Shore Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toms River, New Jersey.
- Location
- 231 Warner Street, Toms River, New Jersey 08755
- CMS Provider Number
- 315454
- Inspections on file
- 16
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shore Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and communication deficits experienced an unwitnessed fall and complained of left leg pain while found on the floor partially supported by a chair. An LPN documented no visible injury, noted repeated refusals of pain medication, assisted the resident to bed, and did not return to reassess, later stating they needed to complete a med pass and did not inform the physician of the pain complaint, assuming it was due to chronic arthritis. Neurological flow sheets for the post-fall period contained multiple blanks and incomplete entries for level of consciousness, movement, and staff initials. The DON confirmed that required post-injury monitoring, pain assessment, and direct provider notification were not carried out as expected under facility policies, and the resident was later sent to the hospital for evaluation of left hip pain and a femur fracture.
Surveyors found that the facility failed to provide a safe, clean, and homelike environment, with widespread issues such as peeling paint and wallpaper, broken and soiled furniture, stained toilets, and unclean AC units across all nursing units. Staff and residents confirmed that these problems were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction.
Surveyors identified widespread deficiencies in the facility's environment, including peeling paint, broken furniture, soiled floors, stained toilets, and damaged shower areas. Staff and residents confirmed that these issues were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction. Facility leadership acknowledged awareness of the problems, but documentation did not show that repairs or replacements had been completed.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as dirty floors, broken furniture, and unsanitary conditions observed across multiple units. Staff interviews revealed a lack of communication and follow-through on maintenance and housekeeping concerns, with the Maintenance Director confirming that issues should be addressed within 24 hours. Despite acknowledgment of the poor conditions by the DON and LNHA, no concrete plans for improvement were provided.
The facility failed to properly store potentially hazardous foods and maintain kitchen equipment in a sanitary manner. Opened boxes of raviolis and chicken breasts were found unsealed and unlabeled in the freezer, and the steam table contained murky water with food particles. Additionally, cutting boards were deeply pitted and discolored. The FSD acknowledged these issues, and the LNHA and DON were informed but provided no further information.
The facility failed to properly label and store medications and medical supplies, as observed on two medication carts and in a storage room. Expired medications were found, and supplies were improperly stored under a sink, posing infection control risks. Staff confirmed the deficiencies.
The facility failed to provide a dignified dining experience for residents by serving beverages in disposable plastic cups, as observed in one dining room. The LNHA and DON did not refute this concern, and the facility's meal assistance policy did not address the use of non-disposable dinnerware, leading to a deficiency in promoting dignity and respect.
A resident requested a lock for their closet to prevent theft, but the facility failed to install the necessary hardware despite the request being documented. The resident, who was cognitively intact and independent, experienced instances of their closet being found open. Interviews revealed that the facility's policy required residents or families to provide padlocks, while the facility provided hardware, but the lock was not installed.
An LPN failed to secure a medication cart during administration, leaving it unlocked and out of sight while attending to a resident. This action violated the facility's policy, which mandates that medication carts be locked when not in direct view. The incident was confirmed by the LPN/Unit Manager and acknowledged by the facility's administration.
A facility failed to obtain a physician's order for oxygen tubing care and did not develop a comprehensive care plan for a resident receiving oxygen therapy. The resident, with moderate cognitive impairment and multiple medical conditions, had an oxygen concentrator with improperly placed tubing. The physician's order for oxygen administration was present, but there was no order for tubing changes, and these changes were not documented in the EMR. The facility's policy lacked guidelines for oxygen tubing care, and the resident's care plan did not address respiratory care.
The facility failed to ensure proper accountability of narcotic shift count logs on two medication carts. On one cart, a pre-signed outgoing nurse signature was found, while on another, multiple missing signatures were identified for various shifts. The DON and IP confirmed that narcotics should be counted and signed by both incoming and outgoing nurses at shift changes, as per the facility's policy.
The facility failed to properly dispose of garbage and maintain the grounds, leading to potential rodent and pest issues. Observations included construction debris, litter, and numerous cigarette butts scattered across the grounds. The LNHA acknowledged the problem, and interviews revealed that the MD and HD were unaware of their responsibilities for grounds maintenance until recently.
A facility failed to follow proper infection control practices during medication administration. An LPN was observed handling medication tablets with bare hands without performing hand hygiene or wearing gloves. Interviews with other staff revealed inconsistencies in understanding and implementing proper procedures for medication handling, highlighting a lack of adherence to the facility's hand hygiene policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse involving two cognitively impaired residents. The incident was reported by a family member who found one resident partially undressed. The LNHA forwarded the grievance to the SW, but no investigation was initiated, and key staff were not informed. Interviews revealed a lack of awareness and communication about the incident, and facility policies on abuse prevention and investigation were not followed.
A facility failed to address a grievance regarding alleged resident-to-resident sexual abuse. A family member reported finding a resident in a compromised state with another resident, but the grievance was not properly investigated. The Social Worker did not involve key staff or complete the grievance process as per policy, leading to a deficiency.
A facility failed to investigate an allegation of resident-to-resident sexual abuse properly. A resident was found partially undressed and distressed by a family member, who reported the incident. The LNHA did not read the complaint immediately and only forwarded it to the SW, who did not conduct a comprehensive investigation. The facility's policies on abuse prevention and grievance handling were not followed, highlighting lapses in management and oversight.
Failure to Adequately Assess, Monitor, and Communicate After Unwitnessed Fall With Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to properly assess, acknowledge, monitor, and communicate about pain, and to implement appropriate interventions following an unwitnessed fall with a resulting femur fracture for one resident. The resident had dementia and was documented on the MDS as rarely or never understood, with long- and short-term memory problems. On the evening of 4/2/25, an LPN found the resident on the floor in their room, with the upper body leaning halfway on a chair. The resident could not give an accurate statement but complained of left leg pain. The LPN’s assessment documented no visible injury, no swelling, redness, or signs of trauma, and noted that the resident was offered pain medication but refused it three times before being assisted to bed. The LPN later stated in interview that the resident complained of leg pain, was able to take a couple of steps to the bed, and that the LPN did not return to check on the resident after the initial assessment because the resident did not require pain medication and the LPN needed to complete a medication pass. The LPN reported calling and leaving a message for the physician and calling the family, but did not inform the physician that the resident was complaining of pain, explaining that the resident always complained of leg pain from arthritis. There was no progress note identified from the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts documenting the fall beyond the late entry note, and the care plan later reflected that the resident was sent to the hospital for evaluation of left hip pain after the unwitnessed fall. Review of the neurological flow sheet from the time of the fall through the following morning showed multiple incomplete entries. The resident’s level of consciousness was not completed for several time points overnight, with only a notation of sleep, and movement entries were missing or marked as refused, including a blank entry at 3:00 a.m. The initials section was left blank for multiple time slots on the evening and overnight shifts. The DON stated that after an injury the nurse should monitor a resident according to the neurological flow sheet and complete pain monitoring for 48 hours, that no blanks should be present on the neurological flow sheet, and that the LPN should have spoken directly to the provider and explained that the resident was in pain rather than just leaving a message. Facility policies required immediate practitioner notification by phone when a fall results in significant injury or condition change, observation and documentation of delayed complications for approximately 48 hours, and documentation of pain and related signs and symptoms, as well as prompt initiation and documentation of accident/incident investigations and care plan review when desired outcomes are not met.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across all three nursing units. Observations included widespread issues such as peeling wallpaper and paint, cracked and stained ceiling tiles, broken or missing furniture parts, stained and soiled floors, and malfunctioning or dirty air conditioning units. Bathrooms were found with cracked tiles, stained or rusted toilet bowls, missing or damaged grab bars, and peeling paint. Common areas, such as dayrooms and shower rooms, also exhibited soiled and damaged furniture, missing grout, and rusted fixtures. These conditions were confirmed by both staff and residents, with some residents reporting that broken furniture and soiled conditions had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While a computerized work order system was in place, several staff members admitted to being aware of broken or damaged items but did not always submit maintenance requests. Housekeeping staff reported daily cleaning routines, but surveyors observed persistent soiling and debris, particularly in and around AC units and on furniture. Maintenance staff acknowledged that many of the environmental issues predated their employment and that repairs were often limited to what was immediately visible or reported. The Environmental Service Director and other staff confirmed that some cleaning and maintenance tasks, such as cleaning AC units and replacing filters, were not consistently performed as required. The facility had previously been cited for similar deficiencies and had submitted a plan of correction, which included staff education and regular audits of resident rooms and common areas. However, during the current survey, many of the same issues remained unaddressed, and staff acknowledged that corrective actions had not been fully implemented. Facility leadership, including the LNHA, confirmed awareness of the ongoing environmental concerns and acknowledged the poor condition of resident rooms, bathrooms, and common areas during the survey tour.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of the facility's Quality of Life - Homelike Environment policy and procedures, resulting in a failure to provide a safe, clean, comfortable, and homelike environment for residents. During a survey, multiple deficiencies were observed across all three nursing units, including resident rooms with peeling wallpaper and paint, broken or damaged furniture, soiled and stained floors, stained toilet bowls, grab bars coming off the walls, holes in walls, missing trim, and discolored ceiling tiles. In addition, shower rooms were found with rusted fixtures, damaged shower curtains, broken soap holders, and missing grout. These conditions were confirmed by both staff and residents, with some residents reporting that issues such as broken furniture and soiled areas had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While some staff were aware of the process for submitting maintenance requests through a computerized work order system, not all concerns identified by the surveyor were present in the system. Housekeeping and maintenance staff stated that cleaning and maintenance tasks were performed regularly, but acknowledged that certain issues, such as rust stains in toilets and soiled air conditioning units, had not been adequately addressed. The Environmental Service Director and other staff confirmed the presence of these deficiencies during the surveyor's walkthroughs. The LNHA and other facility leadership acknowledged awareness of the environmental issues and confirmed that many of the problems identified by the surveyor were known to them. Despite previous citations for similar deficiencies and a plan of correction that included regular audits and cleaning protocols, the survey found that many of the same issues persisted. Documentation provided by the facility, such as a quote and a check for new furniture, did not demonstrate that corrective actions had been completed, and there was no evidence that the necessary repairs or replacements had been made at the time of the survey.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment across multiple units, as evidenced by several observations made by the surveyor. On the initial tour, the surveyor noted dirty and discolored floors in the lobby and elevators. In resident rooms, there were issues such as soiled and sticky floors, overflowing trash, broken furniture, and missing or damaged fixtures. The Registered Nurse acknowledged awareness of these issues but admitted to not reporting them through the facility's computer system, which is used to notify housekeeping and maintenance departments. Interviews with various staff members, including the Housekeeping Director, Maintenance Assistant, and Licensed Practical Nurse, revealed a lack of communication and follow-through regarding maintenance and housekeeping concerns. The Maintenance Assistant and Housekeeping Director were unaware of specific issues until pointed out by the surveyor, and the Maintenance Director confirmed that maintenance issues should be addressed within 24 hours of receiving a work order. However, the system's effectiveness was questioned as several staff members reported that concerns were not always addressed promptly. Further observations included damaged walls and furniture in the dining room and resident rooms, as well as unsanitary conditions in the shower room. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the poor environmental conditions and mentioned discussions with corporate about replacing furniture, but no concrete plans were provided. The facility's policies on maintenance and housekeeping were not effectively implemented, leading to the observed deficiencies.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner, as observed by the surveyor. In the walk-in freezer, an opened box of raviolis and an opened box of chicken breasts were found in unsealed bags, exposing the contents to air and ice crystals. These items were not labeled with opened or use-by dates, and the Food Service Director (FSD) could not confirm when the packages were opened. Additionally, the steam table contained murky water with food particles, indicating it had not been drained and cleaned as required. The FSD admitted that the steam table water should be changed daily, but there were no work accountability logs to verify when it was last done. Furthermore, four plastic cutting boards were found to be deeply pitted and discolored, suggesting inadequate cleaning and maintenance. The FSD acknowledged that the freezer items should have been labeled and sealed, and that the cooking equipment should have been cleaned to prevent foodborne illness. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were informed of these issues but did not provide additional information. The facility's policies on sanitation and food storage were reviewed, revealing requirements for maintaining cleanliness and proper labeling, which were not adhered to in this instance.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as observed during a survey. On the Third-floor high side nursing unit's medication cart, fourteen individual, single-use vials of ipratropium bromide/albuterol sulfate inhalation solution were found in an opened foil pouch with a hand-written opened date of 1/2/24, despite the manufacturer's instructions indicating the medication should be used within two weeks of opening. Similarly, on the Second-floor low side nursing unit's medication cart, two boxes of the same medication were found with opened foil pouches, one dated 12/7 and the other undated, both exceeding the recommended usage period. The LPNs present confirmed the medications were expired and should have been discarded. Additionally, the Second-floor medication storage room contained improperly stored medical supplies and expired medications. Items such as sterile dressings, feeding tube irrigation sets, and nebulizer machines were stored in a cabinet under the sink, which was confirmed by the LPN/Unit Manager to be an unacceptable storage area due to infection control risks. Expired intravenous solutions were also found in the storage room. The Director of Nursing and the Infection Preventionist acknowledged the deficiencies, confirming that medications should be labeled with the date opened and discarded upon expiration, and that medical supplies should not be stored in areas that pose an infection control risk.
Deficiency in Resident Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of the three dining rooms. On February 13, 2025, during the lunch meal on the third-floor nursing unit, 14 residents were served cold beverages in disposable plastic cups. This practice was observed by the surveyor and was not refuted by the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) during an interview on February 14, 2025. The facility's Assistance with Meals policy, revised in March 2022, emphasized meal assistance with attention to safety, comfort, and dignity but did not address the use of non-disposable dinnerware. This oversight led to a deficiency in promoting dignity and respect for the residents' dining experience.
Failure to Provide Lock for Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident was provided with a lock to prevent the loss or theft of personal items. This deficiency was identified for a resident who was cognitively intact and independent in activities of daily living. The resident had requested a lock for their closet door after being moved to a new room, as they experienced instances where their closet was found open in the morning. Despite the request being documented in the facility's work order system, the lock and necessary hardware were not installed on the closet door. Interviews with facility staff revealed that the Licensed Practical Nurse/Unit Manager was aware of the lock request and had notified maintenance through the TELS system. However, the facility's policy required the family or resident to provide the padlock, while the facility provided the hardware. The Maintenance Director confirmed that he was informed of such requests through the work order system. The Licensed Nursing Home Administrator stated that the facility did not provide locks for residents, indicating a gap in the process that led to the resident's request not being fulfilled.
Medication Cart Security Lapse During Administration
Penalty
Summary
The facility failed to ensure that the medication cart was secured during medication administration, which is a violation of professional standards of clinical practice. This deficiency was observed when an LPN left the medication cart unlocked and out of sight while administering medications to a resident. The incident occurred when the LPN parked the medication cart outside the resident's room, sanitized their hands, and prepared the medications, including oral medications and injectable insulin pens. The LPN then walked to the resident's bedside, leaving the cart unattended and unlocked, despite acknowledging that it should have been locked. The facility's policy on administering medications requires that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. During an interview, the LPN/Unit Manager confirmed that nurses should always lock the cart and minimize the computer screen when stepping away. The surveyor discussed the findings with the Licensed Nursing Home Administrator and the Director of Nursing, who did not dispute the observations. The deficiency was identified for one of the four residents observed during medication administration.
Failure to Obtain Physician's Order and Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the care of oxygen tubing and did not develop a comprehensive care plan for a resident receiving oxygen therapy. During an initial tour, a surveyor observed an oxygen concentrator in a resident's room with nasal oxygen tubing improperly placed. The resident, who had moderate cognitive impairment and medical diagnoses including chronic obstructive pulmonary disease, heart failure, and kidney failure, informed the surveyor that they had removed the oxygen. The physician's order for oxygen administration was present, but there was no order for changing the nasal cannula tubing, and the tubing changes were not being documented in the Electronic Medical Record (EMR). The facility's policy on oxygen administration, last revised in 2010, did not include guidelines for the care of oxygen tubing. Additionally, the resident's comprehensive care plan lacked a focus area for respiratory care or oxygen. When questioned, the Director of Nursing confirmed that a care plan should be in place for any resident receiving oxygen therapy. This deficiency was identified in one of the four residents reviewed for oxygen therapy.
Narcotic Count Log Deficiency
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, as observed by surveyors on two of three medication carts. On the third-floor high side nursing unit's medication cart, a pre-signed outgoing nurse signature was found for the shift-to-shift narcotic count for a specific shift. The LPN confirmed that the log was pre-signed and should have been signed in the presence of the incoming nurse after a narcotic count was completed. On the second-floor low side nursing unit's medication cart, multiple missing nurses' signatures were identified for various shifts throughout January 2025. The LPN confirmed that the incoming and outgoing nurses were supposed to count the narcotics together and sign the log at the time of shift change. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that medication cart narcotics were to be counted and immediately signed by the incoming and outgoing nurses at the time of shift change. They acknowledged that there should not have been any pre-signed spaces or blanks for previous shifts, and missing documentation indicated the count was not done. The facility's Controlled Substance policy, revised in November 2022, requires nursing staff to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses making the count together and documenting any discrepancies.
Improper Garbage Disposal and Grounds Maintenance
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, leading to a potential rodent and pest problem. During a tour of the facility grounds and loading dock area, the surveyor observed construction debris, broken pallets, plastic wrap, Styrofoam panels, and paper litter scattered across the grassy side yard visible from the first-floor residents' windows. Additionally, numerous cigarette butts were found on the ground along the driveway and grassy area, with a cigarette receptacle lying on its side. Behind a short brick wall, more construction debris, metal benches, milk cartons, and tarps were found haphazardly thrown. Further observations behind a large blue storage trailer shed revealed orange milk crates, construction trash, soda cans, and gloves on the ground. Around the facility's three green trash dumpsters, gloves, soda cans, and cigarette butts were also present. The Licensed Nursing Home Administrator (LNHA) acknowledged the concern, stating it was unfair for residents to view such conditions and that the trash could lead to a rodent and pest problem. Interviews with the Maintenance Director (MD) and Housekeeping Director (HD) revealed that both were unaware of their responsibilities for grounds maintenance until recently. The facility's undated policies on grounds maintenance, food-related garbage and refuse disposal, and smoking were reviewed, indicating that maintenance should keep the grounds free of litter and that storage areas should be kept clear at all times.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection control practices during medication administration, as observed by a surveyor. Specifically, an LPN was seen preparing medications for a resident without performing hand hygiene or donning clean gloves. The LPN used their bare fingers to handle a vitamin tablet, which is against the recommended practices for infection control. When questioned, the LPN acknowledged the mistake and admitted that the contaminated tablet should have been discarded. Further interviews with other staff members, including another LPN and the LPN/Unit Manager, revealed inconsistencies in the understanding and implementation of proper procedures for obtaining medications from a bottle. The staff members provided varying responses regarding the use of gloves and hand hygiene, indicating a lack of uniformity in following the facility's hand hygiene policy. The facility's policy states that hand hygiene should be performed before and after handling medications, but this was not consistently practiced by the staff.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident sexual abuse involving two residents, one with severe cognitive impairment and the other with moderate cognitive impairment. The incident was reported by a family member of the alleged victim, who observed the two residents in a compromising situation. The family member's email described finding the alleged victim partially undressed and frazzled, with a staff member allegedly stating that such interactions were common and left unaddressed. The License Nursing Home Administrator (LNHA) received the grievance via email and forwarded it to the Social Worker (SW) with instructions to write a grievance. However, the SW did not initiate an investigation or follow the facility's policies on abuse reporting and investigation. The SW attempted to arrange an Interdisciplinary Care Team (IDCT) meeting to address the grievance but did not complete the grievance process or involve key staff members such as the Director of Nursing (DON) or the Unit Manager. Interviews with facility staff revealed a lack of awareness and communication regarding the alleged incident. The Unit Manager and Behavioral Monitoring Aide were unaware of any resident-to-resident sexual abuse, and the assigned CNA had never observed the two residents together. The facility's policies on abuse prevention and investigation were not followed, as the Administrator did not ensure a thorough investigation or keep the resident and family informed of the investigation's progress.
Removal Plan
- Initiating an investigation related to the grievance/allegation of the resident to resident sexual abuse.
- Completing an assessment related to any signs and symptoms of psycho-social concerns.
- Initiating in-services for the SW and all staff on the facility's policy on Abuse and Neglect, Investigating and Reporting, the Abuse Prevention Program Policy, and the Grievance Policy and Procedure.
- Auditing of incidents and accident reports and grievances to ensure there were not any additional unresolved investigative allegations of abuse, abuse, and neglect identified.
Failure to Address Grievance of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Grievance Policy and Procedure and the Social Worker Job description after a family member of a resident made an allegation of sexual abuse. The incident involved two residents, one with severely impaired cognition and the other with moderate cognitive impairment. The family member reported finding the resident in a compromised state with another resident in the room, and a staff member allegedly stated that such incidents were known but not addressed. The grievance was initially reported via email to the Licensed Nursing Home Administrator (LNHA), who forwarded it to the Social Worker (SW) for investigation. However, the SW did not conduct a comprehensive investigation or involve key personnel such as the Director of Nursing (DON), unit manager, or other nurses. The SW suggested an Interdisciplinary Care Team (IDCT) meeting to address the grievance, but the family member could not attend. The grievance process was not completed as per the facility's policy, and the IDCT did not review the complaint in a timely manner. Interviews with various staff members, including the Unit Manager, Behavioral Monitoring Aide, and Certified Nursing Assistant, revealed a lack of awareness of any resident-to-resident sexual abuse. The facility's policy requires prompt investigation and resolution of grievances, but this was not adhered to in this case. The Director of Nursing was unaware of the grievance, and the LNHA expected a full investigation, which was not carried out, leading to the deficiency.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility's administration failed to conduct a thorough and complete investigation into an allegation of resident-to-resident sexual abuse, as required by their policies. This deficiency was identified during a survey conducted on specific dates in November 2024. The incident involved two residents, one of whom was found in a compromised state by a family member. The family member reported the incident via email, describing how they found their relative partially undressed and distressed, with another resident quickly leaving the room. The family member also mentioned that a staff member had previously observed similar incidents but did not intervene. The facility's policies on abuse prevention, grievance handling, and investigation were not followed. The Licensed Nursing Home Administrator (LNHA) received the complaint but did not read it immediately and only forwarded it to the Social Worker (SW) the following day. The SW, upon receiving the email, attempted to investigate by speaking with Certified Nursing Assistants (CNAs) but did not engage with other key personnel such as nurses, the Director of Nursing (DON), the Unit Manager, or the Administrator. This lack of comprehensive investigation and communication among staff members contributed to the failure to address the serious allegation appropriately. The facility's policies clearly outline the responsibilities of the administration in investigating allegations of abuse, ensuring resident safety, and maintaining open communication with residents and their families. However, these procedures were not adequately implemented in this case. The Administrator's job description emphasizes the importance of directing the facility's functions in compliance with regulations to ensure quality care, which was not achieved in this instance. The failure to follow established protocols and ensure a thorough investigation highlights significant lapses in the facility's management and oversight of resident safety and rights.
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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