Hartwyck At Oak Tree
Inspection history, citations, penalties and survey trends for this long-term care facility in Edison, New Jersey.
- Location
- 2048 Oak Tree Road, Edison, New Jersey 08820
- CMS Provider Number
- 315251
- Inspections on file
- 15
- Latest survey
- December 20, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hartwyck At Oak Tree during CMS and state inspections, most recent first.
The facility failed to maintain the call bell system volume at an audible level on floor 3, as observed during a survey. Tests from two resident rooms revealed no audible notification of call bell activation. Nursing staff discovered the volume had been turned down and corrected it. The DOM confirmed these findings.
The facility failed to maintain its emergency generators as per NFPA 99:2012, with the generator not tested under load for the required duration and having a history of failures. Additionally, the emergency generator's remote annunciator panel was non-functional, lacking power indication and a lamp test switch. These issues were identified during a documentation review and observation, with no current MOU for a portable rental generator.
The facility failed to maintain proper fire separation between Healthcare and Residential occupancies, with unprotected wire penetrations and missing brick sections compromising the two-hour fire resistance rating. These deficiencies were confirmed during an inspection.
The facility failed to ensure proper functioning of delayed egress locking systems on stairway enclosures, as observed during a survey. The 15-second delayed egress locks near rooms on the second and third floors, as well as the mauve wing, did not function when tested, potentially affecting all residents. These deficiencies were confirmed through interviews with surveyors.
The facility failed to provide a directional exit sign near the kitchen's smoke barrier doors, as required by NFPA 101:2012. This deficiency, observed during a survey, was confirmed by the U.S. FOIA and had the potential to affect all residents due to unclear exit directions.
The facility failed to protect hazardous areas as per NFPA 101:2012, with a laundry room door that did not positive latch, compromising fire safety. This was observed and confirmed during a survey, potentially affecting all residents.
The facility did not maintain its kitchen fire safety equipment according to NFPA standards. Observations revealed that four of the eight discharge spray nozzles on the kitchen range-hood fire suppression system lacked protective caps or covers, and the Class-K fire extinguisher's monthly inspection tag was unsigned. These issues were confirmed by a staff member during an interview.
The facility did not conduct annual inspections of fire door assemblies as required by NFPA 80. Instead, monthly inspections were provided, which did not include all fire doors and assemblies and failed to meet the minimum requirements. This oversight had the potential to affect all residents. The deficiency was confirmed during an interview with a U.S. FOIA representative.
The facility's emergency generator remote annunciator panel was found non-functional at the nurse's station, lacking power indication and a lamp test switch, as per NFPA 99 standards. This deficiency was confirmed during an interview and reported at the Life Safety Code exit conference.
The facility failed to maintain its emergency generators as per NFPA 99:2012, with documentation revealing a lack of testing under load for four continuous hours every 36 months. Maintenance reports indicated potential fuel system issues and a history of generator failures. The facility representative confirmed the absence of repairs and a current MOU for a portable generator, posing a risk to all residents.
The facility failed to document the code status for two residents, both dependent on ventilators, leading to a deficiency in managing their medical instructions for resuscitation. Despite staff identifying them as full code, there was no physician's order (PO) in their records. The Director of Nursing confirmed the absence of a PO and acknowledged the need for such documentation at admission.
A facility failed to adjust medication administration times for a resident undergoing dialysis, resulting in missed doses of essential medications. The resident, with chronic kidney disease and end-stage renal disease, was on a dialysis schedule that conflicted with medication times. Despite procedures requiring adjustments, the facility did not consistently ensure medications were administered appropriately, as confirmed by staff interviews and record reviews.
Call Bell System Volume Deficiency
Penalty
Summary
The facility failed to ensure that the volume on the resident call bell system at the nurse's station on floor 3 was set to a level that could be heard. This deficiency was identified during observations and interviews conducted on 12/19/2024. At 11:50 AM, a test of the call bell from a resident's room revealed no audible notification of activation. A similar observation was made at 11:55 AM from another resident's room, where again, no audible notification was heard. Nursing staff later informed the surveyor that the volume on the call bell system had been turned all the way down, which they subsequently corrected. The Director of Maintenance confirmed these observations during the survey.
Plan Of Correction
1. The call bell volume at the 3rd floor nurses station was immediately restored to an audible level. Rooms 315 and 316 were tested and confirmed operational with both visual and auditory alerts. All nursing staff were notified of the deficiency and instructed on the importance of maintaining appropriate call bell volume levels. A reminder was issued emphasizing that adjusting the call bell volume downwards is unacceptable on 12/20/24. 2. All residents have the potential to be affected by this practice. All 3 call bell systems throughout the facility were checked to ensure appropriate volume levels and functionality. 3. A facility policy and procedure on call bell system management will be created by 1/15/25 to include: - Specific instructions regarding appropriate call bell volume levels. - A prohibition against turning down or muting call bell volumes. - A defined requirement for regular checks of call bell system functionality, including volume levels. - A process for documenting call bell system checks. - Clear instructions on how to troubleshoot call bell system issues. All nursing and maintenance staff will be re-educated on the new policy and procedure by 1/24/25 by the clinical nurse educator. 4. Daily audits of call bell system functionality and volume levels in all resident rooms and common areas will be completed by the maintenance department for 4 weeks and then monthly ongoing. Results will be tracked and reported to the Quality Assurance Committee quarterly and to the QAPI Committee monthly.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, which had the potential to affect all residents. During a documentation review, it was discovered that the generator had not been tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a maintenance report from August 6, 2024, indicated that the fuel system might need rebuilding, including the injection pump and injectors. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. The report recommended repairing or replacing the unit to ensure dependability. During an interview, it was confirmed that the necessary repairs had not been made, and there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one. Furthermore, an observation on December 20, 2024, revealed that the emergency generator's remote annunciator panel at the nurse's station on floor 2 was not functioning properly. The panel lacked a means to show it was receiving power and was not equipped with a lamp test switch to test the operation of all alarm lamps. These deficiencies were communicated to the facility's representative during the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, NJ Ex Order 26.4(b)(1) was contacted and came to assess the generator on 1/6/25 and will complete the following: - The Maintenance Director contacted NJ Ex Order 26.4(b)(10) and executed a new MOU for a portable rental generator on 1/6/25. Rental generator was installed and operational to begin generator repairs on 1/6/2025. - NJ Ex Order 26.4(b)(1) began work to rebuild the generator fuel pump on 1/6/2025. Work was completed on 2/10/2025. Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will perform a four-hour generator load test. Load test was completed on 2/11/2025. - Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will repair/replace the remote annunciator panel to include a means to show that it is receiving power and a lamp test switch(es) to test the operation of all alarm lamps. This work was completed by NJ Ex Order 26.4(b)(1) on 2/11/2025. 2. NJ Ex Order 26.4(b) has been contracted by the facility to provide the required 4 hour load test of the generator every 36 months. The Maintenance Director added the required 4 hour load test to the generator maintenance schedule and will ensure completion every 36 months. The Maintenance Director will be the designated individual responsible for ensuring a current MOU is in place for a rental generator and will provide evidence of this to the administrator annually. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule and ensure completion monthly. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly ongoing to ensure that the required testing was completed timely. The results of this will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Deficient Fire Separation in Facility Occupancies
Penalty
Summary
The facility failed to ensure that sections of health care facilities classified as other occupancies were properly separated from areas of healthcare occupancies by construction with a two-hour fire resistance rating. This deficiency was identified during observations and interviews conducted on December 19, 2024. Specifically, the separation between the Healthcare occupancy and the Residential occupancy was compromised by a 1.5-inch and 2.5-inch unprotected penetration for wire pass-throughs. Additionally, a 2-inch-high by 48-inch-wide section of brick was missing above the fire-rated door assembly between the two occupancies. These observations were confirmed by the USTFOTAT at the time of the inspection. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference on December 20, 2024.
Plan Of Correction
1/9/25 1. All residents have the potential to be affected by this deficient Life Safety Code. The maintenance department repaired the 2 unprotected penetrations for the pass-through of wires on 1/8/25 using UL listed NUEX Order 26.4(DX LC 150 fire-stop sealant. The maintenance department repaired the 2 inch by 48 inch wide section of brick missing above the fire rated door assembly between the two occupancies on 1/8/25 using intumescent fire-stop pillows and UL listed NJ Ex Order 26.4(15) LC 150 fire-stop sealant. 2. The facility's maintenance schedule will be revised by the Director of Maintenance to include a monthly inspection of fire-rated assemblies between the healthcare occupancy and the residential occupancy to confirm that the two hour fire resistance rating is intact with no penetrations using an audit tool. 3. The Director of Maintenance will review the fire rated assembly inspection reports monthly ongoing and report the results to the administrator and to the QAPI committee monthly for 6 months.
Non-Functioning Delayed Egress Locking Systems
Penalty
Summary
The facility failed to ensure that the egress doors equipped with delayed egress locking arrangements were functioning properly, as required by NFPA 101:2012 Edition. During observations conducted on December 19, 2024, it was found that the 15-second delayed egress locking arrangements on the stairway enclosures near room 312 on the third floor, room 212 on the second floor, and the mauve wing did not function when tested. These deficiencies were confirmed through interviews with the U.S. FOIA present during the survey. The malfunctioning of the delayed egress locking arrangements had the potential to affect all residents within the facility. The observations were made by the USSROAD, US FOTIAD, and US FOJA, who confirmed the non-functionality of the locking systems. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference held on December 20, 2024.
Plan Of Correction
1/7/25 1. All residents have the potential to be affected by this deficient Life Safety Code. NJ Ex Order 26.4(b) (1) repaired the delayed egress locks in the following locations on 1/6/25: floor 3 near room 312, floor 2 near room 212, and the stairway enclosure on the mauve wing. The Maintenance Department conducted an audit of all facility delayed egress locks to confirm function on 1/6/25. 2. The Maintenance Director will modify the scheduled maintenance calendar to include monthly delayed egress checks to confirm function. 3. The Maintenance Director will review the monthly delayed egress lock testing documentation to ensure compliance. The details of this testing will be submitted to the administrator and to the QAPI committee monthly for 6 months.
Deficient Exit Signage Near Kitchen
Penalty
Summary
The facility failed to ensure proper exit signage in accordance with NFPA 101:2012 Edition, Sections 19.2.10.1 and 7.10. During an observation at 11:00 AM, it was noted that there was no directional exit sign indicating the direction of travel to the nearest exit when exiting the smoke barrier doors near the kitchen. This deficiency was confirmed through an interview with the U.S. FOIA present at the time of the observation. The lack of appropriate signage had the potential to affect all residents, as the direction of travel to the nearest exit was not apparent.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A directional exit sign was installed near the kitchen on 12/31/24 by [R]. The sign is wall mounted, is internally illuminated, and clearly indicates the direction of travel to the nearest exit. A complete facility-wide inspection of all exit signs was conducted on 12/31/24 to ensure no other areas are lacking proper signage. 2. The Maintenance Director will modify the scheduled maintenance calendar to include a quarterly Exit Sign inspection to be conducted to ensure all facility exit signs are in the proper location and functioning. 3. The maintenance director will review the quarterly exit sign inspection reports with the administrator quarterly and submit to the QAA committee quarterly for 1 year.
Deficient Fire Safety Measures in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were protected in accordance with NFPA 101:2012 Edition, specifically Sections 19.3.2.1, 7.2.1.8, 9.7, 8.4, and NFPA 13. This deficiency was identified during an observation on December 20, 2024, at 11:20 AM, when it was noted that the laundry room door did not positive latch when tested. This issue was confirmed through an interview with the U.S. FOIA present at the time of the observation. The deficiency had the potential to affect all residents, as it compromised the fire safety measures required for hazardous areas. The facility's representative was informed of this deficient practice during the Life Safety Code exit conference on the same day.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. The laundry room door and latching mechanism were repaired by the facility maintenance department on 12/20/24. The door was then tested and confirmed to latch positively. 2. All hazardous areas were audited to confirm door and latching mechanisms were functioning properly by the maintenance department on 12/20/24. 3. The Director of Maintenance will update the maintenance schedule to include a monthly inspection of Hazardous Areas to ensure that doors are functioning properly. 4. The Safety Committee will audit all hazardous area doors for proper function and submit the results to the administrator and to the QAPI committee monthly for 3 months.
Deficiency in Kitchen Fire Safety Equipment Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in accordance with NFPA 101:2012 Edition, Sections 9.2.3, NFPA 17:2009 Edition, Section 4.3.1.5, 7.2.2, and NFPA 96. During an observation, it was noted that the kitchen range-hood fire suppression system had eight discharge spray nozzles, four of which were not equipped with a cap or cover device to protect against grease vapors or moisture. Additionally, the Class-K fire extinguisher's monthly inspection tag was not signed for monthly inspections. These deficiencies were confirmed by a staff member during an interview and were discussed at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. - Nozzle Caps/Covers: Missing caps/covers were installed on all four affected discharge nozzles on 1/7/25 by NJ Ex Order 26.4(b). - Class K Extinguisher Inspection: The Class K fire extinguisher was inspected on 1/7/25 by [R]. The inspection tag was signed and dated to document the inspection. - System Inspection: The entire kitchen fire suppression system was inspected by [R] on 1/7/25 to ensure proper operation and compliance with NFPA 101. 2. The maintenance director modified the facility maintenance schedule to include a requirement for quarterly inspections of the entire kitchen fire suppression system, including checking for missing nozzle caps/covers and inspecting the associated Class K fire extinguisher. 3. The maintenance director, or designee, will audit the kitchen fire suppression system quarterly to check for missing nozzle caps/covers and to confirm inspection of the Class K fire extinguisher. The results of the quarterly audit of the kitchen fire suppression system will be submitted to the administrator and to the QA committee quarterly for one year.
Failure to Conduct Annual Fire Door Inspections
Penalty
Summary
The facility failed to ensure that fire door assemblies were inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. This deficiency was identified during a documentation review and interviews conducted on December 20, 2024. The review revealed that the facility did not conduct annual inspections of fire door assemblies as required. Instead, the facility provided monthly fire door inspections, which did not include all fire doors and assemblies and did not meet the minimum requirements set by the standard. This oversight had the potential to affect all residents in the facility. The observation was confirmed during an interview with the U.S. FOIA representative, and the facility's representative was informed of the deficiency at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. Facility maintenance department completed an annual fire door assembly inspection on 1/10/25. 2. The Maintenance Director modified the facility maintenance schedule to include a fire door assembly inspection and testing to be completed annually. 3. The Maintenance Director will audit the fire door assembly inspection and testing to confirm completion and submit the report to the administrator and to the QAA committee annually.
Emergency Generator Annunciator Panel Deficiency
Penalty
Summary
The facility failed to ensure compliance with NFPA 99 standards regarding the emergency generator's remote annunciator. During an observation, it was noted that the remote annunciator panel for the emergency generator was not functioning properly at the nurse's station on the second floor. Specifically, the panel lacked a means to indicate it was receiving power and did not have a lamp test switch to verify the operation of all alarm lamps. This deficiency was confirmed through an interview with the U.S. FOIA representative present during the survey. The issue was communicated to the facility's representative during the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, NJ Ex Order 26.4(b)(1), was contacted and came to assess the generator on 1/6/25 and will repair/replace the remote annunciator panel to include a means to show that it is receiving power and a lamp test switch(es) to test the operation of all alarm lamps. This work was completed by NJ Ex Order 26.4(b)(1) on 2/11/2025. 2. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, as evidenced by a documentation review conducted on December 19, 2024. The review revealed that the generator was not tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a routine maintenance report from August 6, 2024, indicated potential issues with the fuel system, suggesting that the injection pump and injectors might need rebuilding. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. During an interview, the facility representative confirmed the findings and acknowledged that repairs had not yet been made. Furthermore, the representative admitted that there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one to facilitate repairs to the onsite generator. This deficiency had the potential to affect all residents, as it compromised the reliability of the emergency power source.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, [R] was contacted and came to assess the generator on 1/6/2025 and performed a four-hour generator load test on 2/11/2025. 2. The Maintenance Director added the required 4-hour load test every 36 months to the facility maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing and maintenance was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to document the code status for two residents, leading to a deficiency in the management of their medical instructions regarding resuscitation and other lifesaving measures. Resident #31, who was observed with a tracheostomy and dependent on a ventilator, did not have a physician's order (PO) for code status in their electronic medical record (EMR) or hard paper chart. Although a nurse identified the resident as a full code, this was not supported by a documented PO. The nurse found an admission sheet listing the resident as a full code, but acknowledged it was not a PO. Similarly, Resident #49, who was ventilator-dependent and had a history of traumatic brain injury and epilepsy, also lacked a documented PO for code status. Despite staff stating the resident was a full code, they could not provide evidence of a signed PO. The Admissions Director mentioned checking hospital EMRs for code status before admission, but this information was not translated into a formal PO. The Director of Nursing confirmed the absence of a PO for both residents and acknowledged the need for such documentation at the time of admission. The facility was unable to provide a policy related to code status.
Plan Of Correction
1. Resident #31 and Resident #49 had their [R] clarified with the resident/resident representative and physician by the Director of Nursing. A physician order was obtained and documented in the electronic medical record and a hard copy placed in the appropriate area of the paper chart on 12/18/24. An in-service education was conducted on 12/19/24 by the Director of Nursing for all nursing staff and interdisciplinary team members regarding obtaining a physician's order and the importance of accurate and readily accessible code status documentation, including the facility's process on obtaining, documenting, and verifying code status. Attendance was documented. It was determined by Root Cause Analysis that the deficient practice occurred as a result of not having a formalized process supported by policy regarding the documentation of code status. 2. All residents have the potential to be affected by the same deficient practice. A chart audit was conducted by the Director of Nursing and Unit Managers with the use of an audit tool on 12/19/24 for 100% of current residents to ensure physician's order and code status documentation was present, accurate, and readily accessible. Any issues identified were immediately corrected. 3. A policy and procedure on code status documentation will be developed by 1/15/2025 by the interdisciplinary team and the administrator to include: - Specific location within the medical record for code status documentation (e.g., first page of physician orders, designated tab). - Requirement for code status to be reviewed and updated upon admission, change in condition, and at least annually. - Process for verifying code status during emergencies. - Designated staff responsible for ensuring code status documentation is complete. - Process for obtaining physician order for resident code status. - The nurse admitting the patient will confirm the code status and will get an order from the physician. - The Code status will then be entered into the EMR. A hard copy of the code status will be filed in the designated section of the medical records and scanned into the EMR. - The Code status order will be a part of the admission orders. - During the admission review meeting, the unit manager will ensure that the accurate code status order is obtained from the physician and entered in the EMR and the hard copy of the Advance Directive and/or POLST are filed in the resident's medical record designated code status section and scanned into the EMR. - An alert Icon for the code status will be entered into the EMR as a visual cue. - During the admission, quarterly and significant change care planning meeting, the IDC team will confirm the Code status of the resident and ensure it is documented in the EMR and hard copy is scanned and properly filed into the medical record. - The Social Worker will confirm the code status of the resident when they complete their social assessment and ensure a copy of the code status is properly filed in the code status section of the resident's record. All nursing staff will be re-educated on the revised policy and procedure on Code status order and documentation by the Clinical educator or designee by 1/24/25. Education on new Policy and Procedure on Code status documentation will be integrated into the new nurse orientation program and annual education program by the Clinical Educator. 4. The Social Worker will perform a weekly audit using an audit tool of 10% of resident charts to verify code status order(s) and documentation compliance for 3 months, then monthly for 3 months. Results of the audit will be tracked and reported to the administrator, and will be presented to the Quality Assessment and Assurance Committee quarterly and to the QAPI committee monthly.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident requiring dialysis by not adjusting medication administration times to accommodate the resident's dialysis schedule. The resident, who had a history of chronic kidney disease, end-stage renal disease, and hypertension, was on a dialysis schedule of Tuesday, Thursday, and Saturday. Despite this, the facility did not ensure that the resident's medications were administered at times that would not conflict with the dialysis schedule. The resident's electronic medication administration record (EMAR) showed that medications such as Sevelamer Carbonate and Hydralazine were not administered on days when the resident was out for dialysis. The Licensed Practical Nurse (LPN) confirmed that the medications were not given because the resident was out for dialysis, and there was no documentation of the reason for the missed doses in the electronic progress notes. The facility's procedure required medication times to be adjusted for residents out for dialysis, but this was not consistently done. Interviews with the facility's staff, including the Consultant Pharmacist and the Unit Manager/Registered Nurse, revealed that there was a lack of communication and follow-through in adjusting medication times. The Licensed Nursing Home Administrator and the Director of Nursing acknowledged the oversight, and it was noted that the facility's policies did not specifically address medication timing adjustments for dialysis. This deficiency in care was identified through observation, interview, and record review by the surveyor.
Plan Of Correction
1. The medication administration records (MARS) for resident #56 were immediately reviewed by the Director of Nursing with the Administrator to ensure the medication administration times were adjusted appropriately to accommodate the NU EX Ordar 26 schedule. The attending physician of resident #56 was notified on 12/18/24 of the medication timing issues on & and the missed doses of medications: On and the doses for NJ Ex Order 26.4(b)(1) at 2:30pm was not administered. On and the doses for NJ Ex Order 26.4(b)(1) at 2pm were not administered. On and the dose for NJ Ex Order 26.4(b)(1) was not administered at 12 noon. An in-service education was conducted by the Director of Nursing for all nursing staff involved in medication administration for Resident #56 on 12/19/24. The training emphasized the importance of coordinating medication times with dialysis schedules, identifying medications affected by dialysis, and reviewing physician orders for specific instructions. Attendance was documented. A root cause analysis was conducted to identify the underlying causes of the deficient practice. It was determined from RCA that the underlying cause was lack of education/training of agency nurses on adjusting the timing of medication for individuals on dialysis to accommodate dialysis schedules. It was also identified that adjustment of timing of medication was not included in the dialysis policy. 2. All dialysis patients have the potential to be affected by the same deficient practice. No other dialysis residents were identified in the facility. 3. The facility's Dialysis Policy and Procedure was revised on 1/7/24 to include: Adjustment of medication administration times per doctors order to accommodate dialysis schedule. A process for clear communication between the dialysis unit and the facility nursing staff regarding medication administration. All nursing staff will be re-educated on the revised policy and procedure by 1/15/24. The facility orientation process of agency nurses will be revised to add the updated Dialysis policy to general orientation of agency nurses upon hire and annually. The updated Dialysis Policy will be included in the general orientation and annual education for all clinical team members. The unit manager will check the medication administration record of patients on dialysis to ensure the medication administration time is adjusted to accommodate the dialysis schedule. Pharmacy consultant to review the dialysis medication administration record to ensure proper medication times and any identified concerns with medication adjustment will be immediately communicated verbally to the administrator or Director of Nursing. During the daily clinical meeting, the medication administration record of each dialysis resident will be reviewed by the clinical team for appropriate adjustment of medications. 4. The Director of Nursing, or designee, will audit 2 agency nurse's education files monthly for one year to ensure that education on the dialysis policy was provided. The Director of Nursing, or designee, will audit the medication administration record of all dialysis patients weekly and ongoing for one year for proper medication administration time adjustment to accommodate dialysis schedule. The Director of Nursing will report the audit results to the QAA Committee quarterly and to the QAPI team monthly.
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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