Alaris Health At St Marys
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, New Jersey.
- Location
- 135 South Center Street, Orange, New Jersey 07050
- CMS Provider Number
- 315352
- Inspections on file
- 13
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Alaris Health At St Marys during CMS and state inspections, most recent first.
Surveyors identified that two residents did not have consistent documentation of required nursing treatments on the TAR, including wound care, skin care, and regular turning and repositioning. Multiple treatments were left blank across various shifts and dates, despite staff statements that documentation should be complete and accurate after each intervention.
Two residents with significant care needs had multiple instances where ADL care tasks such as personal hygiene, turning and repositioning, and continence care were not documented as completed across several months. Staff interviews confirmed that both CNAs and nurses were responsible for ADL documentation, and facility policy required complete and accurate records.
A resident who was cognitively intact and required assistance for mobility was discharged to a boarding home without the ordered VNS/PT/OT services being initiated. The Director of Social Services did not coordinate the required community services or follow the facility's discharge policy, and the resident's physician was not informed of the discharge location or the lack of services.
The facility failed to ensure smoking safety for a resident in a piped-in oxygen room, leading to an Immediate Jeopardy situation. Additionally, a ventilator-dependent resident was injured during an unsafe transfer due to inadequate staff presence. The facility also failed to effectively supervise a resident with a history of substance abuse, who was found with drug paraphernalia and tested positive for illicit substances.
A resident in a persistent vegetative state sustained a traumatic hematoma of the right eye, and the facility failed to conduct a thorough investigation into the injury. Discrepancies in staff statements and a lack of adherence to transfer protocols were identified. The Director of Nursing acknowledged miscommunication, and hospital records indicated a suspicion of elder abuse.
The facility failed to manage residents' Personal Needs Accounts (PNA) effectively, resulting in 21 residents having balances exceeding the $2,000.00 Medicaid eligibility threshold. Interviews revealed a lack of clear responsibility and communication between the Certified Social Worker, Business Office Manager, and Per Diem Social Worker, leading to inadequate oversight and management of PNA funds.
The facility did not have a Surety Bond to protect resident funds, affecting all residents with Personal Needs Accounts. The LNHA provided a Certificate of Liability Insurance instead, as instructed by corporate oversight. A review showed eighty-five resident accounts with a total balance of $84,036.27, and the LNHA could not confirm if funds were in interest-bearing accounts.
The facility failed to maintain an effective QAPI program, leading to deficiencies in resident safety. A resident was found smoking in their room despite a no-smoking policy, another resident with substance abuse issues was not adequately managed, and a third resident sustained an injury of unknown origin. The facility's QAPI program did not effectively review or address these incidents, and the Medical Director was not informed of critical safety concerns.
A resident with paralysis was unable to reach their call bell due to it being placed on the wrong side, despite requests for it to be moved. Observations confirmed the call bell was consistently placed out of reach, contrary to the resident's care plan and facility policy.
Two residents in an LTC facility did not receive appropriate incontinence and personal hygiene care. One resident was found with saturated briefs and a lack of specific care instructions, while another had untrimmed, dirty nails despite receiving morning care. The facility's management confirmed that staff were responsible for these care tasks.
A resident with Diabetes Mellitus experienced a delay in podiatry care, with a consult ordered in early December but not completed until mid-January. The resident was observed with dry, cracked skin and blackened areas on the feet, and was not wearing the prescribed pressure-relieving boots. The facility's policy for routine and emergency podiatry services was not followed, as the podiatrist was available weekly but the consultation was delayed by six weeks.
Two residents experienced a lack of dignified care in the facility. One resident was left without bed linens, pillows, or blankets, despite having severe cognitive impairment and needing assistance for mobility. Another resident reported that staff failed to empty urinals and did not respond promptly to call lights, with urinals found full during meal times. The facility's policies on dignity and respect were not adhered to, as observed by surveyors.
A resident with severe cognitive impairment was found with a hematoma and facial bruising, which was not reported by the CNA who observed it. The RN was informed five hours later by the resident's representative. The facility failed to notify the family or responsible party as required by policy, leading to a deficiency.
The facility failed to maintain safe handrails on the 3rd floor Dementia Unit, with multiple unsecured and cracked handrails observed. Despite being identified, the issues were not addressed promptly, and maintenance logs were incomplete. Maintenance staff acknowledged the problem but lacked a process to address it, and the facility had no specific policy for handrail maintenance.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care management. One resident was incorrectly coded as not being a smoker, despite evidence to the contrary. Another resident's discharge MDS was not completed in a timely manner, only being addressed after surveyor inquiry. These issues highlight lapses in the facility's process for updating resident records.
A resident was observed with medications left at their bedside, contrary to facility protocol, which requires nurse supervision during administration. The LPN admitted to leaving the medications unattended and failing to ensure they were taken. The resident was not assessed for self-administration capability, and the Comprehensive Care Plan lacked focus on this aspect. The facility's policy mandates safe and timely medication administration, with self-administration only allowed after proper assessment.
A facility failed to administer oxygen therapy according to a physician's order and did not ensure proper storage of oxygen equipment for a resident with multiple health conditions, including COPD and diabetes. The resident received oxygen at incorrect flow rates, and the nasal cannula was improperly stored, contrary to facility policy and physician orders. Staff interviews confirmed the discrepancies in oxygen administration and equipment storage.
A facility failed to ensure a resident had the cognitive ability to sign an arbitration agreement. The resident, who was legally blind and had severe cognitive impairment, was unable to understand or sign documents. Despite this, the arbitration agreement was signed without the involvement of a legally authorized representative. The facility's policy required that agreements be explained in a manner understandable to the resident or their representative, which was not followed.
The facility failed to prevent the spread of infection by not adhering to PPE protocols for residents on contact precautions. A RN/UM and a RD entered the rooms of two residents with C. Auris colonization without donning the required gowns and gloves, despite clear signage and prior training. Both residents had severe medical conditions necessitating contact precautions.
Failure to Consistently Document and Provide Nursing Treatments on TAR
Penalty
Summary
The facility failed to ensure that nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficiency was identified for two residents who required multiple treatments and interventions, including topical ointments for wound prevention and care, skin care, use of gel cushions and heel lifts, and regular turning and repositioning. Review of the TARs for these residents over several months revealed multiple instances where required treatments were not documented as completed, with blank entries noted for various shifts and dates. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, the TAR showed missing documentation for several treatments such as application of Boudreaux's butt paste ointment, Lac-Hydrin lotion, turn and reposition every two hours, gel cushion placement, heel lifts, vitamins A and D ointment, zinc oxide cream, and pressure-relieving mattress checks. These omissions occurred across multiple dates and shifts, indicating a pattern of incomplete documentation for essential nursing interventions. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had missing documentation for required turning and repositioning on several occasions. Interviews with the Unit Manager and Director of Nursing confirmed that nurses were expected to document treatments on the TAR after completion, and that documentation should be objective, complete, and accurate as per facility policy. However, the review of records demonstrated that this standard was not consistently met.
Failure to Consistently Document ADL Care Provided to Residents
Penalty
Summary
The facility failed to consistently document the provision of Activities of Daily Living (ADL) care for two residents who required assistance. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, multiple blank entries were found in the ADL documentation forms over several months. These blank entries indicated that tasks such as personal hygiene, turning and positioning every two hours, bladder and bowel continence care, rolling left and right, and use of a preventative mattress were not documented as completed on numerous shifts across June, July, and August. The resident was assessed as cognitively intact, and the documentation gaps were identified through a review of the resident's medical records and documentation survey reports. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had multiple blank spaces in their ADL documentation forms. These omissions included personal hygiene, turning and repositioning, bladder and bowel continence care, rolling left and right, and use of a preventative mattress, with missing documentation noted on various day, evening, and night shifts. The review of documentation for this resident covered the months of June and July, with similar patterns of incomplete records for required care tasks. Interviews with staff revealed that CNAs were responsible for turning and positioning residents who were incontinent and in bed, and that nurses provided reports to CNAs identifying which residents required this care. The Director of Nursing (DON) confirmed that if care was not documented, it was considered not done, and stated that both nurses and CNAs were responsible for completing ADL documentation. The DON also indicated that the Assistant Director of Nursing (ADON) and nurse manager were tasked with auditing ADL documentation for completion. Facility policy required that documentation in the medical record be objective, complete, and accurate.
Failure to Coordinate Discharge Services and Follow Discharge Policy
Penalty
Summary
The facility's Director of Social Services (DSS) failed to assist a resident in obtaining needed community services and did not follow the facility's Discharge Policy. The resident, who was cognitively intact and required supervision or assistance for mobility, had a care plan indicating a wish to be discharged home with arrangements for community resources such as home care, PT/OT, and nursing services. Physician orders were in place for discharge to home with VNS/PT/OT services. However, the resident was instead discharged to a boarding home, and there was no documentation of discussions with the resident or family about this change prior to discharge. The DSS admitted that the ordered VNS/PT/OT services were not initiated and expressed uncertainty about which facilities could accommodate these services, citing unfamiliarity with the area. The resident's physician was not informed of the discharge to a boarding home and confirmed that the ordered services were not provided. The facility's policies and the DSS job description require coordination of discharge planning and provision of medically related social services, which were not followed in this case.
Deficiencies in Smoking Safety, Resident Transfer, and Substance Abuse Supervision
Penalty
Summary
The facility failed to ensure effective interventions for a resident who was identified as a smoker and resided in a piped-in oxygen room. Despite the facility's smoking safety policy, the resident was observed smoking inside their room, creating an Immediate Jeopardy situation. The resident's room contained smoking materials within reach, and the facility's staff, including the security guard and social worker, were not adequately informed or updated about the resident's smoking status. The resident's smoking assessment was incomplete, and the smoking agreement contract was unsigned, indicating a lack of proper documentation and monitoring. Another deficiency involved the unsafe transfer of a ventilator-dependent resident who sustained a traumatic hematoma to the right eye and required hospitalization. The facility failed to ensure that two staff members were present during the transfer, as required for residents dependent on mechanical lifts. The investigation into the incident was not thorough, with discrepancies in staff statements and a lack of clarity on the cause of the injury. The facility's policy for transferring residents with ventilators was not provided, and the incident was not adequately investigated as a potential abuse incident. Additionally, the facility failed to provide effective interventions and supervision for a resident with a history of substance abuse. The resident was found with drug paraphernalia and tested positive for illicit substances on multiple occasions. Despite being placed on one-to-one supervision and having room searches initiated, the resident continued to access and use illicit drugs. The facility's documentation of monitoring was incomplete, and the interventions were insufficient to prevent the resident from obtaining illegal substances.
Removal Plan
- The resident's room was searched and smoking material was removed from the room.
- Resident's representative party was re-educated about the smoking policy and that any smoking material needed to be handled directly to the security guard or staff.
- A new smoking contract was completed with Resident #143 and responsible party.
- IDT team met to discuss resident's smoking plan of care.
- Physician's orders were added to Medication Administration Record for room search for any smoking material.
- All department heads and Unit Managers were in-serviced on smoking procedures by the Director of Nursing.
- Smoking policy was revised.
- Smoking list was updated to reflect all current smokers in the building.
- Smoking contract was revised.
- All current smokers had a new smoking assessment completed.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough and complete investigation into an injury of unknown origin sustained by a resident in a persistent vegetative state, who was dependent on staff for all care and required a mechanical ventilator for breathing. The resident was found with a hematoma and ecchymosis on the right side of the face, and was subsequently diagnosed with a traumatic hematoma of the right eye. The investigation into the incident was inadequate, as it did not identify a causal factor for the injury, and there were discrepancies in the statements provided by the staff involved. The investigation revealed inconsistencies in the accounts of the staff members who were responsible for the resident's care on the day of the incident. CNA #1 provided two conflicting statements regarding the timing and circumstances of the injury, and CNA #2, who was claimed to have assisted with the transfer, denied being involved. The RN on duty did not notice any changes during her rounds and was only informed of the injury by the resident's family member. The Respiratory Therapist confirmed that proper protocol for transferring a ventilator-dependent resident was not followed, as there was no documented evidence of assistance from a nurse or RT during the transfer. The Director of Nursing acknowledged the discrepancies in the investigation and admitted to a misunderstanding and miscommunication regarding the incident. The facility's Abuse Prevention Program requires that all injuries of unknown origin be investigated as potential abuse incidents, but the investigation failed to meet this standard. The Medical Director was informed that the injury was caused by the mechanical lift, but no additional information was provided. The hospital records indicated a suspicion of elder abuse, highlighting the severity of the oversight in the facility's investigation.
Failure to Manage Resident Personal Needs Accounts
Penalty
Summary
The facility failed to ensure that residents with Personal Needs Accounts (PNA) were notified when their account balances approached the limit that could jeopardize their eligibility for Medicaid or Supplemental Security Income (SSI). This deficiency was identified for all residents maintaining PNAs at the facility. A review of the Funds Balance Report revealed that 21 residents had PNA funds ranging from $1,852.93 to $3,997.38, exceeding the $2,000.00 threshold for Medicaid eligibility. Interviews with the Certified Social Worker (CSW) and the Business Office Manager (BOM) indicated a lack of clear responsibility and communication regarding the management of these accounts. The CSW stated that the business office handled the PNA, and the BOM confirmed that the list of residents with PNA was reviewed monthly, but there was no effective system in place to ensure funds were spent down appropriately. Further interviews with the Per Diem Social Worker (PDSW) revealed that she was not regularly involved in managing the PNA accounts and only received the list of accounts with balances over $2,000.00 on the day of the surveyor's inquiry. The PDSW acknowledged that the list had not been addressed and that funds should be spent down when approaching $1,800.00. The facility administration was unable to provide additional information regarding the PNA balances, indicating a systemic issue in managing resident funds and ensuring compliance with Medicaid eligibility requirements.
Failure to Secure Resident Funds with Surety Bond
Penalty
Summary
The facility failed to ensure the security of all personal funds of residents deposited with the facility by not having a Surety Bond in place. This deficiency affected all residents who maintained a Personal Needs Account with the facility. During the survey, the Licensed Nursing Home Administrator (LNHA) provided a Certificate of Liability Insurance, which included coverage for crime and burglary, instead of a Surety Bond. The LNHA stated that this was the document provided by corporate oversight. A review of the Funds Balance Report revealed that there were eighty-five active resident accounts with a total balance of $84,036.27. When questioned about whether the residents' funds were kept in interest-bearing accounts, the LNHA was unable to provide this information and confirmed that the facility used the Certificate of Liability as their documentation, as instructed by corporate management.
Deficiencies in QAPI Program and Resident Safety
Penalty
Summary
The facility failed to maintain an effective comprehensive data-driven Quality Assurance and Performance Improvement (QAPI) program by not reviewing all services provided, including significant events, to determine root causes and prevent further occurrences. This deficiency was evident in several incidents involving residents with a history of smoking in their rooms, possession of drug paraphernalia, and an injury of unknown origin. Specifically, a resident with a history of smoking in their room was found with cigars and a lighter despite the facility's smoking policy prohibiting smoking in rooms, especially with piped-in oxygen present. Another resident with a history of substance abuse was found with drug-related equipment and tested positive for multiple substances, including cocaine and opiates. The facility failed to adequately address the resident's substance abuse issues, and the Medical Director was not informed of the resident's condition or the presence of smoking materials, which could pose a significant fire risk. The facility's QAPI program did not effectively manage or review these incidents, as evidenced by the lack of documentation and follow-up on the substance abuse and smoking issues. Additionally, a resident who was dependent on staff for all care sustained an injury of unknown origin that required hospitalization. The investigation into the injury was not thorough, with discrepancies in staff statements and a lack of clarity on the cause of the injury. The facility's QAPI program did not adequately review or address this significant event, and the Licensed Nursing Home Administrator acknowledged the investigation was not concise or thorough. The failure to maintain an effective QAPI program had the potential to affect all residents in the facility.
Removal Plan
- Assess and care plan for all current smokers
- Ensure awareness of the facility smoking policy among residents and staff
- Ensure residents who smoke do so safely
- Address resident non-compliance
- Identify residents needing frequent monitoring
- Educate resident responsible parties on the facility smoking policy
- Implement a program to identify and manage substance abuse
- Reduce incidents of substance abuse
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible and within reach, as evidenced by multiple observations on different dates. Resident #43, who was paralyzed from a stroke and unable to move their right arm, repeatedly had their call bell placed on their right side, which they could not reach. Despite the resident's requests to have the call bell placed on their left side, where they had some mobility, staff continued to place it on the right side. This was observed by the surveyor on three separate occasions, and the resident confirmed their inability to use the call bell when it was placed on the right side. The resident's medical records indicated a diagnosis of paraplegia and muscle weakness, with a care plan that required the call bell to be within reach. Interviews with facility staff, including a CNA and an RN, revealed a misunderstanding of the resident's abilities, as the CNA believed the resident could use their right side, while the RN confirmed the resident's inability to use the call bell when placed on the right side. The facility's policy required call bells to be accessible for communication, yet this was not adhered to, leading to the deficiency.
Deficient Incontinence and Personal Hygiene Care
Penalty
Summary
The facility failed to provide appropriate incontinence care and personal hygiene for two residents. Resident #33 was observed in bed with a strong urine odor in the room, indicating that they had not been changed since the previous night. The resident was found wearing two saturated incontinent briefs, and the care plan did not specify the frequency of care or repositioning. The CNA responsible for the resident had not provided care since starting her shift, and the resident's care plan lacked specific instructions for incontinence management. Resident #8 was observed with long, jagged nails and a yellow substance underneath, despite having received morning care. The resident, who was on hospice and required extensive assistance for ADLs, did not have a care plan addressing ADL self-care performance deficits. The hospice aide stated that she was not allowed to trim the resident's nails, and the responsibility fell to the CNAs. The facility's management acknowledged that staff were responsible for providing nail care.
Delayed Podiatry Care and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to provide timely podiatry care for a resident who had a podiatry consult ordered on December 4, 2024, but the consultation was not completed until January 20, 2025. During this period, the resident, who had a diagnosis of Diabetes Mellitus and was at risk for endocrine complications, was observed with dry, cracked skin on both feet and blackened areas on the right heel and the ball of the left foot. The resident was also not wearing the prescribed pressure-relieving boots, which were ordered to be worn every shift starting December 11, 2024. The surveyor's observations and interviews with the LPN Unit Manager revealed that the podiatrist was available weekly, yet the consultation was delayed by six weeks. The LPN confirmed the resident was supposed to wear heel protectors, but they were not in use during the surveyor's visits. The facility's Podiatry Services Policy, which mandates routine and emergency podiatry services, was not adhered to, as evidenced by the delay in consultation and the lack of adherence to the physician's orders for pressure relief boots.
Failure to Maintain Dignity and Hygiene for Residents
Penalty
Summary
The facility failed to provide a dignified environment for two residents, as observed by surveyors. Resident #113 was found in their room without bed linens, pillows, or blankets on multiple occasions. The resident, who had severe cognitive impairment and required assistance for mobility, was left in a bed stripped of linens after it was soiled, and the Certified Nurse Aide (CNA) did not return promptly to address the situation. The Registered Nurse Unit Manager acknowledged the issue as a dignity concern but did not provide a satisfactory explanation for the delay in addressing the resident's needs. Resident #91 expressed concerns about the staff's failure to empty urinals, which were observed to be almost full and hung on the footboard of the bed. The resident, who was alert and oriented, reported that the night shift staff did not empty the urinals and did not respond promptly to call lights. The Quality Assurance CNA confirmed that the norm was to check residents and provide care before breakfast, but the urinals were still found full during meal times. The Unit Manager acknowledged that staff should have emptied the urinals before serving meals. The facility's policies emphasize the importance of treating residents with dignity and respect, ensuring their comfort and quality of life. However, the observations and interviews revealed a failure to adhere to these policies, resulting in a lack of dignified care for the residents involved. The issues were presented to the facility administration, but no further information was provided regarding corrective actions.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family or responsible party when a resident experienced a change in condition that required transport to the emergency room. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found by a resident representative with a hematoma to the right eye and ecchymosis to the facial area. The incident was not reported by the Certified Nursing Assistant (CNA) who observed the bruise after transferring the resident to bed, and it was only brought to the attention of the Registered Nurse (RN) five hours later by the resident representative. The resident's medical records did not document the presence of the bruise or hematoma prior to the resident representative's report, and there was no record of how the injuries were acquired. The facility's policy required immediate notification of the resident's family or legal representative in such cases, but this was not adhered to. The Director of Nursing (DON) classified the incident as significant and reported it to the Department of Health, but discrepancies in staff statements were noted, and the DON chose not to ask staff to amend their statements. The resident was transferred to the hospital and diagnosed with a traumatic hematoma of the right orbit. The failure to notify the family or responsible party of the resident's condition change and the delay in reporting the incident by the CNA contributed to the deficiency. The resident representative expressed concerns about not being informed of the incident before discovering the bruise, and the resident was subsequently transferred to another facility.
Failure to Maintain Safe Handrails on Dementia Unit
Penalty
Summary
The facility failed to maintain safe handrails on one of its resident units, specifically the 3rd floor, which is a Dementia Unit. During a surveyor's tour, multiple instances of unsecured and cracked handrails were observed outside various rooms and areas, including the soiled linen room and a telephone out cove. The maintenance worker confirmed that the handrails were not safe or secure and acknowledged that maintenance staff was responsible for checking them. Despite the issues being identified, the handrails remained in the same condition the following day, indicating a lack of timely repair. The maintenance log for the 3rd floor showed only two entries from before the surveyor's observations, with no entries on the day the handrails were identified as needing repair. The RN/UM stated that she had entered the handrails into the maintenance log, but pages related to the handrails appeared to have been removed. Maintenance staff admitted that residents frequently tear out the handrails and acknowledged the absence of a process to address this issue. The facility lacked a specific policy or procedure for handrail maintenance, although a general maintenance policy was provided. The concerns were presented to the facility administration.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the management of their care. For one resident, the MDS was incorrectly coded as not being a current tobacco user, despite evidence from the resident's care plan and direct observation that the resident was a smoker. The MDS Coordinator acknowledged the oversight, stating that the resident should have been coded as a smoker in the MDS. This discrepancy was identified during a surveyor's review of the resident's medical records and confirmed through an interview with the MDS Coordinator. For another resident, the facility failed to complete a discharge MDS in a timely manner. The resident was discharged home, but the most recent MDS on record was an admission assessment dated prior to the discharge. The discharge MDS was only completed after the surveyor's inquiry, indicating a lapse in the facility's process for updating resident records. The facility's policy requires MDS assessments to be completed at specific intervals, including upon discharge, but this was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication in accordance with the physician's order and professional standards of nursing practice. During an initial tour, a surveyor observed a resident sitting in a wheelchair with a medication cup containing five tablets on the bedside table. Additionally, five vials of albuterol sulfate were also present. The nurse responsible for administering the medication was observed at the other end of the hallway, and the medications were identified as colace, Steglator, lasix, potassium chloride, and metoprolol. The resident informed the surveyor that nurses would leave the medication at the bedside for them to take with meals, although the breakfast meal had been delivered earlier. The Unit Manager Registered Nurse confirmed that the resident was not assessed as capable of self-administering medication, and the nurse should have ensured the medication was taken before leaving the room. The Licensed Practical Nurse admitted to leaving the medications at the bedside and forgetting to return to ensure they were taken, acknowledging that this was against facility protocol. A review of the resident's records showed no assessment for self-administration of medication, and the Comprehensive Care Plan did not reflect a focus on this. The Physician Order Sheet included orders for various medications, but the electronic medication administration record indicated that the LPN documented the medications as administered, despite them being left on the bedside table. The facility's policy stated that medications should be administered safely and timely, and residents could only self-administer if assessed and approved by the Interdisciplinary Care Team and the attending physician.
Failure to Administer Oxygen Therapy as Ordered and Improper Equipment Storage
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of oxygen equipment for a resident. During an initial tour, a surveyor observed a resident receiving oxygen at 5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 4 LPM. The nasal cannula was improperly stored, being wrapped around the wheelchair handle and exposed to the environment. On a subsequent observation, the resident was on 4 LPM, but the nasal cannula was again improperly stored, in contact with the resident's socks and not in a protective covering. The resident in question was admitted with multiple health conditions, including pneumonia, anemia, chronic obstructive pulmonary disease (COPD) with exacerbation, and type 2 diabetes mellitus. The resident's medical records indicated a physician's order for oxygen therapy at 4 LPM, which was not consistently followed. Additionally, the resident's care plan included instructions for oxygen therapy related to shortness of breath and congestive heart failure, with interventions to administer oxygen as ordered. Interviews with facility staff revealed a lack of adherence to physician orders and proper storage protocols for oxygen equipment. A registered nurse acknowledged the discrepancy in oxygen administration and improper storage of the nasal cannula. The Assistant Director of Nursing confirmed that oxygen equipment should be stored in a special plastic bag when not in use, which was not done in this case. The facility's revised oxygen therapy policy also emphasized the importance of following physician orders and proper storage of equipment, which was not adhered to in this instance.
Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign arbitration agreements, as evidenced by the case of a resident who was legally blind and had severe cognitive impairment. The resident, identified as Resident #61, was observed by a surveyor to be unresponsive and unable to see. The resident's representative confirmed that the resident was legally blind and unaware of any arbitration agreement, stating that the resident was not capable of signing any documents. A review of the resident's records showed a diagnosis of legal blindness, brief psychotic disorder, and cerebral infarction, with a Brief Interview for Mental Status (BIMS) score of 02 out of 15, indicating severe cognitive impairment. The facility's Admissions Director stated that it was her responsibility to provide the Voluntary Binding Arbitration Agreement (VBAA) to residents and/or their families, ensuring they understood the agreement. She mentioned that a BIMS score of 13 or higher was required for a resident to sign such agreements, acknowledging that a score of 02 was insufficient for understanding. Despite this, the VBAA was signed by the resident without the involvement of a legally authorized representative. The facility's policy required that the arbitration agreement be explained in a manner understandable to the resident or their representative, which was not adhered to in this case.
Failure to Adhere to PPE Protocols for Contact Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not donning Personal Protective Equipment (PPE) before entering the rooms of residents on contact precautions. This deficiency was observed in two instances. In the first instance, a Registered Nurse Unit Manager (RN/UM) entered the room of a resident with a diagnosis of C. Auris colonization without wearing a gown or gloves, despite signage indicating the need for contact precautions. The RN/UM acknowledged the oversight when questioned by the surveyor. The resident had severe cognitive impairment and was on contact precautions due to C. Auris colonization. In the second instance, a Registered Dietitian (RD) was observed inside the room of another resident on contact precautions, handling a tube feeding bottle without wearing the required PPE. The RD admitted to not following the contact precaution signage. This resident also had a diagnosis of C. Auris and CPO colonization. Both staff members had previously received training on the proper use of PPE, yet failed to comply with the facility's infection control policy, which mandates the use of gowns and gloves for all entries into rooms of residents on contact precautions.
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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