Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Harborage Llc during CMS and state inspections, most recent first.
Physical abuse of a resident with severe cognitive impairment, trach, and ventilator dependence occurred when a respiratory therapist was captured on hidden-camera video pushing the resident’s hand down, throwing a towel on the resident’s face, pulling and twisting the resident’s hands, hitting the resident on the face and head, and forcibly holding the resident down. The resident later had ED findings of contusions and a subdural hematoma, and the facility’s investigation determined the staff member’s actions were not consistent with policy.
Failure to Report Injuries of Unknown Origin: The facility did not report multiple injury events involving two residents with severe cognitive impairment and total dependence for ADLs. One resident had bruising to the cheek after pulling at trach tubing and another cheek bruise after return from ER for GT placement; a second resident had forehead bruising after leaning against a side rail. The investigations found no staff misconduct, but the incidents were not reported to NJDOH.
Incomplete abuse investigations for resident injuries: The facility did not complete thorough I/A reviews to rule out abuse for two residents with severe cognitive and physical impairment. One resident had bruising to the cheek after returning from the ER and another episode of facial injury after pulling at trach tubing, but one event had no I/A report and the other lacked documented prevention interventions. A second resident developed a forehead bruise after leaning against a side rail, yet the investigation included only one nurse statement and no additional staff statements.
Surveyors found multiple medication handling and documentation failures involving controlled meds and other drugs. An RN did not sign the narcotic log when removing and administering Hydromorphone, left an unlabeled Oxycodone/APAP tablet in a med cup after a resident refused it, and a patch was thrown in the trash instead of being properly disposed of. An LPN also failed to sign the narcotic log when removing controlled meds, and another LPN administered insulin without timely eMAR documentation, leaving orders overdue on the screen.
Surveyors observed a med pass with 4 nurses and found a 13.33% med error rate. One RN gave an OTC multivitamin instead of ordered Strovite One and initially selected the wrong Lidoderm strength for a resident’s patch orders, while another RN mismeasured Pro-Stat Oral Liquid and did not administer the full 30 mL dose to another resident. The observed errors involved incomplete or incorrect med preparation and administration that did not follow the ordered dose and strength.
Missing credential and background check verification for newly hired staff: Surveyors found that multiple employee files lacked prior-to-hire CBI documentation, and some CBIs were completed or reported after hire. Files for several RNs and LPNs also lacked license verification, and some CNA files lacked certification verification. The LNHA and DHR acknowledged that a number of background checks were documented after the employees’ hire dates, and the facility’s abuse prevention policy required employee background checks and screening for abuse-related findings.
Missing Nursing Competencies and Evaluations: The facility failed to ensure that nursing staff had and maintained required competencies and annual performance evaluations for 5 of 5 nurses reviewed. The ADON provided 94 in-service sign-in sheets, but none documented competencies, skills content, assessments, minutes, time, or hours credited. The DON acknowledged that no other in-servicing, competencies, or annual evaluations were available for the selected RN and LPN staff, despite the facility policy requiring formal written employee evaluations.
The facility failed to ensure annual written performance evaluations were completed for 4 of 5 CNAs reviewed. The DON confirmed the CNA files lacked the required evaluations, despite the facility policy calling for formal written employee reviews each year.
Surveyors found opened blood glucose test strips without an opened date, multiple expired disinfecting caps and other expired supplies in medication carts and a med room, and an opened inhalation solution package without a date. They also found two residents' insulin pens stored together in one bag labeled for only one resident, and an RN acknowledged the pens should not have been kept that way.
CNA In-Service Training Documentation Deficient: Surveyors found the facility did not ensure or document that CNAs completed the required annual in-service training, including abuse prevention and dementia management. The DON and ADON acknowledged there was no tracking record for CNA training hours or topics, the attendance sheets lacked credited time, minutes, and a syllabus, and written annual evaluations were missing for most of the CNAs reviewed.
The facility failed to promptly notify and document notification to the resident representative for two residents: one who died and one who had an unwitnessed fall. The deceased resident had multiple serious diagnoses, and the chart showed hospice, the UM, and supervisor were notified, but no record of RR notification. For the resident who fell, the LPN documented the assessment and return to bed, but the RR was not documented as notified until the next day, and staff gave inconsistent accounts of when the family was contacted.
A resident’s floor mat was repeatedly observed dirty, stained, and wet, and a CNA said housekeeping had been called but the mat was still dirty. In addition, a resident council member reported a morning towel shortage, and the 4th floor unit had 63 residents but the 7-3 cart listed only 60 towels; the supply closet had no towels while the laundry room had towels being processed and folded.
A facility failed to complete a timely initial nursing assessment for a newly admitted resident, failed to document administration of a physician-ordered PRN Lomotil, and failed to consistently document and coordinate hospice services in the resident’s record. Surveyors found no baseline nursing notes for the first days after admission, no MAR signature or explanation for the omitted med, and gaps in weekly hospice documentation for a resident with severe cognitive impairment and multiple chronic conditions.
Uncovered urinary catheter bag. A resident with an indwelling suprapubic catheter was observed with an uncovered urinary catheter bag. The resident’s record showed neurogenic bladder and an order for catheter care with placement and patency checks every shift. An LPN stated that a privacy bag was always required and acknowledged that no privacy bag was present, while the facility policy did not address covering catheter bags.
Call Devices Left Out of Reach: Two residents were observed in bed with their call devices positioned out of reach, including one device wrapped around itself and dangling over a wall outlet and another stretched across an HVAC unit. CNAs acknowledged the devices were not accessible. One resident was identified in the care plan as high risk for falls, with interventions to keep the call light within reach and encourage use for assistance.
A resident with heart failure and HTN, who had intact cognition, voiced dissatisfaction with facility care and staff assignment preferences and was documented in a PN as yelling and saying they would continue to call the state. Although staff acknowledged the resident frequently complained and discussed the concern with leadership, the complaint was not entered on the grievance form or found in the grievance binder, and no written grievance response was documented as required by policy.
Late and Untimely MDS Assessments: The facility failed to complete and transmit required MDS assessments on time for two residents. One resident with diabetes, stroke-related deficits, and fractures had a late comprehensive MDS and a late quarterly MDS, while another resident with Parkinson’s disease, OA, and COPD had a late comprehensive MDS and a discharge MDS that was completed but not transmitted. The RN/MDSC said she was new to the role, and the LPN/MDS staff said delays were related to incomplete department sections and high discharge volume.
A facility failed to accurately code the MDS for three residents. One resident’s MDS did not reflect antidepressant use despite an order for venlafaxine for depression and a care plan noting an antidepressant medication. Another resident’s MDS miscoded a urostomy in Section H, and a third resident’s MDS coded shortness of breath when lying flat in Section J without supporting documentation in the record.
Incomplete Care Plans for Anticoagulant, Catheter, and Antidepressant Use A resident receiving apixaban for DVT had no care plan for anticoagulant use, another resident with an indwelling catheter had no care plan for catheter care, and a third resident receiving Lexapro for depression/anxiety had no care plan for the antidepressant or related monitoring. Nursing staff and the DON acknowledged the missing care plan elements.
Failure to Follow Physician Orders for BP Monitoring, PRN Midodrine, and Pro-Stat: The facility did not follow physician orders for three residents. One resident with HF and HTN had an order for BP checks supine and sitting every shift, but the eMAR had unclear rows and incomplete entries marked NA or single numbers. A second resident with ESRD and DM had a PRN midodrine order entered without BP parameters, even though staff noted the medication should have hold parameters. A third resident with pleural effusion, HF, chronic respiratory failure, ESRD on dialysis, severe cognitive impairment, and malnutrition had a Pro-Stat order that was not started for several days, resulting in missed doses with no documentation explaining the delay.
A resident with a healed left humerus fracture, stroke-related deficits, and severe cognitive impairment was observed without a prescribed left arm sling even though the order remained active and nurses were signing the eTAR as if it had been applied. Staff stated the resident may have refused it, but there was no refusal documentation, and the sling was later found in the drawer. In a separate case, another resident with a left radial fracture was using a left arm sling that was included in the care plan, but no physician order was in place for the device.
A resident with severe cognitive impairment and a prior fall injury was observed in a low bed without the floor mat that remained listed in the care plan, despite staff acknowledging the intervention should have been in place. In a separate finding, a resident with dementia and Alzheimer’s disease who was at risk for elopement had a Wander Guard with blank eTAR checks, an expired device date listed on the order, and no PN documenting replacement after staff found the device was not on the resident.
A resident with Alzheimer's disease, severe protein-calorie malnutrition, and tube feeding had a PO for 200 mL water flushes every 8 hours, but the eMAR showed the flushes were given at set times of 9 AM, 1 PM, and 5 PM instead of the ordered frequency. An LPN, LPN/UM, RD, and DON reviewed the order and acknowledged the mismatch between the PO and the scheduled administration in the eMR.
A resident receiving neb therapy had the mask left attached to the machine and lying on a dresser instead of stored in a bag, and staff acknowledged the equipment should have been bagged. Another resident receiving O2 had no warning sign posted on the room door, and the NC was not labeled with a date or initials despite an order requiring weekly tubing changes and labeling. The RN acknowledged the labeling issue and stated they did not know when O2 signage should be displayed.
A facility failed to post an accurate Nursing Home Resident Care Staffing Report daily. Surveyors observed a lobby posting with an outdated date and an incorrect resident census, while the LNHA confirmed the census records did not match the posted information. The SC and RNS stated the staffing sheet should be updated and posted at the beginning of each shift, and the facility policy required the current date and census to be displayed.
A CP failed to identify an irregularity during the monthly DRR for a resident with CKD and anemia who was receiving Epogen. The resident had an order for Epogen injections with hematocrit monitoring, but no hold parameter was reflected, the CP did not recognize the boxed warning, and no recommendation was made to the prescriber regarding the medication review.
Improper Disposal and Housekeeping in Refuse Area: Surveyors observed the refuse area with used gloves, a used mask, debris, and garbage on the ground around and in front of a covered compactor. The DPO said housekeeping was responsible for cleaning the area weekly and confirmed the items should not have been there, while the LNHA stated the area usually was not checked. On a later tour, the same conditions remained, and the facility's Waste Handling Policy did not include a policy for the refuse area.
Hand hygiene was not followed by multiple staff during resident incontinence care and observed handwashing. Three CNAs donned gloves without first cleaning their hands, and two leadership staff washed for less than the required time and turned off faucets with bare hands instead of using a paper towel. The IPN stated that gloves do not replace hand hygiene and that proper soap-and-water technique requires at least 20 to 30 seconds of scrubbing and use of a clean towel to shut off the faucet.
The facility failed to ensure medication rooms on the second, third, and fifth nursing units were free of expired medical products and items left open. Observations revealed expired items such as central line trays, Huber needles, sterile water vials, and glucose control solutions. The DON stated that unit managers should oversee medical supplies and expiration dates.
A facility failed to develop a comprehensive care plan for a resident prescribed psychoactive medications for depression and anxiety. The care plan lacked interventions for monitoring side effects or behaviors, contrary to facility policy. The DON confirmed the necessity of such interventions for residents on psychoactive medication.
A resident with end-stage renal disease and other conditions did not receive necessary medications during dialysis days due to a lack of communication and collaboration between the LTC facility and the dialysis center. Medications such as furosemide, carvedilol, and Humalog were not administered as scheduled, and the facility failed to ensure these were given or rescheduled, contrary to their policy.
The facility failed to secure medications on the fifth floor, with an unlocked medication cart left unattended and a rolling cart with insulin pens unsecured. An LPN admitted the cart was unlocked due to lost keys, and the Unit Manager confirmed the oversight with the insulin pens. The DON emphasized the expectation for staff to secure medications.
Two residents in an LTC facility were not provided with necessary repositioning and incontinence care, despite being at high risk for pressure ulcers. Observations showed extended periods without repositioning or checks, and documentation revealed missed care opportunities. Staff interviews confirmed inadequate monitoring, highlighting deficiencies in adherence to care plans and facility policies.
The facility failed to maintain accurate medical records for two residents, resulting in undocumented medication administrations. One resident's MAR lacked documentation for several medications, and interviews revealed no explanation for the omissions. Another resident's MAR showed multiple medications not administered as per orders, with the responsible LPN claiming they were given but not documented. The facility's policy requires accurate and timely documentation, which was not followed.
Physical abuse of a ventilator-dependent resident by a respiratory therapist
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident with a tracheostomy and ventilator dependence was free from physical abuse by a respiratory therapist. The resident had severe cognitive impairment, required total assistance with activities of daily living, and had diagnoses including chronic respiratory failure with hypoxia, COPD, adjustment disorder with anxiety, tracheostomy status, and gastrostomy status. The resident’s care plan identified impaired cognitive/communication function after a CVA, resistance to care related to anxiety and pulling out the trach, and behaviors including flailing arms and contracted hand resulting in unintentional injuries to the face, arms, and hands. Law enforcement notified the facility of an allegation of abuse after reviewing hidden-camera video placed in the resident’s room by a family member. The facility’s reportable event record stated that the facility was made aware of the alleged staff-to-resident abuse and that the respiratory therapist was immediately suspended pending investigation. The surveyor reviewed video footage from 4/28/26, 5/1/26, and 5/2/26 that showed the respiratory therapist pushing the resident’s hand down, throwing a towel on the resident’s face multiple times, pulling the resident’s hands by the wrists, holding the resident’s head and letting it drop on the pillow, hitting the resident on the face, twisting and bending the resident’s hand back, squeezing and bending the resident’s hand, pushing the resident’s arm down, squeezing a towel on the resident’s face while the resident was gasping for air, and forcibly holding the resident’s hand down on the bed. The resident’s hospital emergency department record dated 5/11/26 showed an admitting diagnosis of subdural hematoma and documented contusions to the face, left chest, and right arm. The CT head without contrast showed a right convexity subdural hematoma. The facility’s investigative summary concluded that the respiratory therapist was not returned to the facility because the reviewed video footage demonstrated behaviors not consistent with facility policy. The report identified the incident as physical abuse involving one resident.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report to the New Jersey Department of Health potential abuse related to multiple incidents of resident injuries of unknown origin. The deficiency involved 2 of 4 residents reviewed for abuse and neglect, specifically a resident with severe cognitive impairment, total dependence for ADLs, chronic respiratory failure, tracheostomy status, gastrostomy status, and a history of anxiety and resistive behavior during care. For one resident, the record showed a large bruise to the left cheek after the resident attempted to pull at tracheostomy tubing and struck themself in the face multiple times. A nursing note also documented skin discoloration from the left cheek down to the neck, and the resident could not recall what happened. The incident investigation concluded there was no evidence of abuse, neglect, or staff misconduct, but the event was not reported to NJDOH. For the same resident, another nursing note documented a bruise/ecchymosis to the left cheek after the resident returned from the emergency room following gastrostomy tube placement. That incident was also not reported to NJDOH. For a second resident with severely impaired cognition, short- and long-term memory problems, total dependence for ADLs, non-traumatic intracerebral hemorrhage, respiratory failure, tracheostomy status, and gastrostomy status, the record showed a bruise/discoloration to the forehead after the resident was observed leaning toward the side rail with the forehead resting against it. The investigation stated the bruise was consistent with accidental contact/pressure against the side rail related to positioning behavior and anticoagulant use, and this incident was also not reported to NJDOH.
Incomplete Abuse Investigations for Resident Injuries
Penalty
Summary
The facility failed to ensure complete and thorough investigations were completed to rule out abuse for multiple resident injury incidents involving two residents. For Resident #1, who had severely impaired cognition, total dependence for ADLs, chronic respiratory failure, tracheostomy status, gastrostomy status, COPD, and anxiety with episodes of pulling at the trach and flailing her arms, the surveyor reviewed injury events from March and April 2026. One incident involved a bruise to the left cheek noted after the resident returned from the ER following GT placement, and another involved a large bruise to the left cheek after the resident reportedly attempted to pull at the tracheostomy tubing and struck herself in the face multiple times. The investigation for the 4/16/26 injury to Resident #1 concluded there was no evidence of abuse, neglect, or staff misconduct, but the report did not identify interventions to prevent further injury. For the 3/21/26 bruise to Resident #1, there was no incident/accident report or investigation provided to the surveyor. The record showed only a progress note documenting the left cheekbone ecchymosis after the resident returned from the ER, with no new order received. For Resident #3, who had non-traumatic intracerebral hemorrhage, atrial flutter, gastrostomy status, respiratory failure, tracheostomy status, short- and long-term memory problems, severely impaired cognitive skills, and total dependence for ADLs, the surveyor reviewed an injury event involving a small bruise/discoloration to the forehead. The facility’s investigation stated the bruise was consistent with accidental contact/pressure against the side rail related to the resident’s positioning behavior and anticoagulant use, but the I/A report contained only one staff statement from the nurse who assessed the resident and no other staff statements were supplied to the surveyor.
Controlled substance tracking and medication documentation failures
Penalty
Summary
The facility failed to ensure consistent accountability and proper disposition of controlled substances and non-narcotic medications during medication cart inspections and medication pass observations. In one instance, RN #1 reviewed the controlled drug administration record for a resident’s Hydromorphone and Oxycodone-Acetaminophen and found discrepancies between the inventory log and the bingo card counts. RN #1 stated he had removed Hydromorphone from the resident’s inventory but had not signed the declining inventory log when it was removed or after administration. The eMAR showed the Hydromorphone had been administered earlier that morning, and the timing of the administration was discussed with RN #1. During the same observation, an Oxycodone-Acetaminophen tablet was found in a med cup in the med cart, outside the mounted double-locked narcotic box and unlabeled. RN #1 stated the resident had refused the medication and requested Hydromorphone instead, but the refusal was not documented on the eMAR and the medication was not disposed of. The ADON confirmed that the removal should have been signed on the declining inventory log, the refusal should have been documented, and the medication should have been disposed of by two nurses. In another observation, RN #2 removed two Lidocaine 4% patches, dated one, then threw both patches into the trash when she realized the wrong strength had been selected. The UM could not state where the patches should have been disposed of, and RN #1 stated they should have been placed in the drug disposal solution. A separate medication pass observation found an LPN removing controlled medications for another resident and not signing the declining inventory log when the medications were removed or after they were administered. The LPN later stated the log should have been signed right away. In another observation, an LPN administered Novolog and Lantus to a resident, but the eMAR remained unsigned for a period of time and the orders stayed highlighted as overdue on the computer screen. The LPN stated the medications had already been given earlier that day but had not been signed for, and the audit report showed the medications were documented hours after administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medication administration errors remained below 5 percent. During an observed medication pass involving 4 nurses and 5 residents, surveyors identified 4 errors out of 30 opportunities, resulting in a 13.33% medication error rate. The deficient practice involved 2 residents and 2 nurses during direct observation of medication preparation and administration. For one resident, RN #1 prepared Strovite One and Lidoderm patches. The resident had orders for Strovite One, one tablet daily, and two Lidoderm 5% patches, one for the left leg and one for the left shoulder. RN #1 removed an opened multivitamin bottle from the med cart and stated it was a stocked OTC medication, then later stated she had substituted the ordered Strovite One with an OTC multivitamin that contained no folic acid because the pharmacy had not sent the ordered medication. RN #1 also removed two Lidocaine 4% patches, then later acknowledged the wrong strength had been selected and that the original orders for Lidoderm 5% and Lidocaine 4% were incomplete because they did not specify the quantity of patches or the exact locations for application. For another resident, RN #2 prepared Pro-Stat Oral Liquid ordered at 30 mL twice daily. Surveyors observed RN #2 pour the liquid while holding the med cup in the air, then read the meniscus after the cup was placed on a flat surface and found the amount was below 30 mL. RN #2 added more liquid, but after administration surveyors observed liquid remained in the cup, and RN #2 acknowledged the full dose had not been given. The facility’s medication administration policies required the six rights of medication administration and administration according to the order, but the observed actions did not follow those requirements.
Missing Credential and Background Check Verification for Newly Hired Staff
Penalty
Summary
The facility failed to ensure that licensed staff credentials were verified upon hire and failed to document verification of required certifications for some employees. During review of human resource records for employees hired since the prior recertification survey, surveyors found that 37 of 112 employee files did not contain a prior-to-hire criminal background investigation, and several background checks were completed or reported after the employee’s date of hire. The records reviewed included RNs, LPNs, CNAs, and housekeeping staff, with multiple examples showing the CBI was ordered or reported after employment began. Surveyors also reviewed the files of 52 nurses hired since the prior inspection and found missing documentation of nursing license verification for 5 nurses. These included an LPN and multiple RNs whose files did not contain any documentation showing the license had been verified. In addition, review of 45 CNA files showed missing documentation of nursing assistant certification verification for 3 CNAs. The facility’s HR records were reviewed on multiple dates, and the LNHA and DHR acknowledged that a number of background checks in the employee files were documented after the employees’ hire dates. The survey team also reviewed the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, updated 1/2023, which stated that the facility should conduct employee background checks and not knowingly employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment. The deficiency was cited under NJAC 8:39-4.1(a)5; 43.15 based on the missing and late background checks, along with missing license and certification verification documentation in the employee files.
Missing Nursing Competencies and Annual Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff possessed and maintained the appropriate competencies and skills to provide nursing care to residents for 5 of 5 nursing employees reviewed. On 4/29/26, the surveyor requested documentation of nursing competencies and annual performance evaluations for five nurses selected from the facility’s active employee roster. On 5/1/26, the ADON provided 94 in-service sign-in sheets completed since 1/1/25, but none of the sheets reflected nursing competencies performed, a syllabus of information or skills presented, skill assessments, or minutes from the in-service. None of the 94 sheets included a time of the in-service or hours credited to attendees. Later that day, the DON, in the presence of the ADON, acknowledged that no other in-servicing or competencies were available for the five selected nurses and that no annual performance evaluations were available for them. The DON also acknowledged the facility policy to evaluate nursing employees and that nurses should have an evaluation performed at least annually and competencies for job skills as needed. The DON and ADON confirmed that E#1, an RN hired on 1/30/24; E#2, an LPN hired on 11/29/21; E#3, an LPN hired on 8/10/20; E#4, an LPN hired on 6/15/92; and E#5, an RN hired on 5/30/23 had no competencies or evaluations on file. A review of the facility’s Evaluation Process Policy, dated 9/1/25, reflected that it is the policy of the facility to review employee work performance with a formal written evaluation.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants employed by the facility received annual written evaluations of their work performance for 4 of 5 employees reviewed. During the survey, the surveyor requested annual performance evaluations for five CNAs from the Director of Nursing, and the DON later confirmed that four of the five selected employees had no written annual evaluations on file. The employees without evaluations were CNA employees hired on 2/24/14, 1/11/23, 12/17/24, and 6/19/24. The facility’s Evaluation Process Policy, dated 9/1/25, stated that employee work performance is to be reviewed with a formal written evaluation, and the DON confirmed that CNA files were required to have an annual evaluation on file every year.
Improper labeling, expired supplies, and insulin storage issues
Penalty
Summary
The facility failed to properly label opened blood glucose test strips, failed to identify and remove expired biological supplies, and failed to properly store insulin pens in accordance with accepted professional principles and facility policy. During inspection of the 5th floor south/center medication cart, surveyors found loose disinfecting caps for needleless connectors, including three caps with an expiration date of 4/25/26 and no original container on the cart. In the same cart, an opened bottle of blood glucose test strips had no written opened date, and the RN stated she was not sure when the strips had been opened and that the opened date was needed as the reference for expiration. Surveyors also found an opened, half-full box of disinfecting caps in the 5th floor medication room with the same expired date of 4/25/26. On the 5th floor ventilation unit cart, surveyors observed an opened foil package containing three vials of Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg inhalation solution with no date of opening written on it, and another drawer contained nonconductive connecting tubing that had expired on 10/1/25. On the north cart on the third floor, surveyors found an opened box containing more than 100 disinfecting caps for needleless connectors, all with an expiration date of 2/6/25. On the south cart on the second floor, surveyors observed Resident #76's insulin lispro pen and Resident #5's Lantus Solostar pen stored together in the same bag labeled only with Resident #5's name and medication label. RN #3 stated they did not know where Resident #76's bag was located and acknowledged that insulin pens belonging to two different residents should not be kept together in one resident's bag. Review of the records showed Resident #76 remained in the facility and was receiving insulin lispro before meals, while Resident #5 was receiving insulin glargine at bedtime.
CNA In-Service Training Records Missing Required Hours and Topics
Penalty
Summary
The facility failed to ensure and document that all CNAs completed the required 12 hours of annual in-service training, including abuse prevention, dementia management, and areas of weakness identified in each CNA’s annual review, for 4 of 5 CNA employees reviewed. Surveyors reviewed facility-provided training records and found that 94 attendance sheets for in-services given to staff since 1/1/25 did not include credited hours or minutes for the topics covered, did not include a syllabus or minutes from the in-services, and did not identify any in-service as dementia management training. During interviews on 5/1/26, the DON and ADON acknowledged that the facility did not have a register or tracking record showing which CNAs completed trainings, which topics each CNA received, or the individual training hours completed. The ADON stated she knew each CNA was required to complete 12 hours of annual in-service training and that dementia management and abuse prevention were required topics. The DON also acknowledged that written annual evaluations were not available for 4 of the 5 CNAs to identify areas of weakness for inclusion in annual in-servicing, and that the attendance sheets lacked credited time, minutes, and a syllabus.
Failure to Notify and Document Representative Notification for Death and Fall
Penalty
Summary
The facility failed to ensure the resident representative was notified of a significant change in condition and failed to document that notification in the medical record for two residents. One resident had diagnoses including acute respiratory failure, pleural effusion, anemia, heart failure, and malignant neoplasm of the bladder. The record showed the resident expired at 12:53 PM, and while hospice services, the Unit Manager, and supervisor were notified, there was no documentation that the resident’s representative was informed of the death. Interviews with hospice and facility leadership confirmed that the facility was responsible for notifying the representative, but documentation of that notification could not be provided. For another resident with diagnoses including a right pubic fracture, gait and mobility impairment, generalized weakness, dementia, heart failure, acute kidney failure, and chronic kidney disease, the record showed a fall in which the resident was found on the floor by a CNA. The nurse documented that the resident was confused, denied discomfort, had no visible injuries, vital signs were taken, the supervisor was notified, and the resident was returned to bed. However, there was no documentation in the nursing note that the resident representative was notified of the fall at that time. The fall investigation report later indicated the resident representative was notified the next day, approximately 18 hours later. Interviews with the DON, ADON, and LPN showed inconsistent accounts of when and how the representative was contacted, and the facility could not provide documentation that the primary emergency contact was notified. The facility’s policies stated that the resident representative or family member should be notified promptly of significant changes, including death and falls, and that such notification should be documented.
Dirty Floor Mat and Insufficient Towels
Penalty
Summary
The facility failed to maintain a resident’s environment in a safe, clean, comfortable, and homelike condition when Resident #221’s floor mat was observed dirty, stained, and wet in multiple places. On the first observation, the resident was lying in bed with the mat on the right side of the bed showing wet pools; on a later observation the same mat remained stained and wet; and on a third observation it was moved vertically by the window wall and was still stained with dried colored chunks and pieces. A CNA stated the mat had been dirty the prior day and that housekeeping had been called, and also acknowledged that the mat was still dirty at the time of interview. The report also identified a shortage of towels on the fourth floor unit. During resident council, an unsampled resident stated there was a shortage of towels in the morning and that only one towel was received, which was not enough, and that this had been an issue for months. The unit census was 63 residents, while the par list for the 7-3 shift showed 60 towels on the cart, which did not provide one towel per resident for morning care when the census exceeded 60. The list also showed 15 towels delivered to the unit supply closet at 10, 12, and 2, and the 3-11 and 11-7 shift carts each had 60 towels. Further observation of the fourth floor supply closet found no towels in the closet, while the laundry room contained seven carts with 15 towels each, approximately 45 towels on a table, and an additional pile of laundry being folded from the dryer. The DH stated that 50 dozen towels had been ordered and approved, but had not arrived as expected. The DH also stated that the expectation was for staff to prepare carts for later shifts and that some days the cart was incomplete depending on what came back from the floors to wash. The facility policy stated that linen pars should satisfy daily resident needs and that bath towels had a par level of 3.0 per resident.
Delayed Admission Assessment, Missed PRN Medication, and Incomplete Hospice Documentation
Penalty
Summary
The facility failed to ensure a timely initial nursing assessment was completed for a resident admitted with atrial fibrillation, cerebral infarction, type 2 diabetes mellitus, hypertension, and dementia. The record showed no initial nursing assessment was completed on the day of admission, and no nursing progress notes were documented for the first three days after admission to establish the resident’s baseline status. The surveyor reviewed the closed record and found the initial nursing assessment was not completed until several days after admission. The facility also failed to ensure a physician-ordered PRN Lomotil was administered as ordered for a resident whose record included diagnoses of atrial fibrillation, stroke, diabetes, hypertension, and dementia. The electronic MAR showed the order for Lomotil 2.5-0.025 mg by mouth every 12 hours as needed for diarrhea after stool for C-diff had been collected for one day, but there was no signature showing the medication was given. The progress notes also contained no documentation explaining why the medication was not administered or omitted. In addition, the facility failed to document, communicate, and coordinate hospice services in accordance with the resident’s plan of care for a resident with Alzheimer’s disease, chronic kidney disease, peripheral vascular disease, and functional quadriplegia. The resident’s MDS showed severe cognitive impairment and indicated hospice services were being received, and the care plan addressed hospice care, poor appetite, and difficulty chewing and swallowing. Surveyors found hospice notes in the miscellaneous section of the eMR but identified gaps in weekly hospice documentation, and hospice visit notes provided by the hospice agency were not included in the facility’s eMR. Interviews with facility and hospice staff confirmed that hospice documentation was not consistently maintained in the medical record and that communication between hospice and facility staff was not clearly defined.
Uncovered urinary catheter bag
Penalty
Summary
The facility failed to ensure that the urinary catheter bag was covered for one resident with an indwelling suprapubic catheter. On 4/27/26 at 8:42 AM, the surveyor observed that Resident #122’s urinary catheter bag was uncovered. The resident’s record showed diagnoses including other neuromuscular dysfunction of the bladder, and an order dated 2/25/26 for an indwelling suprapubic catheter, size 20 Fr with a 10 cc balloon, with instructions to check placement and patency every shift for neurogenic bladder. On 4/28/26 at 12:55 PM, an LPN stated that a privacy bag for the urinary catheter bag was always required and acknowledged that there was no privacy bag on 4/27/26. On 4/30/26 at 1:48 PM, the surveyor discussed the concern with the LNHA, DON, and President of Clinical Services, and the LNHA did not provide a verbal response at that time. The facility’s Appropriate Use of Indwelling Catheters Policy, revised 1/15/26, did not address covering urinary catheter bags.
Call Devices Left Out of Reach
Penalty
Summary
The facility failed to ensure that residents' call devices were readily accessible for two residents reviewed for reasonable accommodations of needs and preferences. Resident #122 was observed lying in bed on 4/27/26 with the call device wrapped around itself, dangling over the outlet on the wall and out of reach. The same resident was observed again on 4/28/26 lying in bed with the call device in the same out-of-reach position. CNA #1 and CNA #2 later observed and acknowledged that the call device was out of reach. Resident #221 was observed lying in bed on 4/27/26 with the call device extended across the top of the heating and air conditioning unit against the window wall, with the device dangling over the side and out of reach. CNA #1 later acknowledged that the call bell was out of reach. The resident's care plan, initiated on 1/28/24, identified the resident as high risk for falls and included interventions to keep the call light within reach and encourage use for assistance as needed, with prompt response to requests for assistance. The facility policy stated that staff will ensure the call light is within reach and accessible while the resident is in bed or other sleeping accommodations.
Grievance Not Documented or Resolved per Policy
Penalty
Summary
The facility failed to ensure that grievances were documented on the facility grievance form and that responses were documented according to facility policy for one resident. Resident #9 was admitted with diagnoses including heart failure and hypertension, and the most recent cMDS showed a BIMS score of 15 out of 15, indicating intact cognition. On 2/19/26, a progress note documented that the resident was observed in the bedroom yelling and expressing dissatisfaction with the facility and staff assignments, stating they would continue to call the state. The resident did not identify unmet clinical care needs but repeatedly requested the same CNA daily and was told that consistent assignment could not be guaranteed due to staffing requirements. A review of the facility grievance binder for 2025 and 2026 showed no grievance listed for Resident #9. Interviews with the CNA, ADON, patient relations, SSD, DON, LNHA, and other facility leaders showed differing descriptions of how complaints were handled, including that concerns might be written up, forwarded to social services, addressed by nursing leadership, or logged by the LNHA. The SSD stated she was not aware of the situation documented in the progress note and said she did not write a grievance for it. The ADON and DON acknowledged that Resident #9 frequently complained about the CNA and the facility, and staff stated that the resident often bypassed facility staff and contacted the ombudsman. Facility policy required staff receiving a grievance to record it on the designated grievance form, forward it to the Grievance Official, document actions taken to resolve it, keep the resident informed of progress, and issue a written decision at the conclusion of the investigation. Despite the resident’s documented complaint and staff awareness of the concern, there was no grievance form in the binder for Resident #9 and no documented grievance response in the facility records reviewed.
Late and Untimely MDS Assessments
Penalty
Summary
The facility failed to complete and transmit Minimum Data Set (MDS) assessments within the required timeframes for 2 of 38 residents reviewed. The report cited federal RAI guidance stating that admission MDS assessments must be completed no later than the 14th calendar day after admission, quarterly MDS assessments must be completed within 14 days of the ARD, and discharge return-not-anticipated MDS assessments must be completed and transmitted within the required timeframes. The deficiency involved late completion and, in one case, failure to transmit a discharge assessment. Resident #14 was admitted with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, a wedge compression fracture of the first lumbar vertebra, and an upper left humerus fracture. The resident’s comprehensive MDS had an ARD of 1/2/26 with an admission date of 12/26/25; the CAA completion date and MDS completion date were both 1/9/26 and were marked in red, and the assessment was accepted on 4/22/26. The quarterly MDS had an ARD of 4/2/26, was completed on 4/17/26, and was accepted on 4/22/26, also marked in red for lateness. Resident #229 was admitted with diagnoses including Parkinson’s disease without dyskinesia, unilateral primary osteoarthritis of the right knee, and chronic pulmonary disease. The resident’s comprehensive MDS had an ARD of 1/9/26 with an admission date of 12/24/25; the CAA completion date and MDS completion date were both 1/9/26 and the assessment was transmitted on 1/12/26. The resident’s discharge MDS return-not-anticipated had an ARD of 2/5/26, was completed on 3/6/26, and was not transmitted. During interviews, the RN/MDSC stated she was new to the position and still learning MDS, while the LPN/MDS staff stated that some departments did not complete sections timely and that high discharge volume contributed to late MDSs; he also acknowledged that red dates meant the assessments were late.
Inaccurate MDS Coding for Medications, Appliances, and Health Conditions
Penalty
Summary
The facility failed to accurately reflect resident status in the MDS for 3 of 38 residents reviewed for MDS coding accuracy. For one resident, the quarterly MDS with an ARD of 3/17/26 showed a BIMS score of 13 out of 15 and did not code the use of antidepressant medications in Section N, even though the resident’s medication orders included venlafaxine 75 mg daily for depression and the care plan identified an antidepressant medication. The RN/MDSC stated that venlafaxine was an antidepressant and should have been coded as such on both quarterly MDS assessments reviewed. For another resident, the quarterly MDS with an ARD of 3/19/26 showed a BIMS score of 3 out of 15 and coded an ostomy in Section H. The resident’s record included diagnoses of obstructive and reflux uropathy, and the medication record showed foley catheter care and drainage. The RN/MDSC stated that the resident’s urostomy was miscoded in Section H of the MDS. For a third resident, the quarterly MDS with an ARD of 4/2/26 showed a BIMS score of 6 out of 15 and coded shortness of breath when lying flat in Section J. The resident’s record included multiple diagnoses, including diabetes with polyneuropathy, cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis, and fractures, but the medical record did not contain documented evidence supporting shortness of breath when lying flat. The RN/MDSC stated that the coding was wrong and that the MDS was modified to reflect an accurate assessment.
Incomplete Care Plans for Anticoagulant, Catheter, and Antidepressant Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with identified medical needs. For Resident #5, the record showed diagnoses including peripheral vascular disease, a quarterly MDS with a BIMS score of 13 indicating intact cognition, and an order for apixaban 2.5 mg by mouth every 12 hours for DVT. The care plan report did not include a care plan for anticoagulant use, and nursing staff stated that anticoagulant therapy should be included to monitor effectiveness and side effects such as bleeding. For Resident #85, the record showed diagnoses including obstructive and reflux uropathy, a quarterly MDS with a BIMS score of 3 indicating severe cognitive impairment, and an indwelling catheter documented in the MDS and in the order summary for foley catheter care and drainage. The care plan report did not include a care plan for the indwelling catheter. Nursing staff stated that the catheter should be part of the care plan and should be added. For Resident #14, the record showed diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, and fractures of the lumbar vertebra and left humerus. The quarterly MDS showed a BIMS score of 6 indicating severely impaired cognition and documented antidepressant use during the lookback period, while the order summary showed Lexapro 5 mg daily for depression/anxiety. The medical record did not reflect a care plan focused on antidepressant or other psychoactive medication use, and nursing staff and the DON acknowledged that the resident was receiving Lexapro without a corresponding care plan or monitoring documentation.
Failure to Follow Physician Orders for BP Monitoring, PRN Midodrine, and Pro-Stat
Penalty
Summary
The facility failed to ensure services met professional standards of practice by not following physician orders for three residents. The deficiency was identified through observation, interview, record review, and review of facility documents, and involved medication and treatment orders that were either not carried out as written or were documented in a way that did not reflect the ordered regimen. For one resident with heart failure and hypertension and a BIMS score of 15, the physician order required blood pressure to be measured supine and sitting every shift. The eMAR showed two BP rows for each shift, but there was no indication which row represented the supine reading and which represented the sitting reading. Many entries were recorded as NA or as a single number rather than a complete BP result, and the chart codes did not explain what NA meant. The DON stated the top row would be supine and the bottom row sitting, but no additional explanation was provided for the missing or incomplete documentation. For another resident with end-stage renal disease and type 2 diabetes, a PRN midodrine order was transcribed without BP parameters. The resident had a prior order for midodrine with a BP threshold, and the progress note and nursing note both referenced holding the medication based on BP limits, but the active PRN order in the eMAR did not include those parameters. Staff interviewed acknowledged that midodrine orders should include parameters and that the order lacked them. For a third resident with pleural effusion, heart failure, chronic respiratory failure with hypoxia, end-stage renal disease requiring dialysis, severe cognitive impairment, and moderate malnutrition, a physician order for Pro-Stat 30 mL twice daily was dated 4/10/26, but the eMAR showed the order was not initiated until 4/13/26. As a result, five doses were missed between the order date and the start of administration. The record contained no documentation explaining the delay in starting the order or the missed doses.
Failure to Follow Sling Orders and Obtain Order for Assistive Device
Penalty
Summary
The facility failed to follow a physician order to maintain a left upper arm sling for one resident with multiple diagnoses including type 2 diabetes with polyneuropathy, cerebral infarction, cognitive communication deficit, hemiplegia/hemiparesis after stroke, and a healing left humerus fracture. The resident’s quarterly MDS reflected severely impaired cognition. The current order summary showed an order to maintain the left upper arm sling with skin checks every shift and no weight bearing to the left upper extremity. Although the sling order was transcribed to the eTAR and nurses signed it each shift as administered, there was no documented evidence that CNAs documented application of the sling, and there was no documentation that the resident refused it. Surveyors observed the resident in a low bed without the sling on multiple occasions. The RN/UM initially stated that the resident was cognitively impaired, required total care, and that no adaptive device was needed because the fracture was already resolved. When the surveyor asked about the sling order, the RN/UM stated the resident probably refused it, but there should have been documentation of refusal. The RN assigned to the resident stated the fractured arm was healed, that the resident had used a sling previously, and that the sling had not been seen for about two weeks; the RN also acknowledged that the eTAR checkmark meant the sling was provided or administered, and said the signing without the sling being applied was a mistake. The sling was later found in the resident’s drawer. The facility also failed to obtain a physician order for a left arm sling for another resident who had diagnoses including a left radial fracture and two rib fractures. The resident’s care plan included use of a left arm sling as an intervention, and surveyors observed the resident wearing a black sling on the left arm during two separate observations. The resident stated the sling had been on since admission and that the resident had fractured the left arm. The LPN caring for the resident stated the resident did have a left arm sling and that there should have been an order in place for it, but no physician order was present in the record.
Fall Intervention Not Maintained and Wander Guard Monitoring Not Documented
Penalty
Summary
The facility failed to consistently implement fall interventions for a resident identified as high risk for falls after the resident sustained an injury from a fall. The resident had diagnoses including type 2 diabetes with diabetic polyneuropathy, cerebral infarction, cognitive communication deficit, hemiplegia/hemiparesis following cerebral infarction, and fractures of the lumbar vertebra and left humerus. The quarterly MDS reflected severely impaired cognition with a BIMS score of 6 out of 15. The care plan identified the resident as at risk for falls and included fall mats at bedside as an active intervention after a prior fall at the facility. During survey observations, the resident was seen lying in a low bed with the call bell within reach, but no floor mat was present. Multiple staff members, including the RN/UM, RN, CNA, DON, and others, were asked about the missing floor mat. The RN/UM stated the resident should have a floor mat for safety, but also stated the resident did not need it because the resident was not getting out of bed and had no further falls. The RN/UM and other staff confirmed that no floor mat was in the room at the time of observation, and there was no documentation showing that the intervention had been discontinued from the care plan. The facility also failed to appropriately supervise and monitor a resident with severe cognitive impairment who was at risk for elopement and had a history of wandering. The resident had diagnoses including dementia and Alzheimer’s disease, and the quarterly MDS showed a BIMS score of 5 out of 15. The resident’s elopement risk evaluation identified the resident as a moderate risk for elopement, and the care plan included use of a Wander Guard/Wander Elopement Device on the left wrist with placement checks every shift and function checks daily. Survey review of the eTAR showed blank documentation for required checks on multiple shifts, and one note stated the wander guard was not on the resident’s wrist and the unit manager was notified. The order listed an expiration date that had already passed, and staff could not explain why the date remained on the order or care plan. Staff interviews showed the resident frequently removed the device, that a new device was often placed, and that documentation of replacement was expected in a progress note, but no progress note was found after the device was noted missing. The facility’s policy stated that residents at risk for wandering or elopement should receive adequate supervision and that interventions should be added to the care plan and documented accordingly.
Feeding Tube Water Flush Order Not Followed as Written
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident receiving enteral feeding. Resident #73 had diagnoses including Alzheimer's disease and unspecified severe protein-calorie malnutrition, and the quarterly MDS indicated the resident was rarely/never understood and was receiving nutrition through a feeding tube. A physician's order dated 4/21/26 directed that the tube be flushed with 200 mL of water every 8 hours for hydration support, with scheduled times listed as 9 AM, 1 PM, and 5 PM. Review of the April 2026 eMAR showed the water flushes were administered at 9 AM, 1 PM, and 5 PM rather than every 8 hours as ordered. During interview, the LPN stated enteral feeding and water flushes were administered according to the PO, but could not explain the discrepancy when the surveyor pointed out that the order also specified every 8 hours. The LPN/UM acknowledged the order needed clarification, and the RD stated the recommendation was every 8 hours but the eMR system automatically entered a scheduled frequency when the order was entered as three times a day. The DON stated the resident still received the total amount for the day, while the order remained unscheduled according to the PO.
Respiratory Equipment Not Properly Stored or Labeled; Oxygen Signage Missing
Penalty
Summary
The facility failed to ensure that respiratory equipment was labeled and stored in accordance with infection control measures and that oxygen cautionary signage was posted for residents receiving oxygen. For one resident with diagnoses including type 2 diabetes mellitus and heart failure, a nebulizer treatment mask was observed still attached to the machine and lying on top of the dresser, not stored in a bag. The resident had a BIMS score of 15 out of 15, and the electronic record showed an order for ipratropium-albuterol nebulizer treatment with instructions to obtain lung sounds, oxygen, and respirations before and after treatment and to rinse after each use. During interview, the LPN stated that nebulizer treatments should be wiped down and placed in a bag after administration, and acknowledged that the observed mask should not have been left that way. The DON also stated that nebulizer treatment equipment should be in a bag. The facility’s nebulizer therapy policy required the nebulizer cup and mouthpiece to be stored in a zip lock bag once completely dry. The record also showed the resident’s nebulizer treatment had last been administered several days earlier, and the treatment order had been changed shortly before the observation. For another resident with COPD with acute exacerbation, surveyors observed the resident actively receiving oxygen without cautionary signage posted on the room door. The nasal cannula was also observed without a date or initials, despite an order requiring oxygen tubing changes weekly and labeling each component with date and initials. The RN stated the cannula was expected to be labeled and acknowledged it was not labeled, and also stated they did not know when oxygen signage was supposed to be displayed. The facility’s oxygen administration policy required oxygen warning signs on the resident’s room door when oxygen was in use.
Inaccurate Staffing Report Posting
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report daily for 1 of 5 days. On 4/27/26 at 6:18 AM, the surveyor observed a staffing report posted in the lobby that was dated 4/25/26 and listed the day, evening, and night shifts with a current census of 230 for all shifts. When the surveyor later requested census and admission records, the Licensed Nursing Home Administrator stated there were no new admissions on 4/25/26 or 4/26/26, and the midnight census reports for both dates showed a census of 227. The Staffing Coordinator stated she was responsible for posting the staffing report and that it should have an accurate date, census, and staffing information at the beginning of each shift. The Registered Nurse Supervisor who worked the 11-7 shift on the day the survey team entered the facility stated the Staffing Coordinator provided the posted staffing information and changed the census if needed before it was printed and posted. The facility policy required the Nurse Staffing Sheet to be posted daily, to include the current date and current resident census, and to be posted at the beginning of each shift.
Pharmacist Failed to Identify Epogen Irregularity During DRR
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified an irregularity during the monthly drug regimen review for a resident with chronic kidney disease and anemia who was receiving Epogen (epoetin alfa). The resident’s record showed an order for Epogen 10,000 units subcutaneously every Monday, Wednesday, and Friday, with monitoring for hematocrit, but no hold parameter was reflected in the order. The resident’s MDS indicated the resident was cognitively intact and receiving injectable medications, and the comprehensive care plan did not show the injectables were care planned. The 4/8/26 medication regimen review did not identify any irregularity, and the physician was not informed of the boxed warning for Epogen. During interview, the CP stated he was familiar with Epogen and its need for blood laboratory monitoring, but acknowledged that hematocrit monitoring on the eMAR was unnecessary and did not prohibit administration. He also stated he was not aware of the black box warning, did not make recommendations to prohibit administration based on hemoglobin results, and did not inform the prescriber of the boxed warning. The DON stated the expectation was that the CP review medications and provide recommendations thereafter.
Improper Disposal and Housekeeping in Refuse Area
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the refuse area in an unsanitary condition. On 4/27/26, a tour of the refuse area found one covered compactor with six used gloves around the perimeter, a used mask, debris, and garbage on the ground in front of the compactor. The Director of Plant Operations stated that hospital housekeeping staff were responsible for cleaning the area once a week and confirmed that the garbage and gloves should not have been present around the perimeter. On 4/28/26, the refuse area was observed again and still had garbage in front, along with used gloves and a mask. The DPO stated the company picked up the compactor every Friday and that the hospital also used it. The LNHA stated they usually did not check the area. Later interviews with the Director of Environmental Services indicated the kitchen had separate refuse and that the refuse area process was to sweep the dock daily and clear the area, but she also stated she did not check the kitchen refuse because it used a separate company. A review of the facility's Waste Handling Policy, dated 3/1/26, did not mention a policy for the refuse area.
Hand Hygiene Not Followed During Resident Care and Staff Handwashing
Penalty
Summary
The facility failed to follow appropriate hand hygiene practices during incontinence care and observed handwashing activities. During an incontinence tour, three CNAs entered residents’ rooms and donned gloves without performing hand hygiene first. One CNA removed gloves and performed hand hygiene with alcohol-based hand rub outside the room after checking a resident’s incontinence brief. Another CNA performed handwashing inside the resident’s room after glove removal, but scrubbed her hands for only seven seconds and turned off the faucet with her left elbow. A third CNA also donned gloves without hand hygiene and washed her hands for 13 seconds after removing gloves. The Infection Preventionist Nurse stated that hand hygiene should have been performed before donning gloves, that hands should be scrubbed for at least 20 seconds, and that a clean paper towel should be used to turn off the faucet. The report also documented hand hygiene concerns involving two leadership staff members during a kitchen tour. The Director of Safety washed hands for 18 seconds and turned off the faucet with bare hands without using a paper towel. The Director of Plant Operations washed hands for 18 seconds, with soap suds still on the right hand, then turned off the faucet with bare hands and did not use a paper towel. The Infection Preventionist Nurse stated that the handwashing process required rubbing hands for 25 to 30 seconds, rinsing, drying with a single-use towel, and using a paper towel to close the faucet. The facility’s hand hygiene policy stated that all staff were to perform proper hand hygiene to prevent the spread of infection and that gloves did not replace hand hygiene. The policy required hand hygiene before donning gloves and immediately after removing gloves, and specified that soap-and-water handwashing should include rubbing hands together vigorously for at least 20 seconds, drying thoroughly with a single-use towel, and using a clean towel to turn off the faucet.
Expired Medical Products Found in Medication Rooms
Penalty
Summary
The facility failed to ensure that medication rooms on the second, third, and fifth nursing units were free of expired medical products and items left open. During observations conducted with an LPN, several expired items were found in the resident care supplies across these units. On the second-floor nursing unit, expired items included central line trays with chloral prep, Huber needles, a microbore extension set, an IV securement kit, a 30ml sterile water syringe left open, an IV administration kit, and replacement caps. On the third-floor nursing unit, expired items included a Huber needle, sterile water vials, a specimen transport tube, lubricating jelly, and needleless connector caps. On the fifth-floor nursing unit, expired items included saline enema laxatives, micro scaffold collagen, germicidal alcohol wipes, and glucose control solutions. During an interview, the Director of Nursing stated that unit managers should be responsible for overseeing medical supplies and checking expiration dates. The presence of expired items in the medication rooms has the potential to increase the risk of infections due to expiration.
Failure to Develop Comprehensive Care Plan for Psychoactive Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed psychoactive medications. The resident was admitted with diagnoses of depression and anxiety and had physician orders for Divalproex Sodium for agitation, Mirtazapine for depression, and Buspirone for anxiety. However, the care plan did not include the use of these psychoactive medications or interventions for monitoring side effects or behaviors. The facility's policy requires a person-centered care plan to address medical, nursing, and psychosocial needs identified in the resident's comprehensive assessment. The Director of Nursing confirmed that residents receiving psychoactive medication should have a care plan with interventions for monitoring behaviors and reporting side effects.
Failure to Administer Medications During Dialysis
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center and did not administer necessary medications to a resident requiring dialysis. The resident, who had end-stage renal disease, congestive heart failure, hypertension, and diabetes, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. Despite having orders for medications such as furosemide, carvedilol, and Humalog, these were not administered on several occasions when the resident was out for dialysis. The Medication Administration Record (MAR) showed that furosemide was not given on multiple occasions in October, November, and December, as it was marked that the resident was out of the facility. Similarly, carvedilol and Humalog were also not administered during these times. The facility's policy required communication with the dialysis center regarding medication administration, but the dialysis center did not administer these medications, nor was there documentation of such administration. Interviews with nursing staff and the Director of Nursing revealed that the facility did not send medications to the dialysis center, and there was no arrangement for the dialysis center to administer them. The Director of Nursing confirmed that the physician should have been contacted to reschedule or withhold medications if necessary, but this was not done. The facility's policy emphasized the need for communication and documentation regarding medication administration, which was not adhered to in this case.
Medication Security Lapses on Fifth Floor
Penalty
Summary
The facility failed to ensure the security of medications on the fifth floor, leading to a potential risk of medication diversion and unauthorized access by residents. During an observation, a medication cart on the fifth floor south was found unlocked and unattended from 12:07 PM to 12:15 PM. The LPN responsible for the cart admitted that the keys were lost, and the cart had been left unlocked since 7:15 AM. The facility's policy requires medications to be stored in locked compartments and under the observation of the administering nurse during medication passes. Additionally, a plastic rolling cart with three insulin pens was observed unattended and unsecured on the fifth floor. The Unit Manager confirmed the oversight and acknowledged that the medications should not have been left unattended. The Director of Nursing stated that nursing staff are expected to keep medications secured and not leave them unattended, highlighting a lapse in adherence to the facility's medication storage policy.
Deficiency in Repositioning and Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary repositioning and incontinence care for two residents, R139 and R108, who were dependent on assistance with activities of daily living (ADLs). R139, admitted with diagnoses including sepsis and muscle weakness, was observed in the communal area for extended periods without being repositioned or checked for incontinence, despite orders to turn and position every two hours to prevent pressure wounds. Documentation revealed significant gaps in care, with numerous missed opportunities for repositioning and incontinence checks. Interviews with staff confirmed that R139 was not adequately monitored or cared for during these periods. R108, diagnosed with Alzheimer's disease, was also observed in a Broda chair for several hours without being repositioned or checked for incontinence. The care plan for R108 indicated a high risk for pressure ulcer development due to immobility and incontinence, with interventions requiring weight shifting every 15 minutes. However, observations showed that these interventions were not consistently implemented, and documentation indicated infrequent toileting and incontinence care. Interviews with the Director of Nursing and other staff members highlighted a lack of adherence to care plans and facility policies regarding monitoring and care for residents at risk of skin breakdown. The facility's policy required regular checks for incontinence and repositioning to prevent skin deterioration, but these were not consistently followed, leading to deficiencies in the care provided to R139 and R108.
Failure to Document Medication Administration for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, R71 and R22, as part of their nursing services. For R71, the Medication Administration Record (MAR) lacked documentation for several medications, including Lasix, Sertraline, Divalproex, Memantine, and Donepezil, which were not administered on specific dates in November 2024. Interviews with the resident's representative and nursing staff revealed that there was no documentation or nurse notes explaining the missed administrations. The Director of Nursing (DON) was unaware of these omissions and attributed them to incomplete documentation, emphasizing that any missed or late medication should be documented in the MAR with a corresponding nurse note. Similarly, R22's MAR indicated that multiple medications, such as Allopurinol, Amlodipine, Cyclosporine, and others, were not administered as per physician orders on a specific date in October 2024. The DON, upon reviewing the MAR, found no documentation explaining the missed administrations. An LPN responsible for administering R22's medications claimed they were given but not documented. The facility's policy on the accuracy of medical records mandates that documentation should be accurate, relevant, and completed by the end of the shift in which care was provided, which was not adhered to in these cases.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near North Bergen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudsonview Health Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| The Riverside | 1 mi | ★★★★★ | 0 | 0 |
| Harbour View Senior Living Corp | 1.3 mi | ★★★★★ | 1 | 0 |
| The New Jewish Home, Manhattan | 1.8 mi | ★★★★★ | 0 | 0 |
| Amsterdam Nursing Home Corp (1992) | 1.9 mi | ★★★★★ | 0 | 0 |
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