Belle Care Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trenton, New Jersey.
- Location
- 439 Bellevue Avenue, Trenton, New Jersey 08618
- CMS Provider Number
- 315124
- Inspections on file
- 15
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Belle Care Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to report a resident-to-resident altercation to the State Agency within the required 24-hour timeframe. An internal incident form documented that an altercation occurred and that there were no injuries, and it showed a call to the Department of Health the following day, but the written report date and the State’s intake record reflected that the email report was not received until about two weeks later. During interviews, the DON claimed the date on the form was a typographical error but could not provide documentation of timely notification, while the administrator and the facility’s abuse policy both confirmed that such allegations must be reported within strict 2-hour or 24-hour time limits depending on harm.
Nursing staff failed to accurately document and administer medications as ordered for multiple residents, including instances where an LPN administered a medication dose that did not match the physician's order and then signed the eMAR for a different dose. Several residents' MARs showed missing nurse signatures for scheduled medications, and staff interviews confirmed that medications should be signed out immediately after administration. Facility policy requiring verification and immediate documentation was not consistently followed.
The facility did not submit the results of its investigation regarding an incident between two residents to the NJDOH within the required timeframe, as confirmed by staff interviews and lack of documentation. The delay was attributed to the facility's involvement in a Directed Plan of Correction, and the facility also failed to follow its own abuse reporting policy.
A review of staffing records revealed that the facility did not meet the required CNA-to-resident ratios on 12 out of 14 day shifts, with staffing levels falling below the minimum mandated by state law. This widespread deficiency had the potential to affect all residents in the facility.
The facility did not provide the required minimum nurse staffing hours on three separate days, with actual staffing falling short of the calculated requirements based on resident census and specialized care needs. This deficiency was identified during the review of staffing reports related to multiple complaints.
A resident in an LTC facility experienced a decline in quality of life due to a persistent urine odor in their room, caused by their roommate's behavior. Despite being aware of the issue, facility staff failed to address it promptly, leaving the resident in an unpleasant environment. The facility's policies emphasize a clean and homelike setting, but staff did not take timely action to resolve the situation.
A justice-involved resident was not treated with dignity and respect, as they were physically restrained, secluded, and unable to participate in group activities or communicate freely with visitors. The resident, who had several medical conditions, was confined to their room, guarded by corrections officers, and not allowed to leave at will or retain personal possessions. This treatment led to feelings of loneliness and depression, with the resident expressing a desire to return to the correctional facility.
A justice-involved resident in an LTC facility was denied self-determination and choice, being confined to their room with corrections officers, unable to participate in group activities, community dining, or have visitors without correctional facility approval. The resident was restricted in clothing choice, had meals in their room on disposable ware, and was not allowed phone use, leading to feelings of loneliness and depression. Facility staff confirmed these restrictions, which were dictated by the correctional facility's protocols.
A resident, identified as a Justice Involved Resident (JIR), was subjected to involuntary seclusion and the use of physical restraints at the facility. The resident was confined to their room, guarded by Corrections Officers, and not allowed to participate in group activities or community dining. The resident reported feelings of loneliness and depression due to the lack of privacy and restricted communication. Facility policies and practices, including the requirement to wear an orange jumpsuit and restricted visitor access, contributed to the deficiency.
A justice-involved resident in an LTC facility was subjected to physical restraints and seclusion by corrections officers, leading to feelings of loneliness and depression. The resident was not allowed to leave their room or participate in activities, and the facility lacked a physician's order for the restraints. The resident's care plan did not address the use of restraints, and the facility's policies were not followed, resulting in an immediate jeopardy situation.
The facility's LNHA failed to ensure proper infection control, staffing ratios, and special population assessments, leading to deficiencies. The absence of a certified Infection Preventionist and reliance on agency staff resulted in inadequate care and documentation. Additionally, the facility did not address Consultant Pharmacist recommendations promptly and failed to include special populations in their assessment, impacting the Quality Assurance and Performance Improvement program.
A resident on 1:1 monitoring in an LTC facility sustained bruising and a lower spine fracture from an unwitnessed fall. The resident, with cognitive impairments and a history of falls, was found with multiple injuries, but the facility's investigation was inadequate. Inconsistencies in monitoring logs and staff statements were noted, and the facility failed to ensure continuous monitoring, as required by their policy.
The facility failed to timely implement CP recommendations for four residents, affecting medication management and documentation. Residents with complex medical conditions did not have their medication regimens adjusted or clarified as recommended, leading to deficiencies in care.
The facility failed to include registered sex offenders and inmates in its facility-wide assessment, despite their presence in the resident population. This oversight was acknowledged by the LNHA and was previously cited during the last survey. The facility did not have a main contract with the prison but had individual contracts for the two inmate residents.
The facility failed to implement an effective QAPI program, resulting in repeated deficiencies in areas such as MDS assessments, medication storage, and antibiotic stewardship. The facility did not provide a QAPI program plan and failed to account for special populations like registered sex offenders and inmates. Despite awareness of previous deficiencies, the facility's efforts were insufficient to prevent recurrence.
The facility failed to monitor antibiotic use according to its stewardship program from January to June 2024. The IP position was vacant, and responsibilities were shared among uncertified staff. Reviews revealed missing documentation on antibiotic use, including diagnostic tests and symptoms. Despite claims of a log, no additional documentation was provided.
A resident with breast cancer did not receive prescribed tramadol for pain management on multiple occasions due to pharmacy delays and lack of documentation. The facility failed to consistently assess and monitor the resident's pain, as required by their Pain Management policy. Interviews with the DON and ADON confirmed the absence of a backup supply and inadequate monitoring of the resident's pain management.
The facility failed to provide adequate nursing staff, resulting in insufficient incontinence care and improper medication administration. Two residents were found with soiled linens and briefs, and several residents received medications outside prescribed times. The facility relied heavily on agency staff and could not maintain accurate staffing records, contributing to these deficiencies.
The facility failed to issue required ABN and NOMNC forms before discharging three residents from Medicare Part A services, despite having benefit days remaining. The forms were either unsigned, incorrectly dated, or lacked estimated costs for non-covered services. The LNHA acknowledged the deficiency, citing the absence of a Social Worker as a contributing factor.
The facility failed to implement its abuse policy by not conducting required pre-employment checks for two employees. A registered nurse was hired without a reference check, and an administrator was hired without a license check, reference check, or criminal background check. The HR Director claimed these checks were standard practice, but the LNHA acknowledged the oversight during a survey team interview.
The facility failed to accurately assess several residents' statuses in the MDS, leading to deficiencies in care evaluations. Errors included misidentification of mental illness, tobacco use, bladder incontinence, ventilator use, and oxygen therapy. The MDS Coordinator attributed these inaccuracies to a disorganized department and a transition to a new computer system, with facility leadership acknowledging the errors.
The facility failed to administer medications on time and did not update records to reflect a discontinued order for a resident's ankle foot orthosis (AFO). Medications for several residents were administered outside prescribed time frames, and staffing records were incomplete, contributing to these issues. Additionally, the facility's records did not reflect the discontinuation of a resident's AFO order, leading to inaccurate documentation.
A Justice Involved Resident in a LTC facility was not provided with activities to support their well-being, leading to feelings of loneliness and depression. The resident, who had paraplegia and a stage 4 pressure ulcer, was confined to their room with two armed COs and had limited social interaction. The facility's care plan lacked a focus on activities, and restrictions imposed by the Correctional Facility further isolated the resident.
The facility failed to ensure proper pharmaceutical services, as evidenced by a nurse using another's login to document medication administration, incorrect Depakote dosing due to an electronic record error, and missing documentation for controlled substances like methadone and pregabalin. The DON and ADON acknowledged these issues, which violated facility policies requiring accurate documentation and inventory counts.
A facility failed to ensure proper medication administration, resulting in a 10.3% error rate. Two agency nurses were observed making errors: one did not administer Lamictal due to unavailability, and another failed to provide Risperdal for the same reason. Additionally, a resident received an incorrect dose of Depakote due to an error in the electronic medication record. The facility's policy lacked procedures for unavailable medications, and no recent inservices were conducted.
The facility failed to properly store and label medications, as observed by surveyors. Unsecured sodium chloride inhalation solution vials were found in a resident's room, and medication carts on two nursing units contained unidentifiable loose pills and expired inhalation solutions. The RN, LPN, and DON confirmed these practices were against facility policy.
The facility failed to provide nourishing snacks to residents during a fifteen-hour gap between dinner and breakfast. Observations and interviews revealed that snacks were not distributed to all residents, with only seventy-five snacks prepared daily. Staff inconsistencies and lack of documentation further contributed to the deficiency, as confirmed by the Regional FSD and other staff members.
The facility failed to follow infection control protocols, including not changing a resident's oxygen tubing weekly, using unsanitary toilet paper during medication administration, and allowing a Unit Manager to have long nails against policy. The facility lacked an Infection Preventionist.
The facility failed to hire a designated Infection Preventionist (IP) with specialized training in infection control and prevention. The previous IP left, and the position remained vacant, with the DON, ADON, and unit managers collectively handling infection control responsibilities. However, only one UM/LPN had a certification in infection control, and the ADON, responsible for staff training, was not certified. The facility's policy required an infection prevention specialist to oversee the program, which was not being met.
A facility failed to provide a discharged resident's medical records in a timely manner after a request was made. The resident, who had kidney failure, was discharged in 2022. A representative requested the records in 2023, but there was no evidence they were received. The facility's policy lacked a clear process for obtaining records, and the paper records from the resident's stay could not be located.
A resident with unclear speech and multiple diagnoses was found on the bathroom floor after slipping. The facility failed to notify the resident's family of this change in condition due to the absence of a phone number in the medical record. The DON claimed family notification was standard, but the ADON confirmed the oversight, and no change of condition policy was provided.
A resident on 1:1 monitoring in an LTC facility experienced an unwitnessed fall, resulting in multiple injuries, including a lower spine fracture. Despite the facility's policy requiring prompt investigation of injuries of unknown origin, the investigation was delayed, and inconsistencies were found in monitoring logs and staff statements. The resident had cognitive impairments and was on 1:1 monitoring due to being combative and a fall risk.
The facility failed to provide adequate incontinence care for two residents, as observed during rounds. One resident was found with a dry brief but urine-stained sheets, while another had a very wet brief and sheets. Additionally, two residents did not receive proper nail care, with long and dirty nails observed. The facility's policies on incontinence care and grooming were not followed, as confirmed by staff interviews and observations.
The facility failed to maintain accurate and complete medical records for three residents, including missing investigation reports, discharge summaries, and medication administration records. Despite multiple requests, the facility could not provide necessary documentation, highlighting deficiencies in record-keeping and documentation practices.
The facility failed to maintain a sanitary and homelike environment, as evidenced by a wheelchair with fecal matter and a resident's room with a strong urine odor and wet, sticky floors. Staff, including an RN and the DON, acknowledged these deficiencies, which were contrary to the facility's policies on cleanliness and pleasant scents.
The facility failed to provide a safe and homelike environment, as observed by the lack of clean towels on the Second Floor nursing unit and a soiled privacy curtain in a resident room. Interviews revealed that linens were not adequately stocked, and the facility's policies on cleanliness were not followed.
A facility failed to include a resident's history as a registered sex offender in their individualized comprehensive care plan (ICCP). Despite the resident's medical conditions being documented, the ICCP did not address their history, which was acknowledged by the DON during a survey. The facility's policy requires timely updates to care plans, which was not followed in this instance.
A resident with hemiplegia and hemiparesis was observed not wearing a prescribed left ankle foot orthotic (AFO), which had been discontinued due to discomfort and refusal to use it. Despite this, the facility failed to update the resident's individualized comprehensive care plan (ICCP) to reflect the discontinuation, as confirmed by the Director of Nursing and other staff. This oversight violated the facility's policy requiring timely updates to care plans.
A resident with a history of pressure ulcers was found on a regular mattress atop a deflated air mattress, contrary to their care plan which required a pressure reducing device. The facility lacked a physician's order for the device, and the DON confirmed the setup was improper and not standard practice.
A facility failed to monitor an enteral tube feeding pump to ensure the total volume administered matched physician's orders for a resident with multiple medical conditions. The pump indicated a total volume inconsistent with the prescribed amount, and staff acknowledged potential overfeeding due to incorrect pump settings. The facility lacked documentation practices to confirm the total volume administered, violating their Enteral Feeding policy.
The facility failed to adequately monitor psychoactive medication use for several residents, leading to a deficiency in care. Residents with conditions such as dementia, bipolar disorder, and schizophrenia were on multiple psychoactive medications, yet there was no episodic documentation of targeted behaviors in their MAR or TAR. Despite recommendations from the Consultant Pharmacist to monitor and document behaviors and side effects daily, the facility did not follow through, and no monthly psychotropic summaries were found. The DON acknowledged the lack of documentation and could not provide the necessary summaries.
A survey revealed deficiencies in the facility's kitchen sanitation and equipment maintenance. The walk-in freezer lacked sufficient vinyl strip curtains, leading to ice accumulation around the door frame. Additionally, cutting boards were pitted and discolored, and chicken juice was found on a metal work surface, which was not immediately cleaned and sanitized. These issues were acknowledged by the facility's administration.
The facility failed to implement its policy to ensure that all eligible residents were educated on the benefits and potential side effects of the pneumococcal immunization and to document this education and any refusal in the medical record. This deficiency was identified for two residents, both with fully intact cognition and various medical conditions, whose pneumococcal vaccines were not up to date. The facility could not provide documentation of the residents' declination forms from admission, as required by their policy.
Failure to Timely Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to timely report an allegation of a resident-to-resident altercation to the State Agency within the required 24-hour timeframe. An AAS-45 incident report showed that a resident-to-resident altercation occurred on 11/27/2024, with no injuries reported as a result of the event. The same AAS-45 indicated that the incident was called into the Department of Health on 11/28/2024, but the date of the written report on the AAS-45 was documented as 12/12/2024. A New Jersey Department of Health Intake Information sheet showed that the Department received the intake via email on 12/13/2024, approximately 16 days after the incident. During an interview, the DON stated that the date on the AAS-45 was a typographical error and asserted that the incident would have been reported on the date it occurred, but was unable to provide documentation to support that the notification was made within the required timeframe. In a separate interview, the Licensed Nursing Home Administrator confirmed that allegations of abuse must be reported within two hours if there is harm and within twenty-four hours if there is no harm. Review of the facility’s Abuse Policy under Reporting and Response confirmed that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property must be reported immediately, but not later than two hours if involving abuse or serious bodily injury, or not later than twenty-four hours if not involving abuse and not resulting in serious bodily injury, to the administrator and the State Survey Agency, consistent with N.J.A.C. 8:39-9.4(f).
Failure to Accurately Document and Administer Medications per Physician Orders
Penalty
Summary
Nursing staff failed to properly document and administer medications according to physician orders and facility policy for four out of five residents reviewed. During medication administration, an LPN was observed preparing a medication dose that did not match the physician's order in the electronic Medication Administration Record (eMAR). The LPN administered the medication and then signed the eMAR for a different dose than what was actually given. When questioned, the LPN admitted to signing for the incorrect dose and expressed confusion during the process. For multiple residents, review of the Medication Administration Records (MARs) revealed missing nurse signatures for scheduled medication administrations, indicating that medications may not have been given or were not properly documented. Progress notes for these residents did not contain any documentation to support that the medications were administered at the scheduled times. Interviews with staff confirmed that medications are expected to be signed out on the MAR immediately after administration, and that blank spaces on the MAR indicate either an omission or a refusal, which should be documented accordingly. The facility's policy on medication administration requires verification of the pharmacy prescription label against the MAR, confirmation of the correct medication, dose, and time, and immediate documentation of administration on the MAR. Despite this, the observed practices and record reviews showed that these procedures were not consistently followed, resulting in incomplete or inaccurate medication records for several residents with various medical diagnoses and cognitive statuses.
Plan Of Correction
F755 - Pharmacy Srvcs/Procedures/Pharmacist/Records Element 1: Corrective Actions Based on observation, interview, and review of the facility documents it was identified for residents #2, #3, #4, and #5 that the facility failed to accurately document medication administration. On 4/22/25, the Director of Nursing initiated re-education to the nursing staff on the Policy and Procedure Medication Administration. On 4/23/25, the facility initiated an audit to monitor for the administration of medication in accordance with physician orders. Element 2: Identification of at-Risk Areas All residents have the potential to be affected by the same practice. Element 3: Systemic Change The Assistant Director of Nursing (ADON) re-in-serviced the nursing staff on the Policy and Procedure for Medication Administration. The Director of Nursing/designee will audit and monitor 3 residents' charts to check for compliance with Medication Administration policy and procedure weekly times four (4), then and after the 4-weeks and competency is established, the facility will continue auditing 3 charts monthly for one (1) quarter, to monitor for compliance and report to QA. Element 4: Monitoring/Quality Assurance On 4/22/2025, the facility initiated a QAPI - Performance Improvement Project identifying any non-compliance with Medication Administration. The facility's goal is to ensure that all protocols are followed.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to submit the results of its investigation regarding an incident involving two residents to the New Jersey Department of Health (NJDOH) within the required timeframe. The incident, which involved an event between two residents, was reported to facility administration, and body assessments were conducted. However, the Facility Reportable Event (FRE) was not sent to the NJDOH until several days after the event, as confirmed by staff interviews. The delay was attributed to the facility being engaged in a Directed Plan of Correction (DPOC) at the time. Additionally, the facility did not provide documentation to the surveyor that the investigation was submitted electronically to the NJDOH as required. A review of the facility's undated "Abuse Policy" indicated that a follow-up investigation should be submitted to the State Agency within five working days, including evidence that all alleged violations are thoroughly investigated. The facility's failure to adhere to both federal regulations and its own policy resulted in the deficiency.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the F609 tag, the facility noted the root cause of this issue to be because the facility failed to submit the electronic notification of a reportable event to the DOH within 24 hours of the time of the event. F609 Corrective Action: On 4/25/2025, the Administrator coordinated with the Director of Nursing and Regional Clinical Service Director a review of all reportable events to date to ensure timely submission of all reportable events. On 4/25/2025, the Regional Clinical Services Director conducted an in-service with the Administrator and Director of Nursing on the facility policy and procedure for the submission, with emphasis on facility procedure for timely reporting of all reportable events via DOH electronic reporting site within 2 hours of any allegation of abuse or serious bodily injury and within 24 hours of any allegation not involving injury or abuse incident. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the Administrator, Director of Nursing, and it was found that all residents are at risk of this practice. Systemic Change: The Facility Administrator and Director of Nursing initiated education for all staff within the facility on the facility policy for the reporting of any alleged violations. The Administrator/Designee will review all facility reportable events to ensure timely reporting of all reportable events via DOH electronic reporting site within 2 hours of any allegation of abuse or serious bodily injury and within 24 hours of any allegation not involving injury or abuse incident. This review will be maintained weekly for 1 month and then monthly for the next 3 months. Quality Assurance: The Administrator will submit the findings from the monthly reportable events audit to the QA/QAPI committee. If further actions are deemed necessary, the team will address them. The QA/QAPI committee will meet monthly for the next 3 months to review all findings and assess whether further action is necessary.
Failure to Meet Mandatory CNA Staffing Ratios on Day Shifts
Penalty
Summary
The facility failed to comply with mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates a minimum of one Certified Nurse Aide (CNA) for every eight residents during the day shift. During a review of facility documents covering a two-week period prior to the complaint survey, it was found that the facility did not meet the required CNA staffing levels on 12 out of 14 day shifts. For example, on several days, the number of CNAs scheduled was significantly below the minimum required, with as few as 6 CNAs present for 100 residents when at least 12 were needed, and similar shortfalls on other days for varying resident counts. This deficiency was identified through a review of staffing records and was determined to have the potential to affect all residents in the facility. The report does not specify individual residents or their medical conditions but notes that the deficient practice was widespread across multiple days and shifts, impacting the facility's ability to meet the mandated standard of care for its resident population.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the S560 tag, the facility noted the root cause of this issue to be because the facility failed to ensure that all call outs were covered. S560 Immediate Corrective Action: The Facility cannot retroactively respond to this deficient practice. On 4/25/2025, the Administrator, Human Resource Director/Staffing Coordinator, and Director of Nursing conducted a root cause analysis based on the findings in the alleged deficient to ensure that the facility provides sufficient nursing staff to promote the highest practical wellbeing of each resident. On 4/25/2025, the Administrator/Designee conducted in-services and education with the staffing coordinator and nurse management team on the facility's policy and procedure for sufficient nurse staffing, with specific emphasis on the facility's protocol for emergency staffing. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. III. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offer our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referral bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus IV. The Human Resources Director/Designee will report the findings to the administrator. V. Quality Assurance: The Human Resources Director/Designee will aggregate findings from these rounds weekly for 1 month and then monthly for 3 months. The Human Resources Director/Designee will provide a report of his/her findings to the QA committee for action as appropriate. The QA/QAPI committee will meet monthly for the next 3 months and review all findings to assess whether further action is necessary.
Failure to Meet Minimum Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for three out of fourteen days, as evidenced by a review of Nurse Staffing Reports for the weeks of 04/06/25 and 04/19/25. Specifically, on three separate days, the actual nursing staff hours provided were below the required minimum, with deficits of 17.25, 14.75, and 6.75 hours respectively. The required staffing hours were calculated based on the total number of residents and the additional care needs of residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular or orthopedic care. This deficiency was identified during the investigation of complaints NJ181841, NJ178109, and NJ182273.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the S1680 tag, the facility noted the root cause of this issue to be because the facility failed to ensure that it was staffed at least minimum staffing ratio based on its acuities. S1680 Immediate Corrective Action: The Facility cannot retroactively respond to this deficient practice. On 4/25/2025, the Administrator, Human Resource Director/Staffing Coordinator, and Director of Nursing conducted a root cause analysis based on the findings in the alleged deficient to ensure that the facility provides sufficient nurse staffing based on the total number of residents multiplied by 2.5 + the facility's current acuities. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. V. Quality Assurance: The Human Resource Director/designee will aggregate findings from these rounds daily for 1 month and then monthly for 3 months and review the findings with the administrator and submit to QA/QA committee for review. The QA/QAPI committee will meet monthly for the next 3 months and review all findings to assess whether further action is necessary.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain an environment that promoted the quality of life for a resident, identified as Resident #60, who was observed in a room with a strong odor of urine. The resident expressed discomfort due to their roommate's behavior of urinating on the floor, which made the room smelly and unpleasant. Despite being aware of the issue, the facility staff did not address the situation promptly. On one occasion, the surveyor observed two staff members sitting nearby, engaged in conversation, without taking action to resolve the odor issue. The facility's policies on resident rights and quality of life emphasize the importance of a clean, comfortable, and homelike environment. However, the staff, including a Registered Nurse and the Unit Manager, acknowledged the persistent odor and the failure to clean the room in a timely manner. The Director of Nursing and the Licensed Nursing Home Administrator were aware of the ongoing issue but had not approached the resident to discuss the impact of the living conditions. Resident #60 had a medical history of hemiplegia, hemiparesis, candidiasis, and bipolar disorder, with a moderately impaired cognition, which further underscores the need for a supportive living environment.
Violation of Resident Rights for Justice-Involved Resident
Penalty
Summary
The facility failed to ensure that a justice-involved resident was treated with dignity and respect, as required by federal guidelines. The resident was physically restrained and secluded, unable to participate in group activities, community dining, or communicate freely with visitors. The resident was confined to their room, guarded by corrections officers, and was not allowed to leave the room at will or retain and use personal possessions. This treatment led the resident to feel lonely and depressed, expressing a desire to return to the correctional facility. The resident, who had been at the facility for over a year, was admitted with several medical conditions, including paraplegia, chronic pain, depressive disorder, anxiety disorder, insomnia, and a stage 4 pressure ulcer. Despite receiving rehabilitation and wound care, the resident was not allowed to participate in activities or have visitors without approval from the correctional facility. The resident was also required to wear an orange jumpsuit, which caused embarrassment, and was not permitted to use the telephone or have privacy during care or visits. The facility's policies and practices, as observed by the surveyor, did not align with the resident's rights to a dignified existence and self-determination. The resident's care plan reflected restrictions on phone use and dining, and the facility's staff confirmed that the resident was always accompanied by corrections officers, even during rehabilitation sessions. The facility's administration acknowledged that the correctional facility controlled many aspects of the resident's life, including clothing, phone use, and visitation, which contributed to the resident's feelings of isolation and depression.
Removal Plan
- The resident was returned to the CF.
- The facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs.
- The LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR.
- The LNHA was responsible for the implementation of all facility policies and regulations.
Facility Fails to Support Resident Self-Determination for Justice-Involved Resident
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and support resident choice for a justice-involved resident. The resident was admitted to the facility and was secluded by corrections officers from the correctional facility. The resident was not allowed to participate in group activities, community dining, or leave their room at will. They were also restricted from having visitors unless approved by the correctional facility, could not choose their clothing, and had to wear an orange jumpsuit, which caused embarrassment. Meals were served in the resident's room on disposable ware, and they were not allowed to use the telephone, leading to feelings of loneliness and depression. The resident had a stage 4 pressure wound and required additional personal protective equipment for care. Despite this, the resident was confined to their room with two armed corrections officers and was only allowed to leave for rehabilitation sessions. The facility's staff, including the Licensed Practical Nurse Supervisor, Director of Rehab, and Director of Activities, confirmed that the resident did not participate in activities and was restricted in their interactions and movements. The resident expressed a desire to return to the correctional facility due to the lack of autonomy and choice in their daily life. The facility's policies for justice-involved residents, including dining and phone use, were restrictive and controlled by the correctional facility. The resident's comprehensive care plan reflected these limitations, and the facility's staff acknowledged that the correctional facility dictated many aspects of the resident's life. The facility's Licensed Nursing Home Administrator and Director of Nursing stated that the resident received the same level of nursing care as other residents but lacked the freedoms afforded to them. The facility's policies and the correctional facility's protocols contributed to the deficiency in promoting and facilitating resident self-determination and choice.
Removal Plan
- The resident was returned to the CF.
- The facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs.
- The LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR.
- The LNHA was responsible for the implementation of all facility policies and regulations.
Failure to Protect Resident from Involuntary Seclusion and Restraints
Penalty
Summary
The facility failed to ensure that all residents, including a Justice Involved Resident (JIR), were free from abuse, specifically involuntary seclusion and the use of physical restraints. The JIR was admitted to the facility and was secluded by Corrections Officers (COs) from the Correctional Facility (CF). The resident was confined to their room, guarded by two COs, and was not allowed to participate in group activities or community dining. The resident reported feeling lonely and depressed due to being confined to their room 24/7 with no privacy, limited visitor access, and restricted communication. The facility's policies and practices contributed to the deficiency. The resident was required to wear an orange jumpsuit, which caused embarrassment, and was not allowed to choose their clothing. Meals were served in the resident's room on disposable ware, and the resident was not permitted to use the telephone or have unscheduled visitors. The facility's staff, including the Licensed Practical Nurse Supervisor and the Director of Activities, confirmed that the resident was not allowed to participate in activities or have access to personal items like playing cards, which were supposed to be provided by the CF's Social Worker. The facility's policies regarding inmate dining and phone use further restricted the resident's autonomy and choice. The resident's medical record indicated a history of anxiety, depression, and insomnia, and the resident expressed feelings of stress and depression due to their living conditions. The facility's staff, including the Licensed Nursing Home Administrator and the Director of Nursing, stated that the CF controlled many aspects of the resident's life, including visitor access and clothing, which contributed to the resident's feelings of isolation and lack of privacy.
Removal Plan
- The resident was returned to the CF
- The facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs
- The LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR
- The LNHA was responsible for the implementation of all facility policies and regulations
Deficiency in Resident Autonomy and Use of Restraints
Penalty
Summary
The facility failed to ensure that a justice-involved resident was free from abuse, including the use of physical restraints for discipline or convenience. The resident was admitted to the facility and was secluded by corrections officers from the correctional facility. The resident was not allowed to leave their room, participate in group activities, or have visitors unless approved by the correctional facility. The resident expressed feelings of loneliness and depression due to being confined to their room with two corrections officers and a television. The resident was observed being transported in a wheelchair with wrist and ankle cuffs, accompanied by armed corrections officers. The facility did not have a physician's order for the use of these restraints, and the resident's care plan did not include a focus area for the use of restraints. The facility's policies stated that restraints should only be used when necessary to treat medical symptoms and not for staff convenience. However, the use of restraints in this case was determined to be a standard protocol by the correctional facility, not the facility itself. The resident had a history of paraplegia, chronic pain, depressive disorder, anxiety disorder, insomnia, and a stage 4 pressure ulcer. Despite these conditions, the resident was not permitted to use the telephone, and their access to visitors and activities was severely restricted. The facility's failure to provide the resident with autonomy and choice, as required by federal guidelines, resulted in an immediate jeopardy situation, posing a likelihood of serious injury and psychological harm to the resident.
Removal Plan
- The resident was returned to the CF.
- The facility ended their contract with the CF to accept JIR and has no other contracts with additional CFs to accept JIRs.
- The LNHA and DON were inserviced regarding CMS's S & C memo regarding JIR.
- The LNHA was responsible for the implementation of all facility policies and regulations.
Deficiencies in Infection Control, Staffing, and Special Population Assessment
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of policies and procedures, resulting in several deficiencies across two nursing units. The facility did not have a certified Infection Preventionist (IP) for two to three months, and the responsibility for infection control was shared among staff who lacked proper certification. This led to inadequate infection control practices and antibiotic stewardship. Additionally, the facility relied heavily on agency staffing, which contributed to issues such as improper medication administration and documentation. An agency nurse used another staff member's login credentials to sign off on medication administration records, violating facility protocols. The facility also faced challenges with staffing ratios, failing to meet state requirements for Certified Nursing Aide (CNA) to resident ratios. This resulted in inadequate incontinence care, as observed during the survey, where residents were found with soiled linens and briefs. The facility's failure to act promptly on Consultant Pharmacist (CP) recommendations further highlighted the lack of effective oversight and coordination among staff. Recommendations from March to May 2024 were not addressed until prompted by surveyor inquiry, indicating a delay in addressing potential medication safety concerns. Moreover, the facility's assessment did not account for special populations, such as registered sex offenders and incarcerated individuals, despite their presence in the facility. This oversight was not reflected in the facility's Quality Assurance and Performance Improvement (QAPI) program, which failed to address repeated deficiencies from previous surveys. The LNHA, despite being new to the facility, was aware of these issues but did not implement sustainable measures to rectify them, as evidenced by the repeated concerns noted by the survey team.
Failure in 1:1 Monitoring Leads to Resident Injury
Penalty
Summary
The facility failed to ensure continuous one-to-one (1:1) monitoring for a resident, resulting in an unwitnessed fall that caused bruising to both ears and a lower spine fracture. The resident, who had cognitive impairments and was on 1:1 monitoring due to being a fall risk, was found with multiple injuries, including a 3 cm x 3 cm abrasion on the right knee and discoloration on the right side of the face and mid-arm. The incident was not witnessed, and the resident was unable to communicate how the injuries occurred due to confusion. The investigation revealed inconsistencies in the monitoring logs and staff statements. The 1:1 monitoring logs indicated that different CNAs were assigned to monitor the resident, but there were contradictions in the statements regarding the times and observations of the resident's condition. The facility's Director of Nursing (DON) acknowledged that the resident should have been monitored at all times, and the investigation did not adequately address how the resident, who was supposed to be under constant supervision, experienced an unwitnessed fall. The facility's investigation process was found lacking, as it did not immediately investigate the initial discovery of the abrasion on the resident's knee. The investigation only commenced after further injuries were observed the following day. The facility's abuse policy mandates prompt and thorough investigations of such incidents, but the investigation failed to determine how the resident sustained the injuries while on 1:1 monitoring. The lack of documentation confirming a physician's order for 1:1 monitoring and the absence of a comprehensive investigation into the unwitnessed fall were significant deficiencies identified by the surveyor.
Delayed Implementation of Pharmacist Recommendations
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for four out of five residents reviewed for medication management. This issue was previously cited during the facility's last standard survey. The CP's recommendations were not acted upon promptly, leading to deficiencies in medication administration and documentation. For instance, Resident #34's medication regimen was not adjusted according to the CP's recommendations until months later, despite the resident having severe cognitive deficits and behavioral issues. Similarly, Resident #80, who had a fully intact cognition and was receiving antipsychotic medications, had several CP recommendations that were not implemented until much later. These included adjustments to medication dosages and clarifications on medication orders. The delay in addressing these recommendations could have impacted the resident's treatment and safety. For Residents #60 and #61, the facility also failed to act on the CP's recommendations in a timely manner. These residents had complex medical conditions, including hemiplegia, hemiparesis, and diabetes, which required careful medication management. The facility's inaction on the CP's recommendations, such as clarifying medication orders and ensuring proper documentation, highlights a significant deficiency in the facility's medication management processes.
Failure to Include Special Populations in Facility Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to identify the necessary services and procedures required to protect the health, safety, and welfare of all residents, particularly those who are registered sex offenders and inmates from a correctional facility. This deficiency was previously identified during the facility's last standard survey. During the entrance conference, the surveyor requested the facility's assessment from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). However, the assessment provided did not include registered sex offenders or incarcerated residents as part of the facility's population. During the initial tour, the surveyor observed a resident and their unsampled roommate, both incarcerated, with four Corrections Officers present in the room. The LNHA confirmed the presence of registered sex offenders and inmates from the local county jail but acknowledged that these populations were not included in the facility assessment. The LNHA also informed the survey team that the facility did not have a main contract with the prison, but had individual contracts for the two inmate residents currently residing at the facility. This oversight in the facility's assessment process was acknowledged by the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and the survey team.
Facility's QAPI Program Ineffectiveness and Repeated Deficiencies
Penalty
Summary
The facility failed to effectively implement its Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies from a previous survey. The surveyors noted that the facility did not provide a copy of its QAPI program plan when requested, and the program was not being used to ensure sustainability of improvements in areas previously cited for deficiencies. These areas included the accuracy of Minimum Data Set (MDS) assessments, medication storage, acting on Consultant Pharmacy (CP) reports, and the antibiotic stewardship program. Additionally, the facility's assessment did not account for special populations, such as registered sex offenders and inmates from the local county jail, which were part of the facility's resident population. During the survey, it was revealed that the facility relied on the CMS 2567 statement of deficiencies from previous surveys to identify concerns for their QAPI program. However, the survey team found that the facility had not implemented effective measures to address and sustain improvements in the identified areas of concern. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged awareness of the previous deficiencies, but the facility's efforts, such as staff education and report completion, were insufficient to prevent recurrence. The facility's failure to include special populations in their assessment and the lack of a comprehensive QAPI program plan contributed to the ongoing deficiencies.
Failure to Monitor Antibiotic Use and Implement Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive system to monitor antibiotic use in accordance with its antibiotic stewardship program from January 2024 through June 2024. This deficiency was previously cited during the facility's last standard survey in October 2022. The facility's policy required the Infection Preventionist (IP) or designee to review antibiotic utilization and document all resident antibiotic regimens on a tracking form. However, the position of IP was vacant since April 2024, and the responsibilities were shared among the Director of Nursing (DON), Assistant Director of Nursing (ADON), and unit managers, none of whom were certified in infection control except for one unit manager. The surveyor's review of the facility's Monthly Antibiotic Summary revealed significant gaps in documentation. For several months, many residents who received antibiotics had missing information regarding diagnostic tests, symptoms, and whether the criteria for antibiotic use were met. The ADON admitted to completing May's review only recently and acknowledged the lack of a dedicated IP since April 2024. Despite the DON's claim of a log on the medication cart, no additional documentation was provided to the surveyor, indicating a failure to adhere to the facility's antibiotic stewardship policy.
Failure in Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to ensure proper pain management for a resident with a history of breast cancer and other serious conditions. The resident was prescribed tramadol for pain management, but there were multiple instances where the medication was not administered as ordered. On 6/22/23, the resident did not receive the 9:00 AM dose of tramadol, and there was no documentation explaining the omission. Additionally, on 7/21/23, the resident missed three doses due to a delay in receiving the medication from the pharmacy, and there was no documentation of the resident's pain assessment during this period. Another dose was missed on 7/27/23 without any explanation provided. The facility's records revealed inconsistencies in pain assessment and monitoring. The June 2023 Medication Administration Record (MAR) included a physician's order for pain assessment every shift using a pain scale, but this was not consistently documented in July 2023. The Director of Nursing (DON) confirmed that pain should be monitored every shift and that any missed medication should be documented with a reason. However, the facility was unable to provide complete documentation for the resident's tramadol inventory or pain assessments during the periods when medication was missed. Interviews with the DON and Assistant Director of Nursing (ADON) confirmed that the facility did not have a backup supply of tramadol and that the resident's pain management was not adequately monitored. The facility's Pain Management policy requires regular reassessment of pain and adjustments to the pain management plan if necessary, but these procedures were not followed. The lack of documentation and failure to administer prescribed pain medication as ordered led to a deficiency in the resident's care.
Inadequate Staffing and Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received necessary care, as evidenced by inadequate incontinence care and improper medication administration. Two residents were observed with soiled bed linens and incontinence briefs that had not been changed in a timely manner. The staff, including CNAs and LPNs, acknowledged that the residents should have been checked and changed every two hours, but this was not done, leading to residents being left in soiled conditions. Additionally, the facility did not maintain adequate staffing levels, as required by state regulations, and relied heavily on agency staff. The staffing records for a specific period in 2022 were incomplete, and the facility could not provide accurate documentation of staffing levels. This lack of sufficient staffing contributed to the failure to administer medications according to physician orders for several residents, with medications being given outside the prescribed time frames. The facility's policies on incontinence care and sufficient staffing were not adhered to, resulting in deficiencies in resident care. The Director of Nursing and other staff members acknowledged the issues with staffing and care practices, but the facility's reliance on agency staff and inability to maintain proper records exacerbated the problem. The surveyor's observations and interviews with staff highlighted the facility's failure to meet the required standards for resident care and staffing.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms prior to the discharge of three residents from Medicare Part A services, despite having benefit days remaining. This deficiency was identified during a review of the facility's records and interviews with staff. Resident #28 was discharged on 4/12/24 without signing the NOMNC form, and the ABN form was unsigned and dated two months after discharge, lacking estimated costs for services not covered by Medicare. Resident #55 was discharged on 6/13/24, with the NOMNC form signed eight days after the last covered day, and the ABN form was signed two months prior to discharge, also missing estimated costs. Resident #82 was discharged on 5/31/24 due to non-participation, with the NOMNC form unsigned as the resident refused to sign, and the ABN form was unsigned and dated two days before discharge, again lacking estimated costs. The Licensed Nursing Home Administrator (LNHA) acknowledged that the ABN and NOMNC forms were not completed appropriately, attributing the issue to the absence of a Social Worker (SW) from October 2023 until recently. The facility's guidelines require timely completion and retention of these forms, with the Minimum Data Set Coordinator responsible for ensuring compliance. The guidelines also specify that the ABN should be issued when Medicare is expected to deny payment, allowing beneficiaries to make informed decisions about accepting financial responsibility. The LNHA confirmed that the Rehab Department provided the NOMNC forms, but the ABN forms were not being completed due to the lack of a SW.
Failure to Implement Pre-Employment Screening Procedures
Penalty
Summary
The facility failed to implement its abuse policy by not completing necessary pre-employment checks for new hires. Specifically, the facility did not conduct criminal background checks, reference checks, and license verifications for two out of ten employees reviewed. Employee #9, a registered nurse, was hired without a reference check, while Employee #10, an administrator, was hired without a license check, reference check, or criminal background check. These omissions were identified during a review of employee personnel files. The Human Resources Director claimed that the facility's policy was to complete these checks before the first day of employment to ensure the safety of residents. However, the Licensed Nursing Home Administrator, along with the Director of Nursing and Assistant Director of Nursing, acknowledged the missing checks when interviewed by the survey team. The facility's failure to adhere to its own screening policy was confirmed, highlighting a deficiency in the implementation of procedures designed to prevent abuse, neglect, and theft.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess the status of several residents in the Minimum Data Set (MDS), an essential tool for evaluating residents' care needs. This deficiency was identified for five residents, including one who was inaccurately assessed as not having a serious mental illness despite a previous positive screen for mental illness and a completed PASARR II. The MDS Coordinator acknowledged the inaccuracies, attributing them to a change in computer systems and errors in data transfer. Another resident was observed smoking cigarettes on multiple occasions, yet their MDS did not identify them as a current tobacco user. The MDS Coordinator confirmed the coding error, noting that the department was disorganized upon their arrival and they have been working to rectify the issues. Additionally, a resident with bladder incontinence was incorrectly coded as continent in their MDS, despite staff confirming the resident's incontinence and the care plan addressing this issue. Further inaccuracies were found in the MDS of a resident who was not on a ventilator, yet their assessment indicated otherwise. Similarly, a resident receiving oxygen therapy was not coded for this treatment in their MDS. The MDS Coordinator and facility leadership acknowledged these errors, which were partly due to the transition to a new computer system. The facility's policies require accurate completion of the MDS by the nursing and therapy departments, overseen by the Clinical Reimbursement Manager, but these protocols were not followed, leading to the deficiencies.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to administer medications on time and did not remove a discontinued physician's order from active orders, affecting multiple residents. During a survey, it was found that medications for four residents were not administered within the prescribed time frames on several occasions. The facility's Director of Nursing (DON) acknowledged that medications should be administered as ordered, within one hour before or after the scheduled time. However, the Medication Administration Record revealed numerous instances where medications were given outside these parameters, with some doses being administered several hours late. Additionally, the facility did not maintain proper staffing records for the period in question, relying heavily on agency staff whose records were not included in the reports. The Licensed Nursing Home Administrator (LNHA) and DON admitted that staffing levels were not acceptable and that the necessary records could not be located. This lack of documentation and reliance on incomplete records contributed to the medication administration issues. Furthermore, the facility failed to update its records to reflect the discontinuation of a resident's order for a left ankle foot orthosis (AFO). Despite the order being discontinued, the electronic medical record still showed it as active, and nurses were signing off on its application when it was not being used. The DON confirmed that the AFO should have been discontinued in the system, and the facility could not provide a policy regarding the discontinuation of physician's orders.
Failure to Provide Activities for Justice Involved Resident
Penalty
Summary
The facility failed to provide a Justice Involved Resident (JIR) with activities of their choice that support their physical, mental, and psychosocial well-being. The resident, who had been at the facility for over a year, was confined to their room except for rehabilitation sessions and was accompanied by two armed Correctional Officers (COs) at all times. The resident expressed feelings of loneliness and depression due to the lack of activities and social interaction, as well as restrictions on visitors and phone calls, which were controlled by the Correctional Facility (CF). The resident's medical history included paraplegia, chronic pain, depressive disorder, anxiety disorder, insomnia, and a stage 4 pressure ulcer. Despite having a fully intact cognition, as indicated by a mental status score of 15 out of 15, the resident was not provided with any activities or engagement opportunities. The facility's Director of Activities confirmed that activity staff rarely interacted with the resident due to the presence of COs and restrictions imposed by the CF. The resident's request for playing cards was denied, as the facility was not allowed to provide them, and the CF's Social Worker was responsible for such provisions. The facility's comprehensive care plan did not include a focus area for activities for the resident. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) stated that the CF controlled all aspects of the resident's life outside of nursing care, including phone usage, visitors, and clothing. The resident was required to wear an orange jumpsuit, which they found embarrassing, and had no privacy during care or visits. The facility's Social Worker had not yet spoken to the resident, and the CF's Social Worker visited infrequently, resulting in missed phone calls and further isolation for the resident.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by multiple deficiencies in medication administration and documentation. During a medication administration observation, a registered nurse (RN) used another nurse's login credentials to sign off on medications for several residents, including those with critical needs such as diabetes, dialysis, or feeding tubes. This practice was confirmed by the Unit Manager/Licensed Practical Nurse (UM/LPN) and the Assistant Director of Nursing (ADON), who acknowledged that the RN should not have used another's login. The Director of Nursing (DON) confirmed that each nurse should have their own login and that medications should be signed for immediately after administration. Another deficiency involved the incorrect documentation and administration of Depakote for a resident with bipolar disorder. The resident was supposed to receive a total dose of 625 mg, combining 125 mg and 500 mg tablets. However, due to an error in the electronic medical record system, the 500 mg dose was not administered from the time the system changed until the surveyor's inquiry. The UM/LPN verified the error and acknowledged that the order was entered incorrectly, leading to the missed doses. The DON confirmed the error and was investigating how it occurred. Additionally, there were issues with the documentation of controlled substances, such as methadone and pregabalin. The Methadone Chain of Custody Record for a resident was missing a nurse's signature for a dose administered, and the Narcotic Count Sheet had several missing signatures for shift changes. The ADON and DON both acknowledged the importance of signing these records to prevent discrepancies. The facility's policies required thorough documentation and inventory counts at each shift change, but these were not consistently followed, leading to gaps in accountability for controlled medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 10.3%. During the morning medication administration observation, two nurses were observed administering medications to three residents, with three errors identified. The first error involved a nurse who was unable to administer Lamictal 200 MG to a resident due to the medication being unavailable in the cart. The nurse, an agency nurse unfamiliar with the facility's procedures, did not inform the Unit Manager or check the backup supply, leading to the resident not receiving the medication as ordered. The second error occurred when another nurse was unable to administer Risperdal 0.25 MG tablets to a resident because they were not available in the medication cart. The nurse, also an agency nurse, did not check the backup supply or inform the Unit Manager, resulting in the resident not receiving the medication as prescribed. The Director of Nursing acknowledged that the facility's Medication Administration policy lacked a procedure for handling unavailable medications, and the facility had not conducted recent inservices on medication administration. The third error involved the incorrect administration of Depakote to a resident. The nurse administered only a 125 MG tablet instead of the total prescribed dose of 625 MG, due to an error in the electronic medication administration record. The facility had recently changed electronic charting systems, and the error was attributed to an incorrect entry in the new system. The Director of Nursing confirmed the error and noted that no medication administration observations or inservices had been conducted recently.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications, maintain clean and sanitary medication storage areas, and properly label opened multidose medications. During an initial tour, a surveyor observed unsecured sodium chloride inhalation solution vials in a resident's room, which was occupied by four residents. This medication was stored openly on a table next to the room door, contrary to the facility's policy that medications should not be stored in resident rooms. Further observations revealed issues with medication carts on both the First and Second Floor nursing units. The First Floor cart contained 32 unidentifiable loose pills and two opened foil packages of inhalation solutions that were past their one-week expiration date. The Second Floor cart also had ten unidentifiable loose pills. Both the RN and LPN confirmed that these conditions were not compliant with the facility's policies. The Director of Nursing acknowledged that medications should not be stored in resident rooms, and expired or loose pills should not be present in medication carts.
Failure to Provide Nourishing Snacks Between Meals
Penalty
Summary
The facility failed to provide nourishing snacks to residents when there was a more than fourteen-hour gap between dinner and breakfast, as observed during a survey. The surveyor noted that the facility's Regional Food Service Director (FSD) confirmed that approximately seventy-five snacks were prepared daily, but not all residents received them. During a Resident Council meeting, five out of seven residents reported not receiving hour of sleep (HS) snacks, indicating that snacks were only provided to those on a specific list. The facility's meal schedule showed a fifteen-hour gap between dinner at 4:30 PM and breakfast at 7:30 AM, which necessitated the provision of HS snacks. Interviews with various staff members, including the Unit Manager/Licensed Practical Nurse (UM/LPN), Director of Nursing (DON), and Registered Dietitian (RD), revealed inconsistencies in the distribution and documentation of snacks. The UM/LPN and DON stated that snacks were distributed by certified nursing aides (CNAs) and nurses, but there were no signature sheets to confirm receipt. The RD admitted there was no formal policy regarding snacks and was unsure about regulations concerning the time between meals. The facility's Snack Program Policy indicated that snacks should be prepared in sufficient quantity for all residents and offered upon admission and throughout their stay, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Respiratory Care, Medication Administration, and Staff Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several instances. One deficiency involved a resident receiving humidified oxygen via nasal cannula, where the tubing had not been changed for over two weeks, despite a physician's order to change it weekly. The tubing was dated 6/5/24, and the resident confirmed that the tubing was only changed upon request. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged that the tubing should not be used past seven days due to infection control concerns. Another deficiency was observed during a medication pass, where a Registered Nurse (RN) used toilet paper from a resident's bathroom to dab the eyes after administering eye drops, instead of using tissues from the medication cart. The RN, an agency nurse unfamiliar with the cart's contents, believed the toilet paper was clean. The DON confirmed that using toilet paper in this manner was unsanitary and that tissues were available for use. Additionally, a Unit Manager/LPN was observed with long, manicured acrylic nails, which were not in compliance with the facility's dress code. The DON and Licensed Nursing Home Administrator (LNHA) acknowledged that the nail length was inappropriate and could lead to bacterial growth. The facility lacked an Infection Preventionist, which may have contributed to these lapses in infection control practices.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to hire a designated Infection Preventionist (IP) who worked at least part-time and had completed specialized training in infection control and prevention. During the entrance conference, the Director of Nursing (DON) informed the surveyor that the previous IP had left two or three months ago, and the position was currently vacant. The DON, along with the Assistant Director of Nursing (ADON) and two unit managers, were collectively handling infection control responsibilities, including reviewing immunizations, antibiotic stewardship, and infection control issues. However, none of them, except for one Unit Manager/Licensed Practical Nurse (UM/LPN), had a certification in infection control. Throughout the survey, the surveyor repeatedly requested documentation of infection control certifications and the last working date of the previous IP, which was eventually confirmed to be May 3, 2024. The ADON, who was responsible for providing staff with infection control training, also lacked certification in infection control. The facility's Infection Prevention and Control Program policy stated that the program should be coordinated and overseen by an infection prevention specialist, but this requirement was not being met due to the vacancy of the IP position.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a discharged resident with a copy of their medical records in a timely manner following a written request. This deficiency was identified for a resident who was admitted in 2022 with a diagnosis of kidney failure and discharged in July 2022. The issue arose when a representative for the resident requested the medical records on October 27, 2023, but there was no evidence that the records were ever received by the representative. The Medical Records personnel had made copies and provided them to the previous Administrator, but it was unclear if they were sent to the representative. The Licensed Nursing Home Administrator (LNHA) acknowledged that the facility had a form for releasing medical records and that authorized individuals could access them for a fee. However, the facility was unable to locate the paper medical records from the time of the resident's stay. Additionally, the facility's Medical Record Policy, last revised on May 1, 2024, did not include the process for obtaining medical records, contributing to the deficiency.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's family after a change of condition, which was identified for one of the sampled residents. The resident, who had unclear speech and was usually understood, had diagnoses including hypertension, depression, bipolar disorder, and schizophrenia. On a specific date, the resident was found sitting on the floor in their bathroom with no injuries after attempting to stand up from their wheelchair without assistance and slipping on feces. The nurse left a message for the physician but was unable to call a responsible party due to the absence of a phone number. During the survey, the Director of Nursing (DON) stated that family was notified anytime there was a change in condition, but could not explain why there was no phone number for the resident's representative. The Assistant Director of Nursing (ADON) later confirmed that the phone number should have been in the resident's medical record and that the responsible party should have been informed of the change in condition. Despite requests, the facility did not provide a change of condition policy.
Failure to Investigate Unwitnessed Fall and Injuries
Penalty
Summary
The facility failed to initiate and complete a thorough investigation when a resident on one-to-one (1:1) monitoring experienced an unwitnessed fall and sustained injuries of unknown origin. The incident involved a resident with cognitive impairments and a history of schizoeffective disorder and bipolar disorder, who was on 1:1 monitoring due to being combative and a fall risk. On 8/13/23, an incoming staff member noted an abrasion on the resident's knee, but the investigation was not initiated until the following day, 8/14/23, when further injuries were discovered. The resident was found with blue discoloration on both ears, a 3 cm x 3 cm abrasion on the right knee, and discoloration on the right side of the face and mid-arm. The resident screamed in pain when turned, prompting a physician to order an emergency room evaluation, which revealed a fracture in the lower spine. Despite being on 1:1 monitoring, the fall was unwitnessed, and there was a lack of clarity regarding the exact timing of the incident. The facility's investigation process, as described by the Director of Nursing (DON), involves interviewing staff and obtaining statements, but there were inconsistencies in the monitoring logs and statements from the Certified Nursing Assistants (CNAs) involved. The facility's failure to promptly investigate the initial abrasion and the subsequent unwitnessed fall highlights deficiencies in their monitoring and investigation processes. The 1:1 monitoring logs showed discrepancies, and not all CNAs provided statements. The facility's policy mandates that reports of abuse, neglect, or injuries of unknown origin be promptly and thoroughly investigated, which was not adhered to in this case. The lack of immediate investigation and the inability to determine how the resident sustained the injuries indicate a significant oversight in ensuring resident safety and compliance with regulatory standards.
Deficiencies in Incontinence and Nail Care
Penalty
Summary
The facility failed to provide adequate incontinence care for two residents, Resident #32 and Resident #147, as observed during incontinence rounds. Resident #147 was found with a dry incontinent brief and chuck, but the fitted sheet underneath was stained with urine and bowel movement, indicating that the sheet had not been changed during incontinence care. The Unit Manager/LPN confirmed that the sheet should have been changed and attributed the oversight to the CNA from the previous shift. Similarly, Resident #32 was found with a very wet brief and urine-stained sheets, which had not been changed. The CNA responsible for Resident #32 admitted to conducting rounds in the dark and missing the wet brief and sheets. The facility also failed to provide nail care for two residents, Resident #60 and Resident #73, as part of their activities of daily living (ADLs). Resident #73 was observed with long and dirty fingernails and expressed a desire to have them cut. The CNAs confirmed their responsibility for nail care, which includes cleaning and filing nails. Resident #60 was also observed with long and dirty nails, and both the RN and UM/LPN acknowledged that the nails were unacceptable. The DON confirmed that nail care should have been addressed by the CNAs. The facility's policies on incontinence care and grooming were not adhered to, as evidenced by the observations and interviews conducted by the surveyor. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the deficiencies in care, including the inappropriate practice of making rounds in the dark and the failure to change soiled linens and provide nail care. The facility's policies emphasize the importance of maintaining a clean and healthy environment for residents, which was not upheld in these instances.
Deficiencies in Medical Record-Keeping and Documentation
Penalty
Summary
The facility failed to maintain accurate, complete, and easily accessible medical records for three residents, leading to deficiencies identified during a survey. For one resident, the facility was unable to provide a complete investigation report for a reportable event to the New Jersey Department of Health. Despite multiple requests from the surveyor, the facility could not locate the investigation, which should have included assessments, interviews, and interventions to prevent recurrence. Another resident's medical records were incomplete as the discharge summary was missing. The resident was discharged in 2022, but the facility, which used paper records at the time, could not locate the discharge summary. The Licensed Nursing Home Administrator confirmed that the records should have been complete and accessible, but the facility was unable to provide the necessary documentation. For a third resident, there were discrepancies in the Medication Administration Record (MAR) regarding the administration of tramadol. Several doses were not administered, and the facility could not provide a complete inventory of the medication. The surveyor's requests for the declining inventory sheets were not fulfilled, indicating a lack of proper documentation and record-keeping for controlled substances.
Deficiencies in Maintaining a Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by observations made during a survey. On the first floor, a wheelchair was found with brown matter resembling fecal matter smeared across the seat cushion and down the leg onto the wheels. This indicates a lack of proper cleaning and maintenance of equipment used by residents. Additionally, on the second floor, a strong urine odor was detected near a resident's room, where the floor by Bed B was wet and sticky, and puddles of wetness were observed on the bed. These conditions were acknowledged by the nursing staff, including a Registered Nurse and the Unit Manager, who confirmed the unacceptable state of the room. The Director of Nursing and the Licensed Nursing Home Administrator, along with other staff, acknowledged the deficiencies during interviews with the surveyor. The facility's policies on maintaining a homelike environment and cleaning equipment were reviewed, revealing expectations for cleanliness and pleasant scents, which were not met in these instances. The facility's failure to adhere to its own policies and maintain a clean and safe environment for residents was evident in the observations made by the surveyor.
Deficiency in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by the lack of clean linens and soiled privacy curtains. During multiple observations on the Second Floor nursing unit, surveyors noted that the clean linen carts were consistently lacking towels, with some carts having no towels at all. Interviews with the Director of Housekeeping and a housekeeper revealed that linens were processed throughout the day, but there was no designated storage area for clean towels, leading to shortages. The housekeeper admitted that the facility often ran low on towels due to agency nurses discarding them, and the Vice President of Environmental Services confirmed the issue, stating that additional towels had been ordered. Additionally, a privacy curtain in a resident room was observed to be soiled with a reddish/brown substance, which was not in compliance with the facility's policy for maintaining clean and well-repaired privacy curtains. The Director of Nursing acknowledged that the curtain should not have been in such a condition and that curtains were supposed to be cleaned monthly or more frequently if needed. The facility's policies on resident rights and maintaining a homelike environment were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Failure to Include Resident's History in Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident with a history of sex offenses. This deficiency was identified during a survey when the surveyor observed the resident in their room and later interviewed the Registered Nurse (RN) and the Director of Nursing (DON). The RN explained that an ICCP should include a picture of the resident and details about their needs and expected behaviors, confirming that ongoing behavior patterns should be identified. However, the ICCP for the resident did not include a focus area identifying their history as a registered sex offender. The resident was admitted to the facility with diagnoses including diabetes mellitus, mood disorder, and hypertension. Despite these medical conditions being documented, the ICCP failed to address the resident's history as a sex offender. During a review of the medical record and discussions with the DON, it was acknowledged that the care plan should have included this critical information. The facility's Care Plan policy mandates that all residents have adequate person-centered care plans that are updated timely, but this was not adhered to in this case.
Failure to Update Care Plan for Discontinued Orthotic
Penalty
Summary
The facility failed to revise an individualized comprehensive care plan (ICCP) in a timely manner for a resident whose orthotic was discontinued. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was observed not wearing any orthotics. The ICCP initially included an intervention to apply a left ankle foot orthotic (AFO) when out of bed, with a note indicating its use in the morning and removal at night. However, the AFO was discontinued due to the resident's refusal to use it, citing discomfort, and despite adjustments made by an orthotist. The surveyor's review revealed that the order for the AFO was still active in the ICCP, even though it had been discontinued. The Director of Nursing confirmed that the resident was not wearing the AFO, and the Director of Rehabilitation provided documentation of the discharge order. The Licensed Nursing Home Administrator, along with other staff, acknowledged that the care plan had not been updated to reflect the discontinuation of the AFO, which was a violation of the facility's care plan policy requiring timely updates and revisions.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to obtain a physician's order for pressure reducing devices and did not implement the individualized comprehensive care plan (ICCP) intervention to use a pressure reducing device on a resident's bed. This deficiency was identified during a survey when a resident, who had a history of pressure ulcers, was observed lying on a regular mattress placed atop a deflated low air loss mattress that was not plugged in or turned on. The resident's ICCP included interventions for using a pressure reducing device due to their risk for skin breakdown, but no physician's order for such devices was found in the medical records. The Unit Manager/Licensed Practical Nurse (UM/LPN) and the Director of Nursing (DON) confirmed the improper setup of the resident's bed and acknowledged the absence of a physician's order for the pressure reducing device. The facility's Wound Prevention and Treatment policy required a pressure reduction surface for residents at risk of skin breakdown, but this was not adhered to in the case of the resident. The DON stated that the arrangement of a regular mattress on top of a deflated air mattress was unacceptable and not in line with facility practices.
Failure to Monitor Enteral Tube Feeding Volume
Penalty
Summary
The facility failed to monitor an enteral tube feeding administration pump to ensure the total volume administered was in accordance with physician's orders for a resident. The resident, who had a history of cerebral infarction, gastro-esophageal reflux disease, dysphagia, aphasia, and vitamin deficiency, was observed with a tube feeding pump administering Jevity 1.5 at a rate of 70 mL per hour. However, the total volume infused did not match the physician's order, which specified a total volume of 1260 mL to be administered starting at 4:00 PM. The surveyor noted discrepancies in the administration of the tube feeding, as the pump indicated a total volume of 600 mL infused by 12:30 PM the following day, which was inconsistent with the expected completion time. The Unit Manager/LPN acknowledged that the pump settings might have been cleared incorrectly, and the feeding could have continued beyond the prescribed volume, potentially leading to overfeeding. The Director of Nursing confirmed that the facility did not have a system in place to document the total volume administered each shift, and there was no documentation to confirm if the resident received the ordered amount. The facility's Enteral Feeding policy required documentation of the administration of feeding, including the total intake and other relevant details. However, the facility did not adhere to this policy, as there was no documentation of the total volume infused or any communication regarding deviations from the physician's orders. The Director of Nursing acknowledged the need for improved tracking and documentation practices to ensure compliance with physician orders and prevent similar deficiencies.
Inadequate Monitoring of Psychoactive Medications
Penalty
Summary
The facility failed to adequately monitor the use of psychoactive medications for several residents, leading to a deficiency in care. Resident #34, who was admitted with diagnoses including unspecified dementia with behavior disturbance and bipolar disorder, was observed to be on multiple psychoactive medications. Despite being on 1:1 supervision due to behaviors such as touching others and eating non-food items, there was no episodic documentation of these behaviors in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The Consultant Pharmacist had recommended monitoring and documenting target behaviors and side effects daily, but this was not followed, and no monthly psychotropic summaries were found in the electronic medical record. Resident #61, admitted with conditions including hemiplegia and persistent mood disorder, was also on psychoactive medications. Similar to Resident #34, there was no episodic documentation of targeted behaviors in the MAR or TAR, despite recommendations from the Consultant Pharmacist to monitor and document these behaviors and side effects daily. The Director of Nursing (DON) acknowledged that behaviors were documented in the Progress Notes but could not provide a monthly Psychotropic Summary Sheet (PSS) or evidence of monthly psychotropic drug summaries. Resident #60 and Resident #80 were also identified as having inadequate monitoring of psychoactive medication use. Both residents were on multiple psychoactive medications, yet there was no episodic documentation of targeted behaviors in their MAR or TAR. The facility's policy required behavior monitoring for residents on such medications to be incorporated with the MAR monthly, and monthly psychotropic summaries to be completed. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and the inability of the DON to provide the necessary summaries.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining sanitary conditions in the kitchen, as observed during a survey. In the walk-in freezer, there were only two vinyl strip curtains at the entrance, which are essential for preventing outside dust particles from entering and maintaining the freezer's temperature. Additionally, there was ice accumulation around the door frame, which the Regional District Operations (RDO) acknowledged as a result of temperature changes in the freezer. The RDO confirmed that the freezer required more vinyl curtains and that the ice should not be present. During the kitchen tour, several large multi-colored cutting boards on the storage rack were observed to be pitted and discolored, which the Food Service Director (FSD) acknowledged needed replacement. Furthermore, a pinkish-colored liquid was found on the metal work surface around the preparation sink, which was identified as chicken juice discarded by a staff member. Both the FSD and the staff member acknowledged that the chicken juice needed to be cleaned up and sanitized immediately. These observations were acknowledged by the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the survey team.
Failure to Document Pneumococcal Vaccine Education and Refusal
Penalty
Summary
The facility failed to implement its policy to ensure that all eligible residents were educated on the benefits and potential side effects of the pneumococcal immunization and to document this education and any refusal in the medical record. This deficiency was identified for two residents. Resident #87, who had diagnoses including diabetes mellitus, hypertension, heart failure, and stroke, was found to have a fully intact cognition. The resident's pneumococcal vaccine was not up to date, and although it was noted that the resident was offered and declined the vaccine, there was no documentation in the progress notes of the education or offer prior to the survey. The facility could not provide documentation of the resident's declination form from admission. Similarly, Resident #76, with diagnoses of hypertension, stroke, and end-stage renal disease, also had a fully intact cognition. The resident's pneumococcal vaccine was not up to date, and while it was noted that the resident was offered and declined the vaccine, there was no documentation of the education or offer in the progress notes prior to the surveyor's inquiry. The facility's policy stated that residents should be assessed for eligibility and offered the vaccine within thirty days of admission, with documentation of education and refusal in the medical record, which was not adhered to in these cases.
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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