Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 New Vista Nursing & Rehabilitation Ctr during CMS and state inspections, most recent first.
A cognitively impaired resident with severe dementia developed a new left periorbital bruise and reported being hit by an aide. The facility’s internal report identified a CNA as a suspected abuser and noted no witnesses and no earlier injury, but the documentation did not show that other residents or the CNA were interviewed, and law enforcement was not contacted. Progress notes reflected assessment, stable VS, an ordered orbital X-ray with negative results, and ongoing monitoring, while the resident exhibited combativeness and required assistance with transfers. An MD later stated they would have sent the resident to the ER for possible CT imaging due to the head injury, but the resident was not transferred. The facility’s policy required periodic refresher training on abuse/neglect recognition, yet records showed only one abuse training with no subsequent refreshers provided.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson’s disease, had a physician order in the EMR for a recheck test for Trichomonas. The EMR contained no documentation that the ordered lab test was completed and no lab results were available, and the DON confirmed that the test was not performed and no results were reported to the physician. This occurred despite facility policy requiring RNs/LPNs to carry out all physician orders and for incoming shifts and unit managers to check admission orders, resulting in noncompliance with professional standards of quality.
Food Storage and Kitchen Sanitation Deficiencies: The facility failed to store potentially hazardous foods properly and failed to keep kitchen equipment and storage areas sanitary. Surveyors observed sticky debris and a liquid spill at the juice dispenser, soiled oven knobs and handles, ice buildup in the walk-in freezer, open containers of rice and flour in the dry storage room, a dry storage temperature of 78 degrees F, and dented cans of carrots and marinara in rotation for use.
Controlled substance records were inaccurate when an LPN and RN documented counts that did not match the actual bingo card balances for Clonazepam and Alprazolam, and a discontinued Clonazepam order remained in active inventory and was given to the wrong resident. In another event, an LPN gave a resident only part of a Lactulose dose because the ordered supply was unavailable and then used Lactulose from another resident’s medication supply, while the chart lacked timely documentation that the provider was notified.
A facility failed to ensure call devices were readily accessible for three residents. One resident with dementia had no call light near the bedside, another had a call light unplugged and lying on the floor while reporting delayed staff response, and a third had the call light placed behind a cabinet out of reach. Records showed each resident had cognitive impairment and care plans directing that the call light be within reach.
A facility failed to ensure that the PMD signed and dated monthly physician orders and documented monthly progress notes for two residents over a 3-month period. Records showed missing MRRs and PMFNs for both residents, and the NUM confirmed the documentation was absent. The PMD stated he believed physician visits only needed to be documented every 90 days and said he was catching up with his notes.
An observed med pass showed a 6.25% error rate, above the allowed threshold. An LPN gave rapid-acting insulin after the resident had already eaten instead of before the meal, and also administered only half of an ordered Lactulose dose while documenting the full dose on the MAR. The resident involved had DM, schizophrenia, convulsions, and neurosyphilis, with intact cognition.
The facility failed to provide enough linens, such as towels and washcloths, for all residents, resulting in staff being unable to meet basic hygiene needs. Staff and residents reported frequent shortages, with some units receiving only one towel per resident and insufficient blankets during cold conditions. Staff often had to borrow linens from other units or were unable to obtain more when needed, impacting the ability to maintain cleanliness and comfort.
The facility did not report multiple allegations of abuse and misappropriation to the state agency within the required timeframe. Incidents included inappropriate touching between two residents with visual impairments, a resident experiencing a psychotic episode causing fear in a roommate, and a resident with quadriplegia accusing staff of theft. Documentation was present, but staff were unclear about reporting responsibilities, and required notifications were not made.
The facility did not complete required investigations into allegations of abuse and misappropriation involving several residents, including incidents of suspected sexual abuse, theft of money, and resident fear during a roommate's psychotic episode. Although some witness statements and grievances were documented, there was no evidence of thorough investigations as required by facility policy.
The facility did not ensure that POLST forms were fully completed with required dates and physician signatures for three residents, resulting in unclear code status and inconsistent documentation of life-sustaining treatment preferences. Staff interviews confirmed that the process for finalizing these forms was not consistently followed, leading to uncertainty about residents' wishes.
Two residents with complex medical needs reported grievances involving misappropriation of funds, delayed staff response, and transportation issues. Facility records showed no documented follow-up or resolution, and interviews confirmed that the residents were not informed of any investigation outcomes, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on ADLs did not receive a required follow-up appointment after a laparoscopic cholecystectomy, despite hospital discharge instructions specifying the need for a visit in two weeks. Facility staff failed to identify and schedule the appointment, and documentation review confirmed the omission.
A resident with multiple chronic conditions had several instances where medication administration was not properly documented in the MARs, with blank entries and codes indicating missing progress notes or explanations. Staff interviews confirmed that medications were sometimes unavailable due to insurance delays, and required documentation was not consistently completed in the EMR, despite facility policy mandating such records.
The facility failed to maintain proper kitchen sanitation and food storage practices, including unlabeled food items, improper hand hygiene, and unclean equipment. Issues were observed with the juice machine, salad preparation, bread labeling, wet nesting of pans, and storage of items in non-functional ovens. Additionally, items were stored too close to the ceiling in refrigerators and freezers, and the dry storage area had debris on the AC unit and broken ceiling tiles.
The facility failed to ensure the QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies, with the last QAPI Plan being from 2019. The LNHA provided an untitled and undated document that did not reflect a comprehensive QAPI plan, and concerns were identified regarding employee files, non-certified Nursing Aides, staffing, vaccinations, and food temperature.
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly QAPI meetings, as confirmed by the LNHA and a review of attendance records. The IP's absence, crucial for addressing infection control issues, had the potential to affect all 273 residents.
The facility failed to provide a safe, clean, comfortable, and homelike environment. A resident's room was found with unsanitary conditions, including a dirty tube feeding pole, dusty oxygen concentrator, and broken nightstand. In the dining area, a commode with rust-like substances and wood blocks from a broken nightstand were inappropriately placed. The DON and LNHA acknowledged these issues, highlighting a lack of proper cleaning and maintenance protocols.
The facility failed to verify the credentials of newly hired licensed staff before their date of hire. Five out of seven newly hired staff members, including an OT, RN, LPN, and two CNAs, either had their licenses verified after their hire date or lacked documented evidence of verification. Interviews confirmed that verifications should be done before the hire date, but the facility lacked a specific hiring policy beyond a checklist, which was not found in the reviewed files.
The facility failed to develop and implement comprehensive care plans for four residents, including those requiring anticoagulant medication, pain management, smoking safety, and palliative care. The deficiencies were confirmed by the LPN, DON, and MDSC/RN, highlighting a lack of adherence to the facility's policies on care plan development and updates.
The facility failed to provide appropriate respiratory care for three residents. One resident received incorrect oxygen flow, another had an unreadable oxygen concentrator setting, and a third had improperly labeled and stored respiratory equipment. The Director of Nursing confirmed that proper orders and care plans were missing or not followed.
The facility failed to ensure that CNAs received annual performance reviews for five CNAs whose files were reviewed. Despite multiple requests, the facility did not provide the requested performance reviews, and there was no documented evidence that these reviews had been conducted. The issue was discussed with the LNHA and the DON, but no additional information or policy was provided.
The facility failed to maintain infection control standards during a COVID-19 outbreak by not conducting testing according to CDC guidelines, not adhering to proper hand hygiene practices, and improperly storing PPE. Three residents and three staff members were tested on incorrect days, and staff were observed washing hands for less than the required time and storing masks inappropriately.
The facility failed to document and administer influenza and pneumococcal vaccinations for several residents, as per their policies and CDC guidelines. This resulted in multiple deficiencies in resident care, with no proper documentation of vaccine administration or refusal in the medical records.
The facility failed to serve all residents seated at a table their lunch trays in a timely manner, with one resident receiving their tray 16 minutes after others had started eating. Interviews with CNAs revealed no explanation for the delay, and the facility's Meal Service Policy lacked procedures for dining room service.
The facility failed to ensure that a resident with severe cognitive impairment or their representative was offered the opportunity to formulate an Advance Directive, resulting in a default Full code status without documented discussion of end-of-life wishes.
A resident with severely impaired cognition was found with a bump and discoloration on their face, but the facility failed to report the injury of unknown origin to the NJDOH as required. Conflicting accounts and lack of proper documentation led to the deficiency.
A facility failed to thoroughly investigate a fall incident involving a cognitively impaired resident with multiple medical conditions. The initial documentation lacked details on the cause of the fall and preventive interventions, and there were significant delays and discrepancies in updating the care plan. The DON admitted to recent edits and delays in the investigation, and the facility did not provide the fall policy when requested.
The facility failed to accurately code the MDS for three residents, leading to discrepancies in their medical records. Errors included incorrect influenza vaccine dates and missing documentation of oxygen therapy. These issues were identified through observations, interviews, and record reviews.
The facility failed to follow professional standards in medication administration and did not ensure proper care for a resident at risk for wandering. An LPN did not instruct a resident to rinse their mouth after administering an inhalation medication, and the placement of a wander guard was not checked on ten shifts. The resident's Wandering Risk Assessment form was also incomplete.
A facility failed to provide proper wound care for a resident by not adhering to hand hygiene protocols. The Wound Care Registered Nurse (WCRN) missed 12 of 17 hand hygiene opportunities during the wound treatment, including not washing hands after removing gloves and handling supplies with bare hands. The resident had a diagnosis of type 2 diabetes mellitus and chronic obstructive pulmonary disease, and was at risk for pressure ulcers. The facility's policies emphasize the importance of hand hygiene, but these were not followed, leading to the observed deficiency.
The facility failed to monitor and document urinary output for two residents with indwelling catheters, contrary to its policy and procedure. One resident had severe cognitive impairment and multiple diagnoses, while the other had intact cognition and diagnoses including urinary tract infection. The deficiency was confirmed by staff and the Director of Nursing (DON).
The facility failed to ensure that a non-certified Nurse Aide did not continue to work after the specified 120 days and lacked a policy for hiring and staffing non-certified NAs. NA #1 worked for more than 120 days without proper certification, and the facility's administration was unaware of the correct certification requirements.
The facility failed to post the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) in a prominent place, making it inaccessible to residents and visitors for two consecutive days. The responsible staff member had a medical emergency and came in late, and the usual posting location was not readily visible. The facility lacked a policy on posting staffing information.
The facility failed to properly label, store, and administer medications, including undated vials, expired Omeprazole, and unadministered Pneumococcal syringes. Staff interviews revealed awareness of protocols but inconsistent adherence, leading to multiple deficiencies.
The facility failed to maintain a sanitary environment by not keeping the garbage compactor and dumpster area free of garbage and debris. The FSD acknowledged that the area should have been cleaned by the maintenance and dietary departments, and the LNHA admitted that the facility maintenance department is responsible for this task. The facility policy states that outside dumpsters should be kept closed and free of surrounding litter, which was not followed.
The facility failed to ensure timely physician visits and address nutritional issues for a resident with significant weight loss. The resident, with multiple medical diagnoses, had not been seen by the primary physician since 11/19/23, despite a documented 5.2% weight loss over the past month.
The facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. A resident expressed dissatisfaction with the food quality, and observations revealed that lunch had not arrived on time. The delay in delivering meal trays caused the food to lose its temperature, with temperatures recorded below recommended levels. The facility's policies on food quality and meal distribution were reviewed, and it was noted that the policies lacked creation or revision dates.
The facility failed to maintain complete and accessible medical records for two residents. One resident's ADL care documentation was missing, and another resident's physician discharge summary was not present in the medical records. Despite multiple inquiries, the facility could not provide the necessary documentation, indicating a significant lapse in record-keeping.
The facility failed to notify the LTCO of a resident's emergency transfer to the hospital due to vaginal bleeding. The Nursing Clerk responsible for LTCO notifications confirmed the omission, which was attributed to a possible oversight by the previous DON. The facility lacked a specific policy for LTCO notifications, relying on a monthly submission process that contributed to the deficiency.
The facility failed to implement a comprehensive Antibiotic Stewardship Program as per their policy and national standards. The documentation provided was incomplete, lacking essential details such as diagnostic testing and signs/symptoms of residents. Interviews revealed inconsistent documentation of feedback reports, trend reports, and surveillance, leading to the identified deficiency.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse and Provide Required Abuse Training
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse and did not follow its Reporting & Investigation Policy requiring comprehensive investigation and periodic refresher training on abuse recognition. A cognitively impaired resident with severe dementia and a BIMS score of 3/15 was observed with a new left periorbital injury and stated she had been hit by an aide. The facility’s FRIDAY report identified a CNA as the suspected abuser, noted that no staff witnessed the incident, and that multiple staff reported no injury earlier that morning. The CNA denied the allegation and was suspended pending investigation, and the allegation was ultimately deemed unsubstantiated due to lack of evidence, witnesses, and the resident’s severe cognitive impairment. However, the investigation documentation did not show that other residents or the involved CNA were interviewed about the incident, and law enforcement was not contacted. Progress notes showed that the social worker first noted bruising of the left upper eyelid, with the resident denying pain or visual changes and a full body assessment revealing no additional injuries. Vital signs were stable, the physician was notified, an X-ray of the left orbital area was ordered, and the family was notified. Follow-up documentation described bluish discoloration of the left periorbital area, negative X-ray results for fracture or contusion, and ongoing monitoring, with the resident exhibiting declining mobility, needing assistance with transfers, and being combative during morning care. The resident was care planned for combativeness and physical and verbal aggression toward staff. The attending MD interviewed later stated that standard protocol typically warrants hospital transfer and possible CT imaging for such a peri-orbital injury and that they would have sent the resident to the ER, but the resident was not sent to the hospital and law enforcement was not called. Additionally, the facility’s policy required periodic refresher training on abuse and neglect, yet the last abuse training was documented on 06/26/25 with no subsequent refresher training provided.
Failure to Complete and Report Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure a physician-ordered laboratory test was performed and that results were reported to the ordering physician for one resident. The resident had diagnoses including syncope and collapse, unspecified dementia, unspecified mental disorder, and Parkinson’s disease without dyskinesia, and had a BIMS score of 3, indicating severe cognitive impairment. The electronic medical record showed a physician order dated 09/02/25 from a medical doctor to recheck a test for Trichomonas in November 2025. Review of the laboratory results section in the record revealed no documentation that this ordered test was ever completed and no laboratory results were present. In an interview, the DON confirmed that the ordered test was not performed and no results were reported to the physician. Facility policy on carrying out physician’s orders required that all physician orders be carried out by the RN/LPN on duty and that all admission orders be checked by incoming shift nurses and the unit manager, but this did not occur for the ordered Trichomonas recheck test. This deficiency was cited under NJAC 8:39-11.2(b), based on the failure to carry out and document the physician’s laboratory order and to communicate results to the ordering physician as required by facility policy and professional standards of quality.
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. During observation in the food preparation area, red sticky debris was seen on the tubing of the juice dispenser, and a clear liquid spill was observed below the juice dispenser legging. The surveyor also observed oven knobs and handles soiled with white and brown substances on two ovens. In the walk-in freezer, approximately 3 inches of ice had built up on the brown box underneath the condenser unit and approximately 3 inches of ice had built up on the floor next to it. In the dry storage room, two food storage containers holding rice and flour were left open to the air, and the FSD stated the lids should have been closed. The dry storage room thermometer read 78 degrees F, and the FSD stated the room is always warm and that the temperature should be between 50 and 70 degrees F. The surveyor also observed a number 10 can of sliced carrots with four 1-inch dents and a number 10 can of marinara with a 4-inch dent, while the facility policy stated dented cans should be placed on a designated shelf marked Dented Cans.
Controlled Substance Documentation Errors and Borrowed Lactulose Dose
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when controlled substances were not accurately documented and a discontinued medication remained in active inventory. During a medication cart inspection, the surveyor found that the remaining count on the declining inventory log for one resident’s Clonazepam 0.5 mg half-tablets did not match the actual balance in the bingo card, and the same type of discrepancy was found for another resident’s Clonazepam 1 mg tablets. The facility’s review later identified that the discontinued Clonazepam 0.5 mg half-tablet labeled for one resident had been administered to the other resident, and the nurse had signed the inventory control log for the wrong medication. The discontinued medication had not been removed from active inventory before the error occurred. A second controlled substance discrepancy involved Alprazolam 0.25 mg for another resident. The surveyor found that the bingo card balance did not match the declining inventory log, which showed one fewer tablet than was actually present. The nurse who had signed the shift count could not explain the discrepancy or confirm whether the scheduled dose had been administered. Facility staff later stated that the nurse had pre-signed the declining inventory log without administering the medication, and that another nurse had signed the eMAR without actually giving the dose. A third medication administration issue involved Lactulose for a resident with diagnoses including type 2 DM, schizophrenia, convulsions, and neurosyphilis, with a BIMS score of 13 indicating intact cognition. The resident had an order for Lactulose 20 GM/30 ML, 30 ML three times daily for elevated ammonia levels, but the nurse only poured 15 ML because that was all that remained in the bottle. The nurse stated the medication had been reordered but was not available, and then used Lactulose from another resident’s supply to give the dose. The record contained no note that the physician was called at the time of the partial dose, and the facility stated that nurses were not to borrow medications from another resident.
Call Lights Not Readily Accessible for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents' call devices were readily accessible for 3 of 7 residents reviewed for reasonable accommodations of needs and preferences. Resident #24 was observed in bed without an available call light near the bedside on two separate observations, and the outlet on the resident's side of the wall unit did not have a call light cord connected. The resident stated they were unsure where the call light was located. Record review showed the resident had diagnoses including unspecified dementia and major depressive disorder, a BIMS score of 3 indicating severe cognitive impairment, and a care plan intervention to ensure the call light was within reach and to encourage use of the bell for assistance. Resident #88 was observed with the call light wrapped around the siderails, lying on the floor, and not connected to the outlet. On a later observation, the call light was still attached to the siderails but remained unplugged. The resident stated they did not know the call bell was not connected and reported that staff response to calls took 10 to 15 minutes. Record review showed diagnoses including hypertensive heart disease without heart failure and major depressive disorder, a BIMS score of 9 indicating moderate cognitive impairment, dependence on staff for daily living activities, and a care plan intervention to place the call light within reach and encourage its use. Resident #140 was observed in bed with the call light placed behind a cabinet about 3 to 4 feet away from the resident. The resident was unable to answer the surveyor's inquiries. Record review showed diagnoses including vascular dementia, a BIMS score of 0 indicating severe cognitive impairment, dependence on staff for daily living activities, and care plan interventions to place the call light within the resident's reach. Staff interviews confirmed that call lights should be within easy reach and functioning, and the facility policy stated that call lights should be positioned conveniently, shown to residents, and never placed on the floor or bedside stand.
Missing Monthly Physician Signatures and Progress Notes
Penalty
Summary
The facility failed to ensure that the residents' primary physician signed and dated monthly physician orders and documented monthly physician progress notes for 2 of 35 residents reviewed, Resident #53 and Resident #248, over a 3-month period. For Resident #53, the surveyor reviewed the hybrid medical record and found that the PMD had not signed the monthly Medication Review Reports (MRRs) for April, May, and June 2025, and had not documented monthly Physician Monthly Follow-Up Notes (PMFNs) for those same months. The Nurse Unit Manager confirmed the record did not contain the required MRRs or PMFNs and stated there was a stack of printed MRRs in the nursing office waiting for the PMD to sign. For Resident #248, the surveyor reviewed the hybrid medical record and found that the PMD had not signed the monthly MRRs for the prior 3 months and had not documented monthly PMFNs for the prior 3 months. The Nurse Unit Manager confirmed the missing documentation. During interview, the PMD stated he thought physician visits should be documented every 90 days and said he was catching up with his notes. The facility policy stated that care and treatment must be based on timely physician orders that are clear, complete, dated, and signed according to regulatory timeframes.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medication administration errors remained below 5 percent. During an observed medication pass involving four nurses and five residents, surveyors identified two errors out of 32 opportunities, resulting in a 6.25 percent medication administration error rate. One resident involved had diagnoses including Type 2 DM, schizophrenia, convulsions, and neurosyphilis, and had a BIMS score of 13 out of 15, indicating intact cognition. One error involved Humalog (insulin lispro) ordered as sliding scale coverage before meals. The LPN obtained the resident’s blood sugar of 156 before breakfast and later administered 2 units subcutaneously after the resident had already eaten breakfast. The EMAR showed the insulin was ordered for administration before meals at 7:30 AM, and the LPN acknowledged that the insulin was given after the meal rather than before it. The DON and consultant pharmacist stated that rapid-acting insulin should be administered before a meal, with the pharmacist noting it should be given within 15 minutes before eating. The second error involved Lactulose oral solution ordered as 30 mL by mouth three times daily. The LPN found only 15 mL available in the bottle and administered that amount, then signed the EMAR as if the full ordered dose of 30 mL had been given. The record showed no note that the physician was called about the reduced dose at the time of administration, and the resident’s medication was later found to have been delivered to the unit. The facility policy required medications to be administered as ordered and documented appropriately when withheld, refused, or given at a time other than scheduled.
Inadequate Linen Supply for Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of linens, including towels and washcloths, for resident care, affecting all residents in the census. Multiple interviews with staff, including CNAs and LPNs, revealed that there were not enough linens available to meet the basic hygiene needs of residents. Staff reported having to borrow linens from other units, make repeated calls to laundry that often went unanswered, and sometimes having to deny residents' requests for additional towels or washcloths. One resident was found in a soiled brief and could not be changed due to the lack of clean linens. The Director of Building Services acknowledged issues with linen disappearance, including being thrown away, hidden, or given to families. The Director of Nursing confirmed that the expectation was for sufficient linen supply to meet resident care needs, especially during the day shift when bathing and frequent brief changes occur. The facility's policy on maintaining a homelike environment specifies the provision of clean bed and bath linens in good condition. However, staff interviews and resident reports consistently indicated that the linen supply was inadequate, with some units receiving only one towel per resident and not enough blankets during colder conditions. The deficiency was observed to impact the facility's ability to maintain cleanliness and comfort for its residents.
Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to report three allegations of abuse involving three residents and one allegation of misappropriation of property involving another resident to the state survey agency within the required two-hour timeframe. For one incident, a resident with paranoid schizophrenia and major depressive disorder was reported by an activities assistant to have inappropriately touched a legally blind roommate. Multiple staff documented the event, but the incident was not included in the facility's Accident and Incident Log, and the Director of Nursing (DON) was unaware of the allegation being classified as sexual abuse. The DON confirmed that such incidents should be reported immediately, but the state agency had not received any reportable incidents from the facility since a date prior to these events. Additionally, the Social Services Director was not aware of his role as Abuse Coordinator and was unfamiliar with the requirements, indicating a lack of clarity in staff responsibilities regarding abuse reporting. Another incident involved a resident with hemiplegia and hemiparesis who became fearful when a roommate, experiencing a psychotic episode, threw objects around the room. The event was documented, but again, there was no evidence that it was reported to the state agency as required. The facility's own policy mandates that all alleged violations involving abuse or misappropriation of property be reported immediately, but this was not followed in these cases. A separate allegation of misappropriation involved a resident with quadriplegia and hypertension who accused staff of stealing money. Progress notes documented the accusation, but the DON was not aware of the allegation and stated it should have been addressed in a morning meeting. Interviews with LPNs revealed uncertainty about the identity of the Abuse Coordinator and the proper reporting process. The facility's failure to report these incidents as required by policy and regulation had the potential to allow continued abuse and misappropriation for all residents.
Failure to Investigate Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to properly investigate multiple allegations of abuse and misappropriation of property involving several residents. For one incident, a resident with paranoid schizophrenia and major depressive disorder was alleged to have inappropriately touched another resident with legal blindness, diabetes, and end stage renal disease. Although witness statements were collected, there were no investigation notes or summary indicating that a full investigation into the suspected sexual abuse was completed. In another case, a resident with quadriplegia and hypertension reported concerns about staff taking his money, and a grievance was filed, but no further investigation was documented by the facility. Additionally, an incident involving a resident with hemiplegia and hemiparesis, who became fearful during a roommate's psychotic episode, was not fully investigated. The Director of Nurses confirmed that investigations were not completed for these incidents by the previous Abuse Coordinator, despite facility policy requiring thorough investigation and documentation of all reports of abuse and misappropriation. The lack of completed investigations for these events constituted a failure to respond appropriately to alleged violations.
Incomplete POLST Documentation and Unclear Code Status for Multiple Residents
Penalty
Summary
The facility failed to ensure that Practitioner Orders for Life-Sustaining Treatment (POLST) forms were properly completed and documented for three residents. For one resident with severe cognitive impairment and diagnoses including dementia and cerebrovascular disease, the paper chart contained two undated POLST forms with conflicting code statuses (DNR and full code), both lacking a date and physician signature. Staff interviews confirmed that the process for obtaining physician signatures and dating the forms was not followed, resulting in unclear code status for the resident. Another resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease, had a POLST form in the paper chart that was signed by the resident but lacked both a date and physician signature. Staff confirmed that this form was incomplete. For a third resident, also cognitively intact and with diagnoses including pneumonia and chronic obstructive pulmonary disease, the EMR documented full code status, but the paper chart contained an advanced directive indicating DNR, signed by the resident and witnesses but not by a physician. Staff interviews revealed uncertainty about the resident's actual code status due to incomplete documentation. Facility policy required that residents' treatment preferences and advance directives be documented and that the plan of care be consistent with these preferences. However, interviews with staff, including the Social Services Director, DON, and Administrator, confirmed that the process for completing and obtaining physician signatures on POLST forms was inconsistent and not reliably followed, resulting in incomplete documentation and unclear communication of residents' wishes regarding life-sustaining treatment.
Failure to Resolve Resident Grievances Related to Misappropriation and Care Concerns
Penalty
Summary
The facility failed to resolve grievances for two residents regarding misappropriation of funds and transportation concerns related to medical appointments. One resident, admitted with diagnoses including type two diabetes, bipolar disorder, hypertension, and bladder cancer, reported ongoing issues with staff mismanaging doctor appointments, including mixing up dates and forgetting transportation arrangements. The resident also expressed frustration that previous grievances about medication administration and other concerns were not addressed, leading to a lack of trust in the grievance process. Documentation of the resident's concern showed no action taken or follow-up recorded. Another resident, admitted with quadriplegia, hypertension, muscle weakness, and benign prostatic hyperplasia, reported two separate grievances: one involving delayed staff response to call lights, resulting in the resident calling 911, and another involving accusations of staff stealing money and not providing proper hygiene care. In both cases, facility documentation lacked evidence of follow-up or resolution. Interviews confirmed that the residents were not informed of any investigation outcomes or corrective actions, and the facility's grievance policy requiring investigation and communication of findings was not followed.
Failure to Schedule Post-Surgical Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medical follow-up appointment was identified and scheduled for a resident following a surgical procedure, specifically a laparoscopic cholecystectomy. The resident, who was severely cognitively impaired and totally dependent on all activities of daily living, was readmitted to the facility after surgery with discharge instructions from the hospital indicating the need for a follow-up appointment in two weeks. However, a review of the facility's records and appointment log confirmed that no such appointment was scheduled or attended during the specified period. Interviews with facility staff revealed that the process for reviewing hospital discharge documents and scheduling follow-up appointments was not consistently followed. The unit clerk, who was not employed at the time of the incident, confirmed that no appointment was logged, and the DON stated that the nurse re-admitting the resident should have reviewed the discharge documentation and relayed recommendations for follow-up to the physician. The RN Supervisor was unaware of the missed appointment, and the facility's policy did not address ongoing treatment requirements. This lapse resulted in the resident missing the recommended post-surgical follow-up care.
Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for one resident by not properly documenting the completion of physician orders on the medication administration records (MARs). The resident, who had a primary diagnosis of diabetes mellitus and multiple comorbidities including bipolar disorder, hyperlipidemia, and major depressive disorder, was prescribed several medications such as atorvastatin, eszopiclone, gabapentin, omeprazole, hydroxyzine, Seroquel, tamsulosin, and trazodone. Review of the resident's MARs for several months revealed multiple instances where medication administration was either left blank or marked as '9', indicating the need for a progress note regarding medication availability or administration, but no such documentation was found in the electronic medical record (EMR). Interviews with the resident and staff confirmed that there were occasions when medications were not available, particularly tamsulosin, due to issues such as insurance authorization delays. The resident reported being told by staff that medications had been ordered but then went without them. LPNs and the DON acknowledged that when medications were unavailable or not given, it was expected that a progress note would be entered, the physician notified, and the situation documented in the EMR. However, this documentation was not consistently present, and the DON was unaware that these documentation errors were ongoing despite previous pharmacy audits identifying similar issues. Facility policy required that all medications administered, withheld, or refused be documented on the MAR, including reasons for any deviations. Despite this policy, the MARs contained blank entries and '9' codes without corresponding progress notes or explanations in the EMR, making it unclear whether medications were administered, withheld, or unavailable. This lack of documentation compromised the accuracy and completeness of the resident's medical record.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store and discard potentially hazardous foods correctly, leading to multiple deficiencies. During a kitchen tour, surveyors observed several issues, including unlabeled rice crispy cereal cups, a juice machine with brown spots on the tubing, and a dietary aide preparing salads without washing the lettuce despite manufacturer instructions. Additionally, multiple loaves of bread and hamburger buns were found without labels, and wet nesting was observed in the dry pots and pans area. The Food Service Director (FSD) also failed to perform proper hand hygiene, using contaminated paper towels to turn off the faucet due to an empty towel dispenser, despite clean towels being available nearby. Crumb-like debris was found between the ovens, and non-functional ovens were improperly used for storage of seasoning and leftover cooking materials. The cast iron griddle was observed with black debris, indicating it had not been cleaned after use. In the walk-in refrigerators and freezers, items were stored too close to the ceiling, and black dust-like debris was found on the light bulb and wiring. Opened seasonings in the dry storage area lacked use-by or discard dates, and the air conditioning unit had a thick layer of black debris on the vent. Additionally, multiple broken, partially moved, and missing ceiling tiles were observed in the dry storage area, with no explanation provided for their condition.
Failure to Update and Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure had the potential to affect all 273 residents currently living in the facility. During the entrance conference, the surveyor requested information regarding the QAA committee, sign-in sheets for QAPI meetings, and the QAPI plan. The provided documents revealed that the QAPI Policy was last reviewed in December 2021, and the QAPI Plan was last updated in 2019. The Infection Preventionist was not included as a member of the QAA committee, and there was no documented evidence of plans of action developed and implemented to correct identified quality deficiencies for the last four years. Further review showed that the QAPI Program did not have a review date, and the goal descriptions for various departments were outdated, with the last updates being in 2019. When asked about the QAPI plan, the LNHA provided an untitled and undated piece of paper that did not reflect a comprehensive QAPI plan. The LNHA was unable to explain why the QAPI plan was outdated and why certain departments were not included. The surveyor identified concerns about employee files, non-certified Nursing Aides, staffing, vaccinations of staff and residents, and food temperature. The facility management was notified of these concerns, but no additional information was provided to address the deficiencies.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficiency was identified during an interview with the Licensed Nursing Home Administrator (LNHA) and a review of the QAPI attendance records for the last three quarters. The LNHA confirmed that the IP did not attend the QAPI meetings held on 5/11/23, 9/07/23, and 11/30/23. Additionally, the QAA Committee Information provided by the facility did not list the IP as a member of the committee, which is a requirement according to the facility's QAPI policy dated 12/2021. The policy mandates that the QAA Committee must include the Administrator, Director of Nursing (DON), Medical Director, and at least three other staff members, including the IP. During the survey, the LNHA acknowledged the absence of the IP and confirmed that the IP's role is crucial for addressing infection control issues, such as COVID-19 testing and vaccinations for residents and staff. The survey team met with the LNHA and DON multiple times to discuss the deficiency, and the LNHA had no explanation for why the IP was not included in the QAA Committee list. The failure to include the IP in the QAPI meetings had the potential to affect all 273 residents currently living in the facility, as infection control is a critical aspect of resident care and safety.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. In one resident's room, the surveyor observed an air mattress with an indwelling catheter, a tube feeding pump, and an oxygen concentrator, all of which were in unsanitary conditions. The tube feeding pole and the surrounding floor had dried brownish substances, the oxygen concentrator had an accumulation of black and grayish substances, and an electric fan was covered in dust. Additionally, the nightstand table in the room was broken. The LPNs confirmed these observations and acknowledged that the room should have been cleaned and the broken items reported to maintenance. The resident in question was cognitively impaired and required total assistance with activities of daily living, further emphasizing the need for a clean and safe environment. In the dining area on the 4th floor, the surveyor observed a commode with rust-like substances placed in the hallway near a dining table, and two blocks of wood outside a resident's room. The nightstand table in the room was broken, with a missing wood cover for the first drawer. The CNA confirmed that the wood blocks were from the broken nightstand and that the commode should not have been left in the dining area. The LPN also confirmed that the commode should not be in the dining area and asked the CNA to remove it. The presence of these items in the dining area during mealtime was inappropriate and posed a safety concern. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged the issues and stated that there should be no broken supplies or equipment in residents' rooms and that the rooms should be cleaned. The facility had a log for cleaning oxygen concentrators but lacked a cleaning log or accountability for other items such as tube feeding poles and electric fans. The facility's Quality of Life-Homelike Environment Policy emphasized the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Failure to Verify Credentials of Newly Hired Licensed Staff
Penalty
Summary
The facility failed to ensure that the credentials of newly hired licensed staff were verified upon hire. This deficiency was identified for five out of seven newly hired licensed staff members. Specifically, the review of employee files revealed that the license verifications for an Occupational Therapist, a Registered Nurse, a Licensed Practical Nurse, and two Certified Nursing Assistants were either completed after their date of hire or lacked documented evidence of verification prior to their date of hire. The Director of Activities, who previously worked in Human Resources, confirmed that license verifications should be done before the date of hire, but the reviewed files did not include such documentation. During interviews, both the Director of Activities and the Director of Nursing acknowledged that license verifications should be dated and completed before the employees' first physical day at the facility. The Licensed Nursing Home Administrator admitted that the facility did not have a specific policy for new employee hiring other than a checklist, which was not found in the reviewed employee files. The facility's policy on residents' rights to freedom from abuse, neglect, and exploitation stated that individuals with certain negative findings or disciplinary actions should not be employed, but there was no additional information provided to ensure compliance with this policy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals, addressing their medical, physical, mental, and psychosocial needs. This deficiency was identified for four residents. Resident #19, who was cognitively impaired and required total care, did not have a care plan for anticoagulant medication despite having a physician's order for Apixaban. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed the absence of a care plan for anticoagulants, and it was noted that there had been no Unit Manager for one and a half years to oversee care plan development and updates. Resident #132, who had multiple hospital-acquired wounds and was on pain medication, did not have a care plan for pain management. The LPN and Minimum Data Set Coordinator/Registered Nurse (MDSC/RN) acknowledged the necessity of a pain care plan, but it was not in place. The MDSC/RN stated that the admitting nurse was responsible for initiating care plans, and she would update them during quarterly assessments. However, it was unclear if the nurses were aware of their responsibilities regarding care plan initiation and updates. Resident #36, a smoker with diagnoses including type 2 diabetes mellitus and major depression disorder, did not have a care plan for smoking despite a smoking assessment indicating the need for one. The DON confirmed that all residents who smoke should have an individualized care plan. Additionally, Resident #267, who was placed on palliative care and had a DNR, DNI, and DNH order, did not have a care plan for palliative care. The DON stated that care plans should be created and updated for residents on palliative care. The facility's policies on comprehensive care plans and palliative care were not followed, leading to these deficiencies.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice and physician's order for three residents. For Resident #19, the surveyor observed that the resident was receiving oxygen at 5 LPM via nasal cannula, contrary to the physician's order of 3 LPM. The LPN acknowledged the discrepancy and adjusted the oxygen flow. Further review revealed that there was no current physician's order for oxygen use, and the resident's care plan did not include oxygen use, goals, and interventions. The Director of Nursing confirmed that there should be an order and care plan for oxygen use, which was missing in this case. For Resident #145, the surveyor observed that the oxygen concentrator in use did not have a visible indicator to show the LPM of oxygen being administered. The LPN was unable to read the oxygen setting and acknowledged that the concentrator needed replacement. The resident's medical records showed that there were five unsigned entries for oxygen therapy in the January 2024 electronic Treatment Administration Record. The Director of Nursing acknowledged that the electronic Treatment Administration Record should be signed by the nurses and that the concentrator was replaced immediately. For Resident #235, the surveyor observed that the nasal cannula tubing and nebulizer equipment were not properly labeled with a date, and the face mask was not stored in a bag or labeled. The resident's medical records indicated that the oxygen cannula should be changed weekly, but the observation did not reflect this practice. The LPN confirmed that the tubing should be dated and labeled and that the equipment should be stored properly to prevent infection. The Director of Nursing stated that the oxygen should be administered based on the doctor's order and that the nursing staff is responsible for checking the oxygen concentrator and following the schedule for changing the tubing and storing the equipment properly.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received annual performance reviews for five CNAs whose files were reviewed. This deficiency was identified during a survey when the survey Team Coordinator requested a list of CNAs along with their performance reviews and competencies. Despite multiple requests, the facility did not provide the requested performance reviews, and there was no documented evidence that these reviews had been conducted. The issue was discussed with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing, but no additional information or policy regarding CNA annual performance reviews was provided.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain infection control standards and procedures during a COVID-19 outbreak. Specifically, the facility did not conduct COVID-19 testing according to CDC guidelines and its own policies. Three residents and three staff members were tested on Day 1 and Day 4, instead of the required Day 1, Day 3, and Day 5. The Director of Nursing (DON) and the RN Supervisor acknowledged the discrepancy in testing dates, and the RN Supervisor admitted to conducting tests on incorrect days due to a high volume of testing at the time. The facility's policy required testing on Day 1, Day 3, and Day 5, but this was not followed, leading to a failure in appropriate surveillance for COVID-19 during the outbreak. Additionally, the facility did not adhere to proper hand hygiene practices. A Certified Nursing Aide (CNA) was observed washing hands for only 11 seconds after an incontinence check, contrary to the facility's policy of at least 15 seconds. The CNA admitted to rushing and not following the protocol. Similarly, an LPN was observed washing hands for only 11 seconds after administering medications, and there was no garbage can in the resident's toilet room to dispose of used paper towels. The LPN acknowledged the short duration of handwashing and the absence of a garbage can. The facility also failed to follow appropriate storage of personal protective equipment (PPE). An LPN was observed taking a surgical mask from her uniform pocket before entering a resident's room, which the DON confirmed was inappropriate as it could lead to contamination. The DON stated that infection control education, including hand hygiene and PPE use, was a collaborative effort but acknowledged the lapses in adherence to the facility's protocols. The facility's policies on hand hygiene and PPE use were not consistently followed, contributing to the risk of infection transmission.
Failure to Document and Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and administration of influenza and pneumococcal vaccinations for several residents. For Resident #7, there was no documentation in the hybrid medical records indicating the administration or refusal of the influenza vaccine for the 2023/2024 season. The Director of Nursing (DON) was unable to provide further information, and a declination form was later found in a separate binder, not in the resident's paper chart or electronic medical record (EMR). Similar issues were observed for Residents #132, #149, and #214, where there was no documentation of the influenza vaccine being administered or declined for the current season, despite their severe cognitive impairments and the presence of resident representatives responsible for their care planning. The facility's policies on immunization documentation were not followed, as confirmed by the DON and the MDS Coordinator/Registered Nurse (MDSC/RN) during interviews with the surveyor team. Additionally, the facility failed to ensure the administration of the pneumococcal vaccine for Residents #100 and #127. During a medication storage and labeling observation, pneumococcal syringes labeled for these residents were found, but there was no documentation in their medical records indicating the administration or refusal of the vaccine. The DON acknowledged that the nurse responsible for placing the order should have obtained the informed consent or refusal form from the residents. The facility's policies on immunization documentation were not adhered to, as evidenced by the lack of informed consent/refusal forms in the residents' physical charts. The surveyor team discussed these concerns with the DON and the Licensed Nursing Home Administrator (LNHA), but no additional information was provided to address the deficiencies. The facility's failure to document and administer influenza and pneumococcal vaccinations as per their policies and CDC guidelines resulted in multiple deficiencies in resident care.
Failure to Serve Lunch Trays Timely
Penalty
Summary
The facility failed to serve all residents seated at a table their lunch trays in a timely manner for one of five tables observed, involving a total of four residents. On 1/31/24, the surveyor observed the 4 East dining area during lunch, where three CNAs and one nurse were present with 18 residents. At Table two, only one resident received their lunch tray while the other three residents had not been served. The delay in serving the lunch trays to the remaining residents at Table two was noted, with the last resident receiving their tray at 12:27 PM, 16 minutes after the first resident at the table had started eating. Interviews with the CNAs present during the observation revealed that they could not explain why the residents at Table two were not served simultaneously. The facility's Meal Service Policy, provided later, did not include procedures for serving residents in the dining room. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were informed of the observations and concerns, but no additional information or explanation was provided regarding the issue.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was offered the opportunity to formulate an Advance Directive (AD). This deficiency was identified for a resident with severe cognitive impairment, who was admitted with multiple medical diagnoses including Dementia, Hypertension, Type II Diabetes Mellitus, and Anxiety Disorder. The resident's medical records indicated a Full code status, but there was no documentation showing that the resident's end-of-life wishes had been discussed with the responsible party. The facility's social worker confirmed that the topic of AD had not been discussed with the resident's responsible party, despite the resident's inability to make decisions due to cognitive impairment. The facility's policy stated that if a resident is incapacitated, information about the right to formulate an AD should be provided to the resident's legal representative. However, this policy was not followed in the case of the resident in question. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) acknowledged the issue but did not provide further information. The surveyor noted that the facility defaulted to a Full code status if no AD or POLST form was indicated upon admission, which contributed to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required by federal and state regulations. The deficiency was identified for a resident who was observed with a bump and discoloration on the left side of their face. The resident had a history of falls and severely impaired cognition, making it difficult for them to explain the source of the injury. The injury was first noted by a nurse who observed the resident with a hematoma that was not present the previous day. Despite the resident's confusion and inconsistent explanations about the injury, the facility did not classify it as an injury of unknown origin and failed to report it to the NJDOH. The Director of Nursing (DON) and other staff members provided conflicting accounts of the incident. The DON believed the injury was caused by the resident hitting their head on the side rail, based on statements from staff and the resident's own inconsistent explanations. However, there was no documentation or witness to confirm this. The facility's incident report and investigation did not include all relevant information, such as a physician's progress note that was faxed to the facility after the initial investigation. The DON did not consider the injury to be of unknown origin and therefore did not report it to the NJDOH. The facility's policies on incident reporting and resident rights were not followed correctly. The policies required that all injuries of unknown origin be reported immediately, but the DON and other staff members did not adhere to this requirement. The DON's interpretation of the incident and the lack of proper documentation and communication among staff led to the failure to report the injury as required. The facility did not provide any additional information to justify their actions, and the survey team identified this as a deficiency in the facility's compliance with reporting requirements.
Failure to Complete Thorough Investigation of Fall Incident
Penalty
Summary
The facility failed to complete a thorough investigation of a fall incident involving a resident with multiple medical conditions, including dysphagia, heart failure, and chronic kidney disease. The resident, who was severely impaired in cognitive skills, was found on the floor by a CNA during morning care. The initial progress notes documented that the resident was assessed for injuries, none were noted, and the responsible party and physician were notified. However, there was no documentation on the cause of the fall or interventions to prevent recurrence, and no Fall Risk Assessment was completed at the time of the incident. The care plan interventions were not updated promptly, with significant delays and discrepancies noted in the documentation. The DON provided an investigation report that included additional information not present in the initial report provided by the MDS Coordinator. The investigation was not completed within the facility's stated timeframe of one week, and there were no documented statements from the CNA who found the resident. The DON admitted to editing the information recently, which did not reflect in the initial investigation report. During interviews, the DON confirmed the delays in completing the investigation and acknowledged that the interventions to prevent recurrence should have been documented in the care plan. The surveyor noted discrepancies between the reports provided by the DON and the MDS Coordinator, and the facility management did not provide the facility's fall policy when requested. The surveyor's attempts to contact the CNA for further information were unsuccessful.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their medical records. For Resident #77, the MDS assessment incorrectly reflected the influenza vaccine date as 10/14/22, which was not updated for the 2023 influenza season. The MDS Coordinator/Registered Nurse (MDSC/RN) admitted that the dates auto-populated from the electronic medical record and were not verified for accuracy. Similarly, Resident #242's MDS assessment incorrectly indicated that the resident did not receive the influenza vaccine for the current season, despite medical records showing the vaccine was administered on 11/28/23. The MDSC/RN acknowledged this as a coding error. For Resident #145, the MDS assessment failed to document the use of oxygen therapy, despite the resident being observed with a nasal cannula and a physician's order for oxygen therapy at 2 liters per minute. The MDSC/RN confirmed that this was a data entry error after reviewing the resident's medical records. These inaccuracies were identified through observations, interviews, and record reviews conducted by the surveyor, and were discussed with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), who did not provide additional information.
Medication Administration and Wander Guard Deficiencies
Penalty
Summary
The facility failed to ensure that medication was administered in accordance with manufacturer's cautionary specifications and professional standards of clinical practice. During a medication administration observation, an LPN administered budesonide and formoterol fumarate combination aerosol to a resident without instructing the resident to rinse their mouth afterward, as indicated by the cautionary label on the medication box. The LPN acknowledged the mistake and admitted that the sequencing of the medication administration was not in accordance with professional standards. The resident had a history of type II diabetes, hypertension, and paranoid schizophrenia, and their cognition was intact as indicated by a BIMS score of 15 out of 15. The facility also failed to ensure that care and services were followed for a resident at risk for wandering. The resident was observed with a wander guard bracelet, but a review of the Treatment Administration Record (TAR) revealed that the placement of the wander guard was not checked on ten different shifts in January 2024. The DON confirmed that the TAR had blanks and that the placement should have been checked every shift. Additionally, the resident's Wandering Risk Assessment form was found to be incomplete and inconsistent with the resident's diagnosis of dementia and the use of a wander guard bracelet. The facility's policies on administering medications and elopement did not include specific instructions regarding the issues observed. The DON and LNHA were made aware of the concerns, but no additional information was provided to address the deficiencies. The facility's failure to follow professional standards and ensure proper care for residents at risk for wandering was evident in the observations and documentation reviewed by the surveyors.
Failure to Adhere to Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to provide wound care in accordance with its policy and professional standards of clinical practice for a resident observed for wound care. During the wound treatment observation, the Wound Care Registered Nurse (WCRN) did not perform hand hygiene on 12 of 17 opportunities. This included instances such as not washing hands after removing gloves, not performing hand hygiene before donning new gloves, and handling wound care supplies with bare hands. The WCRN also failed to follow proper hand hygiene protocols when moving from a soiled body site to a clean body site on the same patient and when handling the resident's environment and supplies. The resident involved had a diagnosis of type 2 diabetes mellitus and chronic obstructive pulmonary disease, and was at risk for pressure ulcer development due to immobility and comorbidities. The resident's care plan included specific wound care orders for the left heel, which were not followed correctly by the WCRN. The WCRN admitted to not realizing the missed hand hygiene opportunities and acknowledged that hand sanitizer could have been used more appropriately during the wound care process. The facility's handwashing policy and wound care policy both emphasize the importance of hand hygiene in preventing the transmission of infections. The Director of Nursing (DON) confirmed the necessity of handwashing during wound care to protect against infection. Despite these policies, the WCRN did not adhere to the required hand hygiene practices, leading to the observed deficiency.
Failure to Monitor and Document Urinary Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that the urinary output of residents with indwelling catheters (IC) was monitored to ensure patency and prevent infections. This deficiency was observed in two residents. Resident #242, who had severe cognitive impairment and multiple diagnoses including cerebral infarction and type II diabetes mellitus, was transferred to the hospital due to stomach pain and inability to urinate. Upon return, the resident had a new IC, but there were no physician orders to monitor urinary output, and no documentation of urinary output was found in the electronic Medication Administration Record (eMAR) for January and February 2024. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed that urinary output should be documented every shift, but this was not done for Resident #242, contrary to the facility's policy and procedure for emptying urinary collection bags and documenting the amount of urine emptied from the drainage bag in the resident's medical record. Resident #266, who had intact cognition and diagnoses including urinary tract infection and benign prostatic hyperplasia, was observed with a catheter draining clear yellow urine. The resident's active physician orders did not include monitoring urinary output, and there was no documentation of urinary output in the January 2024 eMAR and electronic Treatment Administration Record (eTAR). Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) indicated that urinary output was previously documented in the computer system but was now recorded in an Activities of Daily Living (ADL) binder, which did not include any amounts of urine output for Resident #266. The DON acknowledged that the facility did not document urinary output but stated that for quality improvement, it should be done. The surveyor discussed these concerns with the facility's Licensed Nursing Home Administrator (LNHA) and DON, who did not provide any additional information. The facility's failure to monitor and document urinary output for residents with indwelling catheters was identified as a deficiency, as it did not comply with the facility's policy and procedure and could potentially lead to undetected issues with catheter patency and increased risk of infections.
Failure to Ensure Proper Certification and Training of Nurse Aides
Penalty
Summary
The facility failed to ensure that a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days. This was identified for one of three NAs reviewed during the Sufficient and Competent Nurse Staffing task. The facility also lacked a delineated policy and/or program for the hiring, staffing, and assignments of non-certified NAs. The deficiency was evidenced by the fact that NA #1, who was hired on 9/15/23, had been working for more than 120 days without proper certification. Despite passing the written exam, there was no verification that NA #1 was licensed or enrolled in a training program during their employment. The surveyor's investigation revealed that the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were unable to provide a complete list of CNAs with their license numbers. The Staffing Coordinator (SC) admitted that the schedule did not differentiate between certified and non-certified NAs, and the Human Resources Clerk (HRC) was unaware of any non-certified NAs working at the facility. The Director of Activities (DoA) and the Human Resources Manager (HRM) both believed that NAs could work for up to a year as long as they were enrolled in a training program and had passed the skills test, which was incorrect according to state regulations. Further interviews with the LNHA, DON, and NA #1 confirmed that there was a misunderstanding regarding the certification requirements. NA #1 had been working at the facility for eight months since passing the written exam but had not received a license. The facility did not have a policy regarding the employment of non-certified NAs, and the LNHA incorrectly believed that NAs could work for a year under the supervision of a Registered Nurse. The facility's failure to ensure proper certification and training of NAs led to this deficiency.
Failure to Post 24-Hour Staffing Report
Penalty
Summary
The facility failed to ensure that the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) was posted in a prominent place within the facility and readily accessible to residents and visitors. On two consecutive days, the survey team observed that the NHRCSR was not posted at the entrance area or elevator area. Interviews with the Security staff and the Staffing Coordinator confirmed that the report was not posted on these days. The Staffing Coordinator admitted that she did not post the report because she was running late, and the Licensed Nursing Home Administrator (LNHA) acknowledged that the usual posting location was not readily visible. The surveyor discussed the issue with the LNHA and the Director of Nursing (DON), who explained that the person responsible for posting the report had a medical emergency and came in late on the days in question. The facility did not have a policy on posting staffing information, and no additional information was provided by the facility. This deficiency was noted as a failure to comply with N.J.A.C. 8:39-41.2 (a)(b)(c).
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by several deficiencies in medication labeling, storage, and administration. During an inspection of a medication cart, an open and undated multiple-dose vial of Lantus was found, which should have been dated once removed from the refrigerator. Additionally, an expired bottle of Omeprazole was found in the medication room, and it was administered to a resident despite being past its use-by date. The pharmacist confirmed that the compounded Omeprazole had a shelf life of 14 days, but the bottle had a beyond-use date of 21 days, leading to its improper use beyond the recommended period. Further deficiencies were observed in the storage and labeling of medications. Two Pneumococcal syringes were found in the medication room, labeled for specific residents but not administered or documented as refused. Additionally, a box of Ipratropium/Albuterol nebules for inhalation was found on a medication cart, despite being discontinued and not included in the active electronic administration record. The facility's policy required that expired and discontinued medications be removed from active inventory, but this was not adhered to. Interviews with nursing staff revealed that they were aware of the requirements for medication labeling and expiration checks but failed to consistently follow these protocols. The Director of Nursing and the Licensed Nursing Home Administrator were informed of these concerns, highlighting the facility's failure to label opened biologicals, remove expired and discontinued medications from active inventory, and ensure proper medication administration practices. The facility's policies on drug storage, labeling, and administration were reviewed, indicating that these deficiencies were in violation of established guidelines.
Failure to Maintain Sanitary Garbage Disposal Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the garbage compactor and dumpster area free of garbage and debris. During a tour of the kitchen and designated garbage area, the surveyor observed garbage debris, including food, cups, bottles, gloves, paper products, and brown paper bags, surrounding the garbage compactor and dumpster. The Food Service Director (FSD) acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator (LNHA) admitted that the facility maintenance department is responsible for keeping the area clean and free of debris. The facility policy, revised in December 2008, states that outside dumpsters should be kept closed and free of surrounding litter, which was not adhered to in this instance.
Failure to Ensure Timely Physician Visits and Address Nutritional Issues
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits at least once every sixty days and wrote progress notes to address nutritional issues for a resident with weight loss. Resident #77, who had medical diagnoses including dementia, hypertension, type II diabetes mellitus, and anxiety disorder, was observed lying in bed with eyes closed. The resident's medical records indicated a significant weight loss of 5.2% over the past month, as documented by the facility's dietician on 01/16/24. The dietician stated that she would refer any resident with weight loss to the primary physician. However, a review of the interdisciplinary progress notes revealed that the most recent physician visit to Resident #77 was on 11/19/23, and there was no additional documentation that the resident was seen and examined by the primary physician since then. The Licensed Nursing Home Administrator and Director of Nursing were informed of these concerns, but no further information was provided. The surveyor attempted to contact the physician but was unavailable for an interview.
Deficiency in Maintaining Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficiency was identified for one resident complaint and confirmed during the lunchtime meal service for one of three nursing units tested for food temperatures. During the initial tour, a resident expressed dissatisfaction with the food quality. Observations revealed that the lunch had not arrived on time for the residents seated in the main dining area. The meal trucks arrived late, and the process of passing out the meal trays took an extended period, causing the food to lose its temperature. The surveyor observed that the food temperatures were below the recommended levels for hot and cold foods. Further investigation showed that the kitchen equipment was functioning adequately, and the food items were within normal temperature limits before leaving the kitchen. However, the delay in delivering the meal trays resulted in the food cooling down. The facility's policies on food quality and meal distribution were reviewed, and it was noted that the policies lacked creation or revision dates. The policies stated that food should be palatable, attractive, and served at a safe and appetizing temperature, and that meals should be transported and delivered in a timely manner to maintain proper temperatures. The Licensed Nursing Home Administrator acknowledged the issue and stated that the facility is exploring options to improve the timeliness of meal delivery.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for two residents. For one resident, the surveyor found that the Certified Nurse Assistants (CNAs) were documenting Activities of Daily Living (ADL) care on paper forms instead of electronically. However, the facility could not provide any CNA documentation of ADL care for the resident, despite multiple requests and searches by the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). This lack of documentation included important aspects of care such as incontinence and hygiene care, which were not available in either the electronic or paper medical records of the resident. For another resident, the surveyor discovered that there was no physician discharge summary in the medical records after the resident was discharged against medical advice (AMA). The DON confirmed that the discharge summary should have been in the hard medical chart but was not present. The facility's policy on transfer and discharge, which was provided later, indicated that a physician should document the discharge summary. Despite the surveyor's inquiries, the discharge summary was only faxed to the facility after the surveyor's request, raising concerns about the timeliness and accuracy of the documentation. The survey team met with the facility management multiple times to discuss these concerns, but the facility was unable to provide satisfactory explanations or the missing documentation. The lack of proper documentation for both residents indicates a failure to maintain complete and accessible medical records, which is a critical aspect of resident care and regulatory compliance.
Failure to Notify LTCO of Resident Transfer
Penalty
Summary
The facility failed to provide written notification of the emergency transfer to the Office of the Long-Term Care Ombudsman (LTCO) for one resident who was hospitalized. The resident, who had multiple diagnoses including dysphagia, heart failure, chronic kidney disease, bipolar disorder, and anxiety disorder, was transferred to the hospital due to vaginal bleeding. The review of the medical records and the New Jersey Universal Transfer Form confirmed the transfer, but there was no corresponding notification to the LTCO as required by regulations. The Nursing Clerk, responsible for LTCO notifications, confirmed that the notification for this transfer was not submitted and speculated that it might have been missed by the previous Director of Nursing (DON) during the review process. The facility did not have a specific policy for LTCO notifications and followed a monthly submission process, which contributed to the oversight. During the survey, the Nursing Clerk explained the process of LTCO notification, which involved checking electronic medical records, listing residents transferred to the hospital, and preparing a draft report for the DON's review. The DON would then verify the information before the final submission to the LTCO. However, the notification for the resident transferred on 4/19/23 was not found in the provided binder, and the Nursing Clerk could not explain the omission. The Licensed Nursing Home Administrator (LNHA) confirmed the absence of a facility policy regarding LTCO notifications and acknowledged the deficiency. The survey team discussed the concern with the facility management, who confirmed that no additional information was available to address the issue.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive Antibiotic Stewardship Program (ASP) as per their policy and national standards. The Director of Nursing (DON) acknowledged that the newly hired Infection Preventionist (IP) was still in training, and the facility was relying on the previous IP's reports and documentation. However, the documentation provided was incomplete and lacked essential details such as diagnostic testing, type of organism identified, and signs/symptoms of the residents. The facility's policy required a standardized assessment form and comprehensive tracking measures, which were not in place at the time of the survey. The surveyor's interviews with the DON, the former IP, and the Licensed Nursing Home Administrator (LNHA) revealed that infection control was discussed in QAPI meetings, but there was no consistent documentation of feedback reports, trend reports, or surveillance. The provided documentation, including an untitled and undated ABT tracking document and an email summary for the 3rd quarter QAPI for infection control review, lacked detailed information on the specific antibiotics prescribed, diagnoses, and microorganisms of infection identified. The facility's policy outlined the need for regular review of infections, monitoring of antibiotic usage patterns, and reporting on antibiotic resistance patterns, which were not adequately followed. The deficiency was further evidenced by the lack of a standardized assessment form for antibiotic use assessment and the absence of comprehensive documentation for recent antibiotic stewardship activities. The facility's policy required the ASP team to review infections, monitor antibiotic usage patterns, and report on the number of antibiotics prescribed and residents treated each month. However, the facility failed to provide sufficient documentation to demonstrate compliance with these requirements, leading to the identified deficiency in their antibiotic stewardship program.
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Nursing homes near Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway House For Continuing Care | 0 mi | ★★★★★ | 1 | 0 |
| Forest Hills Center For Rehabilitation And Healing | 0.5 mi | ★★★★★ | 0 | 0 |
| Alaris Health At Belgrove | 0.6 mi | ★★★★★ | 16 | 0 |
| Alaris Health At Kearny | 1.1 mi | ★★★★★ | 17 | 0 |
| Sinai Post-acute Nursing & Rehab Center | 1.2 mi | ★★★★★ | 1 | 0 |
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