Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Little Brook Nursing And Convalescent Home during CMS and state inspections, most recent first.
Missing monitoring orders for psychotropic medication: A resident with depression, psychotic disturbance, and anxiety was receiving an antidepressant and an antipsychotic, but the chart lacked physician orders to monitor behaviors and potential side effects. The RN stated such monitoring should be ordered for residents on psychiatric meds, and the DON acknowledged the orders were missing after the resident returned from acute care.
The facility failed to follow its abuse policy by not completing prior employee reference checks for 37 of 37 employee files reviewed. The LNHA stated that the BOM would ensure references were complete, while the BOM stated she did not do the reference checks. The facility policy required prospective employee references to be checked prior to hiring.
Unlocked medication carts and an unlocked medication room were observed during med passes, including times when an LPN and an RN turned away from their carts while meds were being administered. An RN also disposed of crushed Metoprolol ER mixed with applesauce into a resident’s trash bin despite a hold order tied to low BP, and staff were unable to find a pill buster for proper disposal; the DON stated the device was expired and not available.
No designated IP was in place after the prior IP resigned, and the DON was covering both DON and IP duties. The LNHA and facility owner acknowledged the IP role was not designated as a part-time or full-time position, and the facility could not provide CDC certificate documentation for staff during the survey period. Facility policy identified the IP as responsible for oversight of the IPCP, surveillance, antibiotic stewardship, and related reporting.
Call bells were not kept within reach for three residents who were observed in bed with the cord wrapped around a wall-mounted receptacle and out of reach. The residents had diagnoses including dysphagia, PVD, depression, Alzheimer's Disease, diabetes mellitus, dementia, and Parkinson's Disease, and records showed impaired cognition or dependence on staff for ADL care. One care plan included keeping the call bell within reach, while another identified fall risk without that intervention; the DON confirmed the call bells were not within reach and should have been.
A resident’s call light plug was observed taped into the wall outlet in the resident’s room, and the resident stated it had been that way for over six months because the plug falls out unless taped in place. The DON later observed the same condition, and maintenance acknowledged the repair request had been in the logbook for months while waiting on a part.
A resident identified as a smoker had no care plan developed or implemented to plan and manage smoking. The resident was admitted with HTN and alcohol induced dementia, had an MDS score of 15/15 indicating intact cognition, and was observed smoking under staff supervision and wearing a smoking apron. The DON confirmed the resident did not have a smoking care plan, despite facility policy requiring a baseline care plan for each resident.
A resident with a pressure ulcer and two other residents with specialty mattresses were found with low-air-loss mattress pumps set far above their documented weights, and the records lacked physician orders and monitoring documentation for the mattresses. In addition, wound care for the resident with the pressure ulcer was observed to involve cross-contamination during cleansing and treatment, while EBP signage was not posted and a CNA repositioned the resident without a gown; the RN also failed to remove trash and disinfect the overbed table after care.
A resident with an indwelling urinary catheter was observed with the drainage bag hung on the bed rail and visible from the doorway, with no privacy bag in place. The resident had diagnoses including dysphagia, PVD, and depression, and the MDS confirmed the catheter. The DON stated all urinary bags should have a privacy bag but could not explain why one was missing, and the facility did not provide a Foley catheter policy when requested.
A resident receiving tube feeding was observed with the enteral feeding machine running, but the feeding container and water flush bag were missing labels with the resident’s name, date, and time started. The resident had dysphagia, PVD, and depression, and the chart included orders for Jevity 1.5 tube feeding and scheduled water boluses; the DON stated these items must be labeled, but no enteral feeding policy was provided.
Failure to maintain respiratory care and O2 equipment for a resident receiving continuous O2. A resident with COPD and chronic respiratory failure was observed with a NC attached to a humidification water bottle and O2 concentrator, and neither item was properly labeled or dated. The resident’s PO called for continuous O2 at 3 L/min via NC and tubing/humidifier changes on Mondays. The DON and RN stated the equipment should be labeled and dated, and the RN admitted the tubing was not labeled or dated.
A resident received a steroid inhaler without being instructed to rinse the mouth afterward, even though the order required rinsing after each use. In a separate observation, an unidentifiable partially chewed tablet was found on another resident’s overbed table, and an LPN stated she did not know where it came from. The facility’s medication policy required checking the label three times before administration.
Medication Administration Error Rate Exceeded 5 Percent: A nurse was observed administering medications to a resident and crushed medications that should not have been crushed, including an ER beta blocker, an EC aspirin, and an antibiotic tablet. The nurse also prepared other medications with applesauce and held the ER beta blocker after checking the resident's BP, but the medication had already been crushed. The resident had HTN, CHF, and moderate cognitive impairment, and the observed medication pass resulted in an 11.54% error rate.
Meals were not served at safe and palatable temperatures. Four residents reported that hot foods were not hot and cold foods were not cold. Surveyors observed a regular diet tray on the unit and later tested the reserved tray, finding diced carrots at 133.8 F, salad at 58.8 F, and fruit cup at 49.7 F. The FSS stated the kitchen equipment was working and foods were within range before leaving the kitchen, but tray passing caused temperatures to drop, and he said the facility had no policy or procedure for food preparation or temperature checks of test trays.
QAPI committee meetings were not held quarterly, with more than 3 months between documented meetings. The BOM stated delays occurred when the medical director was on vacation and that one scheduled meeting was canceled when the survey team arrived. The facility owner and BOM later said another meeting may have occurred, but they could not find the sign-in sheet or meeting information. The QA plan and policy did not address the requirement for quarterly meetings.
Improper N95 use and inaccurate COVID status communication: The LNHA was observed wearing the required N95 loosely on her chin and later without it in the vestibule, nursing station, and resident day area, while a SW was also observed with the N95 down on her chin while doing paperwork in the resident day area. When asked about COVID status, the LNHA told surveyors there were no active cases, despite the facility being on the tail end of a COVID outbreak, and the SW stated she did not think the mask needed to be worn above her nose because there was no COVID in the building.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient supervision in the area.
A CNA was accused of rough handling and causing injury to a resident with dementia, who reported pain and bruising. The LNHA suspended the CNA but did not interview other residents or notify police, as required by policy. Another resident later reported mistreatment by the same CNA to the Ombudsman. The facility's incomplete investigation allowed the CNA to return to work, resulting in continued complaints before eventual termination.
Surveyors found that Section C of the MDS, which includes cognitive assessments, was not completed for six residents with various diagnoses such as dementia, depression, and chronic illnesses. The deficiency occurred because the Social Worker responsible for this section was not present, and the MDS Coordinator, who resigned, was not assigned this task according to facility policy.
The facility did not update care plans for a resident involved in an abuse allegation and for two residents following a resident-to-resident altercation, despite existing behavioral concerns and cognitive impairments. The DON confirmed that care plans should have been revised after these incidents, but no new interventions were added.
A resident with moderate cognitive impairment reported being physically harmed by a CNA, resulting in visible bruising and severe pain. The incident was witnessed by the Ombudsman and reported to the LNHA, who initiated an internal investigation but did not notify law enforcement as required by facility policy and state regulations.
A CNA did not receive a required annual performance evaluation due to a lapse in oversight after the responsible DON left the facility. Staff interviews and policy review confirmed that annual evaluations are required to assess job performance and determine training needs.
A facility failed to provide a cognitively impaired resident with the prescribed nectar thick liquid diet, leading to an Immediate Jeopardy situation. The resident, at high risk of aspiration due to Parkinson's Disease, was served inappropriate food. Additionally, the facility did not properly investigate a fall incident involving another resident, failing to follow their policy on fall investigations.
The facility failed to transmit MDS records for 20 residents within the required timeframe, with some records being over 120 days old. The MDS Coordinator, working remotely and part-time, cited delays from other disciplines as a reason for the late submissions. The DON and LNHA acknowledged the issue but provided no further information.
The facility did not conduct required annual performance reviews for four CNAs, as revealed during a survey. The DON admitted to not completing these reviews, despite facility policy requiring them during orientation, job description changes, and annual evaluations. The facility provided educational post-tests but lacked performance reviews for the CNAs.
The facility failed to maintain proper kitchen sanitation practices, risking foodborne illness. Observations included dented cans stored with intact goods, canned goods stored in a warm area, and unclean air conditioning units. Additionally, the dish machine's sanitizing solution was ineffective, with zero PPM recorded, and logs were incomplete. The FSD acknowledged these issues, but no corrective actions were noted.
Surveyors identified multiple infection control deficiencies in the facility, including improper disposal of a used COVID-19 test card, overflowing sharps containers, and a soiled device in the clean linen room. Additionally, a contaminated PPE cart was left in the hallway. The DON and LNHA acknowledged these lapses in policy adherence.
The facility failed to maintain resident dignity by not providing appropriate care during feeding and incontinence management. A CNA was observed standing while feeding a resident, against policy, and residents were given incorrect sizes of incontinence briefs due to supply shortages. The DON confirmed these practices were not in line with facility standards.
The facility failed to issue the required SNF ABN to two residents, leading to a deficiency. The SNF ABN is essential for informing beneficiaries about their potential financial liability for services not covered by Medicare. The DON indicated that the SNF ABN was not provided to these residents, and there was no additional documentation about the communication of these forms to the residents or their representatives.
The facility failed to report an incident involving two residents to the NJ DOH within the required timeframe. One resident with severe cognitive impairment attempted to remove another resident's glasses, leading to a physical reaction. The incident was reported to the NJ DOH four days later, beyond the 24-hour requirement. The DON acknowledged the delay but could not explain the reason for it.
The facility failed to notify a resident's representative and the Office of the Ombudsman in writing for an emergency hospital transfer. The resident had a recent hospitalization, and the Discharge MDS indicated a return to the facility was anticipated. The DON could not find the required notifications and stated that due to the absence of a social worker, no notifications were sent for April. The facility's policy requires such notifications, which were not followed.
A facility failed to accurately complete the MDS for a resident, incorrectly indicating that a pneumococcal vaccine was not offered, despite documentation showing it was received. The DON acknowledged the error, noting the MDSC/RN completed assessments remotely and was not frequently present in the facility.
The facility failed to ensure timely intervention by the RD for two residents experiencing significant weight changes. One resident had a 7.98% weight gain over 30 days, and another had a 5% weight loss since late September. The RD admitted that not all residents with significant weight changes had been addressed, despite facility policy requiring timely re-weighing and documentation. The facility staff could not explain the delay in addressing these changes.
A resident with severe cognitive impairment received improperly administered medications when an LPN crushed several medications, including Ferrous Sulfate, against manufacturer instructions. The medications were mixed with applesauce and given to the resident, contrary to the facility's policy requiring adherence to physician orders.
The facility failed to properly label, store, and dispose of medications in one of the two medication carts inspected. An inspection revealed an opened vial of Fiasp insulin and two opened bottles of Pro-Stat AWC protein supplement, all expired. An LPN acknowledged the expired status of these medications, which should have been removed. The facility's policy required the removal of outdated drugs, but this was not followed.
A resident received liquids in the incorrect consistency due to a failure in communication between nursing and dietary staff. The resident's tray card indicated nectar thick liquids, while the physician's order specified regular/thin consistency. The dietary aide was unaware of the change, and facility policies requiring adherence to physician orders were not followed.
A facility failed to maintain complete medical records for a resident on Risperidone, lacking psychiatric consult sheets after an initial consultation. The DON confirmed the absence of these records, stating they were with the psychiatrist. The facility also did not provide a policy on medical record keeping.
Missing monitoring orders for psychotropic medication
Penalty
Summary
The facility failed to ensure that a physician’s order remained in place to monitor behaviors and side effects for a resident receiving psychotropic medications. Resident #3 was admitted with diagnoses including major depressive disorder, depressive episodes, psychotic disturbance, and anxiety. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The care plan included focus areas for mood and behavior, antidepressant medications, and antipsychotic medications, with interventions to monitor behaviors and side effects, but the February 2026 order summary showed active orders for mirtazapine and quetiapine without any corresponding physician’s order to monitor behaviors or potential side effects. The record review also showed that prior physician’s orders for monitoring behaviors such as withdrawal, refusal of care, and crying, and for observing side effects of antipsychotic medication, had been discontinued on 12/26/25. During interview, the RN stated that residents taking psychiatric medications should have physician’s orders to monitor both behaviors and potential side effects, and the DON acknowledged that Resident #3 was receiving both an antidepressant and an antipsychotic without those orders in place. The DON stated the orders should have been added when the resident returned from an acute care facility in December and acknowledged the importance of documenting behaviors and potential side effects.
Missing Employee Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing previous employee reference checks for 37 of 37 employee files reviewed. The surveyor reviewed the files and found that each listed employee, with dates of hire ranging from 11/4/24 through 2/11/26, did not have a previous employee reference on file. The facility’s Resident Abuse Prohibition Policy, revised 1/26, stated that prospective employee references are checked prior to hiring. During interviews on 3/2/26, the LNHA stated that she hires all staff who enter the building and that the BOM would make sure the references were complete. The BOM stated that she did not do the reference checks and provided no further explanation. The deficiency was identified after review of the employee records and the facility policy.
Unlocked Medication Storage and Improper Medication Disposal
Penalty
Summary
The facility failed to secure medication carts and a medication room during medication administration and failed to properly dispose of medications for one resident. During observation, an LPN was seen bringing a partially consumed, unidentifiable tablet from a resident’s room back to the medication cart, and the cart was observed unlocked. The same LPN was later observed looking through two medication carts for a pill buster and then calling the DON, who opened the medication room door that was not locked. The surveyor also observed the LPN administering medications in the dining room while turning away from the medication cart, which remained unlocked. Later, an RN was observed administering medications in the dining room/activity room with her back turned to the medication cart, and the cart was unlocked at that time. The surveyor also observed an RN administering medications to a resident whose blood pressure was 93/63 with a heart rate of 65, despite a hold order for the medication when systolic blood pressure was below 110. The RN disposed of crushed Metoprolol ER 25 mg mixed with applesauce into the resident’s trash bin and stated it was acceptable because it was crushed. When the RN later attempted to dispose of the medication properly, staff could not find a pill buster. The DON stated the pill buster was expired after he had destroyed an unidentifiable medication found in a resident’s room the day before, and he acknowledged that he should always have one available in the facility.
No Designated Infection Preventionist
Penalty
Summary
The facility failed to provide a designated qualified Infection Preventionist (IP) responsible for the infection prevention and control program. The report states the IP resigned effective November 28, 2025, and facility staff interviews confirmed that no designated IP was in place during the survey period. On 2/25/26, the LNHA stated the facility did not have a designated IP, and on 3/3/26 the LNHA confirmed the DON was performing both DON and IP duties, while acknowledging that the IP should be a designated part-time or full-time position. During the survey from 2/25/26 through 3/4/26, the facility was unable to provide CDC certificate documentation for facility staff. The LNHA also stated the facility had a COVID outbreak with onset on 1/16/26 and the last positive COVID test on 1/30/26, and that the outbreak was removed on 3/2/26 by the Public Health Epidemiologist. The facility owner stated on 3/3/26 that he was unaware the IP needed to be a designated part-time or full-time employee. Facility policies reviewed by the surveyor identified the IP as responsible for oversight of the infection prevention and control program, surveillance activities, antibiotic stewardship, and related reporting duties.
Call Bells Not Kept Within Reach
Penalty
Summary
The facility failed to maintain residents' call bells within reach for 3 of 12 residents reviewed for accommodation of needs. Resident #2 was observed in bed with the call bell cord wrapped around the wall-mounted receptacle and not within reach on two separate observations. The resident's record showed diagnoses including dysphagia, peripheral vascular disease, and depression, and the admission MDS indicated the BIMS could not be performed because the resident was rarely understood. The care plan identified the resident as at risk for falls and included an intervention to keep the call bell within reach. Resident #5 was also observed in bed with the call bell cord wrapped around the wall-mounted receptacle and not within reach on two separate observations. The resident's record reflected diagnoses including Alzheimer's Disease and diabetes mellitus, and the quarterly MDS showed severely impaired cognitive skills for daily decision making and dependence on staff for ADL care. The care plan identified the resident as high risk for falls but did not include an intervention to keep the call bell within reach. Resident #28 was observed in bed with the call bell cord wrapped around the wall-mounted receptacle and not within reach on two separate observations. The resident's record reflected diagnoses including dementia and Parkinson's Disease, the quarterly MDS showed dependence on staff for ADL care, and the care plan included an intervention to encourage use of the call bell for assistance.
Resident Room Call Light Plug Taped in Outlet
Penalty
Summary
The facility failed to provide a homelike environment in a resident room when Resident #16’s call light plug was observed taped into the wall outlet. During an interview while the resident was lying in bed, the resident stated the call light plug falls out of the outlet if it is not taped in place and said the condition had been present for over six months, with maintenance aware of it. The surveyor later returned to the room with the DON and both observed the same taped call light plug. The maintenance worker stated the facility used a logbook for room problems and acknowledged that a request to fix Resident #16’s call light plug had been entered on 4/29/25. The maintenance worker also stated the department was waiting on a part to repair the outlet and said that waiting over eight months was excessive and that the outlet should have been fixed in a timelier fashion. The facility did not provide requested policies related to the concern.
Missing Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was identified as a tobacco smoker. The resident was admitted with diagnoses including hypertension and alcohol induced dementia, and the admission MDS dated 2/24/26 reflected a brief interview for mental status score of 15 out of 15, indicating fully intact cognition, and also identified the resident as a tobacco smoker. During observation on 2/25/26, the resident was awake in bed and stated that he/she was a smoker and was supervised while smoking. On 3/4/26, the resident was observed outside on the smoking patio with a staff member and was wearing a smoking apron. Review of the resident’s care plan report showed that no care plan had been developed or implemented to plan and manage the resident’s smoking. During interview, the DON confirmed that the resident did not have a smoking care plan and stated that all residents who smoke should have a care plan in place to ensure resident safety. The facility policy stated that a baseline care plan is to be developed for each resident and used to plan and manage resident care from admission through discharge.
Improper Mattress Settings and Unsafe Wound Care
Penalty
Summary
The facility failed to ensure that specialty low air loss mattresses were accurately set and monitored according to resident weight for three residents. One resident with dysphagia, peripheral vascular disease, and depression was observed in bed with a specialty mattress pump set to 250 lbs, while the resident’s last known weight was 187 lbs. The resident’s record did not include a physician order for the specialty mattress, and the treatment record did not show documentation that the mattress was being monitored for function and proper placement. A second resident with hemiplegia and hemiparesis following cerebral infarction was observed with a specialty mattress pump set to 250 lbs, although the resident’s weight was documented as 152 lbs. The resident’s record also did not include a physician order for the specialty mattress, and the treatment record did not include documentation that the mattress was being monitored for function and proper placement. The DON confirmed that specialty mattresses should be set to the resident’s current body weight and that the mattress had been ordered to help prevent skin breakdown. A third resident with Alzheimer’s disease and diabetes mellitus was observed with a specialty mattress pump set to 450 lbs, while the resident’s weight was documented as 133 to 135 lbs. The resident had a stage 2 pressure ulcer and pressure ulcers on both buttocks, and the care plan included a pressure-relieving mattress. The current order summary included a low-air-loss mattress with a check function every shift, but the RN confirmed the pump was set at 450 lbs and acknowledged signing the TAR indicating the mattress had been checked even though it had not been properly monitored. The facility also failed to provide necessary treatment and services for the resident with the pressure ulcer in a manner consistent with professional standards of practice. During observation of wound care, the RN cleansed the wound from the peri-wound to the inner wound bed, then repeated the same technique, and used the same applicator to apply zinc oxide barrier cream to both the peri-wound and the wound bed. The CNA repositioned the resident without donning a gown despite the resident being under Enhanced Barrier Precautions for a wound. The RN also did not remove trash from the room or disinfect the overbed table after the treatment was completed. The DON confirmed that signage should have been posted, the CNA should have worn a gown, the wound should have been cleansed and treated from the wound bed to the peri-wound, and the table should have been disinfected after the treatment.
Missing Privacy Bag for Resident with Indwelling Catheter
Penalty
Summary
Failure to provide a privacy bag for a resident with an indwelling urinary catheter was identified during observation, interview, and record review. On 2/25/26 at 10:25 AM, the resident was observed in bed with eyes closed and an indwelling urinary drainage bag hung on the bed rail and visible from the doorway, with no privacy bag present. The deficiency was cited for 1 of 1 resident reviewed with a Foley catheter. Record review showed the resident was admitted with diagnoses including dysphagia, peripheral vascular disease, and depression. The admission MDS dated 2/6/26 indicated the resident had an indwelling catheter and that the BIMS could not be performed because the resident was rarely understood. The current physician order summary included an order dated 2/25/26 for urinary catheter care every shift. On 2/26/26, the DON stated all urinary bags should have a privacy bag but could not explain why one was not present for the resident. The facility did not provide a policy for Foley catheters when requested.
Unlabeled Enteral Feeding and Water Flush Bags
Penalty
Summary
The facility failed to label and date an enteral tube feeding container and a water flush bag for a resident receiving tube feeding. During observation, the resident was found in bed with eyes closed while the enteral feeding machine was running, and both the enteral feeding container and the water flush bag were observed without labels showing the resident’s name, the date, or the time they were hung and started. The resident had been admitted with diagnoses including dysphagia, peripheral vascular disease, and depression. The record showed physician orders for enteral feeding with Jevity 1.5 at 65 ml/hr starting in the afternoon until 1170 ml was delivered, along with 250 ml of clear water by bolus every 8 hours for hydration. The care plan identified the resident as dependent on tube feeding and water flushes. The DON stated that enteral feeding containers and water flush bags need to be labeled with the resident’s name, date, and time started, and no facility policy for enteral feeding was provided when requested.
Failure to Maintain Oxygen Equipment
Penalty
Summary
Respiratory care and equipment were not maintained for a resident receiving continuous oxygen. The resident had diagnoses including COPD and chronic respiratory failure with hypoxia, and the care plan included oxygen therapy via nasal cannula. The physician orders directed oxygen via nasal cannula continuously at 3 L/min for shortness of breath, with tubing and humidifier changes one time a day on Mondays. During observation, the resident was seen in bed and later out of bed in a wheelchair with a nasal cannula attached to a humidification water bottle and oxygen concentrator, and neither item was properly labeled or dated. The oxygen concentrator was set at 3 L/min during both observations. The DON stated that nursing staff are supposed to follow physician orders and facility policy for oxygen equipment changes, and that equipment should be labeled and dated to show when it was completed and to help other staff know how old it is. The assigned RN stated tubing should be changed weekly and labeled, as well as the humidification water, to prevent contamination and infection, and admitted the tubing was not labeled or dated. The facility policy reviewed stated respiratory care equipment used in patient care will be stored in a manner that maintains cleanliness and use of the equipment.
Medication Administration and Storage Deficiencies
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when a Registered Nurse administered Fluticasone-Salmeterol inhaler to a resident without asking the resident to rinse the mouth afterward, despite the medication directions stating, "Rinse mouth after each use." The resident was observed seated in the front activity room, and the nurse prepared and administered the inhaler along with Metformin 500 mg. During the observation, the nurse read the inhaler directions in the presence of the surveyor and acknowledged afterward that the resident should have been asked to rinse the mouth after inhaling the medication. The resident’s record reflected diagnoses including chronic diastolic heart failure, anxiety disorder, and hypertension, and the quarterly MDS dated 02/13/26 indicated severely impaired cognition with a cognitive skills for daily decision-making score of 4 out of 15. Medication storage was also deficient for another resident when a partially chewed, unidentifiable tablet was found on the resident’s overbed table during the initial tour. The surveyor observed the tablet in the resident’s room, then brought the resident’s nurse to the room, where the LPN acknowledged the tablet was present and stated she did not know where it came from. The LPN put on gloves, picked up the tablet with a tissue, and took it to the medication room for destruction. The facility’s medication administration policy stated that the individual administering medication must check the label three times to verify the right resident, medication, dosage, time, and method before giving the medication.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that medication administration error rates remained below 5 percent. During morning medication administration observations, one nurse administered medications to five residents, with 26 opportunities and three observed errors, resulting in an 11.54% medication administration error rate. The deficient practice was identified for one resident who received medications from the observed nurse. For one resident, the nurse prepared eight medications and was observed crushing Metoprolol Succinate ER 25 mg, Aspirin EC 81 mg, and Sulfamethoxazole-Trimethoprim 800-160 mg and mixing them with applesauce. The nurse also crushed Folic acid and added the contents of an opened Florastor capsule to medication cups. The nurse entered the resident's room, obtained a blood pressure of 93/63 with a pulse of 65, and held the Metoprolol ER, but the other medications had already been prepared. When questioned, the nurse stated she was unaware that Metoprolol ER, Aspirin EC, and Bactrim DS could not be crushed, and then acknowledged that enteric coated and delayed release medications should not be crushed. The resident had diagnoses including hypertension, congestive heart failure, and malignant neoplasm of the bladder. The admission MDS showed the resident's cognitive skills for daily decision-making score was 11 out of 15, indicating moderate impairment. The physician orders and e-MAR showed orders for Metoprolol Succinate ER with hold parameters, Sulfamethoxazole-Trimethoprim for MRSA prophylaxis, and Aspirin EC for prophylaxis. Manufacturer information reviewed by the surveyor stated that Metoprolol Succinate ER should not be crushed or chewed, Aspirin EC should never be crushed, chewed, or broken, and Sulfamethoxazole-Trimethoprim should be swallowed whole with water.
Meals Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a safe and palatable temperature. During the Resident Council meeting, four alert and oriented residents stated that the food temperatures were not palatable, reporting that hot foods were not hot and cold foods were not cold. The surveyor then calibrated a state-issued digital thermometer and observed a regular diet tray on the food truck at the unit. The tray was removed and placed at the nurse's station, and when the surveyor tested the reserved tray after the last tray was delivered, the temperatures were 133.8 F for diced carrots, 58.8 F for salad, and 49.7 F for fruit cup. The Food Service Supervisor stated that the kitchen equipment used to maintain meal temperatures was working adequately and that the items were within normal temperature limits before leaving the kitchen, but that passing out the lunch trays caused the food items to lose temperature. The FSS also stated that the facility had no policy or procedure for the preparation or temperatures of foods and had never checked the temperatures of a test tray; temperatures were only taken in the kitchen before the food was delivered to the unit. A facility policy titled Food: Preparation, revised 9/2017, stated that dining services staff were responsible for food preparation techniques that minimize the time food items are exposed to temperatures greater than 41 F or less than 135 F.
QAPI Committee Failed to Meet Quarterly
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to hold quarterly meetings for 2 of 4 QAPI meetings reviewed. During the entrance conference, the surveyor requested sign sheets for the past four quarters of QAPI committee meetings. Review of the attendance sheets and QAPI book showed meetings documented on 9/10/24, 3/18/25, and 7/23/25, with more than 3 months between each meeting. The Business Office Manager, who attended the QAPI meetings, stated that the facility usually had quarterly meetings but that delays occurred when the medical director went on vacation, and that the facility knew the medical director had to be present. She also stated that the meeting scheduled for 2/25/26 was canceled when the survey team came to the facility. The facility owner and BOM later stated that another meeting must have occurred but they were unable to find the sign-in sheet or meeting information. Review of the facility QA plan and policy dated 5/20 showed the policy was intended to support QAPI/QAA activities, but it did not address the requirement for quarterly meetings.
Improper N95 Use and Inaccurate COVID Status Communication
Penalty
Summary
The facility failed to follow its infection prevention and control practices for PPE use, specifically the required N95 respirator mask. During the survey entrance on 2/25/26, surveyors were told an N95 mask was required for entry and complied, but the LNHA was observed wearing her N95 loosely fitted and down on her chin while in the vestibule and resident day area. At that same entrance, the team asked whether there were any active COVID-positive cases in the building and was told there were not, even though the facility was coming off a COVID-positive outbreak with an initial case on 1/16/26 and the last case on 1/30/26. Additional observations showed the same LNHA again wearing the N95 incorrectly on 2/26/26 and later not wearing it at all in the vestibule and nursing station area on 3/2/26. On 3/2/26, the SW was also observed wearing the N95 loosely on her chin while in the vestibule and resident day area, and when questioned, stated there was no COVID in the building and that she did not feel it needed to be pulled above her nose because she was not sitting directly with residents. The LNHA stated that staff and visitors were required to wear the N95 for the entire shift, except when outside on the patio or deck, and the owner stated he was aware the Infection Preventionist had resigned effective 11/28/26 and that all staff, including the LNHA and SW, were required to wear the N95 respirator mask in the facility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Thoroughly Investigate Abuse Allegation and Notify Authorities
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving a Certified Nursing Assistant (CNA) and a resident. After being notified by Ombudsman representatives that a CNA was attempting to get a resident out of bed while the resident was screaming, the Licensed Nursing Home Administrator (LNHA) suspended the CNA and conducted an investigation. However, the LNHA did not interview other residents who had received care from the CNA, as required by the facility's abuse investigation policy. The LNHA also did not notify local police of the abuse allegation, believing police notification was only necessary for serious injuries or elopements. The resident involved had a history of dementia, depression, and required moderate assistance with activities of daily living. During the incident, the resident reported pain and bruising to the left arm, which was confirmed by a Registered Nurse's assessment. Another resident later reported to the surveyor that the same CNA had previously humiliated and mistreated them, but had only reported this to the Ombudsman and not to facility staff. The LNHA confirmed that she did not follow up with other residents or obtain statements from them regarding the CNA's conduct, nor did she ask the Ombudsman for the identities of residents who had complaints. The facility's failure to follow its own abuse investigation policy, specifically the requirement to interview other residents cared for by the accused staff member, resulted in the CNA returning to work after the initial allegation. This allowed the CNA to continue providing care until further complaints were brought to the LNHA's attention by the Ombudsman, at which point the CNA was terminated. The lack of a thorough investigation and failure to notify authorities constituted a deficiency in the facility's response to alleged abuse.
Removal Plan
- CNA #1 was terminated from the facility
- The LNHA conducted an investigation into abuse allegations involving CNA #1, which included resident interviews
- All facility staff were re-educated on the facility's abuse policy regarding when to report abuse allegations and to whom
- The facility's owner re-educated the LNHA on the abuse and investigation sections of the abuse policy
- The Director of Nursing (DON) conducted audits to see if any residents had experienced any form of abuse
Failure to Complete Cognitive Assessment Section of MDS for Multiple Residents
Penalty
Summary
The facility failed to complete Section C of the Quarterly Minimum Data Set (MDS) for six sampled residents, as identified through interviews, medical record reviews, and examination of facility documents. For each resident, the MDS assessment tool indicated that a Brief Interview for Mental Status (BIMS) and a staff assessment for mental status should be conducted, but the corresponding sections were left blank. These sections included critical cognitive assessments such as repetition of three words, temporal orientation, recall, BIMS summary score, short-term and long-term memory, memory/recall ability, cognitive skills for daily decision making, and signs and symptoms of delirium. The residents involved had a range of diagnoses, including dementia, depression, diabetes, anxiety, personality disorder, hypertension, spinal stenosis, morbid obesity, congestive heart failure, chronic obstructive pulmonary disease, and a history of falls. Despite the presence of these conditions, which require careful cognitive assessment, the relevant MDS sections were not completed for any of the six residents sampled. During an interview, the Licensed Nursing Home Administrator (LNHA) stated that the Social Worker (SW) was responsible for completing Section C of the MDS, but the facility had not had a SW since November. The LNHA also noted that the MDS Coordinator, who resigned at the end of February, was not responsible for this section. The facility's policy confirmed that the Social Services Department was responsible for completing Section C, and that the MDS Coordinator was responsible for entering the data into the computer software.
Failure to Update Care Plans After Abuse and Resident-to-Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans for three residents following significant incidents, as required by regulation and facility policy. One resident, with diagnoses including dementia and depression and a BIMS score indicating moderate cognitive impairment, was involved in an abuse allegation where a CNA was witnessed being rough during a transfer. Despite the incident being reported and investigated, the resident's care plan was not updated with new interventions related to the abuse allegation. Additionally, two other residents, one with intact cognition and another with moderate cognitive impairment and a history of mental health conditions, were involved in a resident-to-resident altercation in the dining room. One resident attempted to bite the other, who responded by pushing back. Although both residents had care plans noting a potential for physical aggression, there were no updates or new interventions added to their care plans following the incident. The DON confirmed that care plans should have been updated after these events but acknowledged that this was not done.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an abuse allegation involving a Certified Nursing Assistant (CNA) and a resident to the local police department, as required by both facility policy and state regulations. The incident involved a resident with moderately impaired cognition, as indicated by a BIMS score of 8 out of 15, who required partial to moderate assistance with most activities of daily living. The resident reported to a Registered Nurse that the CNA pulled and hurt their left arm, resulting in observed bruising and severe pain, which led to an x-ray being ordered. The event was witnessed by the Ombudsman, who notified the Licensed Nursing Home Administrator (LNHA), prompting an internal investigation and suspension of the CNA. Despite the facility's policies mandating prompt notification of law enforcement in cases of suspected abuse, the LNHA did not contact the police, believing it was only necessary in cases of serious injury or elopement. The facility's documentation and policies specifically required reporting such incidents to law enforcement, but the Facility Reportable Event form did not indicate that the police had been notified. The LNHA confirmed during an interview that the police were not contacted regarding the abuse allegation.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to complete an annual performance evaluation for a Certified Nursing Assistant (CNA) who was hired on 10/23/23. During a review of personnel files, it was found that there was no documentation of an annual performance evaluation for this CNA. The Business Office Manager/Human Resources confirmed that the evaluation had not been completed and stated that it was the responsibility of the Director of Nursing (DON), who was no longer employed at the facility. The facility's policy requires annual evaluations to assess employee performance and determine if in-service training is needed. Interviews with facility staff, including the Licensed Nursing Home Administrator, confirmed that annual performance evaluations for CNAs are expected to be completed by the DON. The facility's job description for the DON also specifies responsibility for developing and conducting annual performance reviews for nursing staff. The lack of an annual evaluation for the CNA was identified as a deficiency during the survey.
Failure to Provide Appropriate Diet and Investigate Fall Incident
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident with a physician's order for nectar thick liquid (NTL) was provided the appropriate consistency diet to prevent aspiration. During a lunch observation, a surveyor noted that a resident was coughing after being fed whole mandarin oranges in thin juice by an LPN. The LPN was unaware of the resident's dietary requirements and the meaning of the yellow dot on the meal card, which indicated a chopped diet rather than the required NTL. The Food Service Director confirmed that the meal card should have had a yellow dot with an 'N' to indicate nectar thick liquids, which was missing. The resident, who had a medical diagnosis of Parkinson's Disease and was at high risk of aspiration, was served inappropriate food that could lead to serious health consequences. Interviews with the medical doctor, speech language pathologist, and registered dietician confirmed that the resident was on a nectar thickened liquid diet and should not have been served mandarin oranges in thin juice. The facility's failure to adhere to the prescribed diet posed a likelihood of choking and aspiration, resulting in an Immediate Jeopardy situation. Additionally, the facility failed to accurately investigate the cause of a fall incident involving another resident. The resident, who had severe memory impairment and was at moderate risk for falls, was found lying in the bathroom. The facility did not complete a fall investigation report or obtain witness statements, contrary to their policy. The Director of Nursing confirmed that no complete fall investigation was conducted, and the facility's policy on fall investigations was not followed.
Removal Plan
- Resident was assessed by the Registered Nurse and MD
- All nursing and kitchen staff were in-serviced on facility's consistency and added diet policy
- Any food with liquid consistency added such as sauce, gravies, natural juices and syrups will have added thickener for appropriate diet consistency
- Any diet changes will be communicated to the Charge Nurse who will communicate to the kitchen
Failure to Timely Transmit MDS Records
Penalty
Summary
The facility failed to accurately and timely transmit the Minimum Data Set (MDS) for 20 out of 32 residents reviewed. The MDS is a federally mandated process for clinical assessment of all residents, which must be completed and submitted to the Quality Measure System within 14 days of the assessment being completed. The surveyor found that several residents had MDS records that were not transmitted within the required timeframe, with some records being over 120 days old. For instance, Resident #25 had an Admission MDS with an Assessment Reference Date (ARD) of 6/10/24, which was due by 6/30/24 but was not transmitted until 7/24/24. Similarly, Resident #3 had a Quarterly MDS with an ARD of 6/16/24, due by 7/14/24, but it was not transmitted until 7/24/24. The surveyor's review revealed that multiple residents had MDS records that were either not transmitted on time or were still open and not transmitted at all. For example, Resident #31 had an Admission MDS with an ARD of 10/2/24, which was due by 10/22/24, but it remained open and untransmitted. Additionally, Resident #17 had a Discharge MDS with an ARD of 9/17/24, due by 10/15/24, which was also open and not transmitted. The facility's policy and procedure for electronic transmission of the MDS, as per the Omnibus Budget Reconciliation Act (OBRA) regulations, were not adhered to, leading to these deficiencies. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS assessments were not completed and submitted in a timely manner due to other disciplines, such as the Dietician, Social Worker, and Activities staff, not completing their assigned sections. The MDS Coordinator, who worked remotely and part-time, stated that these delays contributed to the late submissions. The Licensed Nursing Home Administrator (LNHA) and DON acknowledged the late submissions according to federal and state guidelines, but no additional information was provided to address the concern.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received annual performance reviews, as required by their policy. During a survey, the Director of Nursing (DON) and Business Office Manager were unable to provide performance reviews for five randomly selected CNAs. Although the facility provided educational post-tests for these CNAs, performance reviews were missing for four of them. The DON admitted that she had not completed the required annual performance reviews for all CNAs hired within the last year, except for one. The facility's policy mandates that department directors review job descriptions with employees during orientation, when job descriptions change, and during annual performance and competency evaluations. Despite acknowledging the issue, the facility did not provide additional information or evidence of completed performance reviews for the remaining CNAs.
Deficient Kitchen Sanitation Practices Observed
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. Three dented cans of food were stored with intact canned goods, contrary to facility policy that requires dented cans to be removed and placed in a separate area. Additionally, canned goods were stored in a warm area due to a heat vent located nearby, which could compromise food safety. The surveyor also noted that three portable window air conditioning units had a blackish dust-like buildup on the vents, with one unit near the food prep area having a brown sticky substance on the vent. The Food Service Director (FSD) acknowledged that the maintenance department was responsible for cleaning the AC units. Furthermore, the surveyor observed issues with the low temperature dish machine (LTDM). The FSD tested the sanitizing solution and recorded a concentration of zero parts per million (PPM), indicating that the sanitizer was not effective. The LTDM log, which should record daily temperatures and sanitizer PPM, was missing entries for the sanitizer concentration. An empty bottle of sanitizing solution was connected to the dish machine, suggesting a lack of proper monitoring and maintenance. The facility's policies require that sanitizer concentrations be recorded and corrective actions taken if concentrations are too low, but these procedures were not followed. The survey team discussed these concerns with the Licensed Nurse Home Administrator (LNHA), Director of Nursing, and Business Office Manager (BOM), but no further comments were provided by the facility representatives.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to properly manage infection prevention and control measures, as evidenced by several observations made by surveyors. A used COVID-19 antigen test card was found exposed on a table near the entrance, despite the facility's policy requiring such items to be discarded in a biohazard bin immediately after use. The Business Office Manager and Director of Nursing confirmed the oversight, acknowledging that the test card should have been disposed of properly. Additionally, the facility's clean storage room contained overflowing sharps containers filled with contaminated needles, which had not been picked up by the licensed vendor since January 2024. This was contrary to the facility's policy, which mandates that sharps containers be sealed and stored securely until disposal. Further deficiencies were noted in the clean linen room, where a soiled heel elevator device was found on top of clean gowns, and in the hallway, where a PPE cart with visible contamination was left unattended. The Director of Nursing/Infection Preventionist acknowledged that the device should not have been in the clean linen room and that the PPE cart should have been cleaned and stored properly. These observations indicate lapses in adherence to the facility's policies on infection control and equipment handling, as confirmed by the Director of Nursing and the Licensed Nursing Home Administrator during discussions with the survey team.
Dignity Issues in Feeding and Incontinence Care
Penalty
Summary
The facility failed to maintain the dignity of residents by not providing appropriate care during feeding and incontinence management. In one instance, a Certified Nurse Aide (CNA) was observed standing over a resident while feeding them, contrary to the facility's policy that requires staff to be seated to ensure a dignified feeding process. This resident, who was dependent on staff for eating due to cognitive impairments, was not afforded the dignity and comfort outlined in their care plan. The Director of Nursing (DON) confirmed that standing while feeding a resident is not a dignified practice. In another instance, the facility did not provide the correct size of incontinence briefs (IB) for residents, leading to dignity issues. A resident reported being given IBs that were either too small or too large due to a shortage of supplies, which was confirmed by the DON as a result of shipment issues. This resident, who was cognitively intact, expressed discomfort with the ill-fitting IBs. The facility lacked a policy for the use of IBs, and the issue was discussed with the survey team without further information provided.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for two residents, leading to a deficiency. The SNF ABN is crucial as it informs beneficiaries about their potential financial liability for services not covered by Medicare and their standard claim appeal rights. The surveyor's review revealed that Resident #14 and Resident #27, who were discharged from Medicare Part A coverage, did not receive the SNF ABN. Resident #14's last covered day was on 8/2/24, and Resident #27's was on 10/9/24. The facility's Director of Nursing (DON) had filled out a form indicating that the SNF ABN was not provided to these residents, and there was no additional documentation about the communication of these forms to the residents or their representatives. During an interview, the DON stated that the beneficiary notifications were usually sent out by one of the staff at the facility. However, it was noted that Resident #27 was sent the notification on 10/24/24, while Resident #14 was not sent out at all. The surveyor discussed these concerns with the facility's Licensed Nursing Home Administrator and the DON, but no additional information was provided. This lack of proper notification to the residents about their Medicare coverage and potential financial liability constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Timely Report Resident-to-Resident Incident
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the New Jersey Department of Health (NJ DOH) within the required timeframe for two residents. An incident occurred where one resident, who had severe cognitive impairment due to Alzheimer's Disease, touched another resident's face and attempted to remove their glasses. The second resident, who was cognitively intact, reacted by swatting the first resident's hand away. The incident was witnessed by the facility's activity director, who separated the residents and informed the nurse. However, the facility did not notify the NJ DOH until four days after the incident, which was beyond the required 24-hour reporting period. The Director of Nursing (DON) acknowledged the delay in reporting the incident but could not provide a reason for the failure to report in a timely manner. The facility's policy on resident abuse did not specify a timeframe for reporting incidents, which may have contributed to the oversight. The surveyor's review of the residents' records confirmed the details of the incident and the delay in reporting. The deficiency was identified as a failure to comply with federal and state regulations regarding the timely reporting of abuse or neglect.
Failure to Notify Representative and Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the resident's representative and the Office of the Ombudsman in writing for an emergency transfer to the hospital. This deficiency was identified for a resident who was reviewed for hospitalization. The surveyor reviewed the electronic medical record and found that the resident had a recent hospitalization, as noted in the physician's progress note. The Discharge Minimum Data Set (MDS) indicated that the resident was discharged to the hospital with a return anticipated to the facility. During an interview, the Director of Nursing (DON) stated that she reviewed the book of letters containing reports to the Office of the Ombudsman and to the residents' representatives but was unable to find them. The DON further explained that she began handling notifications in May 2024 due to the absence of a social worker, resulting in no notifications being sent for April 2024. The facility's policy on emergency transfer or discharge requires notification of the representative or family members, which was not followed in this instance.
Inaccurate MDS Completion for Resident's Pneumococcal Vaccine Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, leading to a deficiency in reflecting the resident's status in accordance with federal guidelines. The deficiency was identified for Resident #7, who was observed to be seated in a wheelchair and able to communicate with the surveyor. The resident's medical record indicated a diagnosis of atrioventricular block. The admission MDS and the recent quarterly MDS both incorrectly reflected that the pneumococcal vaccine was not offered to the resident, despite documentation showing that the resident's representative had consented to and the resident had received the vaccine. The Director of Nursing (DON) acknowledged that the MDS should have been coded to reflect that the vaccine was offered and declined because the resident had already received it. The MDS Coordinator/Registered Nurse (MDSC/RN), who completed the MDS remotely and was not a full-time employee, had not been present in the facility for some time, which may have contributed to the oversight. The survey team discussed the issue with the Licensed Nursing Home Administrator (LNHA) and the DON, who confirmed the error in the MDS coding.
Failure to Address Significant Weight Changes in Residents
Penalty
Summary
The facility failed to ensure timely intervention by the Registered Dietitian (RD) for residents experiencing significant weight changes. This deficiency was identified for two residents. Resident #3 experienced a 7.98% weight gain over 30 days, with the last nutrition note documented on 9/9/2024, despite the weight change being recorded on 10/2/24. Resident #14 experienced a 5% weight loss since 9/23/24, with the last nutrition note documented on 9/21/2024. Both residents had significant weight changes that were not addressed by the RD in a timely manner, as required by the facility's policy. The RD stated that residents with significant weight changes should be re-weighed immediately, and a nutrition weight change note should be documented to address potential reasons and interventions. However, the RD admitted that not all residents with significant weight changes had been addressed. The facility's policy required monthly weights to be completed by the 5th of each month and evaluated by dietary staff by the 7th. Despite these guidelines, the RD and facility staff could not provide an explanation for the delay in addressing the significant weight changes for the residents involved.
Improper Medication Administration Observed
Penalty
Summary
The facility failed to adhere to acceptable standards of clinical practice for medication administration, as observed during a medication pass for a resident. A Licensed Practical Nurse (LPN) was seen preparing and administering medications to a resident with severe cognitive impairment. The medications included Norvasc, Cyanocobalamin, Ferrous Sulfate, Januvia, Depakote, and Colace. The LPN crushed several of these medications, including Ferrous Sulfate, and mixed them with applesauce before administering them to the resident. The deficiency was identified when it was noted that the manufacturer's instructions for Ferrous Sulfate explicitly stated that the tablets should not be split, chewed, or crushed. The LPN acknowledged this error during an interview, stating that an alternative liquid form of Ferrous Sulfate should have been obtained if the resident had difficulty swallowing the tablet. The facility's policy on medication administration requires adherence to physician orders and specified time frames, which was not followed in this instance.
Failure to Properly Label, Store, and Dispose of Medications
Penalty
Summary
The facility failed to properly label, store, and dispose of medications in one of the two medication carts inspected. During an inspection of medication cart #1, a surveyor found an opened vial of Fiasp insulin and two opened bottles of Pro-Stat AWC protein supplement, all of which were expired. The Fiasp insulin had an expiration date of 28 days once opened, and the Pro-Stat AWC had an expiration date of 90 days once opened. A Licensed Practical Nurse (LPN) acknowledged the expired status of these medications and confirmed they should have been removed from the cart. The facility's policy on the storage of medications, as provided by the Director of Nursing (DON), stated that discontinued, outdated, or deteriorated drugs or biologicals should not be used and must be returned to the dispensing pharmacy or destroyed. However, this policy was not adhered to, as evidenced by the presence of expired medications in the medication cart. The survey team discussed these concerns with the Licensed Nursing Home Administrator and DON, but no additional information was provided.
Failure to Provide Correct Liquid Consistency per Physician Orders
Penalty
Summary
The facility staff failed to ensure that a resident received liquids in the appropriate consistency at meals in accordance with physician orders. During a kitchen inspection, a surveyor observed a resident's lunch tray with a tray card listing the resident's diet, diet consistency, and liquid consistency. The tray card indicated a regular diet with mechanical soft consistency and nectar thick liquids. However, the physician's order dated 12/16/24 specified a No Concentrated Sweets (NCS) diet, mechanical soft texture, and regular/thin consistency liquids. This discrepancy was not communicated to the dietary staff, resulting in the resident receiving the incorrect liquid consistency. The dietary aide interviewed by the surveyor was unaware of the change in the resident's liquid consistency, indicating a communication breakdown between nursing and dietary staff. The facility's policy requires all staff to follow physician orders without question and mandates that dietary staff change diet texture, liquid consistency, and therapeutic diet orders based on physician directives. Despite these policies, the failure to communicate the updated physician order led to the resident receiving inappropriate liquid consistency, highlighting a lapse in adherence to established procedures.
Deficiency in Maintaining Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for a resident reviewed for unnecessary medication. The deficiency was identified during a survey when the surveyor observed the resident in bed, unable to respond to inquiries. A review of the resident's hybrid medical record revealed a physician's order for Risperidone, which was administered as per the electronic Medication Administration Record. However, the medical record lacked psychiatric consult sheets after an initial consultation in December of the previous year. The Director of Nursing confirmed the absence of psychiatric consult sheets in the resident's medical record, stating that the psychiatrist had not yet sent them to the facility. Additionally, the facility did not provide a policy regarding medical record keeping. The Licensed Nursing Home Administrator and the Director of Nursing acknowledged the missing psychiatric notes during a meeting with the survey team.
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Illustrative
What surveyors actually found near you
We read the 383 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Califon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heath Village | 6.6 mi | ★★★★★ | 8 | 0 |
| Warren Haven Rehab And Nursing Center | 8 mi | ★★★★★ | 19 | 0 |
| Country Arch Care Center | 9.4 mi | ★★★★★ | 11 | 0 |
| Rolling Hills Care Center | 10.1 mi | ★★★★★ | 0 | 0 |
| Forest Manor Hcc | 13.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.