Allendale Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Allendale, New Jersey.
- Location
- 85 Harreton Road, Allendale, New Jersey 07401
- CMS Provider Number
- 315497
- Inspections on file
- 17
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Allendale Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Deficiencies were identified in infection control practices, including a CNA failing to change gloves or perform hand hygiene during incontinent care for a resident with severe cognitive impairment, improper separation of clean and soiled laundry with inadequate PPE in the laundry area, and an incomplete water management program for Legionella lacking documentation and testing protocols.
The facility failed to adhere to its kitchen sanitation policy, as observed by a surveyor who noted the Food Service Director and a Dietary Aide wearing prohibited jewelry. This violation of the hygiene policy, which mandates minimal jewelry and proper coverage during food handling, was acknowledged by the FSD.
The facility inaccurately coded the MDS for three residents, affecting the management of their care. One resident's MDS did not reflect dialysis treatment, another's failed to indicate hospice care and flu vaccination status, and a third's discharge location was incorrectly recorded. The errors were acknowledged by the MDS Coordinator and the LNHA.
A facility failed to complete a PASRR for a resident diagnosed with paranoid schizophrenia. The resident's medical records showed diagnoses of heart failure, anxiety disorder, major depressive disorder, and schizophrenia, with the onset of schizophrenia occurring during their stay. Despite this, no PASRR Level I screen was documented. Interviews revealed that a PASRR should have been completed prior to admission and for new serious mental disorders, but it was only done after surveyor inquiry.
A long-term care facility failed to adhere to professional standards, resulting in deficiencies in documentation and monitoring. A resident's MAR had numerous unsigned entries for insulin and other medications, while another resident's dialysis communication records were incomplete. Additionally, behavior and side effect monitoring for a resident with anxiety and depression were not consistently documented. These lapses were acknowledged by the facility's staff, including the LPN and DON.
A resident with dysphagia and moderately impaired cognition was supposed to receive enteral nutrition through a bolus feeding method six times daily, but was only receiving it five times daily due to an unaddressed order discrepancy. The LPN and RD failed to identify and correct the error, which was contrary to the facility's policy requiring complete orders for enteral nutrition.
A CP failed to clarify the medication route for a resident with dysphagia and an NPO order, leading to an inappropriate oral medication order. The CP's reviews did not identify this issue, despite facility policy requiring quarterly medication administration record reviews.
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training before assuming the role. The IP was hired and signed a job description on 6/10/21, but the training certificates showed completion dates from August 2021, indicating the training was not completed prior to starting the role. This discrepancy was confirmed during interviews with the IP and facility staff.
A facility failed to report an abuse allegation within the required two-hour timeframe to the NJDOH. The incident involved a resident being hit by a confused roommate. The event occurred late at night, but the report was delayed by two days. The facility's policy mandates immediate reporting within two hours for such incidents, but this was not followed.
A resident with severe cognitive impairment was found with a swollen thumb, but the facility failed to complete a thorough investigation. The investigation lacked interviews from the staff on the shift prior to the injury being identified, contrary to the facility's policy requiring staff interviews over the prior 48 hours.
The facility failed to provide written notification of its bed hold and reserve payment policy to two residents upon hospital transfer. The Business Office Manager confirmed that notifications were mailed and calls were made, but documentation lacked necessary details, leading to the deficiency.
Infection Control Deficiencies in Resident Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to maintain proper infection control measures in three key areas. During incontinent care for a resident with severe cognitive impairment and bowel and bladder incontinence, a CNA did not remove soiled gloves or perform hand hygiene after providing peri care and before continuing to clean the resident's legs. The CNA confirmed during an interview that she did not change gloves or use hand hygiene, and the DON acknowledged awareness of infection control protocols but noted the CNA should have known better. In the laundry area, clean and soiled linens were not adequately separated. Soiled laundry was sorted on the unit and brought into the laundry room, then after washing and drying, clean laundry was transferred across a soiled area to a folding room. The laundry room lacked appropriate PPE such as gowns, gloves, or masks, and disinfectant was stored with clean items. The Infection Preventionist was not aware of the issue with clean linen passing through the soiled area. Additionally, the facility's water management program for Legionella was incomplete, lacking documentation of water flow, identification of potential pooling sites, and testing protocols, as confirmed by the Maintenance Director.
Improper Kitchen Sanitation Practices Observed
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could potentially lead to foodborne illness. During a kitchen tour, the surveyor observed the Food Service Director (FSD) and a Dietary Aide (DA#1) wearing earrings that hung more than one inch from their earlobes, which is against the facility's policy on employee hygiene and sanitary practices. The policy, revised in November 2022, specifies that jewelry should be kept to a minimum and that hand and wrist jewelry should be covered with gloves during food handling. Despite this policy, both the FSD and DA#1 were found to be in violation, as acknowledged by the FSD during the observation.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of their care. For one resident, the MDS did not indicate that the resident received dialysis treatment, despite the resident's medical record showing a diagnosis of end-stage renal disease and dependence on renal dialysis. The MDS Coordinator acknowledged the error after it was pointed out by the surveyor. Another resident's MDS failed to identify the resident as being under hospice care and inaccurately recorded the status of a flu vaccine, which was documented as received in the resident's immunization record. The MDS Coordinator admitted that the hospice care status was missed during the assessment. For the third resident, the discharge MDS inaccurately recorded the resident as being discharged to an acute hospital, while the interdisciplinary progress notes indicated the resident was discharged to home. The facility's policy on discharge assessments was reviewed, and it was found that the MDS was not coded correctly. The Licensed Nursing Home Administrator confirmed the inaccuracies in the MDS coding for all three residents.
Failure to Complete PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosis of paranoid schizophrenia. The resident, who was alert and oriented, was observed by a surveyor, and their medical records were reviewed. The records indicated that the resident had diagnoses including heart failure, anxiety disorder, major depressive disorder, and paranoid schizophrenia, with the onset of schizophrenia occurring during their stay at the facility. Despite these diagnoses, there was no documentation of a PASRR Level I screen being completed for the resident during their time at the facility. Interviews with the Social Worker and the Director of Social Services revealed that a PASRR Level I screen should have been completed prior to admission and that a new onset of a serious mental disorder, such as schizophrenia, during the resident's stay should have prompted a PASRR screen. The Director of Social Services confirmed that a PASRR Level I was only completed after the surveyor's inquiry and that any prior PASRR could not be found. The facility's policy required a Level I PASRR screen for all admissions, but this was not adhered to in the case of the resident, leading to the deficiency.
Deficiencies in Documentation and Monitoring in LTC Facility
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice, as evidenced by multiple deficiencies in documentation and monitoring. One resident, who was diabetic, had numerous unsigned entries in their Medication Administration Record (MAR) for insulin administration, blood sugar checks, and other medications over several months. The Licensed Practical Nurse (LPN) acknowledged that the MAR should be signed at the time of medication administration, and the Director of Nursing (DON) confirmed the expectation for complete documentation. However, the facility's policy on medication administration was not adhered to, resulting in blank entries for critical medications. Another deficiency was observed with a resident who required dialysis. The Dialysis Communication Binder, which should have been completed by the facility upon the resident's return from dialysis, had multiple blank entries. The LPN admitted to not filling out the post-dialysis assessment, and the Unit Manager confirmed that the Hemodialysis Communication Record (HCR) should be completed by the nurse. Despite the facility's policy on dialysis communication, the necessary documentation was not completed, leaving gaps in the resident's care records. Additionally, a resident with chronic obstructive pulmonary disease, anxiety disorder, and depression had incomplete behavior and side effect monitoring records. The June 2024 MAR/Treatment Administration Record (TAR) showed numerous blanks for behavior monitoring and side effect monitoring, which were supposed to be documented every shift. The LPN and Unit Manager both acknowledged the importance of this monitoring to assess the necessity and effectiveness of medications. However, the facility's policy on behavioral assessment and monitoring was not followed, resulting in incomplete documentation.
Enteral Feeding Order Discrepancy
Penalty
Summary
The facility failed to identify and accurately address an Enteral Feeding (EF) order discrepancy for a resident who was receiving tube feeding. The resident, who had moderately impaired cognition and was diagnosed with dysphagia following a cerebral infarction, was supposed to receive enteral nutrition through a bolus feeding method. The physician's order indicated that the resident should receive Jevity 1.5 Cal 237 ml six times per day, but the Medication Administration Record (MAR) showed that the resident was only receiving the feeding five times daily. This discrepancy was not identified by the facility staff, including the Licensed Practical Nurse (LPN) overseeing the resident's care and the Registered Dietitian (RD) responsible for monitoring the resident's nutritional needs. The surveyor's investigation revealed that the LPN had not previously observed the error in the feeding order and acknowledged the need for clarification. The RD also confirmed that the order should have been for six feedings per day but could not explain why the error was not caught earlier. The facility's policy on enteral feeding requires that orders be complete and include the product, administration method, and volume and rate of administration. However, this policy was not adhered to, resulting in the resident receiving inadequate nutrition as per the prescribed order.
Consultant Pharmacist Fails to Clarify Medication Route for NPO Resident
Penalty
Summary
The Consultant Pharmacist (CP) failed to clarify the medication route for a resident during the monthly medication reviews. This deficiency was identified for one of six residents, specifically a resident who was admitted with diagnoses including dysphagia following a cerebral infarction and severe protein-calorie malnutrition. The resident's medical records indicated a physician order for a Nothing by Mouth (NPO) diet and tube feeding, yet there was an order for Ascorbic Acid to be administered orally, which was not appropriate given the resident's condition. The CP's medication reviews for April and May did not identify any issues with the resident's medication orders, despite the inconsistency with the resident's NPO status. During an interview, the CP acknowledged missing the error in the medication route, which should have been administered via the PEG tube instead of orally. The facility's policy required the CP to review medication administration records quarterly and document any concerns, but this was not adhered to in this instance, leading to the oversight.
Infection Preventionist Lacked Required Training Before Role Assumption
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed the required specialized training in infection prevention and control as per CMS guidance before assuming the role. The IP was hired on 6/10/21, and the job description signed by the IP acknowledged the necessity of specialized training. However, the training certificates provided by the facility showed completion dates ranging from 8/07/21 to 8/23/24, indicating that the IP did not complete the necessary training before starting the role. During an interview, the IP confirmed the date of hire and acknowledged that the specialized training was completed in August 2021, after assuming the role. The Licensed Nursing Home Administrator (LNHA) and other facility staff were informed of this deficiency, and the LNHA noted that the IP's job description was updated when the facility was acquired by a new company. However, the timeline provided by the facility did not align with the job description, further highlighting the discrepancy in the IP's training timeline.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the New Jersey Department of Health (NJDOH). The incident involved a resident who was hit by a confused roommate with occasional aggressive behaviors. The event occurred on March 18, 2023, at 11:00 PM, but the report was not submitted to the NJDOH until March 20, 2023, at 3:00 PM. The facility's Reportable Event Record (RER) was incomplete, lacking documentation on whether the incident was significant and if it was called in. The resident involved was awake, alert, and oriented, and expressed that they were okay and did not wish to press charges. The resident was immediately transferred to another room, and no injuries were noted. Interviews with the Director of Nursing (DON) revealed that the incident should have been reported within two hours, regardless of whether the abuse was substantiated. The DON, who had been at the facility for only three weeks, confirmed the reporting requirement. The facility's policy on abuse reporting, revised in September 2022, mandates immediate reporting of abuse allegations to the administrator and relevant authorities within two hours if the incident involves abuse or results in serious bodily injury. Despite this policy, the facility did not adhere to the required reporting timeframe.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had a history of essential hypertension, unspecified dementia, and anxiety, was found by a family member to have a swollen and discolored left thumb. This injury was reported to a nurse, and a facility reportable event was documented. However, the investigation was incomplete as it lacked interviews from the staff on the shift prior to the injury being identified, specifically the 11-7 shift on the day before the injury was noted. The facility's policy required interviews and statements from staff over the prior 48 hours when an injury of unknown source was identified. Despite this, the investigation did not include statements from the nurse and CNA who worked the 11-7 shift before the injury was discovered. The Director of Nursing and the Regional Director of Operations acknowledged the oversight and the importance of these interviews in completing the investigation. The facility's policies on investigating resident injuries and reporting abuse were not fully adhered to, as the necessary staff interviews were not conducted.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide appropriate written notification of its bed hold and reserve payment policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for two residents who were reviewed for hospitalizations. For the first resident, the medical record did not include a written notification of the bed hold policy prior to the transfer to the hospital. The Business Office Manager (BOM) stated that she would leave a message and mail a letter regarding the policy, but no additional information was provided at the time of transfer. The surveyor noted that the facility's documentation did not include the payor information, which is a critical component of the bed hold policy. For the second resident, the medical records indicated a transfer to an acute care hospital, but there was no evidence of a written notification of the bed hold policy being provided. The BOM confirmed that the policy was mailed and that a call was made to the resident's representative. However, the facility's policy documentation was undated and lacked specific details required by state regulations, such as the rights and limitations regarding bed holds and the facility's per diem rate for holding a bed. This lack of proper documentation and communication led to the identified deficiency.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
