The documents didn't exist in the designated binder at the nurse's station. They weren't in the unit manager's office. Staff had to call the hospice provider and ask them to send over the records, which arrived hours later with that day's date printed on each page.
Resident 43 had lived at the facility since April, with a brief departure and return in July. The 105-bed nursing home was caring for someone with vascular dementia, cerebral atherosclerosis, bone disorders, and hypertension. A quarterly assessment revealed the resident scored just 9 out of 15 on a cognitive test, indicating severely impaired decision-making abilities.
The hospice arrangement was substantial. A hospice staff member told inspectors on August 19 that the resident was scheduled to receive nursing assistant services three times weekly, nursing care weekly, and monthly social services visits. After each visit, hospice workers were supposed to complete care summaries and fax or email them to the facility.
But when Registered Nurse 243 showed inspectors where hospice notes were kept, the binder contained only a sign-in log. No care notes. No treatment summaries. Nothing documenting what hospice workers had been doing during their regular visits.
The nurse suggested the unit manager might have the records in her office. She didn't.
Inspectors requested the hospice documentation that morning. The facility couldn't produce it. Staff had to contact the hospice provider directly, and the documents finally arrived later that day. Each page bore the date August 19, 2025 — the same day inspectors had asked to see them.
Licensed Practical Nurse 215 confirmed what had become obvious: the documents weren't available at the facility when requested. Staff had to reach out to the hospice organization to get copies forwarded over.
This created a gap in care coordination that the facility's own policy was designed to prevent. Embassy of Newark's hospice program policy, written in July 2017, specifically required the facility to designate a staff member to ensure communication between the nursing home and the hospice medical director, the resident's attending physician, and other practitioners involved in care.
Without readily available hospice records, facility staff couldn't effectively collaborate with the hospice team or monitor the resident's care plan. They couldn't verify what services had been provided, track changes in the resident's condition, or coordinate with hospice workers who were visiting multiple times per week.
The missing documentation meant that for a resident with severely impaired cognition who couldn't advocate for themselves, the facility had no immediate way to review what hospice care was being delivered or whether it aligned with the resident's needs.
The inspection, conducted as part of a complaint investigation, found that this record-keeping failure affected the one hospice resident reviewed. But it raised questions about whether Embassy of Newark had systems in place to maintain proper documentation for the complex care arrangements that hospice patients require.
For Resident 43, the consequences of this administrative breakdown remained unclear. The resident continued receiving hospice services, but the facility's inability to produce basic care records on demand suggested a fundamental gap in how it managed information for some of its most vulnerable patients.
The facility's policy promised coordination and communication. The reality was staff scrambling to locate documents that should have been immediately available, while a severely cognitively impaired resident's care history existed only in files the nursing home couldn't access without making phone calls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Embassy of Newark from 2025-08-21 including all violations, facility responses, and corrective action plans.