Family Of Caring At Park Ridge Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Park Ridge, New Jersey.
- Location
- 120 Noyes Drive, Park Ridge, New Jersey 07656
- CMS Provider Number
- 315438
- Inspections on file
- 18
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Family Of Caring At Park Ridge Llc during CMS and state inspections, most recent first.
The facility did not properly follow TB testing and documentation protocols for three residents, including missing documentation of PPD administration, duplicate PPD administration due to communication lapses, and incomplete or unclear documentation of PPD test results, as confirmed by nursing staff and facility leadership.
A resident with multiple comorbidities developed hip blisters that were not properly assessed, reported to the physician, or documented according to orders. Nursing staff failed to consistently follow or document physician orders for wound care, and CNA logs showed missing documentation for essential care tasks. The physician was not informed of the wounds, and facility management could not clarify the origin of the skin impairments.
Two residents experienced accidents due to staff not following care plans and safety protocols: one resident fell from bed and sustained injuries after being left unattended during care that required a two-person assist, and another was injured during a Hoyer lift transfer when an untrained representative assisted a CNA, contrary to the care plan. In both cases, required documentation and adherence to protocols were lacking.
The facility failed to identify, assess, and implement timely interventions for residents experiencing significant weight loss. One resident lost 25.71% of their weight over six months without consistent monitoring or intervention. Another resident experienced a 10.03% weight loss in one month, with delayed interventions and missing physician orders for recommended supplements. A third resident lost 13.4% of their weight in one month, with no timely assessment or reweigh. These deficiencies highlight the facility's failure to adhere to its weight assessment and intervention policy.
The facility was found to have deficiencies in kitchen sanitation and food storage practices. Observations included unlabeled open bags of bread, a dented can of fruit mix in regular rotation, dust-covered fans in the walk-in refrigerator, and improper storage of boxes above the 18-inch limit in both the refrigerator and freezer. Additionally, Dietary Aides were seen wearing large hoop earrings, against the facility's hygiene policy.
The facility failed to store medications properly, with issues such as undated budesonide inhalant suspension, Novolog FlexPen, and Novolin R Pen, as well as incorrect refrigerator temperatures. Medication carts contained unidentified tablets, and the facility's policy lacked specific guidelines for dating and temperature maintenance.
The facility failed to ensure CNAs received the mandatory 12 hours of in-service training, with four CNAs not meeting the required hours. The deficiency was identified during a review of training records, and interviews revealed unclear responsibility for CNA education oversight after the previous ADON left. A QAPI initiative was started to address the issue, but the deficiency remained uncorrected at the time of the survey.
The facility failed to maintain a safe, clean, and homelike environment for three residents. Observations revealed missing privacy curtains, dusty fans, broken window shades, and unclean surfaces. Residents reported these issues had been known for months without resolution. The maintenance log showed no work orders for these concerns, indicating a lack of proper reporting and action.
The facility's laundry room was found to be in a deficient state, with personal items placed on clean laundry, used gloves on a washer, and dirty items on the floor. The Environmental Services Director acknowledged broken laundry equipment, contributing to overflowing dirty laundry in residents' rooms. The facility lacked a policy on laundry equipment maintenance, and grievances related to laundry issues were confirmed by the Licensed Nursing Home Administrator.
The facility failed to provide meals in a dignified manner, with two residents at the same table receiving meals 26 minutes apart. Additionally, a CNAS assisted residents with eating without performing hand hygiene, despite facility policy requiring it. Unopened hand wipes on trays indicated inconsistent hand hygiene practices.
The facility failed to transmit completed MDS assessments within the required timeframe for two residents and one additional resident. One resident had diagnoses including muscle weakness and hypertension, while another had dementia and anxiety. Their assessments were completed but not transmitted. A third resident's assessment was transmitted late, as confirmed by the Regional MDS Coordinator. The facility's leadership was informed, but no further information was provided.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in medical records. A resident's pressure ulcer was not documented correctly, another was inaccurately recorded as using a walker, a third had discrepancies in cognitive and communication abilities, and a fourth had a miscoded discharge status. Staff confirmed these errors.
A facility failed to update a resident's care plan, leading to inaccuracies regarding the resident's elopement risk and code status. The resident, with severe cognitive impairment and multiple medical conditions, was observed using an air mattress not reflected in the care plan. The care plan inaccurately listed the resident as an elopement risk with a wander guard, despite being non-ambulatory, and incorrectly indicated the resident was full code, while a physician's order confirmed DNR status. The DON acknowledged the care plan was not updated to reflect current care.
The facility failed to provide necessary discharge documentation for two residents discharged to the community. One resident, with conditions like muscle weakness and hypertension, lacked a physician discharge order, summary, and care plan. Another resident, with a cervical fracture and metabolic encephalopathy, also lacked these documents, with an incomplete discharge summary. The DON confirmed these deficiencies.
The facility failed to document and manage a surgical wound for a resident, who had 15 staples on their abdomen, and did not ensure follow-up care. Additionally, the facility did not set an air mattress according to another resident's weight, lacking a policy for checking settings. Interviews revealed inadequate documentation and communication regarding these issues.
A resident with severe cognitive impairment and a history of falls experienced another fall, but the facility failed to update the care plan with a new intervention to prevent further incidents. Despite the facility's policy requiring new interventions after recurrent falls, the care plan was only revised after surveyor inquiry, indicating a lapse in adherence to policy.
A facility failed to obtain orders and develop care plans for residents with indwelling catheters on enhanced barrier precautions. One resident's catheter bag was observed touching the floor, which was acknowledged as inappropriate by an LPN. The deficiencies were confirmed by the DON and discussed with facility leadership.
The facility failed to adhere to physician's orders for oxygen administration for two residents, leading to a repeat deficiency. One resident with ataxia and other conditions was observed with an O2 setting of 1.5 LPM instead of the prescribed 2 LPM. Another resident with heart failure had an O2 setting between 1.5 and 2 LPM, contrary to the order for 2 LPM. Staff confirmed the discrepancies and adjusted the settings, acknowledging potential misreading of the gauge.
A facility failed to complete Hemodialysis Communication Records and did not implement a recommended fluid restriction for a resident receiving dialysis. The resident's HCRs were incomplete for several days, and the facility did not follow the dialysis center's recommendation for a 1000 ml/day fluid restriction. Staff were unaware of the restriction, and the physician preferred the resident to eat and drink without restriction.
A facility failed to ensure regular physician visits and documentation of progress notes for a resident with Alzheimer's and dementia, as required by policy. The resident's records showed only two documented visits over several months, contrary to the policy of visits every 60 days after the initial 90-day period. Facility leadership acknowledged the issue and confirmed reassignment of some residents to other physicians.
The facility did not ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) for two days during the survey. The staffing coordinator was responsible for updating and posting the report but did not work on weekends, leading to a lack of clarity on who should post the report during those times. The LNHA confirmed the expectation for daily postings but acknowledged the absence of a facility policy and responsibility for weekend postings.
The facility did not offer bedtime snacks to residents, as reported by five residents during a Resident Council meeting. Despite a policy requiring nursing staff to offer snacks, there was no system or documentation to ensure this practice. The Licensed Nursing Home Administrator acknowledged the requirement but could not provide evidence of compliance.
The facility failed to follow proper hand hygiene and PPE practices, with staff observed wearing masks incorrectly and not performing hand hygiene after glove removal. A nebulizer machine was found soiled and improperly stored on the floor. Facility policies lacked specific guidance on mask usage.
A facility failed to ensure a resident's call device was within reach, resulting in a repeat deficiency. The call bell was observed tied to side rails and later found on the floor, both times out of the resident's reach. The resident had a history of falls and an intact cognitive status. The facility's policy requires call lights to be within easy reach, but this was not adhered to, as confirmed by staff.
The facility failed to notify CMS and receive authorization for a change in facility name, as required by 42 CFR 424.516. The surveyor observed that the facility's signage and documents did not match the approved CMS name. The LNHA was unaware of the issue, and the facility had not filed the necessary 855B form with CMS, as the name change was still awaiting state approval.
Failure to Follow TB Testing and Documentation Protocols
Penalty
Summary
The facility failed to follow appropriate tuberculosis (TB) testing and documentation protocols for three residents, as required by professional standards and the facility's own policies. For one resident, the electronic Medication Administration Record (eMAR) entry for the administration of the Purified Protein Derivative (PPD) solution was left unsigned and blank, with no documentation in the progress notes to indicate whether the PPD was administered. The Director of Nursing (DON) confirmed that it was expected for eMAR entries to be signed and not left blank, and the facility's policy required TB screening for all residents, though it did not address documentation specifics. Another resident received two PPD administrations on consecutive days due to a lack of communication and incomplete documentation. The admitting nurse failed to document the initial administration, leading the Assistant DON to instruct another nurse to administer the PPD again the following day. This resulted in a duplicate administration, which was only discovered after the resident's representative notified the facility. The involved staff confirmed the sequence of events and acknowledged the error. For a third resident, the records showed that the first step of the two-step PPD test was administered, but there was no documented evidence that the result was read or that it was negative before proceeding to the second step. Additionally, the documentation for the reading of the second step was unclear, with a code used that did not have a corresponding explanation in the facility's chart codes. Interviews with nursing staff revealed uncertainty about the correct procedures when a resident is hospitalized during the testing period, and the DON acknowledged the required protocol for reading and documenting PPD results.
Failure to Address and Document Skin Impairments and Physician Orders
Penalty
Summary
The facility failed to ensure that skin conditions and impairments for a resident were appropriately addressed, that physician orders for skin impairments were obtained and followed, and that reasons for not following orders were documented. The resident in question had a history of colon cancer, muscle weakness, and difficulty walking, and was noted to be frequently incontinent. Initial skin assessments documented pitting edema in the lower extremities and a surgical drain, but no other skin impairments. However, subsequent progress notes revealed the presence of a fluid-filled blister on the right hip, which was cleaned but not reported to the physician for further assessment or orders. Later, a ruptured blister was found on the left hip, for which the physician was notified and an order was received and followed, but there was no documentation explaining why the previous order for a different treatment was not followed, nor was there evidence that the physician was notified of the change or the status of the right hip blister. Further review of the treatment administration records showed inconsistencies in the documentation and execution of physician orders related to skin assessments and wound care. Orders for regular skin assessments and specific wound treatments were not consistently documented as completed, and there was no explanation for deviations from prescribed care. Interviews with nursing staff revealed a lack of recall regarding the resident and the events in question, and the physician stated he was not informed about the hip blisters, as there was no documentation or communication from the facility regarding these wounds. Additionally, the Certified Nursing Aide (CNA) accountability logs for the relevant period contained multiple blanks for essential care tasks, including documentation of interventions related to skin care, repositioning, and hygiene. The CNA assigned to the resident during the period in question did not sign the accountability log on several days and could not recall the resident or the events. Facility management was unable to clarify whether the hip blisters were facility-acquired wounds, and there was no evidence that the required assessments, notifications, and documentation were completed as per facility policy and state regulations.
Failure to Follow Care Plans and Safety Protocols During Resident Transfers and Bed Mobility
Penalty
Summary
The facility failed to follow care plans and implement appropriate safety precautions for two residents, resulting in deficiencies related to accident hazards and supervision. In the first case, a resident with multiple diagnoses including lumbar spinal cord lesion, morbid obesity, and chronic pain, was care planned for two-person assist with bed mobility and had interventions for fall risk. Despite this, a CNA provided care alone, turned the resident to the side, and left the resident unattended while retrieving a towel. The resident subsequently fell from the bed, sustaining multiple injuries including bruising, skin tears, and bleeding from the mouth. Documentation at the time of the incident was incomplete, with no progress note from the night shift nurse, and the incident was only recorded in a separate risk management report, not in the resident's medical record. In the second case, another resident with right hemiplegia and moderate cognitive impairment required total care and was care planned for two-person Hoyer lift transfers. During a transfer, a CNA allowed the resident's representative, who had not been trained in Hoyer lift use, to assist with the transfer. During this process, the Hoyer lift pad swung and the holder grazed the resident's forehead. The incident was reported, and neuro checks were initiated, but there was no evidence that the representative had received any education or training on safe transfer procedures, as required by the care plan and facility policy. Both incidents demonstrate failures to adhere to established care plans and protocols for resident safety, including the requirement for two-person assistance during bed mobility and transfers, and ensuring that only trained personnel participate in resident care activities. The lack of proper documentation and deviation from care plans directly contributed to the occurrence of accidents and potential harm to the residents involved.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately identify, assess, and implement interventions for residents experiencing significant weight loss. Resident #35 experienced a significant weight loss of 25.71% over six months, with no documented weights for several months and no timely interventions. Despite being on a diuretic, which could contribute to weight loss, the facility did not consistently monitor the resident's weight or nutritional intake, leading to a lack of timely response to the resident's nutritional needs. Resident #92 also experienced a significant weight loss of 10.03% in one month, yet interventions were delayed by 48 days. The resident's nutritional needs were not adequately addressed, as there were no physician orders for recommended supplements like super cereal and super mash. The facility's failure to promptly address the resident's weight loss and implement necessary dietary interventions contributed to the deficiency. Resident #3 experienced a significant weight loss of 13.4% in one month, yet there was no Nutrition/Dietary Note addressing this loss or a reweigh to confirm the weight change. The resident's weight loss was attributed to multiple hospitalizations and comorbidities, but the facility did not adequately monitor or document the resident's nutritional status. The lack of timely assessment and intervention for these residents highlights the facility's failure to adhere to its weight assessment and intervention policy.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could potentially lead to foodborne illness. During a kitchen tour, the surveyor observed several deficiencies. Five open bags of bread were found without open and use-by labels, contrary to the facility's policy requiring all opened items to be labeled. Additionally, a large dent was found in a can of fruit mix, which was still in regular rotation with other canned items, despite the policy that dented cans should be removed from regular use. In the walk-in refrigerator, the fans were covered with a black dust-like substance, and six boxes were stored above the 18-inch limit from the ceiling. Similarly, in the walk-in freezer, twelve boxes were stored above the 18-inch limit. Furthermore, three Dietary Aides were observed wearing large hoop earrings, which is against the facility's policy on employee hygiene for food safety. The facility's policies, revised in October 2024, clearly state the requirements for labeling, food storage, kitchen sanitation, and employee hygiene. The Labeling and Dating policy mandates that all food products be dated upon receipt, preparation, and opening. The Food Storage policy requires food to be stored at least 6 inches above the floor and 18 inches from the ceiling. The General Sanitation of Kitchen policy emphasizes maintaining kitchen sanitation through a comprehensive cleaning schedule. The Employee Hygiene for Food Safety policy restricts jewelry to a minimum, allowing only plain band rings and watches. Despite these policies, the facility's practices did not align with the established standards, as evidenced by the observations made during the survey.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications according to manufacturer specifications and standards of practice, as observed by the surveyor. During the inspection of medication carts and refrigerators on the 2nd and 3rd floors, several deficiencies were noted. On the 3 West medication cart, a foil package of budesonide inhalant suspension lacked a date indicating when it was opened, and a Novolog FlexPen and three unidentified tablets were found without proper labeling. The refrigerator in the 3rd-floor medication storage room was observed to have a temperature of 27 degrees Fahrenheit, which is outside the accepted range of 36 to 46 degrees Fahrenheit, despite the temperature log indicating a different reading. On the 2nd floor, similar issues were identified. A Novolin R Pen in the medication cart was not dated, and the refrigerator in the medication storage room had two thermometers showing conflicting temperatures, one of which was outside the acceptable range. Additionally, on the 3 East medication cart, two foil packages of ipratropium/albuterol vials were found without dates, and two unidentified tablets were present. These observations were verified with the nursing staff, who confirmed the lack of proper dating and identification of medications. The facility's policy on medication storage, revised in June 2024, was reviewed and found lacking in specific guidelines for dating opened packaging of nebulizer solutions, insulin delivery systems, and temperature maintenance of medication refrigerators. The surveyor confirmed with the Consultant Pharmacist that medications should be dated and stored within the correct temperature range, and that no loose medications should be present in the carts.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the mandatory 12 hours of in-service training, as required. This deficiency was identified during a review of the in-service education records for five randomly selected CNAs. Four of these CNAs did not meet the required training hours. Specifically, CNA #1 had only 1 hour and 50 minutes, CNA #2 had 5 hours and 55 minutes, CNA #3 had 8 hours and 20 minutes, and CNA #4 also had 8 hours and 20 minutes of training. The facility's policy mandates that CNAs demonstrate competency in skills necessary for resident care, including abuse prevention, dementia management, and infection control. Interviews with facility staff revealed that the responsibility for overseeing CNA education was not clearly managed after the previous Assistant Director of Nursing (ADON) left in August 2024. The Assistant Administrator (AA) and the Licensed Nursing Home Administrator (LNHA) acknowledged the deficiency, noting that a Quality Assurance Performance Improvement (QAPI) initiative was started in December 2024 to address the issue. However, at the time of the survey, the deficiency remained uncorrected, as evidenced by the lack of additional information or corrective actions provided by the facility.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents. During an observation, it was noted that one resident's room was missing a privacy curtain, and a fan on the bedside table was covered in dust. Another resident's room had broken window shades, overbed tables with splattered substances, a broken soap dispenser, and floors with dark stains. The Unit Manager confirmed these findings, and the Housekeeping Director acknowledged the issues. Residents reported that the facility was aware of these problems for months but had not addressed them. Additionally, another room had walls with brown substances splattered and broken window shades. The Housekeeping Director confirmed these findings, noting that the resident often threw drinks on the wall. A review of the maintenance log revealed no work orders for these issues, indicating a lack of proper reporting and resolution of maintenance concerns. The facility's policies on cleaning and maintenance reporting were reviewed, highlighting the expectation for regular cleaning and prompt maintenance action, which were not followed in these instances.
Deficient Laundry Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry room, as observed by surveyors. During a tour of the laundry area, personal cellphones were found on top of clean folded clothing, and a radio/cassette recorder was placed on clean folded linens and incontinent pads. Additionally, used gloves were found on top of a personal clothing washer, and a white gown, face towel, and linen were observed on the floor next to a washer. The floor had an accumulation of grayish and brownish substances, indicating a lack of cleanliness. The Environmental Services Director (ESD) acknowledged the issues, stating that the personal items should not have been near clean laundry and that the used gloves should have been discarded. The ESD also confirmed that some laundry equipment was broken, contributing to concerns about overflowing dirty laundry in residents' rooms. The Licensed Nursing Home Administrator (LNHA) confirmed grievances related to overflowing laundry and acknowledged that staff should have reported such issues. The facility lacked a policy on laundry equipment maintenance, and repairs had been ongoing for several months. The LNHA admitted that older equipment was being fixed due to financial limitations, but new machines were on order. The facility's policy on handling soiled laundry was not being followed, as evidenced by the presence of dirty items on the floor and the improper handling of clean and soiled items.
Failure to Provide Dignified Meal Service and Ensure Hand Hygiene
Penalty
Summary
The facility failed to provide meals in a dignified and homelike manner for two residents in the recreation dining area. The surveyor observed that meals were not served simultaneously to residents seated at the same table, with one resident receiving their meal 26 minutes after the other. This delay in meal service was noted during the lunch meal pass, where food trays were delivered from multiple food trucks at different times, resulting in residents at the same table being served at different times. Additionally, there was a lack of hand hygiene observed during meal service. A Certified Nursing Aide Student was seen assisting residents with eating without performing hand hygiene for the residents or themselves. The facility's policy requires that residents be reminded of meals, assisted with hand hygiene, and served together when feasible. However, the surveyor noted unopened hand wipes on meal trays, indicating that hand hygiene was not consistently practiced.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit the completed Minimum Data Set (MDS) assessments within the required fourteen days for two residents, identified as Residents #110 and #155, and one additional resident, identified as Resident #589. For Resident #110, the Admission Record indicated diagnoses including muscle weakness, hypertension, and adjustment disorder with depressed mood. The Discharge Return Not Anticipated (DRNA) MDS was completed but not transmitted. Similarly, Resident #155, who had diagnoses including muscle weakness, dementia, and anxiety, also had a completed DRNA MDS that was not transmitted. The MDS/Lead Registered Nurse (MDS/LRN) was unable to initially confirm the transmission timeline and later acknowledged the oversight. For Resident #589, the Discharge Return Anticipated (DRA) MDS was completed but not transmitted until after the required period, as confirmed by the Final Validation Report. The Regional MDS Coordinator verified the late transmission. The surveyor's interviews and record reviews highlighted these deficiencies, and the facility's leadership was informed during meetings, but no additional information was provided by the facility to address these concerns.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their medical records. Resident #38 was observed with a pressure ulcer, which was not accurately documented in the MDS. The resident's medical records indicated the presence of pressure ulcers upon readmission, but the MDS did not reflect this accurately, leading to a coding error. The MDS/Lead Registered Nurse confirmed the error and stated that the MDS would be modified. Resident #118 was observed using an air mattress, and their medical records indicated severe cognitive impairment. However, the MDS inaccurately documented the resident as using a walker for mobility, despite the resident being non-ambulatory. The Licensed Practical Nurse confirmed that the resident does not ambulate, and the MDS/Lead Registered Nurse acknowledged the coding error. Resident #176's MDS contained discrepancies regarding cognitive patterns and communication abilities. The MDS inaccurately indicated that the resident participated in discharge planning, while the medical records showed that the responsible party was interviewed instead. Additionally, the communication status was miscoded. Resident #188's discharge MDS was also miscoded, indicating an unplanned discharge to home, while the resident was actually taken to the hospital by a family member. The Regional MDS/Registered Nurse confirmed the miscoding.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident, identified as Resident #118, as required. The deficiency was identified during a survey when the surveyor observed the resident using an air mattress, which was not reflected in the care plan. The resident was admitted with multiple medical diagnoses, including Alzheimer's Disease, Type 2 Diabetes Mellitus, and Acute Kidney Failure, and had severely impaired cognition. The care plan inaccurately listed the resident as an elopement risk with a wander guard, despite the resident being non-ambulatory and not having a wander guard. Additionally, the care plan incorrectly indicated the resident was full code, while a physician's order confirmed the resident was DNR. The Licensed Practical Nurse caring for the resident confirmed that the resident does not ambulate and does not have a wander guard. The Director of Nursing later acknowledged that the care plan was not updated to reflect the current care being provided, confirming the resident was not at high risk for elopement and was indeed a DNR. The facility's policy requires the Care Planning/Interdisciplinary Team to review and update care plans, which was not adhered to in this case.
Failure to Provide Required Discharge Documentation for Residents
Penalty
Summary
The facility failed to ensure that residents discharged to the community had the necessary discharge documentation, including a discharge order, discharge summary, and care plan. This deficiency was identified for two residents. The first resident was admitted with diagnoses such as muscle weakness, hypertension, and adjustment disorder with depressed mood. Upon review, it was found that there was no physician order for discharge, no discharge summary from the physician, and no discharge care plan initiated for this resident. Similarly, the second resident, who had diagnoses including a displaced fracture of the cervical vertebra, metabolic encephalopathy, and a benign kidney neoplasm, was also discharged without the required documentation. The review revealed no physician order for discharge, an incomplete discharge summary, and no discharge care plan. The Director of Nursing confirmed the absence of these documents and acknowledged the incomplete discharge summary, which lacked information about the resident's stay and status.
Deficiencies in Surgical Wound Management and Air Mattress Settings
Penalty
Summary
The facility failed to properly document and manage a surgical wound for a resident, identified as Resident #119, upon their admission. The resident was admitted with several medical conditions, including syncope, osteoarthritis, and chronic kidney disease, and had undergone exploratory laparoscopic surgery with drainage of an abscess. Despite the presence of 15 staples on the resident's abdomen, there was no documentation in the admission assessment or care plan addressing the surgical site. The staff did not obtain a physician's order for the assessment, follow-up, or removal of the staples, and there was no consistent monitoring or documentation of the surgical site. The deficiency was further compounded by the lack of follow-up for the removal of the staples. The Unit Manager and Licensed Practical Nurse were aware of the staples but failed to ensure the resident was transported for a follow-up appointment with the surgeon. The resident's representative was unable to transport the resident, and there was no further action taken by the facility to address the situation. Interviews with the staff, including the Director of Nursing, revealed that the facility did not have adequate documentation or communication with the physician regarding the surgical site and the necessary follow-up care. Additionally, the facility failed to properly set an air mattress for another resident, identified as Resident #118, according to their weight. The air mattress was set at 450 lbs, while the resident's actual weight was 92 lbs. The Licensed Practical Nurse assigned to the resident acknowledged the incorrect setting and adjusted it accordingly. However, the facility lacked a specific policy on how and when to check the air mattress settings, leading to a lack of accountability and proper support for the resident.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement and document a new intervention in the care plan of a resident after a fall, which was necessary to prevent further falls. The resident, who had a history of falls and was diagnosed with conditions such as hemiplegia, hemiparesis, hypertension, and vascular dementia, experienced a fall in October 2024. Despite the resident's severely impaired cognition and previous falls, the facility did not update the care plan with a new intervention following this incident. The resident's care plan included interventions such as encouraging the use of a call light and frequent rounding, but these were not updated after the October fall. The facility's policy required that if falls recur despite initial interventions, additional or different interventions should be implemented. However, the care plan was only revised after the surveyor's inquiry, indicating a lapse in the facility's adherence to its own policy. Interviews with the facility's staff, including the Licensed Nursing Home Administrator and the Director of Nursing, revealed that the new intervention was missed and only entered into the care plan after the surveyor's inquiry. The facility did not provide an incident report or investigation for the October fall until prompted by the surveyor, further highlighting the deficiency in managing the resident's fall risk effectively.
Deficiencies in Catheter Care and Care Planning
Penalty
Summary
The facility failed to obtain an order and develop a care plan for a resident with an indwelling catheter who was placed on enhanced barrier precautions (EBP). Resident #40, who had intact cognition, was observed with a urinary catheter in a privacy bag and a sign indicating EBP outside their room. However, their order summary report did not include an order for EBP, and their care plan lacked a focused area and interventions related to EBP. The Director of Nursing confirmed that an order and care plan should have been in place. Another deficiency was noted for Resident #115, who had severely impaired cognition and an indwelling catheter. The resident's care plan did not reflect the current plan of care for the use of the indwelling catheter, as confirmed by the Director of Nursing. This oversight was identified during a review of the resident's medical record and care plan. Additionally, Resident #289 was observed with a urinary catheter drainage bag touching the floor, which was acknowledged by a Licensed Practical Nurse as inappropriate. The resident had severely impaired cognition and multiple medical diagnoses, including retention of urine. The facility's failure to ensure the catheter bag was properly affixed to the bed was discussed with the facility's leadership, but no further information was provided.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow a Physician's Order for respiratory care for two residents, leading to a repeat deficiency. Resident #58 was observed with an oxygen (O2) nasal cannula set at 1.5 Liters Per Minute (LPM), despite a physician's order for 2 LPM. This discrepancy was confirmed by a Licensed Practical Nurse (LPN), who was unable to explain why the O2 was not set correctly. The resident had been admitted with diagnoses including ataxia, hyperlipidemia, bipolar disorder, and hypertension, and had severely impaired cognition as indicated by a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS). Similarly, Resident #105 was observed with an O2 setting between 1.5 LPM and 2 LPM, contrary to the physician's order for 2 LPM. The resident had been admitted with end-stage heart failure, acute congestive heart failure, and pulmonary hypertension, and also had severely impaired cognition with a BIMS score of 3 out of 15. The Unit Manager and an LPN confirmed the incorrect setting and adjusted it to the correct level. The Director of Nursing (DON) acknowledged that staff might be misreading the gauge due to viewing it from a down angle. The facility's Oxygen Administration Policy, revised in 2010, requires verification of a physician's order for O2 administration, which was not adhered to in these cases.
Incomplete Dialysis Records and Fluid Restriction Oversight
Penalty
Summary
The facility failed to provide appropriate dialysis care for Resident #76 by not completing the Hemodialysis Communication Record (HCR) consistently and not adhering to a recommended fluid restriction. The HCRs for Resident #76 were incomplete for 7 out of 16 days, with missing pre and post-dialysis treatment sections. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed that the HCRs were not filled out completely, which was against the facility's policy that required all sections of the HCR to be completed. Additionally, the facility did not implement a fluid restriction for Resident #76 as recommended by the dialysis center. The resident's previous facility had an order for a 1000 ml/day fluid restriction, which was not continued at the current facility. The facility's Registered Dietician (RD) and the resident's physician were unaware of the fluid restriction recommendation, and the physician expressed a preference for the resident to eat and drink without restriction, contrary to the dialysis center's recommendation. The surveyor's review of the facility's records and interviews with staff revealed a lack of communication and documentation regarding the fluid restriction. The facility's Care of the Resident Receiving Dialysis Treatments Policy emphasized the importance of monitoring for fluid overload and completing the dialysis communication form, but these procedures were not followed for Resident #76, leading to the deficiency.
Failure to Conduct Regular Physician Visits and Document Progress Notes
Penalty
Summary
The facility failed to ensure that the responsible physician conducted face-to-face visits and wrote progress notes at least once every sixty days for a resident, as required by the facility's policy and procedure. This deficiency was identified for a resident who was admitted with diagnoses including Alzheimer's disease, unspecified osteoarthritis, and unspecified dementia. The resident's medical records revealed that the physician's progress notes were only documented on two occasions, with significant gaps between visits, contrary to the facility's policy that mandates visits every 60 days after the initial 90-day period. The surveyor's review of the facility's policy on physician services indicated that the attending physician is responsible for conducting routine visits and maintaining progress notes in accordance with OBRA regulations and facility policy. However, the records showed a lack of documentation for the required visits, with only two progress notes recorded over several months. The facility's leadership, including the Licensed Nursing Home Administrator and Director of Nursing, acknowledged the issue and confirmed that some residents had been reassigned to other physicians due to these concerns.
Failure to Post Daily Staffing Reports
Penalty
Summary
The facility failed to ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) at the beginning of the current shift for two out of five days during the survey. On two separate occasions, surveyors observed that the NHRCSR was not updated to reflect the current date and shift. On January 6th, the report posted was dated December 16th, and on January 7th, the report was dated January 5th. The staffing coordinator (SC) was responsible for updating and posting the NHRCSR but did not work on weekends, and no one else was assigned to this task during those days. The SC explained that she updated the staffing data upon arrival at work and posted the report for the next shift at 3:00 PM. However, there was confusion about who was responsible for posting the report for the night shift and on weekends. The SC was not aware of the regulations regarding the posting of the NHRCSR, and there was no facility policy in place to guide this process. The Licensed Nursing Home Administrator (LNHA) confirmed that the expectation was for the NHRCSR to be posted for the current date, but acknowledged the lack of clarity and responsibility for weekend postings.
Failure to Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to ensure that bedtime (HS) snacks were offered to residents, as identified during a Resident Council group meeting with five alert and oriented residents. All five residents reported that HS snacks were not offered, despite expressing a desire for them. A review of the Resident Council meeting minutes from October 2024 through December 2024 showed no mention of HS snacks. During a meeting with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and Director of Nursing (DON), the LNHA acknowledged that HS snacks should be offered but could not provide evidence of accountability for this practice. The facility's policy, reviewed in June 2024, stated that nursing staff are responsible for offering snacks between meals and at HS, but there was no documented evidence or system in place to ensure compliance with this policy.
Improper PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) practices, as observed by surveyors. On multiple occasions, staff members, including three housekeepers and a certified nursing aide (CNA), were seen wearing surgical masks improperly, with masks not covering their mouths and noses. The CNA was also observed removing gloves inappropriately in the hallway without performing hand hygiene afterward. Despite being educated previously, these staff members continued to demonstrate improper PPE usage, which was acknowledged by the facility's administration. Additionally, the facility did not ensure the proper storage and cleanliness of medical equipment, specifically a nebulizer machine. During an initial tour, a nebulizer machine was found with a black substance around it and placed on the floor next to a garbage can in a resident's room. The Licensed Practical Nurse (LPN) present was unaware of the machine's ownership and confirmed that it was soiled and improperly stored. The facility's policies on PPE and hand hygiene were reviewed and found lacking in specific guidance on the proper wearing of face masks. The facility's administration was informed of these deficiencies, but no additional information or corrective measures were provided during the survey process.
Resident Call Device Out of Reach
Penalty
Summary
The facility failed to ensure that resident call devices were within reach for a resident, leading to a repeat deficiency. During an observation, a surveyor found the call bell tied to the side rails, out of reach for the resident. The LPN acknowledged that the call device should be within the resident's reach. The resident, who had an intact cognitive status with a BIMS score of 15 out of 15, was admitted with a non-displaced fracture of the anterior wall of the left acetabulum and a history of falls. The care plan for the resident included interventions to ensure the call light was within reach due to a risk for falls related to impaired balance. On a subsequent observation, the call bell was found on the floor, again out of the resident's reach. An LPN confirmed that the call bell should not be on the floor and clipped it to the resident's bedsheet. The Licensed Nursing Home Administrator stated that the call bell should be clipped to the bed sheets to prevent it from falling on the floor and should not be tied to the side rails. The facility's policy on answering the call light, revised in October 2024, specifies that the call light should be within easy reach when the resident is in bed or confined to a chair.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify CMS and receive authorization for a change in facility name, as required by 42 CFR 424.516. This deficiency was identified when a surveyor observed that the signage outside the facility did not match the approved CMS facility name. Further review of facility documents and policies revealed inconsistencies with the approved CMS facility name. The Licensed Nursing Home Administrator (LNHA) was unaware of the issue and stated that the facility was now managed by a new company. However, the application for the name change was still awaiting state approval, and the facility had not filed the necessary 855B form with CMS. During discussions with the LNHA, Assistant Administrator, and Director of Nursing, it was confirmed that the facility's license issued by the New Jersey Department of Health still reflected the approved CMS facility name, not the new company name. The LNHA explained that they were waiting for state approval before applying to CMS for the name change. Despite these explanations, the facility did not provide any further pertinent information during the exit conference with the survey team.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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