Trenton Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trenton, New Jersey.
- Location
- 512 Union Street, Trenton, New Jersey 08611
- CMS Provider Number
- 315324
- Inspections on file
- 19
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 37 (5 serious)
Citation history
Health deficiencies cited at Trenton Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
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 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.
Surveyors found that the facility failed to maintain and monitor its dish machine and three‑compartment sink according to manufacturer instructions and facility policy, resulting in improper sanitation of dishware, cookware, and utensils. After a snowstorm, the dish machine’s hot water booster failed and the vendor converted it to a low‑temp chemical system, but staff did not check or document temperatures or sanitizer concentrations, and the attached sanitizer was later found to be expired and ineffective. Logs for the dish machine stopped months earlier, staff could not locate or correctly use test strips, and one dietary staff member skipped the rinse step when using the three‑compartment sink and admitted not checking anything. While most residents were served on disposable ware, some continued to receive meals on regular dishware and utensils, and the LNHA and acting FSD gave inconsistent explanations and showed lack of awareness of required sanitizer monitoring, leading to an Immediate Jeopardy determination related to food safety practices.
Surveyors found that meals were being served on a mix of disposable and reusable dishware while the dish machine had been non-functional or improperly converted to low-temp chemical sanitization, and dietary staff, including the acting FSD and LNHA, could not operate the dish machine, locate or use appropriate test strips, or produce required sanitation logs. A dietary staff member was observed using the three-compartment sink incorrectly, skipping the rinse step and unable to verify sanitizer concentration, and the acting FSD demonstrated unfamiliarity with the correct chemicals and test procedures despite a posted quaternary sanitizer protocol. Facility policies addressed dish machine temperatures and failure but did not cover conversion to low-temp chemical sanitization, and there was no documentation of staff competencies or routine monitoring of sanitizer concentrations, resulting in a failure to ensure competent dietary personnel and proper sanitation for all residents’ meal service.
Surveyors found that several rooms housing eight residents lacked privacy curtains, preventing full visual privacy. During a tour of one floor with the LNHA, rooms 511A, 514A, 517A, and 519A were observed without privacy curtains despite being occupied by residents transferred from another facility. When questioned, the LNHA reported that maintenance staff had forgotten to install the curtains. The facility’s Residents Rights policy states that staff must treat residents with dignity and that residents are guaranteed rights to privacy and confidentiality under applicable regulations.
Surveyors found that two residents sharing a room did not have access to a functioning call system, despite facility policy requiring all residents to always have access to a call bell. One resident, who was dependent on staff and had multiple conditions including Parkinson’s disease and peripheral vascular disease, reported never having a call device since transfer, and relied on the roommate—who required only minimal assistance—to go into the hallway and shout for staff when help was needed. The DON later acknowledged knowing the room’s call device was not working and stated she had requested a manual call device, but none had been provided.
A resident with severe cognitive impairment and a history of falls sustained a clavicle fracture after staff failed to implement care plan interventions for increased supervision during a period of restlessness. The resident was not transferred to a recliner chair at the nursing station as required, and staff did not document or communicate the resident's behavior, resulting in inadequate supervision and subsequent injury.
Surveyors identified extensive environmental deficiencies, including unsanitary ice machines, food debris, soiled linens, and broken furniture, along with a persistent cockroach infestation affecting resident rooms, personal belongings, and common areas. Multiple residents and staff reported ongoing pest sightings and distress, with measures such as wrapping belongings in plastic and blocking beds with towels. Delayed removal of soiled items and strong odors from unaddressed incontinence episodes further contributed to an environment that was neither clean nor homelike.
The facility failed to provide adequate nursing staff, resulting in delayed incontinence care for two residents, improper medication administration when a resident's medications were left unattended at the bedside, and unaddressed cleanliness issues in a resident room. Staff shortages were confirmed, and staffing records showed repeated noncompliance with state minimum CNA staffing requirements.
Surveyors found that the facility did not implement an effective IPCP, as evidenced by a persistent cockroach infestation throughout all resident units, improper storage of clean linens, and the absence of a water management policy to prevent Legionella. Staff and residents reported frequent cockroach sightings on personal belongings, linens, and in living areas, while interviews revealed a lack of coordinated response and follow-up. The facility was unable to provide documentation of water testing or preventive measures for Legionella, and the infection preventionist was not involved in pest control efforts.
Surveyors found that ice machines on multiple floors were heavily soiled with visible debris, rust-like buildup, and peeling parts. The Maintenance Director was unaware of cleaning schedules or procedures, and there was no documentation of regular maintenance. Manufacturer guidelines for cleaning and sanitizing were not followed, resulting in unsanitary equipment conditions.
Surveyors found that staff did not consistently provide timely incontinence care or maintain fingernail hygiene for three dependent residents. One resident had visibly dirty, untrimmed fingernails despite requests for care, another was left in soiled bedding overnight without incontinence care or repositioning, and a third was found saturated with urine and wearing two briefs, with a saturated dressing. Staffing shortages and lack of communication between shifts contributed to these deficiencies, contrary to facility policy and resident care plans.
Staff did not receive required behavioral health training to manage a resident with psychiatric and neurocognitive diagnoses who exhibited disruptive and aggressive behaviors, resulting in an incident where the resident spat at a CNA and alleged physical abuse. The facility could not provide documentation that the CNA had completed necessary mental health or behavioral health in-service training, despite facility policies requiring such training for staff caring for residents with mental health needs.
A resident with a history of noncompliance was found smoking in another resident's room where oxygen was in use, despite having their smoking privileges revoked. The resident was able to access cigarettes and alcohol, and staff interviews revealed inconsistent enforcement and documentation of the facility's smoking policy. The incident involved a resident with severe cognitive impairment and continuous oxygen therapy, highlighting a failure to prevent unsafe smoking in a high-risk environment.
The facility's FA did not include documentation or evaluation of residents with a history or current use of tobacco, drugs, or alcohol, despite the presence of 41 smokers. The DON confirmed that these populations were not identified in the assessment, resulting in a failure to determine the necessary resources for their care.
A deficiency was cited due to the facility's failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent accidents. The report highlights that the environment did not meet safety standards, increasing the risk of accidents for residents.
A resident with a known history of drug use experienced multiple drug-related medical emergencies within the facility, requiring hospitalization. Facility staff failed to implement effective interventions to prevent drugs from entering, did not consistently investigate or report the incidents, and did not notify regulatory authorities as required.
A resident was found with injuries of unknown origin after sharing a room with another resident known for behavioral issues. Staff did not immediately separate the residents or follow the facility's abuse policy, and failed to document or investigate the incident thoroughly. Key steps, such as interviewing all involved parties and filing a required report, were missed, resulting in a lack of protection for the resident.
A resident experienced multiple incidents resulting in hospitalizations and changes in condition, but the care plan was not updated to reflect new interventions or diagnoses. Staff interviews and documentation confirmed that the care plan remained unchanged despite clear evidence of the need for revision, in violation of facility policy and federal requirements.
The facility did not prevent unauthorized entry and substance use, failed to investigate incidents involving a resident found in distress and a staff-to-resident allegation, and did not notify authorities as required. Investigations were incomplete, and safety measures were not enforced, placing all residents at risk.
The facility did not report several alleged incidents of abuse, neglect, or mistreatment to the NJDOH and other authorities within required timeframes. In one case, a resident was found with unexplained injuries and no report was submitted. In another, a resident's allegation involving an LPN and another resident was not reported because staff felt it was unsubstantiated. A third incident involving inappropriate communication by an LPN was reported late. These actions were not in accordance with the facility's policy or regulatory requirements.
The facility did not conduct thorough investigations into allegations of abuse and failed to follow its own policy, including not interviewing all potentially affected residents or staff and not documenting investigative steps. These failures placed multiple residents, including those with cognitive impairments, at risk by not ensuring proper protection or a complete assessment of potential abuse.
Surveyors found that central bath areas on two units were not maintained in a clean or homelike condition, with sinks and shower beds cluttered with discarded items, visible water on floors, and brown, green, and black substances present in shower stalls and drains. Staff interviews revealed confusion about cleaning responsibilities, and job descriptions indicated that housekeeping was responsible for maintaining cleanliness, but these standards were not met.
A resident was discharged following an incident with a roommate without receiving the required 30-day advance discharge notice or a documented discharge plan. Staff communicated the discharge by phone and provided medications to the responsible party, but there was no evidence of written notification or proper discharge preparation as required by regulations.
A resident did not receive physician-ordered treatment and medication on multiple occasions, with no documentation of administration, refusal, or physician notification. Nursing staff confirmed that facility policy requires all treatments to be documented on the TAR, and that blanks indicate the treatment was not done. The deficiency was identified through record review and staff interviews.
The facility did not meet required CNA staffing ratios on multiple day shifts and was also deficient in total direct care staff on one evening shift, as mandated by New Jersey law. These deficiencies were identified through review of staffing records and interviews, with the shortfall in CNAs and direct care staff having the potential to affect all residents.
The facility did not provide the minimum required nursing staff hours on two days, falling short of the mandated hours needed to care for all residents, including those requiring specialized services such as wound care, tube feedings, and respiratory support.
The facility failed to store, label, and date potentially hazardous foods properly, leading to several deficiencies observed during a survey. Issues included undated and expired food items, improper storage conditions, and lack of sanitary practices in the kitchen and storage areas. The Dietary Director and Licensed Nursing Home Administrator acknowledged these deficiencies.
The facility failed to perform proper hand hygiene during medication administration and meal service, and did not maintain enhanced barrier precautions for residents. Staff were observed not adhering to hand hygiene protocols, and oxygen tubing was not changed as per policy. The DON and IP/RN confirmed these lapses during interviews.
The facility failed to follow its smoking policy and assess a resident's ability to smoke safely. Despite the resident's smoking assessment indicating they were not a smoker, the resident was observed smoking and listed on the smoking schedule. The resident's care plan did not address smoking, and staff were unaware of the resident's smoking status.
The facility failed to ensure safe and appetizing temperatures of food for residents on the Third Floor nursing unit. Most hot foods were below the required 135 degrees Fahrenheit and cold foods were above the required 41 degrees Fahrenheit when served to residents. The Dietary Director acknowledged the deficiency, and the Licensed Nursing Home Administrator and Director of Nursing were informed.
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 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.
Improper Dishwashing and Sanitizer Monitoring Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dishwashing equipment and manual warewashing processes were maintained and operated according to manufacturer specifications and facility policy, resulting in improper sanitation of dishware, cookware, and utensils. Surveyors found that the dish machine’s hot water booster had not been functioning since a snowstorm, and the machine had been converted by the vendor from a high‑temperature to a low‑temperature chemical sanitizing system. Despite this change, there was no evidence that staff were monitoring or documenting dish machine temperatures or chemical sanitizer concentrations. The last recorded entry on the dish machine temperature log was dated 12/31/25, and the acting Food Service Director (FSD) could not demonstrate how to check or interpret chemical concentrations, nor locate appropriate test strips. The dish machine vendor later informed the facility that the chemical sanitizer attached to the dish machine was expired and not properly sanitizing dishware. Surveyors also observed significant deficiencies in the use of the three‑compartment sink for manual warewashing. A dietary staff member was seen washing pots and pans in the first sink and then placing them directly into the third sink containing sanitizer, skipping the required rinse step in the second sink. The staff member stated, "I don't check for anything" and was unable to explain the correct setup or process for the three‑compartment sink. There was no log documenting sanitizer concentration checks for the three‑compartment sink, and the acting FSD could not initially locate test strips or provide policies beyond a poster above the sink. When the acting FSD attempted to test the sanitizer in the three‑compartment sink, she first used chlorine test strips incorrectly (wrong contact time and no color change), then later used the correct quaternary test paper and obtained a reading between 200–400 ppm, but still reported there was no documentation system in place. During meal service observations, surveyors noted that most residents were being served meals on disposable dishware and utensils, while some residents continued to receive meals on regular washable dishware and utensils. On two nursing units, breakfast trays included both disposable and regular dishware, and used meal trays in the hallway contained a mix of ceramic and disposable items. The acting FSD stated that disposable dishware was being used for most residents because the dish machine was not reaching the required sanitizing temperature, but that two residents who refused disposables continued to receive meals on regular dishware and washable utensils. Nursing staff on the units could not explain why disposables were being used and deferred questions to kitchen staff. The LNHA gave conflicting explanations, at one point stating the dish machine had been working and disposables were used due to an influx of evacuated residents, and at another point acknowledging that the machine had been converted to low‑temperature chemical sanitizing. The LNHA was not aware that sanitizer levels needed to be monitored with the low‑temperature setup, and neither he nor dietary staff could provide documentation that sanitizer concentrations were being checked or recorded. These combined failures in equipment maintenance, monitoring, staff competency, and adherence to written policies led to an Immediate Jeopardy determination related to food safety and sanitation for all residents. The facility’s written policies required specific wash and final rinse temperatures for high‑temperature dishwashers and specified sanitizer concentration requirements for low‑temperature dishwashers, but there was no policy guidance on converting from high‑temperature to low‑temperature chemical sanitization when the booster failed. The dish machine failure policy directed the use of disposables when the dishwasher was out of service, but did not address monitoring of chemical sanitizers or procedures for a low‑temperature system. The Safety Data Sheet for the low‑temperature sanitizer attached to the dish machine described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed, underscoring the need for correct use and monitoring. Despite this, staff were unable to demonstrate proper testing of sanitizer concentrations, did not maintain logs, and in at least one instance did not follow the manufacturer’s required wash‑rinse‑sanitize sequence in the three‑compartment sink. These documented observations and interviews formed the basis of the cited deficiency for failure to procure, prepare, and serve food under sanitary conditions and in accordance with professional standards.
Removal Plan
- The LNHA contacted the dish machine vendor.
- The LNHA re-educated the Cook, dietary cooks, and dietary aides regarding kitchen sanitation to ensure proper handling of pots, pans, cutlery, and dishware.
- The LNHA re-educated dietary staff on proper use of the dish machine and the three-compartment sink to ensure washing, rinsing, and sanitizing are done correctly, in the correct order, with proper temperatures and sanitizing.
- The LNHA re-educated dietary staff on the importance of documenting sanitizer test results on flow sheets with each use.
- Return demonstrations/competencies were completed by the pot washers and observed by the LNHA and interim FSD.
- All dietary staff will be re-educated and required to complete competencies and return demonstrations prior to working.
- The LNHA re-educated the Cook and dietary staff regarding the use of disposables/paper goods in the event the dishwasher is out of service.
- All necessary dishware was immediately re-sanitized.
- Signs in English and Spanish with instructions for sanitizer use were posted by the dish machine and three-compartment sink.
Failure to Ensure Competent Dietary Staff and Proper Dishwashing/Sanitizing Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure competent dietary staffing and proper sanitation practices in the food and nutrition service, particularly related to dishwashing and use of the three-compartment sink and dish machine. Surveyors observed that residents on multiple nursing units were being served meals on disposable dishware and utensils, while some residents still received meals on regular ceramic dishware and utensils. Used meal trays in the hallway contained a mix of disposable and reusable items. When the surveyor questioned staff, the acting Food Service Director (FSD) stated that the dish machine had not been functioning for one week and that disposable dishware was being used throughout the facility. The acting FSD also stated that insulated bowls and cups, which were non-disposable, had been washed in the non-functioning dish machine and that the LNHA was aware. During kitchen observations, a dietary staff member was seen using the three-compartment sink incorrectly by scraping and washing pots and pans in the first compartment, skipping the rinse compartment, and then submerging them directly into the sanitizer compartment. This staff member stated he did not have to check anything and was unable to check the sanitizer concentration due to lack of test strips. The acting FSD could not provide a log or test strips for the three-compartment sink. When the surveyor requested information about the dish machine, the acting FSD could not operate it, could not locate the dish machine log, and could not identify who had checked the chemical sanitizer that morning. The LNHA also could not operate the dish machine, stated that the temperature did not need to be checked because it was a low-temperature machine, and could not locate test strips. The dish machine log that was eventually found showed the last entry dated more than a month prior to the survey. Information from the dish machine vendor showed that the dish machine had been converted to a low-temperature, chemical-sanitizing process due to a non-functioning heat booster and roof exhaust issues, and that staff had been advised to check the chemical sanitizer regularly. The facility was unable to provide documentation that the sanitizer had been checked. On a subsequent observation, the surveyor found that the dish machine was not in use, disposable dishware was still being used, and non-disposable meal trays were submerged in the sanitizer compartment of the three-compartment sink. The sanitizer level in the sink did not meet the fill line, and when the acting FSD tested the solution with chlorine test strips, the strip did not change color and was used for an incorrect immersion time. The acting FSD stated the solution was “no good” and admitted unfamiliarity with the chemicals. A poster above the sink described a quaternary sanitizer process requiring different test strips and a specific concentration range, and when the correct quaternary test paper was used, the sanitizer registered between 200–400 ppm, but there was no thermometer to check water temperature and no log documenting concentrations. The facility’s policies addressed high- and low-temperature dishwashing and dish machine failure but did not address conversion to low-temperature chemical sanitization when the heat booster failed, and there was no documentation of staff competencies or consistent monitoring of sanitizer concentrations as required by the vendor’s instructions and the facility’s own policies. The surveyor also reviewed the Safety Data Sheet for the low-temperature sanitizer attached to the dish machine, which described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed. Despite this, there was no evidence that staff were consistently monitoring or documenting the sanitizer concentration in the dish machine or the three-compartment sink. The Food Service Director job description indicated responsibility for ensuring infection control and the highest sanitation standards in the dietary department, but the observations showed that dietary staff, including the acting FSD, were not competent in operating the dish machine, using appropriate test strips, following posted procedures for the three-compartment sink, or maintaining required logs. These actions and inactions resulted in a failure to maintain the kitchen in a sanitary manner and to ensure appropriate measures were in place to prevent potential foodborne illness or exposure to hazardous chemicals for all residents served by the dietary department. The facility’s written policies on dishwasher temperature and dish machine failure specified required wash and rinse temperatures for high-temperature machines, required hypochlorite concentration for low-temperature machines, and the use of disposable products when the dishwasher was out of service. However, there was no policy guidance on converting to a low-temperature chemical sanitizing process when the heat booster failed, and no documentation that staff had been trained or deemed competent in this process. The LNHA acknowledged that staff had only been verbally instructed on how to use test strips and that there were no completed competencies. The combination of a non-functioning or improperly converted dish machine, lack of appropriate test strips and logs, incorrect use of the three-compartment sink, and staff unfamiliarity with chemical sanitizers and posted procedures led to the cited deficiency in providing sufficient, competent support personnel to safely and effectively carry out the functions of the food and nutrition service. Residents throughout the facility were affected in that their meals were being served on a mix of disposable and reusable dishware without assurance that reusable items were being properly washed, rinsed, and sanitized. The report notes that this deficient practice had the potential to affect all residents, as the dietary department serves the entire resident population. No specific resident medical histories or conditions are described in the report, but the observations and interviews collectively demonstrate that the facility did not ensure dietary staff competency in maintaining kitchen sanitation and managing hazardous sanitizing chemicals in accordance with regulatory requirements and facility policies.
Failure to Provide Privacy Curtains for Multiple Residents
Penalty
Summary
Surveyors determined that the facility failed to provide privacy curtains in certain resident rooms, resulting in residents not being afforded full visual privacy. On 2/5/26, between 9:00 AM and 10:45 AM, during a tour of the 5th floor with the LNHA, the surveyor observed that rooms 511A, 514A, 517A, and 519A, which housed a total of eight residents recently transferred from another facility, did not have privacy curtains installed. Later that day at 12:55 PM, when the surveyor asked the LNHA why those residents did not have privacy curtains, the LNHA stated that the maintenance staff had forgotten to install them. The deficiency was communicated to the Administrator at 3:28 PM during the Life Safety Code exit conference. The facility’s written Residents Rights policy, provided by the LNHA, states that employees should treat all residents with kindness and dignity and that federal and state laws guarantee residents’ rights to privacy and confidentiality, including visual privacy, as referenced in NJAC 8:39-31.2(e) and 31.8(c)5. No additional clinical details or specific medical histories of the eight affected residents were provided in the report.
Failure to Provide Functioning Call System for Two Roommates
Penalty
Summary
Surveyors determined that the facility failed to ensure residents had access to a functioning call system, as required by facility policy. During a tour on 2/5/26 at approximately 10:10 AM, a dependent resident with diagnoses including sciatica, depression, Parkinson’s disease, and peripheral vascular disease asked a surveyor to call the nurse. When the surveyor instructed the resident to activate the call bell, it was observed that there was no functioning call bell available. At 10:30 AM, this concern was shared with another surveyor, and at 10:45 AM both surveyors returned to the room and again observed that the residents in that room did not have a functioning call bell. At 10:50 AM, one resident reported that they had been transferred from another facility on 2/3/26 and had not had a call device since the transfer, explaining that their roommate had to go into the hallway to call staff for assistance. The roommate, who reported needing only minimal assistance with care, confirmed that the other resident could not get out of bed and that she had to get out of bed and shout for staff to assist the dependent resident. In a subsequent interview at 12:30 PM, the DON acknowledged awareness that the room’s call device was not functioning and stated she had previously requested that a manual call device be provided, but neither resident had been given one. Review of the facility’s “Call bell Use Responsibility” policy dated 12/25 showed that it required all residents to always have access to a functioning call bell system and stated that failure to ensure access or timely response may place residents at risk.
Failure to Implement Supervision Interventions for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of restlessness, impulsivity, and multiple prior falls sustained a non-displaced fracture of the left clavicle. The resident was known to be at high risk for falls, as indicated by repeated high scores on the Morse Fall Scale and documented incidents of previous falls resulting in injuries such as skin tears and hematomas. The resident's care plan included specific interventions, such as transferring the resident to a recliner chair at the nursing station for increased supervision during periods of restlessness at night. On the night in question, the resident exhibited restlessness from approximately 11:00 PM until 4:00 AM, as reported by the CNA assigned to the shift. However, the intervention to transfer the resident to the recliner chair at the nursing station was not implemented, despite the resident not refusing the transfer. There was also a lack of documentation regarding the resident's restlessness in the plan of care or progress notes, and the nurse on duty was not informed of the resident's behavior. The following morning, the resident was found to be guarding their left arm and grimacing in pain, which led to the discovery of the clavicle fracture after an x-ray was performed. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's behavior during the night. The CNA stated she was aware of the care plan intervention but did not carry it out or properly document the resident's restlessness. The nurse on duty confirmed that, had she been informed, she would have taken additional steps to address the resident's needs. The failure to implement the care plan intervention and provide adequate supervision during a period of increased restlessness directly contributed to the resident's injury.
Widespread Environmental Deficiencies and Pest Infestation
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions, pest infestations, and delayed removal of soiled items. Surveyors observed heavily soiled ice machines with black and white substances, rust buildup, and water leaks on several floors. Food carts with leftover, uncovered food from previous meals were left unattended, and resident rooms contained food debris, soiled linens, and broken furniture. Bathrooms were found with debris, broken fixtures, and in one instance, a cockroach was observed crawling on the wall during incontinence care. Staff confirmed the presence of cockroaches and described the protocol for reporting pest sightings, which included documentation in a pest control log and notification of the Maintenance Director. Pest logs revealed ongoing documentation of cockroach sightings in resident rooms and common areas dating back several months. Residents and staff consistently reported and observed cockroach infestations throughout the facility, including in bedrooms, bathrooms, closets, and on personal belongings. Surveyors directly observed swarming live cockroaches and dead cockroaches on sticky traps in resident closets, with personal items such as blankets and clothing exposed to the pests. Multiple residents expressed distress about the presence of cockroaches, describing them crawling on their faces and beds, and reported taking measures such as blocking beds with towels to prevent contact. Staff also reported wrapping their personal belongings in plastic bags to protect them from cockroaches. Despite ongoing pest control efforts, the infestation persisted, with sightings documented on all resident floors and in various locations, including on a clean linen cart and near medication carts. In addition to pest issues, the facility failed to promptly clean up resident excrement and address strong odors. Surveyors noted a strong odor of feces in a hallway, and upon investigation, found that a resident's bedside commode had not been cleaned after an episode of incontinence and vomiting overnight. The roommate reported the odor to staff, but the issue was not resolved in a timely manner, and the responsible LPN acknowledged being aware of the situation but did not ensure it was addressed. Damaged and chipped furniture, cracked countertops, and exposed wallboard were also observed, contributing to an environment that was not clean or homelike. Residents and staff confirmed that these conditions had been ongoing and were not adequately addressed.
Failure to Provide Adequate Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in multiple deficiencies across several units. Two residents were observed to have not received timely incontinence care, with one resident remaining unchanged and un-repositioned for over 10 hours, resulting in saturated bedding and visible skin redness. Another resident, who was nonverbal and totally dependent on staff, was found with two saturated incontinence briefs and a wound dressing soaked with urine and bloody drainage. Staff interviews confirmed that incontinence care was not provided as required, and that staff shortages contributed to the lack of care, with CNAs responsible for an excessive number of residents per shift. Medication administration practices were also deficient. One resident was found with a medication cup containing four tablets left unattended at the bedside for over three hours after the MAR had been initialed as administered. The resident was unable to reach the medication due to weakness, and staff interviews confirmed that medications should not be left unattended and that the nurse failed to ensure the resident swallowed the medications before documenting administration. The facility's policy prohibits leaving medications in resident rooms or unattended on the medication cart. Additionally, the facility failed to maintain cleanliness and respond to resident needs in a timely manner. A strong odor of feces and vomit was noted in a resident room, with one resident reporting that the smell persisted overnight and that staff had not cleaned the bedside commode or removed vomit from the garbage can. Staff confirmed awareness of the issue but cited workload and staffing shortages as reasons for not addressing it. Review of staffing records revealed that the facility did not consistently meet New Jersey's minimum CNA staffing requirements on multiple day shifts, with several days falling below the mandated ratios.
Failure to Implement Infection Control Program Amid Cockroach Infestation and Lack of Water Management
Penalty
Summary
The facility failed to develop and implement an effective infection prevention and control program (IPCP), as evidenced by a widespread cockroach infestation affecting all resident units, improper handling and storage of clean linens, and the absence of a water management policy to prevent Legionella and other pathogens. Surveyors observed cockroaches in multiple locations, including resident rooms, closets, bathrooms, and on clean linen carts. Food debris and soiled linens were found on floors, and residents and staff reported frequent sightings of cockroaches on personal belongings, clothing, and even on residents themselves. Documentation in pest control logs confirmed ongoing cockroach activity for several months, with staff and residents consistently reporting the problem. Interviews with staff, including CNAs, the Infection Preventionist (IP), the Maintenance Director, and the Licensed Nursing Home Administrator (LNHA), revealed a lack of coordinated response to the infestation. The IP was not involved in pest control efforts and was unaware of the extent of the problem, deferring responsibility to the maintenance department. The pest management company identified the cockroaches as German cockroaches, known for being difficult to eradicate and capable of transmitting disease. Despite recommendations from pest control service reports for improved sanitation, there was little evidence of follow-up or comprehensive action to address the infestation or to protect residents' personal belongings and clean linens from contamination. Additionally, the facility did not have a water management program or policy in place to prevent the growth and spread of Legionella. When surveyors requested documentation of water testing or preventive measures, facility management was unable to provide any evidence of such activities. The Director of Nursing confirmed the absence of a water management program, and no logs or policies were available to demonstrate compliance with infection control standards related to water safety.
Ice Machines Not Maintained in Clean and Sanitary Condition
Penalty
Summary
Surveyors identified a deficiency related to the maintenance and sanitation of ice machines on the 2nd, 3rd, and 4th floor resident units. During initial tours, surveyors observed that all three ice machines had significant visible soiling, including white and black substances inside the ice chutes, rust-like buildup on drain covers, peeling molding, and spatter-type debris on the exteriors. The drain areas were also noted to be soiled and stained. These observations were confirmed in the presence of the Licensed Nursing Home Administrator (LNHA), who acknowledged the debris and unsanitary conditions. Interviews with the Maintenance Director (MD) revealed a lack of knowledge regarding the cleaning schedule and procedures for the ice machines. The MD was unable to confirm when the machines were last cleaned, whether there was documentation of cleaning, or the steps required for proper cleaning. The MD also stated that he had not cleaned the machines since his appointment and was unaware of the need to do so. The facility had discontinued service contracts for the ice machines after a change in management, and the MD indicated that the previous company had performed monthly cleanings, but this practice had not continued. A review of the manufacturer's manual provided by the facility outlined specific maintenance requirements, including weekly exterior cleaning and descaling/sanitizing procedures at least every six months. The manual also described additional procedures for heavily soiled machines and emphasized the use of appropriate cleaning agents. The surveyors found that these maintenance protocols were not being followed, as evidenced by the condition of the machines and the lack of staff knowledge or documentation regarding cleaning and maintenance activities.
Failure to Provide Timely Incontinence and Nail Care for Dependent Residents
Penalty
Summary
Surveyors identified that staff failed to provide routine and appropriate incontinence care and maintain fingernail hygiene for residents dependent on staff for activities of daily living. One resident was repeatedly observed with long, jagged fingernails containing a black substance underneath, despite being alert, requesting nail care, and having a scheduled weekly shower. The resident's care records did not include a physician's order for fingernail care, and nail care was not completed during the scheduled shower. Another resident reported not receiving incontinence care or being repositioned since the previous night, resulting in the resident being found saturated with urine and lying in soiled bedding. The resident, who was cognitively intact and required assistance with personal hygiene, stated that staff did not respond to their call light. The CNA assigned to the resident was unaware of the lack of care due to not receiving a shift report, and the unit was short-staffed due to a call-out, with each CNA responsible for 23 residents. A third resident, who was nonverbal and totally dependent on staff, was found with contracted extremities, saturated with urine, and wearing two incontinence briefs, both soaked. The resident's dressing was also saturated with urine and bloody drainage. The CNA responsible for the resident confirmed placing two briefs on the resident and could not recall when the resident was last changed. Staff interviews confirmed that incontinence care was expected every two hours, but staffing shortages impacted care delivery. Facility policy required individualized ADL care, including regular incontinence care and maintaining resident dignity and hygiene.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that staff received behavioral health training as required, specifically in managing residents with maladaptive behaviors such as being disruptive, cursing, and spitting at staff. This deficiency was identified during the review of an incident involving a resident with diagnoses including bipolar disorder, post-traumatic stress disorder, and frontotemporal neurocognitive disorder. The resident, who had a history of making false statements and being easily frustrated with staff, was involved in an altercation where they took a piece of cake intended for another resident, ate it, and then spat it at a CNA after being confronted. The CNA involved in the incident attempted to retrieve the cake and placed her hand in front of the resident's mouth to prevent being spat on, which led to the resident alleging that the CNA hit them. The CNA later acknowledged that her response was inappropriate and that she should have walked away instead. The facility's documentation did not provide evidence that the CNA had received specific behavioral health or mental health training, nor was there documentation confirming completion of the required annual in-service training on these topics. The facility's assessment indicated that services were provided for residents with mental health and behavioral needs, and that training and competency checks were to be conducted upon hire, monthly, and annually, including dementia management and care of cognitively impaired residents. However, the lack of documented evidence of behavioral health training for the CNA contributed to the deficient practice, as staff were not adequately prepared to cope effectively with residents exhibiting challenging behaviors.
Resident Smoked in Room with Oxygen Despite Revoked Privileges
Penalty
Summary
A deficiency occurred when a resident, whose smoking privileges had been revoked due to repeated violations of the facility's smoking policy, was found smoking a cigarette inside another resident's room where oxygen was in use. The Nursing Supervisor observed the resident in a wheelchair, smoking in the room of two other residents, one of whom was receiving continuous oxygen therapy for chronic respiratory failure and had severely impaired cognition. Upon entering the room, the supervisor confiscated the cigarette, and a subsequent search of the resident's wheelchair revealed a pack of cigarettes and a bottle of vodka. The resident had a documented history of noncompliance with the smoking policy, including sharing cigarettes, smoking outside designated areas, and failing to leave tobacco products at the front desk, as required by facility policy. The facility's records indicated that the resident's smoking privileges had been revoked prior to this incident, and the care plan had been updated to reflect this, with interventions such as re-education on the smoking policy and the use of nicotine patches. Despite these measures, the resident continued to access and use tobacco products within the facility. Staff interviews revealed that previous incidents involving the resident's possession and use of smoking materials had been reported, but there was inconsistency in follow-up actions and documentation. Additionally, the facility's documentation did not include statements or assessments for the other residents present in the room at the time of the incident, one of whom was cognitively impaired and dependent on supplemental oxygen. The facility's smoking policy explicitly prohibited residents from keeping tobacco products or lighting materials on their person or in their rooms, especially in the presence of oxygen, due to the risk of fire or explosion. However, the resident was able to circumvent these safeguards, resulting in a situation where smoking occurred in a high-risk environment. The lack of consistent enforcement of the smoking policy and insufficient monitoring allowed the resident to possess and use prohibited items, directly leading to the identified deficiency.
Removal Plan
- The Nursing Supervisor (NS) removed the cigarette from Resident #2.
- Resident #2 was searched, and a pack of cigarettes and a pint of vodka was confiscated and destroyed.
- Resident #2 was placed on 1:1 assignment until their discharge from the facility.
- The NS educated Resident #2 and Resident #3 that smoking was prohibited in a resident room.
- Nurse leaders began educating all residents who smoked on the facility's smoking policy and the dangers of smoking near oxygen, and their rooms and equipment were searched by the Assistant Director of Nursing (ADON) for violation of the smoking policy.
- The nurse leaders and Consultant Registered Nurse (RN) re-educated all staff on the smoking policy and the dangers of smoking near oxygen.
Facility Assessment Lacked Evaluation of Residents with Tobacco, Drug, or Alcohol Use
Penalty
Summary
The facility failed to ensure that its facility-wide assessment (FA) adequately evaluated the resident population and identified the necessary resources to provide care and services for residents with a history or current use of tobacco, drugs, or alcohol. The FA, completed on 05/03/2025 and provided by the DON, did not include documentation addressing residents admitted with these specific needs. During an interview, the DON confirmed that the FA did not identify smokers as a category of the population served, despite the facility currently having 41 smokers. The deficiency was identified through interviews and review of facility documentation, and the DON acknowledged the omission after reviewing the FA in the presence of the surveyor.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. The deficiency centers on the lack of appropriate measures to identify and eliminate accident hazards, as well as insufficient supervision to safeguard residents from potential harm.
Failure to Prevent and Investigate Drug-Related Incidents
Penalty
Summary
The facility failed to ensure the safety of its residents by not implementing effective interventions to prevent illicit drugs from entering the facility and to prevent drug-related incidents among residents. Despite being aware that a resident had a history of drug use and overdose, the facility did not take adequate measures to monitor or restrict access to substances, resulting in multiple incidents where the resident was found unresponsive or in distress and required hospitalization for drug-related diagnoses. The facility also did not conduct thorough investigations into these incidents, and staff were uncertain about the source of the drugs or whether the resident had used substances within the facility. On several occasions, the resident was found in a compromised state, such as being unresponsive in a wheelchair, and required emergency intervention and transfer to the hospital. Documentation and interviews revealed that staff observed symptoms consistent with drug overdose, administered emergency medications, and called for emergency services. However, there was a lack of consistent incident reporting, and some staff did not complete incident reports or investigations, believing the incidents may have been related to the resident's activities outside the facility. There was also confusion among staff regarding the requirements for reporting such incidents to regulatory agencies. The facility's policies acknowledged an increase in residents with a history of drug use and outlined the need for assessment and follow-up treatment if drug use was suspected. However, the facility did not follow its own protocols for incident reporting and failed to notify the appropriate state and local authorities about the drug-related incidents. Staff interviews indicated uncertainty about their ability to search residents or prevent drugs from entering the facility, and there was a lack of clear action to investigate or address the repeated incidents involving the resident.
Plan Of Correction
F 000 F 000 *Free of Accident Hazards/Supervision/Devices ELEMENT ONE: CORRECTIVE ACTION: - The U.S. FOIA (b) (6) [R] and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and [R] and the requirements to report these incidents to the DOH [R] /LTCO or [R]. All nursing staff was re-educated on the illicit drug use policy which includes reporting overdoses to the New Jersey Department of Health and police on 5/9/25. The Director of Nursing re-investigated the incidents involving Resident #6 on [R]. An audit was conducted to identify all residents with a history of [R] and/or [R] on [R]. The Social Worker met with all residents with a history of [R] and/or [R] to educate residents on the medical risks of [R] use and [R] involvement. All residents were notified that upon return from out on pass they will be subjected to a search by nursing and/or security. Upon any suspicion of [R], a room search will be conducted by nursing/security. All residents suspicious of [R] will be required to open any incoming packages/deliveries in the presence of a staff member of nursing or security. If resident is found to be in possession of [R] and/or if an [R] occurs, the resident will be subject to a possible 30-day discharge notice from the facility, and/or revoking of facility out on pass privileges on 5/9/25. The Social Worker provided education to all residents with a history of [R] use and/or [R] on the availability of [R] programs on 5/9/25. The Social Worker met with Resident #6 to educate the resident on the availability of [R] programs, the medical risks of NJ Ex Order 26.4(b)(1) [R] involvement, possible 30-day discharge notice from the facility, and revoking of facility out on pass privileges on 5/9/25. All nursing staff were re-educated on signs of overdose and policies to follow in cases of suspected overdose and availability of drug cessation programs for residents on 5/9/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that drugs and alcohol are not allowed in the home on 5/9/25. All residents are educated about illicit drug use policy at Resident Council meetings. The Social Worker meets with new residents who have a history of illicit drug use / overdose to discuss policy and options for treatment of addiction. Violations of illicit drug abuse policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted, and a QAPI performance improvement project team formed to address clinical concerns. Violations of illicit drug abuse policy are discussed at weekday clinical meetings. Drug overdoses in the home are reported to the Licensed Nursing Home Administrator and Director of Nursing to ensure that the police were called and the New Jersey Department of Health was notified. The Director of Nursing will report on audits of the weekday clinical meetings and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for three months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- Provided education to all residents with a history of drug overdose on the medical risks with illegal drug use, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
- Provided education to the residents on cessation programs and psychiatric consultations.
- Placed signage at the entrance of the facility stating that drugs and alcohol were not allowed in the facility.
- Educated facility staff that any drug overdose is to be reported to the appropriate regulatory agencies immediately.
- Educated facility staff on new interventions implemented to help prevent illegal drug use.
- Implemented new interventions including education to the residents on the risks of a drug overdose, room searches, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
- Implemented an audit process during the morning daily clinical meeting to identify residents with a new history of use and any incidents that occur in the facility, ensuring police were called and appropriate regulatory agencies were notified.
- Re-educated administrative staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts on illicit drug use at the facility.
- Posted signage in the front of the building that no alcohol or drugs were allowed in the facility.
- Educated all facility staff on elimination of illicit drug use in the facility and to report any illicit drug use to the DOH and the police.
- Audited all incidents and accidents to ensure there were no additional unresolved allegations of abuse, neglect, and illicit drug use identified.
- Implemented an audit process during the morning daily clinical meeting to assess potential abuse and any illicit drug activity and ensure these concerns were addressed per the facility policy.
Failure to Protect Resident from Abuse and Incomplete Investigation
Penalty
Summary
The facility failed to protect a resident from abuse and did not follow its own policy titled "Abuse, Resident Behavior and Facility Practice." An incident occurred in which a resident was observed to have injuries of unknown origin after sharing a room with another resident who had a documented history of behavioral issues. The staff did not immediately separate the residents or implement the abuse policy as required. There was no documentation in the medical record or progress notes to indicate that the care plan for the resident with behavioral issues was followed at the time of the incident. Additionally, the facility did not conduct a thorough investigation into the incident. There was no record of a Facility Reportable Event (FRE) being filed with the New Jersey Department of Health, and no investigation was completed for the event. Staff interviews revealed that key steps were missed, such as interviewing the roommate and other potential witnesses, and there was a lack of follow-up outside of a grievance form. The supervisor and LPN involved did not speak with all relevant parties or document their actions in accordance with facility policy. The failure to follow established procedures and policies resulted in the residents not being protected from potential abuse. The lack of immediate action, incomplete documentation, and insufficient investigation placed the affected resident and others at risk. The facility's own staff acknowledged that the abuse policy was not followed and that necessary steps, such as interviewing all involved individuals, were omitted.
Plan Of Correction
F 000 F600 *Free from Abuse and Neglect ELEMENT ONE: CORRECTIVE ACTION: The U.S. FOIA (b)(6) received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for NJ Exec Order 26.4b1 and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. Resident #15 was evaluated for signs of NJ Exec Order 26.4b1 and none were noted. The LPN involved in the incident involving Resident #8 and Resident #15 no longer works at the building. The caring for Residents #8 and #15 on NJ Ex Order 26.4(b)(1) was re-educated on the abuse policy on 5/9/25. The care plans of Residents #8 and #15 were reviewed and updated on 5/9/25. The U.S. FOIA (b) (6) met with Resident #15 to support and offer a room change on NJ Exec Order 26.4b1. Resident #8 and Resident #15's incident of der 26.4b1 was reinvestigated by the U.S. FOIA (b) (6) on 5/9/25. The Director of Nursing / designee re-educated all nursing staff about the abuse policy on 5/9/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect on 5/12/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. All residents were educated regarding the abuse policy at the resident council meeting held on 5/7/25. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 F 600 F 600
Removal Plan
- The facility implemented a corrective action plan to remediate the deficient practice.
- All facility staff were educated on the facility's policy abuse prevention, recognition of and types of abuse, reporting urgency and reporting to the regulatory agencies.
- The facility audited all incidents and accidents to assure there were no additional unresolved of identified.
- The facility implemented an auditing process to assess potential and ensure concerns are addressed through the policy.
- Auditing of all accidents will occur Monday through Friday, with weekend incidents included in the Monday audit.
- The residents that were on LPN #1's schedule were interviewed and assessed for any complaints of NJ Ex Order 26.4(b)(1) requested or witnessed by LPN #1.
- The SMRT and the US FOIA (D) educated the social workers (SW) and administrative nursing staff on the facility's policy on reporting of Exous and conducting a thorough investigation.
- The U.S. FOIA (b)(6) conducted an investigation into incidents and accidents from NJ Ex Order 26.4(b)(1).
- An audit was implemented daily at morning clinical meeting on all accidents and incidents to determine if conducted investigations were completed correctly.
Failure to Update Care Plan After Resident Incidents
Penalty
Summary
The facility failed to update the care plan with appropriate interventions for a resident who experienced multiple incidents while at the facility. Despite the resident being sent to the hospital on several occasions with significant changes in condition and new diagnoses, the care plan was not revised to address these events. Medical record reviews and staff interviews confirmed that the care plan did not reflect updated interventions after each incident, even though the resident returned from the hospital with new or ongoing medical issues. Staff interviews revealed that there was an expectation for care plans to be updated after incidents or significant changes in a resident's condition. However, the responsible staff either believed the existing interventions were sufficient or were unaware that updates had not been made. Documentation showed that the care plan remained unchanged after the resident's hospitalizations and subsequent returns, despite clear evidence of changes in the resident's health status. The facility's own policy required care plans to be reviewed and updated as changes in the resident occurred, including changes in diagnosis or condition. The failure to update the care plan as required by both facility policy and federal regulations resulted in a deficiency, as the care plan did not accurately reflect the resident's current needs or provide guidance for staff following significant health events.
Plan Of Correction
F 000 F657 Care Plan Timing and Revision ELEMENT ONE: CORRECTIVE ACTION: The care plan of Resident #6 was reviewed and updated to reflect history and potential risk of NJ Exec Order 26.4b1 [R]. The staff caring for Resident #6 were educated on the updates to the care plan. The Director of Nursing / designee re-educated the nursing administrative team and U.S. FOIA (b) (6) on the resident care plan policy. An audit of the care plans of residents with history and/or potential risk of NU EXOD or NJ Ex Order 26.4(b)(1) [R] was conducted and care plans updated as needed. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Residents with incidents of illicit drug abuse and/or overdose will be discussed and care plans updated at weekday clinical meetings. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Illicit drug abuse and/or overdose are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of care plans at the weekday clinical meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- Resident #6's care plan was updated.
- Administrative nursing staff and social workers were educated on updating and implementing care plans when incidents occur.
- A process was implemented to occur during daily morning clinical meetings to ensure that care plans are updated when incidents occur.
Failure to Prevent and Investigate Resident and Staff Incidents
Penalty
Summary
The facility failed to ensure resident safety and well-being by not preventing unauthorized individuals from entering the facility and not preventing incidents involving residents. There was a lack of safety measures to prevent the use of prohibited substances by residents, and the facility did not conduct thorough investigations into incidents involving staff-to-resident and resident-to-resident interactions. Specifically, the administrative staff did not investigate an incident involving a resident who was found in distress and later transferred to the hospital, despite the resident's history of substance use and suspicious behavior observed by staff. The staff did not report or investigate the incident as required, and there was no notification to the Department of Health or law enforcement regarding the event. Additionally, the facility failed to conduct a thorough investigation into an allegation involving a staff member and a resident. When a resident reported observing an LPN in a resident's room under suspicious circumstances, the administrative staff did not interview all relevant residents or staff members, nor did they collect statements as per facility policy. The investigation was limited and did not follow the established procedures for handling such allegations, as acknowledged by the staff during interviews with surveyors. The facility's job descriptions for the Administrator and Director of Nursing outlined responsibilities for maintaining safety standards and conducting thorough investigations, but these were not followed in practice. The lack of proper investigation and failure to implement safety measures placed all residents at risk and resulted in a finding of Immediate Jeopardy by surveyors.
Plan Of Correction
F835 Administration ELEMENT ONE: CORRECTIVE ACTION: The abuse and illicit drug policies were reviewed and updated. The U.S. FOIA (b) (6) and U.S. FOIA (b) (6) received re-education by the corporate officer on job description and abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Licensed Nursing Home Administrator and Director of Nursing re-educated staff on abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Social Worker met with residents with a history of NJ Ex Order 26.4(b)(1) and/or NU EXOTORRADX to educate on the availability of NJ Ex Order 26.4(b)(1) programs, the medical risks of NJ Ex Order 26.4(b)(1) NJ Ex Order 20 involvement, possible discharge from the facility, and revoking of facility leave privileges on 5/9/25. Nursing staff was re-educated on signs of NU EXOrder 26.4DX and policies to follow in cases of suspected ExOrder 254(DX(1)) and the availability of NU Ex Order 26.4(b)(1) programs for residents on 5/9/25. The Director of Nursing / designee re-educated staff on signs of J Ex Order 25.4(D)(1) and policies to follow in cases of NJ Ex Order 26.4b1. The Director of Nursing re-investigated the incidents involving Residents #3, #6, #8, and #15. Care plans of residents cited in the 2567 were reviewed and/or updated by the interdisciplinary team. Incidents and accidents occurring from January through May were audited to ensure there were no identified, unresolved NJ Ex Order 26.4(b)(1) and/or NJ Ex Order 26.4(b)(1). ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that [R] and [R] are not allowed in the home on 5/9/25. The Social Worker meets with new residents who have a history of [R] and/or [R] to discuss policy and options for treatment of [R]. [R] and violations of [R] policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Abuse allegations and violations of illicit drug abuse policy are discussed at weekday clinical meetings, and all concerns are reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- The Corporate Officer re-educated staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts.
- Signage was posted in the front of the building that no alcohol or drugs were allowed in the facility.
- The designee educated all the facility staff on elimination of use in the facility and to report any use to the Department of Health.
- Incidents and accidents were audited to ensure there were no additional unresolved issues identified.
- An audit process was implemented during the clinical meeting to assess concerns and ensure these were addressed per the facility policy.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to report multiple alleged violations involving abuse, neglect, or mistreatment to the New Jersey Department of Health (NJDOH) and other required authorities within the regulatory timeframes. In one instance, a resident was observed with injuries of unknown origin, and the facility did not provide documentation that a Facility Reportable Event (FRE) was completed or submitted to the NJDOH. The resident was unable to recall how the injury occurred, and the staff member interviewed stated they did not consider the incident reportable due to the resident's lack of recollection, despite acknowledging that such events should be reported. In another case, a resident reported to an LPN that they intended to report the LPN for an incident involving another resident. The LPN was suspended pending investigation, but the FRE did not indicate whether the required notification to the NJDOH was made. The staff member interviewed admitted to not notifying the appropriate authorities because they felt the allegation was unsubstantiated, contrary to regulatory requirements. A third incident involved a resident reporting to staff and the Ombudsman that an LPN had spoken to them inappropriately. The event was eventually reported to the NJDOH, but not within the required timeframe. The staff member confirmed that the report was delayed and acknowledged that it should have been made sooner. The facility's own policy requires timely reporting of all allegations of abuse, neglect, or mistreatment to regulatory agencies, but this was not followed in these cases.
Plan Of Correction
F609 Reporting of Alleged Violations ELEMENT 1 The U.S. FOIA (b) (6) and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. The Director of Nursing / designee re-educated all leadership staff about the abuse policy to include abuse prevention, recognition of and types of abuse, reporting urgency, and reporting to the regulatory agencies. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. The New Jersey Department of Health, police, and ombudsman were notified regarding the 10/12/24 incident between Residents #8 and #15. The police were notified regarding the 4/25/25 incident between LPN #1 and Resident #3. ELEMENT 2: All residents have the potential to be affected by this practice. ELEMENT 3: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT 4: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025
Failure to Conduct Thorough Abuse Investigations and Follow Facility Policy
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, neglect, or mistreatment as required by federal regulations and its own policies. In one instance, a resident was observed to have experienced an incident involving another resident, but the facility did not conduct a comprehensive investigation beyond speaking with the two residents involved. There was no documented follow-up, no collection of witness statements, and no further inquiry outside of a grievance filed for the affected resident. The facility's policy, which mandates timely and thorough investigation including obtaining written statements from staff and interviewing witnesses, was not followed. In another case, a resident reported witnessing an incident involving an LPN and another resident. The LPN was suspended immediately after the report, but the investigation was limited to interviews with the reporting resident, the accused LPN, and two other staff members. The facility did not interview or assess other residents who were under the care of the LPN, nor did it obtain statements from other staff who worked on the unit during the time frame in question. The responsible staff member acknowledged that a more thorough investigation, including interviews with all potentially affected residents and staff, was not conducted due to uncertainty about the timing of the alleged incident. These failures to follow investigative protocols and facility policy resulted in the facility not ensuring the protection of residents during the investigation process. The lack of comprehensive investigation and documentation placed multiple residents at risk, as the facility did not take all necessary steps to determine the extent of potential abuse or mistreatment. The surveyor found that these deficiencies affected several residents, some of whom had cognitive impairments or other medical conditions, and that the facility did not implement its abuse prevention and investigation policy as required.
Plan Of Correction
F610 *Investigate/Prevent/Correct Alleged Violation ELEMENT ONE: CORRECTIVE ACTION: The U.S. FOIA (b) (6) received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for NJ Exec Order 26.4b1 and the requirements to report these incidents to the DOH/police/LTCO on NJ Exec Order. The Licensed Nursing Home Administrator and Director of Nursing re-educated the U.S. FOIA (b) (6) and all nursing staff on the abuse policy to include reporting abuse and conducting a thorough investigation on NJ Exec Order 25 and NJ Exec Order 2. The resident-to-resident involving Resident #8 and Resident #15 on NJ Exec Order 26.401 was reinvestigated by the U.S. FOIA (b) (6) on NJ Exec Order. The NJ Exec Order 26.4(b)(1) involving LPN #1 and Resident #3 on 4/25/25 was reinvestigated by the U.S. FOIA (b) (6) to include interviews with residents on LPN #1's work assignment and witness statements from staff on 5/8/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. All residents are educated about abuse policy at Resident Council meetings. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 202
Removal Plan
- All facility staff were educated on the facility's abuse-prevention policy, recognition of and types of abuse, reporting urgency, and reporting to regulatory agencies.
- Audited all incidents and accidents to assure there were no additional unresolved incidents identified.
- Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
- Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.
- Residents that were on LPN #1's schedule were interviewed and assessed for any complaints of inappropriate behaviors requested or witnessed by LPN #1.
- Educated the social workers and administrative nursing staff on the facility's policy on reporting of abuse and conducting a thorough investigation.
- Conducted an investigation into incidents and accidents.
- Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
- Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.
Failure to Maintain Clean and Homelike Bathing Areas
Penalty
Summary
Surveyors identified a failure to maintain a clean and homelike environment on two of three units, specifically on the second and fourth floors. During tours, the surveyor observed multiple sanitation and housekeeping deficiencies in the central bath areas. These included a sink filled with discarded items such as an isolation gown, black pad, wash sponge, and basin; a shower bed with hair clippings, toilet paper, personal care products, and debris; visible water on the floor inside and outside the shower stall; and the presence of brown, green, and black substances in various corners and on the floors of the shower stalls. Additional findings included wet towels and socks left in the shower, a build-up of unknown debris and hair in the shower drain grate, and missing molding with a hard brown substance on the wall. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and maintaining the shower areas. An LPN stated that CNAs were responsible for gathering residents' belongings after showers, and that housekeeping was responsible for cleaning the shower rooms. However, staff were unsure about the nature of the substances found in the showers and who was responsible for cleaning specific areas such as the shower grate. Staff confirmed that the observed conditions did not create a homelike environment for residents. A review of the facility's housekeeping and environmental services job descriptions indicated that housekeeping staff were expected to perform cleaning and sanitation of resident rooms and common areas, conduct regular inspections, and collaborate with other team members to maintain cleanliness. The director of environmental services was responsible for supervising housekeeping and laundry activities to keep the facility orderly, clean, and sanitary. Despite these outlined responsibilities, the observed deficiencies indicated that these standards were not met in the central bath areas on the affected units.
Plan Of Correction
F584 Safe/Clean/Comfortable/Homelike Environment ELEMENT ONE: CORRECTIVE ACTION: The second and fourth floor Central Baths were cleaned and sanitized by housekeeping on 5/9/25. Noted black, brown, green, and red substances were removed from the second and fourth floor Central Baths on 5/9/25. Personal hygiene and linen items were removed from the second-floor Central Bath sink on 5/9/25. Hygiene and toiletries were removed from the second-floor Central Bath shower bed. The molding in the 1st stall in the second-floor Central Bath was repaired on 6/7/25. The build-up of unknown debris and hair in the 1st stall second-floor Central Bath shower was removed on 5/9/25. Visible water on the floor inside and outside the second-floor Central Bath shower stall was removed on 5/9/25. The housekeeping staff were re-educated in daily responsibilities to clean showers and to report any cleaning concerns to their director. The nursing staff was re-educated to remove all personal items after showers on 6/9/25. The maintenance staff was alerted to evaluate drainage in the second-floor shower. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Leadership makes weekly rounds to check on cleanliness of showers. The process for requesting maintenance work was reviewed and staff re-educated. Maintenance and housekeeping issues are discussed at daily operation meetings. The Licensed Nursing Home Administrator reviews and acts upon issues reported. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address maintenance and housekeeping concerns. The housekeeping director/nurse leadership designee will conduct weekly rounds to inspect the cleanliness, neatness, and functioning of showers. Maintenance will be notified to correct any repairs needed. Findings of rounds shall be reported to the Licensed Nursing Home Administrator weekly for 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Failure to Provide Required 30-Day Discharge Notice and Proper Discharge Planning
Penalty
Summary
A deficiency was identified when a resident was discharged from the facility without receiving the required 30-day advance discharge notice. The resident, who had a documented history of certain diagnoses and a Brief Interview of Mental Status (BIMS) score, was involved in an incident with a roommate. Following this incident, the resident did not return to the facility, and staff communicated the discharge to the resident's responsible party via phone call. There was no evidence in the record that the required written notification was provided to the resident or their representative. Interviews with facility staff, including two social workers and another staff member, revealed that the decision to not readmit the resident was made by administration and admissions, not by the social workers. Staff described the discharge as 'safe' because the resident had nowhere else to go and because medications and the electronic Medication Administration Record (eMAR) were provided to the responsible party upon the resident's departure. However, there was no documentation of a formal discharge process or orientation to ensure a safe and orderly transition, as required by regulations. Record review confirmed the absence of documentation for a 30-day advance discharge notice or evidence of a comprehensive discharge plan. The facility failed to comply with federal and state requirements regarding transfer and discharge, including the need for proper documentation, communication, and preparation for discharge. The lack of adherence to these procedures resulted in the resident being discharged without the protections and planning mandated by regulation.
Plan Of Correction
F 627 F627 Inappropriate Discharge ELEMENT 1 The Director of Nursing reviewed the discharge documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 The policy for discharge when necessary was reviewed and updated as appropriate by the Licensed Nursing Home Administrator and Director of Nursing. The Director of Nursing re-educated leadership on documentation of discharge when necessary. Discharges occurring from January 2025 through May 2025 were audited to ensure that there were no other occurrences of discharge when necessary. The documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 4 A root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Social Worker reports on discharges monthly. Findings shall be reported to the Licensed Nursing Home Administrator weekly for three months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025
Failure to Administer and Document Physician-Ordered Treatment
Penalty
Summary
The facility failed to follow a physician's order for a treatment for one resident, as well as its own policies regarding physician orders and medication administration. Specifically, the treatment and medication ordered by the physician were not administered on several specified dates, as evidenced by blank entries on the Treatment Administration Record (TAR). There was no documentation of the treatment being provided, nor was there any record of the resident refusing the treatment or the physician being notified of missed doses. Interviews with nursing staff confirmed that the expectation is for all treatments to be administered as ordered, with proper documentation on the TAR. Staff stated that a blank on the TAR indicates the treatment was not done, and that refusals or missed treatments should be documented, with the physician notified as appropriate. The facility's policies require that all treatments and medications be documented, and that any medication not given, including refusals, must be recorded with the reason and physician notification as needed. A review of the resident's medical record showed that the required treatment was not administered on multiple occasions, and there was no documentation in the progress notes or TAR to indicate that the physician was notified of these missed treatments. The deficiency was identified for one of eighteen residents reviewed, and the failure to follow physician orders and facility policy was confirmed through record review and staff interviews.
Plan Of Correction
F658 Services Provided Meet Professional Standards ELEMENT 1 The staff caring for Resident #5 on days 7/6, 7/7, 7/20, 7/25, and 7/31/24 were re-educated on physician order and medication administration policies on documentation. Staff was re-educated to follow up with notification to medical provider and document when treatments are not performed. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 Leadership staff are educated on use of the Point Click Care dashboard to track missing medication and treatment signatures. Staff are directed by nurse leadership to complete electronic treatment record documentation before the end of shift. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Director of Nursing / designee audits numbers of missed documentation monthly. Findings shall be reported to the Licensed Nursing Home Administrator x 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet mandatory staffing ratios as required by New Jersey law for certified nurse aides (CNAs) and direct care staff. During a review of staffing records for a two-week period, it was found that the facility did not have the required number of CNAs on 12 out of 14 day shifts and was also deficient in total direct care staff on one evening shift. Specific examples include having only 17 CNAs for 176 residents on one day when at least 22 were required, and similar shortfalls on multiple other days. The facility also had one overnight shift where the total staff was below the required minimum. These deficiencies were identified through interviews and document reviews conducted during the complaint survey. The staffing requirements referenced are based on New Jersey statutes and regulations, which mandate specific CNA-to-resident ratios for each shift. The facility's failure to meet these ratios was documented for several consecutive days, with the number of CNAs consistently falling short of the minimum required for the number of residents present. The report does not mention any specific residents affected or detail any adverse outcomes, but it notes that the deficient practice had the potential to affect all residents in the facility.
Plan Of Correction
S560 Mandatory access to care ELEMENT 1 • The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 • All residents have the potential to be affected by this practice. ELEMENT 3 The Staffing Coordinator will report staffing weekly to the Administrator / Director of Nursing / designee. Flyers are hung in staff areas advertising open staff positions. Indeed is used to advertise for open staff positions. Agencies are used to fill open staff positions. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for three months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025
Failure to Meet Mandatory Nurse Staffing Levels
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2). Specifically, the review of Nurse Staffing Reports for the weeks of 04/20/2025 to 05/03/2025 revealed that on two out of fourteen days, the actual nursing staff hours provided were below the minimum required levels. On 04/27/25, the facility provided 416 actual staffing hours against a required 459.25 hours, resulting in a shortfall of 43.25 hours. On 05/03/25, the facility provided 440 actual staffing hours, which was 19.25 hours less than the required amount. These deficiencies were identified during the investigation of multiple complaints, as referenced by the complaint numbers listed in the report. The calculation of required staffing hours included both the base requirement per resident and additional hours for residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy care, intravenous therapy, respirator use, and advanced neuromuscular or orthopedic care. The report does not provide specific details about individual residents or their medical histories, but it documents the facility's failure to provide the mandated level of nursing care on the identified dates.
Plan Of Correction
S1680 Mandatory nurse staffing ELEMENT 1 The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 • The Staffing Coordinator will report staffing daily to the Administrator / Director of Nursing / designee. • Flyers are hung in staff areas advertising open staff positions. • Indeed is used to advertise for open staff positions. • Agencies are used to fill open staff positions. ELEMENT 4 • Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. • Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. • The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 2025
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, label, and date potentially hazardous foods properly, leading to several deficiencies observed during a survey. The handwashing sink in the kitchen lacked paper towels, and multiple food items in the walk-in refrigerator were improperly stored, labeled, or dated. For instance, a gallon of ranch dressing had spillage on the rim and lid, a jug of salsa had no opened date, and a gallon of hot sauce had spillage on the container. Additionally, a jar of dill pickle chips had a slit in the lid, exposing the contents to air, and a gallon of sweet relish had green fuzzy debris on the packaging and inside contents. Other items, such as French dressing, sour cream, and cream cheese, were either past their expiration dates or lacked proper labeling and dating. The ice cream freezer chest had significant ice accumulation, preventing proper air circulation and raising sanitation concerns. In the milk refrigerated box, an opened half-gallon container of milk was not dated, and in the Cook's refrigerator, several items, including cole slaw, provolone cheese, and sliced tomatoes, were either undated or past their discard dates. In the dry storage area, food items were improperly stored on the floor, and cans had black debris on the lids or were dented and unlabeled. The Dietary Director (DD) acknowledged these issues during the survey. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) confirmed the deficiencies during interviews with the survey team. The facility's Food Storage policy and Labeling and Dating Procedure were reviewed, revealing that the facility failed to adhere to its own guidelines for food storage, labeling, and dating. The policies emphasized the importance of maintaining sanitary conditions, proper labeling, and timely disposal of perishable items, which were not followed in this instance.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to perform proper hand hygiene during and after medication administration, as well as before and after serving residents meals. On multiple occasions, staff members were observed not washing their hands for the required duration or not using alcohol-based hand rub (ABHR) between glove changes. For instance, a Unit Manager/Licensed Practical Nurse (UM/LPN) did not perform hand hygiene correctly during tracheostomy care for a resident, breaking sterility multiple times. Similarly, another LPN was observed not washing hands for the required time after administering medications and handling oxygen tubing that had fallen on the floor. The Director of Nursing (DON) and Infection Preventionist/Registered Nurse (IP/RN) confirmed these lapses in hand hygiene practices during interviews with the surveyor. The facility also failed to maintain enhanced barrier precautions (EBP) for residents requiring such measures. A resident on EBP had a sign indicating the need for gloves and gowns during high-contact care activities, but staff members were observed not adhering to these precautions. For example, an LPN flushed a resident's gastrostomy tube without wearing a gown, and multiple staff members entered and exited rooms without performing hand hygiene. The IP/RN and DON confirmed that these actions were against the facility's policy and the importance of following EBP to prevent the spread of multi-drug resistant organisms (MDROs). Additionally, the facility did not ensure that oxygen tubing was changed and dated according to their policy. A resident's oxygen tubing, dated 4/15/24, was observed to be unchanged for several weeks. The DON and IP/RN confirmed that the tubing should be changed every two weeks and that this practice was not documented in the Electronic Medical Record (EMR). The facility had a Respiratory Therapist until February 2024, who managed the tubing changes, but the protocols were not put on paper until May 2024. The DON acknowledged that the tubing should have been changed and dated on 4/30/24, and that nurses should check the expiration dates during respiratory care.
Failure to Follow Smoking Policy and Assess Resident's Ability to Smoke Safely
Penalty
Summary
The facility failed to ensure that the smoking policy was followed to screen and assess a resident for the ability to safely smoke cigarettes. This deficiency was identified for one resident who was observed smoking despite the most recent smoking assessment indicating that the resident was not a smoker. The resident's electronic medical record and interdisciplinary care plan did not contain any focus area for smoking, and the smoking contract in the paper medical record was crossed out and marked as 'Do Not Smoke.' Despite this, the resident was listed on the smoking schedule and was observed smoking on multiple occasions. The surveyor's investigation revealed that the facility's staff, including the Unit Manager/Registered Nurse (UM/RN) and the Receptionist, were not aware of the resident's smoking status. The UM/RN confirmed that the smoking assessment was completed inaccurately and that the resident was not care planned for smoking. The facility's smoking policy required residents to be screened for tobacco use and their ability to smoke safely upon admission, with assessments to be repeated quarterly and annually. However, this policy was not followed for the resident in question. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that there was no smoking contract in the resident's medical record and that smoking was not addressed in the resident's interdisciplinary care plan. The facility's failure to adhere to its smoking policy and procedures resulted in a lack of proper assessment and supervision for the resident, potentially compromising the safety of the resident and others in the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure safe and appetizing temperatures of food for residents on the Third Floor nursing unit. During a Resident Council meeting, one resident reported that lunch and dinner had been served cold and in takeout containers since February 2024. On 5/8/24, the surveyor observed the lunch meal preparation and noted that the facility used disposable Styrofoam containers due to a shortage of insulated bases and dome lids. The surveyor recorded the temperatures of various food items before and after delivery to the Third Floor nursing unit, finding that most hot foods were below the required 135 degrees Fahrenheit and cold foods were above the required 41 degrees Fahrenheit when served to residents. The Dietary Director (DD) acknowledged that only the barbecue chicken and scalloped potatoes were served at acceptable temperatures. The facility's Food Serving Policy and Procedure, revised in May 2024, mandates that hot food be served at a minimum of 135 degrees Fahrenheit and cold food at a maximum of 41 degrees Fahrenheit. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing acknowledged the deficiency in food and beverage temperatures when informed by the survey team.
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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