Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Elmora Hills Health & Rehabilitation Center during CMS and state inspections, most recent first.
Medication administration observations found a medication error rate above 5% after an LPN gave an undiluted KCl solution and documented a full dose of MiraLax even though the resident did not finish it. The resident had HTN, a cardiac pacemaker, and severe cognitive impairment. The KCl order required dilution with at least 4 oz of fluid and administration with or after meals, and the MiraLax order required dissolution in water or juice. The LPN acknowledged she did not review the order details during the med pass and should have diluted the KCl and documented the partial dose.
Unlabeled food, expired items, and unsanitary conditions were found in two pantry areas. In one pantry, surveyors observed a resident-labeled container with an unreadable date, a stained microwave, dust, staff cups stored in the cabinet, and an unlabeled yogurt cup. In another pantry, surveyors found an unlabeled container with partially eaten food, an open unlabeled bottle of prune juice, and residue on the ice machine; the CNs and FSD acknowledged the items should have been labeled and the equipment cleaned.
A facility failed to provide a hands-free trash container in the laundry room and failed to follow proper hand hygiene after PPE removal. Surveyors observed laundry staff using a sheet to cover a garbage container, handling it with paper towels and bare hands, and washing hands in a manner that did not match the facility’s hand hygiene policy, including applying soap before turning on the water and turning off the faucet without using a paper towel.
The facility's assessment failed to include necessary resources for staffing contingency plans and linen supplies management, potentially affecting all 186 residents. A resident reported linen shortages, and the LNHA acknowledged the absence of a staffing contingency plan, which was only provided after surveyor inquiry.
The facility failed to follow proper infection control practices, including hand hygiene and PPE use, as observed with four staff members. Recreation staff and a CNA did not perform adequate hand hygiene, while personal items were improperly stored in the laundry area, compromising cleanliness. A hospice aide wore gloves inappropriately in the hallway, violating the facility's Enhanced Barrier Precautions policy.
The facility failed to provide mandatory QAPI training to its CNAs, as revealed by a surveyor's review of in-service education records. Interviews with the ADON, DON, and CNAs confirmed the absence of QAPI training documentation and a general lack of awareness about the program, indicating a systemic issue in the facility's training protocols.
The facility failed to provide mandatory Compliance and Ethics training for five CNAs, as revealed by a surveyor's review of education records and interviews with staff. The ADON and DON could not provide evidence of such training, and the facility's education list did not include Compliance or Ethics requirements. Interviews with CNAs showed a lack of awareness of receiving this training.
A facility failed to accurately document a resident's advance directives, resulting in a discrepancy between the paper chart and the electronic medical record (EMR). The resident, with severe cognitive impairment, had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, but the EMR only reflected the DNI status due to an oversight during readmission. The Charge Nurse and Social Worker were responsible for maintaining these records, but the DNR order was not re-entered into the EMR, contrary to the facility's policy of quarterly reviews.
The facility failed to verify the credentials of two newly hired staff members, an Administrator and a CNA, before their hire dates. The CNA's license verification was completed after hiring, and the Administrator's verification was missing. The HR director confirmed the absence of a formal policy for conducting these checks.
A facility failed to accurately code the MDS for a resident receiving continuous oxygen therapy and respiratory care. Despite documentation in medical records and administration by nursing staff, the MDS did not reflect these treatments. The MDSC/RN acknowledged the oversight, which was identified during a survey.
A resident with congestive heart failure and hypertension did not receive Metoprolol multiple times due to hold parameters, but the physician was not notified of this pattern. Interviews with staff revealed that the facility's policy required physician notification for frequent medication holds, but this was not followed. The facility's policy also required documentation of physician notification and monthly review by the Consultant Pharmacist, which was not evident in this case.
A facility failed to follow physician orders and hypoglycemic protocols for a resident with diabetes, leading to deficiencies in care. The resident's blood sugar levels were not managed according to the prescribed protocol, and there were discrepancies in the timing of insulin administration and tube feeding. Nursing staff did not clarify orders with the physician, and documentation was altered after surveyor inquiry, indicating a lack of adherence to facility policies.
A facility failed to maintain infection control during pressure ulcer treatment for a resident, as an LPN did not change gloves or perform hand hygiene before applying Medihoney directly from the tube. Additionally, the facility did not conduct quarterly Braden Scale assessments to evaluate pressure ulcer risk, contrary to policy. Another resident's new wound was not comprehensively assessed or documented, with no wound assessment or measurements recorded in the medical record.
A facility failed to perform a quarterly fall risk assessment for a resident with a history of falls, as required by their policy. The resident, admitted with conditions like a femur fracture and cerebral infarction, had assessments done on admission, readmission, and after a fall, but not quarterly. Interviews with staff revealed confusion about the policy's requirements, indicating assessments were done on admission, after falls, and upon condition changes, but not quarterly.
A resident with severe cognitive impairment was observed receiving tube feeding at an incorrect rate of 90 ml/hr instead of the ordered 80 ml/hr. The error persisted since the physician's order change, and the facility's records did not reflect the updated rate. The Charge Nurse/LPN acknowledged the mistake, and the facility's Enteral Feeding policy lacked specific guidance on adhering to physician orders.
The facility failed to provide adequate respiratory care for residents receiving oxygen therapy. A resident's oxygen tubing was not dated or properly stored, and there was no cautionary sign indicating oxygen use. Another resident had incorrect oxygen flow rates and improper tracheostomy care, with lapses in hand hygiene and PPE protocols. The facility's policies on oxygen administration and infection control were found lacking, contributing to these deficiencies.
The facility failed to clarify Physician's Orders for pain management for two hospice residents, leading to confusion in medication administration. One resident had severe cognitive impairment and was prescribed Acetaminophen and Morphine without clear sequencing based on pain level. Another resident received Morphine for both pain and shortness of breath without separate indications. The facility's Pain Management Policy lacked guidelines for medication sequencing, contributing to the deficiencies.
A facility failed to ensure a non-certified NA did not work beyond the allowed 120 days without completing required training. The NA's file lacked proof of enrollment in a NATCEP or completion of 90 hours of training. Despite having a Home Health Aide certificate, there was no evidence of CNA program completion. The HRD could not provide documentation of enrollment at hire, and the facility lacked a clear hiring policy for non-certified NAs.
A resident was administered Ropinirole for 'Other Muscle Spasm' without a proper diagnosis, as the medication is FDA-approved for Parkinson's Disease and RLS. The resident experienced dizziness and headache, and the facility failed to provide documentation justifying the medication's use. Attempts to contact the resident's physician were initially unsuccessful, and the facility's DON later stated the medication was continued due to coding difficulties.
The facility failed to ensure proper storage and labeling of medications, as observed by surveyors who found loose medications in two medication carts on different floors. LPNs confirmed that medications should not be loose, and the facility's policy requires secure storage and labeling. A previous inspection had already noted this issue, but it remained unaddressed.
The facility failed to serve food at a palatable temperature during a lunch meal on one unit. Two residents complained about receiving cold food, and a test tray revealed that the food temperatures were below the required levels. The Food Service Director admitted to infrequent testing and acknowledged the issue, while the LNHA was informed of the deficiency.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a morning medication administration observation. Two surveyors observed two nurses administer 33 doses of medication to four residents and identified two errors, resulting in a medication error rate of 6.06%. The deficient practice involved one resident who received medications from one of the observed nurses. During the medication pass, an LPN prepared 10 medications for the resident, including MiraLax powder and Potassium Chloride (KCl) solution. The LPN mixed the MiraLax with water, but poured the KCl directly into a medicine cup without diluting it. The resident drank the undiluted KCl, and then drank only about three-fourths of the MiraLax solution, leaving about one-third in the cup. The nurse discarded the remaining MiraLax solution in the trash can on the med cart and signed for administration of the KCl and the total dose of MiraLax. The resident had diagnoses including hypertension and a cardiac pacemaker, and the MDS reflected severe cognitive impairment with a brief interview for mental status score of 7 out of 15. The physician’s order for KCl required that it be diluted with at least 4 oz of fluid and administered with or after meals, and the order for MiraLax directed that it be dissolved in 4 to 8 oz of water or juice. The LPN stated she did not click on the order details during medication administration and acknowledged she should have diluted the KCl and documented that the resident did not finish the MiraLax. The CN stated KCl should be diluted in 4 oz of water and that partial medication intake should be documented as partial dose taken and partial dose refused.
Unlabeled food and unsanitary pantry conditions
Penalty
Summary
The facility failed to store potentially hazardous food and maintain sanitation in a safe and consistent manner in 2 of 3 pantries reviewed, specifically the 2 North and 3rd floor pantries. In the 2 North pantry, the surveyor observed a transparent plastic container with a red lid in a plastic bag that had a handwritten resident name and room number, but the current date could not be read and the use-by date was 12/7/25. The surveyor also observed a microwave with a paper towel on the plate and brown stains on the back wall, and the Charge Nurse stated it looked like something had burnt in it and that resident food should not be warmed there until it was cleaned. The Charge Nurse attempted to wipe the stain with a bare hand and stated CNAs were supposed to clean the microwave after use. Additional observations in the 2 North pantry included a closed Styrofoam cup on top of the refrigerator containing a small amount of clear liquid, which the Charge Nurse did not know why it was there, dust on the left corner top cabinet shelves, two empty tall personal cups and one large wide personal cup with two pouches of brown sauce in the top cabinet, and an unlabeled and undated yogurt cup on the bottom shelf. The Charge Nurse stated the cups belonged to 11-7 shift CNAs and should not have been in the pantry, and did not know who the yogurt cup belonged to. In the 3rd floor pantry, the surveyor observed an unlabeled and undated black container with a transparent lid containing partially eaten food and a white plastic spoon, with condensation on the lid. The Charge Nurse stated he was not sure who the container belonged to and acknowledged it should have been labeled. The surveyor also observed an open, undated, unlabeled 64-ounce bottle of prune juice in the refrigerator and white residue on the inner and outer lip of the ice machine. The Charge Nurse stated the prune juice should be used within 5 days once opened and that staff should label items with an open date and use-by date, and stated the ice machine needed daily cleaning by housekeeping, though he was not sure how often or who was responsible for cleaning the inside of the machine.
Laundry Room Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to provide a hands-free garbage container in the laundry room and failed to follow appropriate infection control protocol for hand washing after removing PPE. During a tour of the laundry room, the surveyor observed a blue garbage container covered with a white sheet instead of having a working lid. The Housekeeping Director acknowledged the missing lid and stated staff washed their hands at the sink, used a dry paper towel to move the sheet, and then placed garbage in the container. He was unable to explain what staff did with the gloves after they were removed. The surveyor then observed one laundry aide wash her hands, dry them with paper towels, and drop the paper towels on top of the sheet covering the garbage container. Another laundry aide entered the room wearing a gown, gloves, and face shield, removed her PPE, and washed her hands in a manner that did not follow the facility's hand hygiene procedure: she applied soap before turning on the water, lathered for 10 seconds, rinsed, turned off the water without using a paper towel, and then dried her hands. She used paper towels to move the sheet covering the garbage container, dropped the paper towels into the container, and used her bare hands to replace the sheet. The HSKD, REVS, Infection Preventionist, DON, LNHA, and President of Clinical Services reviewed the observations, and the LNHA stated the employee needed education while the DON stated the laundry room needed a new trash can.
Deficiency in Facility-Wide Assessment for Staffing and Linen Supplies
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included necessary resources for establishing policies and procedures for a staffing contingency plan and linen supplies management. This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unable to provide a comprehensive Facility Assessment (FA) that included these critical components. The FA submitted did not address the New Jersey mandated staffing law, nor did it include a contingency plan for staffing or a grid for linen supplies. This oversight had the potential to affect all 186 residents in the facility. During the survey, a resident reported occasional shortages of linen and towel supplies, highlighting the deficiency in resource management. The LNHA acknowledged the absence of a staffing contingency plan and provided it only after the surveyor's inquiry. Despite the facility's adherence to the New Jersey mandated staffing ratios, the lack of a documented contingency plan and a comprehensive FA that addressed all resident needs was a significant oversight. The survey team met with facility management to discuss these findings, but no additional information was provided to address the concerns.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, as observed during a survey. Four staff members, including two recreation staff, a certified nursing aide (CNA), and a hospice aide, did not follow appropriate hand hygiene practices. The recreation staff were observed not performing hand hygiene after removing gloves and handling disinfecting wipes during a lunch service. The CNA was noted to wash her hands inadequately, scrubbing for less than the recommended 20 seconds. These actions were contrary to the facility's infection control policies and CDC guidelines. In the laundry area, the facility did not maintain a clean environment, which is crucial for infection control. Personal items such as cell phones, snacks, and beverages were found on tables designated for folding clean linens, which were uncovered. Additionally, there was a significant accumulation of dust and lint in the laundry area, and a blower was used as a fan, potentially spreading contaminants. The staff responsible for the laundry area could not confirm when it was last cleaned, indicating a lack of accountability and adherence to cleanliness protocols. The hospice aide was observed wearing gloves inappropriately in the hallway after exiting a resident's room, which was against the facility's Enhanced Barrier Precautions (EBP) policy. The aide carried soiled linens down the hallway while wearing gloves, which should have been removed before leaving the resident's room. This practice was not in line with the facility's infection control procedures, which require PPE to be discarded before exiting a resident's room to prevent the spread of multidrug-resistant organisms (MDROs).
Lack of QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that its staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of QAPI training for five Certified Nurse Assistants (CNAs) reviewed. The surveyor's review of the annual in-service education records for these CNAs revealed that none had completed QAPI training, despite it being a mandatory requirement for CNA renewal. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the absence of formal sign-in sheets or documentation proving that QAPI education had been conducted. Further interviews with CNAs and the Staffing Coordinator indicated a general lack of awareness about QAPI training, with several staff members unable to confirm whether they had received such education. The ADON, who was responsible for staff education since February 2024, could not account for training prior to her tenure and was unaware of the requirement to use the CNA hire date as an anniversary for education. The DON and Licensed Nursing Home Administrator (LNHA) also failed to provide evidence of QAPI training, highlighting a systemic issue in the facility's training protocols.
Deficiency in Compliance and Ethics Training for CNAs
Penalty
Summary
The facility failed to ensure that its staff received mandatory training on Compliance and Ethics, as evidenced by the lack of such training for five Certified Nurse Assistants (CNAs) reviewed. The surveyor's review of the annual in-service education hours for these CNAs revealed that none had completed the required Compliance and Ethics training. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the absence of this training in the facility's education records. The ADON, who was responsible for staff education from February 2024, could not account for training prior to her tenure, and the DON could not provide complete proof of mandatory in-services. Further interviews with CNAs and the Staffing Coordinator indicated a lack of awareness or recall of receiving Compliance and Ethics training. The facility's list of mandatory education requirements, provided by the ADON, did not include Compliance or Ethics training, and the DON mentioned that Ethics education was done annually but could not provide sign-in sheets as evidence. The Licensed Nursing Home Administrator (LNHA) confirmed the education list, and no additional information was provided during the exit conference with the survey team.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with severe cognitive impairment. The resident was admitted with chronic obstructive pulmonary disease, dementia, and hypertension, and had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status. However, the electronic medical record (EMR) did not reflect the DNR status, only the DNI status, due to an oversight when the resident was readmitted to the facility. The Charge Nurse/Licensed Practical Nurse (CN/LPN) and the Social Worker (SW) were responsible for maintaining and reviewing advance directives. During the survey, it was discovered that the resident's paper chart had a DNR sticker, but the EMR lacked a corresponding physician's order for DNR. The SW confirmed that advance directives were reviewed quarterly and annually, but the DNR order was not re-entered into the EMR upon the resident's readmission, leading to the discrepancy. The facility's policy required that advance directives be determined upon admission and reviewed quarterly. Despite this, the failure to update the EMR with the correct DNR status was identified during the survey. The CN/LPN and SW acknowledged the oversight and the need for clarification of the resident's advance directives, which were not accurately documented in the EMR as per the facility's procedures.
Failure to Verify Staff Credentials Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of licensed staff were verified upon hire, as evidenced by the review of employee files for two newly hired staff members. Specifically, the surveyor found no documented evidence of license verification for an Administrator hired on August 1, 2022, and a Certified Nurse Aide (CNA) hired on September 4, 2023. The CNA's file contained a license verification printout from the New Jersey Division Consumer Affairs that was undated, and a background screening and license verification from an outside company dated August 20, 2024, which was after the date of hire. During interviews, the Human Resource (HR) director admitted there was no formal policy for conducting background checks and license verifications upon hiring new employees, relying instead on facility practice. The surveyor noted that the Employee File Check List provided by the HR director included spaces for Criminal Background Check and License Verification, but these were not completed prior to the date of hire for the staff in question. The facility management was informed of these deficiencies, but no further pertinent information was provided.
Inaccurate MDS Coding for Resident's Oxygen and Respiratory Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in the management of care. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the lung, essential hypertension, and dysphagia, was observed receiving continuous oxygen therapy via a laryngeal opening. However, the most recent quarterly MDS did not reflect the resident's oxygen therapy, tracheostomy/laryngeal care, or respiratory treatment, despite these being documented in the resident's medical records and administered by nursing staff. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged that the information for the MDS was gathered from various sources, including nursing notes and physician orders. Upon review, it was discovered that the nurses had been signing off on the electronic Treatment Administration Record (eTAR) for the resident's oxygen and laryngectomy stoma care throughout June 2024, which should have been captured in the MDS. This oversight was identified during a survey, and the MDSC/RN confirmed that the MDS for the assessment reference date of June 15, 2024, did not accurately capture the resident's care needs.
Failure to Notify Physician of Medication Holds
Penalty
Summary
The facility failed to promptly notify the physician about a medication, Metoprolol, not being administered to a resident due to hold parameters. The resident, who had diagnoses including congestive heart failure and hypertension, had a physician's order for Metoprolol with specific hold parameters. The medication was not administered 15 times in June and 9 times in July because the resident's blood pressure or heart rate was outside the specified range. Despite this pattern, there was no documented evidence that the physician was informed of the frequent holds, nor was there any documentation of the physician's response. Interviews with the Director of Nursing (DON), a Registered Nurse (RN), and a Charge Nurse/Licensed Practical Nurse (CN/LPN) revealed that the facility's staff were expected to notify the physician if a medication was held multiple times. The DON stated that he would expect the staff to contact the physician if there was a pattern of holding medications, and the RN and CN/LPN confirmed that they would notify the charge nurse to contact the physician if a medication was held more than once or if a pattern was identified. However, in this case, the physician was not notified despite the medication being held multiple times. The facility's policy on medication holds and physician notification required timely communication with the physician when a trend of medication holds was identified. The policy also required documentation of the date and time of physician notification and any recommendations or orders received. Additionally, the Consultant Pharmacist was expected to review each resident's medication regimen monthly, including any documented medication holds. Despite these policies, there was no evidence of physician notification or documentation regarding the frequent holds of Metoprolol for the resident.
Failure to Follow Hypoglycemic Protocol and Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders and protocols for a resident with type 2 diabetes mellitus and other medical conditions, leading to deficiencies in care. The resident, who had severely impaired cognitive skills, was on tube feeding and required insulin injections. The facility did not follow the hypoglycemic protocol as ordered by the physician, which included administering glucagon or other treatments when blood sugar levels fell below 70 mg/dl. On two occasions, the resident's blood sugar levels were recorded as 66 mg/dl and 50 mg/dl, yet there was no documented evidence that the hypoglycemic protocol was followed or that the physician was notified. The facility's electronic Medication Administration Record (eMAR) showed discrepancies in the timing of insulin administration and tube feeding, which were not coordinated as per the physician's orders. The Licensed Practical Nurses (LPNs) involved did not clarify the orders with the physician, leading to potential mismanagement of the resident's insulin and feeding schedule. Additionally, there were inconsistencies in the documentation of blood sugar levels and the administration of the hypoglycemic protocol, with some records being altered after the surveyor's inquiry. Interviews with the nursing staff revealed a lack of adherence to the facility's policies and procedures regarding the management of hypoglycemia and the coordination of insulin and feeding orders. The Director of Nursing acknowledged that changes to the eMAR were made after the surveyor's inquiry, indicating a failure to maintain accurate and timely medical records. The facility's failure to follow physician orders and document care accurately resulted in a deficiency in the treatment and care of the resident.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to maintain infection control practices during the treatment of a pressure ulcer for Resident #131. The Licensed Practical Nurse (LPN) did not change gloves or perform hand hygiene after cleaning the pressure ulcer and before applying Medihoney directly from the tube onto the resident's sacral pressure ulcer. This practice was contrary to the facility's policy, which required the ointment to be placed in a cup and applied with an applicator. The LPN acknowledged the error when questioned by the surveyor. Additionally, the facility did not perform a quarterly Braden Scale assessment for Resident #131 to assess the risk of developing pressure ulcers. The Braden Scale was only completed on admission and after the resident developed a pressure ulcer, which was not in line with the facility's policy that required quarterly assessments. The Director of Nursing (DON) confirmed that the quarterly assessments were not being conducted, and the policy had been changed without proper documentation or communication. For Resident #164, the facility failed to document a comprehensive assessment of a new wound on the resident's left chest. Although the wound was identified and treated, there was no documentation of a wound assessment or measurements in the resident's medical record. The wound care consultant's notes did not include an assessment of the new wound, and the facility's policy did not adequately address the requirements for wound and skin assessments by nurses.
Failure to Conduct Quarterly Fall Risk Assessment
Penalty
Summary
The facility failed to conduct a quarterly fall risk assessment for a resident, as required by their policy. The resident, who was admitted with conditions including a fracture of the left femur, hypertension, and cerebral infarction, had a history of falls. The facility's policy mandates that fall risk assessments be conducted upon admission, when a fall occurs, and quarterly thereafter. However, the resident's records showed that while assessments were done on admission, readmission, and after a fall, there was no evidence of a quarterly assessment being completed. Interviews with facility staff, including the LPN, Charge Nurse, and MDS/RNs, revealed a lack of clarity and adherence to the policy regarding the frequency of fall risk assessments. The staff indicated that assessments were typically done on admission, after a fall, and upon a change in condition, but not quarterly. Despite the facility's policy stating the need for quarterly evaluations, the surveyor found no documentation supporting that such assessments were performed for the resident in question.
Failure to Administer Tube Feeding per Physician's Order
Penalty
Summary
The facility failed to administer tube feedings according to the physician's order for a resident receiving nutrition via a feeding tube. The deficiency was identified when a surveyor observed the resident's feeding tube infusing at a rate of 90 ml/hr, contrary to the physician's order of 80 ml/hr. The resident, who was severely cognitively impaired and non-verbal, had been receiving the incorrect feeding rate since the order change on 7/27/24. The discrepancy was confirmed by a second surveyor and acknowledged by the Charge Nurse/LPN, who admitted that the feeding rate had not been updated in accordance with the new physician's order. The resident's medical history included cerebral infarction, gastro-esophageal reflux disease, aphasia, and gastrostomy status. The facility's records, including the electronic Medication Administration Record and the Care Plan, indicated that the feeding should have been administered at the correct rate of 80 ml/hr. However, the facility's Enteral Feeding policy did not specify the nurse's responsibility for ensuring adherence to physician orders. The LPN confirmed that the error was due to the failure to update the feeding rate when the new orders were issued, and the facility's management was informed of the findings.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide adequate respiratory care for residents receiving oxygen therapy, as evidenced by several observations and interviews. Resident #66 was observed receiving oxygen via a nasal cannula connected to a portable oxygen tank, but the tubing was not dated, and the oxygen concentrator tubing was improperly stored. Additionally, there was no cautionary sign indicating oxygen use outside the resident's room. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Charge Nurse, confirmed that the oxygen tubing should have been dated and stored in a plastic bag when not in use, and that a sign should have been posted. However, the Licensed Nursing Home Administrator (LNHA) and other staff believed that such signage was not required in a non-smoking facility, citing NFPA 101 regulations. Resident #111, who had a laryngeal stoma and was on continuous oxygen therapy, was found to have discrepancies in the oxygen flow rate, which was set at 3 LPM instead of the physician-ordered 2 LPM. The LPN responsible for the resident's care admitted to not knowing why the oxygen was set incorrectly and adjusted it upon realization. Furthermore, during tracheostomy care, the LPN failed to follow proper hand hygiene and personal protective equipment (PPE) protocols, such as not performing hand hygiene between glove changes and not removing the gown before exiting the resident's room. The Infection Preventionist confirmed these lapses in protocol. The facility's policies on oxygen administration and infection control were reviewed, revealing gaps in the procedures for storing oxygen tubing and ensuring compliance with physician orders. The facility management was informed of these deficiencies, which were consistent with previous survey findings, indicating a repeat deficiency. The facility's policy did not adequately address the storage of oxygen tubing when not in use, contributing to the observed deficiencies.
Deficiency in Pain Management Orders for Hospice Residents
Penalty
Summary
The facility failed to ensure proper clarification of Physician's Orders (PO) for pain management for Resident #111, who was in hospice care and had severe cognitive impairment. The resident's medical records showed orders for Acetaminophen and Morphine Sulfate, but there was no clarification on which medication should be administered first based on the pain level. The Charge Nurse acknowledged that the PRN Tylenol should be for mild pain and the PRN Morphine for moderate to severe pain, but this was not clarified with the doctor. Additionally, the order for Morphine was not separated for its dual indications of pain and shortness of breath (SOB). Resident #164, also in hospice care and non-responsive, had a similar issue with the PO for Morphine Sulfate, which was prescribed for both pain and SOB without separate indications. The resident's electronic Medication Administration Record (eMAR) showed multiple administrations of Morphine for pain, with pain levels documented between 5 and 8. The surveyor noted the concern of having a single order for two different indications, which was not addressed by the facility at the time of order entry. The facility's Pain Management Policy, reviewed in April 2024, outlines the need for assessing and documenting residents' pain and providing effective treatment. However, the policy did not include guidelines for sequencing medications based on pain levels, which contributed to the deficiencies observed. The Director of Nursing confirmed the lack of a policy for medication sequencing, and the surveyor's findings were communicated to the facility's management team, including the Licensed Nursing Home Administrator and the Regional Registered Nurse Consultant.
Non-Certified Nurse Aide Worked Beyond Allowed Period Without Proper Training
Penalty
Summary
The facility failed to ensure that a non-certified Nurse Aide (NA) did not continue to work beyond the specified 120 days without completing the required training and competency evaluation. This deficiency was identified during a review of the employee file for NA #1, who was hired on April 24, 2024. The file lacked proof of enrollment in a Nurse Aide Training and Competency Evaluation Program (NATCEP) or completion of the required 90 hours of state-approved training. Despite having a Certificate of Completion for a Certified Home Health Aide, there was no evidence of completion of a CNA program, and the NA continued to work at the facility beyond the allowed period without proper certification. The Human Resources Director (HRD) was unable to provide documentation showing that NA #1 was enrolled in a training program at the time of hire. The HRD later provided a Certificate of Completion for a CNA program, but it was dated September 20, 2023, indicating that the NA had not completed the necessary training before the hire date. Additionally, the facility lacked a clear policy or program for hiring non-certified NAs, contributing to the oversight. The survey team discussed these concerns with the facility's administrative team, but no further pertinent information was provided.
Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. The deficiency was identified when a surveyor observed a resident who was receiving Ropinirole, a medication approved for Parkinson's Disease and Restless Leg Syndrome (RLS), but the resident did not have a diagnosis for either condition. Instead, the medication was prescribed for 'Other Muscle Spasm,' which is not an FDA-approved indication for Ropinirole. The resident, who was admitted with diagnoses including congestive heart failure and anemia, reported symptoms of dizziness and headache, which were not addressed in the context of the medication's appropriateness. The surveyor's review of the resident's medical records and interviews with facility staff revealed that the medication was continued from a hospital order for muscle cramping, but the facility did not provide documentation justifying its use for the resident's condition. Attempts to contact the resident's physician for clarification were unsuccessful, and the facility's Director of Nursing later stated that the medication was continued due to difficulty in finding an appropriate diagnosis code. The physician eventually suggested a neurology consult and adjusted the medication's administration time, but no further pertinent information was provided by the facility regarding the medication's necessity.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored and labeled appropriately, as observed during a survey. On the third-floor north unit, a surveyor found nine loose medications of various sizes, shapes, and colors in the bottom drawer of a medication cart. The Licensed Practical Nurse (LPN) assigned to the cart confirmed that there should not be any loose medications and disposed of them. Similarly, on the second-floor south unit, the surveyor found two loose white medications in a medication cart, which the assigned LPN also confirmed should not be there and disposed of them. The Director of Nursing (DON) confirmed that there should not be any loose medications in the carts, as per the facility's Medication Storage Policy. The policy, revised in August 2024, mandates that all medications must be securely stored and labeled according to professional principles. A Consultant Pharmacist's inspection report from July 2024 had already noted the issue of loose pills in medication drawers, indicating a failure to address the problem. The survey team discussed these findings with the facility's leadership during an exit conference, but no additional information was provided by the facility.
Deficiency in Serving Food at Proper Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature during a lunch meal on one of the nursing units. This deficiency was identified through observations, interviews, and a review of facility documentation. During a Resident Council meeting, two residents expressed concerns that their hot food was cold by the time it reached them, attributing this issue to staffing problems and delays in tray delivery. Despite these complaints being raised in monthly food meetings, no changes were reported by the residents. On the day of the survey, the Food Service Director (FSD) was asked to place an extra test tray on the food cart destined for the third floor unit. The FSD admitted to conducting test trays only once or twice a week and typically performed these tests in the kitchen rather than on the unit. Upon arrival at the unit, the FSD was observed taking temperatures of the food on the test tray, which revealed that the chicken, spinach, and corn on the cob were below the required temperature of 135 degrees Fahrenheit, with the spinach being particularly low at 118 degrees. The FSD acknowledged that the hot food should have been hotter and attributed the temperature drop to the time taken to pass the trays. The Licensed Nursing Home Administrator (LNHA) was informed of the temperature issues, and although some residents interviewed after the meal expressed satisfaction with the food, the facility's policy on timely meal service was not adhered to. The policy required that food be delivered promptly to ensure it was served at the proper temperature, but the observed practice did not meet these standards, as evidenced by the test tray temperatures and resident complaints.
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Nursing homes near Elizabeth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabeth Nursing And Rehab Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Plaza Healthcare & Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Trinitas Hospital | 1.4 mi | ★★★★★ | 0 | 0 |
| Cornell Hall Care & Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Aristacare At Parkside | 3 mi | ★★★★★ | 0 | 0 |
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