Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcauley Hall Health Care Cente during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when surveyors observed an opened half-full apple juice in the walk-in refrigerator that the FSD said should have been discarded after 48 hours, cook top burners coated with a thick black grease-like substance, and a dry storage room temperature of 87.8 degrees F that the MD and FSD said was too hot. Surveyors also observed a handwashing sink attached to a food prep surface with no partition between the sink and the prep area.
A resident received a medication review involving metoprolol succinate ER ordered for HTN with hold parameters. The RN prepared the med, obtained VS showing a low BP and a HR of 64, and then documented the med as held in the progress notes. The eMAR did not require a parameter entry, and the physician order did not include the parameters when the med was held, reflecting a significant medication error and failure to follow professional standards of practice.
The facility failed to ensure that the IP, DON, and MD attended the required quarterly QA meetings, as evidenced by missing signatures on the sign-in sheets for the last three quarters. This was confirmed through interviews with the LNHA and DON, who could not recall attending the meetings.
The facility failed to maintain proper infection control practices and follow physician's orders during a pressure ulcer treatment for a resident. The RN/UM did not adhere to hand hygiene protocols, used a gloved hand to spread ointments, and did not disinfect the bedside table. Additionally, the facility did not consistently monitor and document the measurements of the resident's sacral wound.
The facility failed to maintain a system of record keeping for DEA Form-222, used for ordering controlled substances. A missing form and lack of a tracking log were found, and the DON admitted to not making copies of the forms. Additionally, the facility did not have a policy for handling narcotic medications and DEA 222 forms, leading to a deficiency in their pharmaceutical services.
The facility failed to maintain a safe and homelike environment in the residents' patio, laundry area, and a kitchenette. Observations revealed ripped screens, peeling paint, and unclean conditions. Staff interviews indicated a lack of accountability and documentation for cleaning and maintenance tasks, with budget constraints cited as a reason for some deficiencies.
The facility failed to provide mandatory training on the QAPI program to all staff, as evidenced by the absence of QAPI education in the education files of five CNAs. The LNHA and DON confirmed the lack of a policy for mandatory QAPI education and acknowledged that the training had not been conducted.
The facility failed to ensure that five CNAs had the mandatory behavioral health training. The surveyor found that the Employee Official Inservice Transcript did not include the required training, and the LNHA and DON confirmed the absence of a policy or procedure for this mandatory education.
The facility failed to verify the credentials of newly hired licensed staff before their hire dates, as required by its abuse policy. Two out of four newly hired staff members reviewed had license verifications dated after their hire dates, which was confirmed by the DON and LNHA during a meeting with surveyors.
A resident with severe cognitive impairment was allegedly forced by a CNA to attend activities despite verbal refusal, and the incident was not reported to NJDOH within the required timeframe. The delay in reporting violated the facility's policy and regulatory requirements.
The facility failed to update the PASaRR for a resident with major depressive disorder, unspecified psychosis, and PTSD, leading to the omission of these diagnoses in the PASaRR Level I Screen. Despite the resident receiving psychotherapy for PTSD, the PASaRR was not updated, and the resident was not referred for a Level II PASaRR evaluation. The deficiency was identified during a surveyor's review and interviews with facility staff.
The facility failed to obtain a physician's order for droplet precaution and did not ensure the required posted sign for droplet and contact precautions was followed for a resident with RSV. The resident's room lacked appropriate signage, and there was no physician's order for droplet precaution, despite the facility's policy requiring both.
The facility failed to provide appropriate care for a resident's hemodialysis access site and did not develop a care plan for the same. The deficiency was identified during an observation and confirmed through a review of medical records and an interview with the RN/UM, who acknowledged the lack of orders and documentation for monitoring the dialysis access site.
The facility failed to ensure the posted Resident Care Staffing Report was up to date and accurate. Surveyors found that the report did not include the resident census, did not indicate if an RN was on duty, and did not specify the total number and actual hours worked by nursing staff. The LNHA and DON were unaware of the specific requirements, and the facility lacked a staffing policy.
A facility failed to maintain complete and accessible medical records for a resident with asthma, hypertension, and heart failure. The electronic medical record was incomplete, only showing information from January 2024 after a readmission. Despite attempts to fix the issue, the complete record remained inaccessible.
The facility failed to ensure consistent coordination and communication between staff and hospice for a resident with multiple diagnoses, resulting in only two documented communications out of 28 hospice visits over nine months. An incident where the resident fell was not reported to hospice, highlighting the deficiency.
The facility failed to issue the required Medicare Beneficiary Protection Notification for two residents. The NOMNC was delivered on the last covered day of service instead of at least two calendar days before the end of Medicare-covered services. The facility did not have a formal policy in place for SNF Beneficiary Notification.
The facility failed to provide written notification to residents, their representatives, and the LTCO regarding the reason for hospital transfers for two residents. Interviews revealed that the required notifications were not being sent, and the facility did not provide additional information to address this deficiency.
The facility failed to provide written notification of the bed hold policy to residents or their representatives prior to hospital transfers. Interviews revealed confusion about who was responsible for sending these notifications, and the facility did not have a specific policy for notifying residents, except for private pay residents.
The facility failed to accurately code the MDS for a resident, leading to a deficiency. The resident's quarterly MDS incorrectly coded the use of bedrails as a restraint, despite the care plan indicating their use for positioning and mobility. The RN/MDS Coordinator admitted to not verifying the auto-populated data, resulting in the error.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store potentially hazardous foods in a manner to prevent food borne illness and failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for the development of food borne illness. During observation with the Food Services Director, a handwashing sink was seen attached to a stainless-steel food preparation area with no partition between the sink and the food preparation surface. In the walk-in refrigerator, an opened half-full apple juice with an open date of 7/23/25 was observed, and the FSD stated it should have been discarded after 48 hours of opening. In the food preparation area, 3 of 12 cook top burners were soiled with a thick black grease-like substance that could be lifted with the tip of a pen, and the FSD stated these burners should have been cleaned. In the dry storage room, with the Maintenance Director present, the temperature was observed at 87.8 degrees Fahrenheit, and both the MD and FSD stated the room was too hot.
Medication Held Without Required Vital Sign Documentation
Penalty
Summary
A significant medication error occurred for Resident #39 when metoprolol succinate ER 25 mg, ordered as 0.5 tablet by mouth in the morning for hypertension with parameters to hold if systolic blood pressure was less than 100 or heart rate was less than 60, was prepared for administration by the RN. The surveyor observed the RN prepare 9 medications for the resident, then obtain vital signs showing a blood pressure of 92/59 and a heart rate of 64. The RN documented a hold on the metoprolol in the progress notes, but the eMAR did not require a parameter entry, and during medication reconciliation review it was revealed that the physician's order did not include the parameters when the metoprolol was held. The survey team later discussed the omission of the resident's blood pressure and heart rate for the held metoprolol and the RN's failure to follow professional standards of practice.
Failure to Ensure Required Attendance at QA Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP), Director of Nursing (DON), and Medical Director (MD) attended the quarterly Quality Assurance (QA) meetings as required. This deficiency was identified during a review of the QA meeting sign-in sheets for the last three quarters. Specifically, the DON did not attend the QA meetings on June 30, 2023, and January 12, 2024. The IP did not attend the QA meeting on June 30, 2023, and the MD or a designee did not attend the QA meeting on September 30, 2023. These absences were confirmed through interviews with the Licensed Nursing Home Administrator (LNHA) and the DON, who could not recall attending the meetings or signing the attendance sheets. The facility's Quality Assurance Performance Improvement (QAPI) plan mandates that the MD, DON, and IP be active members of the quality committee and participate in QAPI activities. The plan also specifies that the administrator is responsible for ensuring QAPI implementation and reporting to the board of trustees. The failure to adhere to these guidelines was confirmed by the surveyor through interviews and record reviews, indicating a lapse in compliance with the facility's own QAPI plan and regulatory requirements.
Failure to Maintain Infection Control and Follow Physician's Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to maintain proper infection control practices during a pressure ulcer (PU) treatment for Resident #39. The Registered Nurse/Unit Manager (RN/UM) did not follow appropriate hand hygiene protocols, such as using the same paper towel to turn off the faucet and not changing gloves after cleansing the wound. Additionally, the RN/UM used a gloved hand to spread ointments instead of an applicator and did not disinfect the bedside table after the treatment, which could increase the risk of infection for the resident. The RN/UM did not follow the physician's order for the PU treatment. The treatment observed by the surveyor did not include the use of Adaptic as prescribed, and the RN/UM did not date the dressing before applying it to the resident. Furthermore, the RN/UM used a red marker from her pocket to date the dressing and returned it to her pocket, which is against infection control practices. The facility also failed to follow the wound care center physician's recommendations, as the February and March 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) did not include a prn order for Nystatin Cream as recommended. The facility did not consistently monitor and document the measurements of Resident #39's sacral wound. Weekly skin assessments often lacked measurements, and progress notes from 02/11/24 to 3/06/24 did not include the necessary weekly measurements. The facility's policy requires weekly documentation of wound measurements to monitor the effectiveness of the treatment and any changes in the wound's status, but this was not adhered to in Resident #39's case.
Failure to Maintain DEA Form-222 Records and Policy
Penalty
Summary
The facility failed to maintain a system of record keeping for DEA Form-222, which is used for ordering controlled substances. During a review, it was found that the facility's binder contained several non-executed DEA 222 forms, but one form (Order Form Number: 202074233) was missing. The Director of Nursing (DON) admitted that she did not make copies of the forms before sending them to the pharmacy and did not have a log to track the forms. This lack of documentation made it difficult to ensure that the medications ordered matched those received and to prevent potential diversion of controlled substances. Additionally, the facility did not have a policy or procedure in place for handling narcotic medications and DEA 222 forms, which further contributed to the lack of accountability and tracking of controlled substances. When questioned, the DON acknowledged the importance of keeping track of DEA 222 forms to prevent diversion and ensure the correct amount of medication was received. Despite this, the facility did not have a policy on narcotics, and the DON had to create a process and tracking log only after the surveyor's inquiry. The surveyor's review of the DEA Form-222 instructions highlighted the requirement for purchasers to make a copy of the order form before mailing the original to the supplier and to keep records of all executed and unaccepted forms for inspection for two years. The facility's failure to adhere to these requirements resulted in a deficiency in their pharmaceutical services.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment in several areas, including the residents' patio, the laundry area, and a kitchenette. Observations revealed ripped screens, peeling paint, and displaced plastic screen panels in the patio area. The laundry area had grayish substances on the ceiling vent, brownish discoloration on ceiling tiles, and a puddle of water on the floor. The kitchenette had a dirty and damaged refrigerator gasket, sediment in the ice machine vent, and an unclean coffee pot, among other issues. Interviews with staff indicated a lack of accountability and documentation for cleaning and maintenance tasks. The Licensed Nursing Home Administrator (LNHA) and the Director of Maintenance (DM) acknowledged the issues but cited budget constraints and lack of documentation for some of the maintenance recommendations. The DM mentioned that the ripped screen was scheduled for replacement, but there was no documentation to support this. The LNHA admitted that the facility had no specific policy regarding the environment, and the DM confirmed that some maintenance recommendations were made verbally and not documented. The Food Service Director (FSD) and the Director of Nursing (DON) also acknowledged the deficiencies in the kitchenette. The FSD stated that the kitchen staff was responsible for stocking and maintaining the refrigerator, while housekeeping was responsible for cleaning. However, there was no accountability log for these tasks. The DON expected staff to notify her and housekeeping of any issues, but this was done verbally and not documented. The housekeeping and laundry service agreement with an outside source did not specify detailed cleaning and maintenance responsibilities, leading to further confusion and lack of accountability.
Failure to Provide Mandatory QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through the review of five Certified Nurse Assistants' (CNAs) education files, which revealed the absence of the mandated QAPI education training for the year 2023. During meetings with the surveyors, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) confirmed that there was no policy or procedure in place for the mandatory education of CNAs on the QAPI program. The LNHA acknowledged that the annual in-service training for the QAPI program had not been conducted and stated that it would be added to the list of yearly mandatory training moving forward.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that the staff had the mandatory behavioral health training for five Certified Nursing Assistants (CNAs) reviewed for mandatory education. The surveyor requested five random CNA education files for the year 2023 and found that the Employee Official Inservice Transcript did not include the mandated behavioral health education training. During a meeting with the surveyors, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) confirmed that they did not have a policy or procedure for the CNA mandatory education and that the annual in-service for behavioral health training had not been conducted. The LNHA acknowledged that the in-services for behavioral health training should have been done and stated that it has been added to the list of yearly mandatory training for the CNAs moving forward.
Failure to Verify Credentials of Newly Hired Licensed Staff
Penalty
Summary
The facility failed to implement its abuse policy by not verifying the credentials of newly hired licensed staff before their hire dates. Specifically, two out of four newly hired staff members reviewed did not have their licenses verified prior to their employment. Staff #1, an LPN hired on 4/27/22, had a license verification printout dated 3/07/24, and Staff #4, an RN hired on 12/08/22, had a license verification printout also dated 3/07/24. This discrepancy was identified during a review of five randomly selected new employee files for license verification. During a meeting with the surveyors, the DON and LNHA were unable to explain why the license verifications for Staff #1 and #4 were dated after their hire dates. The facility's policy on abuse, neglect, and exploitation of residents' property requires the verification of licenses, certifications, and criminal backgrounds before employment. The failure to adhere to this policy was confirmed by the DON, who stated that Human Resources staff were responsible for these verifications but could not account for the oversight.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the New Jersey Department of Health (NJDOH) within the required timeframe for one of the residents. The incident involved a resident with severe cognitive impairment who was allegedly forced by a Certified Nursing Assistant (CNA) to attend activities despite the resident's verbal refusal. The CNA was reported to have physically kneed the back of the resident's wheelchair, causing the resident to thrust forward. This event was witnessed by housekeeping staff and reported to the Human Resource (HR) Department, which then informed the Director of Nursing (DON). The incident occurred on 11/25/23, but the Facility Reported Incident/Event (FRE) was not called in until 11/28/23, exceeding the required reporting timeframe of two hours after the allegation was made. The resident involved had a history of dementia, restlessness, agitation, and mood affective disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The resident's care plan included specific instructions for handling agitation and providing choices in daily care. Despite these instructions, the CNA's actions violated the resident's rights to self-determination and dignity. The facility's policy required immediate reporting of such incidents, but the delay in reporting this event constituted a failure to comply with regulatory requirements.
Failure to Update PASaRR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASaRR) for a resident, leading to the omission of significant psychiatric diagnoses. The resident, who was admitted with diagnoses including major depressive disorder, unspecified psychosis, and PTSD, did not have these conditions reflected in the PASaRR Level I Screen. The PASaRR Level I Screen dated 12/11/18 incorrectly indicated that the resident had no major mental illness, despite the onset of these diagnoses during the resident's stay at the facility. The facility's policy requires PASaRR to be updated at points of significant change in status, which was not adhered to in this case. The deficiency was identified during a surveyor's review of the resident's medical records and interviews with facility staff. The Director of Social Services (DoSS) acknowledged that there had been no updates to the PASaRR since the resident's admission, despite the resident receiving psychotherapy for PTSD. The surveyor informed the facility management, including the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), of the findings, but no additional information was provided to address the oversight. This failure to update the PASaRR documentation resulted in the resident not being referred to the appropriate state-designated authority for a Level II PASaRR evaluation and determination, as required by regulations.
Failure to Obtain Physician's Order and Post Sign for Droplet Precaution
Penalty
Summary
The facility failed to obtain a physician's order for droplet precaution and did not ensure that the required posted sign for droplet and contact precautions was followed according to the facility's practice and policy. This deficiency was identified during a survey when it was observed that a resident with a diagnosis of RSV was on droplet precaution without a physician's order and without the appropriate signage outside the resident's room. The Director of Nursing (DON) and the Infection Preventionist Nurse (IPN) acknowledged the oversight, stating that there should have been a physician's order and proper signage in place for droplet precautions. During the survey, it was noted that the resident's room had a PPE bin and a sign on how to don and doff PPE, but there was no posted sign indicating the type of infection control precaution to observe. Interviews with the Registered Nurse (RN) and Licensed Practical Nurse (LPN) confirmed that the resident was on contact and droplet precaution for RSV, but the necessary signage was missing. The LPN suggested that the sign might have fallen off, but this was not verified. A review of the resident's medical records revealed that there was an active order for contact precaution but no order for droplet precaution. The resident's care plan included an intervention for staff to comply with droplet and contact precautions, which was initiated on a specific date. The facility's Transmission Based Precaution Policy also required both contact and droplet precautions for residents with RSV. The IPN admitted that it was a mistake not to have the sign and physician's order in place, and the DON confirmed that these should have been implemented.
Failure to Provide Appropriate Dialysis Care and Develop Care Plan
Penalty
Summary
The facility failed to provide appropriate care for a resident's hemodialysis access site and did not develop a care plan for the same. The deficiency was identified during an observation where the resident, who had a right upper chest dialysis access site, showed that the site was covered with a clean dressing. However, a review of the resident's medical records revealed that there was no order to monitor and care for the dialysis access site, and no routine documentation was found indicating that the facility was monitoring and caring for the site. Additionally, the personalized care plan for the resident did not mention the care and monitoring of the dialysis access site. During an interview, the Registered Nurse/Unit Manager (RN/UM) confirmed that the facility's process involved monitoring the access site and documenting it in the Hemodialysis Communication Record (HCR). However, the RN/UM acknowledged that there was no order for monitoring the dialysis access site in the electronic Treatment Administration Record (eTAR) and that it was the responsibility of the in-charge nurse to ensure such an order was in place. The RN/UM also confirmed that the care for the dialysis access site should have been included in the resident's care plan but was not. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of these findings, and it was noted that there was no general policy for hemodialysis in the facility.
Inaccurate and Incomplete Staffing Report
Penalty
Summary
The facility failed to ensure that the posted Resident Care Staffing Report was up to date and provided accurate information. On multiple occasions, surveyors observed that the 24-hour staffing report did not include the resident census, did not indicate if a Registered Nurse was on duty, and did not specify the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unaware of the specific requirements for the staffing report, leading to incomplete and inaccurate postings. The receptionist, who was responsible for posting the 24-hour staffing report, stated that she was not instructed to include the census and was following the guidance provided by the LNHA and DON. Despite being informed of the deficiencies by the surveyors, the LNHA admitted to not having reviewed the regulation to ensure compliance. The facility also lacked a policy on staffing, which contributed to the ongoing issues with the accuracy and completeness of the staffing report postings.
Incomplete Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for one of the seventeen residents reviewed. Specifically, the electronic medical record for a resident admitted with diagnoses including asthma, hypertension, and heart failure was incomplete. The surveyor found that the medical record information only went up to January 2024, following the resident's readmission after a hospitalization, and no information was accessible prior to this date. Despite notifying the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the issue, the problem persisted. The Minimum Data Set (MDS) Coordinator attempted to fix the electronic medical record, but the complete medical record remained inaccessible. The LNHA stated that they had notified the computer system again and were awaiting a response, but no additional information was provided to resolve the issue.
Lack of Coordination and Communication with Hospice
Penalty
Summary
The facility failed to ensure consistent coordination and communication between facility staff and hospice staff to meet the needs of a resident receiving hospice care. The resident, who had diagnoses including cerebral aneurysm, dementia, psychosis, and seizures, was observed sleeping on a low-positioned bed. The resident's medical record indicated a physician order for hospice care starting from June 2023, but there was a significant lack of documented communication between the hospice and the facility over a nine-month period, with only two out of 28 visits having any recorded collaboration or communication. A specific incident on February 4, 2024, highlighted this deficiency when the resident was found lying on the floor mat next to their bed. Despite the fall, there was no documentation that hospice was informed of the incident. Interviews with facility staff revealed that hospice aides and nurses were supposed to communicate their visits and recommendations, but this process was not consistently followed. The RN/Unit Manager confirmed the lack of communication records and acknowledged that the incident should have been reported to hospice. Further review of hospice records showed that out of 28 visits, only two had documented communication between hospice and the facility. The facility's policy required the unit manager to coordinate care and communicate with hospice representatives, but this was not effectively implemented. The deficiency was confirmed during meetings with the Licensed Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of coordination and communication between hospice and the facility.
Failure to Issue Timely Medicare Beneficiary Protection Notification
Penalty
Summary
The facility failed to issue the required Medicare Beneficiary Protection Notification for two out of three residents reviewed. According to the regulations, the Notice of Medicare Non-Coverage (NOMNC) must be delivered at least two calendar days before Medicare-covered services end. However, for Resident #170, the NOMNC was delivered on the last covered day of service, and for Resident #10, the NOMNC was also delivered on the last covered day of service. Both residents' representatives were notified on the same day the services ended, which is not in compliance with the required notification period. The surveyor reviewed the facility's records and found that the facility did not have a policy regarding Skilled Nursing Facility (SNF) Beneficiary Notification and was only following the regulation without a formal policy in place. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were informed of these concerns during the survey. The facility's failure to provide timely NOMNCs resulted in non-compliance with the Medicare Beneficiary Protection Notification requirements.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman (LTCO) regarding the reason for transfer to the hospital for two residents. Resident #10's electronic medical record showed that the resident was transferred to the hospital, but there was no written notification of the reason for the transfer to the resident or their representative, nor was a copy sent to the LTCO. Similarly, Resident #16's medical record indicated hospital transfers without the required written notifications to the resident, their representative, or the LTCO. During interviews, the Licensed Nursing Home Administrator (LNHA) and the Director of Social Services (DoSS) revealed that the notifications were not being sent as required. The LNHA believed the DoSS was responsible for the notifications, while the DoSS stated that the nurses would call the family but did not send written notifications. The LNHA confirmed that the ombudsman was not being notified when residents were transferred to the hospital. The facility did not provide any additional information to address this deficiency.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives prior to hospital transfers. This deficiency was identified for two residents who were transferred to the hospital, as their medical records did not include the required written notifications. Interviews with the Licensed Nursing Home Administrator (LNHA), Director of Social Services (DoSS), and Admissions Coordinator revealed confusion and miscommunication regarding who was responsible for sending these notifications. The LNHA believed the DoSS handled the notifications, while the DoSS thought it was the responsibility of admissions. The Admissions Coordinator stated that the bed hold policy was included in the admission agreement but did not send notifications for each transfer. Further investigation revealed that the facility did not have a specific policy for notifying residents or their representatives about bed holds, except for private pay residents. The LNHA confirmed that Medicaid residents were not charged for bed holds, and Medicare residents were taken back without a charge. The facility's admission agreement mentioned bed hold charges but did not ensure that notifications were sent out for each hospital transfer. This lack of written notification was confirmed during interviews and a review of the facility's documentation.
Inaccurate MDS Coding for Resident
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the residents, leading to a deficiency. The surveyor observed a Registered Nurse (RN) administering medications to the resident, who was seated in a recliner chair. The resident's medical records indicated multiple diagnoses, including essential hypertension, encephalopathy, major depressive disorder, unspecified dementia, unspecified psychosis, and chronic PTSD. A review of the resident's quarterly MDS revealed a cognitive status score indicating intact cognition and incorrectly coded the use of bedrails as a restraint. The personalized care plan did not include the use of bedrails as a restraint, only for positioning and mobility assistance. The RN/MDS Coordinator admitted that the MDS was auto-populated from electronic medical records and that she did not verify the accuracy of the assessment, leading to the incorrect coding. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of the findings and acknowledged the error. The facility's policy on MDS and Care Assessment Protocol was reviewed, which emphasized the importance of accurate resident assessments. Despite this, the RN/MDS Coordinator failed to check the auto-populated data, resulting in the inaccurate MDS coding for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Watchung
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aristacare At Norwood Terrace | 1.5 mi | ★★★★★ | 0 | 0 |
| Runnells Center For Rehabilitation & Healthcare | 1.7 mi | ★★★★★ | 11 | 1 |
| Continuing Care At Lantern Hill | 2.9 mi | ★★★★★ | 4 | 1 |
| Autumn Lake Healthcare At Berkeley Heights | 2.9 mi | ★★★★★ | 8 | 0 |
| Complete Care At Plainfield Llc | 2.9 mi | ★★★★★ | 0 | 0 |
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