Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountainview Care Center during CMS and state inspections, most recent first.
Controlled substance management was deficient when the ADS showed unresolved count discrepancies for Ambien, Klonopin, Percocet, and Ultram, and the DON described them as clerical errors tied to incorrect count entry by nurses. The consultant pharmacist was not notified of the discrepancies, and documentation for some investigations was incomplete. Surveyors also found an opened bottle of liquid morphine sulfate on a med cart even though the resident’s controlled drug record showed it had not been administered, and the bottle and box were not dated when opened.
Wet-Nested Pans Stored on Clean Rack: The surveyor observed seven wet pans stacked together on the dried pot and pan storage rack, with liquid dripping from the stack and the pans visibly wet inside and out. The FSD acknowledged the pans were improperly wet nested and said they should have stayed on the drying rack until completely dry before being stored. The LNHA also acknowledged that wet nesting was not allowed because bacteria could grow.
Failure to timely report an allegation of verbal abuse to NJDOH. A resident with depression, anxiety, alcohol abuse, and a BIMS of 15 alleged that the LNHA called them names after a dispute about entering the nourishment room; the resident later rescinded the allegation when questioned. The SW notified the DON, ADON, and LNHA, but the report was not made within the required 2-hour timeframe, and the LNHA acknowledged the delay.
Delayed Significant Change Assessment for Hospice Election: A resident with cancer elected hospice, but the facility did not complete the SCSA within the required 14-calendar-day timeframe. The MDSC stated she did not know the assessment had to be completed within 14 days, and the DON believed they had 2 weeks to complete a significant change for hospice. The facility policy listed the MDS completion date as the 14th calendar day after determination of significant change in status.
A resident with COPD and morbid obesity was observed with an oxygen concentrator and nasal cannula in the room, and stated that oxygen was worn in bed at night. The chart included care plan references to oxygen use for SOB and lying flat, but the EMR had no current physician order for oxygen therapy. An LPN, UM/LPN, and DON all confirmed there was no order for PRN nighttime oxygen, despite the facility policy requiring a physician order before oxygen administration.
The facility's Medical Director failed to attend two of five reviewed quarterly QAPI meetings. Surveyors found no MD signature on the QAPI sign-in sheets for two quarterly meetings, and the LNHA acknowledged there was no evidence the MD attended either meeting. The facility's QAPI policy listed department heads as committee members but did not list the MD as a QAPI member.
A resident on EBP for a suprapubic catheter was observed receiving care from a hospice aide who was not wearing a gown despite an EBP sign and PPE bin being posted outside the room. The resident had severe cognitive impairment, was dependent for most care, and had diagnoses including Alzheimer’s disease, anemia, and right heart failure. Interviews with the LPN/UM, CNA, hospice clinical director, and DON confirmed that hospice staff were expected to follow EBP and wear PPE during direct care, and the facility policy required a gown for relevant resident interactions.
A resident with multiple medical conditions, including obstructive sleep apnea, did not have physician's orders in place for weekly CPAP tubing changes, machine cleaning, or daily filling of the water chamber with distilled water. Although staff reported performing these tasks, there was no documentation or orders to support this, as confirmed by interviews with the LPN, Unit Manager, and DON. Facility policy required such orders, but they were not present in the resident's record.
A resident with severe cognitive impairment was verbally abused and videotaped by a housekeeping aide during a medical appointment. The aide yelled and cursed at the resident, causing distress and confusion. The ENT staff intervened, and the facility's investigation confirmed the abuse, highlighting a failure in implementing the abuse prevention policy.
A facility failed to thoroughly investigate an incident where a Housekeeping Aide verbally abused and videotaped a resident with severe cognitive impairment during a doctor's appointment. The resident, diagnosed with bipolar disorder and schizoaffective disorder, appeared visibly upset and confused. The facility's investigation was inadequate, lacking interviews with all witnesses, including other residents escorted by the aide. This failure resulted in an Immediate Jeopardy situation.
The facility breached confidentiality by leaving residents' EMRs open during medication administration, exposing private information to potential onlookers. Both an RN and an LPN acknowledged the oversight, and the DON confirmed it violated HIPAA and resident privacy rights.
A facility failed to attempt alternative measures before installing bedrails for a resident with hemiplegia and hemiparesis. The resident's care plan required a left bedrail for safety, but no alternatives were explored prior to its use. Staff confirmed that assessments were completed without considering other options, and the DON acknowledged this oversight.
A resident with a DNR order was mistakenly given CPR due to the facility's failure to maintain a complete medical record. The resident's POLST form was not included in the official records, leading to the resident being treated as a full code. The Social Service Director kept relevant documentation in a separate file, unaware that it should have been part of the medical record.
A resident with severe cognitive impairment was video recorded without consent by a Housekeeping Aide at an ENT doctor's office. The resident appeared upset and confused, believing they had been kidnapped. The transport driver continued recording after taking the aide's phone. ENT staff witnessed the aide yelling and belittling the resident. The DON confirmed staff were trained not to record residents, indicating a breach of the resident's rights to dignity and privacy.
A resident with severe cognitive impairment was improperly restrained with a wheelchair lap seatbelt during a visit to an ENT office, without proper documentation or physician orders. The facility's policy requires a physician's written order for restraints, which was not obtained, leading to a violation of regulatory requirements.
A resident with severe cognitive impairment was allegedly sexually assaulted by an unidentified staff member. The facility was informed of the allegation by the ombudsman but failed to report it to the NJDOH or police, as required by their policy. The Director of Nursing believed reporting was unnecessary since the ombudsman had investigated and closed the case.
The facility failed to securely store medications during administration, as observed in two incidents. An RN left a medication cart unlocked and a vial of insulin unsecured, while an LPN also left a cart unlocked without supervision. The DON confirmed the policy requiring carts to be locked when out of sight.
A resident with multiple diagnoses, including COPD and diabetes, was transferred to a hospital for an emergency without the required New Jersey Universal Transfer Form (NJUTF) in their medical record. The Director of Nursing confirmed the absence of the NJUTF, which is against the facility's policy for emergency transfers.
Controlled Substance Discrepancies and Morphine Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a system was in place to document and resolve controlled substance discrepancies for Ambien, Klonopin, Percocet, and Ultram stored in the Automated Dispensing System (ADS). A discrepancy report initially provided to the surveyor listed these medications but did not include dates or resident names. When a dated report was later obtained, it showed multiple discrepancies, including minus and plus counts for the same controlled medications over several dates. The DON stated the discrepancies were due to nurses misunderstanding how to enter counts into the machine and described them as clerical errors. The DON told the surveyor that she had spoken with the nurses involved, reviewed which resident each medication had been dispensed for, and provided education, but the surveyor requested records of the individual education and investigations to rule out diversion. The facility’s policy stated that the DNS shall investigate narcotics reconciliation discrepancies to determine the cause and identify responsible parties and provide a written report to the Administrator. When the survey team requested documentation, the DON later provided investigations for some of the discrepancies, but the Percocet documentation did not include a written conclusion. The consultant pharmacist stated he was unaware of the controlled substance discrepancies and had not been notified of them. The facility also failed to accurately account for and document the administration of a controlled medication, liquid morphine sulfate, on one medication cart. During a medication storage audit, surveyors observed a bottle of morphine sulfate liquid that appeared to have been opened, but the resident’s controlled drug record showed the medication had never been given to the resident for whom it was prescribed. When the bottle was opened in the presence of staff and surveyors, a silver-colored foil seal was observed under the cap, indicating the bottle had been sealed. Staff stated that if the declining sheet was blank, the medication had not been given and should not be opened, and that controlled medications were counted against the declining sheet at the beginning and end of each shift. The bottle and box had no date indicating when it had been opened.
Wet-Nested Pans Stored on Clean Rack
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices when the surveyor observed a utility rack with stacked pans stored upside down on the dried pot and pan storage rack. Seven 4-inch deep full-size pans were stacked together on the third shelf from the top, and when the Food Service Director separated them, the first four pans in the stack revealed a clear, thin liquid dripping onto the floor. The pans were visibly wet on both the inside and outside surfaces, and the FSD acknowledged that the pans should not have been stacked while wet and identified the practice as improper wet nesting. The FSD stated that the pans should have remained on the drying rack until completely dry before being placed on the clean storage rack. The LNHA later acknowledged that wet nesting should not occur because bacteria could grow and stated that it was not allowed. Facility administration was informed of the concern during the survey, and the facility-provided FSD job description and kitchen policy both required food service equipment to be cleaned, sanitized, dried, and maintained in a clean, safe, and sanitary manner.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the New Jersey Department of Health within 2 hours for one resident. The resident had diagnoses including major depressive disorder, anxiety disorder, and alcohol abuse with intoxication, and had a BIMS score of 15 out of 15, indicating cognitive intactness. The care plan noted the resident could at times be verbally and physically aggressive toward staff related to poor impulse control and alcohol intoxication, and that the resident would make false statements against staff which would be immediately rescinded. The event involved the Licensed Nursing Home Administrator and the resident after the resident attempted to enter the nourishment room, which residents were not allowed to enter because of infection control concerns. According to the Director of Nursing, the resident became irritated when questioned about entering the room. The resident later told the Social Worker that the administrator had called them names, and the Social Worker reported that the resident also alleged the administrator pushed into the room and called them names, but when asked what names were used, the resident stated it had not happened. The Social Worker notified the DON, ADON, and LNHA after receiving the resident’s email. The DON attempted to interview the resident more than once, but the resident did not want to speak with her. The DON stated the incident was not reported initially because the resident was care planned for making false statements against staff and because the resident rescinded what was said. The LNHA acknowledged that the allegation should have been reported within 2 hours, but it was not reported until later that day.
Delayed Significant Change Assessment for Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) through the Resident Assessment Instrument (RAI) process within the required time frame for a resident who elected hospice benefits. Resident #11, who had diagnoses including cancer, was admitted to hospice effective 2/20/26. The resident’s MDS showed that the SCSA dated 3/4/26 was completed on 3/10/26, which was not within 14 calendar days of the hospice election and should have been completed by 3/6/26. During the survey, the resident was observed in a wheelchair and stated that hospice was going well. The MDS Coordinator stated that a significant change for hospice should be done within 14 days of going on hospice and acknowledged that this resident’s MDS was dated 3/4/26, but said she did not know it had to be completed within 14 days. The DON stated she believed they had 2 weeks to complete a significant change for hospice, and the Regional LNHA stated the MDSC misinterpreted the guidelines for opening an MDS versus completion of the MDS. The facility policy titled MDS Completion and Submission Timeframes stated the MDS completion date as the 14th calendar day after determination of significant change in status.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for one resident who was observed sitting in a wheelchair in the room with an oxygen concentrator near the bed and a nasal cannula placed on the concentrator. The resident stated that oxygen was worn while in bed at night. The resident's record showed diagnoses including COPD and morbid obesity, and the care plan identified a risk for respiratory distress and noted that the resident required oxygen due to episodes of shortness of breath related to COPD and shortness of breath when lying flat. Record review showed an order for obtaining oxygen saturation every shift for shortness of breath, but no current physician order for oxygen therapy in the July 2026 orders. An LPN stated the resident used oxygen at 2 liters per minute as needed at night and confirmed there was no physician order for PRN oxygen. The UM/LPN also stated the resident wore oxygen PRN at night only and confirmed there were no current physician orders for oxygen. The DON stated that if a resident used oxygen, there should be a physician's order, and the facility's oxygen administration policy required verification of a physician's order before oxygen administration.
Medical Director Did Not Attend Required QAPI Meetings
Penalty
Summary
The facility Medical Director failed to attend mandatory quarterly QAPI meetings for two of five quarterly meetings reviewed. During the entrance conference, the survey team requested quarterly QAPI sign-in sheets, a list of QAPI committee members, and the facility's QAPI policies and procedures. Review of the committee member list showed the Medical Director was listed as a member, but the facility-provided sign-in sheets for the 2025 4th quarter QAPI meeting and the 2026 2nd quarter QAPI meeting did not include the Medical Director's signature. The LNHA later acknowledged there was no evidence that the Medical Director attended either meeting and stated the Medical Director was a key member of the QAPI committee. The facility's undated QAPI policy, however, listed each department head as committee members and did not list the Medical Director as a QAPI committee member.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to ensure contracted hospice staff used proper PPE while providing care to a resident on enhanced barrier precautions (EBP). On 7/9/26 at 10:05 AM, the surveyor observed an EBP sign on the resident’s door, a PPE bin outside the room, and the resident receiving care in Bed B from an individual who was not wearing a gown. The resident, identified as Resident #22, had diagnoses including Alzheimer’s disease, anemia, and right heart failure, and the most recent MDS dated 7/5/26 showed a BIMS score of 2 out of 15, severe cognitive impairment, dependence on staff for most self-care and mobility tasks, and an indwelling urinary catheter. The resident’s care plan included EBP related to a suprapubic catheter, with interventions to apply isolation equipment during direct care, maintain contact precautions, keep an isolation cart outside the room, and post precaution signage at the room entrance. Physician orders included hospice and EBP every shift for infection related to the suprapubic catheter. Interviews with the LPN/UM, CNA, hospice clinical director, and DON confirmed the resident was on EBP, that hospice aides were educated on EBP, and that staff expected hospice personnel to follow facility PPE requirements. The facility’s isolation policy stated that EBP required a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident’s environment.
Failure to Obtain Physician Orders for CPAP Maintenance
Penalty
Summary
The facility failed to obtain physician's orders for the weekly cleaning and tubing changes of a resident's CPAP machine, as well as for the daily filling of the CPAP machine's chamber with distilled water, from March 2025 through the resident's discharge. The deficiency was identified through interviews and record reviews, which revealed that although the facility's staff, including the Infection Preventionist and Unit Manager, stated that these tasks were performed by the night shift nurses, there were no corresponding physician's orders or documentation in the resident's medical record. The Medication Administration Records showed daily administration of the CPAP machine but did not include documentation for cleaning, tubing changes, or water chamber maintenance. The resident involved had multiple medical conditions, including obstructive sleep apnea, multiple rib fractures, a prosthetic heart valve, depression, and a history of falls, and required assistance with all activities of daily living. Interviews with the Unit Manager and Director of Nursing confirmed that physician's orders were required for CPAP maintenance tasks, but none were present in the record. The facility's policy also indicated that such procedures should be performed according to physician's orders and manufacturer instructions, but this was not followed in practice for the resident in question.
Verbal Abuse Incident Involving Resident and Housekeeping Aide
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a housekeeping aide (HA #1) and a resident with severe cognitive impairment. The resident, who had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety, was verbally abused and exploited by HA #1 during an appointment at an Ear, Nose, and Throat (ENT) doctor's office. HA #1 was observed yelling, cursing, and videotaping the resident, causing the resident to become visibly upset and confused, believing they were being kidnapped. The ENT staff witnessed the incident and reported that HA #1 was belittling and yelling at the resident without providing any reassurance of safety. The ENT office requested HA #1 to leave and contacted the facility to send a new escort for the resident. The facility's Director of Nursing (DON) was informed of the incident and advised the ENT office to call the police to have HA #1 removed. The facility's investigation confirmed the abuse, as HA #1's actions were captured on video, which was later deleted. The resident's medical records indicated a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The resident's care plan included interventions for cognitive deficits, such as verbalizing safety rules and engaging in appropriate social conversations. Despite these interventions, the resident was subjected to verbal abuse and exploitation, highlighting a failure in the facility's implementation of its abuse prevention policy.
Removal Plan
- HA #1 was terminated
- Resident #239 received a psychosocial evaluation
- All staff were in-serviced on the facility's abuse prevention and reporting policies
Inadequate Investigation of Verbal Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse and exploitation involving a Housekeeping Aide (HA #1) and a resident with severe cognitive impairment. The incident occurred during an Ear, Nose, and Throat (ENT) doctor's office appointment, where HA #1 was observed verbally abusing and videotaping the resident. The ENT staff reported that HA #1 was belittling and yelling at the resident, who appeared visibly upset and confused, believing they were being kidnapped. The facility's investigation was inadequate as it did not include statements from all witnesses, including other residents escorted by HA #1. The resident involved had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Upon returning from the doctor's office, the resident appeared calm and in no emotional distress, unable to recall the incident. However, the ENT's surveillance video confirmed HA #1's inappropriate behavior, including yelling, cursing, and videotaping the resident without consent. The facility's investigation concluded that the abuse allegation was substantiated, but it lacked thoroughness as it did not interview all relevant parties. The Director of Nursing (DON) received a call from the ENT's office about the incident, but the investigation did not include interviews with the ENT staff, the driver of the contracted transportation company, or other residents who had been escorted by HA #1. The facility's failure to conduct a comprehensive investigation and implement their abuse policy posed a likelihood of serious harm to all residents, resulting in an Immediate Jeopardy situation.
Removal Plan
- A complete investigation was initiated.
- The Licensed Nursing Home Administrator and Director of Nursing were educated on the facility's abuse policy, customer service, professionalism, and complete and thorough investigations.
- The Social Services Director was in-serviced on proper investigation of abuse including interviews of other residents.
- All staff were in-serviced on abuse.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records during medication administration, as observed in two instances. On March 5, 2025, at 11:27 AM, a Registered Nurse (RN) left the electronic medical records (EMR) of a resident open, making confidential information visible to anyone in the hallway outside the dining room. Similarly, at 1:02 PM, a Licensed Practical Nurse (LPN) left another resident's EMR open, exposing private medical information to potential onlookers. Both nurses acknowledged the oversight during interviews, with the RN expressing nervousness and the LPN recognizing the risk of exposure. The Director of Nursing confirmed that leaving computer screens open violates HIPAA and resident privacy rights, as outlined in the facility's Resident Rights policy.
Failure to Attempt Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of bedrails for a resident. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including hemiplegia and hemiparesis. The resident's comprehensive care plan indicated the need for a left bedrail for mobility and safety, but the Bed Rail Evaluation revealed that no alternatives were attempted prior to the placement of the bedrails. During observations and interviews, it was confirmed that the nursing staff completed the bedrail assessment but did not explore alternative options before implementing the use of the bedrail. The Director of Nursing acknowledged that the facility did not explore alternative options and allowed residents to use bedrails upon request. This practice was not in compliance with the requirement to try different approaches before using a bedrail.
Incomplete Medical Record Leads to CPR on DNR Resident
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident, identified as Resident #87. The resident was admitted with diagnoses including atherosclerosis of native arteries of bilateral legs, restless leg syndrome, and nerve pain. A critical incident occurred when the resident was found unresponsive, and CPR was initiated due to the absence of a Practitioner Orders for Life-Sustaining Treatment (POLST) form in the facility's records. The resident's power of attorney (POA) indicated that a POLST form had been signed, specifying a do not resuscitate (DNR) order, but the facility did not have a copy, leading to the resident being treated as a full code. The Social Service Director (SSD) confirmed during an interview that she maintained a soft file with all documentation related to the resident, including discussions with the POA about the POLST. However, this information was not included in the resident's official medical record, which should have been complete, accurately documented, and readily accessible. The facility's policy on medical records emphasized the need for accurate, current, and complete documentation, but the SSD was unaware of the requirement to include all relevant information in the medical record. This oversight resulted in a failure to comply with the facility's policy and applicable regulations.
Resident's Rights Violated by Unauthorized Video Recording
Penalty
Summary
The facility failed to protect a resident's rights when a staff member video recorded the resident without consent. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder. The resident was recorded by a Housekeeping Aide (HA #1) at an Ear, Nose, and Throat (ENT) doctor's office, where the resident appeared upset and confused, expressing a belief that they had been kidnapped by HA #1. The situation escalated when the transport driver took HA #1's cell phone and continued recording the resident. ENT staff members witnessed HA #1 yelling and belittling the resident while recording. The Director of Nursing (DON) confirmed that staff were prohibited from recording residents and had been trained on this policy. The incident was reported to the DON by ENT staff, highlighting a breach of the resident's rights to dignity and privacy.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a wheelchair lap seatbelt that restricted the resident's movement. The resident, who had diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder, was observed in a video recording at an ENT doctor's office with a lap seatbelt applied, preventing them from standing up independently. The resident's comprehensive care plan and physician orders did not include any mention of restraints or a wheelchair seatbelt, indicating a lack of proper documentation and authorization for the use of such restraints. Interviews with staff revealed that the seatbelt was applied by the transport driver, and the facility's Director of Nursing confirmed that the use of the lap seatbelt constituted a restraint. The facility's policy requires a physician's written order for the application of restraints, specifying the type, medical justification, duration, and conditions for use, none of which were present in this case. This oversight led to the resident being improperly restrained without the necessary documentation and authorization, violating the facility's policy and regulatory requirements.
Failure to Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the New Jersey Department of Health (NJDOH) as required by their policies and procedures. This deficiency was identified in the case of a resident who had been admitted with diagnoses including anxiety disorder, dementia with agitation, social phobia, and cognitive communication deficit. The resident, who had a severely impaired cognition with a BIMS score of 4 out of 15, was reported to have been sexually assaulted by an unidentified staff member approximately two weeks before their death. The facility was notified of the allegation by the ombudsman, but the Director of Nursing (DON) did not report the incident to the NJDOH or the police, believing it unnecessary since the ombudsman had investigated and closed the case. The facility's Abuse Prevention policy mandates that all occurrences of abuse, neglect, mistreatment, and other grievances be reported to the appropriate agencies, including the NJDOH and local police. The policy specifies that any suspected crime resulting in serious bodily injury must be reported immediately, and no later than two hours after forming the suspicion. In this case, the DON acknowledged the responsibility for reporting such allegations but failed to do so, keeping only a soft file of the investigation and educating staff on abuse. The failure to report the allegation as per the facility's policy and state regulations constitutes a significant deficiency in the facility's handling of abuse allegations.
Medication Storage Deficiency During Administration
Penalty
Summary
The facility failed to properly store medications safely and securely during medication administration, as observed in two separate incidents. In the first incident, a Registered Nurse (RN) left the medication cart unlocked in the hallway outside of the dining room and left a vial of insulin unsecured on top of the cart while administering medication to a resident. The RN admitted to being nervous and acknowledged that this was not her usual practice. In the second incident, a Licensed Practical Nurse (LPN) also left the medication cart unlocked in the hallway during medication administration, without keeping it in sight. The LPN recognized the risk of someone accessing the medications if the cart was left unlocked. The Director of Nursing (DON) confirmed that the facility's policy required medication carts to be locked when not in the nurse's line of sight during medication administration. The DON acknowledged that leaving the cart unlocked could allow unauthorized access to medications. The facility's Medication Administration policy, dated March 2017, specified that medication carts should be kept closed and locked when out of sight, with no medications left on top of the cart, and all sides inaccessible to residents or passersby.
Failure to Maintain Complete Medical Record for Emergency Transfer
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was sent out for an emergent hospitalization. Specifically, the New Jersey Universal Transfer Form (NJUTF) was not included in the medical record for the resident's transfer to the hospital. The resident, who had multiple diagnoses including benign neoplasm of cerebral meninges, hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes mellitus type 2, experienced an emergency situation where they were noted to be yelling "I can't breathe." The resident's vital signs were recorded, and a call was placed to the physician, resulting in an order to send the resident to the emergency room for evaluation and treatment. Emergency medical technicians arrived immediately, and the resident was transported to the hospital. Upon review, it was found that the NJUTF was missing from the resident's medical record for the transfer that occurred on the specified date. During interviews, the Director of Nursing (DON) confirmed the absence of the NJUTF and stated that they did not see the resident when they were transferred out. The facility's policy on emergency transfers requires the preparation of a transfer form to accompany the resident, which was not adhered to in this instance. This deficiency was identified during a complaint investigation and was based on interviews, record reviews, and other pertinent facility documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlantic Coast Rehab & Health | 0 mi | ★★★★★ | 2 | 1 |
| Leisure Chateau Rehabilitation | 1 mi | ★★★★★ | 15 | 0 |
| Harrogate Village | 2 mi | ★★★★★ | 15 | 0 |
| Concord Healthcare & Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Shore Gardens Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 2 | 0 |
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