Daughters Of Israel Pleasant Valley Home
Inspection history, citations, penalties and survey trends for this long-term care facility in West Orange, New Jersey.
- Location
- 1155 Pleasant Valley Way, West Orange, New Jersey 07052
- CMS Provider Number
- 315029
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Daughters Of Israel Pleasant Valley Home during CMS and state inspections, most recent first.
Improper food storage and wet pan handling were observed in the kitchen. A surveyor found 6 open spice containers in the food prep area and multiple steam table pans stacked while wet with water trapped between them in the dishwashing area. The GM stated the spice lids should have been closed and the pans should have been air dried instead of stacked wet.
Oxygen therapy orders were not followed for multiple residents. A resident with stroke-related deficits, a resident with COPD, a resident with CHF, and a resident with dementia were observed receiving oxygen at higher flow rates than ordered, and one resident had no humidifier attached despite oxygen being above 3 L. An LPN stated the humidifier was not used because there was no order, and the treatment record for one resident did not show oxygen treatments documented.
Surveyors found multiple infection control failures, including missing EBP signage at resident room entrances for residents with wounds, catheters, and enteral feeding tubes, despite orders and care plan interventions calling for EBP. Staff were unsure what the orange door markers meant and some believed the PPE bin alone indicated precautions. Surveyors also observed an LPN fail to disinfect a shared glucometer after use, place an insulin pen in a pocket and return it to the cart after it was dropped on the floor without cleaning, and store an eye drop bottle in a shirt pocket instead of the med cart.
Call devices were not kept within easy reach for four residents. One resident with severe cognitive impairment and dependence for ADLs had the call bell hanging out of reach while in bed, another resident with Alzheimer’s disease had the call device clipped above the headboard and out of reach, a third resident with hemiplegia and a BIMS of 0 had the call device on the floor under the bed, and a fourth resident with dementia and limited right-hand movement had the call device tied to the bed rail and hanging out of reach. Staff interviews confirmed the expectation that call bells be placed within the resident’s reach.
Disrepair and staining were observed in a resident room and in HP unit common areas, including peeling and missing wallpaper, broken wall protection, stained ceiling tiles, and a baseboard heater with a crusty brown substance and dents. The DBS, DON, Assistant Administrator, and Administrator acknowledged the areas were in disrepair and detracted from the homelike environment.
A resident with severely impaired cognition, a sacral pressure ulcer, and urinary retention had an indwelling catheter observed at the bedside, but the admission MDS did not code the catheter in the bowel and bladder section. The record also included a physician order to check the catheter every shift and a care plan focused on the indwelling catheter, and the RN/MDSC stated the catheter should have been coded.
A resident with pressure injuries had duplicate wound treatment orders for the same site, and an RN documented a wound treatment as completed in the eTAR before actually performing it. Another resident with DM had no care plan focuses or interventions for diabetes, and although a BG of 473 was treated with Humalog per sliding scale, there was no documentation that the physician or NP was notified as ordered.
A resident with severe cognitive impairment and G-tube feeding had CP recommendations left unsigned and not documented as followed up. The CP had recommended clarifying a Flomax order because the capsule should be swallowed whole and adjusting Lidoderm patch timing to 9 AM to 9 PM, but the MAR showed different patch times and the record initially showed no follow-up by the DON or nursing staff.
Surveyors found expired IV fluids, unclear dating on eye drops and insulin, and Duoneb medications in a cart that were not properly labeled, dated, or stored in resident-specific packaging. They also found a controlled-drug compartment that was not permanently affixed to the cart and could be removed, leaving controlled meds visible and accessible.
The facility did not update care plans to include new interventions after falls and failed to complete thorough fall investigations, including missing staff witness statements and incomplete documentation. Three residents with cognitive and physical impairments experienced multiple falls, and interventions such as increased monitoring and use of safety equipment were not consistently documented or communicated to staff, resulting in deficiencies in accident prevention and supervision.
The facility did not conduct performance reviews for five CNAs, as required by policy, which mandates reviews at least every 12 months. The DON stated that reviews were only conducted if competency concerns arose, which was not the case for these CNAs. The facility's policy requires consistent monitoring and training to ensure competent care, but this was not adhered to.
The facility failed to ensure the Infection Control Preventionist (IP) attended three consecutive quarterly Quality Assurance (QA) meetings. The IP was absent due to working the evening shift and serving as the nursing supervisor. Although the IP provided reports to the Director of Nursing (DON), their absence was noted as a deficiency. The facility's QAPI Program did not explicitly require the IP's attendance, but their role in infection control was deemed essential.
The facility did not maintain and display the most recent State inspection results in an accessible area. Six residents were unaware of where to find these results. The surveyor found outdated inspection results at the LP and HP Nursing Stations, with the latter's binder hidden in a closet. The DON confirmed the absence of the 2023 results, which were later found mixed with other binders, not accessible to residents or the public.
The facility failed to follow physician's orders for side rail use for a resident, using two side rails instead of one as prescribed. Additionally, an LPN did not adhere to the medication administration policy by not taking a resident's vital signs within the required 15-minute window before administering blood pressure medications. These deficiencies were confirmed by the Director of Nursing and the LPN involved.
A resident with severe cognitive impairment and multiple health issues was observed with long, jagged, and soiled fingernails, indicating a failure in personal hygiene care. Despite the resident's request for nail care, the CNA did not address the issue, citing that activity staff were responsible for clipping and filing nails. However, the LPN stated that CNAs were responsible for all aspects of nail care. The resident required moderate assistance with personal hygiene, as documented in their care plan, but had not received adequate care since their last salon visit over a month prior.
A facility failed to administer oxygen therapy according to a physician's order and did not ensure proper storage of nasal cannula tubing for a resident with dementia and chronic respiratory failure. The resident received oxygen at 2.5 LPM instead of the prescribed 2 LPM, and the tubing was not stored in a bag as required. Both a CNA and an LPN confirmed these lapses during interviews.
The facility failed to ensure proper reconciliation and accountability of narcotic medications, with discrepancies found in the records for a resident's Tramadol administration. The CDIR was not consistently signed by two nurses, and there were inconsistencies between the IPCDR and eMAR. The resident, who was cognitively impaired, confirmed receiving medication but could not recall specific dates. Additionally, missing signatures were found on the shift-to-shift log for another medication cart.
A facility failed to ensure proper infection control practices during dining services. A CNA did not perform hand hygiene between assisting residents, and an AC failed to sanitize hands between residents while also tying a trash bag to a resident's wheelchair. Both staff members acknowledged the need for hand hygiene but did not follow procedures.
Improper Food Storage and Wet Pan Handling
Penalty
Summary
Food storage and sanitation practices were deficient in the kitchen. During observation with the General Manager and Executive Chef present, the surveyor found 6 spice containers on a shelf in the food preparation area with their tops opened on the dairy side of the kitchen. The surveyor also observed 2 large shallow steam table pans and 3 two-thirds sized steam table pans on the dairy side of the dish washing area that were stacked while wet and nested with water between them. The General Manager stated the spice container lids should have been closed and that the steam table pans should not have been stacked when wet and should have been air dried first. Facility policy stated that all foods are to be labeled, dated, and securely covered, and that dishes should be air dried and wet dishes should not be stacked.
Oxygen Therapy Orders Not Followed and Humidifier Not Provided
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were followed for four residents reviewed for respiratory care. Resident #8, who had diagnoses including dysphagia, cerebral infarction, left hemiplegia, and severe cognitive impairment, was observed receiving oxygen via nasal cannula at 3.5 lpm even though the physician order directed continuous oxygen at 2 lpm. A nurse later confirmed the order and adjusted the flow to the prescribed rate. Resident #72, who had COPD and severely impaired cognition, was observed receiving oxygen via nasal cannula at 4 lpm, while the physician order directed continuous oxygen at 2 lpm. The care plan for this resident included oxygen therapy as ordered. Resident #108, who had CHF and severely impaired cognition, was observed receiving oxygen via nasal cannula at 3.5 lpm and later at 4.5 lpm. The physician order directed oxygen at 3 lpm via nasal cannula continuously every shift for shortness of breath. The surveyor also observed that no oxygen humidifier was attached to the concentrator during the observations. An LPN stated that he did not place a humidifier in the room because there was no order. The facility policy stated that if oxygen is more than 3 liters, a humidifier bottle with sterile water is to be used. Resident #114, who had unspecified dementia with psychotic disturbance, was observed receiving oxygen via nasal cannula at 3 lpm and later at 3.5 lpm. The physician order directed oxygen at 2 lpm via nasal cannula as needed for oxygen saturation less than 92%, shortness of breath, or respiratory distress. The resident treatment administration record did not show oxygen treatment entries for the dates reviewed. The facility’s oxygen therapy policy required staff to check the order for the amount and frequency of oxygen administration and to use a humidifier bottle when oxygen is more than 3 liters.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to follow infection prevention and control practices in multiple areas, including Enhanced Barrier Precautions (EBP), medication handling, and glucometer disinfection. Surveyors observed that EBP signage was not posted at the entrances or doorways of multiple resident rooms, even though residents had orders or care plan interventions for EBP related to wounds, indwelling catheters, or enteral feeding tubes. In several rooms, the facility used bins with PPE and orange markers on the door frame, but staff members interviewed were unable to explain the meaning of the orange dot or identify the required signage for EBP. The facility’s EBP policy did not address signage, while another infection control document did include instructions to place appropriate isolation signage outside resident rooms. Residents identified in the observations included residents with significant medical needs such as severe cognitive impairment, dependence for activities of daily living, dysphagia with gastrostomy tube feeding, indwelling urinary catheters, wounds, and pressure injuries. For example, one resident with a gastrostomy tube had no EBP signage at the room entrance, and the assigned LPN stated there was no signage in use and acknowledged the resident was on EBP due to the tube. Other residents with wounds or urinary catheters also had no visible EBP signage despite physician orders and care plan interventions indicating EBP. Staff interviews showed that some nurses believed the PPE bin itself indicated EBP, while others were unaware of the signage requirement. The survey also identified medication and equipment handling concerns during observation. One LPN did not clean or disinfect a glucometer after using it on a resident, and later stated the wipes were not at the cart. The glucometer had no resident label and was marked only with a letter that the nurse did not understand, while the administrator later stated the glucometers were shared among residents. In another observation, an LPN placed an insulin pen in a pocket after administration, dropped it on the floor, and then returned it to the medication cart without cleaning or sanitizing it. A separate medication storage review found an eye drop bottle stored in an LPN’s shirt pocket instead of in the medication cart, and both the LPN and RN supervisor acknowledged that storing medications in clothing pockets was not correct.
Call Devices Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call devices were readily accessible for four residents. Resident #19 was observed in bed awake and able to make needs known, but the call device was hanging on the bed and out of reach while the resident leaned to the opposite side and asked where it was, stating they could not reach it. Later the same day, the call device was again observed out of reach. The resident’s record showed severe cognitive impairment with a BIMS score of 6 and dependence on staff for ADLs, and the care plan included keeping the call bell within easy reach when the resident was in bed. Resident #61 was observed asleep in bed with the call device hanging on top of the headboard and clipped to the wall, four inches from the outlet, and it remained out of reach on a later observation. The resident’s record showed Alzheimer’s disease, severe cognitive impairment with a BIMS score of 3, and dependence on staff for ADLs. The care plan activity report did not include any call light intervention, even though the resident required assistance and the call light was expected to be within easy reach. Resident #108 was observed with the call device on the floor under the bed, and the resident stated they could not find it because they wanted the television turned on; the device remained under the bed on a later check. The resident’s record showed hemiplegia following cerebral infarction, severely impaired cognition with a BIMS score of 0, and dependence on staff for ADLs, with a care plan intervention to keep the call bell within reach when in the room. Resident #114 was observed with the call device tied to the right-side rails and hanging off the bed out of reach, and the resident could not reach it because of limited movement in the right hand. The resident’s record showed unspecified dementia with psychotic disturbance and a care plan noting declining ADLs secondary to renal cancer and progressing dementia, with an intervention to keep the call bell within reach when in the room.
Disrepair and Staining in Resident Room and HP Unit Common Areas
Penalty
Summary
The facility failed to maintain a resident's room and the HP unit hallway/common area in a clean, sanitary, and homelike manner. In Resident #3's room, the surveyor observed approximately 10 inches of wallpaper peeling off the wall near the bottom of the window sill and an approximately 2-inch break in the plastic corner protector on the wall. In the HP unit hallway near the smoke doors by room [ROOM NUMBER], the surveyor observed an approximately 24-inch-wide by 4-foot-tall area of missing wallpaper with hanging ragged edges, a second approximately 8-inch-wide by 4-foot-tall area of torn missing wallpaper, and several large brown stains on three ceiling tiles. In the common room marked as the living room for the HP unit, the surveyor observed an approximately 6-foot-wide area of torn missing wallpaper above the heating baseboard unit under the window, with dried brown stains on the exposed wall area and a baseboard heater with a crusty brown substance and dents. The DBS, DON, Assistant Administrator, and Administrator reviewed the findings and acknowledged the disrepair and that the areas detracted from the facility's homelike environment.
MDS Not Accurately Coded for Indwelling Catheter
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was reviewed for MDS accuracy. During survey observations on 3/6/26 and 3/9/26, the resident was awake and lying in bed with an indwelling catheter and privacy bag attached to the lower side of the bed. The resident’s admission record showed diagnoses including a sacral pressure ulcer, unstageable, and the admission MDS dated 2/12/26 documented a BIMS score of 0 out of 15, indicating severely impaired cognition. Review of the admission MDS showed that in section H, Bowel and Bladder, the indwelling catheter was not coded under appliances. The physician order dated 2/6/26 directed staff to check for indwelling catheter placement every shift, and the care plan activity report initiated 2/8/26 addressed the resident’s indwelling catheter due to urinary retention. During interview, the RN/MDS Coordinator stated that the resident’s indwelling catheter should have been coded. The survey team later met with the LNHA, Asst. LNHA, and DON regarding the concern, and no further information was provided.
Failure to Clarify Wound Orders, Document Treatment Accurately, and Manage Diabetes Care
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for two residents. For one resident with no cognitive deficits and admitted with unstageable pressure injuries and skin tears, the electronic record contained two treatment orders for the same right lateral lower leg wound: one order for a medicated topical paste with a covered dressing and another later order for lanolin and petrolatum ointment with the wound left open to air. The wound consultant’s most recent recommendation was to continue the medicated paste, medicated gauze, and thick pad daily until discontinued, yet both treatments were documented as completed on multiple days for the same site. During observation, an RN applied the lanolin and petrolatum ointment and left the wound open to air while the resident questioned why no cover dressing was being used. The RN stated the resident was confusing the order with an older previous order, then documented the treatment as completed in the eTAR before it had actually been performed. The surveyor observed that the treatment had been charted hours earlier, and the RN acknowledged documenting completion before the treatment was done. The LNHA later stated that a wound care consultation had not been uploaded into the electronic record until after the duplicate order issue had occurred. For another resident with type 2 diabetes, COPD, and CHF, the care plan did not include focuses, interventions, or goals for diabetes management despite an active insulin sliding scale order. The order required Humalog insulin before meals and at bedtime based on blood glucose results and directed staff to notify the physician or NP when blood glucose was above 450. The resident had a blood glucose reading of 473, and the MAR showed 12 units of Humalog were given as ordered, but there was no documentation in the MAR or elsewhere in the EHR that the physician or NP was notified as required. The DON confirmed the absence of diabetes care plan documentation and the lack of documented provider notification.
Failure to Follow Up on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to address Consultant Pharmacist recommendations for Resident #113, who had diagnoses including a left above-knee amputation, severe cognitive impairment with a BIMS score of 3, and was receiving nutrition and medications through a gastrostomy tube. During observation, the resident was lying in bed, alert and verbally responsive, with an enteral feeding pump in use and a urinary drainage bag hanging from the bed frame. The Consultant Pharmacist’s admission medication review dated 2/13/26 included a recommendation to clarify the resident’s Flomax capsule order with the physician because the medication should be swallowed whole and the resident received medications via G-tube. The review also included a recommendation for lidocaine 5% patch timing so it would be applied at 9 AM and removed at 9 PM for a 12-hour effect. The recommendations were left unsigned, and the record review found no documentation that the recommendations had been followed up when first reviewed by surveyors. The physician’s order for tamsulosin 0.4 mg documented administration by G-tube once daily, and the March 2026 MAR showed the lidocaine patch scheduled from 7 AM to 3 PM and 3 PM to 11 PM rather than the timing recommended by the Consultant Pharmacist. The RN supervisor stated that the DON was responsible for reviewing and following up on CP recommendations and that reports would be signed to indicate completion, but the surveyor found no evidence of follow-up before inquiry. The facility policy for admission medication reconciliation addressed review and clarification of new admission orders but did not further address follow-up of CP recommendation reports.
Improper Medication Storage and Controlled Drug Compartment Security
Penalty
Summary
Drugs and biologicals were not properly stored and labeled in the HP unit medication storage room and medication cart. In the medication storage room, surveyors found two 0.45% Normal Saline one-liter IV bags that were past the manufacturer's expiration date, and an LPN confirmed they were expired and removed them for disposal. The same room contained eye drops with no clear opening date, and a Novolin R FlexPen for a resident that had conflicting open dates written on the storage bag and on the pen itself; the LPN stated the correct open date was 9/11 rather than 9/1. In medication cart A, surveyors observed an opened Duoneb foil packet with a written date but no resident name, and the LPN could not identify which resident it belonged to or confirm the correct expiration after opening. Resident-specific Duoneb supplies were also found stored loosely in the drawer, including one resident's manufacturer box containing an opened foil packet with no date and four attached vials without dates, and another resident's box containing a foil packet with a written date. In addition, medication cart B had a controlled-drug compartment that was not permanently affixed to the cart; the surveyor was able to lift and fully remove it, and the controlled medications were visible and accessible when the compartment was lifted.
Failure to Update Care Plans and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure that residents' care plans were updated to include interventions implemented after falls, and did not thoroughly complete fall investigations as required by facility policy. For three residents reviewed, care plans did not reflect new or revised interventions following multiple fall incidents, such as increased monitoring, use of anti-roll back wheelchairs, or placement of floor mats. In several cases, interventions that were implemented post-fall were not documented in the care plan, and there was no evidence that staff were consistently informed or able to follow these interventions. Additionally, fall investigations were incomplete for two residents, with missing staff witness statements and incomplete documentation of the circumstances surrounding the falls. The facility's own policies required that all incidents be thoroughly investigated, including obtaining written statements from all witnesses and completing all sections of the accident and incident reports. However, in multiple instances, only partial information was collected, and staff statements were not included, limiting the ability to determine the cause of the falls and the effectiveness of interventions. The residents involved had significant cognitive impairments and were at high risk for falls, as indicated by their medical diagnoses and fall risk assessments. One resident with severe dementia experienced multiple falls in the dining room, another with toxic encephalopathy and muscle weakness had unwitnessed falls resulting in injuries, and a third resident with hemiplegia and moderate cognitive impairment was transferred by a single CNA despite a care plan requiring two-person assistance. In each case, the lack of updated care plans and incomplete investigations contributed to the deficient practice.
Failure to Conduct CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received performance reviews, as evidenced by the absence of such reviews in the files of five randomly selected CNAs. The review of facility documentation from January 2023 to October 2024 did not reveal any performance reviews for these CNAs. During interviews, the Human Resources Director indicated that the Director of Nursing (DON) was responsible for education, competencies, and performance reviews. The DON stated that performance reviews were only conducted if there were concerns with a CNA's competencies, which was not the case for the five CNAs in question. The facility's policy, dated February 6, 2023, required staff to be monitored and trained to ensure competent, effective, and safe care for residents. However, the policy was not followed as the CNAs did not receive performance reviews at least every 12 months, and their education was not based on performance reviews. The surveyor discussed this concern with the DON and noted that no additional information was provided to address the deficiency.
Infection Control Preventionist Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the required staff attended the quarterly Quality Assurance (QA) meetings, as evidenced by the absence of the Infection Control Preventionist (IP) from three consecutive meetings. The surveyor reviewed the QA meeting sign-in sheets for the last three quarters and found that the IP was not present at the meetings held on September 5, 2024, July 16, 2024, and May 23, 2024. During an interview, the Director of Nursing (DON) explained that the IP was unable to attend the meetings due to working the evening shift and serving as the nursing supervisor. Although the IP provided reports to the DON, their absence from the meetings was noted as a deficiency. The facility's Quality Assurance Performance Improvement (QAPI) Program, dated July 2024, listed the required members of the QAPI team, which did not explicitly include the IP. However, the absence of the IP from the meetings was still identified as a deficiency by the surveyor, as the IP plays a crucial role in infection control within the facility.
Failure to Maintain and Display State Inspection Results
Penalty
Summary
The facility failed to maintain and make accessible the prior year's State of New Jersey inspection results, as required by regulations. During a group meeting with six alert and oriented residents, all participants stated they were unaware of where to find the State inspection results. The surveyor's investigation revealed that the inspection results from 2017 and 2018 were available at the LP Nursing Station, while the HP Nursing Station had a binder with 2019 results hidden in a closed closet. The SP Nursing Station's inspection results were not mentioned, indicating they were not readily accessible either. The Director of Nursing (DON) confirmed that the most recent inspection results from August 10, 2023, were not posted in the binders. Although the Administrator later found the current inspection reports on the nursing units, they were mixed with other binders on the counter and not in an area accessible to residents, families, or the public. This oversight led to the deficiency, as the facility did not comply with the requirement to post the location of inspection results in a readily accessible area.
Failure to Follow Physician's Orders and Medication Administration Policy
Penalty
Summary
The facility failed to ensure that staff followed the physician's order for the use of side rails for a resident. The surveyor observed the resident in bed with two full padded side rails in use, despite the physician's order and care plan specifying only one side rail for positioning. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, had a care plan and side rail assessment indicating the use of one side rail. The Director of Nursing confirmed the discrepancy and acknowledged that a side rail assessment should have been completed quarterly, and a physician's order should have been obtained before using two side rails. Additionally, the facility failed to ensure that an LPN followed the physician's order and facility policy during medication administration for another resident. The LPN administered blood pressure medications without taking the resident's vital signs within the required 15-minute window before medication administration. The LPN admitted to taking the vital signs about an hour before administering the medications, contrary to the facility's policy, which requires vital signs to be taken no more than 15 minutes prior to medication administration. The surveyor's interview with the LPN and the Director of Nursing confirmed the failure to adhere to the facility's medication administration policy. The facility's policy clearly states that vital signs should be taken within 15 minutes before removing medications from their packaging, which was not followed in this instance. No further information was provided by the facility regarding these deficiencies.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficiency was identified for a resident who was observed multiple times with long, jagged, and soiled fingernails. Despite the resident expressing a desire to have their nails cleaned and manicured, the Certified Nursing Assistant (CNA) assigned to their care did not address the issue. The CNA stated that while they were responsible for cleaning the residents' nails, the activity staff were responsible for clipping and filing them. However, the Licensed Practical Nurse (LPN) contradicted this by stating that CNAs were responsible for cleaning, clipping, and filing the residents' nails. The resident in question had been admitted with diagnoses including dementia, end-stage heart failure, and chronic respiratory failure with hypoxia, and had a severe cognitive impairment as indicated by a BIMS score of 0 out of 15. The resident required moderate assistance with personal hygiene, as documented in their care plan. Despite being on the salon list, the resident's nails had not been attended to since their last salon visit over a month prior. The facility's ADL policy and procedure emphasized the importance of providing assistance according to residents' personal preferences, and the job description for CNAs included assisting residents with ADLs, which was not adhered to in this case.
Oxygen Therapy and Infection Control Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of respiratory nasal cannula tubing for a resident. The surveyor observed the resident receiving oxygen at 2.5 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the nasal cannula tubing was not stored in a bag as required by infection control measures, and this was confirmed by both a CNA and an LPN during interviews. The CNA acknowledged that the tubing should have been discarded and replaced, while the LPN admitted to not verifying the oxygen flow rate and proper storage of the tubing during morning rounds. The resident involved had a history of dementia, end-stage heart failure, and chronic respiratory failure with hypoxia. The care plan for the resident included oxygen therapy as per the physician's order, but the facility's failure to adhere to these orders and infection control policies was evident. The facility's policy required oxygen tubing to be stored in a bag when not in use, and the oxygen therapy policy specified that a licensed nurse should administer oxygen as prescribed. Despite these guidelines, the facility did not provide additional information or corrective actions during the survey team's meeting with the LNHA and DON.
Failure in Narcotic Reconciliation and Accountability
Penalty
Summary
The facility failed to consistently provide pharmaceutical services in accordance with professional standards, specifically in the reconciliation and accountability of controlled dangerous substances. During an inspection of the narcotic medication cart on the high side of the LP unit, it was observed that the Controlled Drug Inventory Record (CDIR) was not signed by two nurses for the day in question. The Registered Nurse (RN) on duty noted that the previous shift nurse had not signed the Individual Patient Controlled Drug Record (IPCDR) for Tramadol 50 mg administered to a resident the night before. This discrepancy was not identified by the nurses conducting the shift-to-shift count, and the RN reported the issue to the Nursing Supervisor and Director of Nursing (DON). Further review revealed inconsistencies between the IPCDR and the electronic Medication Administration Record (eMAR), with instances of Tramadol being signed as removed from inventory but not administered, and vice versa. The resident involved was admitted with a diagnosis that included low back pain and was receiving scheduled and as-needed pain medications. The resident was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. The eMAR for October and September showed discrepancies in the administration and inventory records of Tramadol, with some doses signed as removed but not administered, and others administered but not signed as removed. The resident confirmed receiving Tramadol the previous night but could not recall other dates. Additionally, the inspection of the narcotic medication cart on the B-side of the HP unit revealed missing signatures on the shift-to-shift log for several dates in October. The RN/Nursing Supervisor confirmed the missing signatures and acknowledged that the log should have been signed by two nurses. The facility's policy requires narcotics to be counted shift-to-shift, with discrepancies reported to the Supervisor or DON, and proper documentation of medication removal and administration. The DON investigated the discrepancies and acknowledged the errors.
Infection Control Deficiency in Dining Services
Penalty
Summary
The facility failed to ensure proper infection control practices during dining services on one of its nursing units. Observations revealed that a Certified Nursing Assistant (CNA) did not perform hand hygiene between assisting residents with hand wipes and applying clothing protectors. The CNA was seen cleaning a resident's hands, applying a clothing protector, and then proceeding to assist another resident without sanitizing her hands. Additionally, the CNA handed out wipes to four residents, who returned the soiled wipes to her, which she discarded without performing hand hygiene before applying clothing protectors to them. Further observations showed that an Activity Coordinator (AC) also failed to sanitize her hands between residents. The AC donned gloves, cleaned a resident's hands, discarded the gloves and wipe, and then donned a new pair of gloves without sanitizing her hands. The AC also tied a trash bag to the back of a resident's wheelchair, which was questioned by the surveyor as a potential infection control and dignity concern. Interviews with the CNA and AC confirmed their awareness of the need for hand hygiene, but they did not follow the proper procedures during the observed incidents.
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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