Allaire Rehab & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Freehold, New Jersey.
- Location
- 115 Dutch Lane Road, Freehold, New Jersey 07728
- CMS Provider Number
- 315387
- Inspections on file
- 18
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Allaire Rehab & Nursing during CMS and state inspections, most recent first.
Surveyors found that the nourishment room was not maintained in a sanitary condition, with misaligned cabinet doors, stained ice maker grates, an empty paper towel dispenser, and a dirty microwave. Staff interviews revealed unclear cleaning responsibilities and infrequent cleaning, despite facility policy requiring monthly cleaning and audits.
A deficiency was cited for not ensuring that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by anyone in the facility.
The facility did not manage its operations to ensure effective and efficient use of resources, as required by regulatory standards.
A nurse left oral medications unattended at the bedside of a cognitively intact resident with ALS and other conditions, contrary to facility policy and professional standards. The LPN stated she was waiting for pudding to administer the medications, but both the UM and DON confirmed that medications should not be left at the bedside and must be documented as refused if not taken.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A resident with significant neurological impairment and pain management needs was discharged with unused Tramadol remaining in the facility. The required destruction of this controlled medication was not properly documented, as the signatures and dates confirming destruction and witnessing by two licensed staff were missing from the controlled drug record, contrary to facility policy and regulatory requirements.
The facility conducted unauthorized searches of all residents' rooms for drugs without obtaining proper consent, violating their rights to dignity and respect. Two residents reported feeling harassed by the searches, which were conducted based on suspicion and probable cause. Despite claims of verbal consent, there was no signed documentation to support this, and law enforcement was not involved during the searches.
The facility failed to ensure cleanliness in medication and treatment carts, with observations revealing dust, debris, and sticky substances in various carts. Staff, including LPNs and RNs, were unclear about the cleaning schedule, and the Unit Manager and Administrator confirmed the carts were dirty. The facility's policy recommended monthly cleaning, but there was confusion about responsibilities between nursing and housekeeping staff.
The facility did not conduct annual performance reviews for several staff members, as required by its policy. Personnel records for a Unit Manager, Companion Aid, Housekeeping staff, Director of Rehabilitation, and a CNA showed no evidence of completed evaluations. The Director of Clinical Operations confirmed that performance reviews were halted, leading to staff dissatisfaction.
A resident's right to unrestricted visitation was violated when the facility enforced a policy limiting visiting hours from 8:00 AM to 8:00 PM, requiring prior permission for visits outside these hours. A family member was initially restricted from visiting before 8:00 AM, despite the resident's admission rights allowing visits at any time. The facility's administrator cited past disturbances as justification for the policy, but it did not align with the resident's rights.
The facility failed to provide complete and accurate SNF ABNs for two residents, omitting estimated costs and leaving options sections blank. The Social Services Director was unaware of the need to document costs and did not follow up with a resident's representative to ensure completion of the ABN.
A resident's privacy curtain was observed to be stained and unchanged over several days, contrary to the facility's cleaning policy. Staff interviews revealed confusion about responsibility for curtain maintenance, with the housekeeping director eventually confirming it was their duty, though he was unaware of the issue.
A resident's grievance regarding inadequate gastrostomy (g-tube) care was not promptly resolved by the facility. Despite family complaints and photographic evidence of improper care, including leaking and undated dressings, the facility failed to update care orders. Interviews revealed that the Social Services Director and an LPN did not ensure necessary changes were made, leaving the resident at risk for infection and diminished quality of life.
A resident with a history of substance abuse experienced an overdose at the facility. The facility failed to assess the resident's risk for substance abuse, develop a comprehensive care plan, or increase monitoring and supervision after the incident. Despite the overdose, there was no evidence of staff education on substance use signs or encouragement for the resident to attend NA meetings.
A resident with a gastrostomy tube did not receive appropriate care as per physician orders, leading to a build-up of matter on the tube and site. The LPN reported that care was provided by the previous shift, but observations showed otherwise. The DON confirmed the expectation to follow orders, indicating a deficiency in care practices.
A justice-involved individual in an LTC facility was denied autonomy and dignity, as they were secluded by correction officers, shackled, and restricted from participating in group activities or community dining. Despite being cognitively intact, the resident's care plan included minimal interactions and required CO approval for activities. Facility staff followed correctional facility protocols, leading to a violation of the resident's rights.
A Justice Involved Individual in a LTC facility was denied the right to retain personal possessions and live in a homelike environment. The resident was secluded by correction officers, restricted from participating in group activities, and served meals without dignity. Despite having intact cognition and requiring assistance with personal care, the resident's preferences for daily routines were not honored due to correctional restrictions.
A Justice Involved Individual in an LTC facility was denied the right to make choices about their care and participate in activities due to restrictions imposed by correction officers. Despite being cognitively intact, the resident was confined to their room, guarded, and not allowed to engage in social interactions or community dining. The facility failed to implement its policies on resident rights, leading to an Immediate Jeopardy situation.
A Justice Involved Individual in an LTC facility was involuntarily secluded by correction officers, restricting their autonomy and participation in activities. Despite having no cognitive impairments or behaviors requiring restraints, the resident was confined to their room, only leaving for showers and therapies under supervision. Facility staff followed correctional guidelines, limiting the resident's interaction and participation, contrary to facility policies on resident rights.
A resident, identified as a Justice Involved Individual, was admitted to the facility with metal ankle shackles applied daily by correction officers, leading to an Immediate Jeopardy situation. The facility's records lacked documentation or consent for the use of restraints, and care plans did not address the need for constant supervision or movement restrictions. Interviews with staff confirmed the routine use of shackles, and facility leadership agreed to follow correctional guidelines despite policies against such restraints.
A Justice Involved Individual admitted to the facility was subjected to seclusion and physical restraints by correction officers, violating resident rights. Despite being cognitively intact, the resident was shackled and unable to participate in activities or interact with others. Facility staff acknowledged that these restrictions were imposed by correctional officers, not the facility, leading to a deficiency in upholding resident rights.
Failure to Maintain Sanitation and Cleanliness in Nourishment Room
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation in the nourishment room, which was found to be in disrepair. Specifically, the cabinet doors were misaligned and had not been reported to Maintenance, stains were present on the grates of the ice maker, and the paper towel dispenser was empty with a roll of paper towels placed on top of the refrigerator. The microwave contained brown debris on the bottom, and the Unit Manager was unsure of the cleaning frequency, stating that either a CNA or nurse would clean it if there was a mess. Additionally, paint chips and peeling paint were noted around the soap dispenser. Interviews with staff revealed that the nourishment room was scheduled to be cleaned once a month by the porter, and additional cleaning would occur if staff reported a need. The Director of Housekeeping confirmed that the ice maker grates should be cleaned during the monthly cleaning, and the cleaning log indicated the room was last cleaned at the beginning of the month. The Director of Nursing acknowledged that the microwave was not assigned to anyone's responsibility and should be cleaned if dirty. The facility's cleaning policy required monthly cleaning and completion of an audit sheet, but the observed conditions indicated these standards were not consistently met.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility did not meet the required standards for resource management as outlined in regulatory guidelines. No specific details regarding individual residents, staff actions, or particular events leading to this deficiency are provided in the report excerpt.
Medications Left Unattended at Bedside by LPN
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications according to professional standards and facility policy for a resident diagnosed with Amyotrophic Lateral Sclerosis (ALS), hypertension, mood disorder, and anxiety disorder. The resident, who was cognitively intact, had active physician orders for several oral medications, including a neuromuscular agent that required administration on an empty stomach. During a survey, the resident was observed in bed with six pills left in a medicine cup at the bedside while being fed lunch by a caretaker. The nurse responsible for the resident admitted to leaving the medications at the bedside, stating she was waiting for pudding to administer the medications, despite knowing this was against facility policy. Facility policy clearly states that medications must be administered in a safe and timely manner, as prescribed, and should not be left at the bedside. Both the Unit Manager and the Director of Nursing confirmed that leaving medications at the bedside is not permitted and that the expectation is to document medications as refused if not taken. The nurse's action of leaving the medications unattended at the bedside was not in accordance with the facility's medication administration policy and professional standards of nursing practice.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Document Destruction of Controlled Medication
Penalty
Summary
A deficiency was identified when a facility failed to ensure the proper destruction and documentation of a controlled medication for a resident who was no longer present at the facility. The resident, who had diagnoses including anoxic brain damage and required a gastrostomy tube, was on a scheduled pain management regimen that included Tramadol, a controlled substance. Upon review of the resident's records, it was found that although 30 tablets of Tramadol were received and only six were administered, the required documentation for the destruction of the remaining 24 tablets was incomplete. Specifically, the section of the Individual Patient's Controlled Drug Record (IPCDR) for documenting the destruction—'destroyed by,' 'witnessed by,' and 'date'—was left blank. Interviews with facility staff confirmed that the destruction of controlled substances should be witnessed by two licensed staff members and properly documented, as outlined in the facility's own policy. The DON acknowledged that although the medication was placed in the drug destruction system, the required signatures and documentation were not completed due to being called away for a rapid response. The Assistant DON also confirmed that the declining inventory sheet should have been signed after destruction. This failure to follow established procedures resulted in a lack of accountability for the controlled medication as required by state and federal regulations.
Facility Conducts Unauthorized Room Searches, Violating Resident Rights
Penalty
Summary
The facility failed to protect the residents' rights to be treated with respect and dignity by conducting searches of all 136 residents' rooms for drugs, including marijuana, without properly obtaining informed consent for two residents. The searches were conducted on multiple occasions, with the first full facility search occurring after a resident was found with a bottle of pills belonging to another resident. The facility's policy allowed for room searches based on suspicion and probable cause, but there was no documented evidence of consent from all residents, nor was law enforcement involved during the searches. Resident #105 reported feeling harassed by the weekly searches, which triggered flashbacks of living on the street. The resident had a fully intact cognition and was diagnosed with amyotrophic lateral sclerosis, anxiety disorder, and unspecified mood disorder. Despite the facility's claim that the resident verbally agreed to the searches, there was no signed documentation to support this consent. Resident #65 also expressed concerns about the searches, stating that their room had been searched multiple times without their consent. The resident, who was cognitively intact, had refused to sign the facility's policies related to forbidden items and drug possession. The facility claimed that the resident consented to the search when approached, but there was no signed documentation to confirm this. The searches resulted in the discovery of marijuana vapes and other contraband in the resident's room.
Removal Plan
- Room searches will not be conducted for any resident without suspicion or probable cause.
- The resident must be assessed, the care plan updated to reflect the findings of the assessment, and a written consent must be obtained from the resident.
- If the resident/representative does not consent, a room search cannot be completed.
- All staff were educated on the updated facility's drug policy.
Medication and Treatment Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in four medication storage carts and three treatment supply carts, as observed during a survey. The carts were found to have dust, debris, and residue, which could potentially contaminate resident medications and treatment supplies. The facility's policy recommended cleaning the carts at least once a month and as needed, but there was a lack of clarity among staff regarding the frequency of cleaning. During interviews, several staff members, including LPNs and RNs, were unsure about the cleaning schedule, and some carts were found to be dirty despite recent checks. Observations revealed that the medication carts in various areas of the facility, including the annex, first floor North and South Halls, and the third floor, had significant dust, debris, and sticky substances. The treatment carts also had similar issues, with dust, paper, and loose screws found inside the drawers. The Unit Manager and Administrator confirmed the carts were dirty and acknowledged that there was confusion about the cleaning responsibilities, with nurses expected to clean the carts and housekeeping responsible for cleaning them once emptied.
Failure to Conduct Annual Performance Reviews
Penalty
Summary
The facility failed to conduct performance reviews every 12 months for five out of seven employees whose personnel records were reviewed. The facility's policy, revised in November 2023, mandates annual performance appraisals to discuss, plan, and review employee performance. However, the personnel records of several staff members, including a Unit Manager, Companion Aid, Housekeeping staff, Director of Rehabilitation, and a Certified Nursing Aide, showed no documented evidence of performance evaluations being completed. These evaluations are crucial for assessing employee performance and contributions. During an interview, the Director of Clinical Operations acknowledged the absence of performance reviews, stating that this has led to dissatisfaction among staff, with some quitting or requesting raises. The Director mentioned that performance evaluations were officially stopped in July 2024, and this issue is scheduled for discussion in the next corporate meeting. The lack of performance reviews is a violation of the facility's policy and the New Jersey Administrative Code (NJAC 8:39-43.17(b)).
Violation of Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to uphold a resident's right to receive visitors of their choosing at any time, as evidenced by the case of a resident who was restricted from having family visits before 8:00 AM. The facility's policy, which limited visiting hours from 8:00 AM to 8:00 PM, required visitors seeking access outside these hours to obtain prior permission and restricted them to designated supervised areas. This policy was not aligned with the resident's rights as outlined in the New Jersey Admission Packet, which allowed for visits at any time, provided they did not interfere with care or the privacy of other residents. The deficiency was highlighted when a family member of the resident attempted to visit before 8:00 AM and was initially informed by a security officer that staff had complained about early visits. Despite this, the security officer allowed the visit, as there was no direct instruction from the administration to deny access. The resident's roommate expressed no concerns about the family member's visits and appreciated their presence, indicating that the visits did not disturb them. The facility's administrator acknowledged the existence of a visiting hours policy and stated that 24-hour visits were still possible but required scheduling and supervision if they occurred outside the designated hours. The administrator cited past disturbances caused by visitors as a reason for the policy, aiming to ensure a safe and restful environment for all residents. However, the policy's implementation did not adequately consider the individual rights of residents to have unrestricted access to visitors, as guaranteed by their admission rights.
Incomplete SNF ABN Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was complete and accurate for two residents prior to their discharge from Medicare Part A skilled services. For Resident #12, the ABN indicated that skilled care was no longer required as of 04/02/24, but the estimated cost section was left blank. This omission meant that the resident was not fully informed about potential out-of-pocket expenses for continued care. Similarly, for Resident #57, the ABN indicated that skilled care was no longer required as of 09/17/24, and the estimated cost section was also left blank. Additionally, the options section, which allows the resident or their representative to choose how to proceed with care and billing, was not completed. During an interview, the Social Services Director (SSD) admitted to not being aware of the requirement to document the estimated cost on the ABN form. Furthermore, the SSD acknowledged that although a note was sent to Resident #57's representative, there was no follow-up to ensure the representative completed the options section of the ABN. This lack of follow-up and incomplete documentation placed the residents and their representatives at risk of not being fully informed about their potential financial liabilities.
Failure to Maintain Clean Privacy Curtains
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident by not ensuring that the privacy curtain in the resident's room was clean and unstained. The facility's policy on cleaning and disinfection of environmental surfaces, revised in January 2021, states that window/privacy curtains in resident areas should be cleaned when visibly contaminated or soiled. However, during a facility tour, the privacy curtain for a resident was observed to have multiple large, dried, brown stains along the bottom edge, which remained unchanged over several days. Interviews with staff revealed a lack of clarity regarding responsibility for changing soiled privacy curtains. A housekeeping aide indicated that the maintenance department was responsible, while a licensed practical nurse assumed it was housekeeping's responsibility but was unsure. The housekeeping director, upon being informed, confirmed that it was indeed the housekeeping department's responsibility to change soiled curtains, but he was not previously aware of the issue with the resident's curtain.
Failure to Resolve G-Tube Care Grievance
Penalty
Summary
The facility failed to promptly resolve a grievance related to the care of a gastrostomy (g-tube) for a resident, identified as Resident#126. The resident was admitted with diagnoses including spastic hemiplegia and injury of the oculomotor nerve. The care plan required specific interventions for the g-tube, including daily cleansing and dressing changes. However, the resident's family reported issues with the g-tube care, including leaking and improper dressing, which were not addressed in a timely manner. The family member of Resident#126 communicated concerns about the g-tube care through emails to the Social Services Director Assistant (SSDA), highlighting issues such as the tube not being flushed daily and dressings not being dated. Despite these communications, the facility did not make the necessary changes to the resident's care orders. The family provided photographic evidence of the inadequate care, showing dressings soaked with yellowish to dark gray matter, indicating potential infection and neglect. Interviews with the Social Services Director (SSD) and LPN#1 revealed a lack of follow-through on the grievance. Although the SSD acknowledged receiving the grievance and intended to change the care orders, no verification was done to ensure the changes were implemented. LPN#1 admitted to not obtaining the necessary orders for twice-daily dressing changes, resulting in the grievance being unresolved and the resident at risk for infection and diminished quality of life.
Failure to Address Substance Abuse Risk Leads to Resident Overdose
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident#125, who was at risk for substance abuse and overdose. The resident was admitted with a history of alcohol abuse, opioid abuse, psychoactive substance abuse, and major depression disorder. Despite this, the facility did not assess the risk of substance abuse while the resident was in the facility, nor did they develop a comprehensive care plan with interventions to help prevent an overdose. The care plan lacked specific interventions to monitor for signs and symptoms of substance use and did not encourage the resident to attend Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) meetings. The deficiency was highlighted when Resident#125 experienced an overdose while at the facility. The resident was found unresponsive and hypoxic, requiring Narcan administration, and later tested positive for fentanyl. Despite the overdose incident, there was no documented evidence that the facility increased monitoring and supervision of the resident or visitors, assessed the resident's risk for substance abuse, or educated staff on signs and symptoms of possible substance use. Additionally, the facility did not encourage the resident's participation in NA meetings following the overdose. Interviews with facility staff revealed a lack of proactive measures to address the resident's substance abuse risk. The Social Services Director admitted to not encouraging the resident to attend NA meetings, relying on the resident's self-advocacy. The Licensed Practical Nurse confirmed there was no increased monitoring or supervision provided for the resident. The facility administrator acknowledged the presence of a large population of residents with substance abuse problems but did not indicate any specific interventions implemented for Resident#125 following the overdose.
Failure to Provide Appropriate G-Tube Care
Penalty
Summary
The facility failed to provide appropriate gastrostomy tube (g-tube) care for a resident, identified as Resident#126, which increased the risk of g-tube complications. Resident#126 was admitted with diagnoses including spastic hemiplegia and injury of the oculomotor nerve. The care plan indicated the need for g-tube care to prevent aspiration, with specific physician orders to cleanse the site with normal saline, cover it with split gauze, and secure it with paper tape daily. However, on the day of the survey, the Licensed Practical Nurse (LPN#1) reported that the care had been provided by the previous shift, but upon observation, the resident was found holding a piece of gauze with dried yellowish-brown matter and no date, indicating the care had not been performed as documented. Further observation revealed a build-up of dark brown matter on the underside of the retention ring and small amounts on the tube itself, confirming that the site and tubing had not been cleaned. The Director of Nursing (DON) stated that the facility's policy was to follow physician orders for cleaning gastrostomy sites and tubes, and she expected staff to complete the care. The failure to adhere to these orders and policies was confirmed through interviews and observations, highlighting a deficiency in the facility's care practices.
Violation of Resident Rights for Justice-Involved Individual
Penalty
Summary
The facility failed to ensure that a justice-involved individual (JII), identified as Resident #6, was afforded the autonomy to participate in group activities, community dining, and to freely communicate with visitors. Upon admission, Resident #6 was secluded each day by correction officers (COs) from the Middlesex County Correctional Facility (MCCF), which restricted the resident from leaving the room at will and participating in activities outside the room. The resident was observed shackled in their room, with COs present, and was not allowed to intermingle with other residents or visitors. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. The Minimum Data Set (MDS) indicated that the resident was cognitively intact with no behaviors and did not utilize physical or chemical restraints. Despite this, the resident's care plan included restrictions such as minimal and supervised interactions with staff, and all activities and items had to be approved by the COs. The resident reported feeling like dirt due to the conditions, including being served meals on disposable plates without proper utensils, which forced them to eat with their hands. Interviews with facility staff revealed that the facility was following MCCF protocols, which included shackling the resident and restricting their rights. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the resident's rights were not being followed, as they considered the resident to be under the jurisdiction of the MCCF. The facility's failure to treat Resident #6 with dignity and respect, as required by federal regulations, resulted in an immediate jeopardy situation.
Removal Plan
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Respect Resident Rights and Dignity for Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was afforded the right to retain personal possessions and to have a homelike environment. Upon admission, Resident #6 was secluded daily by correction officers from the Middlesex County Correctional Facility, which led to an Immediate Jeopardy situation. The resident was not allowed to participate in group activities, community dining, or interact with other residents, and was served meals in a manner that lacked dignity. This seclusion and restriction of personal freedoms were observed by surveyors on 8/15/2024. Resident #6 was admitted with several diagnoses, including disease of the pericardium, auditory hallucinations, hypertension, anemia, personal muscle weakness, and shortness of breath, requiring assistance with personal care. The Minimum Data Set (MDS) assessment indicated intact cognition and a need for assistance in Activities of Daily Living (ADL). Despite expressing preferences for daily routines and activities, the resident reported being unable to exercise these choices due to restrictions imposed by the correction officers, such as needing approval to use a phone or receive personal items. The facility's care plan for Resident #6 included interventions that limited interactions and required correction officer approval for any activities or personal items. During a tour, Resident #6 was found shackled in their room, with limited access to personal belongings, such as a cell phone. Interviews with facility staff revealed that the facility followed a correctional agreement with the correctional facility, which dictated the restrictions placed on Resident #6, undermining the resident's rights and dignity.
Removal Plan
- The facility implemented a corrective action plan to remediate the deficient practice.
- The facility provided education to all administrative facility personnel on CMS guidance in reference to federal requirements for providing services to JIIs' and to ensure that the rights of JIIs can be respected if the individuals is admitted into the facility care.
Violation of Resident Rights for Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was afforded the right to make their own choices regarding aspects of life and care, participate in activities, and interact with other residents. Upon admission, Resident #6 was secluded each day by correction officers (COs) from the Middlesex County Correctional Facility (MCCF), which led to an Immediate Jeopardy (IJ) situation. The resident was observed being confined to their room, guarded by COs, and not permitted to participate in group activities or community dining. This seclusion was in direct violation of the resident's rights as outlined by the Centers for Medicare and Medicaid Services (CMS) guidelines. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, the resident was subjected to restrictions that prevented them from engaging in normal social interactions and activities. The care plan for Resident #6 included minimal and supervised interactions with recreation staff, and any leisure materials had to be approved by the COs. The resident was not allowed to use electronics or receive salon services without approval from the correctional institution. Interviews with facility staff and COs revealed that the facility was following MCCF's protocol for inmates, which included restricting Resident #6's movement and interactions. The resident was served meals on disposable plates with plastic utensils, and their cell phone was kept out of reach. The facility's policies on resident rights, abuse prevention, dining room services, and activities were not implemented for Resident #6, as the facility adhered to MCCF's instructions. This failure to uphold the resident's rights and provide a dignified existence was identified as an isolated incident that jeopardized the health and safety of the resident.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights can be fully respected if the individual is admitted into the facility's care.
Involuntary Seclusion of Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was free from involuntary seclusion, leading to an Immediate Jeopardy (IJ) situation. Upon admission, Resident #6 was secluded daily by correction officers from the Middlesex County Correctional Facility (MCCF), restricting their autonomy and choice in daily activities. The resident was not allowed to participate in group activities, community dining, or interact with other residents, which posed a likelihood of psychological harm. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite having a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and no behaviors or restraints noted, the facility did not initiate care plans addressing the need for constant supervision by correction officers. The resident was only permitted to leave their room for showers and physical or occupational therapies, always accompanied by correction officers, and was not allowed to leave the room at will. Interviews with facility staff, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other personnel, revealed that the facility agreed to follow the guidelines of the MCCF, which included restrictions on the resident's participation in activities and visitation. The facility's policies on resident rights and activities were not adhered to, as the resident was not offered activities outside the room and meals were provided in-room without the option to dine with other residents. The correction officers confirmed the use of metal ankle restraints and restricted movement and interaction for Resident #6.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was free from physical restraints, which led to an Immediate Jeopardy (IJ) situation. Upon admission, Resident #6, who had diagnoses including cerebrovascular disease and abnormalities of gait and mobility, was shackled by the ankles daily by correction officers from the Middlesex County Correctional Facility. The resident was observed by surveyors with metal ankle shackles and was guarded by correction officers, indicating a lack of autonomy and choice in their care. The facility's records, including the Electronic Medical Record (EMR) and Individualized Care Plans, did not document the use of restraints or provide any consents for their use. The care plans failed to address the need for constant supervision by correction officers or the restrictions on the resident's movement, such as being confined to their room except for showering and therapy sessions. This oversight violated the resident's rights to be free from physical restraints not required for medical treatment. Interviews with facility staff, including the Licensed Practical Nurse (LPN) and correction officers, confirmed the routine use of shackles on Resident #6. The facility's leadership, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), acknowledged that they had agreed to follow the correctional facility's guidelines, which included the use of restraints. This decision was made despite the facility's policies that restraints should only be used for the safety and well-being of residents and with proper consent and documentation.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Uphold Resident Rights for Justice Involved Individual
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of policies and procedures regarding Resident Rights and Self Determination, as well as the prevention of physical restraints and seclusion. This deficiency was identified during a survey conducted on 8/15/2024, which revealed that a Justice Involved Individual (JII), referred to as Resident #6, was admitted to the facility and subjected to seclusion and physical restraints by correction officers from the Middlesex County Correctional Facility (MCCF). The resident was observed to be shackled and secluded in their room, unable to participate in group activities, community dining, or freely communicate with visitors. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, the resident was not afforded the autonomy to engage in activities or interact with other residents. The care plan for Resident #6 included interventions that restricted interactions and activities, requiring approval from correction officers for any leisure materials or services. The facility's policies did not include any physician's orders for restraints, yet the resident was subjected to such measures by the correctional officers. Interviews with facility staff, including the LNHA, Director of Nursing (DON), and other personnel, revealed that the decision to accept Resident #6 was made collectively with MCCF administrative staff, who insisted on maintaining the use of restraints. The facility staff acknowledged that the interventions and restrictions were imposed by the correctional officers and not by the facility itself. This situation resulted in a violation of federal and state regulations regarding resident rights, as the facility failed to ensure that Resident #6 could exercise their rights and live in a dignified environment.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
- The facility will review, and update policies annually and as needed.
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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