Atlas Healthcare At Daughters Of Miriam
Inspection history, citations, penalties and survey trends for this long-term care facility in Clifton, New Jersey.
- Location
- 155 Hazel Street, Clifton, New Jersey 07011
- CMS Provider Number
- 315021
- Inspections on file
- 18
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Atlas Healthcare At Daughters Of Miriam during CMS and state inspections, most recent first.
Surveyors found that two residents received inappropriate incontinence care, including the use of double briefs without proper documentation or care plan updates, and that meal trays were not delivered in a timely manner due to insufficient staffing and lack of clear policy. Staff interviews revealed inconsistent practices and a lack of awareness regarding resident preferences and care plan requirements.
Surveyors identified that two residents had incomplete CNA documentation logs and care plans that were not updated to reflect their current incontinence status and care preferences. One resident's ADL records had multiple blank entries, and another resident's care plan was only updated to include the use of double briefs after surveyor inquiry, despite the resident being observed with double briefs. The DON confirmed the missing documentation and the need for care plan updates.
The facility failed to complete and transmit MDS assessments within the required 14 days for multiple residents, as identified by surveyors through interviews and record reviews. The MDSC/RN confirmed the delays, citing workload issues, and the facility relied on the RAI manual for guidelines without a separate policy. Meetings with the LNHA and DON did not yield additional information or corrective actions.
The facility failed to ensure physicians reviewed residents' care, including medications and treatments, and documented progress notes at each visit. This deficiency affected 14 residents, with overdue physician orders and missing progress notes. Interviews confirmed ongoing issues with physician services, despite facility policies requiring regular visits and documentation.
A facility failed to ensure a resident's privacy and dignity during medication administration. An LPN administered medications and checked a resident's blood pressure in the dining area, contrary to the facility's Resident Rights Policy. The resident's preference for this setting was not documented in their care plan, leading to a deficiency.
A facility failed to verify the credentials of a newly hired Social Worker (SW) upon hire. The SW's license was found to be inactive with reinstatement pending, and this was only verified after a surveyor's inquiry. The LNHA acknowledged a user error during the license renewal process and stated that HR should have verified the license upon hire, as per the facility's Hiring Policy.
A facility failed to provide written bed hold notices to a resident or their representative during multiple hospitalizations. The resident, with a complex medical history including dementia and COPD, was hospitalized for issues like catheter malfunction and ESBL. Despite policy requirements, no bed hold notifications were documented for the specified dates, as confirmed by facility staff.
A resident experienced significant cognitive decline and weight gain, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. The MDS Coordinator acknowledged the oversight but could not provide documentation or justification for the decision not to conduct the assessment, resulting in a deficiency.
The facility inaccurately coded the MDS for two residents, leading to discrepancies in assessments. One resident's weight was incorrectly recorded, and another's discharge location was misreported. The errors were acknowledged by staff but highlighted the absence of a specific MDS policy.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with a history of falls did not have an individualized care plan, another with multiple diagnoses had an incomplete plan for ADLs, and a third with a left arm splint lacked documented interventions. Additionally, a resident at risk for skin breakdown had a care plan missing necessary interventions. These oversights highlight the need for improved care planning processes.
A facility failed to conduct routine and accurate monthly Psychoactive Reviews for a cognitively impaired resident on psychotropic medications. The behavior monitoring records showed inconsistencies, and the PR did not account for all medications or documented behaviors. The facility's policy required comprehensive reviews, which were not adhered to, leading to incomplete monitoring.
A facility failed to update a resident's care plan with necessary interventions after falls and did not conduct quarterly fall risk assessments as required. The resident experienced several falls, and the care plan lacked previous interventions. Staff interviews revealed confusion about responsibilities for updating care plans and conducting assessments, contributing to inadequate supervision and increased accident risk.
A facility failed to administer the correct total volume of enteral tube feeding for a resident with a gastrostomy, as per physician's orders. The resident, with a history of stroke, dementia, and diabetes, was prescribed a specific volume of Diabetisource 1.2, but documentation showed significantly lower volumes were infused over several days. Interviews revealed confusion among nursing staff regarding documentation, leading to discrepancies in the Medication Administration Record.
A resident with a history of pneumonia was found with improperly stored nebulizer equipment, and the facility lacked an individualized care plan and necessary orders for equipment maintenance. The Unit Manager confirmed the absence of a care plan and order for weekly nebulizer changes, contrary to facility policy.
The facility failed to adjust medication schedules for two residents requiring dialysis, leading to missed doses and duplicate orders. One resident had duplicate blood sugar check orders, while another had eye drops scheduled during dialysis sessions. The facility's Hemodialysis Policy was not followed, resulting in deficiencies in care.
The facility failed to post accurate daily staffing information on two occasions, with outdated and incorrect Nursing Home Resident Care Staffing Reports observed by surveyors. Staff interviews and policy reviews confirmed the deficiencies, as the reports were not updated at the beginning of each shift as required.
A resident with dietary restrictions due to hypertension and diabetes did not receive meals according to their preferences, despite selecting items from a menu. The resident, who was cognitively intact, frequently received incorrect meals, such as turkey meatloaf instead of roasted chicken. The Food Service Director confirmed the resident's selections were not honored, and the facility's investigation cited unclear writing as the cause, despite clear indications on the menu.
The facility failed to maintain complete and accurate medical records, with late entries for physician visits, missing consent documentation for vaccinations and psychoactive medications, and incomplete bowel and bladder management records. These deficiencies were identified for several residents, highlighting significant oversights in care documentation and consent processes.
The facility failed to follow proper infection control practices, including hand hygiene and PPE use, as observed with a CNA and RN/UM. An LPN left a disinfecting wipes container open, compromising its effectiveness. Additionally, a resident on transmission-based precautions for COVID-19 lacked proper signage and documentation, indicating a failure to adhere to facility policies.
A resident with multiple serious health conditions was observed to be dehydrated, but the LPN on duty failed to promptly notify the physician or escalate the issue according to facility policy. Despite an initial attempt to contact the physician, no further action was taken until after the resident's death, and the required communication with supervisory staff and the Medical Director did not occur.
Deficient Incontinence Care and Delayed Meal Delivery
Penalty
Summary
Surveyors identified deficiencies related to the provision of incontinence care and timely meal delivery for residents. On the observed unit, there was only one CNA present to distribute breakfast trays, resulting in meal trays being left unattended and not delivered to residents within the expected timeframe. The DON confirmed that meal trays should be delivered within 5 to 10 minutes of arrival to keep food warm, but observations showed that the last tray was not delivered until significantly later. Staff interviews revealed that the lack of a written policy and reliance on verbal communication contributed to inconsistent meal delivery practices. Incontinence care deficiencies were also observed for two residents. One resident, who was cognitively impaired and required extensive assistance with ADLs, was found to be wearing double incontinence briefs, a practice not documented in the care plan and not in line with facility expectations unless specifically requested and documented. The CNA responsible stated that the double briefs were applied at the resident's request, but the RN and LPNS were unaware of this and confirmed it was not standard practice. The resident's care plan did not reflect this preference, and the DON stated that such preferences should be documented, especially for residents who are cognitively intact. A second resident was also found with double incontinence briefs, with staff unable to confirm who applied them and the care plan not reflecting this intervention until after surveyor inquiry. The resident was moderately cognitively impaired and had a history of urinary incontinence. The DON stated that double briefs should only be used if requested by the resident and documented in the care plan, and that this practice increases the risk of skin impairment and urinary tract infection. Facility policies reviewed did not provide clear guidance on the use of double incontinence briefs or the process for meal tray distribution, contributing to the observed deficiencies.
Incomplete Medical Records and Inaccurate Care Plans Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by missing documentation in the Certified Nursing Aide (CNA) accountability logs and care plans that were not updated to reflect current resident needs. For one resident with moderate cognitive impairment and incontinence, the CNA documentation logs for activities of daily living (ADLs) had multiple blank entries for specific dates in October, despite the expectation that CNAs document every shift. The Director of Nursing (DON) confirmed that the ADL log was the required care log for CNAs and acknowledged the missing documentation when notified by surveyors. For another resident with a history of stroke, hemiplegia, and urinary incontinence, the care plan was not revised to accurately reflect the resident's incontinence status and preference for extra protection until after surveyor inquiry. The CNA documentation for this resident also had blank entries for several shifts in October. Additionally, the resident was observed wearing double incontinent briefs, a preference that was only added to the care plan on the day of the survey after being brought to the attention of the DON. The DON confirmed that the care plan had not been updated to reflect the resident's current needs prior to the surveyor's inquiry.
Repeated Deficiency in Timely MDS Completion
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set Assessment (MDS) within the required 14 days for 14 out of 38 residents reviewed. This deficiency was identified through interviews and record reviews conducted by surveyors. The MDS Coordinator/Registered Nurse (MDSC/RN) was unable to immediately provide the facility's protocol for completing MDS assessments and later confirmed that the assessments for several residents were completed beyond the required timeframe. The facility relied on the Resident Assessment Instrument (RAI) manual for guidelines but did not have a separate policy for MDS completion. Surveyor #1 found that the comprehensive MDS (cMDS) for five residents were completed late, with completion dates highlighted in red in the electronic medical records. The MDSC/RN confirmed that these assessments were not completed within the 14-day requirement. Similarly, Surveyor #2 identified late completion of MDS for six residents, with the MDSC/RN attributing the delays to the workload and being the only one handling subacute assessments. Surveyor #3 also noted late completion of MDS for three residents, and the facility's policy was found to be based on the RAI manual's current requirements. The survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Clinical Services to discuss the findings. Despite the facility's reliance on the RAI manual, the MDS assessments were not completed within the required timeframes, leading to repeated deficiencies. The facility did not provide additional information or corrective actions during the survey team's meetings.
Deficiency in Physician Services and Documentation
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total program of care, including medications and treatments, and wrote, signed, and dated progress notes at each required visit. This deficiency was identified for 14 out of 35 residents reviewed for physician services. For instance, Resident #18's medical records showed no evidence of progress notes or assessments by Physician #1 from July 2024 through February 2025. Similarly, Resident #175's records lacked documentation from Physician #2 from November 2024 through February 2025, despite the resident being on contact precautions for ESBL in urine. The survey revealed that several residents' monthly physician orders were overdue for signing by their respective physicians. For example, Resident #10's physician had not signed the monthly physician orders for several months, and Resident #13's physician failed to conduct face-to-face visits or write progress notes for multiple months. Additionally, Resident #50's physician did not sign orders or conduct visits for several months, indicating a pattern of non-compliance with required physician services. Interviews with facility staff, including the Licensed Nursing Home Administrator and the Director of Nursing, confirmed ongoing issues with physician services, including the signing of orders and writing of visit notes. The facility's policy required physicians to visit residents monthly for the first 90 days and every 60 days thereafter, with orders to be signed off monthly. However, the survey findings highlighted significant lapses in adherence to these policies, affecting the quality of care provided to the residents.
Failure to Ensure Privacy and Dignity During Medication Administration
Penalty
Summary
The facility failed to treat a resident with respect and dignity during medication administration, as observed by a surveyor. During a medication pass, an LPN prepared and administered medications to a resident in the dining area while the resident was eating breakfast with other residents present. The LPN also checked the resident's blood pressure in the same setting. When questioned, the LPN stated that it was the resident's preference to receive medications in the dining room, but this preference was not documented in the resident's care plan. Further investigation revealed that the resident's care plan did not include any documentation of a behavior of swaying hands or a preference for taking medications in the dining room. The resident's cognitive status was assessed as intact, with no documented behaviors or mood disturbances. The facility's Resident Rights Policy emphasizes the importance of treating residents with respect and dignity, but the lack of documentation and adherence to the resident's care plan led to a deficiency in this area.
Failure to Verify Social Worker's License Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of a newly hired licensed staff member, a Social Worker (SW), were verified upon hire. During a review of ten randomly selected new employee files, it was discovered that the SW's license was not present in her employee file. Upon inquiry, the Regional Nurse indicated that the SW worked full-time and mentioned a pending status on her license. The License Nursing Home Administrator (LNHA) later provided documentation showing that the SW's license was inactive and reinstatement was pending, which was only verified after the surveyor's inquiry. The LNHA acknowledged that the SW's license had erroneously expired due to a user error during the renewal process, where the SW may have selected inactivate instead of renew. The LNHA stated that the Human Resources (HR) department should have verified and printed the license upon hire. The facility's Hiring Policy mandates that the HR Director is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. However, there was no documented evidence that the SW's license was verified before her hire date, indicating a lapse in the facility's hiring procedures.
Failure to Provide Bed Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide written notification of bed hold policies to a resident or their representative during instances of hospitalization. This deficiency was identified for a resident who had multiple unplanned discharges to the hospital on three separate occasions. Despite the facility's policy requiring that bed hold notices be provided within 24 hours of an emergency transfer, there was no documented evidence that such notifications were given for the dates in question. The absence of these notifications was confirmed through a review of the facility's bed hold notification binders for the years 2024 and 2025, which did not contain any notices for the specified dates. The resident involved had a complex medical history, including diagnoses of urinary tract infection, ESBL resistance, dementia, anxiety disorders, malnutrition, and chronic obstructive pulmonary disease. The resident experienced unplanned discharges to the hospital due to issues such as suprapubic catheter malfunction and ESBL of the urine. Despite these hospitalizations, the facility did not provide the required written bed hold notices, as confirmed by the Licensed Nursing Home Administrator and the Director of Nursing during the survey process.
Failure to Complete SCSA for Resident with Significant Changes
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced significant changes in cognitive status and weight. According to the CMS's RAI Version 3.0 Manual, an SCSA must be completed within 14 days of determining a significant change from baseline, especially when the resident's condition is not expected to return to baseline within two weeks. The resident in question had a cognitive decline from a BIMS score of 13 to 5 over two quarterly MDS assessments and experienced an 11% weight gain over three months, which met the criteria for an SCSA. The surveyor's review of the resident's medical records revealed no documented evidence that the Interdisciplinary Team (IDT) met and decided that an SCSA was unnecessary despite the significant changes in the resident's status. The MDS Coordinator/Registered Nurse acknowledged that an SCSA should have been completed but was unable to provide documentation supporting the decision not to proceed with it. The facility's failure to document the IDT's decision and the lack of an SCSA for the resident's significant changes in cognitive status and weight gain constituted a deficiency. During interviews, the MDS Coordinator stated that the team believed the resident's cognitive status fluctuated and did not warrant a significant change assessment. However, there was no documentation to support this claim, and the MDS Coordinator admitted that the BIMS scores for the two quarters might not have been accurate. The facility's inability to provide documentation or a valid explanation for not conducting an SCSA highlighted a lapse in following the required assessment protocols.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their assessments. For one resident, the quarterly MDS indicated a weight of 163 lbs, which did not match the dietary assessment documentation that recorded a weight of 180 lbs on the same date. This resident had a history of significant weight gain, which was unplanned and considered significant. The MDS Coordinator/Registered Nurse acknowledged the discrepancy but did not provide a separate policy for MDS coding. The Licensed Nursing Home Administrator and Director of Nursing were informed of the findings but did not provide additional information. For another resident, the discharge return not anticipated (drna) MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while the progress notes and unit manager confirmed the resident was discharged home with family. The MDS Coordinator/Registered Nurse confirmed the coding error upon review. The Director of Nursing acknowledged the error and stated it was corrected after the surveyor's inquiry. The facility lacked a policy regarding MDS, contributing to these inaccuracies.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #111, who had a history of falls and was at risk due to conditions like diabetes and hypertension, did not have an individualized care plan that included all relevant focus areas and interventions. The care plan was mistakenly canceled when the resident was hospitalized, and upon return, a new care plan was not properly initiated, leaving out important interventions that were previously in place. Resident #172, who had multiple diagnoses including stroke, dementia, and diabetes, was found to have an incomplete and non-individualized care plan for activities of daily living (ADLs). The care plan lacked specific interventions tailored to the resident's needs, despite the resident being dependent on staff for all ADLs and having significant cognitive impairments. This oversight was acknowledged by the facility's Director of Nursing (DON), who noted the need for re-education of staff to ensure care plans are completed. Resident #180, admitted for rehabilitation with a left arm splint, did not have documented evidence of the splint in their care plan, nor were there any interventions for its care. This omission was only addressed after the surveyor's inquiry. Similarly, Resident #442, who had severe cognitive impairment and was at risk for skin breakdown due to incontinence, had a care plan that lacked interventions related to their risk factors and diabetes management. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these were not adequately implemented for the residents reviewed.
Deficient Psychoactive Review and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that the monthly Psychoactive Review (PR) for behavior monitoring was conducted routinely and accurately for a resident, as required by professional standards and facility policy. The resident, who was cognitively impaired with a BIMS score of 3 out of 15, was on psychotropic medications including Quetiapine and Trazodone. However, the behavior monitoring records for December 2024 and January 2025 showed inconsistencies, with several shifts either left blank or not accurately reflecting the resident's behaviors. The PR dated February 1, 2025, only reviewed Trazodone and did not account for other psychotropic medications or documented behaviors from previous months. The facility's policy required a comprehensive review of psychotropic medication use, including evaluation of the resident's signs and symptoms. Despite this, the PR did not reflect the documented behaviors in the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), nor was there evidence of routine PRs being conducted. During meetings with the survey team, the facility's Regional Director of Clinical Services acknowledged the deficiency, noting that only one PR summary was completed. The facility's policy on psychotropic medication use, which mandates monthly reviews, was not adhered to, leading to incomplete and inaccurate behavior monitoring for the resident. The surveyor's findings highlighted a failure to meet the standards of clinical practice and facility policy in monitoring and reviewing psychotropic medication use.
Failure to Update Care Plan and Conduct Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that a resident's current active care plan contained the necessary interventions implemented after each fall to prevent additional falls. This deficiency was identified for a resident who had experienced several falls, including an unwitnessed fall in October 2024. The resident's care plan, initiated in November 2024, only included one intervention to maintain a clutter-free environment, despite previous falls and interventions being documented in a completed care plan that was not transferred to the current active care plan. Additionally, the facility did not conduct fall risk assessments quarterly as required by their policy. The resident's fall risk assessments were not completed for several quarters, including April 2024, July 2024, and January 2025. The assessments that were conducted were either incomplete or not done quarterly, as evidenced by assessments being dated on the same day as the resident's falls. This lack of consistent assessment and documentation contributed to the failure to update the resident's care plan with appropriate interventions. Interviews with facility staff, including the LPN, Unit Manager, and MDS Coordinator, revealed confusion and inconsistency in the process of updating care plans and conducting fall risk assessments. The MDS Coordinator admitted to canceling the care plan by accident when the resident was hospitalized, and there was uncertainty about who was responsible for initiating and updating assessments. The facility's policies on fall prevention and care plans were not followed, leading to inadequate supervision and increased risk of accidents for the resident.
Failure to Administer Correct Enteral Feeding Volume
Penalty
Summary
The facility failed to monitor and administer the correct total volume of enteral tube feeding as per the physician's orders for a resident with a gastrostomy. The resident, who had a history of cerebral infarction, dementia, type 2 diabetes mellitus, and was NPO, was prescribed Diabetisource 1.2 to be administered via feeding tube at 55 ml/hr, with a total volume of 1100 ml to be infused. However, documentation in the Medication Administration Record (MAR) revealed that for six out of eleven days, the total volume infused was significantly less than the prescribed amount, with volumes ranging from 450 ml to 500 ml. The deficiency was identified through observation, interviews, and record reviews. The Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) confirmed that the enteral feeding should be administered according to the physician's orders and documented in the MAR. However, the RN/UM could not explain the discrepancy in the documented volumes. The Director of Nursing (DON) later stated that some nurses were confused about the volume to document, leading to incorrect entries. The facility's policy required verification of physician orders and accurate documentation of the amount and type of enteral feeding administered, which was not adhered to in this case.
Deficient Respiratory Care and Incomplete Care Plan
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident, as evidenced by the lack of an individualized care plan and necessary orders for nebulizer equipment maintenance. During an observation, a resident was found with a nebulizer machine on the bedside table, but the mask was improperly stored in a drawer instead of a plastic bag. The resident, who had a history of pneumonia and was on antibiotics, confirmed that they had not placed the mask back in the bag. The facility's records showed no orders for changing the nebulizer mask or tubing, and the care plan lacked specific goals or interventions for respiratory care. Interviews with the Unit Manager and Licensed Practical Nurse revealed that the facility's practice was to change nebulizer tubing and masks weekly, but there was no documented order for this procedure for the resident in question. The Unit Manager acknowledged the absence of a care plan and order for the nebulizer equipment change, admitting that the care plan was incomplete. The Director of Nursing and the Licensed Nursing Home Administrator were informed of these deficiencies, which were not in compliance with the facility's nebulizer therapy policy and comprehensive person-centered care plan requirements.
Failure to Adjust Medication Schedules for Dialysis Residents
Penalty
Summary
The facility failed to ensure that the medication administration and blood sugar monitoring for two residents requiring dialysis were adjusted to accommodate their dialysis schedules. Resident #77, who has diabetes mellitus and end-stage renal disease, had duplicate orders for blood sugar checks, with one scheduled early in the morning and another before meals and at bedtime. The electronic Medication Administration Record (eMAR) showed inconsistencies in the documentation of blood sugar checks, with some entries marked as 'X' or 'NA' without explanation. The Registered Nurse (RN) and Unit Manager acknowledged the issue but did not address it until after the surveyor's inquiry. Resident #121, also diagnosed with end-stage renal disease, had a physician's order to adjust medication and treatment timing to accommodate dialysis sessions. However, the Brimonidine Tartrate eye drops were scheduled for administration at times when the resident was at dialysis, leading to missed doses. The Licensed Practical Nurse (LPN) confirmed that medication schedules should be adjusted around dialysis sessions, but this was not done for Resident #121. The Director of Nursing (DON) acknowledged the oversight and stated that the order should have been clarified by the nursing staff. The facility's Hemodialysis Policy requires that care and treatment be consistent with professional standards, physician orders, and the resident's care plan. However, the facility did not adhere to this policy, resulting in deficiencies in the care provided to residents requiring dialysis. The survey team discussed these concerns with the facility's administration, but no additional information was provided to address the deficiencies at the time of the survey.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to post the accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily in a prominent place within the facility, as required. On two separate occasions, surveyors observed that the NHRCSR was not updated correctly. On the first occasion, the report dated 2/6/25 was still posted on 2/7/25, and the receptionist admitted to waiting for the Staffing Coordinator to provide the updated numbers. The Staffing Coordinator confirmed that the report was not printed correctly for 2/7/25. The facility's policy requires the staffing sheet to be posted at the beginning of each shift, which was not adhered to in this instance. On another occasion, the NHRCSR posted on 2/10/25 was for the previous day, 2/9/25, and contained incorrect census information. The Staffing Coordinator provided a Nursing Daily Staffing Sheet with handwritten notes indicating discrepancies in the census for the days leading up to 2/9/25. The facility's policy mandates that the staffing sheet be posted at the beginning of each shift, but this was not followed, resulting in outdated and incorrect information being displayed. These deficiencies were confirmed through interviews with staff and a review of the facility's policy.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preferences, as evidenced by the case of a resident who consistently did not receive the meals they requested. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed concerns about not receiving the food items they selected from the menu. Despite discussing these issues with the kitchen staff and the registered dietician, the problem persisted. The resident, who had a no concentrated sweets diet due to hypertension and type 2 diabetes, often received meals that did not match their selections, such as receiving turkey meatloaf instead of the requested roasted chicken. During the survey, it was observed that the resident was served a meal that did not include the requested items, and there was no meal ticket on the table to verify the order. The Food Service Director confirmed that the resident had selected roasted chicken on their menu, but the meal ticket listed turkey meatloaf instead. The director could not explain why the resident received the incorrect meal and acknowledged that the resident's food preferences should be honored. The facility's policy on nutritional management indicated that residents' goals and preferences should be reflected in their care plans, but this was not adhered to in this case. The issue was brought to the attention of the Licensed Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, who were informed of the resident's unmet food preferences. The facility's investigation revealed that unclear writing on the menu led to the dietary staff's confusion. However, the surveyor noted that the resident's menu clearly showed the crossed-out item, indicating the resident's choice. The facility's policy emphasized the importance of interviewing residents to ensure their preferences are met, which was not effectively implemented in this instance.
Deficiencies in Medical Record Maintenance and Consent Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents, leading to deficiencies in care documentation and consent processes. For one resident, the physician's visit notes were entered late, covering a period from September 2024 to January 2025, which was not in compliance with the expected timeline for documentation. This issue was brought to the attention of the facility's administration, who acknowledged the requirement for timely documentation of physician visits. Another resident's medical records lacked documentation of consent for influenza and pneumococcal vaccinations, as well as psychoactive medication use. The facility staff were unable to locate the necessary consent forms during the survey, and it was later discovered that these documents were left in a copying machine. The absence of documented consent and education regarding vaccinations and psychoactive medications was a significant oversight in the resident's care plan. Additionally, the facility failed to document bowel and bladder management for a resident, with numerous missing entries in the CNA Intervention/Task Report sheets. This lack of documentation was confirmed by multiple staff members, who acknowledged the importance of monitoring and recording such information to prevent health complications. The facility's incontinence policy emphasized the need for appropriate treatment and services based on comprehensive assessments, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following hand hygiene protocols and improper use of personal protective equipment (PPE). A Certified Nursing Aide (CNA) was observed with a surgical mask not covering her nose and mouth, and she did not perform hand hygiene before and after touching her mask or donning and doffing gloves. Additionally, the CNA stored gloves in her pocket, which is against facility policy. A Registered Nurse/Unit Manager (RN/UM) also failed to perform hand hygiene before and after glove use. These actions were contrary to the guidelines set by the CDC and the facility's own policies. Further deficiencies were noted during a medication administration pass, where a Licensed Practical Nurse (LPN) left the disinfecting wipes container open, which could compromise the effectiveness of the wipes. The LPN acknowledged the oversight but did not correct it during the medication pass. This practice was not in line with the facility's Safety Data Sheet instructions, which require the container to be closed when not in use. Additionally, the facility did not properly implement transmission-based precautions (TBP) for a resident who was COVID-19 positive. There was no signage outside the resident's room to indicate TBP, and the sign was mistakenly placed inside the door. The resident's Medication Administration Record (MAR) was not signed for TBP for two shifts, and the Progress Notes did not reflect the resident's TBP status. These oversights indicate a failure to follow the facility's policy on TBP, which requires clear signage and documentation to prevent the spread of infection.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure immediate physician notification and adherence to its policy regarding changes in a resident's condition. A resident with multiple complex diagnoses, including Parkinson's Disease, Alzheimer's Disease, multiple myeloma, type 2 diabetes, aortic insufficiency, and dementia, was observed by their responsible party to appear dehydrated. The LPN on duty assessed the resident, noted poor skin turgor, and attempted to contact the resident's physician by phone but was unable to leave a message. No further attempts to reach the physician were documented until several hours later, after the resident had expired. The LPN did not escalate the issue to the Nursing Supervisor or Medical Director as required by facility policy. Interviews with staff revealed that the expectation was for nurses to report any significant changes in a resident's condition to the Nursing Supervisor and, if unable to reach the primary physician, to contact the Medical Director. The Assistant Director of Nursing confirmed that the process for physician notification was not followed in this case. Review of the facility's policy indicated that circumstances requiring a change in treatment, such as new symptoms or the need for new interventions, necessitate prompt physician notification, which did not occur for this resident.
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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