Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alaris Health At The Chateau during CMS and state inspections, most recent first.
Kitchen exhaust hood panels above the stove and oven had two approximately one-inch gaps that remained visible during survey observations. The FSD and RFSD acknowledged the openings, and the FSD stated the gaps could present a fire hazard. Facility policy required kitchen equipment and the hood system to be properly cleaned and maintained for safe operation.
A resident in one dining area was seen trying to eat from a used tray and waiting for breakfast while other residents were already eating, and the tray did not arrive until 19 minutes later. In another dining area, multiple residents were left without breakfast while one resident ate, with trays being taken to rooms instead of the dining area; staff confirmed seven residents had not received breakfast, and the last tray was served 19 minutes after the observation began.
Surveyors found multiple environmental deficiencies in dining areas, shower rooms, and resident rooms, including ceiling tile gaps, dust and dirt buildup, chipped wood, peeled wallpaper, uneven flooring, and a ripped privacy curtain. Staff acknowledged several of the conditions as dust or items needing cleaning or repair. Surveyors also observed a resident with acute respiratory failure with hypoxia and a history of falling lying in bed without a call bell within reach on repeated checks; staff stated the call bell was broken and should have been within reach.
Bed hold notifications for three residents who were transferred to the hospital did not include the reserve payment amount. One resident had heart failure and a tracheostomy with severe cognitive impairment, another had cerebrovascular disease and hydronephrosis, and a third had CHF, COPD, asthma, and pneumonia with multiple acute hospital transfers. Facility staff, including the DSS and DA, described the bed hold process, but the written notices and facility forms did not list the dollar amount for the bed hold reserve payment.
Opened treatment items were found without opening dates in multiple treatment carts across the facility, including Hydrocortisone Cream, Iodine Solution, Retrogel Skin Cream, Santyl, Petrogel, GoodSense Gel, L-Mesitran Honey, and Vashe Wound Solution. The ADON, DON, and LNHA acknowledged the items were not dated when opened, despite facility policy requiring proper labeling of drugs and biologicals.
A RN Supervisor failed to perform hand hygiene before entering a room with EBP signage and before donning new gloves during incontinence care, then performed hand washing only after removing gloves. In addition, sharps containers in multiple resident rooms were observed above the fill line, including rooms of residents receiving insulin injections and other injectable medications. The IPN stated staff were expected to follow hand hygiene and PPE requirements for high-contact care, and the facility policy required sharps containers to be replaced at the designated fill line.
Missing signatures on SNFABN forms: Two residents had SNFABN forms with Option 1 checked, but neither the resident nor the RR signed the forms. The DoSS said she would notify alert residents in person and contact RRs by phone or email for those unable to sign, while the LNHA and DON reviewed the forms and said the option may have been checked by accident or that the form may have been from a previous company.
A resident with dementia, anxiety, and a prior pelvic fracture showed a decline in late-loss ADLs on MDS review, including increased dependence for eating, toileting, transfers, and walking, with new wheelchair use and lower-extremity impairment. Surveyors found no documentation that the IDT met to review the decline or decide whether an SCSA was needed, and the RN/MDSC stated the quarterly MDS should have been treated as an SCSA.
A facility failed to accurately code MDS assessments for two residents. One resident with dementia, anxiety, and prior fractures had multiple documented falls, including falls with no injury, injury not major, and major injury, but several were not captured on the MDSs. Another resident with respiratory failure, diabetes, PVD, and morbid obesity had a documented stage 2 pressure injury and wound treatment orders, but the quarterly MDS coded no pressure injury. The RN/MDSC and LNHA acknowledged the coding discrepancies.
The facility failed to clarify and follow multiple PO for several residents. One resident’s air mattress was set at 300 lbs despite a documented weight of 149 lbs, another resident’s antianxiety med monitoring order was documented with checkmarks instead of the required Y/N notation, a resident with a PEG tube had conflicting enteral feeding amounts, and two other residents had duplicate PO that were not clarified. The residents involved had significant medical conditions including COPD, ESRD with trach/vent dependence, severe cognitive impairment, and ALS.
A resident with severe cognitive impairment and a history of multiple falls had several unwitnessed falls with documented injuries, including swelling, laceration, and hip pain. Some fall investigations lacked witness statements or IDT meetings, and interventions such as floor mats, call bell use, rehab screening, and medication review were not consistently reflected in the care plan or supported by a physician order. Surveyors also observed the resident without floor mats in the room.
A resident with an indwelling catheter and bladder cancer had multiple shifts with missing urine output documentation despite a physician order to measure and record suprapubic urine output every shift. Surveyors also observed two urinals in the resident’s toilet room hanging on a handrail, one with yellowish output and another with blackish substances, both unlabeled and not stored properly. The RN/UM stated the urinals should not be like that and that CNA-to-nurse reporting and eTAR documentation should not have blanks.
A resident with a tracheostomy and respiratory diagnoses had O2 tubing and a humidifier bottle observed without date labels, despite a PO to change tubing weekly and facility protocol requiring labeling. Another resident with cystic fibrosis and bronchiectasis was observed receiving O2 via NC at 4 lpm even though the PO ordered 2 lpm every shift; an LPN confirmed the setting was incorrect and adjusted it to the ordered rate.
Insufficient nursing staffing led to a resident being found wet and wearing double incontinence briefs that were not part of the resident’s care plan, while staffing records showed one RN and three CNAs for the unit’s overnight assignment and mismatched CNA assignment documentation. In a separate event, an LPN working a double shift failed to properly endorse a controlled med accountability discrepancy to the incoming nurse, which the DON attributed to short staffing and the nurse forgetting to communicate the issue.
Inaccurate Daily Staffing and Census Posting: Surveyors found that the NHRCSR was not posted accurately at the start of the shift and was sometimes left outdated or missing. The front desk posting showed an old date on one day, and another posting showed an incorrect census that did not match the staffing sheets. Interviews with the staffing coordinators and LNHA confirmed that weekend updates were not being made, leaving the daily staffing and census report inaccurate.
An LPN removed methadone from a resident’s bingo card and signed the IPCSAR, but the documented count did not match the actual tablets in the card. The facility later found that another LPN had previously found a loose methadone tablet in the narcotic box, wasted it without a second nurse, did not sign the waste, and did not complete the required shift-change count or endorsement with the incoming nurse.
Medication administration errors exceeded the allowed rate when surveyors observed 4 errors in 38 opportunities, resulting in a 10.53% error rate. A nurse gave a resident's carvedilol, gabapentin, levetiracetam, and valsartan late, and carvedilol was not given with breakfast as ordered. The eMAR showed the meds were overdue, and the RN acknowledged the late administration and failure to follow the ordered timing instructions.
Medication Administration Errors With Midodrine Parameters: The facility failed to administer Midodrine according to ordered BP parameters for multiple residents. One resident received PRN Midodrine when systolic BP was not below the ordered threshold and missed doses when BP was within range, another resident’s Midodrine order lacked BP documentation on the eMAR, and a third resident received Midodrine when BP was above the hold parameter. The RNS and LPN stated BP should be checked and documented before giving Midodrine, and the facility policy required meds to be administered according to specific order instructions.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
A resident with severe cognitive impairment, an indwelling urinary catheter, and a g-tube was ordered to be on Enhanced Barrier Precautions and to receive medications and nutrition via g-tube, as well as nebulized treatments, eye drops, and a nicotine patch. During an observed medication pass, an LPN performed initial hand hygiene and donned gloves but then administered g-tube medications, enteral feeding, a nebulizer treatment, g-tube site care and dressing change, a nicotine patch, and eye drops without changing gloves or performing hand hygiene between these different care activities and routes of administration. The LPN also failed to wear a gown despite the resident being on EBP. The LPN later acknowledged not following required hand hygiene and glove-change practices, and the DONs confirmed that facility policies and expectations required hand hygiene, appropriate glove changes, and adherence to EBP for such care.
The facility failed to notify the representatives of two residents about significant changes in their conditions. One resident had critical lab results indicating severe health issues, and the representative was not informed until a day later. Another resident developed a new pressure ulcer, but there was no documentation of family notification until discharge. Interviews confirmed the lack of timely communication, which is required by the facility's policy.
A facility failed to ensure physician response to pharmacy recommendations for a resident with dementia and Alzheimer's. The pharmacist recommended increasing Aricept and Namenda dosages to achieve maximum effectiveness, but the physician did not document any response or rationale for not acting on these recommendations. This lack of action was confirmed through interviews and record reviews.
The facility failed to maintain a homelike environment in eight resident rooms and the Activity room, with issues such as peeling paint, rusted heating units, and broken closet doors. The Maintenance Logbook showed no entries for necessary repairs, and an entry indicated no issues were reported or found, despite evident deficiencies.
The facility failed to maintain handrails in good repair on the second floor, with several secured by duct tape and foam, and others missing. Maintenance logbooks showed no repair requests, and staff were uncertain about the duration of the issues. The Maintenance Director mentioned waiting for parts, but no orders were confirmed.
Kitchen Exhaust Hood Panels Left with Visible Gaps
Penalty
Summary
The facility failed to maintain the kitchen exhaust hood assembly in a safe operating condition by allowing approximately two one-inch gaps to remain in the hood panels above the stove and oven. During a kitchen tour with the Food Service Director, the surveyor observed the gaps visible between adjoining hood panel sections, and the Food Service Director acknowledged the openings and agreed they could present a fire hazard. On a follow-up observation with the Food Service Director and Regional Food Service Director, the same two gaps were still present in the hood assembly. Both leaders acknowledged the condition remained unchanged and stated they would contact maintenance personnel or the hood cleaning contractor to evaluate and correct it. Facility policies reviewed by the surveyor stated that the kitchen hood system was to be professionally cleaned and maintained, and that kitchen equipment was to be properly cleaned and maintained to ensure safe operation.
Residents Left Waiting for Breakfast Trays During Mealtime
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime in two dining areas, affecting 9 of 18 unsampled residents observed. In the North 3rd floor dining area, one resident was seen trying to eat from a used tray and asking for food while staff removed the tray and told the resident to wait. The resident did not receive a breakfast tray while the other residents were eating, and staff confirmed the tray had not arrived yet. The resident was observed wandering and looking for food until the tray arrived after 19 minutes, while all other residents in the dining area were already eating or had finished. In the North 4th floor dining area, a food truck was observed in front of the nursing station and between the dining area without trays being distributed to the residents seated there. Several residents remained without breakfast while one resident was eating, and staff distributed trays to residents in their rooms instead of to those waiting in the dining area. RN/UM #2 confirmed that seven residents had not received breakfast while one resident was eating. The last tray was not served until 19 minutes after the observation began. The facility's Resident Rights Policy stated residents are to be treated with respect, dignity, and self-determination, and the Dining Policy stated meals are to be served three times per day according to scheduled meal times.
Unsafe and Unclean Environment with Missing Call Device
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in multiple dining areas, shower rooms, and resident rooms. During observations, surveyors found ceiling tiles with gaps, ceiling vents with grayish or blackish accumulation, blackish floor molding, chipped wood, peeled wallpaper, brownish buildup around a water dispenser, flooring gaps, and dust and dirt inside AC grills. In one dining area, plate covers were left uncovered near ceiling vents with visible dust accumulation. Facility staff, including the AA, FSD, RN, DM, and LNHA, acknowledged several of the observed environmental concerns as dust or items needing cleaning or repair. Surveyors also observed problems in shower rooms and resident rooms. In a North 3rd floor shower room, a ceiling vent had blackish accumulation, ceiling tiles had gaps, and floor mats were stored in a plastic bag in a shower cubicle. In a North 4th floor shower room, broken and missing tiles and uneven flooring were observed in the training restroom area and toilet area. In room 360, surveyors observed a ripped privacy curtain, peeled molding, peeled wallpaper above the sink, uneven closet doors, and a toilet room vent with blackish accumulation; the resident stated the condition had been present for two months. In room 257, surveyors observed the bed by the window without a mattress, with unfolded clothes placed on the empty bed. Surveyors also found that Resident #123, who had diagnoses including acute respiratory failure with hypoxia and a history of falling, was lying in bed without a call device within reach on two observations. The call device cord had been removed from the wall jack, and staff acknowledged the call bell was broken and that the resident should have had a call device within reach. The LPN searched for the device, and RN/UM #3 later attached a call device to the wall jack and clipped it to the bed within reach of the resident. The resident’s care plan identified the resident as at risk for falls and included keeping the call light within reach and responding promptly to requests for assistance.
Bed Hold Notifications Omitted Reserve Payment Amount
Penalty
Summary
The facility failed to include the bed hold reserve payment amount in the written notification of emergency transfer and bed hold provided to residents or their representatives for 3 of 3 residents reviewed for hospitalization. For Resident #7, who had diagnoses including heart failure and tracheostomy with dependence on a respirator and whose cognitive skills for daily decision making were severely impaired, the discharge-to-hospital letter dated 3/11/26 stated that the resident’s accommodations could be reserved for seven days with payment continuing at the regular daily rate, but it did not list the reserve payment amount. For Resident #16, who had diagnoses including cerebrovascular disease and hydronephrosis and whose cognitive skills for daily decision making were independent, the discharge-to-hospital letter dated 5/19/26 also stated that the resident’s accommodations could be reserved for seven days with payment continuing at the regular daily rate, but it did not include the bed hold reserve payment amount. On 6/3/26, the LNHA, AA, and DON were notified of the concern that the bed hold notifications for Residents #7 and #16 did not include the reserve payment amount. Resident #18, who had diagnoses including acute on chronic diastolic heart failure, COPD with acute exacerbation, moderate persistent asthma with status asthmaticus, and pneumonia, reported returning from the hospital multiple times and stated they were not informed of any payment amount for reserve payment and did not sign anything about a bed hold. The record reflected five acute transfers to the hospital. Interviews with the UM, DSS, and DA showed differing understanding of the bed hold process, and the facility’s transfer/discharge and bed hold policy did not include a written dollar amount for the reserve payment on the bed hold transfer forms, regardless of payor source.
Opened Treatment Items Were Not Dated in Treatment Carts
Penalty
Summary
The facility failed to store medications and biologicals in accordance with its policy by not ensuring opened treatment items were labeled with the date opened in 5 of 5 treatment carts. During a medication storage inspection, the surveyor observed multiple opened treatment items in the North Building and South Building treatment carts that did not have opening dates documented. In the North Building 4th Floor Side A cart, three opened items lacked dates: Hydrocortisone Cream 2.5%, Iodine Solution, and Retrogel Skin Cream. Additional unlabeled opened items were found in other treatment carts, including three opened tubes of Santyl in the North Building 4th Floor Side B cart, two opened items in the North Building 3rd Floor Side B cart (Petrogel and GoodSense Gel), two opened items in the North Building 3rd Floor Side A cart (Santyl and L-Mesitran Honey), and two opened items in the South Building 1st Floor cart, including Vashe Wound Solution and another opened item listed as Hy[DATE].25%. The ADON acknowledged the items did not contain opening dates, and the DON and LNHA also acknowledged that opened treatment products should be dated when opened. The facility policy reviewed in 1/2026 stated that drugs and biologicals must be stored in a safe, secure, and orderly manner and that improperly labeled drug containers should be returned to the pharmacy for proper labeling before storage.
Hand Hygiene and Sharps Container Management Failures
Penalty
Summary
The facility failed to follow infection prevention and control practices during resident care and failed to keep sharps containers replaced when they reached the fill line. During an incontinence round, a Registered Nurse Supervisor entered a resident’s room and donned gloves without performing hand hygiene, then moved to another resident’s room without performing hand hygiene before entry or before putting on a new pair of gloves. The second room had posted EBP and PPE sequencing signs, a PPE box outside the room, and an ABHR dispenser on the wall. The nurse checked the resident for incontinence and performed hand washing only after discarding the used gloves. When questioned, the nurse stated she had not performed hand hygiene after removing gloves in the first room and before entering the second room because the surveyor had asked her to check the resident’s brief. The infection control concern also involved sharps containers in multiple resident rooms. In one room, a sharps container was observed above the full line, and the resident had physician orders for insulin and Lovenox injections. In another room, a sharps container was also observed above the full line, and that resident had insulin orders requiring needle disposal in the sharps container. Additional observations found sharps containers in two other resident rooms filled above the full line. Those residents had diagnoses including tracheostomy, scleroderma, heart failure, and tracheostomy with ventilator dependence, and both had severely impaired cognitive skills for daily decision making. Facility staff acknowledged the sharps containers were full and stated they needed to be changed when they reached the full line. The Infection Preventionist stated staff were expected to perform hand hygiene before entering rooms with EBP signage, wear gown and gloves for high-contact care such as incontinence care, and perform hand hygiene again after doffing PPE. The facility’s Biohazard Waste Storage Policy stated sharps containers were to be replaced when the designated fill line was reached.
Missing signatures on SNFABN forms
Penalty
Summary
The facility failed to provide documented evidence that written notification of potential liability charges for services not covered was given to beneficiaries when Medicare Part A services ended with benefit days remaining. For 2 of 3 residents reviewed for beneficiary notice, Resident #42 and Resident #178, the SNFABN forms showed Option 1 checked under the section for choosing how to proceed, but neither form contained a signature from the resident or the resident representative. For Resident #42, the SNFABN form listed additional information ending 4/30/26 and included a handwritten note that a message was left with the resident representative on 4/27/26. The form had Option 1 marked, but there was no resident or representative signature. For Resident #178, the SNFABN form listed additional information ending 5/11/26 and included a handwritten note that the form was emailed to a named individual above the signature line. The form also stated that the resident was unable to sign with a date of 5/8/26, and Option 1 was marked, but there was no resident or representative signature. During interview, the Director of Social Services stated that admissions notified her when a resident needed the notice, and she would send it. She stated that if a resident was alert and oriented, she would speak with them and have them sign the papers; if not, she would call or email the resident representative and document verbal confirmation on the forms. When shown the two forms, she confirmed the marked option but was not sure why the mark was there. The LNHA and DON also reviewed the forms and stated the mark on Option 1 may have been checked off by accident, and the LNHA later stated the form being used appeared to be from the previous company and should not have been filled out with the option.
Failure to Complete SCSA After Functional Decline
Penalty
Summary
The facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for one resident after a documented decline in function. The resident was admitted with diagnoses including left pubic fracture, difficulty walking, anxiety disorder, and dementia with anxiety. The resident’s MDS assessments showed severe cognitive impairment, with BIMS scores of 4 of 15 on the comprehensive assessment and 3 of 15 on later quarterly assessments. Review of the resident’s MDS records showed a marked decline in Section GG functional status over time. Earlier assessments coded the resident as eating with setup, toileting with partial assistance, and independent with chair-to-bed transfer and walking, with no wheelchair or adaptive devices in use. A later quarterly assessment coded the resident with impairment to one side of the lower extremity, wheelchair use, partial assistance with eating, dependence with toileting and chair-to-bed transfer, and walking not attempted. The record reflected decline in four late-loss ADLs, but there was no documentation that the interdisciplinary team met to discuss the decline or determine whether an SCSA was warranted. During surveyor interviews, the RN/MDS Coordinator stated that if a decline was identified and not expected to return to baseline, an SCSA would be done, and that the interdisciplinary team should meet and document the decision to proceed or not proceed with an SCSA. When asked about the quarterly assessment showing decline, the RN/MDS Coordinator stated it should have been an SCSA and confirmed there was no documentation that the team decided not to initiate one. The facility later stated that the SCSA was not done for the resident and that there was no facility policy specific to SCSA beyond following the RAI manual.
MDS Assessments Were Not Accurately Coded for Falls and a Pressure Injury
Penalty
Summary
The facility failed to accurately code the MDS for two residents. For one resident with diagnoses including left pubic fractures, difficulty walking, anxiety, and dementia, the record showed multiple falls over several months, including falls with no injury, falls with injury not major, and one fall with major injury. However, several of those falls were not captured on the corresponding MDS assessments, including a comprehensive MDS, quarterly MDSs, and a discharge return anticipated MDS. The RN/MDSC acknowledged that the fall events should have been coded differently based on the documented injuries and agreed that the MDSs contained discrepancies. For the second resident, the record showed diagnoses including acute and chronic respiratory failure, type 2 diabetes mellitus with complications, peripheral vascular disease, and morbid obesity. The resident’s quarterly MDS indicated no pressure injury, but the medical record included physician orders for treatment of a left ischial wound, left buttock wound, and scrotal wound, and a wound care consultation note identified a stage 2 pressure injury requiring ongoing assessment and treatment. The RN/MDSC reviewed the wound documentation and stated that the pressure ulcer should have been captured on the MDS. The DON stated that the MDS assessment should accurately reflect the resident’s clinical condition and documented wounds during the assessment reference period. The LNHA acknowledged that the stage 2 pressure injury documented in the record was not accurately coded on the quarterly MDS assessment. The report cited NJAC 8:39-11.2(g); 33.2(d) for the deficient practice.
Unclear and Unfollowed Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were clarified and followed for multiple residents. The report identified duplicate or conflicting orders for Residents #9 and #17, a medication monitoring order that was not followed for Resident #4, an air mattress order issue for Resident #3, and conflicting tube feeding orders for Resident #8. These findings were based on observation, interview, and record review, along with review of facility policies and physician order documentation. Resident #3 was observed lying in bed on an air mattress with oxygen in use via nasal cannula. The mattress control unit was set at 300 lbs, which was the maximum setting available, even though the resident’s documented weight was 149 lbs. The resident stated the mattress was not working properly and believed there was a hole in it because concerns had been repeatedly reported to staff. Review of the record showed diagnoses including COPD, emphysema, fibromyalgia, atrial fibrillation, and osteoporosis, and the record contained an order to check the function of the pressure-relieving bed/mattress every shift, but no physician order was identified for use of an air mattress. Resident #4 had diagnoses including end stage renal disease and tracheostomy with dependence on respirator. The May 2026 eMAR included an antianxiety medication order with specific monitoring instructions to document whether drowsiness, slurred speech, dizziness, nausea, or aggressive/impulsive behavior were observed, using Y or N each shift. Review showed nurses were using a checkmark to indicate administration instead of the required Y or N documentation. Resident #8 had severe cognitive impairment and a gastrostomy tube. The eMAR contained two enteral feeding orders with different amounts: one for 250 ml five times daily and another for 1,185 ml total volume in 24 hours, and the nurses documented different amounts being given. Resident #9 and Resident #17 also had duplicate orders identified in the record, including PRN medication orders for Resident #9 and duplicate bowel regimen orders for Resident #17, and the report states these orders were not clarified at the time they were reviewed.
Incomplete fall investigations and missing care plan interventions
Penalty
Summary
The facility failed to ensure that Resident #17’s active care plan included interventions that were implemented after each fall, failed to ensure fall investigation interventions were appropriate, and failed to thoroughly complete fall investigations in accordance with facility policy and standards of practice. Resident #17 was admitted with diagnoses including unspecified fracture of the left pubis, difficulty walking, other specified anxiety disorders, and unspecified dementia with anxiety. The resident’s cognitive testing showed severe impairment, with BIMS scores of 4 of 15 and later 3 of 15. The record showed multiple falls over an eight-month period, including unwitnessed falls in the resident’s room and bathroom area. Some fall investigations documented no injuries, while others documented injuries such as a 3 cm by 3 cm elevation, laceration to the right forearm with swelling and pain, and right hip pain with bruising. Interventions recorded after some falls included floor mats, use of the call bell, rehab screening, medication review, new shoes, and education to use the call bell for assistance. However, not all fall investigations had statements for unwitnessed falls, one fall had no IDT meeting, and another fall also had no IDT meeting documented. Surveyors observed the resident in the room without floor mats on two separate occasions. The care plan did not include documentation of the floor mat intervention from the IDT meeting, and there was no physician order for floor mats. The medical record also did not document why the floor mat intervention was not followed. Facility staff acknowledged that the floor mats should have been in the care plan, and the DON stated staff were being re-educated about fall investigations and intervention appropriateness because the resident’s severe cognitive impairment affected the resident’s ability to understand interventions.
Missed urine output documentation and improper urinal storage
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter was monitored and documented for urine output in accordance with the physician’s order. The resident was admitted with diagnoses including COPD, bladder cancer, and difficulty walking, and the quarterly MDS coded the resident as cognitively intact with an indwelling catheter. The care plan included monitoring and reporting signs such as pain, burning, blood-tinged urine, cloudiness, and no output. A physician order directed staff to measure and record suprapubic urine output every shift, but the May 2026 eTAR contained multiple shifts with missing nurse initials and missing urine amounts, and there was no documented evidence that the urine output was obtained for those dates. The facility also failed to maintain the collection containers used to empty the drainage bag in a clean and proper manner. During observation, two urinals were found hanging on a metal handrail in the resident’s toilet room, one containing yellowish output and the other containing blackish substances on the bottom; both were not properly stored in a bag and were unlabeled. When questioned, the RN/UM stated that the urinals should not be like that and explained that the CNA emptied the urinary bag, reported the amount to the nurse, and the nurse documented it in the eTAR, with no blanks allowed. The facility’s catheter care policy required an accurate record of daily output and use of a separate, clean collection container for each resident, with the collection bag emptied at least every shift.
Oxygen Equipment Not Labeled and Ordered O2 Rate Not Followed
Penalty
Summary
The facility failed to ensure oxygen tubing was labeled and dated in accordance with physician orders and facility protocol for a resident with a tracheostomy and multiple respiratory diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and atrial fibrillation. During observation, the resident was found in bed with an oxygen concentrator set at 2 lpm, but the oxygen tubing connected to the concentrator had no date label, and the disposable humidifier water bottle also had no visible date label. A non-rebreather mask was observed positioned over the resident's tracheostomy, and the tubing remained without a date label on a later observation. The resident had intact cognition with a BIMS score of 15 out of 15 and received tracheostomy care. The care plan directed staff to administer oxygen via tracheostomy collar as ordered, provide humidified oxygen as prescribed, and monitor respiratory status. The physician order dated 6/1/24 directed staff to change oxygen equipment tubing every 7 days during the night shift every Saturday. The Unit Manager stated the tubing should have the date on it and that tubing and humidifier water were changed weekly and as needed, with documentation on the eMAR or eTAR. The facility also failed to provide ordered respiratory care consistent with professional standards for another resident receiving oxygen via nasal cannula. The resident had diagnoses including cystic fibrosis, bronchiectasis, and acute respiratory failure with hypoxia, and had intact cognition with a BIMS score of 15 out of 15. On two observations, the oxygen flow meter was set at 4 lpm even though the physician order was for oxygen inhalation via nasal cannula at 2 lpm every shift. When the LPN reviewed the setting in the surveyor's presence, the LPN confirmed it was supposed to be 2 lpm and adjusted it to the ordered rate.
Insufficient Nursing Staffing and Medication Accountability Lapses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs when Resident #59 was found wet during an incontinence round and wearing double incontinence briefs that the resident said were not requested. The resident stated that the 11-7 CNA had placed the double briefs because the resident “pee a lot.” The RN supervisor confirmed the resident was cognitively intact and incontinent, stated that double briefs were not the facility’s practice, and observed that the resident was wet. The resident’s care plan documented bowel and bladder incontinence, but there was no documented intervention to provide double incontinence briefs. Staffing records reviewed by surveyors showed that on the 11-7 shift for the North 2nd floor, there was one RN and three CNAs for a census of 45 residents. The assignment sheet identified Resident #59 on one CNA’s assignment, while the daily schedule report and assignment information did not match the census provided. The surveyor also learned that the CNA involved was an agency aide and that the facility later stated she would not be working there anymore. The LNHA acknowledged that staffing shortages occurred, especially on weekends, due to call outs. The facility also failed to maintain controlled medication accountability when an LPN did not accurately endorse and account for a controlled medication bingo card discrepancy. The DON stated the LPN worked a double shift because the facility was short-staffed and forgot to notify the incoming nurse about the discrepancy. The LPN had worked overnight on one unit and then the next day on another unit, and the survey team reviewed the staffing assignments and discussed the discrepancy with facility leadership during the survey.
Inaccurate Daily Staffing and Census Posting
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report (NHRCSR) was accurately posted at the beginning of the current shift, including licensed nurse staffing, CNA staffing, and resident census. On 5/28/26 at 8:53 AM, surveyors observed that the NHRCSR posted at the front desk was dated 5/27/26 for the day shift and there was no NHRCSR posted for 5/28/26. On 6/1/26 at 6:48 AM, surveyors observed a posted NHRCSR dated 5/31/26 showing census information for all shifts, and later that morning another posted NHRCSR dated 6/1/26 showed a census of 189. The LNHA confirmed that the census was 189 that morning. Review of staffing sheets on 6/1/26 showed that the active residents in house for Sunday 5/31/26 totaled 189, with 120 residents in the North building and 69 in the South building, which did not match the posted NHRCSR census of 191. During interviews, the staffing coordinators stated that one coordinator was responsible for posting the NHRCSR and that the report was created by combining numbers from both buildings and then emailed to the front desk for posting. The South building coordinator stated that on Sundays no one was available to update the NHRCSR and that the facility had to wait until Monday morning to update the posting. The survey team also met with the LNHA, AA, and DON regarding the inaccurate postings and the lack of weekend updates, and the facility policy stated that daily staffing and current census are to be posted at reception.
Controlled Substance Count Mismatch for Methadone
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards when the inventory for Resident #127’s methadone did not match the actual tablets in the medication card. During a medication pass, an LPN removed five methadone HCl 10 mg tablets from the resident’s bingo card and signed the IPCSAR, but the card contained 36 tablets while the IPCSAR reflected a balance of 37 tablets. The resident had diagnoses including chronic pain and had physician orders for methadone HCl 10 mg, 5 tablets daily and 1 tablet at bedtime for chronic pain. After the discrepancy was identified, staff searched the medication cart and narcotic box but did not find a loose tablet. The facility’s investigation found that an LPN had previously found one loose methadone tablet in the narcotic box and wasted it in the drug buster without a second nurse, did not sign the waste, did not complete an outgoing controlled-substance count with the incoming nurse, and did not perform an endorsement at shift change. The facility’s controlled substance policy required destroyed doses to be documented by two licensed nurses and required a physical inventory of controlled drugs at each shift change by two licensed nurses.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medications were administered without error at a rate of 5% or greater. During a medication administration observation involving 3 nurses and 6 residents, surveyors identified 4 errors out of 38 opportunities, resulting in a 10.53% medication error rate. The deficient practice involved one nurse administering medications to Resident #82. For Resident #82, the nurse prepared and administered carvedilol 3.125 mg, gabapentin 100 mg, levetiracetam 1500 mg total dose, and valsartan 80 mg later than the scheduled times. The carvedilol order also required administration with breakfast, but it was given after breakfast time. The eMAR showed the medications were overdue, and the nurse acknowledged the medications were given late and that the carvedilol instruction to give with breakfast was not followed. The RN/UM confirmed the expectation was to administer medications within one hour before or after the scheduled time. The nursing progress note documented that the physician was notified about the delayed carvedilol, but it did not include notification about the other late medications until a later clarification note was entered after surveyor inquiry.
Medication Administration Errors With Midodrine Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services by ensuring accurate administration of Midodrine according to physician orders and ordered blood pressure parameters for 3 of 6 residents reviewed. Resident #4 had a PRN order for Midodrine 10 mg via PEG tube every 8 hours for systolic BP less than 100 mmHg, but the medication was administered on 5/30/26 for a BP of 100/77, which was outside the ordered parameter. The same resident also had documented systolic BPs of 96/68 and 99/60 on 5/5/26 and 5/7/26, respectively, and there was no documented evidence that the PRN Midodrine was administered at those times. Resident #7 had an order for Midodrine 15 mg via PEG tube three times daily with a hold parameter for systolic BP greater than 110, but the May 2026 eMAR did not list blood pressures with the medication administration entries. The surveyor reviewed the record and found that the eMAR used check marks or number codes to show whether the medication was given or not given, but there were no BP values documented for the order. Resident #8 had an order for Midodrine 10 mg via PEG tube every 6 hours with a hold parameter for systolic BP above 130 mmHg. The eMAR showed multiple doses marked with an X where BP was not listed, and one dose was administered on 5/29/26 for a BP of 138/66, which was outside the ordered parameter. During interview, the RNS and LPN stated that Midodrine orders with parameters required a BP check before administration and that the BP should be documented on the eMAR. The RNS confirmed that Resident #8’s Midodrine should not have been given when the BP was outside the parameter and stated that Resident #7’s eMAR did not have a section to document the BP because the order had not been set up correctly in the computer. The facility policy stated that medications must be administered according to specific instructions in the physician order, including BP requirements, and that required assessments must be completed and documented prior to administration when indicated.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
Failure to Follow Infection Control Procedures During Medication and G-Tube Care
Penalty
Summary
A deficiency occurred when staff failed to follow infection prevention and control procedures during medication administration and feeding for one resident. The resident had multiple diagnoses, including a history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side. The quarterly MDS showed the resident was severely cognitively impaired with a BIMS score of 1 out of 15 and had both an indwelling urinary catheter and a g-tube in place. Physician orders directed that the resident be on Enhanced Barrier Precautions (EBP) due to the indwelling urinary catheter and g-tube, that all oral medications and feedings be administered via g-tube, and that the resident receive nebulized inhaled medications, eye drops, and a topical nicotine patch. During an observed medication pass, an LPN washed hands and donned gloves before administering ordered medications through the resident’s g-tube, followed by the resident’s feeding via g-tube. After completing the g-tube medications, the LPN administered the first nebulizer treatment without performing hand hygiene or changing gloves between the g-tube administration and the nebulizer treatment. While the nebulizer treatment was in progress, the LPN provided care to the skin around the g-tube and replaced the dressing, again without performing hand hygiene or changing gloves. Following the g-tube dressing change, the LPN applied the resident’s nicotine patch to the upper chest and then administered eye drops to both eyes, all without sanitizing hands or changing gloves between these different care activities and routes of administration. The LPN did not wear a gown at any time during the medication administration or feeding, despite the resident being on EBP. In a subsequent interview, the LPN acknowledged not performing hand hygiene or changing gloves as frequently as required and stated awareness that these actions should occur between feedings, g-tube care, and each route of medication administration, as well as awareness that EBP were required but not followed. The DONs confirmed their expectation that staff perform hand hygiene and change gloves before and after each route of medication administration, before and after g-tube dressing changes, and before and after administering enteral nutrition, and that EBP be followed as ordered. Facility policies on medication administration, nebulizer care, EBP, and hand hygiene all required adherence to infection control procedures, including hand hygiene, glove use, and gown use for high-contact care activities. The facility's failure to ensure infection control procedures were followed for this resident created the potential for this and other residents to develop infection.
Failure to Notify Resident Representatives of Critical Changes
Penalty
Summary
The facility failed to ensure timely notification to the representatives of two residents when significant changes in their conditions occurred. Resident 278, who was severely cognitively impaired, had critically low hemoglobin and hematocrit levels, as well as critically high urea nitrogen and potassium levels. Despite these critical lab results being available on multiple dates, there was no evidence that the resident's representative was notified until a day after the results were received. The Director of Nursing confirmed the lack of timely notification, which is necessary for making informed treatment decisions. Resident 328, who had severe cognitive impairment and multiple health issues including a recent amputation and pressure ulcers, developed a new pressure ulcer on the left anterior lower leg. This new ulcer was first observed on February 28, 2024, but there was no documentation indicating that the family was notified of this new condition. The ulcer was monitored and treated with Skin Prep, but the family was only informed about the treatment at the time of discharge, not when the ulcer was initially discovered. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, revealed that the facility's policy requires family notification of new pressure ulcers, but this was not documented in the case of Resident 328. The Administrator acknowledged that notification was included in the discharge instructions but could not confirm if the family was informed earlier. This lack of timely communication with the residents' representatives is a deficiency in the facility's adherence to its notification policy.
Failure to Address Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were responded to by the physician for a resident, identified as R160, who was part of a sample of 43 residents reviewed for unnecessary medications. The deficiency was identified through a review of records, interviews, and facility policy. The facility's policy required that any medication irregularities identified by the consultant pharmacist be documented and reported to the attending physician and Director of Nursing, with a resolution noted by the physician. However, for R160, the pharmacist's recommendations to increase the dosage of Aricept and Namenda were not addressed by the physician, as there was no documentation of agreement or rationale for rejection. R160 was admitted with diagnoses of dementia and Alzheimer's disease and was on a low dose of Aricept and Namenda. The pharmacist recommended increasing the dosage to achieve maximum effectiveness, but these recommendations were not acted upon by the physician. The pharmacist made these recommendations on three separate occasions, but there was no documented response from the physician. Interviews with the Director of Nursing and the Consulting Pharmacist confirmed the lack of response to the pharmacist's recommendations, which were intended to slow the progression of the resident's dementia and Alzheimer's.
Maintenance Deficiencies in Resident Rooms and Activity Room
Penalty
Summary
The facility failed to maintain a homelike environment in eight resident rooms and the Activity room on the second floor of the north building. Observations revealed various maintenance issues, including peeling paint around sinks, rusted and peeling heating units, sagging ceiling tiles, and broken closet doors. These deficiencies were confirmed by the Regional Maintenance Director and the facility Maintenance Director during their inspection. Additionally, the Activity room had a broken piece of formica on a half wall, posing a potential injury risk to residents. The facility's Maintenance Logbook, which is supposed to document repair requests and maintenance issues, showed no entries for the necessary repairs in 2024 and 2025. An entry dated 01/09/25 indicated no maintenance issues were reported by staff or found during maintenance rounds, despite the evident deficiencies. This lack of documentation and follow-up on maintenance needs contributed to the ongoing issues in the resident rooms and the Activity room.
Deficient Handrail Maintenance on Second Floor
Penalty
Summary
The facility failed to maintain handrails in good repair on the second floor of the north building, affecting all four hallways. Observations revealed several handrails were secured with duct tape and foam, while others were missing entirely. The Maintenance Department's logbooks showed no requests for repairs, and staff interviews indicated uncertainty about the duration of the issues. The Maintenance Director mentioned waiting for replacement parts, but no invoices or orders were available to confirm this. Interviews with the Unit Manager and an LPN revealed a lack of awareness regarding the timeline of the handrail issues. The Assistant Administrator mentioned a potential remodeling plan for the second floor but was unaware of any specific timeline. The facility's policy requires routine checks and timely repairs, but these were not documented or executed, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochelle Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlas Rehabilitation And Healthcare At Maywood | 0.5 mi | ★★★★★ | 0 | 0 |
| Complete Care At Prospect Heights Llc | 1.2 mi | ★★★★★ | 21 | 0 |
| Complete Care At Regent Llc | 1.7 mi | ★★★★★ | 2 | 0 |
| Careone At Wellington | 1.8 mi | ★★★★★ | 13 | 0 |
| Complete Care At Fair Lawn Edge | 3.3 mi | ★★★★★ | 1 | 0 |
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