Optima Care Fountains
Inspection history, citations, penalties and survey trends for this long-term care facility in Secaucus, New Jersey.
- Location
- 595 County Avenue, Secaucus, New Jersey 07094
- CMS Provider Number
- 315476
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Optima Care Fountains during CMS and state inspections, most recent first.
Facility staff did not develop or implement a care plan for a resident with an active order for oxygen therapy, despite the resident's complex medical history and cognitive impairment. Interviews with the RN and DON confirmed that a care plan should have been in place, and facility policy required oxygen administration to be included in person-centered care plans.
A resident with multiple chronic conditions and a history of stroke had incomplete documentation in their ADL records, with blank entries noted for several shifts. Interviews with the RN and DON confirmed that CNAs are responsible for documenting care provided, and facility policy requires all care to be recorded in the medical chart.
A resident with dementia and a history of elopement risk managed to exit a nursing unit through an unsecured door and was later found in the attic with an injury. Despite being identified as an elopement risk, the facility failed to secure exit doors and provide adequate supervision, posing a serious risk to the resident's safety. Staff interviews confirmed that the exit door was unsecured, and the facility's elopement policy was not effectively implemented.
The facility failed to administer medications as prescribed and did not notify the physician when medications were unavailable, affecting two residents. One resident with intact cognition did not receive medications within the appropriate timeframe, while another with moderate cognitive impairment did not receive HIV and diabetes medications due to unavailability. The facility's policies on medication administration and physician notification were not followed.
Facility staff failed to consistently document ADL care for three residents, as evidenced by missing entries in the DSR for various tasks such as bed bath, mobility, continence, and eating. Interviews with staff revealed that CNAs were responsible for documenting ADL care using a mobile app, but the facility lacked a policy on ADL documentation, and the ADON could not explain the blank spaces in the records.
A resident with a stage II pressure ulcer experienced unmanaged pain during a dressing change due to the facility's failure to administer pre-medication. Despite a care plan indicating the need for pain management, the resident did not receive scheduled or PRN Tylenol. The LPN continued the dressing change despite the resident's visible pain, and staff were unaware of the resident's pain issues.
The facility failed to maintain proper food holding temperatures, affecting all residents who consumed meals from the kitchen. During meal preparation, food items were removed from the oven at appropriate temperatures but were not monitored while on the steam table. The final tray from lunch showed significantly reduced temperatures, and previous complaints about low food temperatures had been discussed in meetings without resolution.
The facility did not inform residents and their representatives of their rights regarding arbitration agreements, including the right to rescind within 30 days and that signing was not a condition for admission. Interviews revealed that the arbitration clause was included in the admission packet, but residents were not clearly informed. One resident, with moderate cognitive impairment, did not recall signing the Arbitration Agreement.
The facility did not inform residents of their rights to select a neutral arbitrator and a convenient venue for arbitration, as revealed in their undated Admission Agreement. The Admission Director confirmed that the arbitration agreement was part of the admission packet, and a resident with moderate cognitive impairment did not recall signing it, indicating a lack of clear communication.
The facility failed to provide written bed-hold notices to six residents transferred to hospitals, despite having a policy requiring such notifications. This deficiency was confirmed through record reviews and interviews, revealing that residents and their representatives were not informed about the bed-hold policy, which allows for their return after hospitalization or therapeutic leave.
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program, affecting all 277 residents. Despite policy requirements to share QAPI activities and outcomes through meetings and newsletters, no meeting minutes or newsletters were observed. Interviews revealed that the facility did not keep meeting minutes, only agendas, indicating a lack of centralized documentation and transparency.
The facility failed to address food palatability concerns raised by residents during council meetings, with complaints about taste and temperature occurring in eight out of twelve meetings. A sample meal tray confirmed the food was cold and not palatable, potentially affecting the nutritional status of all 273 residents. The DON and other staff deferred responsibility and did not provide specific plans to address the issue.
The facility failed to inform residents about the process for filing anonymous grievances, as required by its policy. Although the policy allows for anonymous complaints via a Compliance Hotline and grievance boxes, no boxes were present, and residents were unaware of the hotline or the process. The DON and Administrator confirmed the lack of grievance boxes and that the process had not been reviewed with residents.
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. One resident with severe cognitive impairment scratched another resident, while another resident pulled a peer's hair due to agitation. Additionally, a resident with severe cognitive impairment struck multiple residents on separate occasions. These incidents highlight deficiencies in maintaining a safe environment and protecting residents from abuse.
The facility failed to report resident-to-resident abuse incidents to the state agency within the required two-hour timeframe. In one case, a resident with dementia scratched another resident's face, and in another, two residents were involved in a physical altercation. Both incidents were reported late, revealing a misunderstanding of reporting requirements among staff.
The facility failed to thoroughly investigate resident-to-resident altercations involving four residents, as required by their policy. In one case, a cognitively impaired resident scratched another's face, and in another, a resident pulled another's hair. Both incidents were ruled as misunderstandings, but the investigations lacked interviews with other potentially affected residents.
The facility failed to provide palatable and properly heated meals to residents, with reports of cold and tasteless food. Despite ongoing complaints documented in Resident Council Minutes and acknowledged by the RD, the FSD was unaware of these issues and did not attend council meetings. A test tray sample confirmed the food was below required temperatures, and no temperature logbook was maintained.
A resident with cognitive impairment and physical limitations was not treated with dignity during a meal when a CNA stood over them while feeding. The facility's policy requires staff to promote resident dignity, which was not initially followed until a supervisor intervened.
The facility failed to ensure privacy for two residents during care, leading to exposure of their private body parts. In both cases, CNAs left the residents' doors open, compromising their privacy. RN1 intervened by closing the door for one resident, but the CNAs were unaware of the privacy breach.
A facility failed to implement prescribed interventions for a resident with a pressure ulcer on her right heel. Despite the care plan requiring protective heel boots and heel offloading measures, the resident was observed multiple times without the boots, with her heels resting directly on the mattress. Staff confirmed the resident should have been wearing the protective boots, which were found stored in her closet.
The facility failed to ensure staff used appropriate PPE for two residents on Enhanced Barrier Precautions (EBP). One resident with an open leg wound and another with a stage II pressure ulcer received care from CNAs who did not wear gowns, despite EBP signage. The CNAs admitted to not using gowns due to shift changes and oversight, while the Infection Preventionist confirmed proper signage and education were in place.
A public bathroom in Unit 12 was found to have a roach infestation and was in disrepair, with crumbling plaster, peeling paint, and missing tiles. Despite bi-weekly pest control treatments, there was no documentation of roaches in the area. The Director of Housekeeping and Maintenance Director confirmed the need for repairs.
The facility failed to secure medications for two residents, leading to potential hazards. One resident's eye drops were left unattended on a medication cart, while another resident retained a cup of medications after refusing to take them. The LPN was unable to retrieve the medications, and the DON confirmed that medications should not be left unsecured.
Failure to Develop and Implement Oxygen Care Plan
Penalty
Summary
Facility staff failed to develop and implement a care plan (CP) for a resident who had a physician's order for oxygen therapy via nasal cannula at 2 liters per minute. The resident, who was admitted with multiple diagnoses including Parkinson's, COPD, diabetes mellitus, and atrial flutter, was assessed as moderately cognitively impaired with a BIMS score of 5/15. Despite the presence of an active order for oxygen therapy, a review of the resident's care plan did not show any evidence of an oxygen care plan being initiated or documented. Interviews with facility staff confirmed that a care plan should have been in place for any resident receiving oxygen, as it is considered a medication and requires monitoring of respiratory status. Both the RN and the DON acknowledged the absence of an oxygen care plan for this resident. Facility policies reviewed also required that oxygen administration be consistent with professional standards and incorporated into comprehensive, person-centered care plans, but this was not followed in the resident's case.
Incomplete Documentation of ADLs in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident, as evidenced by missing documentation in the Activities of Daily Living (ADL) records. The resident, who had multiple diagnoses including atrial fibrillation, hypertension, diabetes mellitus, and a history of nontraumatic intracerebral hemorrhage, was assessed to have intact cognitive function. The resident's care plan required monitoring and documentation of ADLs, with interventions to encourage self-care where possible. Upon review, the ADL records for the resident showed blank entries for all ADLs during specific shifts on several dates. Interviews with the RN and DON confirmed that Certified Nurse Aides (CNAs) are responsible for completing these records and that blank entries indicate tasks were not documented, even though care may have been provided. The facility's policy requires CNAs to document all care provided, including any refusals or unusual occurrences, in the resident's medical chart during their assigned shift.
Resident Elopement Due to Unsecured Exit Doors
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident who was at risk of elopement. The resident, who had a history of dementia with behavioral disturbances, was able to exit the nursing unit through an unsecured door and was later found in the attic. This incident occurred despite the resident being identified as an elopement risk and having a care plan in place that included interventions such as 15-minute checks and transfer to a locked unit. On the night of the incident, a nurse discovered the resident missing during rounds, prompting a Code Gray alert. Despite a thorough search of the facility and its perimeter, the resident was not found until the following morning when a nurse heard cries for help coming from the attic. The resident was found with a forehead injury and was sent to the emergency room for evaluation. The facility's failure to secure exit doors and provide adequate supervision posed a serious and immediate risk to the resident's health and safety. Interviews with staff revealed that the exit door leading to the stairway was unsecured, allowing residents to access the stairs freely. The Director of Maintenance confirmed that the attic door was unsecured at the time of the incident. The facility's elopement policy was not effectively implemented, as evidenced by the resident's ability to leave the unit and access the attic. The facility was unable to provide evidence that the unit door was secured, highlighting a significant lapse in ensuring a safe environment for residents at risk of elopement.
Removal Plan
- The facility implemented 24/7 monitoring of Unit 11's stairwell door from the first floor to ensure that Residents at risk of wandering and elopement will have the necessary supervision for preventing unsafe access to the stairwell door.
- The role of the BSPEC is to monitor the door. An Elopement Binder was put in place for high-risk Residents including photos of residents who are not allowed upstairs.
- Initiating in-services for all staff on the facility's policy on Elopement and Wandering.
Medication Administration and Notification Failures
Penalty
Summary
The facility failed to administer medications as prescribed and did not notify the physician when medications were unavailable, affecting two residents. For the first resident, who had intact cognition and was diagnosed with Parkinson's Disease, Dementia, and Depression, medications were not administered within the appropriate timeframe on multiple occasions in December 2024. The Medication Administration Record (MAR) indicated that medications were given outside the one-hour window before or after the scheduled time, and the Assistant Director of Nursing (ADON) confirmed that the standard practice was not followed. The ADON also noted that if a resident requested medication outside the timeframe, the nurse should have contacted the physician to adjust the administration time. The second resident, with moderate cognitive impairment and diagnosed with HIV, Diabetes, and Anxiety Disorder, did not receive their HIV and diabetes medications on several occasions because the medications were not available. The Licensed Practical Nurse (LPN) and ADON stated that the nurse should have contacted the pharmacy and the physician when medications were not delivered. However, there was no documentation in the resident's medical record indicating that the physician was notified about the unavailability of medications. The ADON confirmed that the medications were delivered, but the nurses failed to administer them or notify the physician. The facility's Medication Administration Policy, dated March 2023, requires timely and accurate administration of medications and mandates that the physician be informed when medications are unavailable. The facility's document on Medication Pass Observation also specifies that medications should be administered within one hour before or after the scheduled time. The failure to adhere to these policies resulted in the identified deficiencies.
Inconsistent ADL Documentation in LTC Facility
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to residents, as evidenced by the lack of documentation in the Documentation Survey Report (DSR) for three residents. Resident #1, who was admitted with diagnoses including Parkinson's Disease and Unspecified Dementia, had an intact cognition as per the Minimum Data Set (MDS). However, there were multiple instances in December 2024 where documentation was missing for various ADL tasks such as bed bath, bed mobility, bladder and bowel continence, dressing, personal hygiene, toilet use, GG mobility, GG self-care, locomotion, transferring, walking, and eating. Resident #4, with diagnoses including HIV and Diabetes, had impaired cognition and required assistance with ADLs. The review of their DSR and progress notes for December 2024 also revealed missing documentation for several ADL tasks, including bed bath, bed mobility, bladder continence, toilet use, locomotion, personal hygiene, bowel continence, dressing, GG mobility, GG self-care, transferring, walking, and eating. Similarly, Resident #5, who had diagnoses of Unspecified Dementia and Anemia, required assistance with ADLs. Their DSR and progress notes showed missing documentation for bladder and bowel continence, GG mobility, GG self-care, and eating on various dates in December 2024. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed that CNAs were responsible for documenting ADL care using a mobile app at the end of their shifts. The ADON acknowledged the responsibility of CNAs, nurses, supervisors, and Unit Managers to ensure complete ADL documentation. However, the facility could not provide a policy on ADL documentation, and the ADON could not explain the blank spaces in the DSRs.
Failure in Pain Management During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during pressure ulcer treatments. The resident, who was admitted with diagnoses including stroke, impaired thought process, and anxiety, exhibited signs of pain during a dressing change for a stage II pressure ulcer on the right heel. Despite having a care plan that included interventions for pain management, the resident was not pre-medicated for pain, resulting in unnecessary suffering. The resident's Medication Administration Record showed no evidence of receiving scheduled or as-needed Tylenol for pain relief from the beginning of October through mid-October. During an observation, the resident was seen grimacing and moaning in pain while an LPN performed a dressing change without administering pain medication beforehand. The LPN acknowledged the resident's pain but continued the procedure without stopping. Interviews with the facility's staff, including CNAs and the ADON, revealed a lack of awareness regarding the resident's pain during dressing changes. The facility was unable to provide additional information or policies on pain management and pressure ulcer care when requested by the survey team.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to maintain proper food holding temperatures, which had the potential to affect all 273 residents who consumed meals from the kitchen. During the noon meal preparation, food items such as seasoned chicken thighs, Italian green beans, and carrots were removed from the oven at appropriate temperatures but were not monitored for temperature maintenance while on the steam table. The food was placed on the steam table without a temperature logbook, and no temperatures were taken during the meal tray preparation and delivery process. Upon testing the final tray from lunch, the food temperatures had dropped significantly, with the chicken thighs at 117 degrees Fahrenheit, green beans at 114 degrees Fahrenheit, and carrots at 112 degrees Fahrenheit. The Registered Dietician noted that food complaints had been discussed in Morning Meetings/QA meetings, with specific mentions of low food temperatures on certain units. Despite these discussions, the facility did not have a system in place to ensure food temperatures were maintained, leading to the deficiency.
Failure to Inform Residents of Arbitration Rights
Penalty
Summary
The facility failed to inform residents and their responsible parties of their rights regarding arbitration agreements. Specifically, three residents and/or their representatives were not informed of their right to rescind the arbitration agreement within 30 calendar days and their right not to be required to enter into a binding arbitration agreement as a condition of admission. The facility's Admission Agreement and Arbitration Agreement lacked language that clearly communicated these rights. The facility's policy stated that binding arbitration was not a condition for admission or continued care, but this was not reflected in the agreements provided to residents. Interviews with facility staff revealed that the arbitration clause was included in the admission packet, and the Admissions Director explained it to families. However, the Admission Director indicated that signing the Admission Agreement also meant signing the Arbitration Agreement, which was not clearly communicated to residents. One resident, who was moderately cognitively impaired, did not recall signing an Arbitration Agreement, despite having signed the Admission Agreement. This indicates a lack of clear communication and understanding regarding the arbitration process and residents' rights.
Failure to Inform Residents of Arbitration Rights
Penalty
Summary
The facility failed to ensure that their arbitration agreement informed residents and/or their responsible parties of their right to select a neutral arbitrator and a convenient venue for arbitration. This deficiency was identified during a review of the facility's undated Admission Agreement, which stipulated that any disputes would be settled by binding arbitration conducted in Jersey City, New Jersey, without mentioning the residents' rights to choose the arbitrator or venue. The facility's policy stated that arbitration was not a condition for admission or continued care, yet the agreement was included in the admission packet, and signing it was part of the admission process. Interviews conducted with the Admission Director and a resident revealed further insights into the deficiency. The Admission Director confirmed that the arbitration agreement was part of the corporate admission packet and that the facility would select the arbitration location and arbitrator. A resident, identified as moderately cognitively impaired, stated she had signed the Admission Agreement but did not recall signing an Arbitration Agreement. This indicates a lack of clear communication and understanding regarding the arbitration process and the rights of the residents involved.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to six residents who were transferred to a hospital or placed on therapeutic leave. This deficiency was identified during a review of the facility's records and interviews with staff and residents. The facility's policy, revised in July 2023, mandates that residents or their representatives be informed in writing about the bed-hold policy, which allows residents to return to the facility after hospitalization or therapeutic leave. However, documentation for six residents did not include evidence of such notifications. Resident 75 was transferred to the hospital for a possible neurological event, and upon review, there was no documentation that the resident or their representative received a bed-hold notice. Similarly, Resident 111, who was transferred to the emergency room for abdominal pain, did not receive a bed-hold notice. Resident 127, transferred for evaluation of altered mental status, also lacked documentation of receiving a bed-hold notice. Interviews with the Director of Nursing confirmed that these notices were not provided. Additional cases included Resident 209, who was transferred for pneumonia, and Resident 90, who was transferred for a urinary tract infection and pneumonia. Both residents returned to the facility without having received a bed-hold notice. Resident 186, transferred for congestive heart failure, also did not receive a bed-hold notice. Interviews with residents and the facility's Regional Director further confirmed the absence of a bed-hold policy, despite the facility's written policy indicating otherwise.
Lack of QAPI Documentation and Transparency
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program, which had the potential to negatively affect all 277 residents. The facility's policy indicated that QAPI activities and outcomes should be shared with staff, residents, and family members through meetings and newsletters, with minutes posted throughout the facility. However, during the survey, no QAPI meeting minutes or newsletters were observed in the designated areas of the facility. Interviews with the Director of Nursing (DON), Regional Nurse, and Assistant Director of Nursing (ADON3) revealed that the facility did not keep meeting minutes, only agendas. The DON stated that they might need to gather information from each department, indicating a lack of centralized documentation. This lack of documentation and transparency in the QAPI process was a significant deficiency, as it hindered the facility's ability to effectively communicate and implement quality improvement initiatives.
Failure to Address Food Palatability Concerns
Penalty
Summary
The facility failed to obtain feedback, use data, and take action to conduct systematic investigations and analyses of underlying causes or contributing factors of problems affecting facility-wide processes. Specifically, the facility did not address food palatability concerns raised by residents during council meetings. Over the course of a year, residents consistently complained about the taste and temperature of the food during eight out of twelve meetings. A sample meal tray review confirmed that the food was cold and not palatable, which could potentially affect the nutritional status of all 273 residents who consumed meals from the kitchen. During an interview, the Director of Nursing (DON) and other staff members were questioned about the residents' concerns regarding food palatability. The DON indicated that food service was not their department and deferred responsibility to the Food Service Manager. The Assistant Director of Nursing (ADON3) acknowledged that complaints about food were ongoing but did not provide any specific plans or measures in place to address the issue. When asked about prioritizing opportunities for improvement and performance improvement projects, the group did not respond, indicating a lack of action or response to the grievances related to food palatability.
Failure to Inform Residents of Anonymous Grievance Process
Penalty
Summary
The facility failed to provide information on how to file an anonymous grievance for seven residents reviewed for the grievance process. The facility's policy, titled 'Resident and Family Grievances,' states that grievances can be filed anonymously using a Compliance Hotline or complaint/grievance boxes located throughout the facility. However, during an initial tour, no grievance boxes were observed, and residents were unaware of the ability to file anonymous complaints, the compliance hotline, or where to find the hotline number. During a group interview, the residents confirmed their lack of awareness regarding the anonymous grievance process. The Resident Council meeting minutes from October 2023 through August 2024 also showed no documentation that residents had been informed about making anonymous complaints. The Director of Nursing and the Administrator confirmed the absence of grievance boxes and acknowledged that the anonymous complaint process had not been reviewed with residents at group meetings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving resident-to-resident altercations. One incident involved a resident with severe cognitive impairment who scratched another resident on the face with a broken comb after entering the latter's room multiple times. The cognitively intact resident asked the impaired resident to leave, which led to the aggressive behavior. The facility's response included separating the residents and initiating monitoring, but the initial failure to prevent the altercation highlights a deficiency in protecting residents from abuse. Another incident involved a resident with dementia and agitation symptoms who pulled another resident's hair in the day room. The altercation was triggered by the noise made by the second resident, who was confused and had a history of shouting episodes. Despite staff presence, the altercation occurred quickly, and the residents were separated immediately. The facility's inability to prevent the altercation before it happened indicates a lapse in ensuring resident safety and preventing abuse. A third incident involved a resident with severe cognitive impairment who struck multiple residents on separate occasions. The resident's aggressive behavior was unprovoked in some instances and triggered by misunderstandings in others. The facility's failure to prevent these repeated incidents of aggression and physical contact between residents demonstrates a deficiency in maintaining a safe environment and protecting residents from abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the state agency within the required two-hour timeframe. This deficiency involved four residents out of a sample of 45. The facility's policy mandates that all alleged violations involving abuse or serious bodily injury be reported immediately, but not later than two hours after the allegation is made. However, in two separate incidents, the facility did not adhere to this policy. In the first incident, a resident with dementia and mood affective disorder became aggressive and scratched another resident's face, resulting in redness under the eye. The incident was reported to the state agency several hours later, beyond the two-hour requirement. In the second incident, two residents with dementia and bipolar disorder were involved in a physical altercation where one resident pulled the other's hair. Although no injuries were noted, the incident was not reported to the state agency until three days later. Interviews with facility staff revealed a misunderstanding of the reporting requirements, with the Risk Manager incorrectly believing that only major injuries and allegations of abuse needed to be reported within two hours. The Director of Nursing, however, considered resident-to-resident incidents as abuse and stated that they should be reported within the required timeframe.
Inadequate Investigation of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents, which could potentially place other residents at risk. The facility's policy requires immediate investigation of abuse allegations, including interviewing all involved persons and providing thorough documentation. However, in the incidents involving the residents, the investigations were not comprehensive, as other residents who might have been affected were not interviewed. In the first incident, a resident with severe cognitive impairment scratched another resident's face with a broken comb. The incident was reported, and both residents were separated for safety. The investigation concluded that the incident was a misunderstanding due to the resident's confusion, and abuse was ruled out. However, the investigation did not include interviews with other residents who might have witnessed or been affected by the incident. In the second incident, a resident pulled another resident's hair in response to shouting. The staff separated the residents, and no injuries were reported. The investigation concluded that the action was triggered by the noise, and abuse was ruled out. Similar to the first incident, the investigation did not include interviews with other residents who might have been present or affected, indicating a lack of thoroughness in the investigative process.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, flavorful, and at the proper temperature for nine residents reviewed for food palatability. Observations, interviews, and record reviews revealed that residents frequently received meals that were cold and tasteless. The facility's policy required hot food to be held at an acceptable temperature range prior to service, but this was not consistently followed. Residents, including those with cognitive impairments and specific dietary needs, reported dissatisfaction with the food quality, indicating that it was sometimes cold, overcooked, or lacking flavor. Interviews with residents and review of Resident Council Minutes from October 2023 to October 2024 highlighted ongoing complaints about food quality, including issues with temperature and taste. The Resident Council President and several residents confirmed that these concerns were frequently raised, yet the facility had not adequately addressed them. The Food Service Director (FSD) was unaware of these complaints, as they did not attend Resident Council meetings. During a test tray sample, food temperatures were found to be below the required levels, and the food was described as cold and not flavorful by both the surveyor and facility staff. The Registered Dietician (RD) acknowledged awareness of the food complaints and noted that these issues were discussed in Morning Meetings/QA meetings attended by department heads, including the FSD. Despite these discussions, the facility lacked a food temperature logbook for the steam table, and no temperatures were taken during meal preparation and delivery. The FSD admitted to not taking periodic temperatures on the steam table, which contributed to the deficiency in maintaining proper food temperatures.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during a dining experience. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident while feeding them, which is contrary to the facility's policy on promoting and maintaining resident dignity. The policy emphasizes treating each resident with respect and dignity, recognizing their individuality, and providing care in a manner that enhances their quality of life. The resident involved had been admitted with diagnoses including acute stroke with right-sided weakness and aphasia, and required partial to moderate assistance with eating. The resident was also noted to be severely impaired in cognitive skills for daily decision-making. During the observation, a Registered Nurse Supervisor intervened and instructed the CNA to sit while assisting the resident with feeding, indicating that the CNA was aware of the proper procedure but failed to adhere to it initially.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure personal privacy during care for two residents, identified as R75 and R110, which had the potential to cause embarrassment or shame. For R75, who was admitted with diagnoses including cerebral infarction due to embolism, chronic congestive heart failure, and Alzheimer's dementia, an incident occurred on 10/14/24. During this incident, CNA20 and QA/CNA3 were in R75's room with the door closed. However, CNA20 opened the door, exposing R75's private body parts to the hallway. CNA20 then called for UM1 to bring the resident's cream, using the resident's name. UM1 entered the room with the door open, provided the cream, and then left, closing the door afterward. Similarly, for R110, who was admitted with cerebrovascular disease and a personality disorder, an incident was observed on the same day. CNA20 and QA/CNA3 were in R110's room with the door closed, but CNA20 opened the door, leaving R110 exposed to the hallway. CNA20 left the room without closing the door and returned without closing it again, leaving R110 exposed while personal care was being provided. RN1, passing by, noticed the open door and immediately closed it. Both CNA20 and QA/CNA3 later confirmed they were unaware of leaving the doors open, compromising the residents' privacy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement interventions for the healing of pressure ulcers as per the care plan for a resident with a pressure ulcer on her right heel. The resident, who was admitted with diagnoses including stroke, impaired thought process, and anxiety, was cognitively intact with a BIMS score of 14 out of 15. Her care plan included treatments as ordered, referral to a wound physician and dietician, and heel offloading measures. However, during multiple observations, the resident was found without protective heel boots, which were part of her prescribed interventions to aid in the healing of her pressure ulcer. On several occasions, the resident was observed lying in bed with her heels resting directly on the low air loss mattress without elevation, contrary to the care plan's requirements. A Licensed Practical Nurse confirmed that the resident should have had heel protectors on, but they were found stored in the resident's closet instead of being used. The Assistant Director of Nursing and the Minimum Data Set Coordinator also confirmed that the resident should have been wearing protective heel boots at all times, indicating a lapse in following the prescribed care plan for pressure ulcer management.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to residents on Enhanced Barrier Precautions (EBP). Specifically, two residents, identified as R110 and R157, were not provided care with the required PPE by the certified nursing assistants (CNAs). R110, who had an open wound on his left lower leg requiring a dressing, was observed receiving personal care from CNAs who did not wear gowns, despite the presence of EBP signage outside the resident's door. The CNAs admitted to not using protective gowns because it was the end of their shift and they were assisting the next shift. Similarly, R157, who had a stage II pressure ulcer on her right heel, was also not provided care with the required PPE. During a bed bath, CNAs were observed not wearing gowns, and one CNA held soiled linens against her uniform. The CNAs acknowledged their awareness of the EBP requirement but failed to comply, with one CNA stating she had not seen the EBP signage. The Infection Preventionist confirmed that proper signage and supplies were available and that the CNAs had been educated on EBP procedures.
Sanitation and Pest Control Deficiency in Public Bathroom
Penalty
Summary
The facility failed to maintain a sanitary and pest-free environment in one of its public bathrooms, specifically the Unit 12 public bathroom. During an inspection, a surveyor observed a roach running across the floor from under the sink to behind the toilet. The bathroom was also found to be in disrepair, with crumbling plaster and peeling paint on the walls, peeling paint on the heater unit, and missing tiles around the back of the toilet. These conditions were confirmed by a family member who reported seeing roaches on multiple occasions and described the bathroom's state of disrepair. The Director of Housekeeping stated that the facility's pest management company conducted bi-weekly treatments across the campus, and any pest issues were supposed to be documented at each nurses' station. However, a review of the pest control sheets for September 2024 showed no documentation of roaches on Unit 12. Both the Director of Housekeeping and the Maintenance Director acknowledged that there had been no reports of roaches in the bathroom and agreed that the bathroom required repairs.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure the secure handling of medications for two residents, R110 and R76, which could potentially expose residents to hazards of unsecured medications. For R110, during a medication pass observation, the Unit Manager retrieved eye drops from the medication drawer and placed them on top of the medication cart before locking the cart and leaving the area to wash hands. This action left the medication unattended and unsecured, contrary to the facility's policy that requires medications to be kept secured in a locked area or under visible control at all times. For R76, an observation revealed a clear cup containing at least four different medications on the resident's overbed table. The resident had refused to take the medications earlier and did not return them to the LPN, who confirmed that she could not retrieve the medication cup from the resident. The LPN was unable to identify the medications in the cup. The Director of Nursing confirmed that medications should not be left with a resident or on top of the medication cart out of the nurse's line of sight, and if a resident does not take their medication, the nurse is responsible for removing it.
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A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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