the communication between nursing and rehabilitation services was inadequate.
The facility failed to follow the Dietitian's recommendations and ensure proper weight monitoring for two residents, leading to unaddressed significant weight loss. The staff did not communicate or document the necessary actions, and the IDT was not informed of the residents' conditions.
The facility failed to maintain respiratory equipment and obtain a physician's order for a resident with a history of pneumonia, COPD, and lung cancer. The nebulizer mask and tubing had not been changed as required, and there was no physician's order for tubing changes for over nine weeks. The DON acknowledged the oversight.
The facility failed to remove an expired Lorazepam gel from inventory and accurately document its administration. An LPN and the DON acknowledged discrepancies between the IPCDR and EMAR, and the CP confirmed that expired medications should be reported and removed during monthly inspections, which was not done.
The facility failed to accurately document medications and immunizations for two residents. One resident's EMR had discrepancies in insulin documentation, while another resident's immunization records were incomplete.
A resident with multiple health issues experienced significant weight loss and developed a deep tissue injury, but the facility failed to complete a required Significant Change in Status Assessment (SCSA). The MDS Coordinator acknowledged the oversight, and facility management was notified but did not respond to the concerns.
The facility failed to maintain professional standards by not timely assessing the fall risk for a resident with severe cognitive impairment and a history of falls. The required quarterly Fall Risk Evaluation was not completed on time and was created retroactively after surveyor inquiry.
A resident with severe cognitive impairment was not offered a pneumococcal vaccine upon admission, despite facility policy requiring it. The vaccine was only administered after surveyor inquiry, revealing lapses in the verification and administration process by the staff.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and cleanliness during a building tour. The carpet on the stairway to the B unit was heavily soiled and ripped, and there was heavy dust and debris on the stairwell. In the corridor leading to the nourishment room of the B-Unit, a broken exposed pipe with visible debris was noted. In one resident room, a leaking air conditioner cover was yellow stained, and a stained towel was placed on the windowsill next to the unit. The windows in this room were covered with dust and lacked window treatments or drapes, providing an unrestricted view from the street. Another resident room also lacked window treatments, similarly exposing the room to the street. The residents in these rooms could not be interviewed. In the kitchen area where food was transported to the dumbwaiter, the area was heavily soiled with debris, cobwebs were present in the corner, and the lift tray was soiled and covered with debris. The Food Service Director confirmed the need for cleaning in this area. The Maintenance and Housekeeping Director stated that environmental rounds were conducted monthly and that housekeeping staff were responsible for daily cleaning, but he was unaware of the leaking air conditioner and missing drapes, and had not received a work order for the air conditioner repair. He was also unable to provide the last environmental round minutes when requested. A kitchen staff member provided a cleaning schedule indicating the dumbwaiter area was to be cleaned weekly.
Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to consistently document care provided to dependent residents in accordance with its own policies and accepted professional standards. For three residents with moderate to severe cognitive impairment and significant assistance needs for activities of daily living (ADLs), there were multiple instances where documentation of personal hygiene and toilet use was missing across all shifts for extended periods. The lack of documentation was identified through review of the Documentation Survey Reports (DSRs) and confirmed by interviews with staff, who acknowledged that all care provided should be recorded in the electronic medical record without any blanks. Specifically, for one resident with dementia and diabetes, there were numerous days in May where personal hygiene documentation was absent across all three shifts. Another resident with seizures and muscle weakness also had multiple days in May with missing documentation for personal hygiene. A third resident with Alzheimer's disease and severe cognitive impairment had extensive gaps in documentation for both personal hygiene and toilet use throughout January, with missing entries on nearly every day and shift reviewed. Interviews with CNAs, an LPN, and the DON confirmed that CNAs are responsible for documenting ADL care in the electronic record, and that there should not be any blanks in the documentation. Facility policies reviewed by surveyors also required that all skilled and unskilled services, including ADL care, be documented for each resident. The failure to document care as required was observed and verified by both staff and surveyors during the investigation.
Failure to Update Care Plan for Cognitively Impaired Resident Requiring Assistance with Eating
Penalty
Summary
The facility failed to revise and update the care plan for a cognitively impaired resident who required substantial to maximum assistance with eating, following the resident's annual assessment. The resident, who had diagnoses including Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus, and was receiving palliative care, was assessed with a BIMS score of 3/15, indicating severe cognitive impairment. The Minimum Data Set (MDS) and interdisciplinary care conference notes documented that the resident required maximum assistance with activities of daily living (ADLs), including eating. However, a review of the resident's care plan did not reflect the required level of assistance for eating. Interviews with the Director of Nursing (DON) confirmed that the care plan should have been updated to match the MDS and care conference documentation, specifically to indicate the need for maximum assistance with eating. The facility's care plan policy required timely updates and revisions to care plans when there were changes in a resident's condition. Despite this policy, the care plan was not revised after the annual assessment, resulting in a failure to ensure the care plan accurately addressed the resident's needs.
Failure to Submit PBJ Report to CMS on Time
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner for Fiscal Year (FY) Quarter 1 2024, covering the period from October 1, 2023, to December 31, 2023. This deficiency was identified through a review of the PBJ Staffing Data Report CASPER Report 1705D, which indicated that the facility did not submit the required data to CMS. The Licensed Home Administrator (LNHA) informed the survey team that a third party was responsible for submitting the PBJ Staffing Data Report, but there was no documentation or proof of submission provided to CMS for the specified quarter. During an interview, the LNHA stated that the third party handled the communication with CMS, but he could not provide any documentation to confirm that CMS received the data for FY Quarter 1 2024. The survey team requested the facility's policy and procedure for PBJ submission/communication to CMS, which was provided by the LNHA. The policy, revised on February 8, 2024, did not specify the timeframe for submitting data to CMS or who was responsible for the submission. This lack of documentation and clarity in the policy contributed to the failure to submit the PBJ Report on time.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required 14-day period as mandated by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for seven residents, where the MDS assessments were significantly delayed. For instance, Resident #41's Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) of 1/30/24 was not submitted until 3/6/24, well past the 2/13/24 deadline. Similar delays were observed for Residents #9, #53, #3, #50, #66, and #10, with submission dates ranging from several weeks to over a month past the required deadline. The surveyor's review revealed that the facility did not have a specific policy regarding MDS submissions and relied on the RAI Manual. The MDS Coordinator (MDSC) attributed the delays to the time needed for various disciplines to complete their assessments. Despite being informed of these findings and concerns, the facility management, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC), did not provide a response to the survey team's concerns during the exit meeting.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. For Resident #69, the MDS indicated a discharge to the hospital, while progress notes revealed the resident was discharged home against medical advice. The MDS Coordinator acknowledged the error during an interview with the surveyor. Similarly, Resident #9's MDS inaccurately reflected that the pneumococcal vaccination was up to date, despite the resident's son having refused the vaccine. Additionally, there was no record of a PHQ-9 assessment interview on the Assessment Reference Date (ARD) of 2/1/24, as required. Resident #57's MDS also contained inaccuracies, with no record of a PHQ-9 assessment interview on the ARD of 12/21/23. The Registered Nurse (RN) and MDS Coordinator confirmed the absence of these assessments during interviews. For Resident #63, the MDS inaccurately indicated that the pneumococcal vaccine was up to date, although the immunization record showed it was not administered. The MDS Coordinator admitted to inputting incorrect data and noted a discrepancy between the electronic and printed versions of the MDS. Lastly, Resident #24's MDS inaccurately stated that the resident declined the pneumococcal vaccination, despite records showing it was administered on 6/02/23. The MDS Coordinator confirmed the error and stated that the facility follows the RAI Manual for MDS assessments. These inaccuracies in the MDS coding were brought to the attention of the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and other facility management, who did not provide additional information or responses to the surveyor's concerns.
Failure to Implement Timely Wound Care Intervention
Penalty
Summary
The facility failed to implement a timely intervention recommended by the wound physician for a resident with a stage four sacral wound. The resident, who had multiple medical conditions including renal cancer, brain metastasis, and a history of stroke, was observed lying in bed on an air mattress. Despite recommendations from the wound care team for a wound VAC (vacuum-assisted closure) starting from February 14, 2024, the facility did not apply the wound VAC until March 22, 2024. The delay in implementing the wound VAC was due to a lack of communication and follow-up between the wound care team and the facility staff. The resident's care plan and medical records indicated that the resident had a sacral pressure ulcer on admission and required maximal to total assistance with activities of daily living. The wound care team had recommended the wound VAC protocol multiple times, but there was no evidence of an order or treatment clarification from the facility. The Director of Nursing (DON) and Licensed Practical Nurses (LPNs) interviewed during the survey confirmed that they had not received any orders for the wound VAC until March 22, 2024. The wound doctor also acknowledged that the wound VAC was on back order in February 2024 and that better documentation and communication were needed. The facility's policy and procedure for wound care indicated that preventative measures should be instituted to prevent the development or further deterioration of skin integrity. However, the facility did not provide any documentation of the wound VAC being on back order or that the recommendation for the wound VAC was clarified. The delay in applying the wound VAC was discussed with the DON and the wound doctor, who agreed that the recommendation should have been communicated and documented better. The resident's family was informed about the wound VAC application, and the procedure was eventually carried out on March 22, 2024.
Failure to Implement and Revise Care Plan for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to implement interventions designed by the occupational therapist to stimulate functional performance and prevent further decline for a resident with limited range of motion. The resident, who was dependent and required total care, was observed without the prescribed resting hand splint and elbow extension splint. The CNA assigned to the resident stated that the resident often refused the splint, but the electronic communication record did not reflect any task associated with the splint. Additionally, the CNA reported to the medication nurse, who documented the donning, doffing, and refusals of the splint in the electronic medical record, but the system did not show these tasks being assigned to the CNA. The resident's medical record indicated severe cognitive impairment and a history of conditions such as unspecified convulsions, cerebellar stroke syndrome, and unspecified dementia. The occupational therapy discharge summary recommended the use of a resting hand splint and an elbow extension splint, but these were not included in the physician orders or the care plan. The resident was observed without the prescribed splints, and the care plan did not reflect the necessary interventions to prevent contracture. The interdisciplinary care plan meetings did not document the use of medical devices, and the communication between nursing and rehabilitation services was inadequate. The facility's policies on restorative programs and care plans were not followed, leading to the failure to implement and revise the care plan as needed.
Failure to Follow Nutritional Recommendations and Weight Monitoring
Penalty
Summary
The facility failed to follow through with the Dietitian's recommendation for a resident, ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss, and ensure that re-weighs were done according to the standard of clinical practice and facility policy. Specifically, Resident #24 experienced significant weight loss, and the Dietitian recommended an albumin level check, which was not followed through. The Licensed Practical Nurse (LPN) and Registered Dietitian (RD) were unaware of the significant weight loss and the recommendation was not communicated to the physician or documented properly in the medical records. Resident #24, who had diagnoses including essential hypertension, osteoarthritis, glaucoma, type 2 diabetes mellitus, and dementia, was observed in a geri chair with eyes closed. The resident's comprehensive Minimum Data Set (cMDS) indicated severe cognitive impairment and significant weight loss. Despite the Dietitian's recommendation for an albumin level check due to the weight loss, there was no order for the test, and the last lab work was done months prior. The LPN and RD both failed to follow up on the recommendation, and the IDT was not informed of the resident's condition. Similarly, Resident #57, who had leukemia and intact cognition, experienced significant weight loss without a re-weigh being conducted. The Dietitian confirmed that the resident should have been re-weighed but was not, and the Nurse Practitioner (NP) was not informed of the weight loss. The facility's policy on weighing residents was not followed, and there was a lack of communication and documentation regarding the residents' nutritional status and weight changes. The facility management did not respond to the survey team's findings and concerns.
Failure to Maintain Respiratory Equipment and Obtain Physician's Order
Penalty
Summary
The facility failed to maintain the necessary care and maintenance of respiratory equipment and provide a physician's order for respiratory care for a resident. The surveyor observed that the nebulizer mask and tubing for the resident had not been changed since 3/11/24, despite the facility's policy requiring weekly changes. The resident, who had a history of pneumonia, COPD, and lung cancer, was observed using the therapy gym without difficulty breathing but later reported feeling tired and having difficulty breathing after therapy. The RN confirmed that the tubing had not been changed as required and stated that an order would be obtained immediately. Further review of the resident's records revealed that there had been no physician's order for tubing changes for over nine weeks. The resident's medical diagnoses included pneumonia, centrilobular emphysema, COPD, and lung cancer. The facility's policy required that oxygen and nebulizer tubing be dated upon opening and changed weekly, which was not adhered to in this case. The DON acknowledged the oversight during a meeting with the survey team, confirming that the tubing should have been changed weekly as per the facility's policy.
Failure to Remove Expired Controlled Drug and Document Administration Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not removing an expired controlled drug, Lorazepam gel, from active inventory after its expiration date of 1/22/24. This deficiency was identified during a medication storage inspection where the surveyor, along with an LPN, found an expired Lorazepam gel syringe in the medication cart. The LPN acknowledged that the medication should have been removed and stated that controlled drug inventory counts were completed every shift, but the expiration date was not checked during these counts. Further review revealed discrepancies between the Individual Patient's Controlled Drug Record (IPCDR) and the electronic medication administration record (EMAR), indicating that the expired medication was still being documented as administered after its expiration date. The medical record for the resident involved showed a diagnosis of dementia with agitation and anxiety disorder, with a physician's order for Lorazepam gel to be administered as needed for agitation/anxiety. Despite this, there was no documentation in the EMAR for January and February indicating that the Lorazepam gel was administered, and only one entry in March. The LPN confirmed that the IPCDR should correspond with the EMAR for the dates and times the controlled drug was removed from inventory and administered, but this was not the case. The Director of Nursing (DON) also acknowledged the discrepancies and stated that the EMAR and electronic progress notes (EPN) should match the IPCDR. The Consultant Pharmacist (CP) confirmed that unit inspections were completed monthly and any expired medications found should be reported to nursing for removal. However, the unit inspection reports for January, February, and March did not document the expired Lorazepam gel. The facility's policies for medication administration and controlled drugs required proper documentation and removal of expired medications, but these procedures were not followed, leading to the deficiency.
Failure to Accurately Document Medications and Immunizations
Penalty
Summary
The facility failed to follow professional standards and practices to accurately document in the medical record an ordered medication a resident was being administered. For Resident #377, the surveyor identified discrepancies in the electronic medical record (EMR) where the documentation did not accurately reflect the insulin the resident was receiving. Specifically, there were six instances where the records incorrectly documented the type of insulin administered, showing Humalog instead of Lantus. The discrepancies were noted in various physician and nurse practitioner notes over several months. The facility administration attributed the errors to human error without providing further evidentiary information. For Resident #57, the surveyor found that the electronic medical record did not accurately document the resident's immunization status. Although the resident had received the influenza and pneumococcal vaccines outside the facility, this information was not recorded in the immunization tab of the EMR. The surveyor's inquiry led to the Director of Nursing (DON) updating the immunization records after obtaining information from the resident and their family. The failure to maintain accurate immunization records was noted as a deficiency.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for a resident who experienced significant changes in their health status. The resident, who had diagnoses including essential hypertension, osteoarthritis, glaucoma, type 2 diabetes mellitus, and dementia, was observed in a geri chair with eyes closed and covered with a blanket. The resident's comprehensive Minimum Data Set (cMDS) assessment on 12/13/23 revealed a severely impaired cognitive status, significant weight loss, and the presence of an unstageable deep tissue injury (DTI) that was not present in the previous quarterly MDS (qMDS) dated 9/14/23. Despite these significant changes, the facility did not complete an SCSA as required by the Resident Assessment Instrument (RAI) Manual guidelines, which mandate an SCSA when there are major declines or improvements in a resident's status that impact more than one area of health and require interdisciplinary review and care plan revision. The surveyor's review of the resident's medical records showed a weight loss of 5% or more in the last month and the development of a DTI to the left medial heel. The MDS Coordinator (MDSC) acknowledged that the 12/13/23 cMDS should have been an SCSA but stated it was probably a mistake. The facility management, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC), were notified of the findings and concerns but did not respond to the survey team's concerns. The failure to complete the SCSA as required by the RAI Manual constitutes a deficiency in the facility's assessment and care planning processes.
Failure to Timely Assess Fall Risk for Resident
Penalty
Summary
The facility failed to maintain professional standards of clinical practice by not assessing the fall risk for a resident at risk for falls according to their policy. Resident #63, who had severe cognitive impairment and a history of falls, did not have a quarterly Fall Risk Evaluation completed on time. The last documented Fall Risk Evaluation was dated 11/1/23, and the next one was due on 2/1/24 but was not completed until after surveyor inquiry on 3/21/24. The surveyor was unable to view the 11/1/23 evaluation in the electronic medical record, and the 2/1/24 evaluation was created retroactively on 3/21/24 after the surveyor's request. During interviews, the LPN and DON confirmed that fall risk assessments should be done on admission and quarterly. The DON acknowledged that the 2/1/24 Fall Risk Evaluation should have been completed prior to the surveyor's inquiry. Additional fall risk evaluations provided by the facility, dated 12/23/23 and 3/23/24, were also created retroactively in March 2024. The facility's policy on fall risk assessments, revised on 3/20/24, states that all residents should be assessed for fall risk on admission and reassessed quarterly in conjunction with their MDS evaluation or in the event of a change in status. The surveyor's review of the facility's documentation and interviews with staff revealed that the required fall risk assessments were not completed in a timely manner, leading to a deficiency in maintaining professional standards of clinical practice. The facility did not provide any additional information to address the deficiency identified during the survey.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer a pneumococcal vaccine to a resident, identified as Resident #63, who was admitted with diagnoses including anemia, muscle weakness, and dementia. The resident's medical record indicated a severely impaired cognitive status with a BIMS score of 03 out of 15. Despite the resident's immunization record showing a request for the pneumococcal vaccine, there was no documentation of the vaccine being administered or a historical record of it being given. The resident's consent form for the pneumococcal vaccine was signed by the resident's representative, but no date was provided next to the signature, and the vaccine was not administered until after the surveyor's inquiry. Interviews with facility staff, including an LPN, the DON, and the IP, revealed that the process for verifying and administering the pneumococcal vaccine was not followed correctly. The LPN stated that proof of vaccination should be requested, and if not available, an order from the physician should be obtained to administer the vaccine. The DON acknowledged that the vaccine should have been offered and given but was unsure why it was not. The facility's policy required that all residents be offered immunizations upon admission and reviewed quarterly, but this procedure was not adhered to in the case of Resident #63.
Latest citations in New Jersey
A resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
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