Health Center At Galloway, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Galloway Township, New Jersey.
- Location
- 66 West Jimmie Leeds Road, Galloway Township, New Jersey 08205
- CMS Provider Number
- 315210
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Health Center At Galloway, The during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including recent pneumonia, thrombocytopenia risk, and renal issues, had weekly CBC/BMP labs ordered. One set of labs showed a critically low platelet count and significantly worsened renal function. The overnight LPN received the critical values and sent a text to the physician instead of establishing direct voice contact, then later texted about another resident. The physician only saw and responded to the second text and stated he never saw the message about the critical platelet count. No direct call was made, no new orders were obtained, and the critical results were not effectively communicated for approximately three days. The issue came to light when the resident’s representative questioned the labs during a care plan meeting, prompting a unit manager to call the physician, who then reviewed the results and ordered transfer to the ER. Interviews and policy review showed that facility expectations and protocols required emergent, direct phone communication and escalation for critical labs, which did not occur in this case, resulting in delayed care and treatment.
A resident with severe cognitive impairment and neurological conditions alleged abuse, prompting an investigation by facility staff. While initial steps such as reviewing logs and conducting a physical assessment were completed, required witness statements were not included in the investigation documentation provided to the surveyor, contrary to facility policy and training.
A resident admitted with intermittent oxygen use did not have a physician's order for oxygen administration, despite related orders for tubing changes and pulse oximetry monitoring. Staff interviews confirmed the lack of an order and care plan documentation for oxygen use, in violation of facility policy and professional standards.
A resident with multiple medical conditions was allowed to have a sick cat, which had undergone chemotherapy, visit and stay in their room without proper physician orders, care plan documentation, or immunization records for the animal. The cat was observed on the resident's bed with evidence of feces and urine stains, and staff interviews revealed inconsistent enforcement of the facility's pet policy and infection control procedures.
The facility did not ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. On six specific days, there was no RN coverage for the required hours. The DON acknowledged the requirement for 8-hour RN coverage daily. The facility's policy indicates efforts to fill open shifts and monitor staffing daily.
Surveyors found deficiencies in kitchen sanitation and food safety at the facility. Temperature logs for refrigeration units were incomplete, and food items lacked proper labeling. Improper storage of kitchenware and inconsistencies in food labeling policies were observed. Additionally, there were lapses in recording food temperatures during meal service, which the FSD and DM acknowledged as crucial for preventing foodborne illnesses.
The facility failed to document unusual incidents in resident progress notes, including a fracture, a verbal altercation between two residents, and an alleged verbal abuse incident. The lack of documentation violated the facility's policy requiring all services, progress, and changes in condition to be recorded in the medical record.
A facility failed to maintain resident dignity when a staff member was observed standing while feeding a resident in a wheelchair during a meal. The resident required moderate assistance with eating due to dementia and malnutrition. The facility's policy requires staff to be seated at eye level to ensure dignity, which was not followed in this instance.
The facility failed to report an injury of unknown origin and an allegation of staff-to-resident abuse to the NJDOH in a timely manner. A resident with a history of osteoporosis reported hip pain, and an x-ray revealed a fracture, but the cause was undocumented and unreported. Another resident alleged verbal abuse by a CNA, but the incident was not reported until the following day. The facility's policies lacked specific timeframes for reporting, leading to deficiencies in adherence to regulations.
The facility failed to implement comprehensive care plans for two residents, one receiving IV antibiotics through a PICC line and another with PTSD. The care plans did not address the PICC line management or the PTSD diagnosis, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives.
A facility failed to follow up on a psychiatry recommendation to discontinue an antipsychotic medication for a resident with dementia and traumatic hemorrhage. The resident's behavior was not monitored, and a care plan for the antipsychotic use was not developed. Despite a recommendation to discontinue quetiapine, there was no documentation of physician notification. Interviews with staff revealed inconsistencies in policy adherence, and facility policies emphasized the need for comprehensive care plans and monitoring.
Failure to Promptly Communicate Critical Lab Results Leading to Delayed Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s critical laboratory results were promptly and effectively communicated to the attending physician, resulting in a three‑day delay in physician notification and subsequent transfer to the hospital. The resident had multiple significant diagnoses, including acute respiratory failure, heart failure, COPD, type 2 diabetes, and a history of low platelet counts, and had recently completed antibiotics for pneumonia. The resident’s care plan identified risk for bleeding and bruising related to Plavix use, with an intervention to obtain labs as ordered and report abnormal results to the physician as soon as possible. Weekly CBC and BMP labs were ordered, and on 12/8 the resident’s platelets were already low at 59 K/CU.MM, with the physician’s subsequent progress notes referencing trending labs. On 12/15, a CBC and BMP were collected and later reported with critical abnormalities, including a platelet count of 20 K/CU.MM, elevated creatinine of 1.99 mg/dl, sodium of 130 mmol/L, and an eGFR of 27. A nursing progress note dated 12/16 documented that the lab called with critically low platelets (20) and that the physician was notified with no new orders, but the physician later stated he was not called about these labs at that time. Instead, the overnight LPN sent a text message to the physician around 1:28 AM reporting the critical platelet count and asking for orders, and then sent a second text at 5:26 AM about another resident’s dark red urine. The physician responded at 6:23 AM with two brief texts, “Noted” and “Hold Eliquis,” which he and the facility later clarified were in response to the second resident’s issue; he stated he never saw the earlier text about the critical platelet count, and no direct voice communication occurred regarding the critical labs. Over the next two days, there was no documented direct physician notification or follow‑up regarding the critical platelet count and worsening renal function, and no new orders were obtained based on those results. The overnight LPN reported that she assumed the physician’s text responses applied to both residents and endorsed to day shift that the critical labs had been communicated and that there were no new orders, expecting the physician to see the resident. The physician later confirmed that he only became aware of the critical labs when a unit manager called him on 12/18 after the resident’s responsible party questioned the lab results and lack of physician contact during a care plan meeting. Upon reviewing the labs at that time, the physician instructed that the resident be sent to the ER for evaluation due to the drop in platelet count and abnormal blood counts. The resident was transferred with the stated reason of a drop in platelet count and was subsequently admitted to the hospital with septic shock and pneumonia. Facility leadership, the physician, the medical director, and multiple nurses acknowledged that critical labs were expected to be communicated emergently by direct phone call, not solely by text, and that in this case there was a delay in care and treatment due to the failure to promptly and effectively notify the physician of the critical results. Interviews with the physician, medical director, DON, ADON/IP, and nursing staff further established that facility policy and expectations required direct voice communication for critical results, with escalation to the medical director if the attending physician did not respond within a specified time. The physician stated that critical labs must be called in emergently and that, had he been made aware immediately, he would at least have considered additional lab surveillance, escalation of care, or hospital evaluation. After later reviewing the chart, he noted that the substantial decline in renal function, which was not included in the initial text, would also have prompted emergency intervention. The medical director reported that he had previously educated staff that critical results, including labs, radiology, and ultrasounds, must be communicated by phone rather than text because texts are short and can create confusion. The facility’s own policies on lab/diagnostic results and acute condition changes required prompt physician notification, direct voice communication for urgent results, and contacting the medical director if the attending physician did not respond, but these standards were not followed in the handling of this resident’s critical laboratory findings. The resident’s responsible party reported learning during a care plan meeting that lab results had been available for three days without a physician call, and the physician confirmed he had not been notified until contacted by the unit manager on the day of transfer. The LNHA later stated he could not locate a formal investigation specific to the critical lab delay, while the ADON/IP stated she had reviewed the medical record and text messages as part of a review of acute discharges and acknowledged a delay in care. The DON also acknowledged a delay in treatment. Overall, the sequence of events shows that the facility did not ensure that critical lab results obtained on 12/15 were immediately and effectively conveyed to the physician, contrary to professional standards of practice, facility policy, and the resident’s care plan interventions, resulting in a three‑day delay in physician notification and transfer for evaluation and treatment.
Failure to Document Complete Abuse Investigation
Penalty
Summary
The facility failed to maintain an accurately documented and complete investigation in accordance with accepted professional standards following an allegation of abuse made by a resident. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 5, and multiple neurological diagnoses including cerebral infarction, hemiplegia, and hemiparesis. The resident alleged that someone had raped them, describing the perpetrator as a short black male wearing tan, seen outside the window of their second-floor room. The facility's initial investigation included a review of the visitor log and staff schedule, which did not match the description, and a physical assessment of the resident. However, the investigation documentation submitted to the surveyor did not include any witness statements at the time of review. Interviews with facility leadership confirmed that obtaining witness statements is a required part of the abuse investigation process, as outlined in facility policy and training materials. Despite this, no witness statements were provided to the surveyor during the initial documentation request. The Assistant LNHA acknowledged that witness statements are essential and indicated they would continue searching for them. The surveyor did not receive any additional documentation, including witness statements, before exiting the facility. The absence of these statements constituted a failure to follow established investigative procedures for abuse allegations.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident who was admitted with intermittent oxygen use. Review of the resident's medical record showed that while there were orders for changing oxygen tubing, conducting a 6-minute rest/walk test on room air, and monitoring pulse oximetry every shift, there was no physician's order for the actual administration of oxygen. Additionally, the resident's care plan did not reflect that the resident was receiving oxygen. Interviews with facility staff, including the social worker, LPN, unit manager, DON, and ADON, confirmed that the resident used oxygen intermittently and that there was no corresponding physician's order or care plan entry for oxygen administration during the period it was used. Facility policy requires verification of a physician's order prior to oxygen administration and review of the care plan for any special needs related to oxygen use. Staff interviews further revealed that the expectation was to ensure a physician's order was in place for any resident receiving oxygen and to update or discontinue the order as appropriate. The absence of a physician's order and care plan documentation for oxygen use was acknowledged by the DON and ADON, confirming the deficiency in following professional standards and facility policy.
Failure to Follow Infection Control Guidelines for Resident's Visiting Sick Cat
Penalty
Summary
The facility failed to follow infection control guidelines regarding a resident who had a sick cat visiting and staying in their room. The resident, who was cognitively intact and had multiple medical diagnoses including spondylosis, dysphagia, sepsis, and muscle weakness, did not have a physician order or care plan entry for pet therapy or pet presence at bedside. Documentation showed that the cat, which had undergone chemotherapy, was present on the resident's bed and had left feces and urine stains. The facility's policy required that animals be monitored to prevent the spread of infection and that personal pet visits be approved by the resident's physician and primary care nurse, but these steps were not followed. No immunization records for the cat were available, and the cat's presence and condition were not properly managed according to policy. Interviews with staff revealed inconsistent knowledge and enforcement of the pet policy. The administrator acknowledged that the cat was allowed to stay with the resident under certain conditions, such as being kept in a crate and not having a litter box in the room, but these conditions were not consistently enforced. Staff were not able to provide required documentation for the cat, and there was evidence of noncompliance with infection control protocols, including the presence of animal waste in the resident's room. The facility's infection prevention and control program policies were not adhered to in this instance.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the Nurse Staffing Reports for specific weeks, revealing that there was no RN coverage for 8 consecutive hours on six specific days. The days without adequate RN coverage were 11/05/2023, 11/08/2023, 11/11/2023, 12/31/2023, 01/01/2024, and 01/06/2024. During an interview, the Director of Nursing (DON) confirmed that the facility should have an RN on duty for a minimum of 8 hours per day. The facility's policy, revised in October 2017, states that efforts are made to fill open shifts and call-outs using incentive programs and agency staffing, and that staffing is monitored daily.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food safety standards, as observed by surveyors. Temperature logs for the walk-in refrigerator and freezer were incomplete, with no recorded temperatures on specific dates. Additionally, frozen hamburger patties and nutritional supplements were found without proper labeling or dates, and dessert plates and kitchenware were improperly stored, exposing them to potential contamination. The Food Service Director (FSD) acknowledged these issues, attributing the lack of temperature recordings to an aide's absence. Further observations in the resident pantries revealed inadequate monitoring of freezer temperatures and inconsistencies in food labeling and storage policies. The 3rd Floor pantry had a refrigerator with an unidentified substance and improperly labeled resident food items. The facility's policy on food brought by family members was inconsistent with posted signage, leading to confusion about the appropriate use-by dates. The District Manager (DM) admitted the need for a consistent policy and acknowledged the lack of freezer temperature monitoring. The surveyors also found significant lapses in recording food temperatures during meal service, with multiple instances of missing temperature logs for hot and cold foods. The FSD and DM recognized the importance of monitoring food temperatures to prevent foodborne illnesses. Facility policies outlined procedures for food preparation, storage, and labeling, but these were not consistently followed, leading to the observed deficiencies.
Failure to Document Unusual Incidents in Resident Progress Notes
Penalty
Summary
The facility nursing staff failed to document unusual incidents in the progress notes for several residents, leading to a deficiency in meeting professional standards of quality. For Resident #13, there was no documentation in the Electronic Medical Record (EMR) regarding a fracture found on an x-ray, despite a physician order for a bilateral hip x-ray and an orthopedic evaluation. The Director of Nursing (DON) was unaware of how the fracture occurred and acknowledged that it should have been reported to the New Jersey Department of Health (NJDOH). The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented, which was not adhered to in this case. In another incident, a Facility Reported Event (FRE) involving a verbal altercation between two residents, Resident #5 and Resident #48, was not documented in the progress notes. The nurse, LPN #3, was unaware of the altercation and described the facility's process for reporting such incidents, which includes separating the residents, notifying management, and entering a risk management report in the medical record. However, the progress notes for both residents did not reflect any documentation of the incident, despite the facility's policy requiring documentation of events, incidents, or accidents involving residents. Additionally, an alleged verbal abuse incident involving Resident #257 and a Certified Nursing Aide (CNA #1) was not documented in the progress notes. The resident alleged that the CNA spoke to them in an aggressive manner, but there was no documentation of the incident in the EMR. The Certified Social Worker (CSW) confirmed that such encounters should be documented in the social service progress notes, but this was not done. The DON acknowledged that a summary of the alleged incident should have been documented in the resident's progress notes, as per the facility's policy.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain resident dignity during meal assistance on one of its nursing units. A staff member was observed standing while feeding a resident, who was seated in a wheelchair, during a lunch meal. The staff member, identified as an LPN, did not attempt to sit at eye level with the resident, which is contrary to the facility's policy. The resident, who required partial/moderate assistance with eating due to conditions including dementia and moderate calorie-protein malnutrition, was fed from a standing position throughout the meal. During an interview with the facility administration, including the DON and LNHA, it was confirmed that the facility's practice is for staff to be seated at eye level when assisting residents with meals, as it is considered a dignity issue. The facility's policy on meal assistance, revised in March 2022, explicitly states that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, specifically noting that staff should not stand over residents while assisting them with meals.
Failure to Timely Report Injury and Abuse Allegations
Penalty
Summary
The facility failed to report an injury of unknown origin and an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) in a timely manner for two residents. Resident #13, who had a history of HIV, chronic pain syndrome, and osteoporosis, reported hip pain but denied any falls. An x-ray revealed a fracture of the right distal femur, but there was no documentation explaining the cause of the injury. The Director of Nursing (DON) acknowledged the injury as of unknown origin and admitted it should have been reported to the NJDOH. The Licensed Nursing Home Administrator (LNHA) confirmed that the report was made only after the surveyor's inquiry, indicating a communication failure among the staff. In another incident, Resident #257 alleged verbal abuse by a Certified Nursing Assistant (CNA #1) during the night shift. The resident claimed that the CNA spoke aggressively after being asked to lower their voice. The incident was not reported to the DON until the following morning, resulting in a delay in addressing the alleged abuse. The facility's policy requires immediate reporting of such incidents, but the delay was attributed to a presumed lapse in communication. The facility's policies on reporting abuse, neglect, and injuries of unknown origin were reviewed, revealing that they lacked specific timeframes for reporting. The policies stated that any suspicion of abuse or injury must be reported immediately to the administrator and relevant authorities. However, the incidents involving Resident #13 and Resident #257 were not reported within the required timeframes, highlighting deficiencies in the facility's adherence to its own policies and state regulations.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical and nursing needs. Resident #86, who was receiving an intravenous antibiotic through a PICC line for an infection, did not have a care plan that included the management of the PICC line and the antibiotic treatment. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have included these elements. The absence of a care plan for the PICC line and antibiotic administration was identified during a review of the resident's records and physician orders. Similarly, Resident #99, who was admitted with a diagnosis of PTSD, depression, and anxiety disorder, did not have a care plan addressing PTSD. Despite being medicated for PTSD and exhibiting anxiety during an interview, the care plan failed to reflect this diagnosis. The Licensed Nursing Home Administrator and Director of Nursing agreed that PTSD should have been care planned. The LPN responsible for developing care plans admitted to not having experience with PTSD and acknowledged the oversight. The facility's policy on comprehensive person-centered care plans emphasizes the inclusion of measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Discontinue Antipsychotic Medication and Monitor Resident
Penalty
Summary
The facility failed to follow up on a psychiatry recommendation to discontinue an antipsychotic medication for a resident, failed to monitor the resident's behavior for the use of the antipsychotic, and failed to develop a care plan for the use of the antipsychotic. This deficiency was identified for a resident who was admitted with diagnoses including traumatic hemorrhage of the cerebrum and unspecified dementia without behavioral disturbance. The resident was observed multiple times without exhibiting any behaviors that would necessitate the use of an antipsychotic medication. The resident's Electronic Medical Record (EMR) revealed a physician order for quetiapine fumarate, an antipsychotic medication, to be given at bedtime for altered mental status. However, the Medication Administration Record (MAR) for several months did not include monitoring for behaviors or the use of quetiapine. A psychiatric progress note recommended discontinuing the medication, but there was no documentation that the physician was notified of this recommendation. Additionally, the resident's care plan did not include care and monitoring for the use of quetiapine. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the facility's policy regarding follow-up on consultant recommendations and monitoring of psychotropic medications. The LPN was not familiar with care plans, and the DON confirmed that there should be behavior monitoring documented in the EMAR and a care plan for residents on quetiapine. Facility policies reviewed by the surveyor indicated that non-immediate notification situations should be communicated to the physician at the next routine communication, and comprehensive, person-centered care plans should be developed and implemented for each resident.
Latest citations in New Jersey
A resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
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