Alaris Health At Cedar Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Grove, New Jersey.
- Location
- 110 Grove Ave, Cedar Grove, New Jersey 07009
- CMS Provider Number
- 315357
- Inspections on file
- 17
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Alaris Health At Cedar Grove during CMS and state inspections, most recent first.
A resident with multiple serious diagnoses, fully dependent for ADLs and cognitively intact, reported being dropped by ambulance transport on two occasions. The facility's investigation was incomplete, lacking a timely RN assessment after the reported fall and failing to obtain statements from the second transport company, contrary to facility policy.
A resident with dementia, diabetes, and CHF who was dependent for eating did not receive individualized nutritional care, as the care plan did not match the assessment and staff documentation often indicated independence during meals. Required weekly weight monitoring was not performed, and the effectiveness of increased nutritional supplements was not measured, resulting in inadequate monitoring of the resident's nutritional status.
The facility failed to verify the credentials of three newly hired licensed staff members before their date of hire, as required by policy. A Social Worker, a Registered Nurse, and a CNA had their licenses verified after their hire dates or lacked documented evidence of timely verification. Interviews with staff revealed inconsistencies in the verification process, with the LNHA admitting to missing the verification.
A facility failed to ensure that a resident received face-to-face visits from the supervising physician every 60 days, as required by policy. The resident, with multiple medical conditions and moderately impaired cognition, had visit notes completed by an APN instead of the physician. The facility's policy required the physician to see the resident every 60 days, but this was not adhered to, and no additional information was provided by the facility management during the exit conference.
The facility failed to maintain a safe and sanitary environment, with issues such as dust accumulation, stained ceiling tiles, and improperly stored items observed in resident rooms, a shower room, and an electrical room. The Director of Housekeeping acknowledged a lack of documentation for cleaning schedules, contributing to the deficiencies.
A facility failed to maintain full visual privacy for a resident during wound care treatment. An LPN left the resident's body exposed to the hallway by not fully closing the privacy curtain and opening the door to retrieve gloves. The resident had a history of a sacral pressure ulcer and moderate cognitive impairment. The facility's policy emphasizes maintaining physical privacy during medical treatments.
The facility failed to provide written notifications to residents and their representatives about hospital transfers, as well as to the Ombudsman. This deficiency was identified for two residents, with medical records lacking the required documentation. Interviews with staff revealed confusion over responsibility for these notifications, leading to non-compliance with notification protocols.
A facility failed to accurately code the MDS for a resident, resulting in a deficiency. The resident, with diagnoses including atrial fibrillation and hypertension, was discharged home with home care services. However, the MDS was incorrectly coded as a transfer to a hospital. The MDSC admitted the error, which was confirmed by facility leadership during a review of closed records.
The facility failed to follow physician's orders for medication administration with parameters for two residents. One resident received Midodrine HCl despite blood pressure readings above the prescribed limit, while another received Hydralazine and Toprol XL when blood pressure was below the required threshold. Nursing staff acknowledged the errors, which were contrary to the facility's Medication Administration Policy.
The facility failed to complete discharge summaries for two residents, as required by their policy. One resident's electronic medical records had multiple sections left blank, and there was no physician discharge summary. Another resident was discharged without a documented discharge summary, and the last physician note lacked discharge information. The facility's policy required a discharge plan and summary, which were not completed, leading to the deficiency.
A facility failed to consistently apply and document the use of a hand splint for a resident with decreased range of motion, as required by their care plan. The resident's physician order for a Functional Maintenance Program was not properly transferred to the Treatment Administration Record, leading to inconsistent application of the splint. Interviews with staff revealed confusion and lack of documentation, particularly on days when the Restorative Nurse Aid was not present, resulting in a deficiency.
A facility failed to develop an appropriate incontinence care plan for a resident with frequent urine and occasional bowel incontinence. Despite the resident's MDS assessment indicating the need for a care plan, no focused plan with specific goals and interventions was created. The CNA checked on the resident based on personal experience, and the RN and RN/UM were unsure if incontinence should be care planned. The MDS Coordinator confirmed the absence of a care plan, contrary to facility policy.
A facility failed to ensure a non-certified NA did not work beyond 120 days without completing required training and certification. NA #1 was employed for more than 120 days without certification, as revealed during a review of employee files. Interviews with the BOM and DON showed a lack of clarity in the policy for employing non-certified NAs, and the facility's policy did not address the certification requirement within 120 days.
The facility failed to post the 24-hour Nursing Home Resident Care Staffing Report in a prominent place accessible to residents and visitors. The surveyor found the reports missing on two consecutive days, and the receptionist confirmed they were usually posted behind her. The Staffing Coordinator, who was responsible for posting, was off one day and had printer issues. The LNHA acknowledged the issue and stated that staff were inserviced.
A resident was administered Tamsulosin for overactive bladder without a diagnosis of BPH, contrary to the manufacturer's approved use. The facility's documentation was inconsistent regarding the resident's incontinence condition, and there was no justification for the off-label use of the medication. The pharmacy consultant's recommendations did not address this issue, and late entries in physician notes failed to provide adequate documentation of the medication's necessity.
The facility had a medication administration error rate of 12%, exceeding the acceptable 5% threshold. An LPN administered a 100 mg dose of Docusate without a specified dosage in the eMAR and signed for Enoxaparin without administering it during observation. Another LPN left oral meds unattended on a cart, violating facility policy.
The facility failed to properly store and label medications, including an unlabeled Retacrit vial and improperly stored Novolin R Flex Pen. Expired BD Viral transport tubes and inadequate temperature logging for vaccine storage were also noted. Additionally, an opened Ipratropium/Albuterol nebulizer solution lacked a date, contrary to manufacturer instructions. The facility's Medication Administration Policy was not adhered to, and no storage policy was provided upon request.
The facility failed to maintain complete and accessible medical records for residents, leading to a deficiency. A resident with a history of mental disorders exhibited aggressive behavior, but the facility did not document preventive measures or interventions. Another resident's medical records lacked timely physician visit notes, with additional notes only added after surveyor inquiry. The facility's delayed collection of staff statements further contributed to the deficiency.
A facility failed to follow proper infection control practices, including improper storage of a urinary drainage bag and inadequate hand hygiene during a wound treatment. A resident's urinary catheter bag was placed on the mattress instead of below bladder level, and an LPN did not perform hand hygiene correctly during wound care, also wearing a PPE gown in the hallway. These actions were inconsistent with the facility's policies and CDC guidelines.
The facility did not have a dedicated Infection Preventionist (IP) from May 2023 to January 2024, with the Director of Nursing (DON) assuming the role. This absence was noted during QAPI meetings, where infection control reports were inadequately reviewed. The facility's policies required a part-time IP, but recruitment efforts were unsuccessful, leading to non-compliance with infection control standards.
A facility failed to offer and document influenza and pneumococcal vaccinations for a resident with complex medical conditions. The resident's medical records lacked evidence of vaccine offers or refusals, and there was no documentation of education provided to the resident or their representative. Interviews with staff revealed inconsistencies in the facility's protocol for tracking and documenting immunizations, highlighting a deficiency in the implementation of vaccination policies.
Incomplete Investigation of Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who alleged being dropped by ambulance transport on two separate occasions. The incident was initially reported after the resident experienced pain in their elbow and shoulder while reaching for a urinal, which led to a hospital transfer. Upon return, the resident later disclosed to staff that they had been dropped by both transport teams but had not reported it earlier to avoid getting anyone in trouble. The facility's investigation did not include immediate assessment by a Registered Nurse after the fall was reported, and only a Licensed Practical Nurse performed a skin assessment. Additionally, there was no evidence that the facility made an effort to contact the second transport company to obtain statements or further investigate the allegation. The resident involved had significant medical conditions, including multiple myeloma, fatigue fracture of the vertebrae, pathological fracture in neoplastic disease, and malignant neoplasm of the bone. The resident was fully cognitively intact and dependent on staff for all activities of daily living, including transfers. The facility's policy required that investigations include interviews with staff, residents, and witnesses, with statements attached to the incident report and kept on file. However, the investigation was incomplete, lacking both a Registered Nurse assessment and documentation of contact with the second transport company.
Failure to Individualize and Implement Nutritional Care Plan
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia, diabetes, congestive heart failure, and a history of pulmonary embolism, did not receive individualized and consistent nutritional care. The resident was assessed as being dependent for eating and required a mechanically altered diet due to swallowing difficulties. However, the care plan only indicated assistance with meals as needed, which was inconsistent with the comprehensive assessment. Documentation by CNAs showed that the resident was frequently recorded as independent or only receiving minimal assistance during meals, despite being assessed as fully dependent. Further review revealed that the resident's nutritional status was not adequately monitored. The care plan included an intervention to monitor, record, and report significant weight loss, specifically a loss of more than three pounds per week, but only one weight measurement was documented in the medical record. The facility's point-of-care system also failed to consistently document the required level of assistance provided during meals, and the intervention for weekly weight monitoring was not followed. Additionally, when the resident's nutritional supplement was increased in response to family concerns and poor intake, there was no documented method to measure the effectiveness of this intervention. The registered dietician acknowledged that the care plan was generic and not individualized, and that the required weekly weight monitoring was not performed. Facility policies required integration of assessment findings into care planning and regular weight monitoring, but these were not implemented for this resident.
Failure to Verify Staff Credentials Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of newly hired licensed staff were verified upon hire, as required by their policy. This deficiency was identified for three out of five newly hired licensed staff members reviewed. Specifically, a Social Worker hired on 8/21/23 had their license verified only on 10/02/23, after their date of hire. Similarly, a Registered Nurse hired on 8/25/23 had their license verified on 10/02/23 and 11/14/23, both dates post-hire. Additionally, a Certified Nurse Aide hired on 10/23/23 had a license verification printout with no visible date, indicating a lack of documented evidence that the verification was completed before the date of hire. Interviews with facility staff, including the Business Office Manager (BOM), Director of Nursing (DON), and Licensed Nursing Home Administrator (LNHA), revealed inconsistencies in the verification process. The BOM, who was responsible for checking licenses before orientation, was not employed at the facility at the time of the oversight. The LNHA, who acted as a stand-in BOM, admitted to missing the verification. The facility's policy mandates that potential hires of professional staff have their licenses verified by their licensing boards prior to hire, which was not adhered to in these cases.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days, as required by the facility's policy and procedure. This deficiency was identified for one resident, who was admitted with multiple diagnoses including hypotension, traumatic subdural hemorrhage, cerebral infarction, atrial fibrillation, hemiplegia, secondary hypertension, depression, and anxiety disorder. The resident's most recent assessment indicated moderately impaired cognition. Despite these conditions, there was no documented evidence of physician visits and examinations every 60 days from January 2024 through June 2024. The surveyor's investigation revealed that the resident's visit notes for January and March 2024 were completed by an Advance Practice Nurse (APN), with no further notes found in the resident's medical records. During interviews, the facility's Registered Nurse Coordinator and Licensed Nursing Home Administrator confirmed that the facility's policy required the primary physician to see the resident every 60 days, with the APN conducting alternating visits. However, the facility failed to adhere to this policy, as evidenced by the lack of physician documentation in the resident's records. The facility management did not provide additional information or refute the findings during the exit conference.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the Behavioral Unit, affecting multiple resident rooms, a shower room, and a motor access room. During a tour, surveyors observed several issues, including an accumulation of dust on air vent covers, a stained ceiling tile, and a piece of clothing left in a bathroom after a resident transfer. Additionally, dry debris was found hanging from a window, and rust was noted on toilet paper holders. A urine collection container was improperly left on the floor, and a smoke detector was found detached and hanging from the ceiling. Further observations revealed an unlocked electrical room with a dried-up substance and a discolored blanket on the floor. In the eyewash station room, a shower stall had a missing part to close an opening, and an air vent was uncovered with dust accumulation. The Director of Housekeeping admitted to a lack of documentation for cleaning schedules and rounds, indicating a failure in maintaining cleanliness and safety standards as per the facility's policy.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain full visual privacy for a resident during a wound care treatment. On the specified date, a Licensed Practical Nurse (LPN) was observed performing treatment on a resident's sacral wound with the assistance of a Certified Nurse Aide (CNA). During the procedure, the privacy curtain was only partially drawn, leaving the resident's body exposed to the hallway when the LPN opened the door to retrieve gloves from a treatment cart outside the room. This action compromised the resident's privacy as the back side of the resident's body was visible from the hallway. The resident involved had a history of urinary tract infection, a sacral pressure ulcer wound, and epilepsy, with a moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The facility's policy on resident rights to privacy and confidentiality emphasizes the importance of maintaining physical privacy during medical treatments. However, the LPN acknowledged the lapse in ensuring the resident's privacy during the treatment, which was confirmed during an interview with the surveyor.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for their transfer to the hospital, as well as failing to notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for two residents who were transferred to an acute care hospital. The medical records of these residents did not contain the required written notifications, indicating a lapse in the facility's adherence to notification protocols. Interviews with various staff members, including the Director of Social Services, Admissions Director, Regional Director of Case Management and Admissions, Director of Nursing, Licensed Nursing Home Administrator, and medical records staff, revealed a lack of clarity and responsibility regarding who was accountable for providing these notifications. Each department denied responsibility, and there was no established process in place to ensure compliance with the notification requirements. This lack of coordination and communication among the staff contributed to the failure to provide the necessary notifications.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in compliance with federal guidelines. The error involved Resident #142, whose discharge MDS was incorrectly coded as a transfer to an acute hospital, despite documentation indicating the resident was discharged home with home care services. The resident's admission record included diagnoses such as unspecified atrial fibrillation, anxiety disorder, and essential hypertension. On the day of discharge, the resident was noted to be in no distress, had their vitals taken, and was discharged home with a representative, as documented in the progress notes and discharge summary. The MDS Coordinator (MDSC) acknowledged the mistake during an interview, confirming that the resident was discharged home and not to a hospital. This error was further confirmed during a meeting with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Vice President of Operations (VPoO), who reiterated that the MDS was inaccurately coded. The deficiency was identified during a review of closed records, highlighting a lapse in the facility's adherence to proper coding procedures for resident assessments.
Failure to Follow Physician's Orders for Medication Parameters
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration with specific parameters for two residents, leading to a deficiency. Resident #44, who was cognitively intact and diagnosed with conditions including end-stage renal disease and hypotension, was prescribed Midodrine HCl to be administered only if blood pressure was below 120. However, the medication was administered multiple times despite the resident's blood pressure exceeding this threshold, as documented in the electronic Medication Administration Record (eMAR). Similarly, Resident #134, who had moderately impaired cognition and multiple diagnoses including hypotension and cerebral infarction, was prescribed Hydralazine and Toprol XL with specific blood pressure parameters. The eMAR showed that these medications were administered even when the resident's blood pressure was below the prescribed limits. Interviews with the nursing staff revealed that they were aware of the parameters but failed to follow them, resulting in medication errors. The Director of Nursing acknowledged the failure to follow physician's orders and the facility's Medication Administration Policy, which mandates that medications be administered according to prescribed parameters. The policy requires verification of vital signs before administering medications, which was not adhered to in these cases, leading to the deficiency.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that a discharge summary was completed for two residents, as required by their policy and procedure. For Resident #13, the surveyor found that the discharge summary in the electronic medical records was incomplete, with multiple sections left blank, including social services, rehab, dietary, and activities. Additionally, there was no physician discharge summary available. The Director of Nursing and Registered Nurse/Unit Manager confirmed that it was not the facility's practice to have a physician discharge summary, which contributed to the deficiency. For Resident #142, the surveyor discovered that the discharge summary was also missing. The resident was discharged home with home care services, but the last physician note did not include discharge information or a plan. The facility's discharge policy, reviewed in January 2024, required a discharge plan, summary, and instructions to be developed and documented by the interdisciplinary team, which was not adhered to in these cases. The survey team met with facility management multiple times to discuss these findings, and the facility acknowledged the lack of a physician discharge summary. The facility's policy clearly stated the need for a discharge summary, yet it was not completed for the residents in question, leading to the identified deficiency.
Inconsistent Application and Documentation of Hand Splint for Resident
Penalty
Summary
The facility failed to ensure consistent daily treatment for a resident with decreased range of motion and mobility, specifically regarding the use of a hand splint to prevent contractures. The resident, who was observed wearing a splint on their left hand, had a physician's order for a Functional Maintenance Program (FMP) that included passive range of motion exercises and the application of a left hand orthotic device. However, the order was not transferred to the Treatment Administration Record (TAR) for staff signatures, and there was no documented evidence that the care plan was being consistently followed. Interviews with facility staff revealed inconsistencies in the documentation and application of the splint. The Certified Nursing Assistant (CNA) indicated that therapy staff were responsible for the splint when the resident was in therapy, while nursing staff would apply it otherwise. However, the Documentation Survey Report showed no records of splint application by the CNA. The Restorative Nurse Aid (RNA) documented splint application in a binder, but there were numerous days with missing documentation, indicating that the splint was not applied consistently when the RNA was not present. Further interviews with the Director of Rehab (DoR), Registered Nurse/Unit Manager (RN/UM), and Licensed Practical Nurse (LPN) highlighted a lack of clarity and communication regarding the documentation process for the splint. The facility's policy on the Functional Maintenance Program did not address documentation procedures for splints while a resident received skilled therapy, contributing to the deficiency. The absence of documented evidence for splint application on days when the RNA was not at the facility was confirmed by the Director of Nursing (DON), indicating a failure in ensuring the resident's care plan was consistently implemented.
Failure to Develop Incontinence Care Plan
Penalty
Summary
The facility failed to develop an appropriate incontinence care plan for a resident, identified as Resident #134, who was frequently incontinent of urine and occasionally incontinent of bowel. The resident's medical records indicated a significant change in their condition, as reflected in the Minimum Data Set (MDS) assessment, which triggered the need for a care plan addressing urinary incontinence. However, the facility did not create a focused care plan with specific goals and interventions for the resident's bladder and bowel incontinence, despite the assessment's recommendation to proceed with care planning. Observations and interviews conducted by the surveyor revealed that the resident was not on a bladder and bowel toileting program, and the Certified Nursing Aide (CNA) responsible for the resident's care was checking on the resident's incontinence based on personal experience rather than a structured care plan. The Registered Nurse (RN) and the RN/Unit Manager (RN/UM) acknowledged the resident's incontinence but were unsure if it should be formally care planned. The MDS Coordinator/RN confirmed the absence of a care plan for incontinence, which should have been in place according to the facility's policy. The facility's Incontinence Care Policy and Plan of Care and IDCP Team Meeting Policy required individualized care plans for all residents, reviewed and revised after each assessment. Despite these policies, the facility did not implement a care plan for Resident #134's incontinence, as evidenced by the lack of documentation in the electronic medical record system. The survey team informed the facility management of these findings, but no additional information or refutation was provided by the facility.
Non-Certified Nurse Aide Worked Beyond 120 Days Without Certification
Penalty
Summary
The facility failed to ensure that a non-certified Nurse Aide (NA) did not continue to work beyond the specified 120 days without completing the necessary training and certification. This deficiency was identified during a review of employee files, where it was found that NA #1 was hired on January 30, 2024, and terminated on June 11, 2024, exceeding the 120-day limit. The competency report skills test for NA #1 was dated July 27, 2023, indicating that the NA continued to work beyond the allowed period without completing the required certification. Interviews with the Business Office Manager (BOM) and the Director of Nursing (DON) revealed a lack of clarity and adherence to the policy regarding the employment of non-certified NAs. The BOM mentioned reviewing skills tests within 30-60 days, while the DON stated that NAs should be removed from the schedule if they do not pass the test within 120 days. However, the facility's policy, titled 'Nurse Aide Orientation,' did not include information about the requirement for certification within 120 days or the hiring process for non-certified NAs. This lack of a delineated policy contributed to the oversight in NA #1's employment duration.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) was posted in a prominent place accessible to residents and visitors. On two consecutive days, the surveyor observed that the NHRCSR was not posted in the entrance area of the facility. The receptionist confirmed that the reports were usually posted on the wall behind her but were missing, and the last time she saw them posted was the previous week. The Staffing Coordinator (SC) stated that she was responsible for posting the reports daily but was off the previous day and had issues with the printer. She mentioned that in her absence, a colleague should print the reports, and either the Director of Nursing (DON) or the Licensed Nursing Home Administrator (LNHA) would post them. The surveyor informed the LNHA, DON, and VP of Operations (VPoO) about the missing reports. The LNHA acknowledged the issue and stated that he would post the reports if they were not already posted, and staff were inserviced. The facility's policy requires that nurse staffing information be posted in a prominent place, be clear, readable, up-to-date, and reflect staff absences. The facility did not provide any additional information or corrective actions regarding the deficiency.
Unnecessary Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of Tamsulosin. The resident, who was admitted with diagnoses including type 2 diabetes, anemia, and gastritis with bleeding, was observed to have moderately impaired cognition and was always incontinent. Despite the absence of a diagnosis of benign prostatic hyperplasia (BPH), Tamsulosin was prescribed for overactive bladder, a use not approved by the manufacturer. The facility's documentation, including the resident's electronic medical record and physician's progress notes, showed inconsistencies regarding the resident's incontinence condition and lacked justification for the off-label use of Tamsulosin. The surveyor's investigation revealed that the facility's pharmacy consultant recommendations did not address the use of Tamsulosin for this resident. Interviews with the Licensed Practical Nurse/Unit Manager and the Consultant Pharmacist did not provide further clarification on the medication's use. Additionally, late entries in the physician's notes, created after the surveyor's inquiry, attempted to justify the medication's use but still failed to provide adequate documentation of its effectiveness or necessity. The facility's administrative team was unable to provide further documentation to resolve these inconsistencies, leading to the determination of a deficiency.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%, which exceeds the acceptable threshold of 5%. During an observation, a surveyor noted that a Licensed Practical Nurse (LPN) administered a 100 mg dose of Docusate to a resident without a specified dosage in the Electronic Medication Administration Record (eMAR). The LPN assumed the dosage based on the availability of the medication, which was not verified against the order. Additionally, the LPN signed for administering Enoxaparin, an injectable medication, without having administered it during the observation period, claiming it was given earlier. Another incident involved a different LPN who left a dose cup of oral medications unattended on a medication cart while administering other supplements to a resident in a common area. This action was against the facility's policy, which prohibits leaving medications unattended. The facility's policy also requires verification of the right medication, dosage, time, and method before administration, and mandates that the eMAR be signed immediately after administering each medication. The surveyor's review of the facility's policy and interviews with the consultant pharmacist and facility leadership confirmed these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. In the Pink Unit Medication Room, an unlabeled vial of Retacrit was found in the refrigerator, and a Novolin R Flex Pen was improperly stored outside the refrigerator. The Assistant Director of Nursing confirmed that the insulin pen should have been refrigerated and the Retacrit vial should have been labeled with the patient's information. Additionally, expired BD Viral transport tubes were found in the Pharmacy Room, and the temperature log for the refrigerator containing vaccines was not maintained according to CDC guidelines, as it was only recorded once per day instead of twice. On the Blue Unit, a foil package of Ipratropium/Albuterol nebulizer solution was found without a date of opening, despite manufacturer instructions to dispose of it one week after opening. The facility's Medication Administration Policy requires checking expiration dates and recording the opening date on multi-dose containers, but these procedures were not followed. The facility did not provide a policy for medication storage when requested by the surveyor, and the Director of Nursing, Licensed Nursing Home Administrator, and President of Operations were informed of these deficiencies.
Deficiency in Medical Record Maintenance and Incident Documentation
Penalty
Summary
The facility failed to maintain complete, available, and readily accessible medical records for three residents, leading to a deficiency. For Resident #196, the facility did not document evidence of de-escalation, redirection, or monitoring for safety after multiple incidents of aggressive behavior on the same day. Despite the resident's history of mental disorders and a BIMS score indicating cognitive intactness, the facility's records did not reflect adequate preventive measures or interventions following the incidents, including a resident-to-resident altercation. In the case of Resident #134, the facility did not maintain timely and accessible physician visit notes. The resident, who had a history of significant medical conditions including hypotension, cerebral infarction, and anxiety disorder, did not have documented physician visits every 60 days as required. The records showed only two notes from an APN over several months, and additional notes were only added to the chart after the surveyor's inquiry, indicating a lack of proper record-keeping. The facility's failure to maintain complete and accessible medical records was further highlighted by the delayed collection of staff statements related to the incidents involving Resident #196. The LNHA acknowledged that the statements were not gathered promptly, which was necessary for a thorough investigation. This lack of timely documentation and investigation contributed to the deficiency identified by the surveyors.
Infection Control Deficiencies in Catheter Care and Wound Treatment
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by several observations made by the surveyor. One incident involved improper storage of a urinary drainage bag for a resident with a urinary catheter. The drainage bag was observed resting on the resident's mattress instead of being positioned below the bladder level to allow for proper drainage. The CNA responsible for the resident's care acknowledged the mistake, stating that the drainage bag should have been placed in a privacy bag hanging on the side of the bed frame. The LPN and RN/UM also confirmed that the drainage bag should not have been on the mattress, even if the resident was being prepared for transfer. Another deficiency was observed during a wound treatment procedure performed by an LPN. The LPN failed to perform hand hygiene at critical points during the procedure, such as after removing gloves and before donning new ones. The LPN also applied soap before wetting her hands, contrary to the facility's hand hygiene policy. Additionally, the LPN exited the resident's room wearing a PPE gown, which should have been disposed of in the room before leaving. These actions were inconsistent with the facility's infection control policies and the CDC guidelines referenced in the facility's policy. The surveyor's observations highlighted a lack of adherence to established infection control protocols, including proper hand hygiene and PPE usage. The facility's policies clearly outlined the correct procedures for handwashing and the handling of PPE, yet these were not followed during the observed wound treatment. The LPN admitted to not following the correct hand hygiene sequence and acknowledged the error of wearing a PPE gown in the hallway. The Infection Preventionist confirmed the correct procedures and noted the deviations observed during the survey.
Failure to Maintain a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP) and worked at least part-time, as required by the NJ Executive Directive 21-012 and CMS QSO-22-19-NH Memo. The Licensed Nursing Home Administrator (LNHA) acknowledged that there was no IP in the facility from May 2023 until January 2024, during which time the Director of Nursing (DON) was responsible for the IPCP. The absence of an IP was noted during the entrance conference and subsequent interviews, where the LNHA admitted to ongoing but unsuccessful recruitment efforts for an IP. During the period without an IP, the facility's Quality Assurance and Performance Improvement (QAPI) meetings lacked the presence of an IP for two out of three quarters. The LNHA was unable to provide detailed information on infection control reports reviewed during these meetings, aside from COVID-19 statistics. The facility's policies on infection prevention and control, as well as the surveillance plan, outlined the responsibilities of the IP, which were not fulfilled due to the absence of a dedicated IP. The surveyor highlighted the concern that the full-time DON was handling the IP role, which should have been at least a part-time position.
Deficiency in Offering and Documenting Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was offered influenza and pneumococcal immunizations, and that education was provided regarding the benefits and potential side effects of these immunizations. Additionally, the facility did not document that residents or their representatives were given the opportunity to refuse these immunizations unless they were medically contraindicated or previously administered. This deficiency was identified for one of the five residents reviewed, specifically Resident #134, who had a moderately impaired cognition and a complex medical history including conditions such as hypotension, cerebral infarction, and chronic heart failure. The surveyor observed that there was no documentation in the electronic medical record (EMR) for Resident #134 regarding the offering or refusal of influenza and pneumococcal vaccines. The facility's records, including the Immunization tab and the personalized care plan, lacked evidence of any focus on immunization status or education provided to the resident or their representative. Interviews with the Registered Nurse Coordinator (RNC) and the Infection Preventionist Nurse (IPN) revealed inconsistencies and gaps in the facility's protocol for tracking and documenting immunizations, with no clear process for offering vaccines upon admission or during the flu season. Further investigation showed that the facility's policies and procedures for influenza and pneumococcal vaccinations were not effectively implemented. The IPN admitted to not tracking pneumococcal vaccinations and was unable to provide a tracking log for resident vaccinations. The facility's management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were informed of these findings, but no additional information or refutation of the findings was provided during the exit conference.
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.
Trusted data from CMS and state health departments
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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