Atlas Post Acute At Woodbury Country Club
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodbury, New Jersey.
- Location
- 467 Cooper Street, Woodbury, New Jersey 08096
- CMS Provider Number
- 315521
- Inspections on file
- 19
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Atlas Post Acute At Woodbury Country Club during CMS and state inspections, most recent first.
A resident with acute pain from a nasal bone fracture and arthritis received a scheduled dose of Oxycodone nearly two hours late, contrary to facility policy requiring medications to be given within one hour of the prescribed time. Both the ADON and an LPN confirmed the late administration and failure to notify the physician for further instructions.
During an inspection, it was found that the emergency generator's transfer switch location did not have a battery-backed emergency light independent of the building's electrical system and emergency generator, as required by NFPA 101. This deficiency was confirmed by facility staff and had the potential to affect 117 residents.
Surveyors identified that the facility's 400 KW diesel emergency generator lacked a required remote emergency stop button, with the only stop control located on the generator housing. Facility representatives confirmed the absence of a remote stop station, a deficiency that had the potential to affect 117 residents.
Surveyors observed uncovered disposable utensils and lids in dry storage, an unlabeled drink bottle in the refrigerator, and debris on kitchen floors and shelves. Additionally, two dietary aides were seen with hair not fully covered by hair nets during meal service. These findings indicate failures to maintain food storage integrity, kitchen cleanliness, and staff hygiene in accordance with facility policy and food safety standards.
The facility failed to ensure accurate and complete documentation for medication administration and required assessments for two residents. In one case, staff did not consistently record medication volumes or communicate with the physician when issues arose, and in another, required admission and weekly assessments were missing from the medical record. These actions did not meet professional standards or facility policy.
A resident who was dependent on staff for ADL care did not receive a scheduled shower, as confirmed by the resident, staff interviews, and review of documentation. The care plan and physician orders required regular showers, but there was no record of the service being provided or refused, and the facility acknowledged the omission.
A resident with a history of pressure ulcers was found to have an air mattress that was not set to the correct weight, as required by care plans and facility policy. Despite documentation that staff checked the setting each shift, observations and interviews confirmed the setting remained incorrect, and staff acknowledged the importance of proper adjustment for pressure ulcer prevention and healing.
A resident requiring respiratory care had their equipment left unlabeled, undated, and improperly stored, with items found open to air and touching the floor instead of being kept in a labeled bag as required. Staff confirmed these practices did not follow physician orders or infection control standards, and the facility lacked a written protocol for proper equipment storage. Additionally, a physician's order related to respiratory care was not clarified as needed.
A facility was cited for failing to provide sufficient nursing staff and for not responding to a resident's call bell in a timely manner, with several documented response times exceeding 15 minutes. Staff interviews confirmed that call bells should be answered within five to fifteen minutes, and the facility's policy required immediate response. The facility was also found to be understaffed on multiple day shifts, not meeting state minimum CNA-to-resident ratios.
Surveyors found that a resident did not receive medications according to physician orders, with doses administered outside the prescribed time frame and without proper authorization. Additionally, the shift-to-shift controlled substance count log was presigned before the count was performed, and declining inventory logs for two residents were not properly signed after medication administration. An LPN acknowledged these documentation errors, which were not in accordance with facility policy.
A resident was given PRN medications on several occasions when their assessment levels did not meet the criteria outlined in physician orders. Nursing staff administered the medications based on the resident's request rather than following the required parameters, and did not consistently notify the physician as required by facility policy.
Surveyors found that a medication container was left at a resident's bedside instead of being secured in the medication cart, with an LPN unable to explain how it got there. Additionally, a resident received a breakfast tray that did not match their documented dietary preferences, missing several ordered items. Both incidents reflect failures to follow required procedures for medication storage and dietary accommodations.
A resident was served a breakfast tray that did not match their documented dietary preferences, with missing and substituted items, despite facility policies and staff expectations to ensure meal accuracy according to diet slips and physician orders.
Surveyors observed two LPNs failing to use a paper towel to turn off the faucet after handwashing during medication administration, contrary to facility policy and infection control standards. Both LPNs acknowledged the correct procedure but did not follow it, resulting in a deficiency related to infection prevention practices.
The facility did not consistently meet New Jersey's required CNA-to-resident staffing ratios on several day shifts, as confirmed by staffing records and staff interviews. Internal staff, including managers, sometimes filled in for absent CNAs, but the minimum mandated levels were not always achieved.
The facility failed to verify and document residents' code status and end-of-life wishes, resulting in some residents being assigned Full Code status without proper consent or documentation, and in several cases, necessary forms such as POLST or signed physician orders were not provided during hospital transfers. This led to inappropriate interventions, such as CPR being performed on a resident with a DNR order, and caused psychosocial distress when ambulance staff could not honor DNR wishes due to missing documentation. Staff interviews revealed inconsistent practices and lack of training regarding code status verification and documentation.
A resident admitted with a documented DNR status from the hospital was incorrectly listed as Full Code in the facility's records, with no evidence that the resident or family changed this status. Staff performed CPR when the resident was found unresponsive, contrary to the resident's prior wishes. The nurse responsible for entering the code status was agency staff and unfamiliar with facility policy, and the required verification and documentation of advance directives were not completed.
The facility did not ensure accurate documentation of controlled substance administration and removal times for three residents receiving medications such as alprazolam and Lyrica. Staff inconsistently recorded either the scheduled or actual administration times on controlled substance records, rather than the actual time medications were removed from the narcotic lock box, leading to discrepancies between medication administration records and inventory logs.
Staff failed to consistently use required PPE, including N95 masks and eye protection, when entering the rooms of residents on COVID-19 droplet/contact precautions. Despite clear signage and available PPE carts, some staff wore only surgical masks or relied on personal eyeglasses, and in some cases, did not have access to the correct PPE. Facility policy required N95 respirators, gowns, gloves, and eye protection for all staff entering rooms of COVID-19 positive residents, but this was not followed as observed and confirmed by staff interviews.
Late Administration of Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to standards of practice and did not follow its own policy for medication administration. Specifically, a resident with a history of nasal bone fracture and arthritis, who had a moderately impaired cognition as indicated by a BIMS score of 12 out of 15, was prescribed Oxycodone 10 mg to be administered every 8 hours for severe pain. The medication was scheduled for administration at 6:00 A.M., 2:00 P.M., and 10:00 P.M. On one occasion, the 2:00 P.M. dose was administered at 3:53 P.M., which was 1 hour and 53 minutes after the scheduled time. Interviews with the ADON and an LPN confirmed that the medication was given late, the facility's policy was not followed, and the physician was not notified to clarify next steps for the late administration. The facility's policy required medications to be administered within one hour of their prescribed time and in accordance with prescriber orders. This deficiency was identified through review of the resident's records, medication administration audit report, and facility policy.
Lack of Battery-Backed Emergency Lighting at Generator Transfer Switch
Penalty
Summary
A deficiency was identified during an inspection of the Main Electrical room, where it was observed that there was no battery-backed emergency lighting installed for the emergency generator's transfer switch. This emergency lighting is required to function independently of both the building's electrical system and the emergency generator, in accordance with NFPA 101:2012 standards. The absence of this lighting was confirmed through observation and interview with facility staff. The deficiency had the potential to affect 117 residents, as noted during the Life Safety Code survey.
Plan Of Correction
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: A functioning battery emergency light was installed at the emergency transfer switch location. Battery is independent of the building's electrical system and emergency generator system. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The U.S. FOIA (b) (6) was educated on K291 to ensure compliance is maintained by the Administrator. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Administrator or Designee will ensure that the emergency backup light at transfer switch is and remains operational. Audits will be conducted on a monthly basis. Findings will be reported to the QAPI committee meeting until compliance has been met.
Lack of Remote Emergency Stop for Generator
Penalty
Summary
The facility failed to ensure compliance with NFPA 110 requirements regarding the installation of a remote manual stop station for its emergency generator. During an observation, the surveyor found that the 400 KW diesel emergency generator only had an emergency stop button located on the metal housing of the generator itself. There was no evidence of a remote emergency stop button installed as required by NFPA 110, 2010 Edition, Section 5.6.5.6 and 5.6.5.6.1. This deficiency was confirmed during interviews with facility representatives, who acknowledged the absence of a remote emergency stop button for the generator. The issue was brought to the attention of the facility during the Life Safety Code survey exit. The lack of a remote stop station had the potential to affect 117 residents, as noted in the report.
Plan Of Correction
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: A remote manual stop station for 1 of 1 of emergency generators was installed in accordance with NFPA 110, 2010 Edition Section 5.5.6 and 5.6.5.6.1. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: [R] was educated on K918 to ensure compliance is maintained by the Administrator. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Administrator or Designee will ensure that the remote manual stop for 1 of 1 emergency generator is installed and remains operational. Audits will be conducted on a monthly basis. Findings will be reported monthly to the QAPI committee meeting until substantial compliance has been met.
Deficiencies in Food Storage, Sanitation, and Staff Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation practices within the facility's kitchen and food service areas. In the dry storage room, plastic portion cup lids and a box of white plastic forks were found spilling out of their plastic bags and not covered, contrary to facility policy and the Food Service Director's (FSD) statements that these items should be kept covered and in their bags. In the reach-in refrigerator, a half-empty blue sports drink bottle was found without a date or label, and the FSD acknowledged it should not have been there and discarded it. Additionally, the kitchen floor by the stove and food prep area, as well as the bottom shelf of the food prep area, were observed to have debris, despite staff claims that floors were cleaned every shift. During observation of the lunch meal tray line, two dietary aides were noted to have hair not fully covered by their hair nets, with long strands of hair exposed. The FSD confirmed that hair nets should fully cover all hair. Review of facility policies indicated requirements for maintaining clean kitchen and dining areas, proper employee hygiene including hair restraints, and correct storage of dry foods and disposable items. These observations demonstrated failures to consistently follow professional standards for food service safety and the facility's own policies, potentially compromising food safety and sanitation.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified nor immediately affected. All areas of concern were addressed immediately by the Food Service Director and Nursing Home Administrator. The items in the dry storage were covered right away, the floor was immediately cleaned, the beverage in the refrigerator was immediately removed, the floor in front of the stove was immediately cleaned, and the staff hair nets were fixed immediately. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Food Service Director or designee in-serviced dietary department staff on the facility policy on sanitation, employee hygiene including hair nets and dry food storage. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Food Service Director or designee will audit dry storage supplies, sanitation, and employee hygiene via audits to be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Failure to Maintain Accurate Documentation and Assessment per Professional Standards
Penalty
Summary
The facility failed to maintain accurate accountability and documentation for the management and administration of specific medical treatments and assessments as required by professional standards and facility policy. In one instance, a resident with complex medical needs did not have consistent or accurate documentation regarding the administration and monitoring of a prescribed medication. The Medication Administration Record (MAR) and electronic MAR (eMAR) contained multiple entries where the required volume of medication was not documented, or incorrect information such as hours instead of volume was recorded. Interviews with nursing staff confirmed that documentation was incomplete or not performed as required, and that staff were not always clear on the procedures for monitoring and documenting the medication administration. There was also a period where the resident may not have received the prescribed medication, and documentation did not reflect communication with the physician or pharmacy during this time. In another case, a resident was admitted with a specific medical condition that required ongoing assessment and documentation. The medical record review revealed that required assessments were not completed on admission, after a change in condition, or weekly as ordered. The facility's own policies required full body assessments upon admission, daily for three days, and weekly thereafter, as well as after any change in condition or identification of a new issue. However, the medical record did not contain evidence that these assessments were performed or documented as required. Interviews with staff confirmed that these assessments should have been completed and documented, and that incident reports and progress notes were also required when new issues were identified. Facility policies on administration of medications and documentation were reviewed and found to require complete, objective, and accurate documentation of all care provided, including medication administration details and patient assessments. Despite these policies, the facility did not ensure that staff consistently followed procedures for documentation and monitoring, leading to gaps in the medical record and a failure to meet professional standards of quality as outlined in federal and state regulations.
Plan Of Correction
483.21(b)(3) Comprehensive Care Plans 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 179 NJ Ex Order 26.4(b)(1) in the facility. Resident 178 NJ Ex Order 26.4(b)(1) in the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff regarding creation of the comprehensive care plan, maintaining an accurate accountability for the management of [R], and accurate and timely completion of skin assessments. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will audit 5 random residents for timely and accurate completion of skin checks. The Director of Nursing or designee will audit 5 random residents' charts for completion of comprehensive care plans. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 658 The U.S. FOIA (b) (6) who stated that if a [R], he would have expected the facility to insert an [R] until they could get a [R] established. The stated that he would have expected for [R] to have been notified, preferably, to see what they wanted done. The [R] stated, '[R]' 2. The surveyor reviewed the medical record for Resident #178. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, [R]. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [R], included the Brief Interview for Mental Status (BIMS) was not assessed [R]. A staff assessment for Mental Status included that the resident had [R]. Further review of the MDS revealed the resident was [R] and was F 658
Failure to Provide Scheduled Shower for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living did not receive a scheduled shower as required by their care plan and physician orders. The resident reported during a council meeting that they had not received their scheduled shower the previous day, and this was confirmed through observation and interviews. The resident stated that staff typically provided showers on scheduled days without the need for a request. Review of the medical record and care plan confirmed the resident's need for assistance and the established schedule for showers. Further investigation revealed that documentation did not indicate the shower was provided as scheduled, and staff interviews confirmed that residents should not have to request their scheduled showers. The facility's policy required documentation of showers and notification of refusals, but there was no evidence that the missed shower was documented or that a refusal occurred. The facility acknowledged that the resident's scheduled shower was missed, confirming the failure to provide necessary services to maintain personal hygiene as required.
Plan Of Correction
483.24(a)(2) ADL Care Provided for Dependent Residents 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 122 was assessed by the Director of Nursing on 04/17/25. R122 was offered a [R] at that time, accepted, and received a [R]. R122 did not present any additional concerns when asked. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff and certified nursing aides on the center policy for offering and providing showers to all residents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents to confirm that they were offered and received their showers. Audits will be conducted weekly for 4 weeks, then every other week for 4 weeks, and then monthly for 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Failure to Ensure Correct Support Surface Settings for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident with a history of pressure ulcers was observed with a specialized support surface (air mattress) that was not set according to the resident's current weight, as required by professional standards and the facility's own policy. Multiple observations revealed that the mattress setting remained incorrect over several days, despite staff documentation indicating that checks had been completed. The resident and staff interviews confirmed that the mattress was not set to the appropriate weight, and that this setting is critical for the prevention and healing of pressure ulcers. Record review showed that the resident was admitted with a pressure ulcer and had care plans and physician orders specifying the need for a support surface set to the resident's weight. Documentation in the Treatment Administration Record (TAR) indicated that staff were to check the mattress setting every shift, but the setting was not properly adjusted or maintained. Staff interviews further confirmed that the mattress was not set correctly and that the importance of proper settings was understood, yet the deficiency persisted. Facility policy required that support surfaces be used in accordance with evidence-based practice and manufacturer recommendations, including correct weight settings. Despite these requirements, the resident's mattress was not set as ordered, and staff failed to ensure the setting was correct, as evidenced by both direct observation and staff statements. This failure to follow professional standards and facility policy resulted in the identified deficiency.
Plan Of Correction
Treatment/Svcs to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 32 was assessed by the [R] room to ensure the [R] setting was corrected. The [R] completed a [R] on R32. It was unremarkable with no signs of [R]. The Director of Nursing and Unit Managers conducted a facility-wide audit to ensure that all low air loss mattresses were set to the correct settings with no findings of any additional low air loss mattresses being on the wrong setting. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff and certified nursing aides on the center's policy for support services, low air loss mattresses being set to the correct weight setting, and confirming the settings being checked through documentation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents on low air loss mattresses to ensure all are set on the correct settings. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Failure to Properly Store and Label Respiratory Equipment and Clarify Physician Orders
Penalty
Summary
Surveyors identified that the facility failed to properly label, date, and store respiratory equipment in a sanitary manner for a resident requiring respiratory care. During observation, respiratory equipment was found draped over the resident's nightstand and wheelchair, left open to air and in one instance touching the bathroom floor, rather than being stored in a bag as required. Staff interviews confirmed that the equipment should have been labeled, dated, and stored in a bag labeled with the resident's information when not in use, but this was not done. The resident's care plan and physician orders included instructions for proper storage and dating of the equipment, but these were not followed. Additionally, the facility failed to clarify a physician's order related to the resident's respiratory care. Staff acknowledged that the order to wean the resident from the respiratory device should have been clarified to include specific details, but this was not done. Review of facility policies revealed there was no written protocol addressing the proper dating and storage of the respiratory equipment, and the existing oxygen administration policy did not address these requirements. The resident involved had relevant medical diagnoses and was assessed as needing respiratory care, as documented in the admission record and Minimum Data Set.
Plan Of Correction
Respiratory/Tracheostomy Care and Suctioning CFR(s): 483.25(i) 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 88 no longer resides in the facility. On 04/17/25, The Assistant Director of Nursing replaced the x Only 26, labeled and dated it appropriately. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced all licensed nursing staff on ensuring oxygen tubing is stored in bags when not in use and to replace it if it is observed on the floor or not in a bag. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents with NJ Ex Order 26. 4B1 to make sure it is stored appropriately. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Deficiency in Sufficient Nursing Staff and Timely Call Bell Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely response to call bells for at least one resident, as evidenced by multiple call bell response times exceeding 15 minutes. Audit reports for a specific resident showed several instances where response times ranged from 15 minutes and 25 seconds to 17 minutes and 39 seconds. Interviews with staff indicated that call bells should be answered within five minutes or as soon as they are noticed, while an interviewed resident and representative expected responses within 15 minutes or less. The facility's own policy stated that call lights should be answered immediately to ensure timely responses to residents' needs. A review of the resident's electronic medical records and Minimum Data Set (MDS) indicated that the resident had certain diagnoses and a Brief Interview for Mental Status (BIMS) score, but the specific details were redacted. The resident was assessed as needing timely assistance, and the expectation for prompt call bell response was confirmed by both staff and the resident's representative. Despite these expectations and the facility's policy, the documented response times exceeded the expected timeframe on multiple occasions. Additionally, the facility was found to be out of compliance with New Jersey's minimum staffing requirements for three out of fourteen day shifts during a two-week period, having only 11 CNAs for 93 residents when at least 12 were required. This staffing shortfall contributed to the delayed response times and the facility's failure to meet both state and federal regulations regarding sufficient nursing staff and timely care.
Plan Of Correction
Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2) 483.35(a) Sufficient Staff. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 182 NJ Ex Order 26.4(b)(1) in the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Nursing Home Administrator or designee conducted in-servicing on call lights were answered timely. The Nursing Home Administrator or designee will conduct audits on timely call light response, toileting timely, receiving medications timely, receiving meals timely, and timely assistance with dressing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Nursing Home Administrator or Director of Nursing will conduct audits on 10 residents for timely call light response, weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. Facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Nursing Home Administrator or designee conducted in-servicing on call lights were answered timely. The Nursing Home Administrator or designee will conduct audits on timely call light response, toileting timely, receiving medications timely, receiving meals timely, and timely assistance with dressing. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Nursing Home Administrator or Director of Nursing will conduct audits on 10 residents for timely call light response, weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 725
Deficiencies in Medication Administration and Controlled Substance Documentation
Penalty
Summary
Surveyors identified multiple deficiencies related to pharmacy services and medication administration. One resident did not receive medications in accordance with physician orders, as evidenced by multiple instances where the 9:00 AM dose of prescribed medications was administered outside the required time frame. The facility's Medication Administration Audit Report showed that these medications were given at various times significantly later than scheduled, without a physician order authorizing the change in administration time. Facility policy required medications to be administered as per prescriber orders, including any specified time frames. During a medication storage inspection, it was observed that the shift-to-shift controlled substance count log on one medication cart was presigned for the outgoing slot before the actual count was performed. An LPN acknowledged presigning the log in error and confirmed that the count should be completed and signed together with the incoming nurse at the time of the shift change, as per facility policy. Additionally, the declining inventory logs for controlled substances were not properly signed for two residents. In one case, an LPN administered a controlled medication but failed to sign it out on the declining inventory sheet immediately after administration. In another case, the number of tablets recorded did not match the physical count, and the LPN admitted not signing out the medication at the time of administration. Facility policy required that the count be performed and documented by both incoming and outgoing nurses, and that medications be signed out on the inventory log at the time of administration.
Plan Of Correction
Pharmacy Services CFR(s): 483.45(a)(b)(1)-(3) 483.45 Pharmacy Services 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 177 NJ Ex Order 26.4(b)(1) in the facility. Resident 20 was [R] Resident was interviewed and stated they received their medications accordingly. Resident 58 was [R] Resident was interviewed and stated they received their medications accordingly. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee conducted in-servicing on timely medication administration based on the provider’s order, ensuring documentation of controlled substance medications accurately reflect the disposition and administration times, and accurate shift to shift narcotic counts. Education will continue until all nursing staff have received the in-servicing. Staff will receive the in-servicing prior to working their next scheduled shift. Newly hired staff will receive the in-servicing in orientation when they are hired prior to working the floor. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 resident charts to confirm medications were administered timely. The Director of Nursing or designee will initiate audits on 5 residents who received controlled medication to ensure documentation accurately reflects disposition and medication administration times. The Director of Nursing or designee will initiate audits on 2 random nurses’ shift-to-shift narcotic reports to ensure timely and accurate completion. All audits will be conducted weekly for 4 weeks, then every other week for 4 weeks, and then monthly for 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
A deficiency was identified when a resident was administered medications that were not in accordance with physician orders. The medication administration records (MAR) showed that the resident received as-needed (PRN) medications on multiple occasions when their documented assessment levels did not meet the parameters specified in the physician's orders. Despite the orders requiring certain criteria to be met before administration, the medications were given regardless of the resident's reported levels. Interviews with nursing staff revealed that medications were sometimes administered based on the resident's request, even when the required assessment levels were not present. One LPN admitted to giving the medication even though the resident did not meet the criteria and acknowledged that she should have contacted the physician instead. Facility policy requires medications to be administered according to prescriber orders, including any specified parameters, but this was not consistently followed in the case reviewed.
Plan Of Correction
Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 20 was not affected. Resident was interviewed and stated [R]. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Director of Nursing or designee in-serviced licensed nursing staff on documenting appropriate pain rating based on pain medication physician orders. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Director of Nursing or designee will audit 5 resident charts who received pain medications to determine that pain medications are administered appropriately in accordance with physician orders. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Medication Storage and Dietary Preference Deficiencies
Penalty
Summary
A deficiency was identified when a medication container was found left on a resident's overbed table rather than being stored in the designated medication cart. An LPN confirmed that medications should not be left at the bedside and that the container was removed and discarded after use. The LPN was unable to explain how the medication ended up in the resident's room. Further review of the medication cart confirmed the medication was not present, and the LPN stated the last dose had been administered and the empty container discarded. Facility policy requires medications to be stored in an orderly manner in secure locations, not at the bedside. Another deficiency was observed when a resident's breakfast tray did not match the dietary preferences and orders indicated on the resident's diet slip. The tray was missing items such as a Western omelette and yogurt, and included scrambled eggs and only one cold cereal instead of two. The resident confirmed the discrepancy between the ordered and delivered meal items. The facility is required to provide food that accommodates resident allergies, intolerances, and preferences, as well as appealing options of similar nutritive value.
Plan Of Correction
Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2) 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 10 was NJ Ex Order 26.4(b)(1). Resident was interviewed and stated they received their medications accordingly. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or Designee in-serviced licensed nursing staff on proper medication storage. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 5 random residents to ensure that medications are stored properly and not at bedside. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 761 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 20 was interviewed by the Food Service Director on whether they were served a diet taking into consideration their preferences and what they received for meals. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Food Service Director or designee in-serviced the dietary department staff on providing meals as ordered that meet resident preferences.
Failure to Accurately Implement Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences were accurately implemented, as required by federal regulations. During observation, a resident was served a breakfast tray that did not match the items listed on their diet slip. Specifically, the tray was missing a Western omelette and yogurt, included scrambled eggs instead of the omelette, and only one cold cereal instead of two. The resident confirmed the discrepancy during an interview. The diet slip is intended to communicate the correct meal components based on the resident's preferences and dietary orders. Interviews with facility staff revealed that the expectation is for food trays to be prepared and checked for accuracy according to the diet slip, which reflects the physician's orders and the resident's preferences. Staff responsible for distributing meal trays are expected to verify that each tray contains the correct items. A review of the facility's policy indicated that individual food preferences are to be assessed upon admission and communicated to the interdisciplinary team, with any modifications ordered with the resident's or representative's consent. Despite these procedures, the resident did not receive the correct meal as ordered.
Plan Of Correction
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 20 was interviewed by the Food Service Director on whether they were served a diet taking into consideration their preferences and what they received for meals. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Food Service Director or designee in-serviced the dietary department staff on providing meals as ordered that meet resident preferences. The Food Service Director or designee will audit meal trays to ensure the prescribed diet is followed and served, and that the food served meets the resident's preferences. The Food Service Director or designee will interview residents to ensure they receive the correct diet and that their preferences are met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Resident 20 will be interviewed by the Food Service Director or Designee on whether they have received their meals as ordered weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. The Food Service Director or designee will audit 10 meal trays to ensure the prescribed diet is followed and served and that the food meets the residents' preferences. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. The Food Service Director or Designee will interview 10 residents to ensure they receive the correct diet and that their preferences are met. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.
Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control practices during medication administration observations involving two Licensed Practical Nurses (LPNs). On multiple occasions, after administering medication and performing hand hygiene, the LPNs turned off the faucet with their bare hands instead of using a paper towel, as required by both facility policy and standard infection control protocols. In one instance, an LPN dried her hands with a paper towel, used the same damp towel to turn off the faucet, and then obtained additional towels to finish drying her hands. Interviews with the LPNs confirmed their awareness that the correct procedure was to use a paper towel to turn off the faucet after handwashing, but they failed to follow this protocol during the observed events. The facility's hand hygiene policy specifically instructs staff to use a disposable towel to turn off the faucet after washing and drying hands. The observed actions were inconsistent with this policy and with accepted infection control standards designed to prevent recontamination of hands after washing. Further interviews with facility staff demonstrated knowledge of the correct hand hygiene procedure, including the use of a clean paper towel to turn off the faucet. However, the observed lapses in practice by the LPNs during medication administration tasks resulted in a failure to maintain proper infection control practices, as required by federal and state regulations.
Plan Of Correction
F 880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) 483.80 Infection Control 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 112 was [R] Resident 226 was [R] Resident 41 was [R] 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Director of Nursing or designee in-serviced all licensed nursing staff regarding handwashing during medication pass and assisting residents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Director of Nursing or designee will conduct audits on three random staff members to ensure proper hand washing. These audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 880
Failure to Maintain Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey law. Specifically, during several reviewed periods, the number of Certified Nurse Aides (CNAs) scheduled for the day shift did not meet the minimum ratios required for the number of residents present. For example, on multiple occasions, the facility was short by one or two CNAs compared to the required staffing levels for the number of residents on the day shift. These deficiencies were identified through a review of staffing records for specific weeks in January, July, March, and April, where the number of CNAs fell below the mandated ratios on certain days. Interviews with the Staffing Coordinator and the Director of Nursing confirmed awareness of the staffing requirements and acknowledged the facility's challenges in meeting them, particularly on weekends. The facility did not utilize agency staff and instead relied on internal staff, with managers and the Staffing Coordinator sometimes filling in as CNAs. The facility's policy stated that staffing numbers and skill requirements are determined by resident needs and care plans, but the documented staffing levels did not consistently meet the minimum legal requirements during the periods reviewed.
Plan Of Correction
The facility shall comply with applicable Federal, State, and local laws, rules, and regulations. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified nor immediately affected by the failure to provide minimum staffing levels as mandated by the State of New Jersey. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Administrator was educated on S560 by Regional Director of Labor Management and Recruitment. Human Resources and Staffing Director was educated on S560 by the Administrator. Recruitment efforts continue to include: wage analysis and adjustments, vacant shift bonuses, online job listings, ongoing onsite job fairs, on-demand orientation classes, daily interviews to walk-ins, shift differentials, and referral bonuses. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Administrator or designee will review staffing schedules weekly to ensure adequate staffing for all shifts. Any findings will be followed up and documented and then reported during the quarterly QAPI meetings for one year's time, or until staffing levels are no longer an issue.
Failure to Document and Honor Residents' Code Status and Advance Directives
Penalty
Summary
The facility failed to ensure that residents' code status and end-of-life wishes were accurately documented, verified, and honored, as required by both facility policy and state regulations. Multiple residents were admitted or readmitted with documented Do Not Resuscitate (DNR) orders from the hospital, but the facility either failed to verify these wishes with the residents or their families or did not document any such verification. In several cases, the facility defaulted to Full Code status without evidence that the resident had changed their wishes, and there was no documentation of discussions or consent regarding code status changes. For example, one resident was admitted with a DNR status from the hospital, but the facility ordered Full Code without verifying with the resident or family, resulting in the initiation of CPR and EMS intervention when the resident became unresponsive. The facility also failed to provide the necessary documentation to ambulance transport companies to ensure that residents' code status would be honored during transfers. In one instance, a resident with a DNR order was transferred to the hospital, but the facility did not provide the required POLST form or a signed physician's order, leading ambulance staff to inform the resident that CPR would be performed if needed during transport. This caused significant psychosocial distress to the resident. Similar documentation failures were found for several other residents, whose records lacked either a POLST form or a signed physician's order for DNR/DNI, as required by EMS protocols. Interviews with staff revealed confusion and inconsistent practices regarding the verification and documentation of code status. Nurses often relied solely on hospital records without directly confirming residents' wishes, and agency staff reported not being trained on the facility's code status policy. The Social Services Director and other staff did not consistently discuss or document advance directives or code status with residents upon admission. The facility's own policies and job descriptions required that advance care planning and code status discussions be conducted and documented, but these steps were not reliably followed, resulting in a failure to honor residents' end-of-life preferences.
Failure to Honor Resident's Documented DNR Status on Admission
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with a documented Do Not Resuscitate (DNR) status from the hospital, as indicated in both the hospital's History and Physical Report and the New Jersey Universal Transfer Form. Despite this, the resident's admission note in the facility's electronic medical record (EMR) listed the code status as Full Code, and there was no documentation that the resident or their family had been asked about or had changed the code status upon admission. Orders for Full Code were subsequently entered and signed by the Medical Director, with no evidence of verification of the resident's current wishes. When the resident was later found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) and continued until emergency medical services (EMS) arrived and took over. The resident was intubated and transported to the hospital, where they expired. Interviews with the resident's family confirmed that the resident had been a DNR in the hospital and would have continued as a DNR if asked. The nurse who entered the Full Code order was agency staff, unfamiliar with the facility's code status policy, and could not recall why Full Code was selected. Facility policy required that advance directives be determined and documented upon admission, and that the resident's choices be communicated to the care team. However, there was no evidence that these procedures were followed for this resident, resulting in actions that did not align with the resident's documented end-of-life wishes.
Inaccurate Documentation of Controlled Substance Administration and Removal Times
Penalty
Summary
The facility failed to ensure that documentation of controlled substance medications accurately reflected the disposition and administration times for three residents. Specifically, for one resident prescribed alprazolam, the medication was documented as removed from the narcotic lock box at the scheduled administration time, but the actual administration occurred nearly an hour later. In another case, a resident prescribed pregabalin (Lyrica) had documentation showing the medication was administered almost an hour before it was recorded as removed from the lock box. A third resident also received Lyrica, with records indicating the medication was administered over half an hour before it was documented as removed from the lock box. Interviews with facility staff revealed inconsistent practices and misunderstandings regarding the proper documentation of controlled substances. The DON stated that nurses were documenting the scheduled administration time on the controlled substance record, relying on the MAR to capture the actual administration time. The Regional Director of Operations indicated that the time the medication was removed from the lock box should be documented, while some nursing staff reported documenting either the administration time or the scheduled time, rather than the actual time of removal. The facility's policy required accurate documentation of the date and time controlled substances were received and administered, as well as proper reconciliation of inventory to detect potential diversion. However, the observed practice did not align with these requirements, as the controlled substance records did not consistently reflect the actual times medications were removed from secure storage or administered to residents.
Failure to Ensure Proper PPE Use for COVID-19 Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for residents on special droplet/contact precautions for COVID-19. Four residents who tested positive for COVID-19 were observed to have staff enter their rooms without the required PPE, specifically lacking appropriate eye protection. In several instances, staff wore only surgical masks or doubled surgical masks instead of N95 respirators, and relied on personal eyeglasses instead of face shields or goggles, despite signage and care plans indicating the need for gloves, gowns, N95 masks, and eye protection. Observations revealed that PPE carts were available outside the rooms, and signage clearly stated the required PPE for entering rooms of COVID-19 positive residents. However, staff members, including CNAs, LPNs, and RNs, either did not use the correct PPE or were unaware of the specific requirements. Interviews with staff confirmed that some did not wear eye protection unless residents were symptomatic, and in one case, a staff member used two surgical masks due to the unavailability of an N95 mask in the PPE caddy. Staff also reported caring for both COVID-positive and COVID-negative residents during their shifts. The facility's own COVID-19 Prevention, Response, and Reporting policy required healthcare personnel to use a NIOSH-approved N95 respirator or higher, gown, gloves, and eye protection when entering the room of a resident with suspected or confirmed COVID-19. Both the Infection Preventionist and the Director of Nursing confirmed that the expectation was for staff to wear the full set of PPE as outlined in the policy. The failure to adhere to these requirements was confirmed through direct observation, staff interviews, and review of facility policies and resident care plans.
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.
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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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