Abingdon Care & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Brook, New Jersey.
- Location
- 303 Rock Ave, Green Brook, New Jersey 08812
- CMS Provider Number
- 315141
- Inspections on file
- 21
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Abingdon Care & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain a qualified full-time SW despite being licensed for 180 beds, as required by CMS guidelines and state regulations. The LNHA and HRD reported that the full-time SW position had been vacant for several months, with only a part-time or per diem SW providing limited hours before also leaving shortly before the survey. Timecard records showed very low SW hours over multiple pay periods, confirming the lack of full-time coverage. The facility’s own SW job description emphasized responsibility for ensuring residents’ medically related emotional and social needs were met, highlighting the significance of the vacancy.
The facility failed to provide adequate medically related social services, including psychosocial support after an abuse allegation and assistance with discharge planning and community resources. A resident with dementia and mobility dependence was allegedly treated roughly by a CNA during a transfer, but there was no documentation that social services monitored the resident’s psychosocial status as required by facility policy. Another resident with intact cognition, diabetic complications, neuropathy, and an amputation repeatedly requested help from a SW to obtain a phone and community housing, but received limited and partly incorrect assistance and could not complete provided forms due to neuropathy. A third cognitively intact resident with complex medical conditions and a stated goal of community discharge reported a difficult discharge process, and the family stated there was no SW involvement or family meeting, with family members performing most discharge arrangements and no SS progress notes documenting discharge planning.
A resident with dementia, muscle weakness, and dependence on staff for transfers reported back pain and requested to return to bed, and an insurance case worker later alleged that a CNA handled the resident roughly during the transfer, with the resident saying "ow." Although the CNA was suspended during the investigation and the allegation was ultimately unsubstantiated, the resident’s care plan was only updated with a vague focus on documented concerns and generic nursing and Social Services notifications, without clear goals or specific interventions related to the abuse allegation. The UM and RDON acknowledged that the care plan did not clearly address the allegation as required by facility policy for individualized, revised care plans.
A nurse left a resident's medications unattended at the bedside while searching for eyedrops, in violation of facility policy and standard nursing practice. The resident, who had multiple chronic conditions and intact cognition, was not supervised during medication administration, and staff confirmed that medications should never be left at the bedside.
Surveyors found that menus were not consistently reviewed by the RD for nutritional adequacy, and multiple meals did not meet the required protein content. Residents reported limited food choices, poor quality, and inconsistent availability of menu items and alternates. Observations confirmed that some meals and substitutes, such as hot dogs and grilled cheese, did not provide adequate protein, and bread products were sometimes unavailable, leading to further substitutions.
The facility did not consistently provide or document nourishing evening snacks for residents when the interval between dinner and breakfast exceeded 14 hours. Labeled snacks were inconsistently distributed by CNAs, and there was no accountability system in place to track snack provision or refusals. Residents reported that snacks left at the nurse's station were sometimes taken by others, and no extra snacks were available for those without labeled items. Staff interviews and review of facility documents confirmed the lack of a formal process or policy for evening snack distribution and documentation.
Surveyors identified multiple failures in food storage and kitchen sanitation, including unclean equipment, improper storage of utensils and food items, and inadequate maintenance of kitchen facilities. The Food Service Director acknowledged issues such as debris buildup, broken equipment, and improper food handling practices, all of which were inconsistent with facility policies.
Surveyors observed overflowing and uncovered dumpsters, an uncovered and overflowing cardboard container, and a compactor with liquid buildup underneath, with debris scattered around the dumpster area. Staff interviews revealed confusion about responsibility for maintaining cleanliness, and facility policy required maintenance of all areas, including the parking lot.
Surveyors identified multiple environmental deficiencies, including dirty and damaged heater units, cracked and missing floor tiles, stained ceiling tiles, leaking ceilings, and damaged handrails and elevator surfaces. These issues were not consistently tracked in the maintenance system, and staff interviews revealed gaps in reporting and repair processes. Facility leadership acknowledged ongoing challenges with building repairs and maintenance prioritization.
Surveyors found that controlled substances, including opioids and benzodiazepines, were not properly accounted for, stored, or documented. Medications for discharged or deceased residents were left unsecured and not removed from inventory, and required records were missing or inaccurate. Staff were unaware of the presence of these drugs, and shift-to-shift counts did not include them. Additionally, medication administration and destruction records for controlled substances were incomplete or incorrect, with missing witness signatures and discrepancies in inventory counts.
A facility licensed for 180 beds did not employ a full-time social worker for several months, instead relying on a part-time social worker who worked limited weekend hours while holding a full-time position elsewhere. Multiple residents voiced concerns about the lack of social work services, and staff confirmed that key social work responsibilities were handled by other departments during this period.
The facility did not consistently post the required daily nurse staffing report in visible locations. During the absence of the staffing coordinator, no one was assigned to ensure the report was posted, and the Director of Nursing was unclear about who should be responsible. This resulted in several days where the staffing information was not available as required by facility policy.
The facility did not ensure the Infection Preventionist (IP) attended two required QAPI meetings, as confirmed by review of sign-in sheets and administrator interview. The IP's absence was not documented as excused, and there was no evidence that infection control topics were reviewed during those meetings, contrary to facility policy.
Staff failed to use Enhanced Barrier Precautions (EBP) during wound care for a resident with open wounds, as neither a gown nor appropriate signage was used. Both a CNA and an LPN provided care using only gloves, contrary to facility policy requiring gown and gloves for high-contact care activities involving wounds. Interviews revealed staff misunderstanding of EBP requirements, and the Infection Preventionist confirmed EBP should have been in place.
Surveyors observed an ongoing fly infestation in the kitchen, with flies coming from an open floor drain near a grease trap. The FSD acknowledged the issue and stated that exterminator treatments had not resolved it due to the open drain. Pest control logs and invoices lacked documentation of specific treatments for flies, and key staff, including the DES and Regional Property Manager, were unaware of the problem. Facility policies required pest control, but work orders and records did not address the fly issue.
Failure to Maintain Required Full-Time Social Worker Coverage in a Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker (SW) despite being licensed for 180 beds, which exceeds the 120-bed threshold requiring a full-time SW under CMS guidelines implemented on 11/28/17 and N.J.A.C. 8:39-39.3(a); 39.2. During the survey entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the facility did not have a full-time SW and that the part-time SW had left approximately two weeks earlier. The Human Resources Director (HRD) later confirmed that the facility had no full-time SW for the last five months and that, after the full-time SW left, a part-time or per diem SW worked up to 30 hours per week before also leaving two weeks prior to the survey. The LNHA reviewed a Director of Social Work job posting dated 08/16/2024 with the surveyor and stated that it was around that time the facility lost its full-time SW, acknowledging that the facility should have a full-time SW to meet residents' needs. Timecard records for the SW showed minimal hours worked in successive pay periods from mid-November 2025 through late January 2026, with hours ranging from 4.25 to 8.92 per pay period, demonstrating that social work coverage was far below full-time. The facility’s own SW job description specified that the position’s primary purpose was to assist in planning, organizing, and developing the Social Services Department to ensure that residents’ medically related emotional and social needs were met on an individual basis, underscoring the gap created by the absence of a full-time SW.
Failure to Provide Needed Social Services, Abuse-Related Support, and Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to residents who required assistance with outside services and psychosocial support. Resident council minutes from late 2025 showed residents asking when a social worker would be available, and later notes indicated that a part‑time social worker was only in the facility a few days a week, with the LNHA, DON, and ADON expected to help if residents needed anything. At the time of survey, the LNHA reported that the part‑time social worker had left about two weeks earlier and that there was no current social worker in place, despite the facility’s own job description stating that the social worker is responsible for ensuring residents’ medically related emotional and social needs are met. One resident with dementia, muscle weakness, and dependence on staff for transfers reported back pain and requested to return to bed. An insurance case worker later reported that a CNA had been rough with this resident during the transfer, and the CNA was suspended pending investigation. Facility policy required that, when abuse is reported, the LNHA or designee request that social services monitor the resident’s psychosocial status in response to the incident and investigation. However, the documentation related to this incident did not show that social services monitored the resident’s psychosocial status, and the LNHA confirmed that the resident was not seen by social services after the abuse allegation. Another resident with intact cognition, multiple complications of Type 1 diabetes, an amputation, and generalized weakness had expressed a desire to leave the facility and live in the community. This resident requested assistance from a social worker for obtaining a phone and community housing and reported having asked for such help since September 2025. A grievance documented that the Regional Admissions Director, rather than social services, met with the resident and provided some contact information, but the resident stated that the corporate social worker gave incorrect resource information and forms the resident could not complete due to neuropathy, and the resident was not comfortable having other staff complete them. A third resident, also cognitively intact and with significant medical conditions and a stated goal of community discharge, reported that the discharge process was difficult and that they could not speak to the proper people to arrange discharge. The resident’s family member stated there was no meeting with family or discussion with a social worker about discharge, and that family had to handle most discharge arrangements, while no social services progress notes related to discharge planning were provided.
Failure to Clearly Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with a clear focus, goals, and interventions for a resident involved in a staff-to-resident abuse allegation. The resident had diagnoses including other lack of coordination, muscle weakness, need for assistance with personal care, and unspecified dementia without behavioral, psychotic, mood, or anxiety disturbances. A quarterly MDS showed a BIMS score of 9/15, indicating moderately impaired cognition, and documented that the resident was dependent on a helper for transfers from sitting to standing and from chair to bed. Progress notes indicated that the resident complained of back pain and requested to be returned to bed, and staff assisted the resident back to bed. An undated facility document showed that an insurance case worker reported that a CNA was rough with the resident during the transfer to bed and that the resident was saying "ow" during the transfer. The CNA was suspended pending investigation, and the allegation of rough handling was later determined to be unsubstantiated. Review of the resident’s care plan revealed a focus labeled "Documented Resident/Representative Concerns" initiated on the same date as the incident, with interventions limited to the nurse identifying the area of concern, notifying appropriate department leaders per protocol, and notifying Social Services of the concern and possible need for a care conference. The Unit Manager stated that after an abuse allegation, the resident’s care plan should be updated so staff know that allegations were made and what to do, and that he or the DON typically updated care plans. The Regional DON stated that the care plan update for this resident did not meet her expectations and that the issue being addressed was not clear, which did not align with the facility’s policy requiring individualized care plans with measurable objectives and revisions as the resident’s condition dictates.
Medications Left Unattended at Bedside by LPN
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications according to acceptable standards of nursing practice for one resident. The resident, who had diagnoses including atherosclerosis of native arteries with ulceration, muscle weakness, and type 2 diabetes mellitus, was cognitively intact as indicated by a perfect BIMS score. On the date in question, the nurse left the resident's medications unattended at the bedside while searching for the resident's eyedrops, contrary to facility policy and standard nursing protocols. This action was confirmed by multiple staff interviews, including the nurse involved, the unit manager, and the director of nursing, all of whom stated that medications should never be left at the bedside under any circumstances. The facility's policy on medication administration requires that medications be administered safely, timely, and as prescribed, with nurses expected to verify resident identity, check orders, educate residents about their medications, and remain with the resident until the medication is taken. The nurse's deviation from this process by leaving medications at the bedside was identified as a failure to follow both facility policy and professional standards, as it prevented assurance that the resident actually took the medication as intended.
Failure to Provide Nutritionally Adequate Menus and Consistent Meal Options
Penalty
Summary
The facility failed to ensure that its menus met the nutritional needs of residents, as required by regulations and the facility's own dietary manual. The Registered Dietitian (RD) did not consistently review and approve the four-week cycle menus for nutritional adequacy, and there was a lack of documentation confirming that all menu cycles were reviewed. The Food Service Director (FSD) and RD were unable to confirm the process for menu development and review, and the FSD did not have access to the diet manual. The menus provided only one meal option for lunch and dinner, and the Always Available list was not consistently accessible to residents. Several menu items and alternates, such as hot dogs and grilled cheese, did not provide the required minimum of 3 oz. (21 gms) of protein per meal, with some meals providing as little as 6 gms of protein. The FSD and RD acknowledged that these protein amounts were inadequate, and invoices and nutritional information confirmed that multiple meals throughout the cycle did not meet protein requirements. Residents reported limited food choices, poor food quality, and inconsistent availability of menu items and alternates, including bread and buns for sandwiches. During interviews and group meetings, residents expressed dissatisfaction with the lack of variety and the nutritional inadequacy of certain meals, such as fish patties, chicken patties, burgers, and meatballs. One resident specifically requested breakfast meat daily but did not consistently receive it, and when alternate items were requested, they were not always available or nutritionally equivalent. Observations confirmed that residents sometimes received substitutes, such as hot dogs or sandwiches, that did not meet protein requirements, and that bread products were sometimes unavailable, leading to substitutions like serving hot dogs on regular bread instead of buns. The facility's documentation, including food purchase invoices and nutritional labels, supported the findings that several menu items did not meet the required protein content. The RD and FSD acknowledged that some prepared products used did not meet protein requirements, and that recipes provided for review did not always match the products actually served. The dietary manual specified that regular diet portion sizes for protein at lunch and dinner should be 3 oz., but this standard was not consistently met. The deficiency was further corroborated by resident council feedback and direct observations by surveyors.
Failure to Provide and Document Evening Snacks for Residents
Penalty
Summary
The facility failed to ensure that residents received and were properly documented as having received a nourishing evening snack when there was more than a 14-hour span between dinner and breakfast. During a kitchen tour, the Food Service Director confirmed that evening snacks were not routinely sent, and there was no list of residents receiving snacks. Instead, labeled snacks were provided only if requested before the kitchen closed, and after hours, snacks could be accessed by a supervisor with a key. Review of the facility's mealtime schedule confirmed that the interval between dinner and breakfast exceeded 14 hours. Resident council meeting participants, all of whom were alert and oriented, reported that labeled snacks were inconsistently distributed by CNAs, and when left unattended at the nurse's station, snacks were sometimes taken by other residents. There were no additional snacks available for residents without labeled snacks. Interviews with nursing staff and the unit manager revealed that there was no accountability system, either in the electronic medical record or on paper, to track the provision of evening snacks or to document refusals. The Registered Dietitian and Food Service Director both acknowledged the need for snacks when the meal interval exceeded 14 hours and agreed that accountability was lacking. Review of previous resident council meeting minutes showed ongoing reports that CNAs did not distribute snacks as intended. The facility was unable to provide policies related to mealtimes and evening snacks.
Deficient Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store potentially hazardous foods properly and did not maintain kitchen equipment in a sanitary manner, as evidenced by multiple observations during a kitchen tour with the Food Service Director (FSD). Issues included a reddish substance inside the ice machine, built-up debris in a refrigerator, heavy buildup on an exhaust fan, a broken and melted spatula in a prep sink, a soiled rag draped over a sink divider, and a black sticky substance on a grease trap cover. Additional findings included gouged cutting boards, debris on the spice rack, a soiled mop head on the floor, improper storage of a scoop in a flour bin, and a buildup of residue on a can opener and steam table wells. The towel dispenser above the handwashing sink was broken and empty, with the towel ring placed on a spice rack instead. The FSD acknowledged each of these issues during the inspection. Further deficiencies were noted in food storage practices, such as raw eggs stored above liquid pasteurized eggs without evidence of pasteurization, and shelves in the walk-in refrigerator with removable black debris. Facility policies reviewed indicated requirements for maintaining sanitary conditions in food service areas, proper handling of ice, and clean food storage, but these were not followed as observed. No specific residents or patient conditions were mentioned in relation to the deficiencies.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to maintain proper disposal and containment of garbage and refuse, as evidenced by multiple observations of overflowing and uncovered dumpsters, a compactor with a buildup of discolored liquid underneath, and debris scattered on the ground in the dumpster area. The survey team observed two oversized dumpsters overflowing with waste and black garbage bags placed around and between them, as well as an uncovered and overflowing cardboard dumpster. The compactor was also noted to have liquid accumulation beneath it. These conditions were visible from the parking lot and during a tour of the loading dock area. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the cleanliness of the dumpster area. The Food Service Director was unaware of the need to cover the cardboard container and could not specify who was responsible for keeping the area clean. The Director of Environmental Services stated he was ultimately responsible but cited timing issues for the lack of cleanliness and was unable to clarify responsibility for two of the dumpsters. Review of facility policy indicated maintenance service was to be provided to all areas, including the parking lot, but the observed conditions did not align with this policy.
Failure to Maintain Clean and Safe Environment Across Facility Units
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment across two units, as evidenced by multiple observations of unaddressed environmental deficiencies. Surveyors noted dark scuff marks in hallways, heater units with brown and black substances on their surfaces, cracked and missing floor tiles, and broken or misaligned closet doors and dresser drawers. These issues were not consistently documented in the facility's work order system, and some were only tracked informally by the Director of Maintenance/Housekeeping/Laundry (DMHL) on personal lists. Additionally, fluid was observed leaking from ceiling tiles, and the elevator had significant paint peeling and damaged wooden guard rails, with attempts to cover up rather than repair the damage. Further observations included missing floor tiles and discolored ceiling tiles with debris buildup on vents in resident rooms and common areas. Handrails and columns in the nurse's station area were found to be damaged or missing parts, and some of these issues were acknowledged by the DMHL as being difficult to repair due to the age of the building materials. Staff interviews revealed that while some staff attempted to address minor repairs themselves, most relied on the maintenance request system, which was not always effective in ensuring timely repairs. Additional deficiencies included brown stains on ceiling tiles in multiple resident rooms, which persisted over several days of observation. The DMHL acknowledged these issues but indicated they had not yet been added to the maintenance list. Facility leadership confirmed that environmental rounds were conducted by department heads and the DMHL, but also stated that the facility was in the process of being updated and not all repairs could be completed immediately.
Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper receipt, accountability, reconciliation, secure storage, and removal from active inventory of controlled substances for multiple residents. Surveyors observed that controlled drugs, including Lorazepam, Fentanyl patches, Methadone, Hydrocodone/Acetaminophen, Morphine Sulfate, and Alprazolam, were found in an unlocked cabinet and refrigerator in the medication room, some of which were labeled for residents who had been discharged or had expired. Documentation such as Individual Patient Controlled Substance Administration Records (IPCSAR) was missing or inaccurate for these medications, and the drugs were not being included in shift-to-shift controlled substance counts. Staff, including the Unit Manager and DON, were unaware of the presence of these medications and could not provide proper records or explain the discrepancies. Further deficiencies were identified in the management of controlled drugs on medication carts. For one resident, the IPCSAR for Nayzilam spray indicated a remaining balance that could not be accounted for, and the receiving nurse had not properly documented the date or amount received. Additionally, two IPCSARs for Diazepam gel did not accurately correspond to the remaining inventory, and a return medication form was incorrectly attached to a controlled drug that should not have been returned to the pharmacy. The DON acknowledged these inaccuracies and the lack of proper reconciliation and removal from active inventory for discontinued medications. Another deficiency involved the documentation and destruction of a Buprenorphine patch. The Controlled Substance Administration Record for the patch showed that the same patch was both applied and removed on the same date and time, which did not align with the physician's order for weekly application. The nurse involved admitted to not obtaining the required second signature for the destruction of the old patch, and the DON confirmed that proper documentation and witness signatures were not present at the time of wastage. These findings collectively demonstrate a failure to comply with facility policies and regulatory requirements for the handling, storage, documentation, and destruction of controlled substances.
Failure to Employ Full-Time Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility failed to employ a qualified full-time social worker from December 7, 2024, to April 16, 2025, despite being licensed for 180 beds, which exceeds the threshold requiring a full-time social worker. During this period, the facility only had a social worker present for limited hours on weekends, as confirmed by time clock records and staff interviews. The social worker worked primarily on Saturdays and Sundays for approximately five hours each day and had a full-time position at another facility. This arrangement was insufficient to meet the full-time requirement outlined in federal and state regulations. Residents expressed concerns about the lack of a full-time social worker during a resident council meeting, with six out of seven alert and oriented residents noting the absence and limited availability of social work services. The social worker's responsibilities were limited to completing social histories, MDS requirements, and obtaining necessary paperwork for identified residents, with any unresolved concerns referred to other administrative staff. The admissions director and other staff confirmed that discharge and transfer responsibilities were handled by other departments due to the absence of a full-time social worker.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing report as required. On multiple occasions, surveyors did not observe the staffing report posted at the front reception desk, time clock, elevator, or nursing units. Specifically, on several consecutive days, the required staffing information was not visible in any of the designated locations. The staffing coordinator (SC) confirmed during an interview that she was responsible for posting the report but had been absent for two weeks, and no one posted the staffing information in her absence. Upon her return, she resumed posting the reports, but there were still delays in posting until after the morning meeting to ensure accuracy. The receptionist, who was given the report to post, did not consistently do so. Further interviews with the Director of Nursing (DON) revealed uncertainty regarding who was responsible for posting the staffing report when the SC was away, suggesting a lack of clear delegation or backup process. The facility's policy states that staffing will be posted in a visible location, but this was not consistently followed, resulting in the deficiency. No specific residents or patient conditions were mentioned in relation to this deficiency.
Infection Preventionist Not Present at Required QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required Infection Preventionist (IP) was present at two out of four Quality Assurance and Performance Improvement (QAPI) committee meetings reviewed. During an interview, the Licensed Nursing Home Administrator (LNHA) confirmed that QAPI meetings were held at least quarterly and that the required members included the administrator, DON, medical director, and other staff. Upon reviewing the QAPI meeting attendance sign-in sheets, the LNHA was unable to identify the IP as present at the meetings held on 4/17/2024 and 10/16/2024. The LNHA also stated he was not aware that the IP was required to attend these meetings. Further review of facility documentation showed that while the IP was off on 1/15/2025, infection control topics were still reviewed with the committee. However, no evidence was provided to show that infection control was reviewed during the 4/17/2024 and 10/16/2024 meetings. The facility's policy requires the IP to be a member of the QAPI committee and for attendance records to be maintained, but these requirements were not met for the specified meetings.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with open wounds, as required by facility policy and infection control standards. During a wound treatment observation, a CNA and an LPN provided care to a resident with sacral and right heel wounds, both wearing gloves but not gowns, and there was no EBP signage at the resident's doorway or in the room. The LPN cleansed and dressed the wounds without donning a gown, and the CNA assisted without a gown as well. Both staff members indicated in interviews that they did not believe EBP was necessary in the absence of wound drainage or isolation status, despite the resident having open wounds. The resident in question had diagnoses including dementia, hypertension, and diabetes, and had physician orders for wound care treatments. The care plan identified a risk for skin integrity impairment and included wound care interventions. Interviews with the Unit Manager RN and the Infection Preventionist confirmed that EBP should have been implemented for any resident with a wound, regardless of drainage. Facility policy also specified that gown and gloves are required for high-contact care activities involving residents with wounds, to prevent the transfer of multi-drug-resistant organisms (MDROs).
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the kitchen area. During a kitchen tour, the surveyor observed an open floor drain next to a grease trap with many flies coming from the drain, in the air, and on the wall. The Food Service Director (FSD) acknowledged the presence of drain flies and stated that the grease trap needed cleaning. The FSD also reported that exterminator treatments had not resolved the issue due to the open drain. A pest control logbook provided by the FSD indicated weekly visits from the exterminating company, but there was no documentation of specific treatments or areas addressed in the kitchen. Subsequent observations by surveyors confirmed the continued presence of flies near the dish machine room. Interviews with the Director of Environmental Services (DES) and the Regional Property Manager revealed they were unaware of the fly issue in the kitchen. Review of exterminator invoices showed that kitchen pests had not been addressed in recent visits, and one invoice indicated no service was performed due to a state survey. The administrative team, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing, and Chief Clinical Officer, were made aware of the concern. The LNHA later stated that exterminator treatment for flies had occurred about a month and a half prior, but no specific documentation was available. Facility work orders and policies reviewed did not address the fly issue, despite policies stating the facility would maintain an effective pest control program and keep kitchen areas protected from insects.
Latest citations in New Jersey
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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