Livingston Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, New Jersey.
- Location
- 348 E Cedar Street, Livingston, New Jersey 07039
- CMS Provider Number
- 315526
- Inspections on file
- 17
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Livingston Post Acute Care during CMS and state inspections, most recent first.
A resident admitted for IV antibiotic therapy for osteomyelitis did not receive four consecutive doses of prescribed Cefazolin due to medication unavailability and IV access issues. Facility staff did not document timely notification to the physician about the missed doses, and the medical record lacked evidence of physician awareness or alternative orders during the period of missed therapy.
The facility failed to meet the required staffing ratios as per New Jersey law, with deficiencies noted on several day shifts. From August 11 to August 24, 2024, the facility was short of CNAs on five day shifts, affecting the care of all residents. A similar deficiency was noted on one day shift in December 2024, highlighting ongoing staffing issues.
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation, as observed by a surveyor. Unlabeled and undated food items were found in a refrigerator and on carts, and the sanitizing solution in the 3-compartment sink was absent. A box fan with dust was blowing on utensils, and there was dust on the utensil rack and discolored vents and ceiling tiles. The log book for the sink was falsified, and facility policies on food storage and sanitization were not followed.
The facility failed to include a staffing contingency plan in its Facility Assessment (FA) and did not meet its own staffing requirements. The FA lacked necessary details in the staffing plan and policies, despite CMS updates. Staffing reports showed consistent shortfalls in nurse aide numbers, failing to meet the required 16-18 aides per shift.
The facility did not provide a designated dining room for residents, as required by regulations and policy. Instead, room tray services were offered, despite the facility being approved for communal dining on the first floor. During a resident council meeting, four residents expressed a desire for communal dining, which was not being provided. The facility's policy stated that residents' dining preferences should be accommodated, but this was not adhered to.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in care management. A resident's MDS did not reflect antibiotic administration, and there were discrepancies in respiratory therapy documentation. Another resident's MDS was inaccurately coded as a Significant Change in Status Assessment without proper documentation, and a third resident's pain assessment interview was conducted outside the required period. These inaccuracies reflect a failure to adhere to federal guidelines.
The facility failed to maintain adequate staffing levels and timely call bell responses, affecting several residents. Observations showed CNA to resident ratios exceeding state requirements, leading to delayed assistance. Residents reported long wait times, particularly during night shifts, with some needing to call family members for help. Call bell audits revealed response times up to 25 minutes, and a resident council meeting confirmed average wait times of at least 20 minutes.
The facility failed to administer oxygen therapy according to physician orders, improperly stored respiratory equipment, and did not obtain necessary physician orders for oxygen therapy. Observations included residents receiving incorrect oxygen levels, nebulizer masks exposed to contamination, and oxygen tubing not dated or stored properly. These deficiencies were acknowledged by facility management.
The facility exhibited multiple infection control deficiencies, including improper hand hygiene by a CNA, incorrect PPE use by staff, and contamination of clean linen. Additionally, a nurse used the same tissue for both eyes during medication administration, posing an infection risk. These actions were contrary to the facility's policies and CDC guidelines.
A resident with moderate cognitive impairment reported a fall and leg pain, but the facility failed to notify the resident's representative and physician immediately. The incident was not documented, and the physician was only informed after the resident was found in pain. The facility's policy on timely notification was not followed.
A resident with severe cognitive impairment and medical conditions was discharged from a facility without a physician's order and without documented confirmation from the home care service agency that they could provide necessary post-discharge care. The Social Worker Director sent a referral to the agency, but there was no evidence of acceptance. The resident was later taken to the hospital after the agency could not accept the referral.
A facility failed to document a discharge summary for a resident with severe cognitive impairment who was discharged home. The resident's medical record lacked a discharge summary, despite the facility's policy requiring it to include a recapitulation of the resident's stay and a final summary of their status. The facility administration did not provide additional information or confirm the presence of the summary in the electronic medical record.
A facility failed to provide adequate pain management for a resident with moderate cognitive impairment and lower back pain. Despite physician orders for Acetaminophen, there was no documented evidence of routine pain assessments from June through July 2024, and the resident's care plan lacked a pain management plan. Interviews revealed inconsistencies in pain assessment practices, with staff acknowledging that assessments should be documented every shift, but this was not done. The facility's policy required regular pain assessments, which were not followed, leading to the deficiency.
The facility failed to monitor and document a resident's condition post-fall, did not follow a physician's order for urinary catheter output documentation, and administered the wrong form of medication. A resident experienced two falls with inadequate neurocheck documentation. Another resident's catheter output was not consistently recorded, and low output was not reported to a physician. Additionally, a nurse administered a tablet instead of a prescribed capsule, contrary to facility policy.
A resident with a history of chronic conditions developed a new heel wound after admission, but the LTC facility failed to provide timely treatment and accurate documentation. The eTAR showed inconsistent entries, and the wound care policy lacked specific guidance. The facility did not provide additional policies when requested.
A facility failed to provide appropriate care for a resident with decreased range of motion and mobility, leading to a deficiency in maintaining and preventing further decline. The resident's care plan did not address impairments in both upper and lower extremities, and there was no evidence of services or interventions provided. Observations revealed contractures without assistive devices, and the facility could not provide evidence of required quarterly rehab screens.
The facility failed to monitor and document weights for two residents, leading to a deficiency in maintaining adequate nutrition and hydration. One resident experienced significant weight loss without physician notification, while another had missing weight records and duplicate orders for gastrostomy tube flushes. Staff interviews revealed a lack of communication and responsibility in addressing weight changes.
The facility failed to maintain proper dialysis communication records and provide care in accordance with professional standards for two residents requiring dialysis services. For one resident, the Dialysis Center Communication Record was inconsistently filled out, and there was no documentation of the assessment of the dialysis access site post-treatment. Another resident experienced deficiencies in care, with missing dialysis communication forms and incomplete CNA documentation for meal consumption. The facility's policies did not adequately address record-keeping or meal provision for dialysis residents.
The facility failed to post daily staffing information for two out of five days during a survey. The Nursing Home Resident Care Staffing Report was not updated for the current day shift on two occasions. The DON acknowledged the issue, and the Staffing Coordinator confirmed her responsibility to post the information daily, as per facility policy.
A facility failed to address Consultant Pharmacist recommendations for a resident with dementia and hypertension, who was prescribed Lorazepam for agitation and anxiety. Despite recommendations to specify a duration for the PRN medication, there was no follow-up with physicians or hospice, and no documentation by the primary physician or nurse practitioner about the resident's psychotropic medication regimen. The Director of Nursing acknowledged the oversight, which was contrary to the facility's policy requiring timely follow-up on such recommendations.
A surveyor observed a medication storage deficiency where two vials of Acetylcysteine were left unattended on a medication cart. The responsible nurse admitted to leaving the vials while attending to a resident, which was against the facility's policy requiring secure storage of medications. The facility's policy mandates that all drugs be stored in locked compartments and only accessible to authorized personnel.
The facility failed to maintain accurate and accessible medical records for two residents. One resident's advance directives were inconsistently documented, while another resident's pulmonary consultation plan was not properly communicated or documented. The facility's electronic medical records policy did not address these documentation issues.
The facility failed to offer or document the pneumococcal vaccine for three residents, despite their medical conditions and cognitive status. Resident #43, with multiple health issues, had no record of vaccine offer or ineligibility. Resident #62, with moderate cognitive impairment, was noted in the MDS as having declined the vaccine, but this was not documented in the EMR. Resident #148, with COPD and other conditions, was not documented as having been offered the vaccine. The facility's policy to assess and offer vaccines was not adhered to.
Failure to Administer IV Antibiotics and Notify Physician of Missed Doses
Penalty
Summary
A deficiency occurred when a resident admitted with end stage renal disease, Parkinson's Disease, type 2 diabetes, and osteomyelitis did not receive ordered intravenous (IV) antibiotic therapy as prescribed. The resident was admitted for the primary purpose of receiving IV Cefazolin to treat a bone infection. Despite physician orders for daily administration of Cefazolin, the resident did not receive four consecutive doses following admission, with the first dose not administered until several days later. The facility's policy required nursing staff to contact the pharmacy, attempt to obtain the medication from available sources, and notify the physician if a medication was unavailable. Documentation in the resident's medical record indicated that the antibiotic was not on hand and that there were difficulties establishing IV access, including unsuccessful attempts to start a line and delays in obtaining a midline due to the need for renal clearance. However, there was no documentation that the resident's physician was notified of the missed doses or the unavailability of the medication during this period, nor was there evidence of alternative orders or instructions from the physician regarding the missed therapy. Interviews with facility leadership confirmed that the expectation was for the physician to be informed of missed medication doses and for this communication to be documented in the resident's record. The record review and staff interviews revealed that the physician was not made aware of the missed doses until several days after the initial missed administrations, and the medical record did not reflect timely notification or a plan to address the missed antibiotic therapy.
Staffing Ratio Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels in nursing homes. During the investigation of complaints NJ00179449, NJ00179546, and NJ00181407, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on several day shifts. For the period from August 11, 2024, to August 24, 2024, the facility was deficient in staffing on five out of fourteen day shifts. For instance, on August 11, 2024, there were only 15 CNAs for 130 residents, whereas at least 16 were required. Similar deficiencies were noted on August 21, 22, 23, and 24, 2024, where the number of CNAs was consistently below the required ratio. Additionally, a review of staffing levels for the two weeks prior to the complaint survey, from December 22, 2024, to January 4, 2025, revealed a deficiency on one day shift. On December 22, 2024, the facility had 14 CNAs for 120 residents, falling short of the required 15 CNAs. These staffing deficiencies had the potential to affect all residents in the facility, as adequate staffing is crucial for ensuring proper care and safety for residents.
Plan Of Correction
No residents were identified as having been affected. All residents have the potential to be affected. Will add a certified nursing aide to all shifts that did not meet the requirement to be in compliance with staffing ratio of 1:8 during daytime hours, 1:10 for afternoon, and 1:14 for overnight. When an employee calls out coverage to be obtained by nursing supervisor and Director of Nursing. Director of Nursing, Staffing Coordinator and Administrator will meet daily during the week to review recruitment efforts, staffing for next day, and staffing for upcoming week. Trends identified from these meetings will be presented during monthly QAPI meeting. The facility has implemented a multifaceted approach for recruitment and retention of employees, which includes increased utilization of PRN/Per diem staff (Staff hired without any set hours, usually staff who have another job and pickup extra shifts when the need arises), Multimedia advertisements, Partnership with schools, Pick-up shift bonuses, Text message campaigns. Flyers placed around the buildings and on social media. The facility continues to utilize a recruitment company to do paid campaigns with Indeed, and other social media platforms to recruit nursing staff. Daily update emails and weekly meetings help to identify trends in hiring and review all new hires and where candidates stand in the hiring process. Targeted advertising in place to attract licensed nurses and aides. Employee engagement is led by management team/department heads to facilitate staff engagement and reduce employee turnover. Exit interviews being held to determine why staff are leaving. Referral bonus in place for any staff who refer a friend who gets hired, new hire bonus in place and paid out over a year of hire to ensure that employees stay in the position.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation in accordance with professional standards, as observed by the surveyor. During a tour of the kitchen, the surveyor noted several deficiencies, including unlabeled and undated food items in a refrigerator and on wheeled carts. The refrigerator contained packages of waffles, a bowl of salad, and a pan of pasta, all without labels or dates, and debris was found at the bottom of the refrigerator. Additionally, food items on the carts were mostly unlabeled and undated, with only two items properly marked. The surveyor also observed issues with the facility's sanitation practices. DA#2 was seen washing pans in a 3-compartment sink, but the sanitizing solution in the third compartment was not present, as indicated by a test strip showing a result of zero. The test strips used did not have an expiration date, and DA#2 was not aware of the proper use of the sanitizing solution. Furthermore, a box fan with dust accumulation was blowing air on utensils, and there was an accumulation of dust on the utensil rack, as well as discolored air vents and ceiling tiles. The facility's documentation and staff training were also found lacking. The log book for the 3-compartment sink was initially missing and later found, showing entries with DA#2's initials for days he did not work. The LNHA confirmed that no other staff shared the same initials, indicating falsification of records. The facility's policies on food storage and sanitization were not adhered to, contributing to the observed deficiencies.
Deficiency in Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included the necessary resources to establish policies and procedures for a staffing contingency plan, as required by CMS updates. This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unable to provide a comprehensive Facility Assessment (FA) that included a staffing contingency plan. The FA, dated July 23, 2024, lacked details in Part 3, Section 3.2 Staffing Plan, and Section 3.5 Policies and Procedures, which are essential for managing staffing during both regular operations and emergencies. Despite the LNHA's awareness of the CMS updates effective from August 8, 2024, the FA did not reflect these requirements. Additionally, the facility did not meet its own staffing plan as outlined in the FA. The FA indicated a need for 16-18 nurse aides to meet resident needs at any given time. However, staffing reports for the weeks of September 1-7 and September 8-14, 2024, showed that the facility consistently fell short of this requirement. Specifically, nurse aide staffing was below the minimum of 16 on multiple occasions across day, evening, and night shifts. The surveyor, upon reviewing these discrepancies with the LNHA, DON, Regional Nurse Consultant (RNC), and Infection Preventionist (IP), noted the absence of a staffing contingency plan as per the CMS update and the Quality Safety Oversight memo. The facility did not provide any additional documentation to address these concerns.
Facility Fails to Provide Designated Dining Room for Residents
Penalty
Summary
The facility failed to provide a designated dining room for residents, as required by federal regulations, the approved floor plan, and facility policy. This deficiency was identified during a survey conducted by surveyors who met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA admitted that since her tenure began, there had been no physical dining area, resulting in the absence of communal dining services for the 126 residents. Instead, the facility offered room tray services. The surveyors noted that the facility was approved for communal dining on the first floor, according to the submitted floor plan, but this service was not being provided. Further investigation revealed that during a resident council meeting, four residents expressed a desire for communal dining, which was not being offered. The facility's Accommodation of Needs Policy, updated in April 2024, stated that residents' individual needs and preferences should be accommodated, including their dining preferences. However, the facility failed to adhere to this policy by not providing a communal dining option. The survey team communicated these concerns to the facility management, but no additional information was provided during the exit conference.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For Resident #148, the MDS did not reflect the administration of antibiotics, despite documentation in the electronic Medication Administration Record (eMAR) indicating that Cephalexin was given. Additionally, there was a discrepancy in the recorded minutes and days of respiratory therapy, as the MDS showed different values than those documented in the resident's records. The Registered Nurse/MDS Coordinator (RN/MDSC) acknowledged the discrepancies but did not provide a satisfactory explanation. Resident #62's MDS was inaccurately coded as a Significant Change in Status Assessment (SCSA) without proper documentation to support a significant change in the resident's condition. The resident's cognitive status was assessed as moderately impaired, but there was no evidence of a significant change that warranted the SCSA. Furthermore, the MDS inaccurately indicated that the resident had declined a pneumococcal vaccine, with no supporting documentation in the medical record. For Resident #209, the Quarterly MDS was completed with an incorrect timeline for the pain assessment interview, which was conducted outside the required look-back period. The RN/MDSC was unable to provide a clear response regarding the timing of the assessment. These inaccuracies in MDS coding reflect a failure to adhere to federal guidelines, impacting the accuracy of resident assessments and care planning.
Inadequate Staffing and Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely response to call bells, affecting seven residents. Observations revealed that the Certified Nursing Aide (CNA) to resident ratio exceeded the mandated New Jersey staffing law requirement of 1:8, with ratios of 1:8.6 and 1:9 on different days. This staffing inadequacy contributed to delayed responses to residents' call bells, as reported by several residents. Resident #83, who had intact cognition and required assistance with toileting hygiene, reported long wait times for call bell responses, particularly during the night shift. The resident had to call a family member to get assistance after the call bell was not answered, and the staff only responded after the family member contacted the facility. Similar issues were reported by Resident #100, who had a sacral pressure ulcer and other medical conditions, and Resident #36, who experienced long wait times during night shifts. The facility's call bell audits showed response times ranging from 4 to 25 minutes, with some instances of staff re-education when longer wait times were noted. However, the audits were infrequent and did not cover all shifts adequately. During a resident council meeting, four residents reported average call bell response times of at least 20 minutes. The facility's policy stated that calls for assistance should be answered as soon as possible, but this was not consistently achieved, as evidenced by the surveyor's observations and resident reports.
Deficiencies in Respiratory Care and Infection Control Practices
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident who was observed receiving 4 liters per minute (LPM) of oxygen via nasal cannula, despite the physician's order specifying 2 LPM. The discrepancy was confirmed by the Unit Manager/LPN, who was unaware of who changed the oxygen setting. This oversight was acknowledged by the Director of Nursing as a human error. Another resident was observed with a nebulizer mask improperly stored, exposing it to environmental contamination. The resident's care plan lacked documentation on the proper storage of respiratory equipment. Additionally, a pulmonary consultation's recommendations were not communicated to the primary care physician, and there was no documentation of the physician's agreement or disagreement with the recommendations. The Assistant Director of Nursing/Infection Preventionist confirmed the need for proper documentation and storage practices. Further observations revealed that several residents had oxygen tubing and nebulizer masks that were not dated or stored in bags when not in use, contrary to infection control measures. One resident was found to be on oxygen therapy without a physician's order, and the facility's policy did not provide guidance on dating or storing respiratory equipment. These deficiencies were acknowledged by the facility management during meetings with the survey team.
Infection Control Deficiencies in PPE Use and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations during a survey. Several staff members, including a Certified Nursing Aide (CNA), were observed not performing hand hygiene after glove removal, which is a critical step in preventing the spread of infection. The CNA admitted to not performing hand hygiene due to the absence of alcohol-based hand rub (ABHR) in the resident's room, despite having received prior education on hand hygiene and PPE use. Additionally, improper use of personal protective equipment (PPE) was noted among staff members. A CNA was observed with a surgical mask improperly worn below the nose and mouth while assisting a resident, and another CNA failed to wear a PPE gown during high-contact care activities with a resident on Enhanced Barrier Precautions (EBP). These actions were contrary to the facility's infection control policies and CDC guidelines, which require proper PPE use to prevent the spread of multidrug-resistant organisms (MDROs). Further deficiencies were observed in the handling of clean linen and medication administration. A linen cart, considered clean, was found to contain food items, which is against the facility's policy for maintaining hygienically clean linen. During a medication pass, a nurse used the same tissue to wipe both eyes of a resident after administering eye drops, which was acknowledged as an infection risk by the nurse and the unit manager. These observations highlight lapses in maintaining infection control standards during routine care activities.
Failure to Notify Resident's Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative and physician of a change in condition in a timely manner. The resident, who had moderate cognitive impairment, reported to the nursing staff that they had fallen the previous day and were experiencing leg pain. However, there was no documentation of the fall, and the resident's representative and physician were not immediately informed of the incident. The resident was later found crying in pain, and only then was the physician notified, and an x-ray was ordered. Attempts to contact the resident's representative were made, but no immediate notification was documented. The facility's policy on accidents and incidents requires immediate notification of the resident's physician and family, which was not adhered to in this case. The Licensed Practical Nurse involved could not recall if the resident's representative was notified and had to refer to her notes. The facility management acknowledged the lapse in following their process for notifying the resident's representative and physician. The survey team reviewed the facility's policy and found it was not followed, leading to the deficiency.
Failure to Ensure Safe Discharge Due to Lack of Physician's Order and Home Care Referral Confirmation
Penalty
Summary
The facility failed to ensure a safe discharge for a resident by not obtaining a physician's order for discharge and not documenting the acceptance of a referral for home care services. The resident, who had severe cognitive impairment and medical conditions including a pressure ulcer, was discharged without confirmation from the home care service agency that they could provide the necessary post-discharge care. The Social Worker Director (SWD) stated that the referral was sent to Home Care Service Agency #1 (HCSA#1), but there was no documented evidence of acceptance or approval from the agency. The discharge planning process was initiated at the time of the resident's admission, involving the resident's representative and the facility's interdisciplinary team. However, the facility's documentation did not include a physician's order for discharge, and the SWD did not receive or document confirmation from HCSA#1 that they could accept the referral. The SWD later learned that HCSA#1 could not take the resident and had referred them to another agency, HCSA#2, but by that time, the resident had already been taken to the hospital by their representative. The facility's policies required that a discharge summary and post-discharge plan be developed, including arrangements for follow-up care and services. Despite these requirements, the facility did not provide evidence that the home care referral was accepted or that a physician's discharge order was obtained. The lack of documentation and communication between the facility and the home care agency contributed to the failure to ensure a safe discharge for the resident.
Failure to Document Discharge Summary for Resident
Penalty
Summary
The facility failed to document a discharge summary for a resident who was reviewed for discharge. The resident, identified as having severe cognitive impairment with a BIMS score of 03 out of 15, was admitted with medical diagnoses including a pressure ulcer of the sacral region, abnormal posture, and cognitive communication deficit. The resident had a planned discharge to home/community, but upon review, the hybrid medical record did not contain a discharge summary. During the survey, the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse Consultant, and Regional LNHA were informed of the missing discharge summary. The facility's policy requires a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status, which was not present in this case. Despite the facility's policy and the surveyor's request for confirmation, the facility administration did not provide additional information or confirm the presence of a discharge summary in the electronic medical record.
Inadequate Pain Management for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate pain management for a moderately impaired resident, identified as Resident #209, who was admitted with diagnoses including lower back pain, hypertension, and metabolic encephalopathy. The resident's Quarterly Minimum Data Set indicated moderate cognitive impairment. Despite having physician orders for pain management with Acetaminophen, there was no documented evidence of routine pain assessments from June through July 2024, and the resident's care plan did not include a plan for pain management. Interviews with the Director of Nursing (DON) and other nursing staff revealed inconsistencies in the facility's pain assessment practices. The DON stated that pain assessments were conducted upon admission and every shift, but acknowledged that documentation was not always required. The Unit Manager and Licensed Practical Nurses confirmed that pain assessments should be documented every shift, but this was not consistently done for Resident #209. The facility's policy required pain assessments to be conducted and documented regularly, but this was not adhered to in practice. The facility's Pain Assessment and Management policy outlined the need for consistent pain assessment and documentation, especially for acute or worsening chronic pain. However, the facility failed to follow these guidelines, resulting in a lack of documented pain assessments for Resident #209. The survey team highlighted these deficiencies to the facility management, who acknowledged the oversight and confirmed that the pain assessment would be reinstated in the resident's orders.
Deficiencies in Monitoring, Documentation, and Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of a resident's condition following falls. Resident #148 experienced two falls, one on 8/29/24 and another on 9/04/24, with the latter resulting in skin tears and a hospital visit for a CT scan. Despite the nurse practitioner's note indicating the resident was on neurochecks, there was no documented evidence of such monitoring post-fall, except on the day of the incidents. The Director of Nursing acknowledged the expectation for nurses to document every shift for three days post-incident, which was not adhered to in this case. Another deficiency involved the failure to follow a physician's order regarding urinary catheter output documentation for Resident #358. The resident had a history of urinary tract infection and obstructive uropathy, with a physician's order to document catheter output every shift. However, the electronic Treatment Administration Record showed multiple instances of missing or low urine output documentation, with no evidence of physician notification or actions taken for low output. The Assistant Director of Nursing confirmed the expectation for nurses to document output every shift and notify physicians of low output, which was not met. The third deficiency was observed during medication administration for Resident #260, where a Registered Nurse administered a tablet form of Docusate Sodium instead of the prescribed capsule form. The nurse acknowledged the error upon questioning and stated the procedure would be to contact the physician for an order change. The facility's policy requires medications to be administered as prescribed, which was not followed in this instance. The Unit Manager and Consultant Pharmacist both confirmed that the correct dosage form should be administered or the order changed if necessary.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. The deficiency was identified for a resident who developed a new wound on the right heel after being admitted to the facility. The resident, who was cognitively intact and had a history of chronic kidney disease, heart failure, hypertension, diabetes mellitus, and osteoarthritis, reported the new wound to the surveyor. The facility's records indicated that the wound was first noted on 9/09/24, and treatment with Medihoney was ordered, but there was a lack of documentation and timely initiation of treatment. The surveyor found discrepancies in the facility's documentation practices. The electronic Treatment Administration Record (eTAR) showed inconsistent entries for skin evaluations, with one entry marked as 'n' instead of the required numerical codes. The Director of Nursing (DON) was unable to explain the discrepancy initially but later clarified that 'n' indicated no wound or change. Additionally, there was no documentation in the nurse's progress notes about the new wound, and the wound treatment order was missing for the period between 9/09/24 and 9/11/24. The facility's wound care policy was reviewed and found to be lacking in specific guidance on wound assessments and documentation. The surveyor noted that the policy required documentation of any change in the resident's condition, but this was not adequately followed. Despite requests for additional policies related to wound care and skin assessments, the facility did not provide any further information. The surveyor's findings highlighted the facility's failure to maintain accurate and timely documentation and to follow established protocols for wound care.
Failure to Address Resident's Range of Motion Impairments
Penalty
Summary
The facility failed to provide appropriate care for a resident with decreased range of motion (ROM) and mobility, leading to a deficiency in maintaining and preventing further decline in the resident's condition. The resident, who was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had impairments in both upper and lower extremities. Despite these impairments, the resident's personalized care plan did not address these issues, and there was no documented evidence of services or interventions provided to address the impairments. Observations and interviews revealed that the resident had bilateral upper and lower extremities contractures, and no assistive devices or splints were provided since the resident's admission. The Director of Rehabilitation (DoR) and other staff members were unable to provide evidence of quarterly rehab screens for the resident, which were supposed to be part of the facility's process. Additionally, the therapy screen forms for other residents were incomplete, lacking necessary details such as the names of the occupational therapy staff and whether evaluations were recommended. The facility's policy on range of motion devices did not include information about passive range of motion (PROM), and there was no policy provided regarding PROM. The surveyor's inquiries revealed that the resident was not included in the therapy screen list, and the facility management could not provide evidence of quarterly rehab screens for the resident. The lack of a comprehensive care plan and failure to provide necessary interventions and documentation contributed to the deficiency identified by the surveyors.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' weights, leading to a deficiency in maintaining adequate nutrition and hydration. For Resident #2, the facility did not perform or document monthly weights and re-weighs as required. Despite a significant weight loss of 32.8 pounds within a month, there was no evidence that the physician was notified. The resident's medical records showed a history of various health conditions, including diabetes, chronic kidney disease, and heart failure, which necessitated careful nutritional monitoring. The dietitian noted the weight loss but did not communicate it to the physician, and the Unit Manager failed to enter the re-weighs into the electronic medical records. For Resident #67, the facility did not clarify duplicate physician orders for gastrostomy tube flushes, which were transcribed and signed off by nurses without correction. The resident, who was dependent on tube feeding due to severe cognitive impairment and other health issues, had missing weight records for certain months, and the facility did not follow the physician's order for monthly weight checks. The dietitian documented missing weights but did not follow up on them, and the Unit Manager acknowledged that weights were not taken or documented as required. The facility's policy on weight assessment and intervention was not adhered to, as evidenced by the lack of proper weight monitoring and physician notification for significant weight changes. The surveyor's interviews with staff revealed a lack of communication and responsibility in documenting and addressing weight changes, contributing to the deficiency in providing adequate nutrition and hydration to the residents.
Deficiencies in Dialysis Care and Documentation
Penalty
Summary
The facility failed to maintain proper dialysis communication records and provide care in accordance with professional standards for two residents requiring dialysis services. For Resident #98, the Dialysis Center Communication Record (DCCR) was inconsistently filled out, with several dates showing incomplete documentation. The facility's policy did not address the protocol for completing the communication form, and the Licensed Practical Nurse (LPN) confirmed that the expectation was for the record to be fully completed upon the resident's return from dialysis. Additionally, there was no documentation of the assessment of the dialysis access site post-treatment for several dates. Resident #458, who had severe cognitive impairment and multiple health issues including chronic kidney disease and diabetes, also experienced deficiencies in care. The facility failed to provide dialysis communication forms for this resident, and there were no progress notes for several dates when the resident was sent to or returned from dialysis. Furthermore, the Certified Nurse Aide (CNA) documentation for the resident's eating and percentage consumed was largely incomplete, with 84 out of 90 entries left blank. This lack of documentation did not reflect the resident's meal consumption or the assistance provided during meals. The facility's policies on dialysis communication and activities of daily living did not adequately address the record-keeping requirements or the provision of meals and snacks for dialysis residents. The surveyor's interviews with staff revealed inconsistencies in the understanding and implementation of these policies, contributing to the deficiencies observed in the care of Residents #98 and #458.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on two out of five days during the survey. On two separate occasions, the Nursing Home Resident Care Staffing Report (NHRCSR) was not updated for the current day shift. Specifically, on the morning of 9/16/24, the NHRCSR posted was dated for the previous day, 9/15/24, and similarly, on 9/17/24, the report was dated for 9/16/24. This oversight was observed by the surveyor upon entry into the facility on both days. The Director of Nursing (DON) acknowledged the issue when notified by the surveyor, stating that the Staffing Coordinator (SC) was responsible for posting the NHRCSR. The SC confirmed her responsibility and recognized the importance of posting the staffing information daily to inform residents and their families about the staffing levels. The facility's policy, updated in 4/2024, mandates that direct care daily staffing numbers be posted for every shift. Despite the acknowledgment of the deficiency, the facility management did not provide additional information or refute the findings during the exit conference.
Failure to Address Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident reviewed for unnecessary medications. The resident, who had diagnoses including unspecified dementia with psychotic disturbance and hypertension, was observed to be alert and verbally responsive but had moderate cognitive impairment. The resident had a physician's order for Lorazepam to be given as needed for agitation and anxiety, and a care plan involving the use of antipsychotic medication Seroquel. However, there were no psychiatry consultant notes after February 2024, and the resident's representative had requested that the primary physician manage the medication regimen. The CP reports from June, July, and August 2024 recommended specifying a duration for the PRN psychoactive medication Lorazepam unless a clinical rationale was documented by the physician. Despite these recommendations, there was no documentation of follow-up with physicians or hospice regarding the CP's suggestions. The Director of Nursing (DON) acknowledged reviewing the August 2024 CP report and the Medication Administration Record (MAR) but had not yet followed up with the physician or hospice. The facility's policy on psychotropic medication use and medication regimen reviews required timely follow-up on CP recommendations, with documentation of any actions taken. However, the surveyor found that the facility did not adhere to these policies, as there was no documentation by the primary physician or nurse practitioner about reviewing the resident's psychotropic medication regimen. The DON stated that the Assistant Directors of Nursing (ADONs) were responsible for reviewing CP recommendation reports, with an expectation of follow-up within two weeks, but this was not done in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and appropriately, as observed by a surveyor during an initial tour. On the third floor, a medication cart was found with two vials of Acetylcysteine left unattended on top. The nurse responsible for the cart admitted to leaving the vials there while attending to a resident, intending to return them to the refrigerator. This action was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. The surveyor confirmed with the Consultant Pharmacist that medications should never be left unattended or unsecured. The Director of Nursing also acknowledged that medications should not be left on top of the cart unattended. The facility's policy, last updated in April 2024, clearly states that drugs and biologicals must be stored in a safe, secure, and orderly manner, under proper conditions. Despite this policy, the facility did not provide any further pertinent information to address the observed deficiency.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For the first resident, there was a discrepancy in the documentation of their advance directives. Although the resident's medical records, including the POLST and care plan, indicated a DNR status, the physician's progress notes did not accurately reflect this. The facility's management acknowledged the inconsistency but did not provide additional information or policies addressing medical record accuracy. For the second resident, the facility did not properly document or follow up on a pulmonary consultation. The pulmonologist recommended a treatment plan that included duoneb and monitoring of oxygen saturation, but this plan was not communicated to or agreed upon by the primary care physician or nurse practitioner. The DON later revealed that the pulmonologist verbally advised against the plan, but this was not documented. Additionally, there were errors in the nurse practitioner's notes, which were not corrected until after the surveyor's inquiry. The facility's policy on electronic medical records did not address the issues of accuracy or documentation, contributing to the deficiencies observed. The survey team met with facility management multiple times, but no further information or corrective actions were provided to address the documentation issues identified during the survey.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer or document the administration or ineligibility of the pneumococcal vaccine for three residents. Resident #43, who was cognitively intact, had multiple medical conditions including metabolic encephalopathy, multiple myeloma, type 2 diabetes, hypertension, morbid obesity, anemia, and asthma. Despite these conditions, there was no documentation in the resident's medical record indicating that the pneumococcal vaccine was offered, declined, or that the resident was ineligible. The Licensed Nursing Home Administrator (LNHA) was unable to provide documentation to support the claim that the resident was not eligible for the vaccine. Resident #62, who had moderate cognitive impairment, was documented in the Minimum Data Set (MDS) as having been offered and declined the pneumococcal vaccine. However, there was no documentation in the electronic medical record (EMR) or paper chart to support this, nor were there any physician orders for the vaccine. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the lack of documentation and was unable to provide further information on the resident's vaccination status. Resident #148, who was cognitively intact and had conditions such as essential hypertension, anemia in chronic kidney disease, and chronic obstructive pulmonary disease (COPD), was not documented as having been offered the pneumococcal vaccine. There was no evidence in the medical records that the vaccine was offered, declined, or that education about the vaccine was provided. The ADON/IP confirmed the absence of documentation and stated that the vaccine should have been offered. The facility's policy required that all residents be assessed for vaccine eligibility and offered the vaccine unless contraindicated, but this was not followed in these cases.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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