Troy Hills Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parsippany, New Jersey.
- Location
- 200 Reynolds Ave, Parsippany, New Jersey 07054
- CMS Provider Number
- 315138
- Inspections on file
- 14
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Troy Hills Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to provide timely incontinence care to two cognitively intact, dependent residents. One resident was found in bed wearing two saturated incontinence briefs, despite a care plan requiring staff assistance with toileting and hygiene and no documentation that the resident requested double briefs. Another resident, who had frequent bowel incontinence and an indwelling urinary catheter, approached staff requesting a change and was found with heavily soiled, disheveled clothing and a brief down at the knees containing dried and wet feces, reporting they had not been changed for several days. An LPN and the DON confirmed that incontinence care was expected every two hours and that CNAs were required to notify nursing staff of any refusals, but there was no evidence such refusals occurred or were reported.
Surveyors found that the facility failed to follow professional standards and internal policies for pressure ulcer prevention and treatment for two residents. One resident with dementia and a right femur fracture, weighing about 100 lbs, was observed on a low-air-loss mattress set to 220 lbs, despite a physician order for a specialty mattress and a policy requiring mattress settings to match resident weight and be verified each shift; the care plan for skin integrity risk did not list the low-air-loss mattress as an intervention. Another resident with multiple chronic conditions had a full-thickness right lower leg skin tear with physician-ordered daily and PRN wound care, but the eTAR showed no nurse signatures for completion of the ordered treatments over six consecutive days, contrary to the facility’s wound care policy requiring treatments to be completed and documented.
Surveyors found that the facility failed to maintain and serve food at safe and appetizing temperatures, as evidenced by a test tray at lunch with meatloaf and vegetables below the facility’s defined safe hot-holding range and confusion among dietary leadership about proper thermometer calibration. Grievance logs and Resident Council minutes documented repeated complaints over many months about cold meals. During a Resident Council meeting, several residents reported that breakfast and other meals, including coffee and oatmeal, were consistently cold or lukewarm and that food often sat on the units for extended periods before being delivered.
The facility's kitchen environment was found unsanitary, with cereal bowls stored improperly, food debris on prep tables, and soiled cooking pots and steam table trays. These observations indicate a failure to adhere to policies on warewashing and equipment cleanliness, posing potential contamination and foodborne illness risks.
The facility failed to include a staffing contingency plan in its Facility Assessment, leading to deficiencies in CNA staffing ratios. The LNHA was unaware of CMS updates and admitted the facility did not meet state-mandated staffing laws. Residents expressed concerns about short staffing, and the Staffing Plan Template did not meet required ratios.
The facility failed to maintain a clean and safe environment, with issues such as a strong urine smell, dust accumulation, and water-stained ceiling tiles in residents' rooms. The lobby had discolored ceiling tiles due to water leaks, and a resident's wheelchair was damaged. The Unit 3 tub room was poorly lit with a dirty vent. Despite resident complaints, cleanliness issues persisted, and facility management did not refute these findings.
The facility failed to provide adequate care for two residents. One resident did not receive necessary meal setup assistance, leading to significant weight loss without proper notification to the physician or representative. Another resident did not receive prescribed seizure medication, Keppra, due to an oversight in the order summary report, despite the physician's documentation. The facility's policies on nutrition, hydration, and medication orders were not followed, resulting in these deficiencies.
The facility failed to follow its Grievance/Concern policy, resulting in unresolved grievances from residents regarding laundry services and an incident involving a resident attempting to enter another's bed. Despite repeated discussions in resident council meetings, the facility did not provide resolutions, leading to a petition to the corporate office. The LNHA acknowledged the lack of investigation and follow-through on these issues, highlighting a significant deficiency in grievance handling.
The facility failed to accurately code MDS assessments for five residents, leading to inconsistencies in documenting cognitive patterns. For one resident, the MDS was coded as rarely/never understood, despite documentation indicating usual understanding. Another resident's MDS assessments were not completed within the required timeframe, and Section C for cognition was not assessed. Similar issues were observed for three other residents, where MDS assessments were completed after the ARD, and Section C was not attempted despite indications of understanding.
A facility failed to administer a blood thinner to a resident due to pharmacy delivery issues and did not accurately document controlled substance receipts. The resident missed four days of medication, and the facility's records showed discrepancies in administration documentation. Additionally, DEA 222 forms for controlled substances were incomplete, and the facility lacked proper procedures for ordering and receiving these medications.
The facility failed to ensure a licensed pharmacist conducted thorough monthly drug regimen reviews, resulting in medication administration errors for several residents. These errors included administering medications beyond prescribed parameters and failing to identify irregularities in medication orders. The consultant pharmacist did not address these issues in their reports, leading to continued medication errors.
The facility failed to properly store medications and vaccines, as observed in Unit 1 and Unit 4. Temperature logs for vaccine refrigerators were inconsistently recorded, and a lock box for controlled substances was not permanently affixed. Additionally, a medication storage cabinet was not securely locked, allowing access to medications. These practices did not align with the facility's policies or CDC guidelines.
A resident with right-sided hemiplegia was found to have their call bell improperly placed, making it inaccessible. Despite the resident's inability to speak much, they indicated they could not reach the call bell. A CNA confirmed the issue and adjusted the call bell placement. The resident's care plan did not include specific interventions for call bell accessibility, and the facility's policy requiring call lights to be within reach was not followed.
The facility did not complete required reference checks for two newly hired staff members, including an LNHA and an NA, before their start dates. The Staffing Coordinator confirmed the oversight, acknowledging that the facility's hiring policy mandates at least two professional references, which was not followed. Facility management did not dispute the findings.
A facility failed to report an abuse allegation to the NJDOH within the required timeframe. A resident with cognitive impairment and Parkinson's disease reported another resident attempting to enter their bed, a recurring issue. Despite being raised in a resident council meeting, the incident was not resolved or reported promptly. The LNHA admitted the failure to report within two hours as required by policy, and the grievance process was not properly executed.
The facility failed to ensure accurate documentation and adherence to treatment protocols for several residents. A resident with severe cognitive impairment had inconsistent documentation of wound care treatments. Another resident with Multiple Sclerosis had missing entries for vital signs despite a physician's order. Additionally, there were discrepancies in pain medication orders for a resident with a stage 4 pressure ulcer, leading to potential confusion. Staff interviews revealed issues with protocol adherence and order clarification.
A facility failed to apply a physician-ordered wrist splint for a resident with multiple sclerosis, as observed by surveyors over several days. The CNA responsible was unaware of the requirement due to a lack of shift change communication. The splint and instructions were present in the resident's room, but the splint was not applied, and its use was not documented in the electronic Treatment Administration Record, contrary to facility policies.
A facility failed to provide adequate respiratory care for a resident using oxygen, with inconsistent documentation and unclear physician orders. Another resident's nebulizer mask was improperly stored, and the care plan lacked instructions for equipment maintenance. The facility's policies did not adequately address procedures for oxygen use and nebulizer care, leading to deficiencies in compliance and resident safety.
A facility failed to complete post-dialysis communication record assessments for a resident with end-stage renal disease. The resident's dialysis communication binder showed that the post-dialysis section was not completed for six out of eight forms, despite the facility's policy requiring a licensed nurse to evaluate the patient and complete the record upon return from dialysis. Interviews confirmed that the section should have been completed, highlighting a lapse in protocol adherence.
The facility failed to post accurate Nursing Home Resident Care Staffing Reports on two occasions, with discrepancies in the reported census and number of CNAs. The inaccuracies were due to the Staffing Coordinator printing reports before reconciliation, leading to incorrect staff-to-resident ratios. The facility's policy requires ongoing review of staffing levels, but these errors were not corrected until identified by surveyors.
A facility failed to monitor target behaviors for a resident receiving lorazepam for anxiety, as required by their care plan. Despite the resident being alert and cognitively intact, there were no entries in the MAR or documentation in progress notes regarding the resident's target behaviors. The facility's policy required monitoring and documentation of behavioral symptoms, but this was not followed, leading to the deficiency.
A facility failed to serve meals at safe and appetizing temperatures, as observed during a lunch service on Wing 2. A resident reported receiving cold food, and grievances over several months indicated similar issues. During a survey, food temperatures were found to be below the expected 140°F when served, despite being initially correct in the kitchen.
The facility failed to follow proper infection control practices, as observed by surveyors. A housekeeper did not perform hand hygiene after glove removal, and a non-certified nursing aide did not wear a gown while making a bed in a room with Enhanced Barrier Precautions. The resident involved had a history of infections, and the facility's policy required PPE for high-contact activities, which was not adhered to.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate incontinence care to dependent residents on one nursing unit. During an incontinence tour, a surveyor and a CNA observed one resident in bed with two incontinence briefs in place, both saturated with urine. The CNA confirmed that the resident should not have had two briefs on and that both were saturated. The resident, who was cognitively intact with a BIMS score of 13, reported not having been changed since the previous night and denied requesting two briefs. The resident’s care plan documented urinary and bowel incontinence and required staff assistance for personal hygiene, including toileting upon awakening and as needed, monitoring for skin irritation, and providing skin care and moisture barrier after each incontinence episode. There was no documentation that the resident had requested two briefs. A second resident approached the surveyor and CNA in the hallway and requested a diaper change. The surveyor observed that this resident’s clothing was heavily soiled and disheveled. In the resident’s room, the CNA exposed the incontinence brief, which was down by the resident’s knees and heavily soiled with copious amounts of dried and wet feces, while the resident also had an indwelling urinary catheter in place. The resident stated that their brief and clothing had not been changed since Saturday. The CNA confirmed that the brief was heavily soiled and that it did not appear the resident had received care recently. This resident’s medical record showed diagnoses including bipolar disorder and neuromuscular dysfunction of the bladder, an intact cognition with a BIMS score of 14, frequent bowel incontinence, an indwelling urinary catheter, and a care plan intervention to assist with perineal care as needed. Interviews with facility staff further supported that required incontinence care was not being consistently provided. The LPN/Unit Manager for the involved nursing units stated that staff were expected to provide incontinence care every two hours on all shifts and that CNAs should notify a nurse if a resident refused care; she confirmed she had not been informed of any refusal by the second resident. The DON similarly confirmed that incontinence care should be provided every two hours on every shift and that the night-shift CNA should have informed the nurse if the resident had refused care. A facility policy on ADLs stated that residents unable to carry out ADLs independently are to receive services necessary to maintain grooming and personal hygiene, and that if residents with cognitive impairment resist care, staff should attempt different approaches rather than assuming refusal. No additional information was provided by the administrator to refute or explain the observed lack of timely incontinence care.
Failure to Properly Set Pressure-Reducing Mattress and Document Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards and its own policies for two residents. For one resident with a right femur fracture, dementia, and a documented weight of approximately 100 lbs, surveyors twice observed the resident in bed on a low-air-loss specialty mattress with the pump set to 220 lbs. The resident’s admission MDS identified them as at risk for pressure ulcers and using a pressure-reducing device, and the physician’s order required a low-air-loss mattress with function checks every shift. The eTAR showed nurses documented monitoring of the mattress each shift, and the facility’s Air Mattress Policy required setting the mattress according to the resident’s weight and verifying function and settings at least once per shift. However, the mattress setting did not match the resident’s actual weight, and the care plan for risk of skin integrity alteration did not include the low-air-loss mattress as an intervention. For a second resident with diagnoses including congestive heart failure, atrial fibrillation, morbid obesity, COPD, and muscle weakness, a wound care consult documented a full-thickness right lower leg skin tear with moderate drainage that required cleansing with normal saline, application of collagen powder, and coverage with a bordered foam dressing three times weekly and PRN. A physician order initiated on a later date specified daily and PRN wound care with cleansing, collagen powder, and bordered gauze. Review of the eTAR for a six-day period showed no nurse signatures indicating completion of the ordered wound care treatments during that time. The facility’s Wound Care Treatment Policy required that wound care treatments be completed as ordered and documented on the Treatment Administration Record to ensure continuity of care and promote healing. The DON confirmed there was no documentation to support that the ordered wound care was completed for the six consecutive days in question. The DON also confirmed that specialty mattresses were ordered for residents with pressure ulcers or at high risk of skin breakdown and that nurses and CNAs were responsible for ensuring mattress pumps were set to appropriate weights, but no additional information was provided to reconcile the observed incorrect mattress setting or the missing wound care documentation.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and beverages were served at safe and appetizing temperatures. During a lunch meal service observation, a surveyor observed the tray line in the main kitchen and witnessed confusion among dietary leadership regarding proper thermometer calibration, with the Food Service Director initially calibrating a thermometer in ice to 41°F and the Regional President of Dietary Operations first stating it should be 0°F, then correcting to 32°F. A test tray prepared last on the first cart for the common room was checked after all trays were passed, and the meatloaf measured 128°F and the vegetables 104°F. The Regional dietary leader confirmed these temperatures and acknowledged that the food should have been hotter. The facility’s policy defined the “danger zone” as temperatures below 135°F that allow rapid growth of pathogenic microorganisms and required food thermometers to be calibrated for accuracy. Additional evidence of ongoing problems with food temperatures was found in facility records and resident reports. Grievance logs from January 2025 through March 2026 included complaints of cold meals, with one anonymous grievance about a cold meal and another resident complaint about cold food. Resident Council minutes from the prior three months documented prior concerns that meal trays and food were arriving cold. During a Resident Council meeting with five alert and oriented residents, four reported that food was still arriving cold and one reported food was lukewarm; residents specifically stated that breakfast food was always cold, other meals served in rooms were cold, coffee was ice cold, and oatmeal was cold. All five residents reported observing that food sometimes sat on the units for up to forty-five minutes before being delivered to residents. These observations and resident reports demonstrated that the facility did not consistently maintain and serve food at safe and appetizing temperatures in accordance with its own policy and regulatory requirements.
Sanitation Deficiencies in Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and equipment, leading to potential contamination and foodborne illness risks. During a kitchen tour, a surveyor observed several deficiencies, including a metal tray with bowls of cereal resting on boxes of napkins and utensils, with one bowl's lid covered in an unidentified clear liquid. Additionally, a food prep table had dried food debris, and a soiled chef knife was found in a metal pan. In the dry rack storage area, stacked cooking pots were found with dry food debris inside, indicating they were not properly cleaned. Further observations revealed that steam table trays were left uncovered and soiled with debris, with clear water in the compartments. The facility's policies on warewashing and equipment cleanliness were not adhered to, as dishware, serviceware, and utensils were not cleaned and sanitized after each use, and foodservice equipment was not maintained in a clean and sanitary condition. These observations were confirmed by the Food Service Director and other facility staff present during the survey.
Deficiency in Staffing Contingency Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included the necessary resources to establish policies and procedures for managing staffing contingency plans, which is a requirement to meet the needs of all residents. This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) was unable to provide a comprehensive Facility Assessment (FA) that included a staffing contingency plan. The review of the Nurse Staffing Report revealed consistent deficiencies in Certified Nursing Aide (CNA) staffing for residents over several weeks, failing to meet the New Jersey mandated staffing ratios. Residents expressed concerns about short staffing during a Resident Council meeting, indicating that the facility management was aware of the issue. The LNHA admitted to being unaware of updates from the Centers for Medicare and Medicaid Services (CMS) regarding the FA and acknowledged that the facility was not meeting state-mandated staffing laws. The Staffing Plan Template provided by the LNHA did not meet the required CNA staffing ratios, particularly for the evening shift. Despite the facility's policy to review and update the assessment annually or when substantial changes occur, the facility management did not provide additional information or refute the findings during the exit conference with the survey team.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by multiple observations across different units and common areas. On Unit 1, a resident's room was found with a strong smell of urine, dust accumulation, and brownish stains on the ceiling tiles. The nightstand and floor were dirty, and the toilet room vent was covered in dust. Despite being cleaned after the initial observation, the room's windows remained dirty, and a gauze was used inappropriately as a light string. The Assistant Director of Nursing and Regulatory Compliance Advisor were unable to provide explanations for these conditions. In the lobby area, the surveyor observed 20 ceiling tiles with brownish discoloration due to water leaks, which were inadequately addressed by spray painting rather than fixing the leaks. Additionally, a resident in the atrium was found using a wheelchair with cracked armrests covered with tape. The resident council meeting minutes revealed ongoing concerns about cleanliness, including fruit flies and unclean windows, which were not addressed despite being reported by residents. The Unit 3 tub room was found to be dark and poorly lit, with a broken light and a vent covered in blackish-grayish substances. The Licensed Nursing Home Administrator acknowledged that the contracted housekeeping company was responsible for maintaining cleanliness, but the facility failed to ensure that these duties were performed adequately. The surveyor's findings highlighted significant lapses in housekeeping and maintenance services, which were not refuted by the facility management during the exit conference.
Failure to Provide Adequate Meal Assistance and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. For Resident #21, the facility did not ensure the resident received meal setup assistance, which was necessary due to their moderately impaired cognition and physical limitations. The resident experienced significant weight loss, and there was no documented evidence that the physician or the resident's representative was notified of this weight loss. The Registered Dietitian acknowledged difficulties in obtaining accurate weights and did not document communication with the physician or the resident's representative regarding the weight loss. For Resident #57, the facility failed to administer the prescribed medication, Keppra, for seizure management. Despite the physician documenting the need for Keppra in the resident's progress notes, the medication was not included in the resident's order summary report from August to November 2024. The Licensed Practical Nurse was unaware of the omission until informed by the surveyor, and there was no documented reason for the discontinuation of the medication. The facility's management acknowledged the oversight but noted that the resident did not experience any seizures during this period. The facility's policies on nutrition, hydration, and medication orders were not followed, leading to these deficiencies. The survey team met with the facility's management to discuss these findings, but no additional information or refutation was provided. The deficiencies highlight a failure to adhere to professional standards of practice and the comprehensive person-centered care plan, resulting in inadequate care for the residents involved.
Failure to Address Resident Grievances and Concerns
Penalty
Summary
The facility failed to adhere to its Grievance/Concern policy and procedure, resulting in unresolved grievances and concerns from residents. The surveyor's investigation revealed that the facility did not conduct a formal investigation into a grievance filed by a resident regarding laundry services. This issue persisted over four resident council meetings, with residents expressing ongoing problems with missing clothes, receiving incorrect clothing, and the cleanliness of their garments. Despite repeated discussions in council meetings, the facility did not provide a resolution, leading residents to petition the corporate office for reinstating in-house laundry services. Additionally, the facility did not investigate a grievance involving a resident who awoke to find another resident attempting to enter their bed. This incident was reported during a resident council meeting, but there was no follow-up or resolution documented. The Licensed Nursing Home Administrator (LNHA) acknowledged the lack of investigation and stated that the process was still ongoing after the surveyor's inquiry. The facility's failure to address these grievances promptly and thoroughly is a significant deficiency in their grievance handling process. The facility's Grievance/Concern Policy outlines the responsibilities of the Administrator and Social Services personnel in investigating and resolving grievances. However, the surveyor found that grievances voiced by residents were not documented or investigated as required. The LNHA and other facility management confirmed that grievances were not initiated for certain residents, and there was a lack of follow-through on reported issues. This deficiency highlights the facility's failure to ensure residents' rights to voice grievances without discrimination or reprisal, as mandated by their policy.
Inaccurate MDS Coding and Assessment Delays
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for five residents, leading to inconsistencies in the documentation of their cognitive patterns. For Resident #14, the MDS was coded as the resident being rarely/never understood, despite documentation indicating that the resident usually understands. This inconsistency was noted by the surveyor, who discussed it with the Reimbursement Clinical Coordinator (RCC), highlighting the need for a Brief Interview for Mental Status (BIMS) to be attempted when a resident is sometimes understood. Resident #45's MDS assessments were not completed within the required timeframe, and Section C for cognition was not assessed or attempted. The RCC signed off on the MDS without verifying the accuracy of the responses, attributing the responsibility to the Director of Social Services (DSS). The DSS acknowledged that the Section C interview should have been attempted and completed within the lookback period, but it was not, leading to inaccurate coding. For Residents #68, #79, and #81, similar issues were observed where the MDS assessments were completed after the Assessment Reference Date (ARD), and Section C was not attempted despite indications that the residents were sometimes understood. The surveyor noted these discrepancies and discussed them with the facility management, who did not provide additional information or refute the findings.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer a medication to a resident due to the unavailability of the medication and did not accurately account for and administer the medication according to the physician's orders. This deficiency was observed in the case of a resident who was supposed to receive a blood thinner injection daily. The resident reported not receiving the medication for four days due to issues with pharmacy delivery. The facility's records showed discrepancies in the medication administration record, with entries marked as administered, refused, or with notes indicating the medication was not available. The facility's RN confirmed that the resident had reported the missed doses, but there was no documentation of the issue being communicated during shift changes or to the primary physician. Additionally, the facility failed to ensure accurate documentation of the receipt of controlled substances. The surveyor found that the facility did not maintain proper records for the receipt of controlled substances ordered for emergency backup supply. The DEA 222 forms used to order these substances were incomplete, lacking information on the number of containers received and the dates of receipt. The facility's policies did not adequately address the procedures for ordering and receiving controlled substances, leading to a lack of accountability and reconciliation of these medications. The surveyor's investigation revealed that the facility did not keep a log of medications removed from the backup supply, and the forms used to document such removals were incomplete. The facility's DON and other staff members acknowledged the deficiencies in documentation and record-keeping. The lack of proper documentation and communication regarding medication administration and controlled substance management contributed to the facility's failure to meet pharmaceutical service standards.
Medication Administration Errors Due to Inadequate Pharmacist Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for several residents, leading to multiple medication administration errors. For Resident #53, the facility did not document blood pressure or heart rate at the time of administering amlodipine-besylate benazepril, despite the medication having specific parameters for administration. The consultant pharmacist's report for October 2024 did not address this irregularity. Similarly, Resident #24 received losartan medication even when the systolic blood pressure was below the prescribed threshold, and the consultant pharmacist did not identify this issue in their review. Resident #43 had conflicting PRN orders for Milk of Magnesia and MiraLAX, with no clear instructions on which medication to administer first or how frequently MiraLAX could be given. The consultant pharmacist failed to identify this irregularity in their review. Additionally, Resident #82 had a Lidoderm patch applied for 24 hours instead of the recommended 12 hours, and this discrepancy was not noted by the consultant pharmacist. Resident #57 received Lisinopril and Metoprolol medications beyond the prescribed parameters, with multiple instances of administration when the systolic blood pressure was below 120. The consultant pharmacist's review did not identify these irregularities. The facility's policies required the consultant pharmacist to communicate any potential or actual medication therapy problems, but this was not done, leading to the continuation of these medication errors.
Medication and Vaccine Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications and vaccines in accordance with its policy and standard clinical practice. During an inspection of the medication storage areas in Unit 1 and Unit 4, it was observed that the temperature logs for refrigerators containing vaccines were not consistently recorded, with several days missing entries. Additionally, the refrigerator in Unit 1 had a lock box for controlled substances that was not permanently affixed, compromising its security. In Unit 4, the medication storage cabinet was not securely locked, allowing access to medications despite the presence of a chain and combination lock. The surveyor noted that the facility's policy required temperatures to be recorded twice daily, yet the logs showed only once-daily recordings. The CDC guidelines for vaccine storage also recommend checking and recording temperatures at the start of each workday, which was not adhered to. The Assistant Director of Nursing acknowledged these issues during the inspection. The facility's policies also stipulated that controlled substances should be stored in a separately locked, permanently affixed compartment, which was not the case in the observed areas.
Resident's Call Light Inaccessibility Due to Improper Placement
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible within reach, which was identified as a deficiency during a survey. The surveyor observed that the call bell for a resident with right-sided hemiplegia was wrapped around the side rails on the right side of the bed, making it inaccessible to the resident. Despite the resident's inability to speak much, they indicated through gestures that they could not reach the call bell. A Certified Nursing Assistant (CNA) confirmed the improper placement of the call bell and adjusted it to be within the resident's reach. The Registered Nurse/Unit Manager (RN/UM) also acknowledged that the call bell should have been placed on the resident's left side due to their right-sided weakness. The resident's medical records revealed a history of hemiplegia affecting the right side, aphasia, hypertension, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) and care plan indicated limitations in the resident's upper extremities due to a cerebrovascular accident (CVA) and right hemiplegia. However, the care plan did not include specific interventions to accommodate the resident's needs related to the use of the call bell. The facility's policy required that all patients have a call light or alternative communication device within reach at all times, which was not adhered to in this case. The facility management acknowledged the deficiency during meetings with the survey team.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for two out of ten newly hired staff members prior to their start date of employment. Specifically, the file for a Licensed Nursing Home Administrator (LNHA) hired on July 3, 2023, and a Nursing Assistant (NA) hired on September 27, 2024, lacked the required reference checks. During an interview, the Staffing Coordinator (SC) confirmed that a minimum of two reference checks were required before the date of hire and acknowledged the oversight in the presence of the surveyor. The facility's hiring policy, revised on July 1, 2022, mandates checking at least two professional references, which was not adhered to in these cases. The facility management did not provide additional information or refute the findings during the exit conference.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the New Jersey Department of Health (NJDOH) within the required timeframe for a resident reviewed for abuse. The incident involved a resident who was cognitively impaired and had a history of Parkinson's disease with dyskinesia. The resident reported that another resident attempted to enter their bed, and this was not the first occurrence. Despite the complaint being raised during a resident council meeting, there was no documented resolution or follow-through. The Licensed Nursing Home Administrator (LNHA) acknowledged that the incident was not thoroughly investigated or resolved and was still under investigation after the surveyor's inquiry. The LNHA confirmed that the incident should have been reported to the NJDOH within two hours, as per the facility's policy, but it was not reported until after the surveyor's inquiry. The facility's Abuse Prohibition Policy mandates immediate reporting of suspected abuse, but this protocol was not followed in this case. The facility's Grievance/Concern Policy outlines the process for investigating and resolving grievances, with the Administrator serving as the Grievance Officer. However, in this instance, the grievance process was not properly executed, and the incident was not reported in a timely manner. The survey team met with facility management multiple times, but no additional information was provided to refute the findings.
Deficiencies in Documentation and Treatment Protocols
Penalty
Summary
The facility failed to ensure accurate documentation and adherence to treatment protocols for several residents, leading to deficiencies in care. For Resident #15, who had severe cognitive impairment and a history of pressure-induced deep tissue damage, the facility did not consistently document wound care treatments in the electronic Treatment Administration Record (eTAR). The nurse failed to sign the eTAR on multiple occasions in October and November 2024, indicating a lack of documentation for the administration of prescribed treatments. The Infection Preventionist Nurse acknowledged the expectation for nurses to document treatments, whether administered or not, and recognized the issue of blank entries in the eTAR. Resident #68, diagnosed with insomnia and Multiple Sclerosis, had a physician's order for daily vital signs to be taken every evening shift. However, the facility's records showed a lack of documented evidence for vital signs being obtained as ordered, with missing entries for 15 out of 21 days in November 2024. Interviews with nursing staff revealed confusion regarding the protocol for long-term care residents, with some staff indicating that vital signs were not routinely taken daily in long-term care settings. The Assistant Director of Nursing acknowledged that nurses should have followed the physician's order. For Resident #80, who had intact cognition and a stage 4 pressure ulcer, there were discrepancies in the physician's orders for pain medication. The orders for Oxycodone-Acetaminophen were not clearly separated between as-needed administration and administration prior to wound care, leading to potential confusion. The Licensed Practical Nurse acknowledged the need for clarification of the orders. The facility's policy on physician orders did not address the clarification of orders, contributing to the deficiency in managing the resident's pain medication regimen.
Failure to Apply and Document Wrist Splint for Resident
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not adhering to a physician's order for the application of a splint to a resident's right wrist and failing to document this in the Treatment Administration Record. The deficiency was identified during a survey when the resident was observed multiple times without the prescribed splint, despite a posted picture in the resident's room indicating the need for its application during morning care. The resident, who was admitted with diagnoses including multiple sclerosis and muscle weakness, was at risk of contractures and required the splint as part of their care plan. The surveyor's observations over several days revealed that the splint was not applied as ordered, and the CNA responsible for the resident's care was unaware of the requirement. The CNA admitted to not applying the splint and not receiving a sign-off report from the previous shift, which would have informed her of the resident's special equipment needs. The splint and the posted instructions were found in the resident's room, confirming the oversight in care. The facility's policies on Activities of Daily Living and Range of Motion and Mobility emphasize the provision of assistive devices and equipment to maintain or improve residents' mobility. However, the failure to apply the splint as ordered and document its use in the electronic Treatment Administration Record indicates a lapse in following these policies. The facility management acknowledged the deficiency during meetings with the survey team but did not provide additional information or refute the findings.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for Resident #33, who was observed using oxygen via nasal cannula set at 4 liters. The resident's medical record indicated a physician's order for oxygen at 2-4 liters per minute as needed, but the order lacked specific indications for administration. Despite the resident's cognitive impairment and chronic conditions such as COPD, there was inconsistent documentation of oxygen use in the electronic Medication Administration Record (eMAR), with discrepancies between observed oxygen use and recorded entries. Interviews with nursing staff revealed a lack of clarity and documentation regarding the administration of PRN oxygen, highlighting a failure to adhere to the facility's policy and standard clinical practice. In another instance, the facility did not properly store respiratory equipment for Resident #80, who was observed with a nebulizer mask exposed to environmental contaminants and not stored in a bag. The resident's room was noted to have significant cleanliness issues, including dust and stains, which could compromise infection control measures. The resident's care plan lacked specific instructions for the care and maintenance of the nebulizer mask and tubing, and there was no documented evidence of accountability for the equipment's care. Interviews with facility management confirmed the absence of proper storage and care protocols for the respiratory equipment. The facility's policies on respiratory management and medication administration did not adequately address the necessary procedures for oxygen use and nebulizer equipment care. The lack of specific guidelines and documentation contributed to the deficiencies observed during the survey. Facility management acknowledged these shortcomings during discussions with the survey team, indicating a need for improved adherence to established protocols to ensure resident safety and compliance with regulatory standards.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis communication record assessments for a resident who required dialysis services. The deficiency was identified through observation, interviews, and record reviews. A resident with end-stage renal disease, hypertension, and atrial fibrillation was scheduled for dialysis three times a week. However, upon review of the resident's dialysis communication binder, it was found that the post-dialysis section of the communication record was not completed by the facility nurse for six out of eight forms. This section was intended to document the resident's condition and vital signs upon returning from dialysis. Interviews with the registered nurse and the unit manager confirmed that the post-dialysis section should have been completed by the nurses. The facility's policy required a licensed nurse to review the dialysis center's communication, evaluate the patient, and complete the post-dialysis treatment section on the Hemodialysis Communication Record. Despite this policy, there were no progress notes documenting that the resident was assessed after returning from dialysis, indicating a lapse in following the established protocol.
Inaccurate Staffing Reports in LTC Facility
Penalty
Summary
The facility failed to post accurate Nursing Home Resident Care Staffing Reports (NHRCSR) on two occasions within a seven-day period. On the first occasion, the NHRCSR posted on 11/18/24 indicated a census of 98 residents with 10 CNAs, resulting in a staff-to-resident ratio of 1 CNA to 9.8 residents. However, the actual census was 97, and there were only 9 CNAs on duty. On the second occasion, the NHRCSR posted on 11/20/24 showed a census of 97 residents with 12 CNAs, resulting in a staff-to-resident ratio of 1 CNA to 8.1 residents. The actual census was 94, with 11 CNAs on duty. These discrepancies were identified through observations, interviews, and reviews of the facility's Daily Census and Daily Staffing Sheets. The Licensed Nursing Home Administrator (LNHA) acknowledged the inaccuracies and attributed them to the Staffing Coordinator (SC) printing the NHRCSR the night before, prior to reconciliation. The facility's policy, revised on 8/07/23, mandates that staffing levels be reviewed on an ongoing basis to ensure compliance and appropriate care levels. Despite the policy, the inaccuracies in the NHRCSR were not addressed until pointed out by the survey team. The facility management did not provide additional information or refute the findings during the exit conference.
Failure to Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor target behaviors for a resident receiving psychotropic medication, specifically lorazepam for anxiety. The resident, who was alert, oriented, and cognitively intact, had a care plan that required monitoring for changes in mood and the continued need for medication. However, a review of the Medication Administration Record (MAR) for October and November 2024 revealed no entries for monitoring target behaviors, and there was no documentation in the assessments or progress notes regarding the resident's target behaviors. The deficiency was identified during a survey when the surveyor observed the resident and reviewed their medical records. Despite the facility's policy requiring staff to monitor and document behavioral symptoms, the Assistant Director of Nursing acknowledged the lack of documentation for the resident's target behaviors. The facility's policy also required a Psychotropic/Therapeutic Medication Use Evaluation to be completed when a psychotropic medication is newly prescribed and then quarterly, but there was no evidence of this being done for the resident in question.
Deficiency in Serving Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at safe and appetizing temperatures, as evidenced during a lunch meal service on Wing 2. A resident reported that the food was sometimes cold when received. A review of resident council minutes and grievances over the past few months revealed consistent complaints about food and beverages not being served hot enough. Specifically, grievances were noted in August, October, and November 2024, regarding cold food and coffee. During the surveyor's observation on November 22, 2024, the food temperatures were taken at various stages of the meal service. Initially, the chicken patties and mixed vegetables were at appropriate temperatures in the kitchen. However, by the time the meals were served on Wing 2, the chicken patty was at 123°F and the mixed vegetables at 117°F, both below the expected 140°F. The facility's policy requires food to be palatable, attractive, and served at a safe and appetizing temperature, which was not met in this instance.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, as observed by surveyors. A housekeeper was seen exiting a resident's room with gloves on, disposing of garbage, and then entering another room without performing hand hygiene after glove removal. This action was contrary to the guidelines set by the CDC and the facility's policy, which require hand hygiene immediately after glove removal. The housekeeper did not respond when the surveyor pointed out the lapse in protocol. In another instance, a non-certified nursing aide was observed making a bed in a resident's room that had an Enhanced Barrier Precaution (EBP) sign posted, indicating the need for PPE such as gloves and gowns during high-contact care activities. The aide did not wear a gown while performing this task, despite the signage indicating that changing linens is considered a high-contact activity requiring PPE. The aide acknowledged the oversight after reviewing the EBP signage with the surveyor. The resident involved in the second incident had a history of urinary tract infection and enterocolitis due to Clostridium difficile, with a physician's order for enhanced barrier precautions due to multidrug-resistant organisms in the urine. The facility's policy, last revised in May 2024, clearly stated the requirement for gown and gloves during high-contact activities, which was not followed in this case.
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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