Failure to Prevent and Investigate Drug-Related Incidents
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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