Aristacare At Cherry Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherry Hill, New Jersey.
- Location
- 1399 Chapel Ave West, Cherry Hill, New Jersey 08002
- CMS Provider Number
- 315245
- Inspections on file
- 20
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Aristacare At Cherry Hill during CMS and state inspections, most recent first.
A resident with Type 2 DM and other serious conditions experienced multiple hypoglycemic events for which an LPN administered glucagon without obtaining a provider order or having the order transcribed into the medical record. Review of the MAR and OSR showed no glucagon orders, and the DON acknowledged that the LPN did not contact the provider after the events. The DON also documented insulin refusals on the MAR using her own electronic signature based on information from the remote LPN, rather than having the LPN enter the documentation, contrary to facility policies requiring that licensed personnel providing care record verbal orders and clinical entries themselves.
A resident with multiple medical conditions and intact cognition reported being handled roughly by a CNA during bed mobility assistance. Despite the incident being documented and investigated, the care plan was not updated with new interventions related to the abuse allegation, as confirmed by the DON, which was inconsistent with facility policy.
A resident with Huntington's Disease and moderate cognitive impairment did not receive PT/OT assessments after falls, despite IDT recommendations. The facility's care plan intervention for PT was not implemented, and interviews with staff confirmed that expected referrals were not made.
A facility failed to ensure a physician conducted an initial comprehensive visit for a resident with Huntington's Disease and other conditions. Despite NP assessments, no physician assessments were documented. The Medical Director observed the resident but did not document assessments, and the facility's policy lacked clarity on responsibility for initial visits.
A facility failed to maintain accurate medical records for a resident with multiple diagnoses, including seizures and COPD. The resident's MAR showed a blank entry for a scheduled Clonazepam dose, despite it being signed out in the Controlled Drug Administration Record. A grievance was filed by the resident, claiming the medication was not received. The DQE considered the grievance resolved, but the DON noted that the UM should have followed up with the LPN to address the unsigned MAR. Attempts to contact the LPN were unsuccessful, contributing to the deficiency.
The facility failed to provide nourishing bedtime snacks to residents when there was more than a fourteen-hour span between dinner and breakfast. Residents reported that snacks were not offered every night and had to be requested, often limited to chips, pretzels, or cookies. The RD and DD acknowledged the extended time between meals and the lack of automatic provision of nutritious snacks.
The facility failed to store, label, and date potentially hazardous foods properly, leading to several observed issues such as improperly dated sour cream and cottage cheese, missing vinyl strip curtains in the freezer, dusty cans in dry storage, and a malfunctioning milk box latch. The facility's policies on labeling, dating, and food storage were not followed, and senior staff acknowledged these concerns during the survey.
The facility failed to maintain the required minimum direct care staff-to-resident ratios for 75 out of 105 day shifts reviewed. The deficiency was identified through interviews and a review of facility documents, revealing a consistent pattern of understaffing during day shifts. The LNHA and DON acknowledged the issue, and the Staffing Coordinator confirmed that the facility fell short of the required ratios at times.
The facility failed to follow infection control practices, including the use of PPE, maintaining sanitary medical supplies, and performing proper hand hygiene. Staff did not wear isolation gowns or sanitize equipment as required, and medical supplies were found on the floor. These deficiencies were confirmed by the Infection Preventionist and other staff.
The facility failed to implement an adequate antibiotic stewardship program, as evidenced by the lack of proper surveillance documentation for antibiotic use. The Infection Preventionist (IP) could not provide the requested forms, and the Chief Clinical Officer Licensed Nursing Home Administrator (CCO/LNHA) acknowledged that no tracking sheets were available after October 2023.
The facility failed to maintain a resident bathroom sink in working condition and to keep resident rooms and common areas safe and sanitary. The Maintenance Director was unaware of the sink issue, and the electronic work order system did not contain a report of the malfunction. Additionally, several deficiencies were observed in the Second-Floor nursing unit, including peeling wallpaper and holes in the walls. Senior staff acknowledged these issues.
The facility failed to report to the DOH within two hours for allegations of exploitation, misappropriation of resident property, and verbal abuse involving a resident. The facility did not investigate the matters as abuse or report them to the DOH, despite the resident's alert and oriented status and the facility's own abuse policy requiring such actions.
The facility failed to investigate allegations of exploitation and verbal abuse involving a resident and two CNAs. The facility did not follow its abuse policy, leading to deficiencies in handling the reported incidents.
The facility failed to administer medications on time for two residents, complete the dialysis communication book for a resident on dialysis, and follow a physician's order to monitor a resident for urinary retention. These deficiencies were confirmed by the Director of Nursing, Unit Manager, and Licensed Nursing Home Administrator.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, for 5 of the 16 weekends reviewed. Despite efforts to reach out to agency staff, the facility had difficulty scheduling RNs, particularly from the beginning of 2023 until May 2023. The LNHA and DON confirmed the staffing issues during the surveyor's entrance conference and subsequent interviews.
The facility failed to properly label and date medications and did not maintain a medication refrigerator temperature log. Multiple medications were found opened and undated, and the refrigerator temperature log was incomplete. The LPN and UM/LPN acknowledged these deficiencies, and the RDON confirmed that all medications should be dated and refrigerator temperatures monitored daily.
The facility failed to meet residents' nutritional needs and preferences, including serving inadequate protein portions, not following the menu, and not providing requested coffee. Additionally, a resident was served pork despite their preference for non-pork meals.
The facility failed to ensure safe and appetizing food temperatures during a lunch meal observation. Residents reported that meals were often cold, and the surveyor confirmed that food temperatures were below the required 135 degrees Fahrenheit. The Director of Dietary and the LNHA acknowledged the issue.
The facility failed to accurately document the administration of a controlled medication for a resident. An LPN admitted to forgetting to sign the declining inventory sheet after administering tramadol, leading to a discrepancy in the medication count. The Unit Manager and Regional Director of Nursing confirmed the proper procedure was not followed.
The facility failed to assist a resident out of bed daily with a hoyer lift as ordered by the physician. The resident, who had not been out of bed for over a week, expressed a desire to be moved. Staff interviews revealed inconsistencies and a lack of communication regarding the resident's care and the condition of the geri chair.
A resident with a right-hand contracture did not receive appropriate services to prevent further decrease in range of motion. The resident reported pain from a prescribed brace, but no action was taken by the nursing staff. The brace order was not documented in the MAR/TAR, and the care plan was not updated. Staff interviews revealed a lack of awareness and responsibility regarding the brace application and monitoring.
The facility failed to update a resident's care plan with necessary safety interventions post-fall. The resident, with a history of falls, was observed without footrests on their wheelchair, leading to a fall and subsequent fracture. Staff interviews confirmed the care plan was not updated to include footrests, which was identified as the root cause of the fall.
A facility failed to accurately complete the MDS assessment for a resident with multiple diagnoses, including PTSD, which was omitted from the most recent MDS. The MDS Coordinator and LNHA acknowledged the oversight, and the facility's policy lacked a clear process for MDS completion.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident's care plan lacked interventions for urinary retention and wound care, while another's did not address a PTSD diagnosis. Staff acknowledged these oversights, which were contrary to facility policies.
The facility failed to revise comprehensive care plans for two residents, leading to deficiencies in their care. One resident's care plan was not updated to address developed pressure ulcers, and another resident's care plan did not reflect financial interactions with a staff member. The facility's policy requires care plans to be updated to reflect changes in care needs, but this was not done.
The facility failed to serve meals in a dignified manner on the Second-Floor nursing unit. Observations revealed that residents were not served by tables, leading to some watching their tablemates eat while waiting for their own meals. Staff publicly discussed a resident's feeding status in a raised voice, and meal trays were delivered inconsistently. The facility's policies on serving food and resident rights were not adhered to.
The facility failed to provide a wheelchair for a resident, maintain a call bell within reach for another resident, and accommodate a resident's preference to smoke without getting wet during inclement weather. Staff confirmed these deficiencies, and the residents' medical records indicated severe cognitive impairments and dependence on staff for daily activities.
A resident reported that a CNA borrowed money and failed to repay it, but the facility did not investigate the incident as abuse. The resident, who was alert and oriented, felt pressured to give money to receive better care. The facility's policy requiring prompt investigation of abuse and misappropriation was not followed.
The facility failed to develop an abuse policy in accordance with regulatory guidelines and did not implement their abuse policy for an allegation of misappropriation of resident property. A resident reported that a CNA borrowed money and failed to repay it. The facility did not investigate the incident as abuse or report it to state agencies, and the CNA was terminated for refusing to provide a statement.
The facility failed to complete discharge MDS assessments for two residents within the required 14-day period post-discharge. The oversight was confirmed by the MDS/RN, MDS Coordinator, and senior staff during the survey.
Failure to Maintain Accurate and Complete MAR Documentation for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with professional standards, specifically related to a resident with Type 2 Diabetes Mellitus and other serious diagnoses. Surveyors reviewed this resident’s December Medication Administration Record (MAR) and Order Summary Report (OSR) and found no provider orders for glucagon, despite the DON’s statement that an LPN had administered glucagon three times over two days for hypoglycemic events. The DON acknowledged that the LPN gave glucagon without a provider order, describing the situation as emergent, and further admitted that the LPN did not subsequently contact the provider or have an order transcribed into the record, contrary to facility policy requiring verbal orders to be recorded immediately in the resident’s chart. The survey also identified inaccurate MAR documentation when the DON entered medication administration information on behalf of the LPN. The DON stated that the LPN had reported the resident refused insulin on two dates, and because the LPN was remote and did not have access to the MAR, the DON entered the information using her own electronic signature instead of the LPN’s. This practice conflicted with the facility’s charting and documentation policy, which states that entries in the clinical record must be made by the licensed personnel providing the care, in accordance with state law and facility policy. The LPN did not return the surveyor’s call for an interview, and the DON reported that the LPN declined to speak with the surveyor.
Failure to Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with appropriate interventions following an allegation of staff-to-resident abuse involving a resident admitted with diagnoses including diabetes, major depressive disorder, and hypertension. The resident, who had intact cognition as indicated by a BIMS score of 14 out of 15, reported to the social worker that a CNA was rough while assisting with bed mobility, describing being shoved into bed without being given the opportunity to move independently. The incident was documented in the facility's investigation summary, which noted the resident's desire for increased independence and the CNA's intent to prevent a fall. A review of the resident's care plan revealed that no updates or new interventions were added in response to the abuse allegation. The DON confirmed during an interview that the care plan was not revised after the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition or circumstances dictate. The lack of care plan update was identified during a survey and was found to be inconsistent with both facility policy and regulatory requirements.
Failure to Implement PT/OT Consults After Falls
Penalty
Summary
The facility failed to implement a care plan intervention for a physical therapy (PT) consult and did not provide a resident with a PT/OT assessment after a fall, as recommended by the Interdisciplinary Team (IDT). This deficiency was identified for one resident who was admitted with diagnoses including Huntington's Disease, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a moderately impaired cognition with a BIMS score of 9 out of 15. The care plan included a PT consult for strength and mobility initiated on a specific date, but the medical record did not indicate that the consult was completed. Incident reports revealed that the IDT recommended PT/OT assessments after two unwitnessed falls, but the medical record showed no evidence of these assessments being completed. Interviews with the Director of Rehabilitation Services and the Director of Nursing confirmed that referrals for PT/OT assessments were expected but not made. The facility's care plans policy emphasized the importance of revising care plans to prevent or reduce declines in functional status and enhance optimal functioning, but this was not adhered to in the case of the resident.
Failure to Conduct Initial Comprehensive Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit for a resident. This deficiency was identified during a survey conducted on specific dates, where it was found that a resident, who was no longer at the facility, did not have any documented physician assessments. The resident had been admitted with diagnoses including Huntington's Disease, severe protein-calorie malnutrition, and adult failure to thrive, and had a moderately impaired cognitive status as indicated by a BIMS score of 9 out of 15. Despite the presence of Nurse Practitioner assessments in the resident's medical record, there were no documented physician assessments. The Medical Director, who was also the resident's attending physician, stated that he observed the resident and discussed their care in meetings but did not provide documented assessments. The facility's policy did not clearly identify who was responsible for conducting initial comprehensive visits, contributing to the oversight in ensuring the resident received the necessary physician services.
Deficiency in Medication Documentation and Grievance Handling
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in the documentation of medication administration. The resident, who had diagnoses including seizures, severe protein-calorie malnutrition, and COPD, was prescribed Clonazepam for anxiety. However, a review of the Medication Administration Record (MAR) revealed a blank box for the medication on a specific date, despite the Controlled Drug Administration Record indicating that the medication was signed out. This discrepancy was further highlighted by a grievance filed by the resident, stating that they did not receive the scheduled medication. The grievance was reviewed by the Director of Quality Experience (DQE), who considered it resolved after the Unit Manager (UM) found no discrepancies upon reviewing the MAR. However, the Director of Nursing (DON) noted that the UM should have followed up with the assigned nurse to address why the MAR was not signed. The surveyor's attempt to contact the Licensed Practical Nurse (LPN) responsible for the resident's care on the date in question was unsuccessful, as the provided contact number was not in service. This lack of follow-up and incomplete documentation contributed to the deficiency in maintaining accurate medical records.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficiency was identified for five residents who reported that bedtime snacks were not offered every night and that they had to request snacks, which were often limited to chips, pretzels, or cookies. The residents confirmed that dinner was served between 4:30-5:00 PM and breakfast between 8:00-8:45 AM, resulting in a fifteen-hour and twenty-five-minute period between meals. The Registered Dietitian (RD) and the Director of Dietary (DD) were interviewed and acknowledged the extended time between meals and the lack of automatic provision of nutritious snacks to residents. The surveyor reviewed the facility's mealtime schedule and found that the first dinner cart was served at 4:15 PM and the first breakfast cart at 7:40 AM. The RD stated that she did not oversee the snacks and was unsure of the delivery times and the definition of a nourishing snack. The DD confirmed that snacks were available only upon request and acknowledged the need for providing nutritious snacks due to the extended time between dinner and breakfast. The Licensed Nursing Home Administrator (LNHA) confirmed that all residents should have been provided nutritious snacks and acknowledged that a nourishing snack should contain protein. The facility's Serving of Food policy did not include procedures for providing nourishing bedtime snacks when the period between dinner and breakfast exceeded fourteen hours.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to store, label, and date potentially hazardous foods properly, which could lead to food-borne illness. During a kitchen tour, the surveyor observed several issues: a five-pound container of sour cream opened on 2/1/24 with an unclear usage period, a five-pound container of cottage cheese opened on 2/13/24 with an expiration date of 2/24/24, and an opened gallon of mayonnaise without an opened date or use-by date. Additionally, the walk-in freezer had missing vinyl strip curtains, dry storage had cans with visible white particles and dust, a forty-pound bucket of chicken-flavored base had a heavily soiled lid, and the reach-in milk box #2 had a latch that did not close properly. The ice cream freezer also had a built-up accumulation of ice. The facility's policies on labeling, dating, and food storage were not followed, as evidenced by the undated facility-provided Labeling and Dating System Protocol and Food Storage policy. These policies required following the manufacturer's expiration dates and maintaining clean and sanitary food storage areas. The Licensed Nursing Home Administrator, along with other senior staff, acknowledged these concerns during the survey. The failure to adhere to these protocols and maintain sanitary conditions in food storage areas was a significant deficiency observed by the surveyor.
Failure to Maintain Required Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 75 out of 105 day shifts reviewed. This deficiency was identified through interviews and a review of pertinent facility documents. The New Jersey Department of Health memo dated 01/28/2021, which established minimum staffing requirements in nursing homes, was referenced. The facility was found to be non-compliant with the required staffing ratios for multiple weeks between November 2022 and February 2024. For example, on 11/20/22, the facility had only 8 CNAs for 121 residents on the day shift, whereas at least 15 CNAs were required. Similar deficiencies were noted on various other dates, indicating a consistent pattern of understaffing during the day shifts. During the entrance conference on 2/27/24, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged that the facility primarily utilized agency staff for certified nursing aides (CNAs) and had callouts. The surveyor requested the Nurse Staffing Report for several weeks, which revealed multiple instances of non-compliance with the required staffing ratios. The Staffing Coordinator confirmed that she scheduled staff according to state and federal regulations but admitted that the facility fell short at times. The facility used two agency staff companies to cover callouts or lack of facility staff, and the Staffing Coordinator, who was also a CNA, had to work on the floor when the facility was short-staffed. On 3/7/24, the LNHA, in the presence of the Regional DON, Chief Clinical Officer, and survey team, acknowledged that the facility had days where the staffing requirements did not meet state ratios. A review of the facility's undated Staffing policy indicated that the facility aimed to maintain adequate staffing on each shift to ensure that residents' needs and services were met. However, the facility's staffing levels frequently fell below the required ratios, leading to the identified deficiency.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that infection control practices were followed, particularly in the use of personal protective equipment (PPE) for residents on enhanced barrier precautions. Observations revealed that staff did not wear isolation gowns or perform hand hygiene as required when providing care to residents. For instance, a Licensed Practical Nurse (LPN) repositioned a resident and administered nutrition via a gastrostomy tube without wearing an isolation gown. Additionally, the Unit Manager entered the resident's room without performing hand hygiene. The Infection Preventionist confirmed that PPE was not readily accessible, and staff were not adhering to the required precautions. Medical supplies and equipment were not maintained in a sanitary manner, contributing to the risk of infection. The surveyor observed corrugated oxygen tubing and urinary catheter drainage bags on the floor, which were not discarded or replaced as needed. Soiled medical equipment, such as suction machines and feeding pumps, were also noted. The Infection Preventionist and other staff acknowledged that these items should have been cleaned or replaced to prevent infection. Proper hand hygiene was not performed prior to dining, and infection control practices were not followed during medication administration. Certified Nursing Aides (CNAs) did not perform hand hygiene between assisting different residents with hand wipes. During medication pass observations, LPNs failed to sanitize blood pressure cuffs and other equipment between uses, and one LPN used a clipboard as a tray without sanitizing it. The Director of Nursing and other staff confirmed that these practices were not in line with infection control protocols.
Failure to Implement Adequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an adequate antibiotic stewardship program, as evidenced by the lack of proper surveillance documentation for antibiotic use. During a review of the last three months of antibiotic use and conducted surveillance from November 2023 through February 2024, the Infection Preventionist (IP) was unable to provide the requested surveillance documentation. The IP mentioned that nurses filled out blue forms on the units for antibiotic use, which she reviewed during morning meetings and documented in a spreadsheet for the Director of Nursing (DON). However, the IP could not provide these forms when requested. The Chief Clinical Officer Licensed Nursing Home Administrator (CCO/LNHA) later provided antibiotic tracking sheets from April 2023 through October 2023 but acknowledged that no further tracking sheets were available after October 2023. The facility's Infection Control Program Overview indicated that the IP should monitor and document infections, but this was not adequately done.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a resident bathroom sink in a sanitary working condition and to maintain resident rooms and common areas in a safe, sanitary, and comfortable environment. During a water temperature tour, the surveyor observed that the sink in a resident's bathroom did not operate properly, with water only dripping out. The Maintenance Director (MD) was unaware of the issue, and the electronic work order system did not contain any report of the malfunction. Interviews with Certified Nursing Aides (CNAs) revealed that they were aware of the issue but believed it had been reported to the MD or entered into the electronic work order system. The MD later confirmed that the faucet had to be replaced and acknowledged that no work order had been entered into the system. Additionally, during a tour of the Second-Floor nursing unit, the surveyor observed several deficiencies, including a hole in the wall behind a door handle, peeling wallpaper, missing wallpaper panels, and paint peeling from the walls in the day room. The MD acknowledged these issues and stated that repairs were needed throughout the floor. The Licensed Nursing Home Administrator (LNHA) and other senior staff acknowledged that these conditions should not exist and that the facility's policy required a safe, clean, and comfortable environment for residents.
Failure to Report Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to report to the New Jersey Department of Health within two hours for an allegation of exploitation and misappropriation of resident property and an allegation of verbal abuse. This deficiency was identified for two incidents involving Resident #47. The first incident involved a Certified Nursing Aide (CNA #1) who borrowed money from the resident and failed to repay it. Despite the resident's alert and oriented status, the facility did not investigate the matter as abuse or report it to the DOH. The grievance form did not include witness statements or a completed Resident Abuse Form as per facility policy. The second incident involved verbal abuse by another CNA (CNA #2) who allegedly yelled at the resident and made derogatory comments. The resident reported feeling disrespected and upset by the interaction. The facility did not investigate or report this incident to the DOH, as the Licensed Nursing Home Administrator (LNHA) believed the CNA was simply loud and that abuse was ruled out. The facility's abuse policy requires notification to the DOH within one business day, which was not followed in either case. The facility's failure to report these incidents to the DOH within the required timeframe and to conduct thorough investigations as per their policy constitutes a significant deficiency. The LNHA confirmed that the incidents were not reported to the DOH or any other authority, and the facility did not follow its own procedures for handling allegations of abuse and misappropriation of funds.
Failure to Investigate Allegations of Exploitation and Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of exploitation and misappropriation of resident property and an allegation of verbal abuse. In the first incident, a resident reported that a CNA, who no longer worked at the facility, had borrowed money from them and failed to repay approximately $330. The resident had informed the Director of Quality Experience and the Licensed Nursing Home Administrator, who took pictures of the transactions but did not conduct a thorough investigation as required by the facility's abuse policy. The grievance form did not include witness statements or a completed Resident Abuse Form, and the incident was not reported to the Department of Health (DOH). In the second incident, the same resident reported that another CNA had verbally abused them by yelling and making derogatory comments. The resident stated that the CNA had refused to provide ice water and made the resident feel uncomfortable by leaving the light on and the door open. The facility's investigation was limited to removing the employee from the schedule and providing education, without reporting the incident to the DOH or conducting a thorough investigation as per the facility's policy. The facility's failure to investigate these allegations properly and report them to the DOH is a violation of their abuse policy. The facility's undated Abuse Policy & Procedure requires immediate notification and a thorough investigation of any reported incidents or suspected incidents of abuse, neglect, or misappropriation of resident property. The facility did not follow these procedures, leading to deficiencies in handling the reported incidents.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to administer medications within scheduled parameters for two residents. Resident #38 had multiple instances where medications were administered late, particularly during weekend shifts. The April 2023 Medication Administration Record (MAR) showed numerous dates where medications were given hours past the scheduled time. The Director of Nursing (DON) acknowledged these discrepancies, confirming that medications should be administered within an hour of the scheduled time, and if delayed, the physician should be contacted. Similarly, Resident #42's 9:00 AM medications were administered late on 2/29/24, as observed by the surveyor and confirmed by the Licensed Practical Nurse (LPN) and Unit Manager (UM). The LPN admitted to administering treatments and medications simultaneously, which led to the delay. The facility also failed to complete the dialysis communication book for Resident #37, who was on dialysis. The dialysis communication book had multiple instances of missing documentation, including missing staff signatures and vital signs. The Unit Manager (UM) acknowledged these gaps, stating that the dialysis center staff were responsible for post-dialysis vital signs, but the facility staff should have ensured the book was filled out completely. The Licensed Nursing Home Administrator (LNHA) and other senior staff confirmed the missing documentation during a review. Additionally, the facility did not follow a physician's order to monitor Resident #45 for urinary retention. The order required monitoring urine output every shift and documenting the number of wet briefs per shift. However, the Progress Notes showed no entries from 1/25/24 to 3/1/24, indicating a lack of documentation. Interviews with Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) confirmed that urinary retention should be reported and documented, but this was not done for Resident #45. The UM and LNHA acknowledged the missing documentation and confirmed that the physician's order was not fully completed.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, for 5 of the 16 weekends reviewed. This deficiency was identified through interviews, review of Nurse Staffing Report sheets, and other pertinent facility documents. Specifically, there were no RNs scheduled for eight consecutive hours on 1/7/23, 2/18/23, 2/25/23, 3/18/23, and 5/27/23 through 5/28/23. The facility's staffing coordinator acknowledged the difficulty in scheduling RNs, particularly from the beginning of 2023 until May 2023, despite efforts to reach out to agency staff for coverage. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) confirmed the staffing issues during the surveyor's entrance conference and subsequent interviews. The facility's undated staffing policy states that adequate staffing should be maintained on each shift to meet residents' needs and services. However, the review of the Nurse Staffing Reports revealed gaps in RN coverage, with the last RN scheduled on the 3:00 PM to 11:00 PM shift on the day before the deficiency dates. The LNHA, in the presence of the Regional DON, Chief Clinical Officer, and survey team, acknowledged the facility's failure to schedule RNs for the required hours on the specified dates. This failure was in violation of NJAC 8:39-25.2(h).
Failure to Properly Label Medications and Maintain Refrigerator Temperature Log
Penalty
Summary
The facility failed to properly label and date medications in accordance with manufacturer recommendations and did not maintain a medication refrigerator temperature log to ensure safe medication storage. During an inspection of the Second-Floor nursing unit's low cart, multiple multi-dose medications, including inhalers and insulin vials, were found opened and undated. The LPN acknowledged that these medications should have been dated when opened. Additionally, an opened and undated bottle of lorazepam was found in the medication refrigerator, and the refrigerator temperature log had not been completed for one of the days inspected. The UM/LPN confirmed that all medications should be dated when opened and that refrigerator temperatures should be monitored and recorded daily. The facility's policies on medication storage and refrigerator maintenance were reviewed and found to be undated. The policies indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner, and that refrigerator temperatures should be tracked monthly. The RDON stated that all medications should be dated when opened and discarded per manufacturer's instructions, and that nurses should monitor refrigerator temperatures to ensure they are within a safe range for medication storage.
Nutritional and Dietary Preference Deficiencies
Penalty
Summary
The facility failed to ensure that residents received meals that met their nutritional needs and preferences. During the survey, it was observed that the dietary staff did not follow the menu, serving only one fish cake instead of the required two, and cutting sweet potatoes in half instead of serving whole ones. The Registered Dietitian (RD) confirmed that the protein portion served was inadequate and that the menu had not been reviewed for nutritional adequacy. Additionally, residents were not informed of menu changes, and the facility used outdated nutrition guidelines from 2000 instead of the current 2020-2025 recommendations. Several residents reported not receiving their requested coffee with meals. The surveyor observed that Resident #21 and Resident #6 did not receive coffee as indicated on their dietary slips. Staff interviews revealed that the kitchen did not have enough coffee cups, leading to residents frequently missing their coffee. The RD and Director of Dietary (DD) confirmed that the kitchen was responsible for ensuring tray accuracy, but the issue persisted due to a lack of resources. Resident #99, who had a preference for non-pork meals, was served ham despite their dietary slip indicating otherwise. The resident had to request sandwiches instead, and the RD confirmed that the resident's preferences were not updated in the system. The facility's policy required that food preferences be honored, but this was not followed, leading to the resident being served food they did not eat. The Licensed Nursing Home Administrator (LNHA) acknowledged these concerns during the survey review.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure safe and appetizing temperatures of food for residents during a lunch meal observation. During a Resident Council meeting, four out of five residents reported that meals served at the facility were often cold or at room temperature. The surveyor observed the lunch meal service and noted that the food temperatures were not maintained at the required minimum of 135 degrees Fahrenheit for hot foods. The temperatures of the regular texture meal and the alternate regular texture meal were significantly below the required temperature when tested by the Director of Dietary (DD) and the surveyor. Residents on the Second-Floor nursing unit confirmed that their meals were not served hot, with several residents expressing dissatisfaction with the temperature of their food and beverages. The surveyor's observations included the calibration of the facility's digital thin probe thermometer, which was found to be accurate. Despite the use of a plate warmer and insulated domes and bases, the food temperatures dropped below the required levels by the time the meals were served to the residents. The DD acknowledged that the hot food should be at 135 degrees Fahrenheit and confirmed that the food on the test trays did not meet this standard. The Licensed Nursing Home Administrator (LNHA) and other facility leaders acknowledged the issue of cold food temperatures during a meeting with the survey team.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a controlled medication for one resident. During an inspection of the Second-Floor nursing unit's medication cart, it was found that the number of tramadol tablets in the blister pack did not match the declining inventory sheet. The Licensed Practical Nurse (LPN) admitted to administering the medication earlier and forgetting to sign the inventory sheet, which is required to ensure accurate inventory of controlled medications. The Unit Manager and the Regional Director of Nursing both confirmed that the LPN should have signed the declining inventory sheet immediately after removing the medication from the packaging. A review of the facility's Controlled Substance policy indicated compliance with laws and regulations related to controlled medications, but the Administering Medications policy did not include the process for documenting administration using a declining inventory sheet.
Failure to Assist Resident Out of Bed Daily as Ordered
Penalty
Summary
The facility failed to assist a resident out of bed daily with the use of a hoyer lift as ordered by the physician. This deficiency was identified for one resident who had not been assisted out of bed for over a week, despite expressing a desire to be moved. The resident's medical record indicated a physician's order for daily transfer to a geri chair at 11:00 AM, which was not followed. Observations by the surveyor confirmed that the resident remained in bed during multiple visits, and the resident confirmed the lack of assistance. The resident's diagnoses included peripheral vascular disease, obstructive uropathy, and muscle weakness, and the resident had a fully intact cognition as per the most recent assessment. Interviews with staff revealed inconsistencies and a lack of communication regarding the resident's care. The Certified Nursing Aide (CNA) responsible for the resident stated that the resident was only transferred out of bed three times a week, contrary to the physician's order. The geri chair was found in the shower room, and there was confusion among staff about whether the chair was broken. The Director of Rehabilitation was not informed about the chair's condition and stated that a temporary replacement could have been arranged if notified. The facility's Licensed Nursing Home Administrator and Regional Director of Nursing acknowledged the failure to follow the physician's order and the lack of communication regarding the geri chair.
Failure to Ensure Proper Use of Brace for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficiency was identified for one resident who had a contracture in the right hand and was supposed to wear a brace. The resident reported that the brace caused pain, and despite informing the nursing staff, no action was taken. The resident was observed multiple times without the brace, and the order for the brace was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The resident's care plan also did not include the contracture or the physician's order for the splint. Interviews with staff revealed a lack of awareness and responsibility regarding the application and monitoring of the brace. Certified Nursing Aides (CNAs) and Licensed Practical Nurses (LPNs) were not aware of the resident's need for the brace, and there was no documentation of the resident's refusal to wear the brace or the pain it caused. The Unit Manager and Director of Rehabilitation confirmed that the care plan should have been updated to include the contracture and the brace, and that any issues with the brace should have been reported to Physical Therapy (PT) or Occupational Therapy (OT) for further evaluation. The Licensed Nursing Home Administrator (LNHA) acknowledged the deficiencies, including the lack of documentation regarding the resident's refusal to wear the brace, the absence of the order in the MAR/TAR, and the failure to update the care plan. The facility's policies and job descriptions for CNAs, LPNs, and Unit Managers emphasized the importance of accurate documentation, updating care plans, and ensuring that physician's orders are followed, but these were not adhered to in this case.
Failure to Update Care Plan Post-Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed and the comprehensive care plan was updated post-fall with safety interventions for a resident with a history of falls. This deficiency was identified for one resident who was observed seated in a high-back wheelchair without footrests in the dining area. The resident had a history of falls and was admitted with diagnoses including anemia, a fracture of the right femur, and hypertension. The resident experienced a fall on 11/26/23, resulting in an acute right femoral neck fracture and was subsequently sent to the hospital. The incident report indicated that the resident fell from the wheelchair while attending activities, and the post-fall huddle revealed that footrests should have been used as a safety intervention, but this was not updated in the care plan at that time. Interviews with staff, including the CNA, Director of Rehabilitation, Physical Therapist, Recreation Aid, and Director of Nursing, revealed that the resident was not provided with the necessary footrests on the wheelchair, which was identified as the root cause of the fall. The Recreation Aid admitted to lifting the resident off the floor after the fall, which was against the facility's policy. The Director of Nursing confirmed that unit managers were responsible for completing and summarizing conclusions on interdisciplinary team notes after a fall, and that all activity staff were educated not to move a resident after a fall. The Licensed Nursing Home Administrator and Unit Manager/LPN confirmed that the care plan should have been updated to reflect the need for footrests on the wheelchair to prevent further falls. The facility's policy on assessing falls and their causes included evaluating for possible injuries before moving the resident and applying new interventions post-fall. However, the care plan for the resident was not updated with the necessary intervention of using footrests, leading to the deficiency identified in the report.
Failure to Accurately Complete MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident reviewed for unnecessary medications. The resident, who was observed self-propelling in a wheelchair, had diagnoses including schizophrenia, bipolar disorder, and cerebral infarction. A psychiatric progress note also indicated diagnoses of schizoaffective disorder, insomnia, and PTSD. However, the most recent comprehensive MDS did not include PTSD as an active diagnosis, despite the resident having a fully intact cognition as indicated by a BIMS score of 15 out of 15. The MDS Coordinator acknowledged that the PTSD diagnosis should have been included in the MDS and needed to modify it accordingly. The Licensed Nursing Home Administrator confirmed that the MDS had been updated to include PTSD but should have originally included it. Additionally, the facility's MDS submission Timeframes policy did not outline the process for completing an MDS assessment, contributing to the oversight.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #45 was admitted with osteomyelitis, a stage 4 pressure ulcer, and heart failure. Despite having physician's orders to monitor urine output and document wet briefs, these interventions were not included in the resident's care plan. Additionally, the care plan did not address the resident's wound care orders. Interviews with LPN #2 and the Unit Manager confirmed that these interventions should have been included in the care plan, and the Licensed Nursing Home Administrator acknowledged the oversight. Resident #80, who was diagnosed with schizophrenia, bipolar disorder, and PTSD, also had deficiencies in their care plan. The resident's most recent comprehensive MDS did not reflect the PTSD diagnosis, and the care plan lacked focuses, goals, or interventions related to PTSD. The MDS Coordinator admitted that the MDS should have included the PTSD diagnosis, and the Regional Director of Nursing confirmed that the care plan should have addressed the PTSD diagnosis. The Licensed Nursing Home Administrator also acknowledged this deficiency. The facility's policies and job descriptions for LPNs and Unit Managers emphasize the importance of updating care plans to reflect residents' current health statuses and physician's orders. However, these policies were not followed, leading to incomplete care plans for the residents. The facility's failure to update and implement comprehensive care plans compromised the residents' physical, mental, and psychosocial well-being.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise a comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #79, the facility did not update the care plan to address two developed pressure ulcers, despite the resident having a stage III pressure ulcer and an unstageable pressure wound. The Unit Manager confirmed that the care plan should have been updated to reflect these wounds and include appropriate interventions, but this was not done. The resident's medical records and progress notes indicated the presence of these wounds and the need for new treatments, but the care plan remained outdated. For Resident #47, the facility did not update the care plan to reflect that the resident had given money to a staff member. The resident reported multiple financial transactions with a CNA who no longer worked at the facility, and the CNA had stopped repaying the borrowed money. Despite the resident being alert and oriented, and the facility's administration being aware of the situation, the care plan was not revised to include this issue. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's financial interactions with the staff member. The facility's policy on Baseline Care Plan Completion and Ongoing Care Plan Updates requires that care plans be updated by nursing staff to reflect changes in care needs and physician's orders. However, in both cases, the care plans were not revised as required, leading to deficiencies in the residents' care. The facility's failure to update the care plans as needed was confirmed by multiple staff members, including the Unit Managers and the Licensed Nursing Home Administrator.
Failure to Serve Meals in a Dignified Manner
Penalty
Summary
The facility failed to ensure residents were served their meals in a dignified manner during meal services on the Second-Floor nursing unit. During meal observations, it was noted that a CNA placed a tray in front of a resident and walked away, leading to another resident taking the tray and being addressed in a raised voice by another CNA. Additionally, residents were not served by tables, resulting in some residents watching their tablemates eat while waiting for their own meals. The staff also publicly discussed a resident's feeding status in a raised voice, which was acknowledged as a dignity issue by the CNA involved. The surveyor observed that meal trays were delivered inconsistently, with some residents receiving their meals much later than others. The Unit Manager and other staff members acknowledged that residents should be served by tables, and those dependent on staff for feeding should be seated separately from those who could feed themselves. The facility's policies on serving food and resident rights were reviewed and found to include provisions for feeding residents with attention to safety, comfort, and dignity, which were not adhered to in this instance.
Deficiencies in Resident Accommodation and Safety
Penalty
Summary
The facility failed to provide a wheelchair for a resident who required one for mobility. The resident was observed in bed without a wheelchair on multiple occasions, and staff confirmed that the resident had been without a wheelchair for about a month. The resident's primary CNA had to borrow wheelchairs from other residents to get the resident out of bed. The resident was eventually provided with a reclining wheelchair after being evaluated for therapy services for sitting tolerance. The resident's medical record indicated severe cognitive impairment and functional limitations in mobility, necessitating the use of a wheelchair for getting out of bed. Another deficiency was observed when a resident's call bell was found wrapped around a circadian alert system, making it inaccessible to the resident. The call bell was observed in this state on multiple occasions, and staff acknowledged that it should not have been tied around the alert system. The resident's medical record indicated severe cognitive impairment and dependence on staff for all activities of daily living, highlighting the importance of having the call bell within reach for summoning assistance. The facility also failed to accommodate a resident's preference to smoke without getting wet during inclement weather. The designated smoking area did not provide adequate shelter for residents to smoke without getting wet when it rained. The Director of Activities and the LNHA acknowledged that the smoking area was insufficient for the number of residents who smoked, leading to complaints from residents about getting wet during inclement weather. The facility's policies on resident rights and smoking practices emphasized the need for reasonable accommodations and safe smoking environments, which were not met in this case.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
The facility failed to ensure a resident was free of exploitation and misappropriation of property. A resident reported that a CNA, who no longer worked at the facility, had borrowed money from them multiple times and failed to repay around $330. The resident had informed the Director of Quality Experience (DQE) and the Licensed Nursing Home Administrator (LNHA), but no further action was taken. The facility's investigation did not include the abuse allegation made by the resident, and the grievance form lacked witness statements and a completed Resident Abuse Form as per facility policy. The resident, who had diagnoses including multiple sclerosis, major depressive disorder, insomnia, and anxiety, was alert and oriented with a fully intact cognition score. The resident's care plan did not include the issue of giving money to staff, and there was no documentation of the incident in the progress notes. The resident stated that the CNA would take their personal items and borrow money, promising to repay but failing to do so. The resident felt pressured to give money to the CNA to receive better care. Interviews with the Director of Nursing (DON), LNHA, Director of Social Services (DSS), and DQE revealed that the facility did not investigate the incident as abuse because the resident was alert and oriented. The LNHA confirmed that it was against facility policy for staff to accept money from residents. The CNA was terminated for refusing to provide a statement on the incident. The facility's undated Abuse Policy and Procedure required prompt and thorough investigation of all reports of resident abuse, neglect, and misappropriation of property, which was not followed in this case.
Failure to Develop and Implement Abuse Policy
Penalty
Summary
The facility failed to develop an abuse policy in accordance with regulatory guidelines and did not implement their abuse policy for an allegation of misappropriation of resident property. The surveyor found that the facility's abuse policy did not include necessary components such as screening, training, prevention, identification, and protection. Additionally, the policy incorrectly stated that the facility had one business day to report suspected abuse to the New Jersey State Department of Health, instead of the required two hours. The Licensed Nursing Home Administrator (LNHA) confirmed these deficiencies during the surveyor's review and interviews. A resident reported that a Certified Nursing Aide (CNA) had borrowed money from them multiple times and failed to repay approximately $330. The facility's Director of Quality Experience (DQE) and LNHA were aware of the situation but did not take further action beyond completing a grievance form. The grievance form lacked witness statements and did not follow the facility's abuse policy, which required a thorough investigation and completion of a Resident Abuse Form. The LNHA confirmed that the incident was not investigated as abuse and was not reported to any state agencies. The LNHA stated that the facility did not consider the incident as misappropriation of funds because the resident was alert and oriented and had willingly given the money to the CNA. However, the LNHA acknowledged that it was against facility policy for staff to accept money from residents. The CNA was terminated for refusing to provide a statement, not for accepting the resident's money. The LNHA, along with the Regional DON and Chief Clinical Officer, confirmed that the incident was never investigated or reported to state agencies.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments as required for two residents. Resident #13 was discharged on November 4, 2023, and Resident #111 was discharged on October 30, 2023. Both residents' discharge MDS assessments were not completed within the required 14-day period post-discharge. The MDS/Registered Nurse (RN) and the MDS Coordinator confirmed that the assessments were not completed, citing that the MDS Coordinator should have completed the assessments despite assistance with quarterly assessments at the time. The Licensed Nursing Home Administrator (LNHA) and other senior staff confirmed the oversight during an interview with the survey team. The facility's policy and the Centers for Medicare & Medicaid Services' (CMS) Resident Assessment Instrument (RAI) Manual were reviewed, both of which mandate that discharge assessments be completed within 14 days of discharge and submitted within an additional 14 days. The failure to complete these assessments was acknowledged by the facility's staff during the survey process.
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.
