Alaris Health At Belgrove
Inspection history, citations, penalties and survey trends for this long-term care facility in Kearny, New Jersey.
- Location
- 195 Belgrove Drive, Kearny, New Jersey 07032
- CMS Provider Number
- 315366
- Inspections on file
- 20
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alaris Health At Belgrove during CMS and state inspections, most recent first.
Staff did not consistently document completion of physician-ordered treatments on the TAR, specifically failing to record that the call bell was within reach for three residents with various medical conditions. Facility leadership and nursing staff confirmed that required documentation was missing, despite facility policy mandating that all care and treatments be properly recorded.
A facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident, with staff unfamiliar with the equipment's use. Additionally, oxygen concentrator filters for three residents were found unclean, despite documentation indicating otherwise. These deficiencies highlight a failure in ensuring the availability of critical medical supplies and equipment maintenance.
A facility failed to meet delayed egress locking requirements when an exit door did not sound an audible alarm after 15 seconds of pressure was applied. This issue had the potential to affect staff and 12 residents. A staff member confirmed the finding and stated the facility was unaware of the malfunction.
A facility failed to maintain the fire resistance rating of stairwells as required by NFPA 101. A door in a five-story stairwell lacked the necessary latching fire exit hardware and was instead secured by a magnetic locking device. The facility was unaware of the requirement for latching hardware, and the issue had the potential to affect 40 residents.
The facility failed to maintain smoke and heat detectors according to NFPA standards, as observed in the elevator equipment room where the devices were hanging from wires and not securely attached. This issue had the potential to affect 120 residents, and the responsible individual was unaware of the deficiency.
The facility's sprinkler system was found to have two unsupervised outside screw and yoke (OS&Y) valves, which could prevent staff from knowing if the system was impaired. The domestic and sprinkler riser water line shared the same main water line from the city, and the main water riser room was located in a corporate office storage room. This deficiency had the potential to affect 88 residents.
The facility failed to provide residents with transfer notices that included appeal rights information. Nine residents transferred to hospitals for various medical reasons did not receive notices with necessary appeal details, such as contact information for the entity handling appeals. Interviews with staff confirmed the omission, as they believed compliance was met through other means.
The facility failed to provide residents with bed hold notices that included the cost per day, affecting nine residents transferred to hospitals for various medical reasons. The facility's policies did not specify the daily rate, and the Administrator acknowledged the omission, believing it was justified since residents were always allowed to return.
The facility failed to ensure residents with severely impaired cognition understood binding arbitration agreements before signing. Four residents with low BIMS scores signed agreements without the cognitive capacity to comprehend them. In some cases, family members or friends, who lacked legal authority, provided verbal consent for the residents to sign. The facility's staff confirmed the residents' inability to understand the agreements, and the Administrator acknowledged the deficiency.
The facility failed to maintain a functional Antibiotic Stewardship Program, as it did not document whether infections met the McGeer criteria for appropriate antibiotic treatment over a four-month period. Despite having a policy emphasizing the importance of antibiotic stewardship, the facility did not ensure that unit managers completed and submitted the necessary documentation, potentially leading to unnecessary antibiotic prescriptions.
A facility failed to update a resident's advanced directive from full code to DNR in the medical records, despite the resident's documented wishes on a POLST form. The resident, with moderately impaired cognition, expressed a desire not to be resuscitated, but the EMR and paper chart continued to indicate a full code status. Staff interviews confirmed the discrepancy, highlighting a failure to align the medical records with the resident's expressed wishes.
A facility failed to provide a written summary of a baseline care plan to a resident and their family within 48 hours of admission, despite completing the care plan on time. Interviews revealed that the Social Services Director did not document the provision of the care plan, and the Director of Nursing confirmed the expectation for a written summary to be given. The facility's policy requires a baseline care plan and summary to be provided within 48 hours, which was not followed.
A facility failed to develop a care plan with specific goals and interventions for a resident using antipsychotic medication. The resident, with diagnoses of hallucinations and schizoaffective disorder, had an order for Quetiapine Fumarate. Despite a Care Area Assessment trigger, the care plan lacked necessary goals and interventions. The MDS Coordinator acknowledged the oversight, which was against the facility's policy requiring measurable objectives for psychotropic medication use.
The facility failed to properly store medications, with loose tablets and capsules found in medication carts for the 300 hall rooms. LPNs were responsible for destroying these unsecured medications but could not determine their ownership. Interviews revealed that it was the responsibility of all nurses to ensure medication carts were clean and that loose pills should be disposed of in the drug buster solution, as per facility policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a dialysis resident, risking cross-contamination. The resident, with end-stage renal disease, had no EBP order or PPE signage, and staff did not use gowns during care. Despite facility policy requiring EBP for residents with indwelling devices, staff misunderstood CDC guidelines, leading to this deficiency.
Failure to Document Physician-Ordered Treatments on TAR
Penalty
Summary
Facility staff failed to document the completion of physician-ordered treatments on the Treatment Administration Record (TAR) for three residents. Specifically, there were blank entries for the order to keep the call bell within reach every shift, as required by physician orders and facility policy. These omissions were identified during a review of the TARs for multiple months, where specific shifts lacked documentation that the call bell was within reach for each resident. The residents involved had various medical conditions, including acute pyelonephritis, depression, hypertension, chronic kidney disease, restless legs syndrome, type 2 diabetes, major depressive disorder, hyperglycemia, encephalopathy, transient ischemic attack, cerebral infarction, acute kidney failure, hyperlipidemia, and COPD. Their cognitive and functional statuses ranged from cognitively intact and independent to severely impaired and requiring assistance with activities of daily living. Despite these needs, the required documentation confirming that the call bell was within reach was not consistently completed by staff. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), confirmed that staff did not sign off on the TAR as required by physician orders and facility policy. Nursing staff interviewed acknowledged that they either forgot to document or were unaware of the need to sign off, despite performing the required checks. The facility's Clinical Charting and Documentation Policy required that all services provided be documented, including the name and title of the individual providing care, but this standard was not met in the cited instances.
Deficiencies in Emergency Equipment and Oxygen Filter Maintenance
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, identified as Resident #86. During the survey, it was observed that the required emergency supplies, such as an obturator and appropriately sized inner cannulas, were not available at the resident's bedside or in the supply room. The primary nurses responsible for the care of the resident were not familiar with the obturator or its use, indicating a lack of training and awareness among the staff. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents, identified as Resident #33, Resident #44, and Resident #60. Observations revealed that the concentrator inlet filters for these residents were covered with a gray/white substance, indicating they had not been cleaned as required. The Maintenance Director, who was responsible for cleaning the filters, admitted that the filters had not been cleaned until the day of the survey, despite documentation suggesting otherwise. These deficiencies highlight a failure in the facility's processes to ensure the availability of critical medical supplies and the maintenance of equipment necessary for resident care. The lack of emergency tracheostomy equipment and unclean oxygen concentrator filters posed significant risks to the residents' health and safety.
Plan Of Correction
Resident #86 was provided with the proper emergency equipment at his bedside and nursing staff were educated and competencies were completed. Resident #86 is the only resident currently in Alaris Health at Belgrove with [R]. On 12/3/24 upon receiving notification of the Immediate Jeopardy situation, the Director of Nursing in serviced LPN3 and RN1 assigned to work 3-11 shift on the first floor where Resident #86 resides on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. Director of Nursing and/or Infection Preventionist also inserviced the LPN4 and RN2 assigned to the 1st floor for 12/3/24 11-7 shift on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. This was completed prior to start of the shift. Director of Nursing and/or Infection Preventionist repeated this process for RN3, LPN2 and RN4 assigned to the first floor on 7-3 shift 12/4/24 prior to the start of their shift. Starting on 12/4/24, this education and competency will then be completed on all nurses in the facility. Any nurse caring for Resident #86 will be inserviced prior to the start of their shift. Any nurse that is on leave or vacation will receive this education and competency on their first shift upon return. This education and competency will be incorporated in the orientation process for all new hires starting on 12/4/24. The [R] for residents #33, #44, and #60 were cleaned by the Director of Maintenance and replaced back on the [R]. All residents with tracheostomies and all residents that use oxygen supplementation via oxygen concentrators are potentially affected. Nursing Supervisor will check the supplies in Resident #86 room and any residents with tracheostomy q shift for the next 3 months to assure that all required supplies are present in the room. For Resident #86 these supplies include Tracheostomy Care Kit, Ambubag, Suction Machine, Suction Kit, Normal Saline Bottles, Sterile Water Bottles, Drain Gauze, Sterile Gauze, Inner Cannulas (#6), Tracheostomy Set for Emergency Use (includes outer cannula, inner cannula, obturator, trachea ties, size #5), Corrugated Tubing, Yankeauer Suction Catheter, Velcro Trach Ties, Suction Connecting Tubes, Aerosol Drainage Bag w/ Y-Adaptor and Straight Adaptor. Central Supply Coordinator will maintain a weekly inventory of trach supplies. Inventory will be submitted to the Director of Nursing on a weekly basis for review. Director of Nursing will instruct Central Supply Coordinator on a weekly basis of any supplies that need to be ordered. If a potential admission is identified requiring trach supplies, the Director of Nursing will identify supplies needed and assure supplies are available in building prior to admission. Director of nursing or designee will inservice nurses upon hire and annually on tracheostomy care and care of the tracheostomy in an emergency. Director of nursing or designee inserviced the maintenance department on properly cleaning oxygen concentrators filters. Policy of care of the oxygen concentrator was revised to clean filters weekly by the maintenance department. QAPI was implemented to not only address immediate rectification, but also to maintain an ongoing system to ensure proper trach care and supplies present for residents who need. Within this QAPI there will be continued education with all nurses on Trach Care, Emergency Trach Care and supplies needed. The Director of Nursing, Infection Preventionist and/or designee will conduct 5 observations per week of nurses performing trach care and reviewing emergency trach care and supplies starting 12/9/24. Any nurses noted with deviation from standard of practice will be immediately reinserviced and have a successful competency completed prior to being able to care for a resident with a trach. Maintenance director or designee will audit 5 oxygen concentrators weekly to assure they are properly cleaned. Results of these audits will be reported to the Administrator on a weekly basis for review for the next 3 months. QAPI meeting will be held on a monthly basis to ensure proper procedures regarding cleaning of the concentrator filters, trach care, emergency trach care and availability of proper supplies are in place and followed for the next 2 months and quarterly thereafter for the next year.
Removal Plan
- All nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration.
- A nursing supervisor will check the supplies in Resident #86's room to assure all required supplies are present in the room.
- Central supply will maintain inventory of tracheostomy supplies.
- The DON will assure tracheostomy supplies are available prior to admission.
Delayed Egress Lock Failure
Penalty
Summary
The facility failed to meet the delayed egress locking requirements as specified in the NFPA 101 Life Safety Code (2012 Edition). During an observation, it was noted that an exit door between rooms 101 and 118 did not sound an audible alarm after 15 seconds of pressure was applied, as required. The signage on the door indicated that the locks would unlock after 15 seconds and an alarm would sound, but this did not occur. This deficiency had the potential to affect staff and 12 residents. During an interview conducted at the time of the observation, a staff member confirmed the finding and stated that the facility was unaware that the delayed egress lock was not functioning properly.
Plan Of Correction
The delayed egress door for exit between rooms 101 and 118 was repaired to initiate an audible alarm after 15 seconds of pressure is applied to the door. All residents have the potential to be affected by this deficient practice. The Maintenance Director checked all delayed egress doors in the building to assure all had audible alarm after 15 seconds of pressure is applied to the door. All doors were found to be in working order. The Maintenance Director will make monthly rounds to ensure all delayed egress door initiates an audible alarm after 15 seconds of pressure is applied to the door. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Deficiency in Stairwell Fire Resistance Rating
Penalty
Summary
The facility failed to maintain the fire resistance rating of stairwells as required by the NFPA 101 Life Safety Code. During an observation, a door opening into a five-story stairwell was found to lack the necessary latching fire exit hardware. Instead, the door was secured closed by a magnetic locking device. This deficiency was identified during an observation and interview, where it was confirmed that the facility was unaware of the requirement for latching hardware to secure the door in the frame. The magnetic locking device was designed to release upon activation of the fire alarm, allowing the door to swing freely into the exit stairwell. This issue had the potential to affect 40 residents.
Plan Of Correction
The proper latching fire exit hardware was installed on the stairwell lower-level annex door. All residents have the potential to be affected. The Maintenance Director audited all stairwell exit doors to assure they had a proper latching fire exit hardware. All other stairwell doors were found with proper latching hardware. The Maintenance Director will make monthly rounds to ensure the proper latching fire exit hardware is installed on all doors. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Deficient Installation of Fire Detection Devices
Penalty
Summary
The facility failed to maintain smoke detectors and heat detectors in accordance with NFPA 101, NFPA 70, and NFPA 72 standards. During an observation, it was found that the smoke detector and heat detector in the elevator equipment room were not securely attached to their device bases and were hanging from the wires. This deficiency was identified during an observation on December 3rd, 2024, at 11:45 AM. The issue had the potential to affect 120 residents. During an interview at the time of the observation, the responsible individual was not aware of the deficient installation.
Plan Of Correction
The smoke detector and heat detector devices were secured to the device base in the elevator equipment room. All residents have the potential to be affected. The Maintenance Director audited all smoke and heat detector devices in the building to assure they were secured to the device base. No additional issues were identified. The Maintenance Director will make monthly rounds to ensure all smoke and heat detector devices are properly secured to the device base. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Unsupervised Sprinkler System Valves
Penalty
Summary
The facility failed to ensure that the sprinkler system was electronically supervised in accordance with NFPA 101, 2012 Edition, Section 19.3.5.1 and section 9.7. During an observation, it was found that the domestic and sprinkler riser water line shared the same main water line from the city. The sprinkler system's water line had two unsupervised outside screw and yoke (OS&Y) valves. Without supervisory devices on these OS&Y valves, the nursing home staff would not be alerted if the sprinkler system was impaired, such as if the water flow was cut off. This deficiency had the potential to affect 88 residents. The main water riser room for both the nursing home and corporate offices was located in a corporate office storage room. During an interview, it was confirmed that the unsupervised OS&Y valves were on the water line for the facility's sprinkler system.
Plan Of Correction
Two tamper switches and two fire sprinkler control valve signs on the OS&Y valves coming from the street were installed. All residents have the potential to be affected. The Maintenance Director will make monthly rounds to ensure all the automatic sprinkler system supervisory attachments are properly installed. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Failure to Provide Appeal Information in Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with written transfer or discharge notices that included the option to appeal the transfer or discharge. This deficiency was identified for nine residents who were transferred to hospitals for various medical reasons, such as dehydration, urinary tract infections, and altered mental status. The notices provided to these residents did not contain essential appeal information, including the contact name, telephone number, or address of the entity to which appeals could be directed. The review of the facility's documentation revealed that the Notice of Emergency Transfer forms lacked the necessary details about the residents' rights to appeal the transfer decisions. For instance, the forms did not include the name, address, and telephone number of the entity that receives appeal requests, nor did they provide information on how to obtain and complete an appeal form. This omission was consistent across all reviewed cases, indicating a systemic issue in the facility's discharge process. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the current forms used for discharge notices did not include the required appeal rights information. The staff believed that the facility was compliant with regulations because residents were given the bed hold policy upon admission and were always allowed to return to the facility. However, the forms used were not in alignment with the guidance provided by the New Jersey Department of Health, which mandates the inclusion of specific contact information for appeal processes.
Plan Of Correction
1/7/25 The Emergency [R] Notice letter was updated to include the appeal information required before NJ Ex Order 26.4(b)(1). Residents R21, R27, R75, R9, R60, R69, R71, R91, R86 were previously provided an Emergency Letter of [R] prior to their discharge. All residents have returned from their NJ Ex Order 26.4(b)(1) stay. All residents discharged/transferred to the hospital have the potential to be affected. The Emergency [R] Notice letter was revised by the Administrator to include more detailed appeal information. The Administrator inserviced the [R] and all facility social workers on the regulatory requirements for the appeal information for Emergency Transfer Notification (ETN) to the resident, the resident's representative and the NJ Long Term Care Ombudsman's office. The Social Service Director will submit the Emergency Transfer Notifications to the Administrator on a monthly basis to assure the appeal information is in the letter. Administrator will audit this on a monthly basis. The Director of Social Services will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Provide Complete Bed Hold Notices
Penalty
Summary
The facility failed to provide residents and their representatives with a written bed hold notice that included the cost per day information, which is necessary for informed consent. This deficiency was identified for nine residents who were transferred to a hospital for various medical reasons, such as severe lethargy, low blood sugar, altered mental status, and respiratory distress. The bed hold notices issued to these residents or their representatives only indicated the length of the bed hold but omitted the daily cost, which is a requirement under Medicaid guidelines. The facility's policy on temporary discharge and bed hold did not specify the daily rate or cost per day for holding a resident's bed during their absence. This omission was consistent across multiple documents, including the facility's Temporary Discharge (Bed-Hold) policy and the Admission Agreement. The lack of this critical information in the bed hold notices and facility policies meant that residents and their representatives were not fully informed about the financial implications of holding a bed during a hospital transfer. During an interview, the facility's Administrator and President of Operations acknowledged that the bed hold notices did not include the reserve bed payment policy. They believed that since residents were given the bed hold policy upon admission and were always allowed to return to the facility, the omission was justified. However, this belief did not align with the regulatory requirements, which mandate that the cost per day must be clearly communicated to ensure informed consent.
Plan Of Correction
Bed hold letter was revised reflecting cost for services for future issued bed hold letters. No corrective measures were done for residents R21, R27, R75, R9, R60, R69, R71, R91, and R86 as residents were issued bed hold letters and have already returned to the facility from their acute care stay. All residents issued bed hold letters have the potential to be affected. U.S. FOIA (b) (6) was in serviced by Administrator on the revised bed hold letter that now includes the bed hold cost. Director of Admission will present all future acute discharged residents and/or responsible parties with the revised bed hold letter. The Administrator will audit 5 residents weekly to ensure the revised letter reflecting bed hold cost was issued. Director of Admissions or designee will review all issued bed hold letters weekly for 3 months then monthly. Results of these audits will be provided to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by Director of Admission or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign binding arbitration agreements. This deficiency was identified for four residents who were assessed to have severely impaired cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. Resident 71 had a BIMS score of six, while Residents 84, 75, and 44 each had a BIMS score of one, all indicating severe cognitive impairment. Despite this, these residents signed arbitration agreements without the necessary cognitive capacity to understand the terms. In the case of Resident 71, the resident's niece was present during the signing but did not have power of attorney. The niece understood the agreement but chose not to sign it herself, allowing the resident to sign instead. For Resident 84, the Admissions Coordinator communicated with the resident's grandson over the phone, who explained the agreement in Spanish to the resident. However, the Admissions Coordinator could not verify the resident's understanding due to the language barrier. Resident 75's daughter, who did not have power of attorney, explained the agreement to her mother in Spanish and permitted her to sign it. Resident 44, who had no legal representative or family, signed the agreement after a friend, contacted by phone, gave verbal consent. Interviews with the Admissions Director and Admissions Coordinator confirmed that these residents lacked the cognitive ability to comprehend the agreements they signed. The facility's Administrator acknowledged that it was unacceptable for residents to sign arbitration agreements without understanding them and stated that such instances should be considered refusals if the resident or their representative did not wish to sign.
Plan Of Correction
1/7/25 The [R] Agreements for R71, R84, R75 and R44 were rescinded. A facility wide audit was completed on all signed [R] Agreements in comparison to Brief Interview for Mental Status (BIMS) Assessment score and were corrected. All residents have the potential to be affected by this deficient practice. The Administrator inserviced the Admissions Department on the proper procedure for conducting Arbitration Agreements in accordance to their Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will audit 3 new admissions per month for accurate Arbitration Agreements signature in accordance to Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will report the results of these audits to the Administrator on a monthly basis. The Minimum Data Set (MDS) Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Failure in Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program that adhered to the McGeer criteria for antibiotic usage over a four-month period. During this time, the facility did not adequately document whether infections met the criteria for appropriate antibiotic treatment. Specifically, in January 2024, only one McGeer surveillance form was completed despite 36 facility-acquired infections being documented. In February, no McGeer forms were filled out for 24 documented infections. Similarly, in March, no forms were completed for 18 infections, and in April, only two forms were filled out for 23 infections. This lack of documentation meant that it was unclear if the infections met the criteria for antibiotic treatment. Interviews with facility staff revealed that the unit managers were responsible for completing the McGeer criteria forms for each facility-acquired infection. However, the Infection Preventionist (IP) nurse noted that these forms were not submitted regularly during the months in question. The Director of Nursing (DON) expected the unit managers to complete and forward these forms to the IP nurse for review. The facility's policy on Antibiotic Stewardship emphasized the importance of appropriate antibiotic use to prevent drug-resistant bacteria, increased hospitalizations, higher mortality, and escalating costs. Despite this policy, the facility's failure to document and review infections according to the McGeer criteria potentially led to unnecessary antibiotic prescriptions.
Plan Of Correction
No residents were identified to be affected by the deficient practice. All residents have the potential to be affected by the deficient practice. All nurses and the Infection Preventionist nurse were in-serviced by the Director of Nursing on completing and submitting the Revised McGeer Criteria for Infection Surveillance Checklist. A Revised McGeer Criteria for Infection Surveillance Checklist is to be completed for each facility acquired infection by unit managers or designee. The Infection Preventionist nurse will ensure a Revised McGeer Criteria for Infection Surveillance Checklist is collected and reviewed for each facility acquired infection. The Director of Nursing will audit the Antibiotic Stewardship Program monthly to ensure a Revised McGeer Criteria for Infection Surveillance Checklist is completed for each facility acquired infection. Results of these audits will be reported to the Administrator on a monthly basis. All findings will be reported and reviewed monthly and reported quarterly during the QAPI meeting for the next 2 quarters by the DON or designee to the QAPI committee. Evaluation by the committee will determine the continuing frequency of audits.
Failure to Update Resident's Advanced Directive
Penalty
Summary
The facility failed to update a resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) status. This deficiency was identified for one of nine residents reviewed for advanced directives. The resident, who had a moderately impaired cognitive status, expressed their wish not to be resuscitated if found without vital signs. However, the electronic medical record (EMR) and the paper chart continued to reflect a full code status, contrary to the resident's documented wishes on the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Social Service Director (SSD), revealed discrepancies between the resident's documented wishes and the information in the medical records. The SSD and the Administrator acknowledged that the resident's POLST form, signed by both the resident and their physician, indicated a DNR status, but the EMR and paper chart were not updated accordingly. This oversight had the potential to result in the resident receiving unwanted cardiopulmonary resuscitation (CPR).
Plan Of Correction
1/7/25 Resident #66 medical records were immediately updated to reflect NEX Ord order. All residents with Advance Directives could have the potential to be affected. U.S. FOIA (b) (6) and licensed nursing staff were in-serviced by Administrator or designee on updating Medical Records and Physician Orders with any changes with Advance Directives/POLST. Director of Social Services will present Advance Directive/POLST updates to the team during Morning meeting on a daily basis, and nursing will ensure orders are updated accordingly. Director Of Nursing will conduct audits on a sample of 10 residents per month to ensure that medical records reflect the most updated Advance Directive orders. Director of Social Services or designee will review all resident medical records to ensure Advance Directives are updated weekly for 3 months, then monthly thereafter. Results of these audits will be provided to the Administrator on a monthly basis. Director of Nursing and Director of Social Services will report results of all audits at the quarterly QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. This deficiency was identified for one resident, who was admitted with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, obstructive and reflux uropathy, and dementia. The resident's care plan was completed within the required timeframe, addressing various risks and needs, but the written summary was not provided to the resident or their family member. Interviews with facility staff revealed that the Social Services Director did not document the provision of the baseline care plan to residents or their representatives. The Director of Nursing confirmed the expectation that a written summary should be given within 48 hours of admission. The facility's policy mandates the development of a baseline care plan within 48 hours and the provision of a written summary to the resident and/or their representative, which was not adhered to in this case.
Plan Of Correction
A written summary of the baseline care plan was provided to R203 and [R] representative. All residents have the ability to be affected by this practice. The Administrator inserviced the Interdisciplinary Team members to provide a written summary of the baseline care plan to the resident or resident representative within 48 hours of admission to the facility. The MDS Coordinator will audit 5 admissions per month to ensure a written summary of the baseline care plan was provided to the resident or resident representative. Results of these audits will be provided to the Administrator on a monthly basis. The MDS Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Failure to Develop Care Plan for Antipsychotic Use
Penalty
Summary
The facility failed to develop a care plan with resident-specific goals and interventions for the use of antipsychotic medications for one resident. This resident, identified as R69, was admitted with diagnoses including hallucinations and schizoaffective disorder and had an order for Quetiapine Fumarate, an antipsychotic medication. Despite the presence of a Care Area Assessment trigger for psychotropic medication use, the care plan did not include specific goals or interventions related to the use of these medications. During an interview, the MDS Coordinator acknowledged that the care plan for R69 was not updated with the necessary goals and interventions for psychotropic medications. The facility's policy requires that the use of psychotropic medications be reflected in the resident's care plan with measurable objectives. However, the MDS Coordinator mistakenly believed that a goal related to behaviors was sufficient, as the medication was ordered due to behaviors. This oversight was contrary to the facility's policy, which mandates a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident.
Plan Of Correction
The care plan for resident #69 for [R] use was implemented. Unit managers on each unit reviewed all residents on antipsychotic medication to ensure care plans are in place. Those that did not have were implemented. All residents on antipsychotic medication are potentially affected. Director of Nursing inserviced unit managers on care planning all residents with orders for antipsychotic medication. Unit managers or designee will review new admission charts daily for antipsychotic medication and will review residents with new or changes in antipsychotic orders and will implement the care plan. Director of Nursing or designee will review 5 residents on antipsychotic medication weekly to assure care plan is in place and will report all findings to Administrator on a monthly basis. All findings will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of Nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Improper Storage of Medications in Medication Carts
Penalty
Summary
The facility failed to properly store medications, as evidenced by the presence of loose tablets and capsules in the medication carts for the 300 hall rooms. During an observation, surveyors found four loose tablets and one loose capsule in one medication cart, and ten and a half loose tablets in another cart. These medications were unsecured and not properly accounted for, increasing the potential for drug diversion. Licensed Practical Nurses (LPNs) 5 and 7 were responsible for destroying the unsecured medications using the drug buster solution, but they were unable to determine the ownership of the medications. Interviews with LPN5, LPN7, and the Director of Nurses (DON) revealed that it was the responsibility of all nurses to ensure medication carts were clean and that any loose pills should be disposed of in the drug buster solution. The facility's policy on the disposal and destruction of medication indicated that non-controlled medications, which are expired, refused, or adulterated, should be destroyed by nurses without the need for a second nurse. The policy also outlined the procedure for disposing of unused medications during medication pass. However, the presence of loose medications in the carts indicated a failure to adhere to these procedures.
Plan Of Correction
No residents were affected by this deficient practice. All loose medication were disposed of properly. LPN5 and LPN7 were unable to determine who the medications belonged. Both nurses were inserviced on proper handling of medication cards and the responsibility of keeping their medication carts clean and free of loose medications. All residents with medication orders are potentially affected. Director of Nursing or designee inserviced all nurses on the responsibility of maintaining cleanliness of the medication cart and proper disposal of medication. Inservice will be completed upon hire and annually thereafter. All nurses are to check assigned medication cart on their shift. The unit manager or designee will check med carts once per week to assure compliance with proper medication storage. Unit Managers will check med carts once per week to assure compliance with proper medication storage. The findings of these audits will be reported to the Director of Nursing on a monthly basis. All monthly audits will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident receiving dialysis, which could lead to cross-contamination among vulnerable residents. The resident, identified as R12, was admitted with end-stage renal disease and was receiving dialysis. Despite the resident's care plan and physician orders indicating the need for monitoring and reporting signs of infection, there was no order for EBP, and no signage or personal protective equipment (PPE) was available outside the resident's room. Observations and interviews revealed that staff did not use gowns when providing care to R12, and there was a lack of understanding among staff about the necessity of EBP for dialysis patients. The Director of Nursing and other staff members believed that EBP was not required according to CDC guidelines, despite the facility's policy indicating that residents with indwelling medical devices should be under EBP. This oversight in implementing EBP for R12, who had a dialysis shunt accessed multiple times a week, was a deficiency in infection prevention and control measures.
Plan Of Correction
NJ Ex Order 26.4(b)(1) per facility policy was initiated on 12/5/24 for Resident 12. All dialysis residents with access sites are potentially affected. All staff were inserviced by Infection Preventionist Nurse to ensure all dialysis residents with access sites have enhanced barrier precautions per facility policy. All dialysis residents with access sites will be placed on enhanced barrier precautions per facility policy. Unit Manager and/or designee will be responsible to assure residents with dialysis access sites are identified and have physicians order for enhanced barrier precautions on admission and with status changes. Infection Preventionist and/or designee will make rounds weekly on dialysis patients to assure compliance with enhanced barrier precautions. Results of these audits will be reported to the Administrator on a monthly basis. The Infection Preventionist will report the results of these audits quarterly during the QAPI meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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