Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Newark Nursing & Rehab during CMS and state inspections, most recent first.
Failure to Provide Written Discharge Notice: A resident with Alzheimer’s disease and severe cognitive impairment was discharged after staff verbally told the wife the resident needed to go to a psych facility because of behaviors, but no written 30-day discharge notice was issued. Hospice documentation and staff interviews confirmed the lack of written notice, despite facility policy requiring advance written notice to the resident and representative.
A resident with Alzheimer's disease, severe cognitive impairment, and documented wandering, aggression, and other behavioral symptoms did not have behavioral management interventions consistently implemented or documented. Staff notes showed episodes of wandering, pacing, combative behavior, and an altercation with another resident, but the MAR often recorded no behaviors and PRN Ativan or hydroxyzine was not given; interviews with the ADON, RDCS, NP, and MD confirmed the behaviors and that the resident's behavioral meds could have been better managed.
Hand hygiene was not performed during direct resident care for two residents. A CNA provided incontinence care without cleaning her hands, an LPN changed gloves during wound care without hand hygiene, and another LPN performed g-tube care for a resident on EBP without donning a gown or using hand hygiene when entering the room or after changing gloves.
Surveyors found that the facility failed to maintain the building in good repair and provide a safe, clean, and homelike environment across multiple units. Shower rooms on several units had cracked tiles, black or brown substances along walls and floors, leaking fixtures, rusted faucet handles, and damaged cabinetry with wood debris on the floor. Hallways contained damaged flooring, including a raised plumbing cover and a floor hole near a nurse station. On the memory care unit, walls and trim were chipped, stained, or separating from the structure, numerous door frames were separated from the wall near the floor, and upholstered furniture in the common area was heavily stained. Housekeeping staff reported confusion over responsibility for floor cleaning and noted that the floor machine was broken, and maintenance staff confirmed several of the observed structural and cleanliness issues.
Surveyors found that the facility’s medication error rate exceeded 5% when two residents with type 2 DM did not receive insulin as ordered. For one resident, an LPN administered eye drops and oral medications but held the ordered morning Lantus dose without resident refusal, provider notification, or any order parameters to hold the insulin, despite facility policy requiring prescriber contact if a dose is believed inappropriate. For another resident, an RN administered Lantus using a pen device without performing the required priming/safety test steps outlined in the manufacturer’s instructions, instead only checking for air bubbles before injection. These two insulin-related errors, out of 34 observed opportunities, resulted in a 5.8% medication error rate.
Two residents with type 2 DM did not receive insulin as ordered or in accordance with manufacturer instructions. For one resident, an LPN withheld a scheduled morning Lantus dose despite no refusal, no hold parameters, and no contact with the prescriber, even though facility policy required consulting the provider when questioning a dose. For another resident, an RN administered Lantus from a pen injector without performing the required priming/safety test steps outlined in the product instructions, instead only checking for air bubbles before injection.
Surveyors identified infection control lapses involving two residents when staff failed to follow established hand hygiene and sanitary medication handling practices. During incontinence care for a resident with severe cognitive impairment and urinary and bowel incontinence, a CNA donned gloves, handled linens, wash basins, and the bedside table, and then performed peri-care without changing gloves or re-washing hands, contrary to facility hand hygiene and infection control policies. In a separate incident, an RN preparing oral medications for a resident with multiple chronic conditions dropped a Losartan tablet onto the medication cart, then picked it up with bare fingers and placed it into the medication cup, which was then administered, in violation of the facility’s medication administration infection control procedures.
A resident with a history of substance use disorder and multiple behavioral health needs did not receive appropriate assessment, care planning, or interventions to address ongoing substance use and related behaviors. Staff observed drug paraphernalia, erratic behavior, and frequent visitors suspected of bringing illicit substances, but the care plan was not updated and specific interventions were not implemented. The lack of coordinated response and documentation led to neglect of the resident’s mental and psychosocial well-being.
Two residents experienced unmanaged pain due to the facility's failure to maintain an adequate supply of controlled pain medications. One resident with chronic pain conditions did not receive scheduled Methadone for several days, reporting severe pain, while another resident with an amputation missed multiple doses of Oxycodone, resulting in significant distress. Delays in medication reordering and communication breakdowns among staff contributed to the prolonged lack of pain control.
Kitchen sanitation was not maintained when an uncovered commercial floor stand mixer was found with dust and paper in the bowl, a prep-area refrigerator handle had sticky and dried batter-like residue, and a gas cooktop had thick black greasy buildup with dried yellow substance around the burners. The Dietary Director verified all of these observations.
Multiple residents experienced significant medication errors involving controlled substances, including missed doses, extra doses, and incorrect administration times. These errors were confirmed through medical record review, controlled substance log review, and staff interviews, with documentation and notification procedures not consistently followed by nursing staff.
A resident with a history of depression, anxiety, and inappropriate behaviors had restrictions placed on interactions with another cognitively impaired resident, but the care plan did not document these concerns or the facility's interventions. The omission of these psychosocial interventions and restrictions from the care plan led to a deficiency.
Two residents identified as at risk for falls did not have required fall prevention interventions in place, including keeping a bed in the lowest position and posting a reminder sign to call for assistance. Staff confirmed that these interventions, as ordered in care plans and physician orders, were not implemented during multiple observations.
A resident receiving hospice care did not have their hospice records readily available at the facility, as required for effective collaboration between facility staff and the hospice provider. When surveyors requested the records, only a sign-in log was found, and the actual hospice notes had to be obtained from the hospice provider later that day. Staff interviews confirmed the records were not accessible at the time of request, contrary to facility policy.
A resident with multiple chronic conditions and a foot ulcer was found to have maggots in a wound, with flies observed in the room and hallway during care. Staff interviews revealed the resident frequently hoarded food and trash, requiring regular cleaning, but flies persisted, indicating a lack of effective pest control.
A resident with intact cognition and multiple diagnoses, including DM, schizophrenia, seizures, depression, bipolar disorder with psychotic features, anxiety, hyperlipidemia, and HTN, was unable to access facility-managed funds on weekends because no one was available in the office on Saturdays or Sundays. Record review showed no weekend receipts for money released from the resident's account, and the BOM confirmed residents who used facility-managed funds typically received money on Fridays.
Failure to complete a baseline care plan within 48 hours of admission. A resident with dementia, frontotemporal neurocognitive disorder, AFib, HTN, MDD, HLD, and OA was unable to complete the BIMS, had behaviors directed at others and rejection of care, required extensive ADL assistance, was incontinent of bowel and bladder, had a venous wound, and received multiple psychoactive and other medications. Care plan problems were not initiated until more than 48 hours after admission, and an LPN Unit Manager confirmed the delay.
Care plans were not updated for two residents. One resident with severe cognitive impairment had enhanced barrier precautions listed in the care plan even though the wound had healed and the precautions were no longer in place. Another resident with dementia had a 1800 mL fluid restriction in the care plan even though there was no active physician order for it. The RDCS confirmed both items had been missed and remained in the care plans.
A facility failed to implement ordered nutritional supplements for a resident with ESRD, DM2, malnutrition, and hemodialysis after RD and dialysis center recommendations changed the supplement to Nepro. The facility also failed to start nutritional interventions for another resident after a significant weight loss was identified, despite a care plan for weight monitoring and reporting. The second resident had multiple chronic conditions, impaired cognition, and continued to show weights below baseline.
Missing Physician Order for Hemodialysis: A resident with ESRD and dependence on renal dialysis had a care plan stating dialysis was to occur on M/W/F, with staff monitoring the shunt and watching for dialysis-related complications, but the medical record did not include a physician order for hemodialysis treatments or related access-site monitoring orders. An LPN Unit Manager confirmed the missing order, and the Administrator stated the facility did not have a dialysis policy and followed federal regulations.
Physician visits were not documented at the required frequency for a resident with dementia, frontotemporal neurocognitive disorder, AFib, HTN, depression, HLD, OA, incontinence, a venous wound, and significant ADL dependence. The chart contained no PCP progress notes showing the resident had been seen, and an LPN confirmed the absence of physician documentation; the Administrator stated visits were expected per federal regulations.
A facility failed to timely implement a pharmacy recommendation that had been reviewed by the physician for a resident with vascular dementia, mood disorder, and anxiety. The resident had a PRN Ativan order for anxiety/restlessness, and the pharmacist requested documentation of duration and rationale for extended therapy; the physician indicated the PRN should be limited to 14 days, but the order was not updated and remained active until it was later discontinued during the next monthly pharmacy review.
The facility failed to develop comprehensive care plans for several residents, affecting their management of diabetes, depression, anticoagulant use, activities, and skin-picking behaviors. A resident with diabetes did not have a care plan for insulin use, while another lacked a plan for activities preferences. A resident on antidepressants had no care plan for depression, and another on anticoagulants lacked a plan for medication use. Additionally, a resident with skin-picking behavior had no care plan addressing this issue.
The facility failed to offer or assist residents in attending activities, affecting four residents. One resident with severe cognitive impairment was not engaged in activities despite her interests. Another resident with severe cognitive impairment had no activities assessment or care plan and was observed watching TV alone. A third resident with severely impaired cognition was found lying in bed without entertainment, and a fourth resident with intact cognition had no documented activity participation. The Activity Director confirmed the lack of documentation for these residents.
The facility failed to provide meals according to dietary requirements for two residents, with one not receiving a pureed vegetable mix and thickened juice, and another missing a pasta salad. Additionally, the facility lacked an adequate emergency food stock, missing several items from the emergency menu. These deficiencies were confirmed through observations and interviews with staff and residents.
The facility failed to prepare pureed foods to the appropriate texture for residents on a pureed diet. A cook blended barbecue hamburgers and believed the texture was suitable, but a surveyor found dime-sized bits of gristle or fat, indicating it was not safe for residents requiring a pureed diet. The facility's policy requires a pudding-like consistency, which was not met.
The facility's arbitration agreement failed to inform residents of their right to rescind the agreement within 30 days, affecting 51 residents. The Admissions Director confirmed the omission, noting the agreement was developed by the corporate office. The facility also lacked a policy on arbitration agreements.
The facility failed to conduct proper skin assessments and monitoring for two residents, leading to deficiencies in care. One resident with skin conditions was not monitored according to dermatology treatment plans, and another resident on anticoagulant medication had an undocumented bruise. The facility did not adhere to its policies on skin assessments and care, resulting in inadequate monitoring and documentation.
A resident with limited ROM and a left-hand contracture was not provided with a recommended palm guard, as observed over two days. Despite therapy recommendations and a care plan specifying its use, the palm guard was not applied due to its unavailability and lack of an order. Interviews revealed staff were educated on its application, but it was not in use, leading to a deficiency in care.
Two residents in a LTC facility experienced deficiencies in care due to inadequate supervision and safety hazards. One resident with severe cognitive impairment eloped from a secured unit through a malfunctioning window, and the facility's investigation was incomplete. Another resident's room contained a cluttered environment with a coffee maker plugged into an electrical power strip, violating safety policies. These incidents highlight lapses in the facility's adherence to safety protocols.
A resident with complex medical conditions experienced a delay in UTI treatment due to documentation and communication issues. Despite lab results indicating bacterial presence, treatment was delayed as the physician requested a C. Diff check before proceeding. Attempts to obtain a stool sample were unsuccessful, and the lack of documentation contributed to the delay, with treatment starting only after a follow-up visit by a CNP.
A facility failed to monitor a resident on anticoagulants for side effects and did not have a care plan addressing the medication. The resident, with intact cognition and multiple chronic conditions, was prescribed Apixaban without any physician orders for side effect monitoring. The DON confirmed the lack of a care plan and monitoring system for anticoagulant side effects.
The facility failed to manage and store medications properly, leading to deficiencies. An LPN confirmed an expired TB solution vial without an opened date and expired flu vaccines in the medication storage. Additionally, two insulin vials were left unsecured on a medication cart during administration for a resident with diabetes and other conditions. The facility's policy requires medication carts to be locked when out of sight, and no medications should be left on top.
The facility failed to ensure proper hand hygiene during meal service and did not implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. Observations revealed that staff did not sanitize hands between serving meal trays, and EBP signage and PPE were absent for residents with chronic wounds, despite facility policies requiring these precautions.
A facility failed to maintain a safe environment for a resident, as observed in a room where the rubber toe plate covering was loose, revealing a hole exposing drywall and wall support boards. The resident, who used an electric wheelchair and had intact cognition, was unaware of the damage. The Administrator confirmed the damage, attributing it to the wheelchair. The facility's policy requires a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and multiple health conditions was not kept clean shaven as per his preference. The last recorded shaving was done by a CNA during a bed bath, and subsequent observations showed the resident with heavy stubble. A family member had requested shaving, but it was not completed. The DON confirmed that shaving should occur with showers and as needed.
A resident with autism and anxiety did not receive adequate care planning and interventions at an LTC facility. The care plan failed to address the resident's autism and anxiety, and staff lacked training in managing autism. The resident often refused care and exhibited behaviors that were not documented or addressed. Despite being prescribed Xanax for anxiety, non-pharmacological interventions were not attempted, and the facility did not involve a psychiatrist or psychologist.
The facility failed to monitor behaviors for three residents receiving psychotropic medications, leading to a deficiency in managing unnecessary medications. Despite care plans requiring behavior monitoring, there was no evidence of such monitoring until late August. This lack of documentation and adherence to policy was confirmed by the DON.
The facility failed to provide written transfer notices for two residents who were hospitalized, as required by policy. One resident with complex medical conditions was transferred twice in a month without written notice, confirmed by the DON. Another resident was transferred from an outside appointment without notice, confirmed by the SSD. The facility's policy mandates written notification for such transfers.
The facility failed to provide bed hold notices to two residents who were hospitalized, as required by policy. One resident, with multiple medical conditions, was transferred to the hospital from an outside appointment and did not receive a notice. Another resident, with a complex medical history, was hospitalized twice without receiving a bed hold notice. The facility's policy mandates written notification of bed-hold policies, which was not followed.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide Resident #116 and the resident’s representative with written notice of discharge. Resident #116 was admitted with diagnoses including Alzheimer’s disease, chronic kidney disease, and mood disorder, and the MDS showed severe cognitive impairment. The resident was later discharged from the facility, and the record included a discharge-not-anticipated MDS on the discharge date. Hospice documentation showed the resident had been admitted for permanent placement, and hospice later reported that the resident’s wife said the facility stated the resident had to be discharged to a psychiatric facility because of behaviors. An email from the hospice LSW to the Administrator stated the facility had not issued a 30-day discharge notice to the resident’s wife. During interview, the Administrator confirmed the facility verbally notified the wife that it wanted to discharge the resident to a psychiatric facility due to behaviors, but no written 30-day discharge notice had been issued. Additional interviews reflected that staff believed the resident needed discharge because of multiple resident-to-resident altercations, while the Medical Director stated she had seen the resident and was not notified of any problem behaviors during the stay. The facility policy required a 30-day written notice of impending discharge, and the admissions packet stated the resident and representative would be notified in writing in advance of any proposed transfer or discharge.
Failure to Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to implement behavioral management interventions for a resident with dementia, including Alzheimer's disease, chronic kidney disease, and a mood disorder. The resident's MDS showed severe cognitive impairment, dependence on staff for ADLs, use of antianxiety and antidepressant medications, and verbal and physical behavioral symptoms. The care plan identified behavior problems related to Alzheimer's disease, including wandering and physical and verbal aggression toward other residents, with interventions focused on administering psychotropic medications as ordered and observing for effectiveness. Medical record review showed multiple behavior-related events in which staff documentation did not align with the resident's observed behaviors or did not include behavioral interventions. On one occasion, the resident was wandering, refusing redirection, and pacing the hallways; later that same day the resident was rocking in front of another resident and a visitor and was placed on 15-minute checks. On another date, the resident was combative with aides during care, and on another, the resident pulled another resident's hair during an altercation; neither of those notes documented staff interventions related to the behaviors. The MAR documented no behaviors on those dates and showed the resident did not receive PRN Ativan or hydroxyzine. Interviews with the ADON, RDCS, NP, and Medical Director confirmed the resident had behaviors, that behavioral medications could have been better managed, and that the Medical Director and NP were not notified of the behaviors during the review period.
Hand Hygiene Not Performed During Resident Care
Penalty
Summary
The facility failed to ensure staff practiced proper hand hygiene during resident care. Resident #58 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and chronic pain syndrome. The resident was cognitively intact, frequently incontinent of bowel and bladder, and required staff assistance with toileting. During observed incontinence care, a CNA donned gloves, entered the room, set up for care, and provided incontinence care without performing hand hygiene at any point. The CNA later confirmed she did not change gloves or perform hand hygiene after entering the room and had touched multiple items before providing care. Resident #58 also had ordered wound care to the left lower extremity. During observed wound care, an LPN removed the old dressing, removed her gloves, donned a new pair of gloves, and then continued with wound care without washing her hands or using hand sanitizer before putting on the new gloves. Resident #74 was admitted with diagnoses including a pressure ulcer of the right buttock, anxiety disorder, and paraplegia. The resident was cognitively intact, dependent on staff for all ADLs, and on enhanced barrier precautions related to an indwelling g-tube. During observed g-tube care, an LPN entered the room without a gown, donned gloves, and performed care without washing her hands or using hand sanitizer when entering the room or after changing gloves. The LPN confirmed the resident was on EBP and acknowledged she had not donned a gown or performed hand hygiene as required.
Failure to Maintain Safe, Clean, and Well‑Repaired Environment Throughout Facility
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain the building in good repair and provide a safe, clean, and homelike environment, as required by its maintenance policy. Observations on multiple units showed widespread physical deterioration and cleanliness issues in resident shower rooms and common areas. On the 600-unit, the resident shower room had cracked tiles along the wall adjoining the floor, cracked tiles around the toilet, and black and brown substances on multiple tiles near the toilet and in the grout near the floor. One shower was inoperable and contained equipment, with rust on the faucet handles. The shower room sink was leaking and would not turn off, and there was cracked flooring at the shower room entrance. A hole was also observed in the hallway floor near the recreation room by the 600-unit nurse station. Additional observations revealed similar problems on other units. Between two resident rooms in a hallway, a round metal plumbing cover was raised about one inch above the surrounding floor in the middle of the hallway. In the 400-unit shower room, there was a black substance on all four sides of the shower between the wall and floor and under the sink, paint was pulled off the wall near the sharps box, and both wooden cabinets showed water damage extending about twelve inches up from the bottom, with wood dust and chips on the floor. The 300-unit shower room had black substances around the showers between the floor and wall, cracked tiles in the showers, and cracked tiles near the door entrance. On the 700-unit, the shower room had broken tiles at the wall corner near the door frame and a black substance on the shower floor and around the toilet. The carpet in all six nurse stations was worn down with black areas where the carpet had worn through to the underlying floor. On the memory care unit, surveyors observed multiple areas of wall and trim damage and staining. The wall behind a television had black streaks and chipped drywall, drywall was chipped at a corner near double doors, and trim was separating from the wall in several locations, including under an air conditioner and near a kitchenette where a black substance was present along floor corners and trim was coming off the wall. Paint was chipped or missing on the corner wall near an external door and piano, and on all three sides of the nurse’s desk wall facing the common area. Door frames in numerous resident rooms on the memory care unit were separated from the wall near the floor, and the shower room there had cracked tiles around the toilet and a black substance under the sink and window. In the memory care common area, two love seats and two chairs with multicolored circles had black stains on the arms and seat cushions, which an LPN confirmed had been present for at least five years and were worsening. Housekeeping staff reported that some housekeepers believed floor cleaning was the responsibility of the floor technician and that the floor machine was not working, and the housekeeping supervisor confirmed the floor machine was broken. Maintenance staff confirmed the cracked tiles, black and brown substances, leaking sink, cracked flooring, and hallway floor hole on the 600-unit.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 34 opportunities, resulting in a 5.8% error rate. For one resident with type 2 diabetes mellitus and multiple comorbidities, the care plan included administration of insulin as ordered. The physician’s order specified Lantus 18 units subcutaneously in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but held the ordered Lantus dose, despite the resident not refusing the injection and there being no parameters in the order to hold it. The LPN later confirmed she did not contact the provider and that the resident’s blood sugar that morning was 97, and facility policy required contacting the prescriber if a dosage was believed to be inappropriate or excessive. For a second resident with type 2 diabetes mellitus and other diagnoses including dementia, depression, and chronic kidney disease, the care plan identified risk for hyper/hypoglycemia with an intervention to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units subcutaneously in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units but administered the injection without priming the pen. In interview, the RN stated she checked the pen for air bubbles but did not know any other way of priming it. The manufacturer’s instructions for the Lantus SoloStar pen require performing a safety test before each injection, including selecting 2 units, removing caps, holding the pen needle-up, tapping to move air bubbles, and pressing the injection button to ensure insulin comes out and the dose window returns to 0. These observed deviations from ordered insulin administration and manufacturer instructions contributed to the calculated medication error rate above 5%.
Failure to Administer and Properly Prepare Ordered Insulin Doses
Penalty
Summary
The deficiency involves failures in insulin administration for two residents with type 2 DM. For Resident #50, who had multiple comorbidities including type 2 DM with hyperglycemia and no cognitive impairment, the care plan directed staff to administer medications and insulin as ordered. The physician’s order specified Lantus 18 units SQ in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but did not give the ordered Lantus dose. In a subsequent interview, the LPN confirmed that the resident did not refuse the injection, there were no parameters to hold the Lantus, she did not contact the provider, and the resident’s blood sugar that morning was 97. The facility’s medication administration policy required staff to contact the prescriber if a dosage was believed to be inappropriate or excessive or if there were concerns about adverse consequences, but the LPN did not do so. For Resident #545, who had type 2 DM and other diagnoses including dementia and chronic kidney disease, the care plan identified a risk for hyper/hypoglycemia and directed staff to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units SQ in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units, then administered the injection in the resident’s lower left abdomen without priming the pen. In an interview, the RN stated she checked the pen for air bubbles and did not know any other way of priming the Lantus pen. The Lantus SoloStar instruction leaflet specifies that a safety test must be performed before each injection, including selecting a 2‑unit dose, removing caps, holding the pen needle-up, tapping to move air bubbles, pressing the injection button, and confirming insulin comes out and the dose window returns to 0. This required priming procedure was not followed prior to administering the insulin.
Infection Control Lapses During Incontinence Care and Medication Handling
Penalty
Summary
The deficiency involves failure to follow infection prevention and control practices during incontinence care for one resident. The resident was admitted with multiple diagnoses including cerebral infarction, hypertension, dementia, anorexia, abnormalities of gait and mobility, and urinary incontinence. The admission MDS showed severe cognitive impairment with a BIMS score of six, and the resident required supervision with toileting hygiene, being occasionally incontinent of bladder and always incontinent of bowel. The care plan directed staff to check and change the resident approximately every two to three hours and as needed for incontinence. During an observed incontinence care episode, a CNA washed his hands and donned gloves, then, while wearing the same gloves, opened bags of clean linen, placed a clean towel on the bedside table, accepted uncovered wash basins from an LPN, filled the basins with water, placed clean washcloths in them, and moved the bedside table closer to the bed. Without changing gloves after handling these items, the CNA proceeded to perform peri-care on the resident. Only after completing peri-care did the CNA remove his gloves and wash his hands, then don new gloves to place an incontinence brief and pull up the resident’s pants, followed by glove removal and handwashing. In a subsequent interview, the CNA confirmed that he had touched multiple items, including the basins and bedside table, before performing peri-care without changing gloves or re-washing his hands. The LPN present verified that the CNA did not change his gloves after touching multiple items prior to providing peri-care. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene policy, which requires hand hygiene before and after direct contact with residents, and with the facility’s infection control policies intended to prevent transmission of infections. A second deficiency involved failure to handle medication in a sanitary manner for another resident. This resident had multiple diagnoses including spinal stenosis, anxiety disorder, mild cognitive impairment, need for assistance with personal care, muscle weakness, cognitive communication deficit, dysarthria and anarthria, asthma, dementia, hypertension, hyperlipidemia, anemia, and osteoarthritis. The quarterly MDS indicated moderate cognitive impairment with a BIMS score of eleven and no psychosis, behavioral issues, or rejection of care. The resident had an order for Losartan Potassium 50 mg by mouth in the morning for hypertension. During observed medication preparation, an RN removed the Losartan pill from its individual container by popping the back, causing the pill to fall onto the medication cart. The RN then picked up the pill with bare fingers and placed it into the medication cup with the resident’s other oral medications, which were then administered and swallowed by the resident. In an interview, the RN confirmed she picked up the pill with bare fingers and stated she should have used a glove, contrary to the facility’s Administering Medications policy requiring adherence to infection control procedures during medication administration.
Failure to Provide Behavioral Health Care for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of substance use disorder, resulting in neglect of the resident’s mental and psychosocial well-being. The resident, who had multiple diagnoses including paraplegia, anxiety disorder, depression, and chronic pain syndrome, was admitted with a known history of drug abuse, including the use of marijuana, methamphetamines, and cocaine. Despite this, the facility did not include substance use disorder in the resident’s diagnosis list or care plan, nor did it address his history of homelessness or trauma related to his accident and loss of his parents. The care plan lacked any mention of substance use triggers, interventions for substance use, or actions to take when the resident returned to the facility with altered mental status. Throughout the resident’s stay, there were multiple documented incidents of suspected substance use, including episodes where the resident returned to the facility with altered mental status, dilated pupils, lethargy, and abnormal behavior. Staff observed drug paraphernalia in the resident’s room, such as rolled-up dollar bills and pipes, and noted the presence of visitors at odd hours who were suspected of bringing in illicit substances. Despite these observations, the facility did not update the care plan to address substance use, did not consistently monitor or test for drug use, and failed to implement specific interventions to manage the resident’s behavioral health needs. Orders for naloxone (Narcan) and monitoring for adverse effects from substance use were absent, and staff responses were limited to holding narcotic medications and requesting drug screens, which the resident often refused. Interviews with staff revealed a lack of coordinated response and documentation regarding the resident’s substance use and related behaviors. The CNP acknowledged that the diagnosis of drug abuse should have been retained and that conversations about substance use disorder treatment were not documented. The DON confirmed that no care plan updates were made following a significant increase in the resident’s depression score. Staff expressed concerns about their safety and the impact of the resident’s behaviors on other residents and staff, but there was no evidence of supervision or restriction of visitors who may have contributed to the resident’s substance use. The facility’s failure to assess, care plan, and intervene appropriately for the resident’s behavioral health and substance use needs resulted in neglect as defined by facility policy.
Failure to Maintain Adequate Pain Medication Supply Resulting in Resident Harm
Penalty
Summary
The facility failed to maintain an adequate stock of controlled substances necessary for effective pain management, resulting in actual harm to two residents. For one resident with a history of rheumatoid arthritis, osteoarthritis, and temporomandibular joint disorder, scheduled Methadone was not administered for several consecutive days due to the medication being out of stock. Documentation showed that the resident experienced severe pain, rating it as a 10 out of 10, and expressed distress over not receiving the prescribed pain medication. Nursing notes confirmed the medication was unavailable, and pharmacy communication revealed a delay in obtaining a new prescription, during which the resident's pain was not adequately controlled despite the use of as-needed Oxycodone, which was sometimes ineffective. Another resident, who had an amputation and chronic pain syndrome, also experienced a lapse in receiving scheduled Oxycodone for pain management. The resident missed eight scheduled doses over approximately 36 hours because the medication was not reordered in a timely manner. Staff documentation and interviews confirmed that the resident reported severe pain, including phantom limb pain, and was observed in significant distress, unable to get out of bed. Attempts to use backup stock were unsuccessful due to prescription mismatches, and the delay in notifying the physician and pharmacy further prolonged the period without adequate pain control. Interviews with staff and the medical director revealed that medication reorder requests were often delayed until supplies were depleted, preventing timely intervention by physicians and pharmacies. Facility policy required staff to administer medications as ordered and to notify the physician if pain management was ineffective, but these protocols were not followed, resulting in residents experiencing unmanaged pain. The deficiency was substantiated by direct observations, record reviews, and staff and resident interviews.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean kitchen environment during an initial kitchen tour. An uncovered commercial floor stand mixer was observed with the mixing bowl in place, and the bowl contained dust and small pieces of paper. A free standing reach-in refrigerator in the prep area had the right hand door handle covered with a sticky substance and a dried white substance similar to dried batter that dripped from above the handle to below the handle on the outside of the left door. The gas-powered cooktop also had visible buildup, including a thick, black, crusted, and greasy substance on the flat surfaces around the burners and a dried yellow substance on top of that buildup between the front edge of the cooktop and the front right burner. The Dietary Director verified the uncovered mixer, the debris in the bowl, the sticky and dried substances on the refrigerator, and the heavy buildup on the cooktop during interview.
Failure to Prevent Significant Medication Errors with Controlled Substances
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of controlled substances. Multiple instances were identified where residents either missed scheduled doses, received extra doses, or were administered medication at incorrect times. For example, one resident with chronic kidney disease and chronic obstructive pulmonary disease was prescribed Oxycodone every eight hours but missed doses on several days, while another resident with cervical disc disorder received four doses of Norco in one day instead of the ordered three. Additionally, a resident with alcoholic cirrhosis was supposed to receive Oxycodone once daily in the morning but was administered two doses on two separate days. Further review revealed that a resident with chronic pain syndrome and rheumatoid arthritis received five doses of Oxycodone in one day, exceeding the prescribed four doses, and there was a lack of documentation and physician notification regarding this error. The resident reported feeling overdosed and unable to stay awake following the incident. Another resident with chronic obstructive pulmonary disease and chronic kidney disease received both too many and too few doses of Oxycodone on different days, deviating from the physician's orders. In several cases, the errors were confirmed by staff interviews, and documentation on the controlled substance logs and medication administration records did not align with the prescribed regimens. The facility's policies required accurate documentation and prompt investigation of medication errors, but these were not consistently followed. In one instance, management was unaware of a medication error until it was brought to their attention by surveyors, and an incident report was not completed at the time of the event. The lack of timely documentation, notification, and investigation contributed to the ongoing risk of significant medication errors among residents receiving controlled substances.
Care Plan Lacked Comprehensive Psychosocial Interventions for Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan included comprehensive psychosocial interventions to address identified inappropriate behaviors. Specifically, a resident with diagnoses of depression, anxiety disorder, hypertension, and insomnia was known to make inappropriate and sexual comments to staff. Although the care plan included interventions such as one-on-one supervision, periodic safety checks, referral to psychiatric services as needed, and staff monitoring, it did not address the resident's expressed desire to form a relationship with another cognitively impaired resident or the facility's actions to restrict contact between the two residents. Interviews revealed that the resident was unhappy with the restrictions placed on his interactions with the other resident, which included supervised visits or visits behind glass. The facility had informed the other resident's POA, who requested no contact, and staff were instructed to keep the residents apart. However, these current concerns and interventions were not documented in the resident's care plan, as confirmed by the Administrator. This omission resulted in a deficiency related to the development and implementation of a complete care plan that meets all the resident's needs.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions were implemented as ordered for two residents identified as being at risk for falls. For one resident with diagnoses including peripheral vascular disease, deep vein thrombosis, and unsteadiness, physician orders and the care plan required the bed to be in the lowest position when occupied. Despite these orders, multiple observations over several days found the resident in bed with the bed not in the lowest position. An LPN confirmed that the bed was not in compliance with the physician's order during these observations. For another resident with a history of pathological fracture, vascular dementia, and muscle weakness, the care plan included an intervention to post a reminder sign in the room to prompt the resident to call for assistance. Observations on two separate occasions revealed that no such sign was present in the resident's room. An RN confirmed that the required sign was not posted as specified in the care plan. The facility's policy required staff to implement individualized fall prevention plans for residents at risk, but these interventions were not in place for the two residents reviewed.
Hospice Records Not Readily Available for Review
Penalty
Summary
The facility failed to ensure that hospice records were readily available for review, which impeded effective collaboration between the facility and the hospice provider. For one resident with diagnoses including vascular dementia, cerebral atherosclerosis, bone disorders, and hypertension, hospice services were arranged to include CNA visits three times per week, weekly nursing care, and monthly social services. Hospice staff were expected to provide care summaries to the facility after each visit. However, when surveyors requested hospice notes for this resident, only a sign-in log was found in the designated binder at the nurse's station, and no hospice care notes were immediately available. Staff interviews revealed confusion regarding the location of hospice records, with one RN believing the unit manager might have the notes, but they were not accessible at the time of request. The hospice notes were only provided later that day after being printed and forwarded by the hospice provider upon request. An LPN confirmed that the documents were not present in the facility and had to be obtained from hospice. Facility policy required designated staff to ensure communication and documentation with hospice providers, but this was not followed, resulting in the deficiency.
Failure to Prevent Pest Infestation in Resident Wound and Living Space
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including malignant neoplasm of the head and face, diabetes, peripheral vascular disease, and a chronic ulcer, was found to have a wound on the left foot containing maggots. The wound was discovered by CNAs during care, who immediately reported it to nursing staff. The resident was noted to be cognitively intact, dependent on staff for most activities of daily living, and receiving hospice services. Medical record review and staff interviews confirmed that maggots were present in the wound bed upon initial assessment, though the wound was clean the following day. Multiple observations revealed the persistent presence of flies in the resident's room and the hallway outside, including during wound care and dressing changes. Staff interviews indicated that the resident often hoarded food and trash, contributing to the fly problem, and that staff had to regularly clean the room. The presence of flies and maggots in the wound, as well as in the resident's living space, demonstrated a failure to maintain an effective pest control program to prevent and address infestations, directly impacting the resident's environment and wound care.
Resident Funds Not Available on Weekends
Penalty
Summary
The facility failed to have resident funds available to residents on the weekend. Resident #15, who was admitted on 03/10/23 and had diagnoses including diabetes, schizophrenia, seizures, depression, bipolar disorder with psychotic features, anxiety disorder, hyperlipidemia, and hypertension, had an MDS assessment showing a BIMS score of 15, indicating intact cognition. Review of Resident #15's facility-managed funds account records from June 2025 to August 2025 showed no receipts for money released to the resident from the facility-managed account on any weekend days. During interview, Resident #15 stated he was unable to get money from his facility-managed account on the weekend because no one was in the office on Saturdays or Sundays. The Business Office Manager confirmed that no one was available in the facility to access resident funds on Saturdays or Sundays and stated that residents who frequently accessed their facility-managed funds normally got their money for the weekend on Fridays.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan for Resident #2 within 48 hours of admission. Resident #2 was admitted on 06/04/25 with diagnoses including dementia, frontotemporal neurocognitive disorder, atrial fibrillation, hypertension, major depressive disorder, hyperlipidemia, and osteoarthritis. The admission MDS showed the resident was unable to complete the BIMS because the resident was rarely or never understood, had physical behaviors directed at others for four to six days, verbal symptoms directed toward others for one to three days, and rejection of care for four to six days during the assessment window. The MDS also showed the resident required partial to moderate assistance with eating and mobility, substantial assistance with all other ADLs, was always incontinent of bladder and bowel, and had one venous wound. The resident received antipsychotic, antidepressant, hypnotic, anticoagulant, and anticonvulsant medications during the review period. Review of the care plans showed all care plan problems were dated as initiated on or after 06/10/25, and there was no evidence that a baseline plan of care had been initiated within 48 hours of admission. During interview, the LPN Unit Manager confirmed the care plan problems were dated more than 48 hours after admission.
Care Plans Not Updated to Match Current Orders and Interventions
Penalty
Summary
Care plans were not revised to accurately reflect current orders and interventions for two residents. Resident #24 was admitted on 08/09/24 and re-entered on 07/11/25 with diagnoses including chronic systolic heart failure, peripheral vascular disease, and atrial fibrillation. The quarterly MDS showed a BIMS score of 03 out of 15, indicating severely impaired cognition. The undated care plan still included enhanced barrier precautions for infection prevention, but observations on 08/11/25 and 08/19/25 showed the precautions were not in place. During interview, the RDCS stated the resident previously had a wound area that required enhanced barrier precautions, but it had healed and the intervention was no longer required, indicating the care plan had not been updated to remove it. Resident #66 was admitted on 06/03/14 with diagnoses including alcohol induced persisting dementia, hypertension, and hypokalemia. The care plan dated 02/17/2021 identified risk for fluid volume deficit related to cognitive impairment and fluid restriction, with an intervention to maintain a 1800 mL fluid restriction in 24 hours. The quarterly MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition. However, physician orders for August 2025 showed no active fluid restriction order, and the RDCS confirmed during interview that the restriction was no longer ordered but remained in the care plan and needed to be removed.
Failure to Implement Ordered Supplements and Weight Loss Interventions
Penalty
Summary
The facility failed to ensure nutritional supplements were implemented after recommendations were made for Resident #6. The resident was admitted with diagnoses including end-stage renal disease, type 2 diabetes mellitus, gastroesophageal reflux disease, moderate protein-calorie malnutrition, and hypo-osmolality with hyponatremia. The care plan identified the resident as at risk for altered nutrition and hydration related to BMI, therapeutic diet, and weight changes with fluid balance, and the resident was known to refuse weights and supplements. Physician orders included a house nutritional supplement twice daily, and later documentation from the dialysis center recommended changing the supplement to Nepro due to the resident’s kidney condition and dialysis status. Record review showed that the dialysis center recommendation to change the supplement was not documented as having been discussed with the resident or addressed as recommended. A later RD assessment documented that the resident was receiving the house supplement twice daily while on hemodialysis three times per week, and another progress note again recommended changing the supplement to Nepro twice daily due to laboratory results and dialysis status. The RD confirmed in interview that this later recommendation had not been implemented. The facility also failed to implement interventions to prevent further weight loss for Resident #35. The resident had diagnoses including unspecified psychosis, delusional disorders, Parkinson’s disease, major depressive disorder, paranoid personality disorder, osteoporosis, anxiety, hyperlipidemia, and hypertension. The care plan identified the resident as at risk for weight loss and called for monitoring unplanned weight loss and reporting it to the physician and dietitian. The resident experienced a significant weight loss from 148.2 lbs to 135 lbs, and subsequent weights remained below the earlier baseline. Although staff noted a possible scale inaccuracy and later notified the CNP, the RD confirmed that nutritional interventions were not started when the significant weight loss was identified.
Missing Physician Order for Hemodialysis
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to ensure Resident #79’s medical record included a physician order for hemodialysis treatments. Resident #79 was admitted on 02/26/25 with diagnoses including end stage renal disease, congestive heart failure, diabetes, left above-the-knee amputation, dependence on renal dialysis, hypertension, anxiety disorder, and orthopedic aftercare following surgical amputation. The resident’s MDS quarterly assessment showed a BIMS score of 14, indicating intact cognition, and documented that the resident had rejected care one to three days during the review window, was independent with eating, dependent for all other ADLs, and always incontinent of bladder and bowel. The resident’s care plan dated 02/28/25 addressed the potential for complications related to ESRD requiring dialysis and stated the resident was to have dialysis on Mondays, Wednesdays, and Fridays. It also directed staff to observe the shunt daily for infection and bleeding and to monitor for dialysis-related complications such as air embolism, fluid overload, weak irregular pulse, bleeding, and infection. However, review of the physician orders did not reveal an order for hemodialysis treatments, and the record also did not contain orders related to the hemodialysis access site or monitoring for signs or symptoms of complications. An LPN Unit Manager confirmed there was not an order for hemodialysis in the physician orders, and the Administrator stated the facility did not have a dialysis policy and just followed federal regulations.
Physician Visits Not Documented at Required Frequency
Penalty
Summary
The facility failed to ensure that the resident's physician visited at the required frequency. Resident #2 was admitted on 06/04/25 and had diagnoses including dementia, frontotemporal neurocognitive disorder, atrial fibrillation, hypertension, major depressive disorder, hyperlipidemia, and osteoarthritis. The resident's MDS admission assessment showed the resident was unable to complete the BIMS because he or she was rarely or never understood, had physical behaviors directed toward others for four to six days, verbal symptoms directed toward others for one to three days, and rejection of care for four to six days during the assessment window. The resident also required partial to moderate assistance with eating and mobility, substantial assistance with all other ADLs, was always incontinent of bladder and bowel, had one venous wound, and received antipsychotic, antidepressant, hypnotic, anticoagulant, and anticonvulsant medications. Review of Resident #2's progress notes revealed no notes from the primary care physician. During interview, the LPN Unit Manager confirmed there were no physician progress notes in the medical record to show the resident had been seen by a physician. The Administrator stated she expected physician visits to occur as outlined in federal regulations. The facility's Physicians Service Policy, revised 04/2013, stated physician visits and frequency of visits were to be provided in accordance with current federal regulations.
Failure to Implement Pharmacy Recommendation for PRN Lorazepam
Penalty
Summary
The facility failed to ensure pharmacy recommendations that were addressed by the physician were implemented in a timely manner for Resident #43. The resident was admitted on 04/05/24 and re-entered on 07/27/24, with diagnoses including vascular dementia with moderate mood disturbances, mood disorder, and anxiety. A physician order dated 05/16/25 included Lorazepam (Ativan) 0.5 mg by mouth every six hours as needed for anxiety and restlessness. The pharmacy recommendation dated 05/19/25 asked that the duration and rationale for the extended as-needed order be documented, and the physician reviewed the recommendation on 05/28/25 and indicated the medication should have a duration of 14 days. Review of the resident’s physician orders showed no evidence that the Lorazepam order was changed to reflect the 14-day duration after the physician responded to the recommendation. The Lorazepam remained active until it was discontinued on 06/16/25. During interview, LPN #215 stated the facility received the pharmacy recommendation, the physician marked the medication for a 14-day duration and then discontinuation, but the order was not changed until the next monthly pharmacy review identified that the medication was still active without a duration noted. Facility policy titled Consultant Pharmacist Services stated the consultant pharmacist will conduct a medication regimen review at least monthly and provide written reports with findings and recommendations.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, affecting their management of diabetes, depression, anticoagulant use, activities, and skin-picking behaviors. Resident #56, with multiple diagnoses including diabetes, did not have a care plan addressing diabetes or insulin use, as confirmed by the Director of Nursing. Similarly, Resident #2, who had intact cognition and various medical conditions, lacked a care plan for activities preferences until it was noted on 08/26/24. Resident #85, who was on an antidepressant and had communication difficulties, did not have a care plan addressing depression or antidepressant use, as verified by the MDS coordinator. Additionally, Resident #33, who was receiving anticoagulant medication for atrial fibrillation, did not have a care plan for the medication use, which was confirmed by the Director of Nursing. Resident #84, observed with numerous scabbed areas due to skin-picking behavior, did not have a care plan addressing his skin issues or behaviors, as confirmed by the DON. These deficiencies were identified through observation, interviews, and record reviews, affecting five out of thirty residents reviewed for care planning in a facility with a census of 102.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to ensure that residents were offered or assisted in attending activities and did not provide activities as scheduled, affecting four out of five residents reviewed for participation in activities. Resident #52, who had severe cognitive impairment and mobility issues, was observed sitting alone outside the activity room or in her room during scheduled group activities. Despite her interest in music and animals, she was not engaged in group or one-on-one activities, and there was no documentation of her participation in activities for the month of August. Resident #14, with severe cognitive impairment and a history of depression and anxiety, had no activities assessment or care plan. She was observed watching television in her room throughout the day, and her family reported that no one from the activities staff had engaged with her. The Activity Director confirmed that residents who do not attend group activities should be offered one-on-one activities, but there was no documentation of such activities for Resident #14. Resident #406, who had severely impaired cognition and a preference for religious services, was observed lying in bed in a dark room without entertainment. His care plan indicated he had little activity involvement, but he enjoyed spending time with his wife. The Activity Director acknowledged the lack of activity documentation for Resident #406. Similarly, Resident #22, who had intact cognition and a desire to learn knitting, was observed in his room with the TV on and had no documented evidence of activity participation. The Activity Director confirmed that audiobooks, which Resident #22 liked, were not documented as being provided to him.
Deficiencies in Meal Provision and Emergency Food Stock
Penalty
Summary
The facility failed to ensure that two residents received meals according to their dietary requirements and preferences. Resident #22, who was on a regular dysphagia pureed diet with nectar thickened liquids, did not receive the pureed marinated vegetable mix or thickened cranberry juice as ordered. Instead, the resident received confetti coleslaw, which was not part of the prescribed meal. Similarly, Resident #33, who was on a carbohydrate-controlled renal diet, did not receive the garden pasta salad as ordered, and instead received confetti coleslaw and a slice of lettuce. These discrepancies were confirmed through observations and interviews with staff and residents. Additionally, the facility failed to maintain an adequate emergency food stock as required by their policy. An inspection of the kitchen revealed that there was no emergency food set aside, and the facility lacked several items listed on the emergency menu, such as beef stew, canned carrots, ravioli, and reconstituted milk. The Dietary Manager confirmed the absence of these items and stated that they relied on a system to order emergency supplies if needed, rather than maintaining a physical stock on-site. The facility's policy on meal distribution and emergency supplies planning was not adhered to, resulting in deficiencies that affected the nutritional needs of the residents. The lack of compliance with the individualized diet orders and the absence of emergency food supplies posed a potential risk to the residents' well-being, especially in the event of a crisis or disaster situation.
Inappropriate Texture of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to an appropriate texture for residents requiring a pureed diet. During an observation, a cook was seen blending barbecue hamburgers for residents on a pureed diet. After blending, the cook tasted the food and believed it was suitable for serving. However, upon tasting, the surveyor found dime-sized bits of gristle or fat in the pureed food, indicating it was not of the correct texture and required chewing, which is unsafe for residents needing a pureed diet. The cook confirmed the inappropriate texture after the surveyor's intervention. The facility's policy on preparing pureed foods requires a pudding or mousse-like consistency, which was not achieved in this instance.
Arbitration Agreement Lacks Rescission Information
Penalty
Summary
The facility failed to ensure that their arbitration agreement informed residents of their right to rescind the agreement within 30 days of signing. This deficiency affected 51 residents who had agreed to enter into the arbitration agreement. The facility's arbitration agreement, titled 'Agreement to Resolve Legal Disputes through Binding Arbitration,' was undated and lacked the necessary information regarding the right to rescind. During an interview, the Admissions Director confirmed that the agreement did not include this information and mentioned that the facility's corporate office developed the agreement. Additionally, the facility did not have a policy related to arbitration agreements available at the time of the survey.
Failure in Skin Assessment and Monitoring
Penalty
Summary
The facility failed to ensure proper skin assessments and monitoring for two residents, leading to deficiencies in care. Resident #84, diagnosed with schizophrenia, anxiety disorder, pruritus, and paresthesia of the skin, was observed with numerous open and closed scabbed areas on his arms and leg, which were not properly documented or monitored. Despite having a dermatology treatment plan in place, the facility did not conduct weekly skin assessments or document the resident's skin condition accurately. The LPN responsible for wound monitoring assumed that dermatology visits would suffice, and the Director of Nursing confirmed the lack of proper monitoring and documentation. Resident #3, with medical diagnoses including heart failure, atrial fibrillation, and diabetes, was found to have a large bruise on her left hand that was not documented or reported. The resident, who was on anticoagulant medication, had no record of the bruise in her progress notes or skin assessments. The RN confirmed that the bruise was not documented, and no physician or family notification was made. The facility's policy required documentation and investigation of new bruises, which was not followed in this case. The facility's policies on skin assessments and care of skin tears and abrasions were not adhered to, resulting in inadequate monitoring and documentation of residents' skin conditions. This lack of compliance with established procedures led to deficiencies in the care provided to the residents, as evidenced by the unmonitored skin issues and undocumented bruising.
Failure to Provide Recommended Palm Guard for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was provided with the necessary palm guard as recommended by occupational therapy. The resident, who had diagnoses including moyamoya disease, hemiplegia, and a left-hand contracture, was observed over two days without the palm guard in place. The resident's care plan included the use of a palm guard to be applied in the morning and removed at night, as well as a splint as ordered. Despite these interventions being documented, the palm guard was not applied, and there was no order placed for it following the therapy recommendation. Interviews revealed that the therapy manager had educated staff on the application of the palm guard and the importance of performing passive ROM exercises during its application. However, a nursing assistant responsible for the resident admitted to not applying the palm guard, citing its unavailability and the need to check with the laundry. The Director of Nursing confirmed that no order was placed for the palm guard after the therapy recommendation, and the device was not in use, leading to the deficiency in care for the resident.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to maintain adequate supervision and a safe environment for two residents, leading to deficiencies in care. Resident #78, who had severe cognitive impairment and was at high risk for elopement, managed to leave the secured unit through a malfunctioning window. The resident was found in another unit after climbing out of the window and walking through the courtyard. The facility's investigation into the incident was incomplete, lacking witness statements, a timeline of events, and a skin assessment for the resident. Additionally, there was no documentation of staff education on the elopement policy or new interventions to prevent future incidents. Resident #29's room was observed to be cluttered with personal belongings and contained a multi-cup coffee maker plugged into an electrical power strip, posing a potential safety hazard. Despite the resident's intact cognition and independence in activities of daily living, the presence of the coffee maker in the room was against the facility's electrical safety policy. The facility had attempted to encourage the resident to keep the coffee maker at the nurse's desk, but it remained in the room until it was eventually removed. The facility's failure to ensure a safe environment and adequate supervision for these residents highlights deficiencies in their care protocols. The lack of a thorough investigation and appropriate interventions following Resident #78's elopement, as well as the oversight of electrical safety in Resident #29's room, demonstrate lapses in the facility's adherence to safety policies and procedures.
Delayed Treatment of UTI Due to Documentation and Communication Issues
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for Resident #85, who had multiple complex medical conditions including acute respiratory failure, hemiplegia, and cognitive deficits. The resident had a urinary catheter and was rarely or never understood, complicating communication about his condition. On 07/30/24, lab results indicated abnormalities in the resident's urine, but no new orders were made until 08/01/24. Despite preliminary reports on 08/01/24 and 08/02/24 indicating the presence of bacteria, no treatment was initiated until 08/14/24, when a course of Ciprofloxacin was ordered. The delay in treatment was partly due to the physician's request to check for Clostridium difficile (C. Diff) before treating the UTI, which was not documented in the progress notes. The resident had only formed stools during this period, and attempts to obtain a stool sample were unsuccessful. The lack of documentation and communication between the nursing staff and the physician contributed to the delay in addressing the UTI, as the second urinary analysis results were received on 08/12/24, but treatment did not commence until 08/14/24.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for side effects of anticoagulant medication and lacking a care plan for the anticoagulant. The resident, who had intact cognition, was admitted with multiple diagnoses including respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, and other chronic conditions. The resident was prescribed Apixaban, an anticoagulant, but there were no physician orders related to monitoring for its side effects, nor was there evidence in the medical record that such monitoring was taking place. Additionally, the resident's care plan did not address the use of anticoagulants. The Director of Nursing confirmed the absence of a care plan for anticoagulants and acknowledged that the facility did not have a system in place for monitoring anticoagulant side effects, relying instead on the resident's care plan, which was inadequate in this case.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. An observation revealed an opened multi-use vial of Tubersol TB solution in the medication storage refrigerator without an opened date, and the solution had expired in April 2007. The Licensed Practical Nurse (LPN) confirmed the vial was opened without a date and acknowledged it should be discarded after 30 days of opening. Additionally, a box of pre-filled syringes of Fluzone HD flu vaccines was found with an expiration date of June 2024, and the LPN confirmed these syringes were past their expiration date and should be disposed of. Another observation showed two multi-use vials of insulin left unsecured on top of a medication cart during medication administration for a resident with type two diabetes mellitus, depression, schizophrenia, and bipolar disorder. The LPN left the vials unattended while retrieving a multivitamin from the medication storage room. Upon return, the LPN realized the mistake and secured the vials. The facility's policy requires that medication carts be kept closed and locked when out of sight, and no medications should be left on top of the cart.
Inadequate Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service on the Memory Unit, as observed on August 26, 2024. State tested Nursing Assistants (STNAs) #224 and #244 were seen serving meal trays without sanitizing or washing their hands after adjusting clothing and before handling additional trays. Interviews with the STNAs revealed that they were instructed to wash hands only before and after meal tray service, which contradicts the facility's policy that requires hand hygiene before beginning meal service, after touching clothing, face, or a resident, and after every third tray served. The Director of Nursing Services confirmed the policy and the failure to adhere to it. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident #62, who had a diabetic foot ulcer. Observations on August 25 and 26, 2024, showed no EBP signage or available Personal Protective Equipment (PPE) near the resident's door. The resident's medical records indicated a chronic wound, but there was no order for EBP. The Director of Nursing verified the absence of an EBP order, despite the facility's policy requiring EBP for residents with chronic wounds. Similarly, Resident #406, who had a non-pressure chronic ulcer, was not placed under EBP. Observations on August 25, 26, and 27, 2024, confirmed the absence of EBP signage and PPE in the resident's room. The Licensed Practical Nurse was unsure if EBP was needed, and the Director of Nursing confirmed that residents with chronic wounds should be on EBP. The facility's policy mandates clear signage and PPE for residents with chronic wounds, but this was not followed for Resident #406.
Facility Fails to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the condition of the room occupied by Resident #29. An observation revealed that the rubber toe plate covering at the bottom of the wall under the sink in Resident #29's room was loose and falling off, exposing a moderate-sized hole approximately three feet long and two inches wide. This hole exposed the drywall material and wall support boards. The damage extended from the end of the wall to the corner of the two walls, and similar damage was noted on the shorter wall to the right of the sink. Resident #29, who was admitted with diagnoses including cancer of the head, face, and neck, COPD, type two diabetes mellitus, and heart failure, was independent with ADLs and used an electric wheelchair for mobility. Despite having intact cognition, Resident #29 was unaware of the damage in the room. The facility's Administrator confirmed the damage and suggested that it was likely caused by the resident's electric wheelchair running into the wall. The facility's policy on providing a homelike environment was reviewed, which mandates a safe, clean, and comfortable setting for residents.
Failure to Maintain Resident's Personal Hygiene Preferences
Penalty
Summary
The facility failed to ensure that Resident #406 was clean shaven, as per his preference. Resident #406, who has diagnoses including chronic venous hypertension, chronic systolic heart failure, peripheral vascular disease, dysphagia, and hypertension, was admitted with severely impaired cognition and required substantial or maximal assistance with personal hygiene. The last documented instance of the resident being shaved was during a bed bath on 08/19/24 by CNA #234. Observations on 08/25/24 and 08/27/24 revealed that the resident was unshaven with heavy stubble growth. A family member of Resident #406 expressed that the resident liked to be clean shaven and had requested staff to shave him the previous week, but it appeared not to have been done since then. CNA #234 confirmed that she had shaved the resident the previous week but was unsure if it had been done since. The Director of Nursing stated that residents should be shaved with showers and as needed.
Deficiency in Behavioral Health Care for Resident with Autism and Anxiety
Penalty
Summary
The facility failed to adequately care plan and implement interventions for a resident diagnosed with autism and anxiety, leading to a deficiency in behavioral health care and services. The resident's medical record indicated a diagnosis of autism, anxiety disorder, and other conditions, but the care plan did not address the resident's autism, care refusals, or behaviors. Despite having orders to monitor for anxiety and document symptoms related to autism, the facility did not effectively track or manage these conditions. The resident was prescribed Xanax as needed for anxiety, but there was no documentation of non-pharmacological interventions or reasons for administering the medication. Interviews with staff revealed a lack of understanding and training in managing autism, with some staff unaware of techniques to work with autistic individuals. The resident often refused care, hid under blankets, and was sensitive to light, yet these behaviors were not documented or addressed in the care plan. The resident's room was noted to have a strong odor, indicating potential neglect in personal hygiene care. Only one staff member, who had personal experience with autism, was able to assist the resident with showering by using specific techniques. The facility's policy on psychotropic medication use emphasized the need for monitoring and non-pharmacological approaches, but these were not implemented effectively for the resident. The Social Service Director and Therapeutic Behavior Specialist acknowledged the resident's anxiety and behaviors but did not consider involving a psychiatrist or psychologist. The lack of a comprehensive care plan and appropriate interventions for the resident's autism and anxiety led to the deficiency identified in the report.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor behaviors for three residents who were receiving psychotropic medications, leading to a deficiency in the management of unnecessary medications. Resident #22, who had intact cognition, was admitted with multiple diagnoses including anxiety disorder, depression, and dementia. Despite having a comprehensive care plan that included monitoring for target behavior symptoms and side effects of psychotropic medications, there was no evidence of behavior monitoring in the medical record until orders were put in on August 25, 2024. Similarly, Resident #56, who also had intact cognition, was admitted with diagnoses such as major depressive disorder, anxiety disorder, and bipolar disorder. The care plan included monitoring for side effects and adverse reactions of psychoactive medications. However, there was no evidence of behavior monitoring prior to August 25, 2024, when orders for monitoring were finally put in place. This lack of monitoring was confirmed by the Director of Nursing during interviews. Resident #306, who was admitted for a hospice respite stay, exhibited behaviors such as pacing, crying, and anxiety, which were not adequately documented or addressed with specific non-pharmacological interventions. The behavior documentation in the Medication Administration Record was insufficient, with only a check mark and nurse initials recorded once per day. The facility's policy required documentation of any improvements or worsening in behavior, mood, and function, which was not followed, leading to the deficiency.
Failure to Provide Written Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written transfer notice for two residents who were hospitalized, which is a requirement for ensuring residents and their representatives are informed of transfers or discharges. Resident #93, who had multiple complex medical conditions including hydrocephalus, chronic respiratory failure, and schizophrenia, was transferred to the hospital twice in August due to lethargy, muscle twitching, and cognitive decline. Despite these transfers, there was no evidence in the medical records that a written notice of transfer was provided to the resident or their responsible party. The Director of Nursing confirmed the absence of such documentation for Resident #93. Similarly, Resident #103, who had diagnoses such as a displaced fracture, embolism, and severe malnutrition, was transferred to the hospital from an outside medical appointment and did not return to the facility. The facility's records lacked evidence of a written transfer notice being provided to the resident or their representative. The Social Services Director confirmed that no written notice was given because the transfer occurred from an outside appointment, and the resident had not requested the transfer. The facility's policy requires written notification for facility-initiated transfers, which was not adhered to in these cases.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold notice to two residents who were hospitalized, which is a requirement when residents are transferred to a hospital or go on therapeutic leave. Resident #103, who had multiple medical diagnoses including a displaced fracture, embolism, severe malnutrition, and anxiety disorder, was admitted to the facility on 05/17/24 and discharged on 06/13/24. The resident was transferred to the hospital from an outside medical appointment and did not return to the facility. There was no evidence in the resident's scanned documents or progress notes that a bed hold notice was provided. The Social Services Director confirmed that the notice was not given because the transfer occurred from an outside appointment. Similarly, Resident #93, who had a complex medical history including hydrocephalus, traumatic hemorrhage, encephalopathy, and other conditions, was hospitalized twice in August 2024. The resident's medical record showed no evidence that a bed hold notice was provided for either hospitalization. The Director of Nursing confirmed the absence of a bed hold notice for the resident during that month. The facility's policy on transfer or discharge, revised in October 2022, requires that residents and their representatives be notified in writing about the facility's bed-hold policies, which was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 583 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Flint Ridge Nrsg & Rehab Ctr | 0.2 mi | ★★★★★ | 2 | 0 |
| Arlington Care Center | 0.6 mi | ★★★★★ | 7 | 0 |
| The Laurels Of Heath | 1.1 mi | ★★★★★ | 23 | 0 |
| Altercare Newark South Inc. | 1.7 mi | ★★★★★ | 3 | 0 |
| Altercare Newark North Inc. | 3.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.