Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belle Care Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
RN Staffing Requirement Not Met: The facility failed to ensure an RN was on duty 7 days a week for at least 8 consecutive hours per day on multiple days reviewed. Staffing reports showed no RN coverage for all shifts on several dates, and the DON stated she would cover if a licensed nurse was unavailable while the LNHA acknowledged instances of no RNs documented in the nursing reports. A facility policy stated staffing is based on resident needs and PBJ reporting requirements.
The facility failed to properly label and date multiple food items stored in the kitchen, including items in the walk-in refrigerator and freezer such as a pie, frozen waffles, fish, hamburger patties, bacon, shredded cheese, and a halved tomato. The DOD acknowledged the items should have been dated, and an expired honey mustard container was also found in the refrigerator. Facility policies reviewed by the surveyor required food items to be labeled and dated according to the facility’s dating system.
Failure to Provide Survey Records and Accurate Staffing Documentation: The facility did not provide requested survey documents in a timely manner, including resident rosters, IP training records, IPCP policies, and employee medical files. The LNHA also submitted AAS-11 and AAS-12 staffing forms multiple times with inconsistent numbers, blank sections, and repeated data-entry errors, and the final forms were still inaccurate.
PBJ staffing data submitted to CMS was not accurate or complete. Review of the AAS-11 showed multiple days with no RN coverage, but the PBJ CASPER report did not trigger No RN Hours for those dates. The HRM confirmed there were 24-hour periods without an RN and said those shifts were reported through PBJ, while the CMS validation reports only confirmed receipt of the submission and did not verify accuracy or completeness.
Unsafe and Unclean Resident Environment: Surveyors observed multiple environmental deficiencies across the 1st and 2nd floor units, including debris on fall mats and floors, unfinished wall repairs, holes in walls, stained and bulging ceiling tiles, chipped paint, exposed wiring on a thermometer, broken blinds, a leaking sink, and a shower room with an uncovered drain, cracks, peeling molding, and an open pipe. Additional issues included missing toilet paper and paper towels, a broken commode arm rest with a protruding screw, a nonfunctioning bathroom light, drawers that would not close, and stained curtains. The LNHA acknowledged the concerns did not reflect a homelike environment, and the MD said he rounds twice daily and would fix the shower room.
Missing Handrails in Corridor Areas: The facility failed to ensure that corridor walls had firmly secured handrails on both sides. During a tour with the CRM and MD, the surveyor observed the ground floor corridor near the elevator and lobby with no handrails on either side, including multiple measured wall sections without handrails. The CRM and MD confirmed the findings.
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.
Incomplete Pre-Employment Screening for Newly Hired Employees: The facility failed to ensure that newly hired staff were screened before starting work. Review of personnel files showed missing or late license verifications, reference checks, and criminal background checks in many employee records, and some files did not even document a hire date. The HRD and LNHA both acknowledged that personnel files needed improvement and that required pre-employment screening documentation was not consistently present.
A facility failed to thoroughly investigate an abuse allegation involving a resident who reported that an LPN refused needed supplies, kicked an oxygen concentrator, and refused hospital transfer. The investigation file contained witness statements, but they did not address the incident itself and instead described positive personality traits of the LPN; the DON stated the statements were kept neutral, and the abuse policy required statements about the events.
Medication administration errors exceeded the allowed threshold after surveyors observed 3 errors in 29 opportunities, resulting in a 10.34% error rate. An LPN gave a potassium chloride dose late, documented metformin after administration rather than at the time it was given, and administered aspirin chewable when the MAR ordered aspirin EC delayed release.
Medication labeling and storage were not maintained properly on a medication cart. An opened multi-dose Lantus insulin vial for a resident was missing an open date and expiration date, a Humulin 70/30 vial was missing an expiration date, and 15 loose tablets and pills were found scattered in a drawer. An LPN said staff check the cart weekly, and the DON stated insulin vials are expected to be dated.
Open garbage containers and debris were observed in the outdoor trash disposal area. Three GC were seen with lids open and trash exposed to the elements, while the surrounding area contained gloves, plastic bags, and cardboard boxes. The DOM and ESD stated the containers should be closed and the area kept clean, and the facility policy required all garbage/refuse containers to be maintained at all times with a closed lid.
Improper Handling of Indwelling Urinary Catheter: A resident with an indwelling urinary catheter was observed with the drainage bag touching the floor and no privacy bag in place. The IP nurse and DON stated the bag should be hung below the bladder in a privacy bag and kept off the floor, and the facility policy also required catheter tubing and drainage bags to be kept off the floor.
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.
RN Staffing Requirement Not Met
Penalty
Summary
The facility failed to ensure an RN worked 7 days a week for at least 8 consecutive hours a day for 10 of 42 days reviewed from 09/21/2025 through 12/27/2025. Review of the facility's Nurse Staffing Reports showed no RN coverage for all shifts on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/24/2025, 12/25/2025, and 12/26/2025. During interview, the DON stated that if a licensed nurse is unavailable, she will cover, and if an RN cannot work 8 consecutive hours, another RN, regional staff, or agency staff would be contacted; the LNHA stated there had been instances of no RNs documented in the nursing reports. A facility policy dated 10/15/2025 stated that staffing is based on resident needs and that direct care staffing information is submitted to CMS PBJ on the schedule specified by CMS.
Food Items Left Undated or Expired in Kitchen Storage
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. During the initial kitchen tour, the surveyor observed multiple food items in the walk-in refrigerator and freezer that were not labeled or dated, including a covered pie, bagged frozen waffles, bagged frozen fish, frozen hamburger patties, an opened package of bacon, and an opened wrapped package of shredded cheese. The Director of Dining acknowledged that these items should have been dated, and the items were removed. The surveyor also observed a single halved tomato wrapped in clear plastic wrap with no label and no date in the refrigerator, and the Director of Dining stated it should have been dated. In addition, a container of honey mustard in the refrigerator had a use-by date of 11/20/2025; the Director of Dining removed and disposed of the item. The surveyor reviewed the facility’s undated policies on Dating and Labeling and Labeling and Dating System Protocol, which stated that food items must be labeled with a received date and dated according to the facility’s protocol, and that expired foods should be discarded immediately.
Failure to Provide Survey Records and Accurate Staffing Documentation
Penalty
Summary
The facility failed to provide immediate access to records and requested information necessary to conduct the survey. On 12/29/2025 at 9:00 AM, the survey team entered the facility and requested an alphabetical resident roster, a roster by room number, the Facility Matrix for admissions in the last 30 days, and a list of residents who smoke. By 9:56 AM, only an alphabetical resident list had been provided. At 10:01 AM, the Survey Team Coordinator spoke with the DON and LNHA by the ADON's cellular phone, and the DON stated she had been on vacation the prior week and was not expecting a survey. The entrance conference began at 10:36 AM, when the survey team requested the Infection Preventionist's primary professional training and specialized training documentation, IPCP standards, policies and procedures, the surveillance plan, the Antibiotic Stewardship program, and immunization policies. The entrance conference request list required the IP training documentation within one hour of entrance and the IPCP policies within four hours of entrance. The LNHA was also informed during the entrance conference that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification survey on 06/26/2024, and the LNHA stated the facility had the files. On 12/29/2025 at 1:12 PM, the Survey Team Coordinator requested the LNHA complete the AAS-11 and AAS-12 staffing forms and return them by 8:00 AM on 12/30/2025. The IP training documentation and IPCP policies were not received until 12/30/2025 at 12:15 PM, approximately 25 hours and 21 hours after the respective deadlines. On 12/30/2025 at 1:10 PM, the facility provided the human resource portion of the employee files but did not provide the medical files, and the Human Resource Manager stated the IP holds the medical records of employees. The AAS-11 and AAS-12 forms were repeatedly returned by the LNHA with inconsistent numbers, blank sections, and additional errors, and the final forms were still determined to be inaccurate when sent to the survey team on 1/05/2026.
PBJ Staffing Data Was Not Accurate or Complete
Penalty
Summary
The facility failed to ensure that staffing data submitted to CMS through the Payroll-Based Journal (PBJ) system was accurate and complete for 1 of 2 PBJ Staffing Data Reports reviewed under the Sufficient and Competent Nurse Staff Task. The deficiency was identified after review of the facility’s AAS-11 Daily Nursing Staff Report, which showed that no RN services were available on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/25/2025, and 12/26/2025. A review of the PBJ Staffing Data Report (CASPER Report 1705D) for Fiscal Year Quarter 1, 2025, covering 10/01/2025 through 12/31/2025, showed that the facility had not triggered No RN Hours for the dates identified on the AAS-11. During an interview on 1/02/2026 at 11:45 AM, the HRM confirmed there were 24-hour periods without an RN as indicated on the state staffing form and stated that those shifts were reported through PBJ. The LNHA provided two CMS Submission Report PBJ Final File Validation Reports dated 8/14/2025 and 11/14/2025, which stated that the validation only confirmed receipt of submitted data and did not reflect the accuracy or completeness of the facility’s data.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in multiple areas of the 1st and 2nd floor units. Surveyors observed a fall mat with multiple brown debris spots, unfinished spackling and three holes in a wall, a fall mat with white debris, and a floor with a plastic fork, knife, paper cup, and multiple areas of brown debris and food in a resident bedroom. In the same room, the bathroom had a brown-stained and bulging drop ceiling. Another bedroom on the 2nd floor had chipped paint on the entrance door and a unit thermometer with exposed wiring and the protective top cover missing. Surveyors also observed broken blinds in a 2nd floor room, and on the 1st floor a room had broken blinds and a sink leaking out the bottom when turned on. Additional observations on the 2nd floor shower room included no cover on the drain in the shower room floor, cracks in the ceiling, an open pipe in the wall where a shower fixture had once been, molding peeling with a black substance on it, and a warped and peeling sink cabinet bottom. On the 1st floor, surveyors observed a bathroom with no toilet paper on the roll, no additional toilet paper rolls, a stained ceiling tile, and a commode over the toilet seat missing the left arm rest with a screw protruding up. Other observations included no paper towels in a bathroom, a nonfunctioning light bulb in a bathroom, a dresser with two drawers that could not close, a missing toilet paper holder with toilet paper kept on the toilet seat lid, and a brown stain on room curtains. The LNHA stated the issues did not reflect a homelike environment and acknowledged the environmental concerns, while the MD stated he rounds twice daily and would fix the shower room.
Missing Handrails in Corridor Areas
Penalty
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on both sides. During a building tour in the presence of the Corporate Regional Maintenance and Maintenance Director, the surveyor observed that the ground floor corridor next to the elevator and lobby area had no evidence of handrails on either side. The surveyor measured and recorded multiple wall sections without handrails, including one 3-foot section, one 10-foot section, one 7-foot 6-inch section, and one approximately 18-foot section. The Corporate Regional Maintenance and Maintenance Director confirmed these findings at the time of observation.
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).
Incomplete Pre-Employment Screening for Newly Hired Employees
Penalty
Summary
The facility failed to ensure that newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation before beginning work. Based on interviews, record review, and review of facility documentation, 53 of 160 employee files reviewed showed no evidence that required license verifications, reference checks, or criminal background checks were completed prior to the start of employment. During the personnel file review, the surveyors identified multiple examples of missing or late pre-employment screening. Some employees had no documented reference checks, some had no documented license verification, and some had no documented criminal background checks before they started working. In several files, the hire date was not documented at all. In other files, the criminal background check was completed after the employee had already begun working at the facility. The HRD stated that background checks, reference checks, and license or CNA verifications are completed before employees begin work, but also noted that reference checks may be inconsistent for staff converted from agency positions and that only one reference may be documented using agency verification. The LNHA stated that personnel files need improvement and must include the date of hire, license verification, two reference checks, criminal background checks, and documentation of a pre-employment physical examination and Mantoux test completed prior to starting work at the facility. The facility policy dated 09/2025 stated that employees and volunteers are to be screened prior to working with residents, including verification of references, certification and license verification, and criminal background check.
Incomplete Abuse Investigation Documentation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that a nurse refused to provide needed supplies for self-care, kicked an oxygen concentrator, and refused to send the resident to the hospital. The resident had a care plan noting behavior issues related to anxiety disorder, including calling 911, exaggerating events, screaming to the point of exhaustion, yelling, extreme responses to minor inconvenience, irritability, agitation, and fixating. Review of the facility’s investigation file showed four witness statements, but none of them described the specific events of the alleged 5/02/2025 incident. Instead, the statements only reflected positive personality attributes about the involved nurse. During interview, the DON stated the facility kept the witness statements neutral and that they interviewed residents and staff, but the documentation provided did not include statements about the incident itself. The facility’s abuse policy required investigations to include who was involved, residents’ statements, roommate statements, and involved staff and witness statements of events.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that medications were administered without an error rate of 5% or greater. During medication observations conducted from 12/30/2025 to 01/02/2026, surveyors observed four nurses administer medications to ten residents. There were 29 opportunities and 3 errors observed, resulting in a medication error rate of 10.34%. The deficient practice was identified for 2 of 10 residents and involved 1 of 4 nurses. During one observation, an LPN began administering potassium chloride 10 mEq to a resident, and the MAR showed the dose was ordered for 8:00 AM every 2 days, but the administration was documented at 9:31 AM, 31 minutes late per facility policy. In another observation, the same LPN stated that a resident took metformin with breakfast but had not documented it at the time of administration, then entered it into the EMR afterward. The MAR showed metformin 1000 mg twice daily with meals, with the morning dose ordered for 8:00 AM and signed out at 9:33 AM. The LPN also poured aspirin 81 mg chewable from a medication bottle for the resident, while the MAR reflected an order for aspirin 81 mg enteric coated delayed release, not the chewable tablet that was administered.
Medication Labeling and Storage Deficiency
Penalty
Summary
Medications were not properly labeled and stored in an orderly manner on the 2 High - Side, 2nd Floor medication cart. During inspection of the cart with LPN #1, a multi-dose vial of Lantus insulin prescribed to an unsampled resident was found in a clear plastic bag and was opened but not labeled with an open date or expiration date. In the same drawer, a multi-dose vial of Humulin 70/30 insulin did not have an expiration date labeled on it. In the second drawer from the top of the same cart, the surveyor found 15 loose medication tablets and pills scattered across the bottom of the drawer. LPN #1 stated that staff check the medication cart weekly for loose tablets and pills. The DON stated that the facility's expectation is that insulin vials are dated. The facility policy stated that when opening a multi-dose container, the date opened is recorded on the container, and medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.
Open Garbage Containers and Debris in Outdoor Disposal Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the outdoor garbage containers closed and by allowing debris to remain around the trash disposal area. During observation with the Director of Dining, three garbage containers located side by side along the exterior fence were seen with open lids and trash exposed to the elements. The area around the containers was littered with disposable gloves, plastic bags, and cardboard boxes. In interviews, the Director of Maintenance stated that housekeeping and maintenance were responsible for keeping the dumpster area clean and that the containers should be shut with the surrounding area kept clean. The Environmental Service Director stated that the containers should remain free from debris, the lids should be closed, and the containers were monitored at least twice a day and when staff emptied garbage into them. The facility policy dated 09/01/2025 stated that all garbage and refuse containers in utility rooms, refuse storage rooms, and outside the facility must be maintained at all times with a closed lid, and that garbage pickup should occur as often as necessary to prevent sanitary nuisance conditions.
Improper Handling of Indwelling Urinary Catheter
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that Resident #11, who was admitted with benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy and had an indwelling urinary catheter documented on the admission MDS, had a catheter drainage bag in contact with the floor during the initial tour of the unit. The catheter was observed without a privacy bag. During interviews, the Infection Prevention nurse stated that indwelling catheters should be hung below the bladder and in a privacy bag and should never be on the floor for infection control reasons, and the DON stated that indwelling catheters should never be on the floor and should be hung below the bladder in a privacy bag. The facility policy for Catheter Care, Urinary also stated that catheter tubing and drainage bags are to be kept off the floor.
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.
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Illustrative
What surveyors actually found near you
We read the 1,031 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Trenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trenton Gardens Rehabilitation And Nursing Center | 1.7 mi | — | 36 | 4 |
| Avant Rehabilitation And Care Center | 2 mi | ★★★★★ | 14 | 0 |
| Riverside Health And Rehabilitation Center Llc | 2.5 mi | ★★★★★ | 1 | 0 |
| Greenwood House Home For The Jewish Aged | 2.5 mi | ★★★★★ | 12 | 0 |
| Preferred Care At Mercer | 2.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.