Arnold Walter Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazlet, New Jersey.
- Location
- 622 S Laurel Avenue, Hazlet, New Jersey 07730
- CMS Provider Number
- 315119
- Inspections on file
- 18
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Arnold Walter Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hypothyroidism and other serious conditions did not receive prescribed Liothyronine at multiple scheduled times due to medication unavailability. Staff failed to notify the physician or document reasons for missed doses as required by facility policy, and appropriate follow-up actions were not completed, as confirmed by the DON.
The facility failed to maintain proper kitchen sanitation, as observed during a survey. The FSD performed inadequate hand hygiene, and the trash receptacle was improperly positioned, risking contamination of clean supplies. Paper towels were stored incorrectly, and the exhaust hood had chipping paint. Cutting boards were discolored and pitted, and food in the freezer was improperly stored, leading to freezer burn. These issues indicate non-compliance with facility policies and CDC guidelines.
The facility failed to maintain a homelike environment on two nursing units. On the A Wing, issues included standing water in the shower room, discolored heaters, and inadequate window coverings. On the D Wing, there was ripped wallpaper and damaged baseboards. Staff acknowledged these concerns, but the facility did not adhere to its policy of providing a clean and comfortable environment.
The facility failed to manage respiratory equipment properly, leading to potential contamination. Oxygen tubing for two residents was left unbagged, and one resident used oxygen without a physician's order. Another resident's nebulizer tubing was undated and uncovered, with missing documentation for vital signs during treatments. Tracheostomy care for a resident was not performed with aseptic technique, as required by facility policy.
A facility failed to provide adequate pain management for a resident with a right below-knee amputation. The physician's order for acetaminophen lacked a specified pain level, and there was inconsistent documentation of pain assessment and medication effectiveness. Staff interviews revealed that the resident frequently complained of pain, but documentation was often missing due to nurses being busy. Facility policies required documentation of pain assessments, which were not consistently followed, leading to inadequate pain management.
A facility failed to maintain a resident's dignity during feeding assistance, as CNAs were observed standing over a resident while feeding them, contrary to the facility's policy. The resident, who was legally blind and required substantial assistance, confirmed that CNAs usually stood while assisting with meals. The DON acknowledged that the observed practices did not align with the facility's policy, which emphasized feeding residents with attention to safety, comfort, and dignity.
Two residents' care plans were not updated to include necessary interventions for oxygen use and fall prevention. One resident, receiving oxygen and at risk for falls, had no interventions for oxygen administration or floor mats in their care plan. Another resident using oxygen at night also lacked an intervention for oxygen in their care plan. Staff confirmed these omissions, which contradicted facility policies requiring care plans to be revised as conditions change.
Surveyors identified deficiencies in medication security and PICC line care at an LTC facility. An LPN left medications unsecured on a cart, posing a safety risk, while a resident with a PICC line had an outdated dressing that had not been changed according to facility policy. The facility's DON and other staff acknowledged these issues.
The facility failed to ensure proper accountability and documentation of narcotic medications. Reviews of medication carts revealed missing signatures on shift change logs and incomplete documentation of controlled substance administration. Interviews with staff confirmed that these logs should be completed and signed by both outgoing and incoming nurses, as per facility policy, but this was not consistently done.
The facility failed to properly label and secure medications, as observed during a survey. Opened multidose medications were not dated or labeled with resident information, and prefilled normal saline syringes were found unsecured at a resident's bedside. The facility's policy requires medications to be stored in labeled containers and secured in locked compartments, which was not followed.
The facility failed to properly store and label a resident's personal ice cream brought in by family, which was found in the freezer without a name label and past the discard date. The ice cream belonged to a resident no longer at the facility, violating the policy requiring labeling and timely disposal of uneaten portions.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including acute and chronic respiratory failure, congestive heart failure, and hypothyroidism did not receive their prescribed Liothyronine medication as ordered by the physician. The physician's order specified administration of Liothyronine 25 mcg orally four times daily, but the medication was not given at several scheduled times. Documentation in the Medication Administration Record (MAR) indicated missed doses with comments such as 'awaiting pharmacy delivery,' and in some instances, there was no comment or rationale provided for the omission. Interviews with facility staff revealed that the process for obtaining and administering medications involved the Unit Manager entering orders, pharmacy verification, and delivery to the facility. If a medication was unavailable, staff were expected to notify the physician and seek alternatives. However, in this case, there was no documentation that the physician was informed about the missed doses, and the required follow-up actions were not completed. The Director of Nursing confirmed that staff should have documented a rationale for any missed medication and notified the physician and Unit Manager. Facility policy required immediate notification of the nursing supervisor and physician if a medication was unavailable, contacting the pharmacy, and documenting the reason for any missed dose in the EMAR. These procedures were not followed, resulting in the resident not receiving their thyroid medication as ordered and the lack of appropriate documentation and communication regarding the omissions.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, which was observed during a survey. The Food Service Director (FSD) was noted to perform hand hygiene for only 16 seconds, contrary to the facility's policy and CDC guidelines that require at least 20 seconds of lathering. Additionally, the trash receptacle was positioned such that it could come into contact with clean kitchen supplies, and paper towels were improperly stored on a shelf above the trash receptacle, with some appearing wet. The exhaust hood above the cooking area had chipping paint, and several cutting boards in the food preparation area were discolored, stained, and pitted, indicating they were not properly maintained or replaced. In the walk-in freezer, opened boxes of corn on the cob and croissants were found with their contents exposed to air, leading to freezer burn, which was acknowledged by the Regional Food Service Director (RFSD) as inappropriate. The facility's policies on hand washing, equipment maintenance, and food storage were not adhered to, as evidenced by the observations and interviews conducted with the FSD and Infection Preventionist (IP). These deficiencies highlight a failure to follow established procedures designed to prevent foodborne illness and ensure a safe food service environment.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on two nursing units, A Wing and D Wing. On the A Wing, the surveyor observed a shower room with standing water that had a white milky coloring, red/orange discoloration on metal wall heaters, and window coverings made of thin paper-like material with holes, compromising privacy. Additionally, a resident room had a damaged window screen that did not fit properly. The Licensed Practical Nurse/Unit Manager and the Director of Nursing acknowledged these issues, with the latter agreeing that the environment was not homelike. The Maintenance Staff indicated that there was an electronic maintenance system in place, but the issues persisted. On the D Wing, the surveyor noted that the wallpaper behind a resident's bed was ripped, exposing the wall, and the vinyl baseboard in the hallway and a resident room was either wrinkled, coming off, or missing, with the drywall showing rust-like discoloration. The Regional Maintenance Director and the Regional Nurse, along with other facility staff, acknowledged these environmental concerns. The facility's policy emphasized providing a safe, clean, and homelike environment, but the observations indicated a failure to adhere to this policy.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to properly manage and store respiratory equipment, leading to potential contamination and infection control issues. For Resident #85, the oxygen tubing was observed unbagged and exposed to air, contrary to the facility's policy requiring it to be stored in a bag when not in use. This was confirmed by multiple staff members, including the LPN/UM, DON, and IP, who acknowledged the importance of bagging the tubing to prevent contamination. Additionally, Resident #71 was using oxygen without a physician's order, and the tubing was similarly left unbagged and exposed. Resident #73's nebulizer tubing was found undated and uncovered, lying on personal belongings, which could lead to contamination. The facility's policy required the tubing to be labeled, dated, and stored in a designated respiratory bag. Furthermore, there was a lack of documentation for pre and post vital signs and lung sounds during nebulizer treatments, as required by the physician's order. The LPN acknowledged the oversight and the need for proper documentation and storage of the nebulizer equipment. For Resident #115, tracheostomy care was not performed with aseptic technique. The LPN failed to change gloves and perform hand hygiene after removing the resident's trach gauze, leading to potential contamination. The facility's policy required aseptic technique for tracheostomy care, which was not followed in this instance. The IP and DON acknowledged the concerns regarding infection control and the need for proper hand hygiene during trach care.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper pain management for a resident with a right below-knee amputation, who frequently experienced pain in the surgical area. The physician's order for acetaminophen did not specify a pain level for administration, and there was no consistent documentation of pain assessment or reassessment after medication administration. The resident's medical records showed that pain medication was administered on multiple occasions without documented evidence of pain assessment, location, description, or effectiveness of the medication. Interviews with facility staff, including a CNA, PT, and LPN, revealed inconsistencies in pain management practices. The CNA reported that the resident often complained of severe pain and requested medication, while the PT noted that the resident experienced phantom pain and sometimes did not receive medication before therapy sessions. The LPN acknowledged that documentation of pain levels, location, and effectiveness was lacking, attributing it to nurses being busy and forgetting to document. The facility's policies on pain management and physician's orders required documentation of pain assessments and monitoring of medication effectiveness, which were not consistently followed. The Regional Director of Nursing confirmed that physician's orders should include a pain level and that all assessments should be documented in the MAR. The lack of documentation and adherence to policies resulted in inadequate pain management for the resident.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity while providing feeding assistance, as observed by a surveyor. During the initial tour, a Certified Nurses Aid (CNA) was seen standing over a resident in bed while feeding them, with the meal tray positioned behind the CNA. The resident later confirmed that CNAs typically stood while assisting with meals, although one CNA occasionally sat on the bed, requiring the resident to adjust their leg. The resident, who was legally blind and required substantial assistance with eating, was observed again being fed by a CNA standing over them. The Director of Nursing (DON) confirmed that the proper procedure for feeding assistance involved sitting next to the resident to ensure a dignified meal experience. The facility's policy on meal assistance emphasized feeding residents with attention to safety, comfort, and dignity, specifically advising against standing over residents during meals. The DON acknowledged that the observed practices by the CNAs did not align with the facility's policy, which was corroborated by the CNA's own understanding of the proper procedure.
Failure to Revise Care Plans for Oxygen and Fall Prevention
Penalty
Summary
The facility failed to revise the individual comprehensive care plans (ICCP) for two residents, leading to deficiencies in their care. Resident #85 was observed receiving oxygen via nasal cannula at 2 liters per minute, with floor mats folded up in their room. Despite being at risk for falls, the ICCP did not include floor mats as an intervention. Additionally, the ICCP lacked an intervention for oxygen administration, even though a physician's order was in place for oxygen use when the resident's oxygen saturation was below 92%. The Licensed Practical Nurse/Unit Manager acknowledged these omissions and confirmed that the care plan should have been updated to include these interventions. Resident #71, who had a diagnosis of chronic obstructive pulmonary disorder and used oxygen at night, also had an incomplete ICCP. The care plan did not include an intervention for oxygen administration, despite the resident's use of an oxygen concentrator. The resident reported that the facility did not provide a bag to store the oxygen tubing, which was observed lying on the bed. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed that oxygen should have been included as an intervention in the care plan. The facility's policies on comprehensive person-centered care plans and fall prevention emphasize the need for care plans to be revised as residents' conditions change and to include specific interventions for identified risks. However, the care plans for both residents failed to incorporate necessary interventions for oxygen use and fall prevention, as confirmed by the Regional Nurse and other staff members during the survey.
Medication Security and PICC Line Care Deficiencies
Penalty
Summary
The facility failed to properly secure medications during administration, as observed by surveyors. An LPN prepared medications for a resident, including a lidocaine patch and Miralax, and left them unsecured on a medication cart while attending to the resident in their room. This was acknowledged as a safety hazard by the LPN, the Unit Manager, and the Director of Nursing, as residents who wander could potentially access the unsecured medications. The resident involved had a history of spinal stenosis, spondylosis, difficulty walking, and muscle weakness, and was cognitively intact. In another instance, the facility did not ensure proper care for a resident with a peripherally inserted central catheter (PICC) line. The resident, who had chronic respiratory failure and a MRSA infection, showed the surveyor an IV access site with an outdated dressing that had not been changed since insertion. The facility's policy required dressing changes within 24 hours of insertion and weekly thereafter, but there were no records of such changes being made. The RN responsible for the resident confirmed the oversight, and the Infection Preventionist stated that physician's orders were necessary for PICC line dressing changes. The survey team, along with the facility's Regional Nurse, Assistant Administrator, and DON, acknowledged the deficiencies in both medication security and PICC line care. The facility's policies on medication administration and catheter dressing changes were not adhered to, leading to these deficiencies.
Deficiency in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs and accurately document the administration of controlled medications. During a review of medication storage, it was found that the Change of Shift Controlled Medication Accountability Records for two medication carts had missing signatures from both outgoing and incoming nurses across multiple shifts. This included missing signatures for day, evening, and overnight shifts over several months. Additionally, the Individual Patient Controlled Substance Administration Record log showed that a dose of oxycodone for a resident was not signed out by the administering nurse. Interviews with LPNs and the Director of Nursing confirmed that the change of shift accountability sheets and narcotic inventory logs should have been completed and signed by both outgoing and incoming nurses to ensure accurate counts. The facility's policy required that these logs be completed at each shift change and that the administration of controlled substances be documented immediately. However, the review revealed that these procedures were not consistently followed, leading to incomplete documentation and accountability issues.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label and secure medications, as observed during a survey. In two of the four medication carts reviewed, opened multidose medications such as ipratropium bromide/albuterol sulfate inhalation solutions and prescription artificial tears were not dated with an opened date or labeled with the resident's identifying information. This was confirmed by the LPNs present during the observations, who acknowledged that the medications should have been dated and labeled correctly. The facility's Medication Storage policy requires that medications be stored in their original, labeled containers and dated when opened, which was not adhered to in these instances. Additionally, during an initial tour of the facility, unsecured prefilled normal saline syringes were found at a resident's bedside, stored in a plastic cup on the nightstand. The DON confirmed that these syringes should have been secured in a medication storage compartment accessible only to nurses. The facility's policy mandates that all medications, except emergency drug kits, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. This failure to secure medications properly was a deviation from the facility's established guidelines.
Improper Storage of Resident's Personal Food
Penalty
Summary
The facility failed to ensure that food brought in by family and visitors for residents was stored and handled in a safe and sanitary manner. During a kitchen tour, a surveyor observed a container of black raspberry ice cream, which was approximately three-quarters empty and dated as opened on 9/23/24, stored in the facility's ice cream freezer. The ice cream was identified as belonging to a specific resident who was no longer at the facility, and it was not labeled with the resident's name. The facility's policy, last reviewed in November 2023, requires that food and beverages from outside sources be labeled with the resident's name and date, and any uneaten portion should be discarded after 72 hours. The Regional Nurse, along with the Director of Nursing, Assistant Administrator, and survey team, acknowledged that the ice cream should have been disposed of.
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.
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