Allegria At The Fountains
Inspection history, citations, penalties and survey trends for this long-term care facility in Atco, New Jersey.
- Location
- 114 Hayes Mill Road, Atco, New Jersey 08004
- CMS Provider Number
- 315297
- Inspections on file
- 16
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Allegria At The Fountains during CMS and state inspections, most recent first.
Staff failed to follow the facility’s Legionella Water Management Plan and national guidelines by not maintaining and documenting required filters on shower heads and the dining room ice machine, and by not involving the IP in Legionella control activities. Only one of two in-use shower heads in the shower room had a filter in place, and the CMD could not produce logs showing when shower filters or the ice machine filter were checked or replaced. The ice machine, which staff routinely used to provide ice water and beverages for residents’ meals and medications, had been cleaned but its water-line filter had not been changed since installation, contrary to expectations and manufacturer guidance. The IP reported no knowledge of current Legionella issues and had only provided general education, while the LNHA confirmed the IP was not included in remediation efforts and that the WMP still listed former leaders as team members, even though it required documented cleaning, filter changes, and participation of the IP and other key staff when Legionella-positive samples were identified.
Surveyors found that the facility did not maintain required Legionella control measures for resident showerheads and an ice machine. A resident shower room was observed without the mandated 0.2-micron point-of-use filter on the showerhead, and the CMD reported CNAs sometimes removed filters due to low water flow, with no reliable logs showing when filters were checked or replaced. An ice machine near the dining area had a filter device labeled with an installation date more than several months old, and the CMD and HVACM could not confirm that it had been changed according to manufacturer specifications, nor could they provide documentation of filter changes or ordering. The facility’s WMP and prior NJDOH CDS directives required installation and documented maintenance of these filters as Legionella control measures, but the LNHA and maintenance staff were unable to demonstrate that these requirements had been consistently implemented or documented.
The facility failed to provide adequate supervision and effective fall prevention for several high fall‑risk residents, including cognitively impaired individuals with stroke history, aphasia, Alzheimer’s disease, hemiplegia, and repeated falls. One resident, identified as impulsive and requiring supervised activities, was repeatedly observed in dayrooms without staff present while attempting to stand, and experienced numerous falls in the room, hallway, and activity areas, three of which caused head and leg injuries requiring ED evaluation. Another resident with Alzheimer’s and diabetes had multiple falls despite a fall‑risk care plan, but incident reports lacked key details and new interventions were not consistently added or evaluated. A third resident with hemiplegia fell during in‑bed turning when a leg hit the floor, yet the care plan was not updated to include the specific positioning intervention discussed by the IDT. Across these cases, fall investigations were often incomplete or missing, causal factors were not clearly identified, supervision was not ensured in activity areas, and care plans were not consistently revised in accordance with the facility’s own fall‑management policies.
A resident with hemiplegia, epilepsy, severely impaired cognition (BIMS 2/15), and a documented need for an interpreter in a non-English dialect did not have the care-planned communication board available in the room, and staff were unaware of any communication device. The MD and nursing staff reported they did not use translation devices or contracted translation services and instead relied on slow speech, observation, and family presence, despite a facility policy stating that a contracted translation service was maintained and that family should not routinely be used as interpreters. A communication binder with words and images was later found under the bedside table only after surveyor inquiry, demonstrating that the planned communication interventions were not implemented as documented.
A resident with a history of stroke, right hemi craniotomy, left-sided weakness, epilepsy, severe cognitive impairment, and ongoing headaches and dizziness was ordered to follow up with Neurology/Neurosurgery. The resident, dependent on staff for dressing and requiring an interpreter, reported anticipating the appointment and stated no one came to prepare them, and that they did not refuse. Staff interviews and record review showed that the appointment scheduling and communication process relied on a unit clerk, an LPN, and a whiteboard, but December appointment records were not retained, the CNA was not informed to get the resident ready, and there was no documentation of refusal, missed appointment, physician notification, or rescheduling. Physician notes recommending neurology follow-up and documenting headaches and dizziness were not visible in the facility’s eMR until after surveyor inquiry, and the facility lacked a formal policy for scheduling resident appointments.
A resident with severe cognitive impairment, hemiplegia, and a history of brain surgery reported ongoing head pain and stated that staff did not prepare them for a scheduled follow-up neurosurgical appointment, which they denied refusing. Staff interviews revealed that appointment scheduling information was kept on a white board and in progress notes, but the resident’s appointment was not on the list, and the CNA was not told to get the resident ready. The resident’s representative later arrived visibly upset about the missed appointment, and both the ADON and DON were aware of the complaint, yet no grievance was initiated, no refusal or missed appointment was documented in the progress notes, no follow-up appointment was arranged, and the physician was not notified. The grievance officer’s logs contained no entry for this event, and the only investigation document was a single LPN statement and a transport order showing the trip was cancelled as “appointment cancelled,” contrary to the facility’s written grievance policy requiring prompt resolution and communication of grievance findings.
The facility failed to maintain food safety and sanitation standards, as observed by a surveyor. The inspection revealed an unclean meat slicer, unlabeled and undated food items in the refrigerator and freezer, and a dented can in dry storage. The FSAD acknowledged these issues, which were contrary to the facility's policy on proper food labeling and dating.
The facility failed to complete the Quarterly MDS assessments on time for two residents, resulting in a deficiency. One resident with congestive heart failure had their assessment completed three days late, while another with dementia had theirs completed five days late. The MDS Coordinator acknowledged the delays, which were against the facility's policy requiring timely assessments.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. One resident's care plan lacked focus on leg wraps for edema and did not document refusal. Another resident experienced two falls without care plan updates. A third resident with a urinary catheter lacked specific care plan details. Staff confirmed the care plan deficiencies.
A resident with moderate cognitive impairment refused prescribed leg wraps for edema, and the facility failed to educate the resident or notify the physician and family about the refusal. The facility's policy required such actions, but documentation and staff interviews revealed these steps were not taken, resulting in a deficiency.
A facility failed to maintain accurate records for Xanax, a controlled medication, resulting in a discrepancy between the recorded and actual pill count. An LPN admitted to counting the narcotics alone, leading to the oversight. Additionally, Xanax was improperly borrowed for another resident, contrary to facility policy, as confirmed by the DON and other staff.
A facility failed to document the assessment and administration of the influenza vaccine for a resident admitted with Diabetes Mellitus and Hypertension. The resident's MDS indicated the vaccine was not received, and the reason was not assessed. The DON confirmed the vaccine should have been assessed upon admission, but no consent or refusal form was available. Facility policy required offering the vaccine between October and March and assessing new residents' vaccination status upon admission.
Failure to Implement Legionella Water Management Controls and Involve IP in Program
Penalty
Summary
Facility staff failed to implement, maintain, and monitor control measures to prevent the growth of Legionella in accordance with the facility’s Water Management Program (WMP), CDC guidelines, and ASHRAE Guideline 12. During a tour of the skilled nursing section, surveyors observed three shower heads in the shower room, two of which were in use, and only one of those two had a filter in place. The Campus Maintenance Director (CMD) stated that CNAs may have removed a filter to get better water flow and that maintenance checked filters every three months, but he was unable to produce logs showing when shower head filters were checked or replaced. A provided “SNF Community Shower Room” log only showed a date when a new filter was installed, and the CMD could not explain what the log meant. CNAs reported no issues with low water pressure and confirmed that residents regularly received showers in the shower room and in private showers. Surveyors also observed an ice machine in the dining room/pantry area with an inspection sheet indicating it had been cleaned and sanitized by the Heating, Ventilation and Air Conditioning Mechanic (HVACM) several months earlier. A filtration device attached to the water line for the ice machine had a handwritten date that appeared to be the installation date, and the CMD was unsure if the filter had been changed since then or what the manufacturer’s specifications were for changing the filter. The HVACM confirmed he had disassembled, sanitized, and reassembled the ice machine but had not changed the filter device at that time, stated the filter should have been changed, and indicated the filter device now needed to be ordered. The CMD acknowledged he could not provide logs or an ordering schedule for the ice machine filter and attributed missing audits and documentation in part to a terminated Maintenance Supervisor. Interviews with leadership and clinical staff showed that the Infection Preventionist (IP) was not included in Legionella control measures despite the WMP and facility policy identifying the IP as part of the water management team. The IP/LPN reported having been the IP for about a year, stated she had no knowledge of any current Legionella issues in the building, and indicated that upper management and maintenance were handling Legionella. She recalled being told to provide general education on Legionella about a year earlier but had not been involved in remediation activities. The Licensed Nursing Home Administrator (LNHA) confirmed that the IP/LPN was responsible for staff education on Legionella but was not currently involved in remediation and had not been included in discussions about Legionella since he became LNHA. The LNHA also acknowledged that the WMP listed program team members who were no longer employed and that he was unaware of the magnitude of the facility’s Legionella history or the status of mitigation efforts when he assumed his role. Meanwhile, staff routinely used water from coolers and ice from the ice machine for residents’ drinks, meals, and medications, and residents confirmed receiving water with ice and regular showers, while the WMP required documented regular cleaning and filter changes for ice machines and showerheads when Legionella-positive samples were identified. A review of the facility’s WMP dated mid-2025 showed that the current CMD and former executive leadership were listed as program team members, but it did not reflect current responsible individuals. The WMP identified ice machines, medical devices, shower heads, and hoses as devices at risk for Legionella contamination and required regular cleaning, filter changes per manufacturer specifications, and documentation of these activities. It also required regular cleaning, replacing or dismantling, disinfecting, and descaling of showerheads and hoses, and called for more frequent sampling and review when Legionella-positive samples were found outside control limits. The facility’s Legionella Water Management Program policy further specified that the water management team must include at least the IP, administrator, medical director, director of maintenance, and director of environmental services. Despite this, the LNHA could not provide documentation of completed NJDOH Communicable Disease Services recommendations prior to a recent sampling event and initially provided policies that he later acknowledged were not the actual WMP, underscoring that the WMP had not been updated to include current responsible team members or fully implemented as written.
Failure to Maintain Legionella Control Measures for Showerheads and Ice Machines
Penalty
Summary
The deficiency involves the facility’s failure to implement required Legionella control measures on resident showerheads and ice machines as directed by the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS) and as outlined in the facility’s Water Management Plan (WMP). NJDOH CDS written instructions dated 01/21/2025 required immediate installation of 0.2-micron biological point-of-use filters on any showerheads intended for use, or restriction of showers with use of sponge baths instead, and specified that filters must comply with ASTM F838. The same communication directed the facility to assess for additional point-of-use filters at fixtures with elevated aerosolization risk and to follow manufacturers’ recommendations for filter replacement. The WMP, dated 07/15/2025, identified showerheads, hoses, and ice machines as devices at risk for Legionella contamination and required regular cleaning and filter changes per manufacturer specifications, with documentation. On the survey date, during an inspection of a resident shower room, the survey team, accompanied by the Campus Maintenance Director (CMD), a NJDOH CDS Water Systems Analyst, and a Local Health Department representative, observed that the resident showerhead did not have a 0.2-micron biological point-of-use filter in place. The CMD stated that CNAs sometimes removed the filters when water flow was low and that maintenance checked the filters every three months, but he could not produce logs to show when showerhead filters had been checked or replaced. The only record provided was a “SNF Community Shower Room” log indicating a date when a new filter was installed, which the CMD could not interpret. The LNHA reported he was aware filters needed to be checked and changed but relied on maintenance for the schedule and believed audits were being done. During inspection of the ice machine near the resident dining area, the survey team observed a filter device labeled with an installation date of 02/04/2025. The CMD was unsure if the filter had been changed since that date and could not speak to the manufacturer’s replacement specifications. The Heating Ventilation Air Conditioning Mechanic (HVACM) confirmed he had disassembled, sanitized, and reassembled the ice machine in November 2025 and normally would change the filter cartridge, but on that occasion did not change the filter device. He acknowledged the filter device should have been changed and that he did not handle ordering, which he believed was the responsibility of a Maintenance Supervisor who had since been terminated. The CMD was unable to provide any logs or ordering records for the ice machine filter, citing frequent vendor changes and multiple people being involved. The LNHA acknowledged awareness of a history of Legionella issues at the facility and ongoing communication with NJDOH CDS, but he was unable to provide documentation of NJDOH CDS recommendations completed before a February 2026 sampling event and believed he was following the WMP despite the lack of documented compliance with required control measures for showerheads and ice machines.
Failure to Provide Adequate Supervision and Effective Fall Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention for multiple cognitively impaired and high fall‑risk residents, and to thoroughly investigate and respond to falls. One resident with severe cognitive impairment, aphasia after stroke, repeated falls, bipolar disorder, muscle weakness, and a history of traumatic subdural hemorrhage was repeatedly placed in dayrooms without consistent staff supervision despite being identified as impulsive, at high risk for falls, and requiring supervised activities. Surveyors observed this resident multiple times in a wheelchair in the activity/dayroom areas, appearing restless, attempting to stand, and moving back and forth in the wheelchair while no staff were present in the room. The activity aide reported she was the only staff member assigned to cover two separate activity rooms, could not supervise both simultaneously, and that there were no staff physically assigned to monitor the activity area when she had to step out. This same resident sustained at least 13 falls, including several unwitnessed falls in the resident’s room and multiple falls in the activity room and hallway. Documentation showed repeated nursing notes of the resident being found on the floor in the room, in doorways, and in the activity room, sometimes with skin tears or redness, and three falls resulted in injuries requiring emergency department evaluation: a contusion and laceration to the left supraorbital and frontal scalp after a hallway transfer incident where the CNA reported the resident’s legs became caught and the resident fell forward from the wheelchair; a large intramuscular hematoma of the right thigh after a fall in the activity room where the resident stood and missed the chair; and a closed head injury and facial laceration after another fall in the activity room with active bleeding from the forehead. Despite a care plan that specified the resident was impulsive, had poor safety awareness, required prompt response to requests for assistance, should be in common areas when out of bed, should not be left alone in the room in a wheelchair, and needed supervised activities to minimize falls, the facility did not ensure supervision in the dayrooms and did not consistently revise interventions after recurrent falls. Several fall investigations were missing entirely, and when interdisciplinary team notes were present, they often stated that all current interventions remained appropriate and that no additional interventions were needed, even after serious injuries and documentation that the resident required supervision in activities. Another resident with Alzheimer’s disease, anxiety, diabetes, and a high fall‑risk score experienced multiple falls over a short period, including several falls with no injury and one fall with skin tears to the left hand and elbow. The care plan listed general fall‑prevention interventions such as reviewing past falls, attempting to determine causes, anticipating needs, ensuring call light access, prompt response to assistance requests, appropriate footwear, maintaining the bed in the lowest position, toileting schedules, therapy evaluations, and activities to promote exercise and diversion. However, for at least one documented fall, no new interventions were added, and facility accident/incident reports lacked key information such as when the resident was last seen or toileted, footwear at the time of the incident, bed position, or whether the resident had participated in activities as care‑planned. Effectiveness of interventions and root causes of falls were not clearly evaluated or documented, contrary to the facility’s own falls policies that required identification of precipitating factors, cause identification within 24 hours, and ongoing adjustment of interventions until falls were reduced. A third resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, and epilepsy had a documented fall during in‑bed repositioning. A risk management report described that while a CNA was turning the resident onto the right side, the resident’s leg hit the floor while the body remained on the bed. The interdisciplinary team later discussed this event and identified the need for staff to position the resident in the center of the bed before turning to one side or the other. However, the resident’s comprehensive care plan for falls was not updated to include this fall or the specific intervention related to proper positioning prior to turning. Overall, across these residents, the facility’s fall‑related policies did not address supervision, multiple falls were not thoroughly investigated, causal factors were often not identified, and care plans were not consistently updated with new or specific interventions in response to recurrent falls and injuries. The facility’s written policies on managing falls and fall risk, the falls clinical protocol, and the falls risk assessment policy required staff to identify interventions related to specific risks and causes, implement resident‑centered fall prevention plans, monitor and document responses to interventions, and re‑evaluate and modify interventions when falls continued. These policies also required staff to evaluate when and where falls occurred, document precipitating factors, and attempt to define possible causes within 24 hours, with physician involvement when causes were unclear or falls persisted. Despite these requirements, the policies did not address supervision as part of fall management, and in practice, the facility did not ensure adequate supervision in activity areas, did not consistently complete or document fall investigations, and did not reliably implement or update individualized interventions after falls for the residents reviewed.
Failure to Provide and Implement Communication Devices and Translation Services for Non-English-Speaking Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide an effective communication device for a resident with a known language barrier and severe cognitive impairment. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and epilepsy. The most recent quarterly MDS showed a BIMS score of 2/15, indicating severely impaired cognition, and documented that the resident’s preferred language was a non-English dialect and that an interpreter was needed. The comprehensive care plan for communication, initiated/revised on 8/22/25, specified that staff who spoke the same dialect could translate, that the family was available by phone to translate, and that the resident had a communication board in the room. However, during an observation on 1/5/26, the CNA assigned to the resident could not locate a communication device and confirmed there was no communication board in the room. Interviews and record review further showed that the facility did not effectively implement its own translation services policy. A family representative reported arriving at the hospital for an appointment with the resident and being told the facility had cancelled the appointment, then going to the facility and speaking with the resident, who spoke minimal English. Staff interviews revealed that the MD did not speak the resident’s language and communicated only by speaking slowly and observing the resident, without using any translation device or service, and that the facility did not provide such services. An LPN/charge nurse stated there was no translation or ancillary communication device in the facility. Later, in the presence of the DON, the LPN produced binders with words and images that she stated she found under the bedside table, and the surveyor noted staff were not aware of this communication device and it could not be located prior to the surveyor’s inquiry. The facility’s written policy, revised 1/2020, stated that the facility maintained a contracted relationship with a translation service and that family and friends should not be relied upon for interpretation unless explicitly requested by the resident and with written consent, but no further information was provided to demonstrate implementation of this policy.
Failure to Ensure Resident Attended Ordered Neurology Appointment and to Document Missed Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a system was in place and implemented to enable a resident to attend an outside neurology/neurosurgery appointment as ordered and needed. The resident had a history of stroke with right hemi craniotomy, left-sided weakness, epilepsy, and severe cognitive impairment, and was dependent on staff for upper and lower body dressing. The resident’s preferred language required an interpreter. Physician progress notes from late 2024 and 2025 documented ongoing headaches, dizziness, left-sided weakness, and recommendations for follow-up with Neurology/Neurosurgery. However, these 2025 notes were not visible in the facility’s eMR until after surveyor inquiry due to a transcription/transfer issue between the physician’s own eMR and the facility’s system. The resident reported anticipating a neurology appointment the night before and being eager to attend due to persistent deep head pain, dizziness, cramping pain, and headache radiating from the base of the neck to the area of the prior craniotomy. On the morning of the scheduled appointment, the resident stated that no one came to get them dressed or ready and that they did not refuse the appointment. The MDS indicated the resident did not exhibit rejection-of-care behaviors and required total assistance for dressing, meaning staff preparation was necessary for the resident to attend the appointment. Staff interviews confirmed that the resident did not refuse the appointment and that there was no documentation of refusal. Interviews with the ADON, LPN/Charge Nurse, CNA, and DON revealed that appointment scheduling and communication processes were informal and inconsistently implemented. The unit clerk and LPN/Charge Nurse scheduled appointments and were supposed to document them in progress notes and on a white appointment board, but December appointment records were not kept. The CNA stated she was not informed to get the resident ready and did not recall the resident’s name on the appointment board. Review of the resident’s progress notes showed no entry that the appointment was missed, no documentation that the physician was notified of the missed appointment, and no evidence of a rescheduled neurology appointment prior to surveyor inquiry. The facility also could not provide a policy for scheduling resident appointments, despite having a documentation policy that required recording refusals and physician notifications, contributing to the failure to ensure the resident attended the ordered neurology follow-up.
Failure to Log and Process Resident Grievance Regarding Missed Medical Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its method for filing and handling grievances was consistent with its own grievance policy and actual practice. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and a severely impaired cognition (BIMS score of 2/15) reported to surveyors that they had anticipated a follow-up brain surgery appointment scheduled for 12/29/25 due to persistent deep head pain radiating from the base of the neck to the area of a right hemi craniotomy. The resident stated that no one from the facility came to get them dressed and ready for the appointment and confirmed they did not refuse to go. The resident was dependent for upper and lower body dressing and did not exhibit behaviors such as rejection of care per the most recent MDS. Staff interviews and record reviews showed that the facility did not document or process the missed appointment as a grievance, despite the resident and the resident representative voicing concerns. The Social Services Director, who served as the grievance officer, provided grievance logs for several months that contained no entries for this resident, and no grievance report was initiated. The CNA recalled that the resident had a missed appointment and that she was not informed to get the resident ready; she also stated that the resident’s name was not on the appointment list on the white board. The CNA further reported that the resident representative came into the facility visibly upset about the missed appointment and that both the ADON and DON were aware of this. The ADON stated she recalled the missed appointment and that the resident representative arrived visibly upset and yelling in the hallway, but she believed the resident had refused the appointment and acknowledged that she did not speak with the resident or family about the incident and did not think a grievance was made. Review of the progress notes with the ADON confirmed there was no documentation that the resident refused the appointment, no follow-up appointment was made, and the physician was not notified of the missed appointment. The DON confirmed she only learned of the missed appointment when the resident representative arrived angry and that she did not initiate a grievance. An investigation file contained only a single signed statement from an LPN indicating the resident refused to go after transport arrived, and a trip order showed the transport was cancelled by the same LPN with the reason documented as “appointment cancelled.” The facility’s written grievance policy stated that residents and their representatives have the right to file grievances orally or in writing and that the administrator and staff would make prompt efforts to resolve grievances and inform the complainant verbally and in writing of the findings and corrective actions, but no grievance was initiated or resolved for this resident’s complaint.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by a surveyor. During an inspection of the kitchen, the surveyor, along with the Food Service Assistant Director (FSAD), noted several deficiencies. The meat slicer was found uncovered with pink food scraps on it, indicating it had not been cleaned after use. In the walk-in refrigerator, an open package of hard-boiled eggs was wrapped in plastic wrap without an open or use-by date label. Similarly, an unidentified frozen food item in the freezer was wrapped in plastic wrap without a label or date. Additionally, a dented can of baked beans was found in the dry storage area. The FSAD acknowledged these issues, stating that the items should have been labeled and the dented can should not have been on the rack. The facility's policy on labeling and dating emphasizes the importance of proper labeling to ensure food safety and minimize waste, which was not adhered to in these instances.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (QMDS) assessments in a timely manner for two residents, resulting in a deficiency. Resident #43, who was admitted with diagnoses including congestive heart failure and muscle weakness, had their QMDS assessment completed three days late. The Assessment Reference Date (ARD) for this resident was 5/26/2024, but the assessment was not completed until 6/12/2024. Similarly, Resident #4, diagnosed with dementia and anxiety, had their QMDS assessment completed five days late. The ARD for this resident was 5/24/2024, and the assessment was completed on 6/12/2024. During an interview, the MDS Coordinator acknowledged the delay in completing the QMDS assessments for both residents. The facility's policy, revised in March 2022, requires timely and appropriate resident assessments, including quarterly assessments. Additionally, the facility's policy on MDS Completion and Submission Timeframes, revised in October 2023, mandates adherence to federal and state submission timeframes. The deficiency was identified during a survey, and the facility's failure to comply with these requirements was noted.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in addressing their medical and nursing needs. For one resident with a diagnosis of edema, the care plan did not include a focus area for the use of bilateral leg wraps, nor did it address the resident's refusal of the wraps. The Treatment Administration Record showed inconsistencies in the application and removal of the wraps, and there was no documentation of the physician or representative being informed of the refusal. Another resident, who had diagnoses including anxiety, mood disorder, and dementia, experienced two un-witnessed falls. The care plan did not include focus areas, goals, or interventions for these actual falls, despite the resident being identified as high risk for falls. The post-fall evaluations documented the incidents, but the care plan was not updated to reflect these events or to implement measures to prevent future falls. A third resident with an indwelling urinary catheter did not have a care plan focus specifically addressing the catheter, its care, or related interventions. The care plan only mentioned enhanced barrier precautions without detailing catheter care, size, or frequency of changes. Interviews with facility staff confirmed the lack of appropriate care plan documentation for the catheter, and the facility's policies were not followed in developing comprehensive care plans for these residents.
Failure to Educate and Notify Regarding Treatment Refusal
Penalty
Summary
The facility failed to provide necessary education to a resident who was refusing a prescribed treatment and did not notify the resident's physician or family about the refusal. This deficiency was identified for a resident with a history of skin conditions, including cellulitis, localized edema, gout, and local infection of the skin and subcutaneous tissue. The resident, who had moderate cognitive impairment, was observed refusing leg wraps that were prescribed for edema. The Treatment Administration Record indicated that the wraps were not applied or removed on several occasions, and the refusal was documented without evidence of education or notification to the physician or family. The facility's policy required that when a resident refuses treatment, the interdisciplinary team should educate the resident about the risks and benefits, document the refusal, and notify the physician. However, there were no progress notes indicating that the physician or family was informed of the refusal before a specific date, nor was there documentation that the resident was educated about the potential outcomes of refusing the treatment. Interviews with staff confirmed that the process for handling treatment refusals was not followed, leading to the deficiency.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate accountability of a controlled medication, specifically Xanax, for an unsampled resident. During a review of a medication cart, it was found that the Individual Patient Controlled Substance Administration (IPCSA) record indicated 29 Xanax pills should be available, but only 28 were present. The Licensed Practical Nurse (LPN) acknowledged the discrepancy and admitted to counting the narcotics alone, which may have led to the oversight. The Director of Nursing (DON) later confirmed that the extra Xanax was administered to the resident but was not properly documented on the IPCSA. Additionally, the facility improperly acquired a controlled drug by borrowing Xanax for another unsampled resident. The IPCSA record showed that Xanax was borrowed for a resident, and the Medication Administration Record (MAR) confirmed its administration. Both the Unit Manager/Charge Nurse and a Registered Nurse stated that borrowing medication is not permitted. The facility's policy on controlled substances requires individual records for each resident receiving such medications, which was not adhered to in this instance.
Failure to Document Influenza Vaccine Assessment and Administration
Penalty
Summary
The facility failed to ensure proper documentation in a resident's medical record regarding the benefits and risks of immunization, as well as the administration or refusal of the influenza vaccine. This deficiency was identified for one resident who was admitted with diagnoses including Diabetes Mellitus and Hypertension. The resident's admission Minimum Data Set (MDS) indicated that the influenza vaccine was not received, and the reason for not administering the vaccine was not assessed. The resident was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 14/15. During interviews with the surveyor, the Director of Nursing (DON) acknowledged that the influenza vaccine should have been assessed upon the resident's admission. The facility was unable to produce a consent or refusal form for the influenza vaccine. The facility's policy stated that the influenza vaccine should be offered to residents between October 1st and March 31st each year, unless medically contraindicated or if the resident had already been immunized. Additionally, the policy required that all new residents be assessed for current vaccination status upon admission.
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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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