Failure to Report Allegation of Resident Mistreatment to State Authorities
Penalty
Summary
The facility failed to report an allegation of mistreatment to the New Jersey Department of Health (NJDOH) as required by its own policy and state regulations. A resident with diagnoses including muscle wasting and atrophy, Alzheimer's disease, adult failure to thrive, history of falling, an unstageable sacral pressure ulcer, and unspecified dementia was documented on a recent MDS as having severely impaired cognitive skills, rarely or never understanding others, and rarely or never being able to make themself understood. On 11/10/2025, the resident's POA called the facility around 7:10 PM and reported that there was a sheet tied to the edge of the resident's bed, alleging that the resident was tied. RN #1 went to the room to investigate and found that the resident was not tied with the sheet, and family members were present in the room at that time. A Nursing Home Resident Grievance Form was completed and signed by the DON and the Licensed Nursing Home Administrator, and four staff statements were obtained. A skin assessment was completed for the resident on the same date related to the incident and revealed no wounds, marks, or visible injury. During a follow-up telephone interview, the DON stated that the allegation from 11/10/2025 was not reported to the NJDOH because the resident was found not to be tied, and further explained that the family alleged the resident was tied at the end of the bed, not around the body. The facility’s Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy, last reviewed 10/2025, states that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are to be reported immediately or within 24 hours to the administrator and appropriate officials, including the State Survey Agency. Despite this policy, the allegation was not reported to NJDOH.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.