F0677

E

Failure to Consistently Document ADL Care and Intake/Elimination

Egg Harbor Township, New Jersey Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently document the provision of Activities of Daily Living (ADL) care, including elimination and eating, for multiple residents, despite care plans and policies requiring such care and documentation. For one resident with end stage renal disease and dialysis, the care plan addressing decline in functional status included an intervention to provide and assist with ADLs. However, review of the December 2025 Documentation Survey Report (POC) showed blank entries for bladder and bowel elimination, eating, and amount eaten on specified shifts and dates, indicating that these tasks were either not completed or not documented.

A second resident with chronic kidney disease and diabetes, who was cognitively intact per a BIMS score of 14/15, also had a care plan intervention to provide and assist with ADLs. Review of this resident’s July 2025 POC documentation revealed numerous blank spaces for bladder and bowel elimination, eating, and amount eaten across multiple days and all three shifts. Additional review of August 2025 documentation showed a blank entry for amount eaten on one evening shift. For a third resident with dementia and a BIMS score indicating moderate impairment, the care plan noted a current need for extensive assistance with ADL tasks and an intervention to provide and assist with ADLs. Yet, September and October 2025 POC reports contained multiple blank entries for bladder and bowel elimination, eating, amount eaten, and ordered snacks (4 oz Magic Cup with lunch and dinner) on various dates and shifts.

A fourth resident with chronic obstructive pulmonary disease had recent admission status and incomplete BIMS at the time of survey. Review of this resident’s December 2025 POC documentation showed blank entries for bladder and bowel elimination, eating, and amount eaten on multiple dates and shifts. A fifth resident with end stage renal disease, chronic kidney disease, and severe cognitive impairment per a BIMS score of 5/15 had a care plan indicating no change in ADL function and to continue with the POC, including providing and assisting with ADLs. Nonetheless, November and December 2025 POC reports for this resident contained numerous blank entries for bladder and bowel elimination, eating, and amount eaten across day, evening, and night shifts.

During interviews, a CNA stated that ADLs should be completed daily and that she documents them mid-shift and at the end of her shift on the POC; she further stated that if care is not documented, then it is considered not done. An LPN similarly stated that CNAs complete the POC documentation and that if it is not documented, it is not done. The Vice President of Nursing and Clinical Services explained that X’s on the POC indicate PRN or as-needed services, while blanks indicate that no one documented for that shift and there is no way to know if the care was done, reiterating that if it is not documented, it is not done. Facility policies titled “Activities of Daily Living (ADLs)/Maintain Abilities” and “Nursing Documentation” require the facility to provide care and services for elimination and dining (including meals and snacks) and to document all nursing interventions and observations, including ADLs and assistance required, which was not consistently done for the five residents reviewed.