Preakness Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 305 Oldham Road, Wayne, New Jersey 07470
- CMS Provider Number
- 315361
- Inspections on file
- 21
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Preakness Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, including muscle weakness and rheumatoid arthritis, had physician orders and CNA documentation requiring a 2-person assist at all times and mechanical lift transfers with 2-person assistance. Assignment sheets and caregiver forms reflected these requirements, and staff acknowledged awareness that the resident was total care and needed two-person assistance for care and transfers. Despite this, a CNA provided care alone, with another CNA only assisting during the mechanical lift transfer. Following this care, the resident was found with a skin tear and finger laceration on the right hand and was later treated in the ER, returning with stitches and a splinted hand for a laceration and finger fracture.
The facility failed to maintain proper kitchen sanitation practices, including improper storage of dented cans and unlabeled opened items, inadequate cleaning of cooking equipment, and improper storage of boxes. Staff violated dress code by wearing large earrings, and a Chef failed to sanitize a thermometer before use. These actions were contrary to the facility's policies, leading to noted deficiencies.
The facility failed to conduct reference checks for 10 newly hired staff members, including RAs, LPNs, and a Registered Dietician, among others. The HR department did not follow the facility's policy requiring at least one employment reference, as confirmed by the Executive Director and HR Secretary.
The facility failed to transmit MDS assessments for 17 residents within the federally mandated 14-day period. Despite attempts to submit weekly, the assessments were delayed by over 120 days. The MDS Coordinator acknowledged the issue, and the facility's policy did not address MDS data transmission.
The facility was found to have a medication administration error rate of 8%, exceeding the acceptable threshold of 5%. An LPN incorrectly crushed Divalproex capsules for a resident with dementia, misunderstanding the MAR instructions. Additionally, an RN prepared the wrong medication for a resident with constipation, realizing the error before administration. These errors were discussed with the LNHA and DON.
A resident with severe cognitive impairment and a preference for Spanish communication was not provided with a communication board or Spanish TV channels, as required by their plan of care. Staff, including an LPN and CNA, were unable to communicate effectively with the resident, highlighting a failure to adhere to the facility's communication protocols.
The facility failed to follow physician's orders for two residents regarding heel booties and for another resident regarding weekly vital signs monitoring. A resident with Parkinson's and a femur fracture was observed without heel booties, despite orders for them to be worn at all times. Another resident with hypertension had no documented weekly vital signs, contrary to physician's orders. Additionally, a resident with severe cognitive impairment was found without heel booties, as required by their physician's order.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease who refused dialysis, medication, and meals. Despite the resident's intact cognition and expressed preferences, the care plan did not address these refusals. Nursing staff confirmed the non-compliance and lack of documentation, violating the facility's policy requiring updates to the care plan.
A resident's urinary catheter drainage bag was improperly stored, hanging from the bed's side rail and not in a privacy bag, with tubing above the bed. The resident had a history of paraplegia and neuromuscular dysfunction of the bladder. The RN noted the improper placement and attributed it to the night shift CNA. The facility's policy requires the bag to be below the bladder level, which was not followed.
A facility failed to maintain proper infection control during tracheostomy care for a resident in a persistent vegetative state. The RT did not adhere to hand hygiene protocols, using the same gauze for both sides of the neck and failing to change gloves between tasks. Interviews confirmed the RT's non-compliance with established procedures, compromising infection control and patient safety.
A facility failed to provide appropriate dialysis care for a resident, as the Hemodialysis Communication Record (HCR) was not signed by a nurse for 14 days, and vital signs and dialysis site assessments were not documented. A medication change recommendation was not followed, and the resident's Physician Order Form lacked a diet order. Staff acknowledged these deficiencies, which were contrary to the facility's policy.
Due to staff shortages, a resident did not receive a scheduled shower, and two residents experienced delays in morning care, affecting their daily activities. Staffing reports showed high CNA-to-resident ratios, and missing documentation indicated lapses in care. Interviews with staff confirmed the impact of insufficient staffing on care delivery.
The facility failed to accurately document the receipt of Schedule II controlled substances, as required by DEA 222 Forms. The forms were incomplete, lacking the number received and date received, despite supplier packing slips indicating delivery. The Consultant Pharmacist and DON acknowledged the oversight, which was contrary to the facility's policy and procedure manual.
A resident was prescribed two medications for nausea or vomiting, which had not been used in over 60 days. The facility's Consultant Pharmacist recommended discontinuation, but the physician disagreed without explanation. The lack of specific instructions for these medications could lead to treatment delays if unfamiliar staff were on duty. The facility's policy on medication sequencing was not followed.
A survey revealed deficiencies in medication labeling and storage at a facility. An RN and an LPN acknowledged that opened vials of Novolog insulin and blood glucose test strips were not dated as required. Another LPN found an undated Arformoterol inhalation solution and loose, unidentifiable tablets in a medication cart. The facility's policies on medication storage were not adhered to, leading to these deficiencies.
The facility did not maintain and post the most recent Federal and State inspection results in an accessible area. Instead, outdated results from 2021 were observed at the reception desk. The DON confirmed the 2023 results should have been available and acknowledged the absence of a policy for posting survey results.
Two residents receiving psychoactive medications for behavioral symptoms, such as hallucinations and anxiety, did not have care plans addressing these behaviors, despite ongoing psychiatric assessments and documented episodes. Facility leadership confirmed the absence of care plan focus on these issues, contrary to facility policy requiring behavioral care planning for residents on such medications.
A facility failed to follow its Medical Emergency Response policy for a resident with respiratory distress, leading to a delay in emergency care. The resident, with a history of COPD and heart failure, was found lethargic and using accessory muscles for breathing. Despite these symptoms, the facility used a non-emergency transport service instead of calling 911, delaying the resident's transfer to the hospital. Staff interviews revealed confusion about when to use emergency versus non-emergency transport services.
Failure to Provide Required Two-Person Assistance Resulting in Resident Hand Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for all care and transfers was provided that level of assistance, resulting in injury. The resident had multiple diagnoses including rheumatoid arthritis, fibromyalgia, muscle weakness, neurocognitive disorder, and hypertension, and an MDS BIMS score of 99 indicating severe cognitive impairment. Physician orders in the record specified “2 Person Assist at all Times for Safety” and “Mechanical Lift Transfers with 2 Person Assist for Safety using a Large Sling Pad.” These requirements were reflected on the CNA Direct Caregiver Form and on the CNA assignment sheet, which coded the resident as needing a mechanical lift with large sling and assistance of two staff. On the date of the incident, CNA assignment records for the 7:00 AM–3:00 PM shift listed the resident under a specific CNA’s assignment with codes indicating mechanical lift and assist of two. The CNA Direct Caregiver Form also documented the two-person assist requirement and included an FYI notation, but the box for that shift was not initialed. Interviews with the regular unit LPN and the resident’s regular CNA confirmed that the resident was total care, required two-person assistance for care and mechanical lift transfers, and that this information was communicated through the assignment sheets and caregiver forms. Staff also reported receiving regular education on care and transfers, including mechanical lifts. Despite these documented requirements and staff awareness, the investigation found that CNA #1 provided care to the resident alone, with CNA #2 only assisting with the mechanical lift transfer. CNA #1 acknowledged knowing that the resident required two-person assistance for care but proceeded to provide care independently. Subsequently, CNA #1 reported to the nurse that the resident had a skin tear on the right hand. Assessment by the RN identified a 2 cm x 0.5 cm skin tear on the right hand and a 1.4 cm x 0.5 cm laceration on the right pinky finger. The resident was later evaluated in the ER and returned with four stitches and a splinted hand, with documentation of a laceration and a fracture of indeterminate age to the fourth finger, establishing that the facility did not ensure the resident’s environment and supervision were free from accident hazards as required.
Kitchen Sanitation and Policy Compliance Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, as observed during a survey. In the dry storage room, a dented can of sliced potatoes was found among non-dented goods, and several opened items lacked open/use by labels. Additionally, boxes were stored above the 18-inch ceiling clearance in multiple storage areas, and the cooking equipment had a sticky brown substance on it, indicating inadequate cleaning. The Dietary Supervisor and Registered Dietitian were unable to provide explanations for these issues. Further observations revealed that staff members, including the Dietary Supervisor and Chef, wore large hooped earrings, which violated the kitchen dress code. The Chef also failed to sanitize a thermometer before use, acknowledging that it should have been sanitized after being set down. The facility's policies, which were reviewed, outlined proper procedures for handling dented cans, labeling opened items, storing food, cleaning equipment, and maintaining dress code and thermometer sanitization, but these were not followed, leading to the deficiencies noted.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for 10 out of 10 newly hired staff members prior to their employment start dates. This deficiency was identified through a review of 10 randomly selected new employee files, which revealed that none of the files contained documentation of reference checks. The staff members included a Recreation Activity Aide, Licensed Practical Nurses, a Registered Dietician, an Occupational Therapist, a Maintenance staff, a Food Service Worker, a Registered Nurse, and a Physical Therapist, all hired between October 2023 and December 2024. During interviews, the Executive Director, Director of Nursing, and Assistant Director of Nursing acknowledged the absence of reference checks, attributing the oversight to the Human Resources department, which is located off-campus. The HR Secretary confirmed that reference checks were not conducted, as the responsibility had temporarily shifted within the department. The facility's policy, as outlined in their Abuse Policy, requires at least one employment reference to be obtained for prospective employees, which was not adhered to in these cases.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments in accordance with federal guidelines for 17 residents. The MDS is a federally mandated tool for clinical assessment of residents, which must be transmitted to the Quality Measure System within 14 days of completion. However, the facility did not transmit the MDS for these residents within the required timeframe, with delays extending over 120 days. The MDS Coordinator, a Registered Nurse, acknowledged the late submissions and stated that attempts were made to submit the assessments weekly, but they were still not transmitted on time. The surveyor reviewed the MDS assessments for the 17 residents and found that all were completed but not transmitted until nearly a month later. The facility's MDS 3.0 Policy, reviewed in June 2023, did not address the transmission of MDS data, contributing to the deficiency. The survey team discussed the issue with the Licensed Nursing Home Administrator, Director of Nursing, and Assistant DON, but no further information was provided to address the concern.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication administration error rate of 8%, exceeding the acceptable threshold of 5%. This deficiency was observed during a medication pass involving four nurses and five residents, with two errors noted. One error involved a Licensed Practical Nurse (LPN) administering Divalproex to a resident with dementia and behavior disturbance. The LPN incorrectly crushed the contents of the Divalproex capsules, despite the medication administration record (MAR) cautioning against crushing or chewing the contents. The LPN misunderstood the instructions, believing it was acceptable to crush the contents once removed from the capsule. Another error involved a Registered Nurse (RN) preparing medication for a resident with constipation. The RN incorrectly prepared Senna 8.6 mg instead of the prescribed Senna-Plus 8.6-50 mg. The RN realized the mistake after comparing the medication bottles with the MAR, acknowledging the error before administering the medication. These errors were discussed with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), but no further pertinent information was provided by the facility.
Failure to Ensure Communication in Resident's Preferred Language
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring communication in the resident's preferred language, Spanish, as outlined in the plan of care. This deficiency was observed when a surveyor noted that the resident, who spoke Spanish, did not have a communication board in their room, and the television was set to an English channel. During an interaction, both the LPN and CNA were unable to communicate effectively with the resident in Spanish, which hindered the resident's ability to comply with repositioning requests and change the TV channel to Spanish. The LPN acknowledged the absence of a communication board and the need for assistance from the Maintenance department to adjust the TV settings. Further investigation revealed that the resident's medical records indicated a preference for Spanish communication and a need for an interpreter, as documented in the Minimum Data Set and the plan of care. The resident had severe cognitive impairment and was admitted with diagnoses including type 2 diabetes mellitus and essential hypertension. Despite the facility's policy to protect residents' rights to dignified existence and communication, the Registered Nurse Supervisor also struggled to communicate with the resident and was unaware of the Spanish channel settings. The Director of Nursing confirmed the requirement for a communication board, highlighting a lapse in adhering to the facility's communication protocols.
Failure to Follow Physician's Orders for Heel Booties and Vital Signs Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by not following physician's orders for two residents regarding the use of heel booties. Resident #72, who was admitted with conditions including Parkinson's disease and a femur fracture, was observed without the prescribed heel float booties, despite a physician's order for them to be worn at all times. The Treatment Administration Record indicated that the booties were documented as being worn, which was contradicted by the surveyor's observation and the Licensed Practical Nurse's acknowledgment. Additionally, the facility did not comply with a physician's order to document weekly vital signs for Resident #88, who had diagnoses such as hypertension and a history of transient ischemic attack. The Medication Administration Record for December 2024 and January 2025 lacked entries for the weekly monitoring of vital signs, and there was no indication of the scheduled day or frequency. Interviews with nursing staff revealed a lack of clarity and documentation regarding the order, which was not addressed until the surveyor's inquiry. Furthermore, Resident #158, who had severe cognitive impairment and was admitted with type 2 diabetes and hypertension, was also found without the required heel booties. The surveyor's observation and subsequent interviews with nursing staff confirmed the absence of the booties, which were supposed to be in use according to the physician's order. The facility's policies did not adequately address the adherence to physician's orders, contributing to these deficiencies.
Failure to Implement Comprehensive Care Plan for Resident Refusal
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not developing and implementing a comprehensive person-centered care plan that included the resident's refusal of care. This deficiency was identified for a resident with end-stage renal disease who was non-compliant with dialysis, medication, and dietary preferences. The resident, who was alert and oriented with intact cognition, expressed a preference for ordering food from outside the facility and refused to attend scheduled dialysis sessions multiple times. The medical records review revealed that the resident had refused dialysis four times and meals five times, and there was no care plan addressing these refusals and non-compliance. Interviews with nursing staff confirmed the resident's non-compliance and the lack of documentation in the care plan. The facility's policy required changes in the resident's status to be reflected in the interdisciplinary care plan, but this was not done, leading to the identified deficiency.
Improper Storage of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper storage of a urinary catheter drainage bag for a resident, which could lead to an increased risk of urinary tract infections. During an observation, the surveyor noted that the resident's urinary catheter drainage bag was improperly hung from the bed's side rail in an elevated position and not placed in a privacy bag. The tubing leading to the drainage bag was also positioned above the bed, contrary to best practices for catheter care. The resident involved had a history of paraplegia, neuromuscular dysfunction of the bladder, and hyperlipidemia, and was admitted with an indwelling catheter. The RN acknowledged the improper placement of the drainage bag and attributed it to the night shift CNA's actions. The facility's policy on indwelling catheters, last reviewed in 2019, specifies that the catheter should be secured to facilitate urine flow and that the bag should be below the level of the bladder, which was not adhered to in this instance.
Inadequate Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to maintain proper infection control practices during tracheostomy care for a resident. The resident, who was in a persistent vegetative state and dependent on all activities of daily living, had a tracheostomy and was attached to a ventilation system. The respiratory therapist (RT) responsible for the resident's care did not adhere to proper hand hygiene and infection control protocols during the tracheostomy care process. The RT was observed performing tracheostomy care without using a paper towel to turn off the water after washing hands, and did not change gloves between different stages of the procedure, such as after cleansing the overbed table with disinfectant wipes and before handling sterile equipment. Additionally, the RT used the same piece of gauze to clean both sides of the resident's neck and tracheostomy area, which is against standard infection control practices. These actions were contrary to the facility's hand hygiene policy and the RT Practice Resource Guide. Interviews with the RT, Vent Program Manager, and Registered Nurse Infection Preventionist revealed acknowledgment of the improper practices and a lack of adherence to established protocols. The RT admitted to not using a paper towel to shut off the water and not changing gloves as required. The Vent Program Manager and RN/IP confirmed that the RT did not perform tracheostomy care correctly, which was essential for infection control and patient safety.
Deficiencies in Dialysis Care Documentation and Medication Management
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, as evidenced by several deficiencies in the documentation and follow-up of dialysis treatment. The Hemodialysis Communication Record (HCR) was not signed by a facility nurse to acknowledge review for 14 consecutive days. Additionally, there was no section on the HCR for documenting vital signs and the condition of the dialysis access site post-treatment, which was not recorded in the medical record for several days. The facility also did not follow a recommendation for a medication change from Epogen to Mircera, as noted in the HCRs. Despite the recommendation, the Physician Order Form and Medication Administration Record continued to reflect an order for Epogen, and there was no evidence of the new medication being administered. Furthermore, the resident's Physician Order Form lacked a diet order, which was confirmed by the Registered Dietician. The Registered Nurse Supervisor and other staff members acknowledged the deficiencies during interviews with the surveyor. The facility's policy required nurses to review the HCR, document vital signs, and assess the dialysis site post-treatment, but these procedures were not consistently followed, leading to the identified deficiencies.
Staff Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. Specifically, one resident did not receive a scheduled shower due to staff shortages, as reported by the resident during a group meeting with the surveyor. The resident also experienced delays in morning care, which affected their ability to attend a Christmas lunch meal on time. Another resident reported that morning care was delayed over a weekend due to insufficient CNA staffing on their floor. The facility's records corroborated these claims, showing missing signatures on the Weekly Body Inspection forms for certain weeks, indicating a lack of documentation for provided or refused showers. The surveyor's review of staffing reports revealed that the CNA-to-resident ratios on specific dates were higher than optimal, contributing to the care delays. Interviews with facility staff, including a CNA and the Director of Nursing, confirmed that the staffing shortages impacted the ability to provide timely showers and morning care. The facility's policy required weekly showers and skin assessments, but the lack of documentation and staff availability led to deficiencies in meeting these care standards.
Incomplete Documentation of Controlled Substance Receipts
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the accurate documentation of the receipt of controlled substances. This deficiency was identified during a review of DEA 222 Forms, which are used to order controlled substances. The forms for four Schedule II controlled substance medications ordered and received by the facility were incomplete, as the section requiring the purchaser to record the number received and the date received was not filled in. This issue was noted on three separate DEA 222 Forms, despite the presence of supplier packing slips indicating delivery. During interviews, the Consultant Pharmacist acknowledged the oversight, stating that the facility must have missed completing those sections, although they were aware of the correct procedure. The Director of Nursing also acknowledged the incomplete forms and agreed that they should have been completed upon receipt of the items. The facility's policy and procedure manual, revised in February 2023, outlines the requirement for completing DEA 222 Forms in accordance with state and federal regulations, yet this was not adhered to in practice.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving two medications prescribed for nausea or vomiting. The resident, who was cognitively intact, had been prescribed Ondansetron and Tigan, both as needed for nausea or vomiting. The facility's Consultant Pharmacist had recommended discontinuing these medications as they had not been used in over 60 days, but the physician disagreed without providing a reason. Additionally, the Consultant Pharmacist had previously requested clarification on the administration sequence of these medications, but no response was recorded from the physician. The deficiency was further highlighted during an interview with a Registered Nurse, who admitted that if unfamiliar staff were on duty, they would need to call the physician for clarification, potentially delaying treatment. The facility's policy required specific instructions for medications with the same indication, which was not followed in this case. The issue was discussed with the facility's administration, and the Ondansetron order was eventually discontinued after the surveyor's inquiry.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility was found to have deficiencies in the labeling, disposal, and storage of medications during a survey. On one occasion, a surveyor observed an opened and undated vial of Novolog insulin and a bottle of blood glucose test strips in a medication cart, which were not labeled with the date they were opened. The Registered Nurse present acknowledged that these items should have been dated upon opening. Similarly, another medication cart was found to contain an opened and undated bottle of blood glucose test strips, which the Licensed Practical Nurse confirmed should have been dated. The manufacturer's specifications indicated that these items have specific expiration periods once opened, which were not adhered to. In another instance, a surveyor inspecting a medication cart found a box of Arformoterol inhalation solution without a date indicating when it was opened. The Licensed Practical Nurse confirmed that nebulizer solutions are typically dated, and without a date, it was unclear how long the medication had been stored. Additionally, the surveyor discovered loose tablets and capsules in the cart's drawer, which the nurse could not identify and acknowledged should not be stored in such a manner. These loose medications were subsequently disposed of in the drug disposal device. The facility's policies on medication storage, which require medications to be stored in an orderly and organized manner, were not followed. The policies also stipulate that medications should be stored in their original labeled containers and at appropriate temperatures as per pharmacy or manufacturer guidelines. Despite these policies, the facility failed to ensure proper labeling and storage of medications, as evidenced by the surveyor's findings.
Failure to Post Current Survey Results
Penalty
Summary
The facility failed to maintain and post the most recent Federal and State inspection results in an area that was readily accessible to residents, families, and the public. On January 16, 2025, a surveyor observed that the survey results available at the reception desk were from August 12, 2021, instead of the most recent results from 2023. The Security Staff confirmed the outdated survey results, and the Director of Nursing (DON) acknowledged that the 2023 survey results should have been available. The DON was unaware of why the outdated results were posted and later confirmed that the facility had no policy regarding the posting of survey results, although they followed the regulation to post the most recent results. Despite discussions with the survey team, no additional information was provided by the facility.
Failure to Develop and Implement Behavioral Care Plans for Residents on Psychoactive Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing behavioral issues for residents prescribed psychoactive medications. For one resident with multiple chronic conditions, including dementia with hallucinations and delusions, documentation showed ongoing administration of antipsychotic medication (Olanzapine) for target behaviors such as hallucinations and paranoia. Despite psychiatric assessments and behavioral monitoring indicating the presence of these behaviors, the resident's care plan did not include a focus area, goals, or interventions related to these target behaviors. Another resident, diagnosed with end stage renal disease and anxiety related to hemodialysis, was prescribed an antianxiety medication (Alprazolam) to be administered before dialysis sessions. Progress notes documented episodes of anxiety, including screaming, crying, and expressions of distress, which were managed by staff through redirection and monitoring. However, the care plan for this resident did not address the behavioral issues or include interventions for managing anxiety during dialysis, as identified in psychiatric evaluations and nursing notes. Interviews with facility leadership confirmed that while psychotropic medication monitoring and psychiatric follow-up occurred, there was no corresponding care plan focus on the residents' behavioral issues. Review of facility policy indicated that care plans should be initiated and updated for residents receiving psychoactive medications, but this was not done for the residents in question, resulting in a deficiency under the cited regulation.
Failure to Follow Medical Emergency Response Policy for Resident in Respiratory Distress
Penalty
Summary
The facility failed to follow its Medical Emergency Response policy for a resident in respiratory distress, leading to a deficiency. Resident #2, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory issues, and heart failure, was found lethargic and using accessory muscles for breathing. Despite these symptoms, the facility did not call 911 immediately but instead waited for a non-emergency transport service, which delayed the resident's transfer to the hospital. The resident's condition was assessed by the RN/ANS, who determined that the resident was stable and did not require immediate emergency transport. The resident was placed back on a BiPAP machine, and the nurse called the doctor, who ordered the resident to be sent to the emergency room for evaluation of acute respiratory distress. However, the facility used a non-emergency transport service, which took over an hour to arrive, during which time the resident's condition did not improve. Interviews with staff revealed confusion about when to use emergency versus non-emergency transport services. The RN/ANS and other staff members believed the resident was stable and did not require 911, despite the resident's altered mental status and respiratory distress. The facility lacked a clear policy for determining the appropriate type of transport based on residents' symptoms, contributing to the delay in emergency care for Resident #2.
Removal Plan
- Educating all staff on the Non-Emergent Medical Transportation Policy
- Educating all staff on the revised Emergency Medical Response Policy
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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