Our Ladys Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasantville, New Jersey.
- Location
- 1100 Clematis Ave, Pleasantville, New Jersey 08232
- CMS Provider Number
- 315054
- Inspections on file
- 19
- Latest survey
- December 31, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Our Ladys Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility was found deficient as two out of five kitchen exhaust hood grease baffles were missing interior channels, compromising fire protection. This issue was observed over the main 4-burner natural gas cooking appliance and confirmed through staff interviews, potentially affecting all residents.
The facility's fire alarm system was found to be deficient as the main entrance annunciator panel was in trouble mode due to a faulty CO detector module in the basement. This issue was identified by a technician, who noted that the module needed replacement to resolve the panel's boot cycling and supervisory status issues.
A facility was found to be in violation of electrical safety standards when a green extension cord was improperly used to power a 120-gallon holding tank circulating pump in the basement boiler location. This practice, confirmed by two individuals during an observation, did not comply with NFPA standards, which prohibit the use of extension cords as a substitute for fixed wiring. The deficiency had the potential to affect all residents and was noted during the Life Safety Code exit conference.
Surveyors observed multiple deficiencies in maintaining a clean and safe environment in the facility. A resident's bathroom had a loose toilet paper dispenser and stains, while another resident's room had a disconnected bed rail. The smoking area was littered with cigarettes, and nourishment rooms had various issues, including unlabeled substances, rust, and improperly stored items. Staff acknowledged these problems, and efforts to address them were noted.
The facility failed to properly store and label medications in medication carts, as observed by surveyors. Loose tablets were found in multiple carts, and undated insulin vials were noted. An LPN acknowledged the need for dating insulin vials and corrected the storage of Heparin. The facility's policies require orderly storage and dating of insulin vials, which were not adhered to.
The facility failed to ensure emergency illumination operated automatically along the means of egress, as required by NFPA 101:2012. In the C-hall dining room, a single wall switch controlled all ceiling lights, affecting 25 residents. This was confirmed by U.S. FOIA representatives during an observation.
The facility failed to ensure fire-rated doors to hazardous areas were self-closing and properly sealed, affecting 25 residents. Observations revealed gaps in kitchen doors and a door to the dining room that wouldn't close due to air pressure, compromising fire safety.
Access to a fire extinguisher in the E-hall exit/egress corridor was obstructed by a desk, computer monitor, and a 3-tier paper tray, potentially affecting approximately 75 residents. This deficiency was confirmed by U.S. FOIA representatives during an interview.
A facility failed to ensure a resident's call device was within reach while the resident was in bed, despite the resident's diagnosis of Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region. The call device was observed on the floor, outside the resident's reach, on two occasions. The facility's policy requires a call bell system to be accessible for residents to call for assistance.
The facility failed to maintain complete medication records and follow physician orders for two residents. One resident's treatment with Medihoney was not properly documented, with missing nurse initials on the TAR. Another resident received Midodrine HCL despite physician orders to hold the medication if SBP was greater than 135. Interviews with nursing staff confirmed these documentation and administration errors, highlighting deficiencies in adherence to medication policies.
A resident with cognitive intactness but physical limitations was found with long, sharp nails due to the facility's failure to provide necessary nail care. Despite the resident's inability to perform ADLs independently, the CNA did not trim the nails, and the LPN noted a previous refusal of care. Facility policies on nail care and ADLs were not adequately followed, resulting in this deficiency.
A facility failed to adjust medication administration times for a resident undergoing hemodialysis, resulting in missed doses of prescribed hypertension medications. Despite the care plan's directive to coordinate with the physician or dialysis center, the resident did not receive clonidine and isosorb dinitrate-hydralazine on multiple occasions due to being off the unit for dialysis. The LPN and Nurse Manager acknowledged the oversight and the need to clarify medication orders with the physician.
The facility failed to ensure regular face-to-face visits and documentation by physicians for several residents, as required by policy. Residents with various medical conditions, including hypertension and diabetes, had inconsistent or missing progress notes from attending physicians, with gaps in documentation spanning several months. The facility's policy required monthly visits and documentation, but these were not consistently followed.
A facility failed to ensure staff wore appropriate PPE when entering a room under Contact Precautions. A nurse entered a resident's room, diagnosed with a multi-drug resistant organism, wearing gloves but no gown, despite signage indicating the requirement. The facility's policy mandates gown use in such situations, and the incident highlights a lapse in adherence to infection control protocols.
The facility failed to meet the required CNA staffing ratios for 12 out of 14 day shifts, as mandated by New Jersey law. Despite the facility's policy claiming adequate staffing, the 'Nurse Staffing Report' showed consistent understaffing, with the number of CNAs falling short of the required number. Interviews with the Staffing Coordinator and DON revealed awareness of the requirements, yet they incorrectly stated compliance.
The facility did not meet mandatory nurse staffing requirements for two days in early December 2024, falling short by 33 and 9 hours, respectively. Despite claims from the Staffing Coordinator, DON, and Licensed Nursing Home Administrator that staffing was adequate based on census and resident acuities, the facility's policy to maintain adequate staffing was not fulfilled.
A facility failed to obtain a physician-ordered blood test for a resident with multiple diagnoses, leading to a delayed discovery of an abnormally high white blood cell count. The oversight occurred because the order was not entered into the EMR, and the facility's policies lacked pertinent information about lab orders.
Deficiency in Kitchen Exhaust Hood Grease Baffles
Penalty
Summary
The facility failed to ensure that two out of five exhaust hood grease baffles were fully operational, which is necessary to protect against grease and fire from entering above the exhaust hood system in accordance with NFPA 96. During an observation, it was noted that the interior channels of the #1 and #5 baffles were missing, providing no protection in those areas. The #1 grease baffle was specifically observed over the main 4-burner natural gas cooking appliance. This deficiency was confirmed through interviews conducted shortly after the observation, and it was noted that this practice had the potential to affect all residents.
Plan Of Correction
K-0324 (F) Cooking Facilities 1. Replacement of the 2 of the 5 kitchen hood grease baffles identified as missing; the interior channels of the #1 and #5 baffle were ordered and installed on 1/9/2025. 2. All other areas have been inspected and comply. All resident areas are free from hazard and all systems are operating as designed. 3. The Maintenance Director provided education with the Maintenance staff to confirm proper gap penetration in kitchen equipment on 1/10/2025. 4. Every quarter for a year, the Maintenance Director or designee will review random areas for excess penetrations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *photo of replacement of kitchen baffles attached*
Fire Alarm System Deficiency Due to Faulty CO Detector Module
Penalty
Summary
The facility failed to ensure that all components of the fire alarm system were fully operational in accordance with NFPA 70 and 72. During an observation, it was noted that the main entrance fire alarm annunciator panel was in trouble mode, indicating a disconnection in Zone-4 and a trouble with the basement CO detector. A document from the facility vendor dated 12/13/24 revealed that a technician identified a faulty module for the CO detector, which was causing the panel to boot cycle and not return to normal supervisory status. The panel was left in supervisory mode until the necessary monitoring module and programmer could be obtained to correct the issue. This deficiency was acknowledged during the Life Safety Code exit conference.
Plan Of Correction
K-0345 (E) NFPA 101- Testing and Maintenance 1. [R] has restored functionality to the fire alarm system by installing a new module on 1/14/2025. The system was always functioning, and all residents areas are free from hazard. 2. All testing and maintenance paperwork has been completed and inspected on 1/14/2025. 3. The Maintenance Director provided education with Maintenance staff to confirm proper repairs on paperwork once deficiencies are found on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee review paperwork for proper paperwork and deficiency free reporting. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *Invoice of service installation of fire alarm system module attached*
Improper Use of Extension Cord in Facility
Penalty
Summary
The facility failed to comply with electrical safety standards as outlined in NFPA 101, NFPA 70, and NFPA 99. During an observation in the basement boiler location, it was found that a green extension cord was improperly used to supply power to a 120-gallon holding tank circulating pump. This extension cord was plugged into a duplex wall outlet, which is a violation of the requirement that extension cords should not be used as a substitute for fixed wiring. This practice was identified as a deficiency because it did not meet the conditions specified in the relevant NFPA standards, which prohibit the use of extension cords beyond temporary installation. The deficiency was confirmed through an interview with two individuals present during the observation. The improper use of the extension cord had the potential to affect all residents in the facility, as it was not in compliance with the safety standards designed to prevent electrical hazards. The issue was formally communicated to the responsible party during the Life Safety Code exit conference.
Plan Of Correction
K-0920 (E) Power Cords and Extensions. 1. The extension cord plugged into a circulator pump for the hot water system has been removed and replaced with a permanent circuit on 1/10/2025. All residents are free from hazard. 2. All areas are free from extension cords and have been inspected by 1/10/2025. 3. The Maintenance Director provided education with Maintenance staff regarding the need to maintain proper electrical connected with approved electrical connections. 4. Every quarter for a year the Maintenance Director or designee will check surge protectors throughout the facility to maintain logs of what they are used for. This information will then be entered on a log and will be presented to the monthly QAPI meeting quarterly for one year. *extension cord was replaced with permanent circuit to the circulator pump- see attached photo*
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made by surveyors. In one instance, a resident's bathroom had a crooked and loose toilet paper dispenser, stains on the floor near the window, and stains on the wall outside the bathroom door. Another resident's room was found with a disconnected bed rail and a bed remote control left on the floor. Additionally, the smoking area grounds were littered with discarded cigarettes, and an outdoor bench was cracked. Further observations revealed issues in the nourishment rooms across various units. In one unit, a water bottle with an unlabeled blue substance and an open sponge were found under the sink, while the ice machine had white stains and rust. Paper cups were improperly stored facing up, exposing them to germs. Another unit had a kitchen cabinet in poor condition with missing knobs and paperclips used to open doors, along with peeling paint. In yet another unit, cabinets were nailed shut, and there was visible dirt, dust, and a dead bug in the open cabinets. Interviews with staff, including registered nurses, the Director of Housekeeping, and the Maintenance Director, confirmed awareness of these issues. The staff acknowledged that personal items and cleaning supplies were improperly stored, and that the nourishment rooms required cleaning and maintenance. The Licensed Nursing Home Administrator also recognized the need for appropriate storage solutions and replacements for the damaged cabinets, indicating ongoing efforts to address these deficiencies.
Plan Of Correction
F584 Homelike Environment What corrective action will be accomplished for those residents affected by the deficient practice? The following residents were identified as being affected by the deficient practice: resident #11, resident #319, and resident #20. Resident #11 toilet paper dispenser in the bathroom was secured to the wall. The bedroom walls were repainted, and the floor was stripped and buffed. Resident #319 NJ EX Order 26 on the left side was immediately reconnected to NJ Ex Order 26.4. The bed remote control was immediately picked up, wiped clean, tested to be in working condition and placed within residents reach. Resident #20 room was immediately swept and mopped discarding the medication cup, straw and liquid on the floor. The unidentified tablet was discarded via drug buster. The clean left bedside were put away per residents request. The following areas were identified as being affected by the deficient practice: The cigarettes on the ground in the grass and sidewalk area of the designated smoking area were discarded. The cracked outdoor bench in the courtyard was removed and discarded. The pillowcases in room B8 bathroom window were removed. The window was checked by maintenance and is in good working order. Room B4 (A) wall was repainted. The water bottle with blue substance and sponge were immediately removed from Unit C/D nourishment room. The white stains on the ice machine were removed and the rust was removed off the rack. The stack of 3 paper cups observed facing up and open to room air were discarded. The nourishment room cabinet On Unit G/H was discarded and a new cabinet was installed. Cabinet doorknobs were placed on the Unit B nourishment room cabinet doors under the counter. The tied plastic bag with a mop head in it was immediately removed and discarded. The open bag of clothes on the chair was removed. The inside of the upper cabinets in Unit E/F nourishment room were cleaned. The bottom cabinets on Unit E/F nourishment room were replaced. The counter tops in Unit E/F nourishment room were cleaned. Six tied bags of clothes on the counters in Unit E/F nourishment room were removed. The missing paint around the soap dispenser in Unit E/F nourishment room was repainted. The layer of dirt and debris behind the sink in Unit E/F nourishment room was cleaned. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A facility audit was conducted to identify rooms/areas with the following: Resident bathroom toilet paper dispensers were audited for secure placement. The condition of resident bedroom walls and floors were audited. Resident bed rails were audited to ensure proper placement. Unit ice machines were audited for descaling and cleanliness. Unit nourishment rooms were audited for repairs. Nourishment rooms were audited for employee personal belongings. Resident wearing briefs were identified and asked regarding their preference of storing incontinence products. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Housekeeping Director began re-education on January 6, 2025, to the housekeeping staff reviewing the following: Resident room cleaning procedures. Nourishment room cleaning procedures. Smoking area cleaning procedures. The Housekeeping Director or Designee will conduct random audits of the following areas: Resident rooms for cleanliness of floors and walls by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment rooms for cleanliness of counter tops, cabinets and sinks by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Smoking area for cleanliness and removal of cigarettes by rounding and visually observing the smoking area 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Director of Maintenance began re-education on January 6, 2025, to the maintenance staff reviewing the following: Resident room repairs and preventative maintenance. Resident bathroom repairs and preventative maintenance. Nourishment room repairs and preventative maintenance. Equipment repairs and preventative maintenance ie. Bed rails, ice machines. The Director of Maintenance and or Designee will conduct random audits of the following areas: Resident rooms for identified maintenance repairs by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Resident bathrooms for identified maintenance repairs by rounding and visually observing 5 resident bathrooms 5 days a week x4 weeks, then 3 bathrooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. Nourishment room for identified maintenance repairs by rounding and visually observing all nourishment rooms 5 days a week x4 weeks, then all nourishment rooms 3 days a week x4 weeks and then all nourishment rooms 2 days a week x4 weeks. Bed rails to ensure proper placement on the bed frame by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 rooms 5 days a week x4 weeks and then 2 rooms 5 days a week x4 weeks. All Unit Ice machines to ensure descaling and tray maintenance by rounding and visually observing the ice machines 5 days a week x4 weeks and then 3 days a week x4 weeks. The Unit Managers began re-education on January 6, 2025, to the nursing staff on proper storage location of personal items and resident preference of location to store incontinent products. The Unit Managers and or Designee will conduct random audits for employee personal belongings by rounding and visually observing nourishment rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. The Unit Managers and or Designee will conduct random audits of residents who use incontinence products for proper storage in rooms by rounding and visually observing 5 resident rooms 5 days a week x4 weeks, then 3 days a week x4 weeks and then 2 days a week x4 weeks. How will the corrective action be monitored to ensure the deficient practice will not recur? The Director of Housekeeping and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Director of Maintenance and/or designee will report on all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads. The Unit Managers and/or designee will report all the audit results to the Quality Assurance Performance Improvement Committee (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director and Department Heads.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in medication carts, as observed during a survey. On multiple occasions, surveyors found loose tablets in the drawers of medication carts across different halls, indicating a lack of adherence to the facility's medication storage policy. Specifically, on one occasion, two loose tablets were found in a medication cart drawer, and undated multi-use vials of Insulin Lispro and Lantus were observed. Additionally, loose vials of Heparin were improperly stored with insulins, which was acknowledged by an LPN who then corrected the storage. Further inspections revealed similar issues with loose tablets in other medication carts, with one LPN unsure about the frequency of cart cleaning, attributing the issue to the night shift. The facility's policies on medication storage and administration were reviewed, highlighting the requirement for medications to be stored in an orderly manner and for insulin vials to be dated upon opening. These observations indicate a failure to maintain medication storage areas in a clean, safe, and sanitary manner, as required by the facility's policies.
Plan Of Correction
F761- Label/Store Drugs and Biologicals What corrective action will be accomplished for those residents affected by the deficient practice? Destroy all loose pills in the drug buster that were found in D-Hall, B-Hall, A-Hall, G-Hall medication carts, the undated Lantus multi-dose vial and the undated Lispro. Place Heparin vial in the proper box labeled Heparin. Educated USFOIA (b) (6) assigned in A-hall, B-Hall, D-Hall, G-Hall medication carts on the Policy for Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug busters if found. Educated USO assigned in D-Hall cart the Policy on Medication Labeling of Multi-dose Vial. Given specific instructions on proper labeling expiration date of Lantus multi-dose vial once opened. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Unit Managers audited medication carts on their units and no further concerns were noted. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Nurse Educator began education on December 17, 2025 to RN/LPN's on staff of policy on Treatment & Medication Cart Cleaning and Medication Storage. Given emphasis on checking for loose pills in their med carts and destroying loose pills using drug buster if found. Policy on Medication Labeling of Multi-dose Vial will be provided. Given specific instructions on proper labeling of multi-dose vials once opened. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by the Nursing Administration for loose pills in med carts, expiration labels on multi dose vials, and proper storage of Heparin Vials, weekly x4, monthly x3. The results of the audits will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Failure to Provide Automatic Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination that would operate automatically along the means of egress, as required by NFPA 101:2012 Edition, Sections 19.2.8 and 7.8.1.3* (2). This deficiency was identified during an observation and interview conducted on December 30, 2024, in the presence of U.S. FOIA representatives. Specifically, it was observed that in the C-hall occupied dining room, a single wall light switch controlled all eight ceiling light fixtures, which did not comply with the requirement for emergency illumination to operate automatically. This issue was noted in one of four areas and had the potential to affect 25 residents. The findings were confirmed by the U.S. FOIA representatives at the time of observation and were communicated to the facility during the Life Safety Code survey exit conference on December 31, 2024.
Plan Of Correction
K-0281 (E) NFPA 101- Illumination of Means of Egress 1. The facility is scheduled on January 24, 2025, to install emergency lighting in the dining room to illuminate the discharge path. The room has ambient lighting, and all residents were free from hazards. 2. All remaining egress path lights have been inspected and found at least one light that is on constant power. Fixtures have been tested and are in full operation as of 1/10/2025. All resident areas are free from hazards and all systems are operating as designed. 3. Education is completed with Maintenance staff to confirm proper function and maintenance of all egress path lighting on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee reviews random exit path lights for function. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *emergency lighting was installed in the dining room- see attached photo*
Deficient Fire-Rated Door Compliance in Hazardous Areas
Penalty
Summary
The facility failed to ensure that fire-rated doors to hazardous areas were self-closing, properly labeled, and separated by smoke-resisting partitions as required by NFPA 101, 2012 Edition. This deficiency was observed in two of six doors located at the back of the facility, potentially affecting 25 residents in the identified area. Specifically, an observation at 10:10 AM revealed that the set of wooden doors to the kitchen had a gap of approximately 1/2-inch to 3/4-inch when in the closed position, compromising the fire barrier's integrity. Additionally, at 10:21 AM, it was observed that the blue door from the kitchen to the resident dining room would not fully close and latch due to positive air pressure from the kitchen, causing the door to remain open by approximately 6 inches. These observations were confirmed in an interview with the involved staff members. The deficiency was communicated to the facility during the Life Safety Code exit conference.
Plan Of Correction
K-0321 (E) NFPA 101- Hazardous Areas Enclosure 1. Replacement of kitchen-rated doors were ordered on January 14, 2025 with installation prior to compliance date of February 11, 2025. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All hazardous enclosure doors have been inspected, and confirmation of latching and free from gaps completed on 1/10/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee will review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. * See attached quote and receipt of payment for kitchen rated doors* * See attached photo of kitchen double door replacement*
Obstructed Access to Fire Extinguisher
Penalty
Summary
The facility failed to ensure that fire extinguishers were readily accessible and ready for use, as required by NFPA 101, 2012 Edition, Section 19.3.5.12, 9.7.4.1, and NFPA 10, 2010 Edition, Section 5.5.5.3(a). During an observation at 11:11 AM, it was noted that access to a fire extinguisher in the E-hall exit/egress corridor was obstructed by a desk, computer monitor, and a 3-tier paper tray. This deficiency had the potential to affect approximately 75 residents. The observation was confirmed in an interview at 11:15 AM with the U.S. FOIA representatives. The issue was communicated to the U.S. FOIA (b) (6) during the Life Safety Code exit conference.
Plan Of Correction
K-0355 (E) Fire Extinguishers 1. The Fire Extinguisher compromised by the desk has been corrected by having the desk removed on 1/10/2025. All resident areas are free from hazard. 2. All Fire Extinguishers in the facility have been reinspected and are ready for use, and the staff inspect the extinguisher areas to prevent this from happening in the future. All resident areas are free from hazard and all systems are operating as designed as of 1/10/2025. 3. The Maintenance Director provided education with Maintenance staff regarding monitoring Fire Extinguishers by Maintenance Staff on 1/10/2025. 4. Every quarter for a year, the Maintenance Director or designee will check Fire Extinguishers throughout the facility to ensure they are ready for use. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *desk was removed clearing access to fire extinguisher-see attached photo*
Failure to Ensure Resident's Call Device Accessibility
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the resident's call device was within reach while the resident was in bed. This deficiency was identified for a resident diagnosed with Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region, which is an infection of the bone. On two separate occasions, the surveyor observed the resident's call device on the floor, outside of the resident's reach. The facility's policy, effective since March 2020, states that a call bell system is utilized to allow residents to call for staff assistance. Despite this policy, the resident's call device was not accessible, indicating a failure to accommodate the resident's needs and preferences as required.
Plan Of Correction
F558- Reasonable Accommodations What corrective action will be accomplished for those residents affected by the deficient practice? Unit Manager ensured resident's call bell was placed in close proximity to the resident #320 on 12/16/2024 and 12/20/2024. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. Unit Managers completed an audit and if a call bell was not in close proximity of the resident, the call bell was moved toward the resident. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Call bell policy was reviewed. Clinical staff were educated on the importance of ensuring residents' call bells are in reach of residents. Unit managers will monitor call bells to ensure they are in close proximity of residents. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing or designee will complete an audit of the location of resident call bells to ensure they are in close proximity of the resident. The Audit will be completed once a week for 30 days, then monthly x3. The results of the audit will be reviewed at the monthly QAPI team chaired by the facility administrator.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete medication records with staff signatures according to professional standards of clinical practice for Resident #23. The resident, who had diagnoses including dementia and arthritis, was observed on a pressure-relieving mattress. A review of the Treatment Administration Record (TAR) revealed blank areas where nurses' initials should have been, indicating the completion of treatment with Medihoney, a topical cream ordered for daily application to a sacral wound. The blanks were noted on specific dates in December 2024, and interviews with nursing staff confirmed that there should not be blanks on the TAR, as it either indicated a failure to sign or a failure to complete the treatment. The facility also failed to follow physician orders regarding medication administration for Resident #51, who had diagnoses including hypertension, end-stage renal disease, and schizophrenia. The resident had a physician order for Midodrine HCL to be administered with specific parameters to hold the medication if the systolic blood pressure (SBP) was greater than 135. However, the electronic Medication Administration Record (eMAR) showed that the medication was administered on several occasions when the SBP exceeded 135, contrary to the physician's order. Interviews with LPNs revealed that the medication was documented as administered, and one LPN admitted to possible incorrect documentation without providing further explanation. The facility's policy on administering medications, revised in March 2020, states that medications must be administered safely, timely, and as prescribed, including adherence to any required time frames. The Director of Nursing acknowledged the issues with medication administration and documentation, confirming that Midodrine should be held for SBP greater than 135. The surveyor noted these deficiencies in the facility's adherence to medication administration policies and procedures.
Plan Of Correction
F658- Services Provided Meet Professional Standards What corrective action will be accomplished for those residents affected by the deficient practice? A statement was obtained by the Director of Nursing from the nurse who completed the treatment for resident #23. Statement indicated the residents treatment was completed. Resident #23 Treatment administration record could not be retroactively updated to include the initial of the nurse who completed the treatment. The Medical Director was made aware of the residents parameters on the medication administration record for Midodrine. The Medical Director provided no new orders. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Treatment Administration Records were reviewed by Unit Managers for residents and no concerns or blanks were identified. Unit Managers reviewed charts for residents on Midodrine and no concerns were noted for blood pressure. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Medication administration policy was reviewed. Nurses were educated on the importance of documenting treatments on the treatment administration records. Nurses were also educated by the Educator on monitoring and following medication parameters. Unit Managers or designee will monitor Treatment and Medication Administration records to ensure nurses are documenting and following medication parameters. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing will monitor Treatment/Medication Administration Records once a week for 30 days, then monthly x 3 to ensure nurses are documenting or following parameters. The results of the audit will be reviewed at the monthly QAPI team chaired by the facility administrator.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was unable to perform activities of daily living (ADLs) independently. This deficiency was identified during a survey when Resident #122 was observed with long, squared nails with sharp edges. The resident, who had a history of type II diabetes mellitus, anxiety disorder, muscle weakness, and lack of coordination, was cognitively intact but required supervision or assistance with personal hygiene. Despite the resident's inability to cut their own nails due to arm shakiness, the Certified Nursing Assistant (CNA) admitted to not providing nail care, even though it was part of his responsibilities. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that nail care was recognized as important for infection control and hygiene. However, the LPN noted that the resident was confused and had refused nail care on a previous occasion, although the resident was generally calm and cooperative. The facility's policies on nail care and ADLs emphasized the importance of routine cleaning and inspection of nails, yet these were not adequately followed for Resident #122, leading to the observed deficiency.
Plan Of Correction
F677- ADL Care Provided for Dependent Residents What corrective action will be accomplished for those residents affected by the deficient practice? Resident #122 was provided with ex order 26.4 by the caretaker on 12/18/2024. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. The Unit Managers checked all residents for nail care and if nail care was required, the resident care team provided nail care. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Policy for resident hygiene was reviewed. Clinical staff were educated on the importance of providing routine hygiene practices for residents. Unit managers or designee will monitor resident hygiene routine to ensure care is being provided. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing or designee will audit residents' nails to ensure they have been provided with nail care. The audit will be conducted once a week for one month, then monthly x3. The results of the audit will be reviewed at the facility QAPI meeting x3 months.
Failure to Adjust Medication Times for Dialysis Schedule
Penalty
Summary
The facility failed to ensure that medication administration times were adjusted to accommodate a resident's hemodialysis schedule, as per professional standards of practice. This deficiency was identified for a resident with a primary diagnosis of anemia and end-stage renal disease, who required hemodialysis three times a week. The resident's care plan included an intervention to confer with the physician or dialysis center regarding changes in medication administration times as needed. However, the review of the electronic Medication Administration Record (eMAR) indicated that the resident did not receive prescribed medications, clonidine and isosorb dinitrate-hydralazine, on several occasions because the resident was off the unit for dialysis. The Licensed Practical Nurse (LPN) familiar with the resident confirmed that the resident was not receiving these medications while at dialysis and acknowledged the need to clarify the orders with the physician. The Nurse Manager also confirmed that the resident should be receiving the medications as ordered and intended to speak with the doctor to adjust the medication times to align with the dialysis schedule. The facility's policy on hemodialysis, revised in June 2024, stated that medication times might be altered based on dialysis times, but this was not adhered to in practice.
Plan Of Correction
F698- Dialysis What corrective action will be accomplished for those residents affected by the deficient practice? Nurse Manager spoke to the Primary Care Physician clarified and changed Resident #43 medication times of NU EX Order 26.4 (b) and NJ Ex Order 26.4(b)(1) to coincide with NJ Ex Order 26. hours and days. Educated RN/LPN assigned to Resident #43 on the Policy for NJ Exec Order 26.451 Given specific instructions on scheduling meds to coincide with resident dialysis hours and days. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on hemodialysis have the potential to be affected. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Dialysis Policy was reviewed. Nurse Educator conducted education to RN/LPN/Unit Manager/Nursing Supervisor on the Policy for Dialysis. Education on specific instructions regarding scheduling medications to coincide with resident dialysis hours and days. Unit Managers or designee will monitor dialysis residents medication orders to ensure times are scheduled around Dialysis days and hours. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on medication schedules coinciding with dialysis hours and days. The audits will be completed weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Deficiency in Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was observed in four residents who were reviewed for physician visits. The facility's policy required that physicians make rounds every day and document in the electronic medical record (EMR), with an expectation for a history and physical (H&P) within 24 hours of admission and monthly physician visit progress notes. However, the records for these residents showed inconsistencies and gaps in documentation by the attending physician. Resident #51, admitted with multiple diagnoses including hypertension and schizophrenia, had no progress notes from the attending physician from May to December 2024. The nurse practitioner (NP) documented visits, but there was no evidence of alternating monthly visits between the physician and NP. Similarly, Resident #52, with diagnoses including hypertension and anxiety disorder, had only a few documented visits by the attending physician and physician assistant (PA)/NP, with missing progress notes for several months. Resident #119, who had a tracheostomy and was cognitively intact, also lacked progress notes from the attending physician for several months. The NP documented visits sporadically, but there was no consistent alternation of visits. Resident #122, with type II diabetes mellitus and anxiety disorder, had NP visit progress notes but no documentation from the attending physician for several months. The Director of Nursing (DON) confirmed the expectation for physician visits and documentation, but the surveyor noted the deficiencies in the facility's adherence to these requirements.
Plan Of Correction
F712- Physician Visits What corrective action will be accomplished for those residents affected by the deficient practice? The Director of Nursing and Director of Clinical Services spoke with the Medical Director and advised of policy on Physician Visits. The Medical Records for identified residents could not be retroactively updated to include physician visits. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. Managers audited clinical records and contacted physicians with any findings. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Policy for Physician Visits was reviewed. The Director of Clinical Services, Director of Nursing and or the Medical Director began education on January 8th, 2025 to the primary physicians on staff of the policy on Physician Visits. Unit Managers will monitor resident records to ensure physicians are making visits at appropriate intervals. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on Physicians Visits/Frequency/Timeliness, weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Failure to Use Appropriate PPE in Contact Precaution Room
Penalty
Summary
The facility failed to adhere to appropriate infection control practices by not ensuring that staff wore a personal-protective gown while entering a room under Contact Precautions. This deficiency was observed in the case of a resident diagnosed with Methicillin Resistant Staphylococcus Aureus Infection, a multi-drug resistant organism. During the survey, a registered nurse was seen entering the resident's room wearing gloves but not a gown, despite the presence of a sign outside the room indicating the requirement for both gloves and a gown under Contact Precautions. The nurse justified her actions by stating she was not providing direct care, only shutting off a pump alarm. However, the facility's policy on Transmission-Based Precautions, revised in April 2024, clearly states that a gown should be worn whenever there is potential contact with the resident or contaminated surfaces. The Infection Preventionist confirmed the resident was on Contact Precautions, and the Director of Nursing acknowledged the need for staff education on the proper protocol for entering rooms under such precautions.
Plan Of Correction
F880- Infection Control What corrective action will be accomplished for those residents affected by the deficient practice? Educated RN #1 on the Policy for Transmission Based Precautions. With emphasis on wearing proper PPE when entering room and providing care on Resident #320 on NJ Ex Order 26.4(b)(1) Precautions. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on Contact Isolation Precautions have the potential to be affected by this alleged deficient practice. Unit managers checked other residents on Contact Precautions, and no concerns were identified. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The policy on Infection Prevention and Control was reviewed. Nurse Educator began education on December 16, 2024 to RN/LPN/CNAs/Therapists on policy for Transmission Based Precautions. The staff members were educated on the importance of wearing proper PPE when entering and giving care for resident on Contact Isolation Precaution. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on wearing proper PPE when entering and giving care for residents on Contact Isolation Precautions. Audits will be conducted weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.
Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratios for 12 out of 14 day shifts, as mandated by the State of New Jersey. According to the New Jersey Department of Health memo dated 01/28/2021, the law requires one Certified Nurse Aide (CNA) for every eight residents during the day shift. However, the facility's 'Nurse Staffing Report' for the period from 12/01/2024 to 12/14/2024 showed that the facility was consistently understaffed. For instance, on 12/01/24, there were only 13 CNAs for 178 residents, whereas at least 22 CNAs were required. Similar deficiencies were noted on other days, with the number of CNAs consistently falling short of the required number. Interviews conducted on 12/20/24 with the Staffing Coordinator and the Director of Nursing revealed that both were aware of the minimum staffing ratio requirements. Despite this awareness, they stated that the facility was meeting the requirements, which contradicts the documented staffing levels. The facility's policy titled 'Staffing', revised in 4/2024, claims that adequate staffing is provided to meet the care and service needs of the residents, yet the documented staffing levels indicate otherwise.
Plan Of Correction
S560 Staffing Levels What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the week of December 1, 2024. Specifically, on December 1, 2024, the facility provided 480 actual staffing hours, which was 33 hours short of the required 513 hours. Similarly, on December 2, 2024, the facility provided 504 actual staffing hours, falling short by 9 hours. This deficiency was identified through a review of the Supplementary Nurse Staffing Report for the weeks of December 1, 2024, to December 14, 2024. Interviews conducted on December 20, 2024, with the Staffing Coordinator, Director of Nursing (DON), and the Licensed Nursing Home Administrator revealed differing perspectives on staffing adequacy. The Staffing Coordinator indicated reliance on the facility census for scheduling, while the DON asserted that registered nurses were available 24/7 and that staffing requirements were met. The Licensed Nursing Home Administrator emphasized staffing based on resident acuities, claiming the facility was correctly staffed. Despite these assertions, the facility's policy, revised in April 2024, stated that adequate staffing should be maintained to meet resident care needs, which was not achieved on the specified days.
Plan Of Correction
S1680- Mandatory Nurse Staffing What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for professional nurses and certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review professional nurse and certified nurse aides staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.
Failure to Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to provide the needed care and services in accordance with professional standards of practice by not obtaining a laboratory diagnostic, specifically a blood test, as ordered by the physician for the next day. This deficiency was discovered for a resident who had multiple diagnoses, including a fracture, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The physician had ordered a complete blood count (CBC) test for the next morning, but the order was not entered into the Electronic Medical Record (EMR), and the test was not conducted on the specified date. The resident's next CBC test was conducted two days later, revealing an abnormally high white blood cell count, which led to the resident being sent to the emergency room. Interviews with the Unit Managers and the Licensed Nursing Home Administrator confirmed that the physician's order should have been added to the EMR. The Director of Nursing acknowledged that the nurse forgot to enter the order. The facility's policies on physician orders and lab draws did not contain pertinent information about laboratory orders, contributing to the oversight.
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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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