The Fountains Of Atco
Inspection history, citations, penalties and survey trends for this long-term care facility in Atco, New Jersey.
- Location
- 114 Hayes Mill Road, Atco, New Jersey 08004
- CMS Provider Number
- 315297
- Inspections on file
- 17
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at The Fountains Of Atco during CMS and state inspections, most recent first.
Staff failed to follow the facility’s Legionella Water Management Plan and national guidelines by not maintaining and documenting required filters on shower heads and the dining room ice machine, and by not involving the IP in Legionella control activities. Only one of two in-use shower heads in the shower room had a filter in place, and the CMD could not produce logs showing when shower filters or the ice machine filter were checked or replaced. The ice machine, which staff routinely used to provide ice water and beverages for residents’ meals and medications, had been cleaned but its water-line filter had not been changed since installation, contrary to expectations and manufacturer guidance. The IP reported no knowledge of current Legionella issues and had only provided general education, while the LNHA confirmed the IP was not included in remediation efforts and that the WMP still listed former leaders as team members, even though it required documented cleaning, filter changes, and participation of the IP and other key staff when Legionella-positive samples were identified.
Surveyors found that the facility did not maintain required Legionella control measures for resident showerheads and an ice machine. A resident shower room was observed without the mandated 0.2-micron point-of-use filter on the showerhead, and the CMD reported CNAs sometimes removed filters due to low water flow, with no reliable logs showing when filters were checked or replaced. An ice machine near the dining area had a filter device labeled with an installation date more than several months old, and the CMD and HVACM could not confirm that it had been changed according to manufacturer specifications, nor could they provide documentation of filter changes or ordering. The facility’s WMP and prior NJDOH CDS directives required installation and documented maintenance of these filters as Legionella control measures, but the LNHA and maintenance staff were unable to demonstrate that these requirements had been consistently implemented or documented.
The facility failed to provide adequate supervision and effective fall prevention for several high fall‑risk residents, including cognitively impaired individuals with stroke history, aphasia, Alzheimer’s disease, hemiplegia, and repeated falls. One resident, identified as impulsive and requiring supervised activities, was repeatedly observed in dayrooms without staff present while attempting to stand, and experienced numerous falls in the room, hallway, and activity areas, three of which caused head and leg injuries requiring ED evaluation. Another resident with Alzheimer’s and diabetes had multiple falls despite a fall‑risk care plan, but incident reports lacked key details and new interventions were not consistently added or evaluated. A third resident with hemiplegia fell during in‑bed turning when a leg hit the floor, yet the care plan was not updated to include the specific positioning intervention discussed by the IDT. Across these cases, fall investigations were often incomplete or missing, causal factors were not clearly identified, supervision was not ensured in activity areas, and care plans were not consistently revised in accordance with the facility’s own fall‑management policies.
A resident with hemiplegia, epilepsy, severely impaired cognition (BIMS 2/15), and a documented need for an interpreter in a non-English dialect did not have the care-planned communication board available in the room, and staff were unaware of any communication device. The MD and nursing staff reported they did not use translation devices or contracted translation services and instead relied on slow speech, observation, and family presence, despite a facility policy stating that a contracted translation service was maintained and that family should not routinely be used as interpreters. A communication binder with words and images was later found under the bedside table only after surveyor inquiry, demonstrating that the planned communication interventions were not implemented as documented.
A resident with a history of stroke, right hemi craniotomy, left-sided weakness, epilepsy, severe cognitive impairment, and ongoing headaches and dizziness was ordered to follow up with Neurology/Neurosurgery. The resident, dependent on staff for dressing and requiring an interpreter, reported anticipating the appointment and stated no one came to prepare them, and that they did not refuse. Staff interviews and record review showed that the appointment scheduling and communication process relied on a unit clerk, an LPN, and a whiteboard, but December appointment records were not retained, the CNA was not informed to get the resident ready, and there was no documentation of refusal, missed appointment, physician notification, or rescheduling. Physician notes recommending neurology follow-up and documenting headaches and dizziness were not visible in the facility’s eMR until after surveyor inquiry, and the facility lacked a formal policy for scheduling resident appointments.
A resident with severe cognitive impairment, hemiplegia, and a history of brain surgery reported ongoing head pain and stated that staff did not prepare them for a scheduled follow-up neurosurgical appointment, which they denied refusing. Staff interviews revealed that appointment scheduling information was kept on a white board and in progress notes, but the resident’s appointment was not on the list, and the CNA was not told to get the resident ready. The resident’s representative later arrived visibly upset about the missed appointment, and both the ADON and DON were aware of the complaint, yet no grievance was initiated, no refusal or missed appointment was documented in the progress notes, no follow-up appointment was arranged, and the physician was not notified. The grievance officer’s logs contained no entry for this event, and the only investigation document was a single LPN statement and a transport order showing the trip was cancelled as “appointment cancelled,” contrary to the facility’s written grievance policy requiring prompt resolution and communication of grievance findings.
The facility failed to maintain food safety and sanitation standards, as observed by a surveyor. The inspection revealed an unclean meat slicer, unlabeled and undated food items in the refrigerator and freezer, and a dented can in dry storage. The FSAD acknowledged these issues, which were contrary to the facility's policy on proper food labeling and dating.
The facility failed to complete the Quarterly MDS assessments on time for two residents, resulting in a deficiency. One resident with congestive heart failure had their assessment completed three days late, while another with dementia had theirs completed five days late. The MDS Coordinator acknowledged the delays, which were against the facility's policy requiring timely assessments.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. One resident's care plan lacked focus on leg wraps for edema and did not document refusal. Another resident experienced two falls without care plan updates. A third resident with a urinary catheter lacked specific care plan details. Staff confirmed the care plan deficiencies.
A resident with moderate cognitive impairment refused prescribed leg wraps for edema, and the facility failed to educate the resident or notify the physician and family about the refusal. The facility's policy required such actions, but documentation and staff interviews revealed these steps were not taken, resulting in a deficiency.
A facility failed to maintain accurate records for Xanax, a controlled medication, resulting in a discrepancy between the recorded and actual pill count. An LPN admitted to counting the narcotics alone, leading to the oversight. Additionally, Xanax was improperly borrowed for another resident, contrary to facility policy, as confirmed by the DON and other staff.
A facility failed to document the assessment and administration of the influenza vaccine for a resident admitted with Diabetes Mellitus and Hypertension. The resident's MDS indicated the vaccine was not received, and the reason was not assessed. The DON confirmed the vaccine should have been assessed upon admission, but no consent or refusal form was available. Facility policy required offering the vaccine between October and March and assessing new residents' vaccination status upon admission.
Failure to Implement Legionella Water Management Controls and Involve IP in Program
Penalty
Summary
Facility staff failed to implement, maintain, and monitor control measures to prevent the growth of Legionella in accordance with the facility’s Water Management Program (WMP), CDC guidelines, and ASHRAE Guideline 12. During a tour of the skilled nursing section, surveyors observed three shower heads in the shower room, two of which were in use, and only one of those two had a filter in place. The Campus Maintenance Director (CMD) stated that CNAs may have removed a filter to get better water flow and that maintenance checked filters every three months, but he was unable to produce logs showing when shower head filters were checked or replaced. A provided “SNF Community Shower Room” log only showed a date when a new filter was installed, and the CMD could not explain what the log meant. CNAs reported no issues with low water pressure and confirmed that residents regularly received showers in the shower room and in private showers. Surveyors also observed an ice machine in the dining room/pantry area with an inspection sheet indicating it had been cleaned and sanitized by the Heating, Ventilation and Air Conditioning Mechanic (HVACM) several months earlier. A filtration device attached to the water line for the ice machine had a handwritten date that appeared to be the installation date, and the CMD was unsure if the filter had been changed since then or what the manufacturer’s specifications were for changing the filter. The HVACM confirmed he had disassembled, sanitized, and reassembled the ice machine but had not changed the filter device at that time, stated the filter should have been changed, and indicated the filter device now needed to be ordered. The CMD acknowledged he could not provide logs or an ordering schedule for the ice machine filter and attributed missing audits and documentation in part to a terminated Maintenance Supervisor. Interviews with leadership and clinical staff showed that the Infection Preventionist (IP) was not included in Legionella control measures despite the WMP and facility policy identifying the IP as part of the water management team. The IP/LPN reported having been the IP for about a year, stated she had no knowledge of any current Legionella issues in the building, and indicated that upper management and maintenance were handling Legionella. She recalled being told to provide general education on Legionella about a year earlier but had not been involved in remediation activities. The Licensed Nursing Home Administrator (LNHA) confirmed that the IP/LPN was responsible for staff education on Legionella but was not currently involved in remediation and had not been included in discussions about Legionella since he became LNHA. The LNHA also acknowledged that the WMP listed program team members who were no longer employed and that he was unaware of the magnitude of the facility’s Legionella history or the status of mitigation efforts when he assumed his role. Meanwhile, staff routinely used water from coolers and ice from the ice machine for residents’ drinks, meals, and medications, and residents confirmed receiving water with ice and regular showers, while the WMP required documented regular cleaning and filter changes for ice machines and showerheads when Legionella-positive samples were identified. A review of the facility’s WMP dated mid-2025 showed that the current CMD and former executive leadership were listed as program team members, but it did not reflect current responsible individuals. The WMP identified ice machines, medical devices, shower heads, and hoses as devices at risk for Legionella contamination and required regular cleaning, filter changes per manufacturer specifications, and documentation of these activities. It also required regular cleaning, replacing or dismantling, disinfecting, and descaling of showerheads and hoses, and called for more frequent sampling and review when Legionella-positive samples were found outside control limits. The facility’s Legionella Water Management Program policy further specified that the water management team must include at least the IP, administrator, medical director, director of maintenance, and director of environmental services. Despite this, the LNHA could not provide documentation of completed NJDOH Communicable Disease Services recommendations prior to a recent sampling event and initially provided policies that he later acknowledged were not the actual WMP, underscoring that the WMP had not been updated to include current responsible team members or fully implemented as written.
Failure to Maintain Legionella Control Measures for Showerheads and Ice Machines
Penalty
Summary
The deficiency involves the facility’s failure to implement required Legionella control measures on resident showerheads and ice machines as directed by the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS) and as outlined in the facility’s Water Management Plan (WMP). NJDOH CDS written instructions dated 01/21/2025 required immediate installation of 0.2-micron biological point-of-use filters on any showerheads intended for use, or restriction of showers with use of sponge baths instead, and specified that filters must comply with ASTM F838. The same communication directed the facility to assess for additional point-of-use filters at fixtures with elevated aerosolization risk and to follow manufacturers’ recommendations for filter replacement. The WMP, dated 07/15/2025, identified showerheads, hoses, and ice machines as devices at risk for Legionella contamination and required regular cleaning and filter changes per manufacturer specifications, with documentation. On the survey date, during an inspection of a resident shower room, the survey team, accompanied by the Campus Maintenance Director (CMD), a NJDOH CDS Water Systems Analyst, and a Local Health Department representative, observed that the resident showerhead did not have a 0.2-micron biological point-of-use filter in place. The CMD stated that CNAs sometimes removed the filters when water flow was low and that maintenance checked the filters every three months, but he could not produce logs to show when showerhead filters had been checked or replaced. The only record provided was a “SNF Community Shower Room” log indicating a date when a new filter was installed, which the CMD could not interpret. The LNHA reported he was aware filters needed to be checked and changed but relied on maintenance for the schedule and believed audits were being done. During inspection of the ice machine near the resident dining area, the survey team observed a filter device labeled with an installation date of 02/04/2025. The CMD was unsure if the filter had been changed since that date and could not speak to the manufacturer’s replacement specifications. The Heating Ventilation Air Conditioning Mechanic (HVACM) confirmed he had disassembled, sanitized, and reassembled the ice machine in November 2025 and normally would change the filter cartridge, but on that occasion did not change the filter device. He acknowledged the filter device should have been changed and that he did not handle ordering, which he believed was the responsibility of a Maintenance Supervisor who had since been terminated. The CMD was unable to provide any logs or ordering records for the ice machine filter, citing frequent vendor changes and multiple people being involved. The LNHA acknowledged awareness of a history of Legionella issues at the facility and ongoing communication with NJDOH CDS, but he was unable to provide documentation of NJDOH CDS recommendations completed before a February 2026 sampling event and believed he was following the WMP despite the lack of documented compliance with required control measures for showerheads and ice machines.
Failure to Provide Adequate Supervision and Effective Fall Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention for multiple cognitively impaired and high fall‑risk residents, and to thoroughly investigate and respond to falls. One resident with severe cognitive impairment, aphasia after stroke, repeated falls, bipolar disorder, muscle weakness, and a history of traumatic subdural hemorrhage was repeatedly placed in dayrooms without consistent staff supervision despite being identified as impulsive, at high risk for falls, and requiring supervised activities. Surveyors observed this resident multiple times in a wheelchair in the activity/dayroom areas, appearing restless, attempting to stand, and moving back and forth in the wheelchair while no staff were present in the room. The activity aide reported she was the only staff member assigned to cover two separate activity rooms, could not supervise both simultaneously, and that there were no staff physically assigned to monitor the activity area when she had to step out. This same resident sustained at least 13 falls, including several unwitnessed falls in the resident’s room and multiple falls in the activity room and hallway. Documentation showed repeated nursing notes of the resident being found on the floor in the room, in doorways, and in the activity room, sometimes with skin tears or redness, and three falls resulted in injuries requiring emergency department evaluation: a contusion and laceration to the left supraorbital and frontal scalp after a hallway transfer incident where the CNA reported the resident’s legs became caught and the resident fell forward from the wheelchair; a large intramuscular hematoma of the right thigh after a fall in the activity room where the resident stood and missed the chair; and a closed head injury and facial laceration after another fall in the activity room with active bleeding from the forehead. Despite a care plan that specified the resident was impulsive, had poor safety awareness, required prompt response to requests for assistance, should be in common areas when out of bed, should not be left alone in the room in a wheelchair, and needed supervised activities to minimize falls, the facility did not ensure supervision in the dayrooms and did not consistently revise interventions after recurrent falls. Several fall investigations were missing entirely, and when interdisciplinary team notes were present, they often stated that all current interventions remained appropriate and that no additional interventions were needed, even after serious injuries and documentation that the resident required supervision in activities. Another resident with Alzheimer’s disease, anxiety, diabetes, and a high fall‑risk score experienced multiple falls over a short period, including several falls with no injury and one fall with skin tears to the left hand and elbow. The care plan listed general fall‑prevention interventions such as reviewing past falls, attempting to determine causes, anticipating needs, ensuring call light access, prompt response to assistance requests, appropriate footwear, maintaining the bed in the lowest position, toileting schedules, therapy evaluations, and activities to promote exercise and diversion. However, for at least one documented fall, no new interventions were added, and facility accident/incident reports lacked key information such as when the resident was last seen or toileted, footwear at the time of the incident, bed position, or whether the resident had participated in activities as care‑planned. Effectiveness of interventions and root causes of falls were not clearly evaluated or documented, contrary to the facility’s own falls policies that required identification of precipitating factors, cause identification within 24 hours, and ongoing adjustment of interventions until falls were reduced. A third resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, and epilepsy had a documented fall during in‑bed repositioning. A risk management report described that while a CNA was turning the resident onto the right side, the resident’s leg hit the floor while the body remained on the bed. The interdisciplinary team later discussed this event and identified the need for staff to position the resident in the center of the bed before turning to one side or the other. However, the resident’s comprehensive care plan for falls was not updated to include this fall or the specific intervention related to proper positioning prior to turning. Overall, across these residents, the facility’s fall‑related policies did not address supervision, multiple falls were not thoroughly investigated, causal factors were often not identified, and care plans were not consistently updated with new or specific interventions in response to recurrent falls and injuries. The facility’s written policies on managing falls and fall risk, the falls clinical protocol, and the falls risk assessment policy required staff to identify interventions related to specific risks and causes, implement resident‑centered fall prevention plans, monitor and document responses to interventions, and re‑evaluate and modify interventions when falls continued. These policies also required staff to evaluate when and where falls occurred, document precipitating factors, and attempt to define possible causes within 24 hours, with physician involvement when causes were unclear or falls persisted. Despite these requirements, the policies did not address supervision as part of fall management, and in practice, the facility did not ensure adequate supervision in activity areas, did not consistently complete or document fall investigations, and did not reliably implement or update individualized interventions after falls for the residents reviewed.
Failure to Provide and Implement Communication Devices and Translation Services for Non-English-Speaking Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide an effective communication device for a resident with a known language barrier and severe cognitive impairment. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and epilepsy. The most recent quarterly MDS showed a BIMS score of 2/15, indicating severely impaired cognition, and documented that the resident’s preferred language was a non-English dialect and that an interpreter was needed. The comprehensive care plan for communication, initiated/revised on 8/22/25, specified that staff who spoke the same dialect could translate, that the family was available by phone to translate, and that the resident had a communication board in the room. However, during an observation on 1/5/26, the CNA assigned to the resident could not locate a communication device and confirmed there was no communication board in the room. Interviews and record review further showed that the facility did not effectively implement its own translation services policy. A family representative reported arriving at the hospital for an appointment with the resident and being told the facility had cancelled the appointment, then going to the facility and speaking with the resident, who spoke minimal English. Staff interviews revealed that the MD did not speak the resident’s language and communicated only by speaking slowly and observing the resident, without using any translation device or service, and that the facility did not provide such services. An LPN/charge nurse stated there was no translation or ancillary communication device in the facility. Later, in the presence of the DON, the LPN produced binders with words and images that she stated she found under the bedside table, and the surveyor noted staff were not aware of this communication device and it could not be located prior to the surveyor’s inquiry. The facility’s written policy, revised 1/2020, stated that the facility maintained a contracted relationship with a translation service and that family and friends should not be relied upon for interpretation unless explicitly requested by the resident and with written consent, but no further information was provided to demonstrate implementation of this policy.
Failure to Ensure Resident Attended Ordered Neurology Appointment and to Document Missed Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a system was in place and implemented to enable a resident to attend an outside neurology/neurosurgery appointment as ordered and needed. The resident had a history of stroke with right hemi craniotomy, left-sided weakness, epilepsy, and severe cognitive impairment, and was dependent on staff for upper and lower body dressing. The resident’s preferred language required an interpreter. Physician progress notes from late 2024 and 2025 documented ongoing headaches, dizziness, left-sided weakness, and recommendations for follow-up with Neurology/Neurosurgery. However, these 2025 notes were not visible in the facility’s eMR until after surveyor inquiry due to a transcription/transfer issue between the physician’s own eMR and the facility’s system. The resident reported anticipating a neurology appointment the night before and being eager to attend due to persistent deep head pain, dizziness, cramping pain, and headache radiating from the base of the neck to the area of the prior craniotomy. On the morning of the scheduled appointment, the resident stated that no one came to get them dressed or ready and that they did not refuse the appointment. The MDS indicated the resident did not exhibit rejection-of-care behaviors and required total assistance for dressing, meaning staff preparation was necessary for the resident to attend the appointment. Staff interviews confirmed that the resident did not refuse the appointment and that there was no documentation of refusal. Interviews with the ADON, LPN/Charge Nurse, CNA, and DON revealed that appointment scheduling and communication processes were informal and inconsistently implemented. The unit clerk and LPN/Charge Nurse scheduled appointments and were supposed to document them in progress notes and on a white appointment board, but December appointment records were not kept. The CNA stated she was not informed to get the resident ready and did not recall the resident’s name on the appointment board. Review of the resident’s progress notes showed no entry that the appointment was missed, no documentation that the physician was notified of the missed appointment, and no evidence of a rescheduled neurology appointment prior to surveyor inquiry. The facility also could not provide a policy for scheduling resident appointments, despite having a documentation policy that required recording refusals and physician notifications, contributing to the failure to ensure the resident attended the ordered neurology follow-up.
Failure to Log and Process Resident Grievance Regarding Missed Medical Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its method for filing and handling grievances was consistent with its own grievance policy and actual practice. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and a severely impaired cognition (BIMS score of 2/15) reported to surveyors that they had anticipated a follow-up brain surgery appointment scheduled for 12/29/25 due to persistent deep head pain radiating from the base of the neck to the area of a right hemi craniotomy. The resident stated that no one from the facility came to get them dressed and ready for the appointment and confirmed they did not refuse to go. The resident was dependent for upper and lower body dressing and did not exhibit behaviors such as rejection of care per the most recent MDS. Staff interviews and record reviews showed that the facility did not document or process the missed appointment as a grievance, despite the resident and the resident representative voicing concerns. The Social Services Director, who served as the grievance officer, provided grievance logs for several months that contained no entries for this resident, and no grievance report was initiated. The CNA recalled that the resident had a missed appointment and that she was not informed to get the resident ready; she also stated that the resident’s name was not on the appointment list on the white board. The CNA further reported that the resident representative came into the facility visibly upset about the missed appointment and that both the ADON and DON were aware of this. The ADON stated she recalled the missed appointment and that the resident representative arrived visibly upset and yelling in the hallway, but she believed the resident had refused the appointment and acknowledged that she did not speak with the resident or family about the incident and did not think a grievance was made. Review of the progress notes with the ADON confirmed there was no documentation that the resident refused the appointment, no follow-up appointment was made, and the physician was not notified of the missed appointment. The DON confirmed she only learned of the missed appointment when the resident representative arrived angry and that she did not initiate a grievance. An investigation file contained only a single signed statement from an LPN indicating the resident refused to go after transport arrived, and a trip order showed the transport was cancelled by the same LPN with the reason documented as “appointment cancelled.” The facility’s written grievance policy stated that residents and their representatives have the right to file grievances orally or in writing and that the administrator and staff would make prompt efforts to resolve grievances and inform the complainant verbally and in writing of the findings and corrective actions, but no grievance was initiated or resolved for this resident’s complaint.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by a surveyor. During an inspection of the kitchen, the surveyor, along with the Food Service Assistant Director (FSAD), noted several deficiencies. The meat slicer was found uncovered with pink food scraps on it, indicating it had not been cleaned after use. In the walk-in refrigerator, an open package of hard-boiled eggs was wrapped in plastic wrap without an open or use-by date label. Similarly, an unidentified frozen food item in the freezer was wrapped in plastic wrap without a label or date. Additionally, a dented can of baked beans was found in the dry storage area. The FSAD acknowledged these issues, stating that the items should have been labeled and the dented can should not have been on the rack. The facility's policy on labeling and dating emphasizes the importance of proper labeling to ensure food safety and minimize waste, which was not adhered to in these instances.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (QMDS) assessments in a timely manner for two residents, resulting in a deficiency. Resident #43, who was admitted with diagnoses including congestive heart failure and muscle weakness, had their QMDS assessment completed three days late. The Assessment Reference Date (ARD) for this resident was 5/26/2024, but the assessment was not completed until 6/12/2024. Similarly, Resident #4, diagnosed with dementia and anxiety, had their QMDS assessment completed five days late. The ARD for this resident was 5/24/2024, and the assessment was completed on 6/12/2024. During an interview, the MDS Coordinator acknowledged the delay in completing the QMDS assessments for both residents. The facility's policy, revised in March 2022, requires timely and appropriate resident assessments, including quarterly assessments. Additionally, the facility's policy on MDS Completion and Submission Timeframes, revised in October 2023, mandates adherence to federal and state submission timeframes. The deficiency was identified during a survey, and the facility's failure to comply with these requirements was noted.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in addressing their medical and nursing needs. For one resident with a diagnosis of edema, the care plan did not include a focus area for the use of bilateral leg wraps, nor did it address the resident's refusal of the wraps. The Treatment Administration Record showed inconsistencies in the application and removal of the wraps, and there was no documentation of the physician or representative being informed of the refusal. Another resident, who had diagnoses including anxiety, mood disorder, and dementia, experienced two un-witnessed falls. The care plan did not include focus areas, goals, or interventions for these actual falls, despite the resident being identified as high risk for falls. The post-fall evaluations documented the incidents, but the care plan was not updated to reflect these events or to implement measures to prevent future falls. A third resident with an indwelling urinary catheter did not have a care plan focus specifically addressing the catheter, its care, or related interventions. The care plan only mentioned enhanced barrier precautions without detailing catheter care, size, or frequency of changes. Interviews with facility staff confirmed the lack of appropriate care plan documentation for the catheter, and the facility's policies were not followed in developing comprehensive care plans for these residents.
Failure to Educate and Notify Regarding Treatment Refusal
Penalty
Summary
The facility failed to provide necessary education to a resident who was refusing a prescribed treatment and did not notify the resident's physician or family about the refusal. This deficiency was identified for a resident with a history of skin conditions, including cellulitis, localized edema, gout, and local infection of the skin and subcutaneous tissue. The resident, who had moderate cognitive impairment, was observed refusing leg wraps that were prescribed for edema. The Treatment Administration Record indicated that the wraps were not applied or removed on several occasions, and the refusal was documented without evidence of education or notification to the physician or family. The facility's policy required that when a resident refuses treatment, the interdisciplinary team should educate the resident about the risks and benefits, document the refusal, and notify the physician. However, there were no progress notes indicating that the physician or family was informed of the refusal before a specific date, nor was there documentation that the resident was educated about the potential outcomes of refusing the treatment. Interviews with staff confirmed that the process for handling treatment refusals was not followed, leading to the deficiency.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate accountability of a controlled medication, specifically Xanax, for an unsampled resident. During a review of a medication cart, it was found that the Individual Patient Controlled Substance Administration (IPCSA) record indicated 29 Xanax pills should be available, but only 28 were present. The Licensed Practical Nurse (LPN) acknowledged the discrepancy and admitted to counting the narcotics alone, which may have led to the oversight. The Director of Nursing (DON) later confirmed that the extra Xanax was administered to the resident but was not properly documented on the IPCSA. Additionally, the facility improperly acquired a controlled drug by borrowing Xanax for another unsampled resident. The IPCSA record showed that Xanax was borrowed for a resident, and the Medication Administration Record (MAR) confirmed its administration. Both the Unit Manager/Charge Nurse and a Registered Nurse stated that borrowing medication is not permitted. The facility's policy on controlled substances requires individual records for each resident receiving such medications, which was not adhered to in this instance.
Failure to Document Influenza Vaccine Assessment and Administration
Penalty
Summary
The facility failed to ensure proper documentation in a resident's medical record regarding the benefits and risks of immunization, as well as the administration or refusal of the influenza vaccine. This deficiency was identified for one resident who was admitted with diagnoses including Diabetes Mellitus and Hypertension. The resident's admission Minimum Data Set (MDS) indicated that the influenza vaccine was not received, and the reason for not administering the vaccine was not assessed. The resident was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 14/15. During interviews with the surveyor, the Director of Nursing (DON) acknowledged that the influenza vaccine should have been assessed upon the resident's admission. The facility was unable to produce a consent or refusal form for the influenza vaccine. The facility's policy stated that the influenza vaccine should be offered to residents between October 1st and March 31st each year, unless medically contraindicated or if the resident had already been immunized. Additionally, the policy required that all new residents be assessed for current vaccination status upon admission.
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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