Autumn Lake Healthcare At Berkeley Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Berkeley Heights, New Jersey.
- Location
- 35 Cottage Street, Berkeley Heights, New Jersey 07922
- CMS Provider Number
- 315195
- Inspections on file
- 18
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Berkeley Heights during CMS and state inspections, most recent first.
A resident with schizophrenia, anxiety, depression, and gait/mobility issues, but intact cognition, left the facility through the lobby without notifying nursing staff or being signed out, contrary to usual practice and facility policy. An RN last saw the resident around midday and did not see or report their absence before shift end, and later an LPN and CNA noted an untouched dinner tray and absence from the room but initially assumed the resident was out smoking. The resident traveled by public transportation out of town, missed return buses, spent the night in a hospital lobby, and returned the next morning, demonstrating a failure to provide adequate supervision and to follow the facility’s elopement and sign-out protocols.
A facility failed to follow CDC guidelines for pneumococcal vaccinations by not offering the Prevnar 20 vaccine to a resident over 65 who had previously received PCV13 and PPSV23. The facility's policy did not reflect current CDC recommendations, and staff interviews confirmed the oversight, which could increase the resident's risk of pneumonia.
A facility failed to protect residents from abuse, as evidenced by a dietary staff member speaking harshly to a resident, causing them to cry, and a wandering resident physically assaulting another, resulting in a lost tooth. The facility's investigation did not confirm the assault, and care plans were not updated to address the wandering behavior or the incident, highlighting a failure to follow abuse prevention policies.
The facility failed to provide an adequate supply of linens, including towels, to meet the needs of residents across four units. Despite the Housekeeping Director's claim of sufficient supply, resident feedback and a lack of documented linen distribution policy highlighted the deficiency. The DON confirmed the facility's census, but no additional information was provided to address the issue.
The facility failed to ensure that NAs received the required training and competencies before being assigned to provide direct resident care independently. Two NAs, enrolled in a training program, began providing care without completing necessary modules or having competencies verified. Facility staff were unclear about training requirements, leading to NAs providing care without adequate preparation, placing residents at risk.
The facility failed to maintain a clean and sanitary kitchen, risking foodborne illness. Observations included improper dishwashing practices, expired and unlabeled food, and unsanitary conditions throughout the kitchen and storage areas. The Food Service Supervisor and Human Resources Director acknowledged the lack of a cleaning schedule and the facility's failure to adhere to its Food Receiving and Storage Policy.
The facility failed to address resident concerns about staffing, staff training, and incontinence care through their QAPI program. Surveyors observed residents left soiled for extended periods and noted inadequate staff training and communication. Residents reported that agency CNAs were untrained and incontinence care was delayed, particularly by the 3:00 PM to 11:00 PM staff. The QAPI program did not address these issues, as confirmed by the LNHA.
The facility did not designate a full-time Infection Preventionist as required for facilities with 100 or more beds. The current Infection Preventionist has been performing dual roles as both the IP and ADON since 2019, despite completing CDC training and certification. The DON confirmed the facility's bed capacity and acknowledged the requirement for a full-time IP.
A LTC facility failed to follow its policies for abuse investigation and incident reporting, resulting in incomplete investigations for two incidents. One involved a resident alleging verbal abuse by staff, with an incomplete grievance form and no thorough investigation. The second incident involved a resident found unresponsive on the floor, with no comprehensive analysis or witness statements. The facility's policies require thorough documentation and investigation, which were not adhered to in these cases.
The facility failed to provide adequate incontinence and personal hygiene care, as residents were found in soiled conditions for extended periods, with some wearing multiple saturated briefs. Observations revealed strong odors and delayed care, with residents expressing concerns about staffing and response times. Care plans did not adequately address residents' needs, and staff inconsistencies were noted.
The facility failed to ensure proper administration and monitoring of cardiac medications for residents, leading to deficiencies in care. A resident on Milrinone did not receive consistent blood pressure monitoring, and there was no policy for its administration. Another resident did not receive timely administration of cardiac medications upon admission, with no documentation of communication with the physician. A third resident's medication was not administered as ordered, with no evidence of physician notification.
A resident with severe cognitive impairment exhibited wandering and inappropriate urination behaviors, which were not adequately addressed by the facility. Despite documentation and reports from staff and other residents, the care plan lacked specific interventions for these behaviors. The facility's attempts, such as using stop signs, were ineffective, and there was no evidence of non-pharmacological interventions. The facility also failed to investigate incidents thoroughly, contributing to the deficiency.
A facility failed to provide appropriate restorative services for a resident with limited mobility, leading to a deficiency in maintaining or improving their range of motion (ROM). The resident was observed with contracted hands and no assistive devices, and the restorative program documentation was missing. Despite the resident's fall and diagnoses including Parkinson's disease, there was no referral to therapy services, and the facility's policy on ROM was not followed.
A resident with acute respiratory failure was not administered oxygen as ordered, with the concentrator set below the prescribed 3 LPM on multiple occasions. The resident's care plan required continuous oxygen to maintain saturation above 94%, but the facility failed to follow the physician's order. The issue was confirmed by an LPN and escalated to the RN/Unit Manager, but no further information was provided by the facility's administration.
The facility failed to post an up-to-date Nursing Home Staffing Report (NHSR), with surveyors finding the report outdated by several days. The HRD admitted the report was not printed over the weekend, and the Monday report was delayed. The facility's staffing policy lacked procedures to ensure timely posting.
A facility failed to acquire routine medications without delay for a resident, leading to a deficiency. An LPN was observed without the necessary medication in stock, despite a pharmacy order being created. The eMAR showed the medication was documented as administered on several dates, except one where delivery was awaited. The RN/UM and ADON confirmed procedures for out-of-stock medications, but the RN/UM was not informed of the issue. The deficiency was discussed with the survey team, corporate nurse, DON, and LNHA, but no further information was provided.
The facility failed to properly store and label medications, including a narcotic box that was not affixed in a refrigerator and intermingled prescription and OTC medications in a cart. An RN and LPN acknowledged these issues, which were observed during a survey.
Failure to Follow Elopement Protocol Resulting in Resident Leaving Facility Overnight
Penalty
Summary
The deficiency involves the facility’s failure to follow its elopement and supervision protocols, resulting in a resident leaving the building, traveling out of town, and remaining out overnight without staff knowledge. The resident had diagnoses including schizophrenia, anxiety disorder, depression, gait and mobility abnormalities, and other lack of coordination, but had an intact cognition with a BIMS score of 15/15. The facility’s policy on Elopements and Wandering Residents stated that residents at risk for elopement would receive adequate supervision to prevent accidents or elopements. On the day of the incident, the resident left the facility through the lobby without notifying nursing staff or being signed out, which differed from their usual practice of informing a nurse and signing out when going out. The resident later reported that they told a CNA they wanted to go out but did not inform a nurse or obtain a formal sign-out. RN staff last recalled seeing the resident around late morning to midday and did not see the resident again before the end of the shift, nor did they report the lack of contact in shift handoff. During the evening, the resident’s dinner tray was delivered and later found untouched, and the CNA reported this to the LPN, initially assuming the resident was out smoking. Progress notes showed that the resident was not seen in their room at multiple checks in the late afternoon and early evening, and a search was not escalated until it became clear later in the evening that the resident was not in the facility. By that time, the resident had already left, obtained a ride to a train station, traveled by public transportation to their hometown, missed return buses, and spent the night in a hospital lobby before returning the next morning. The facility’s failure to adequately monitor the resident’s whereabouts, recognize and act promptly on the missed meal and absence from the room, and ensure adherence to the sign-out process led to the resident’s elopement in violation of the facility’s policy requiring adequate supervision to prevent accidents or elopements.
Failure to Offer Prevnar 20 Vaccine to Resident
Penalty
Summary
The facility failed to adhere to the CDC guidelines for pneumococcal vaccinations, resulting in a deficiency related to the vaccination of a resident. The facility's policy, dated April 10, 2024, stated that pneumococcal vaccines should be administered in accordance with current CDC recommendations. However, the facility did not offer the Prevnar 20 vaccine to a resident over the age of 65, who had previously received the PPSV23 vaccine in April 2017 and the PCV13 vaccine in March 2016. The CDC guidelines indicate that adults who have received PCV13 and PPSV23 should be offered PCV20, but this opportunity was not provided to the resident or their representative. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that there were no updated pneumococcal policies reflecting the CDC's current recommendations. The Director of Nursing acknowledged that the resident should have been offered the Prevnar 20 vaccine, as it had been more than five years since the last pneumococcal vaccination. This oversight had the potential to increase the resident's risk of contracting pneumonia.
Failure to Protect Residents from Abuse and Inadequate Care Planning
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents involving residents. In the first incident, a dietary staff member spoke to a resident in a harsh and abusive manner during a meal, causing the resident to cry. This behavior was witnessed by a surveyor and confirmed by an activity staff member, who noted that the dietary staff member had previously spoken to residents in a similar tone. The facility's Director of Nursing and Licensed Nursing Home Administrator were not aware of the incident until informed by the surveyor. In the second incident, a resident with a history of wandering entered another resident's room and physically assaulted them, resulting in the loss of a tooth. The assaulted resident reported the incident to staff, but the facility's investigation did not confirm the event through camera surveillance. Despite the resident's report and the presence of a history of wandering behavior, the care plan for the wandering resident was not updated to address the behavior or prevent future incidents. The facility's failure to follow its Abuse, Neglect, and Exploitation Policy and Procedure is further highlighted by the lack of appropriate interventions in the care plans of the involved residents. The wandering resident's care plan did not adequately address their behavior of entering other residents' rooms, and the assaulted resident's care plan was not updated to reflect the incident. This lack of action and oversight contributed to the continuation of abusive interactions and inadequate protection for the residents involved.
Inadequate Linen Supply for Residents
Penalty
Summary
The facility failed to ensure an adequate supply of linens, including sheets, pillowcases, towels, bed linens, wash cloths, bed pads, and gowns, to meet the needs and maintain the dignity and well-being of all residents across four resident units. This deficiency was identified through observation, interviews, and document reviews. During the entrance conference, the Director of Nursing confirmed the facility's census was 97 residents. However, feedback from residents indicated a shortage of towels, as noted in the Resident Council Meeting Minutes from March. Despite the Housekeeping Director's assertion that there was enough linen supply, the surveyor found discrepancies in the reported linen distribution schedule. The facility's linen distribution schedule indicated that each resident unit received a linen cart every shift, with specific quantities of linens and blankets. However, the facility failed to provide a policy regarding the linen process and distribution when requested by the surveyor. This lack of documentation and the residents' feedback about insufficient towels contributed to the determination of the deficiency. The Licensed Nursing Home Administrator and the Director of Nursing were informed of these concerns, but no additional information was provided to address the issue.
Inadequate Training and Competency Verification for Nurse Aides
Penalty
Summary
The facility failed to ensure that Nurse Aides (NAs) received the required training and competencies before being assigned to provide direct resident care independently. This deficiency was identified for two NAs who were enrolled in a Nurse Aide Training School but had not completed the necessary modules of the Nurse Aide Training and Competency Evaluation Program (NATCEP). Despite this, they were assigned to provide independent direct care, including tasks such as bathing, toileting, transferring, feeding, personal hygiene, and grooming. The NAs were enrolled in a training program on June 18, 2024, and completed Module 1 by July 12, 2024. However, they began providing independent care on July 5, 2024, without completing Module 2 or having their competencies verified by the facility. The facility lacked records of the NAs completing the required modules, and there was no evidence of a competency process beyond a checklist. Interviews with facility staff revealed confusion and miscommunication regarding the training requirements and oversight responsibilities for the NAs. The Human Resources Director (HRD) and other staff members were unclear about the training process and the requirements for NAs to work independently. The HRD believed that after two weeks of training, the NAs could be assigned independently, but this was not in line with the facility's policy or state regulations. The Assistant Director of Nursing (ADON) and other staff members were under the impression that the NAs had completed the necessary training, but this was not the case. The lack of proper oversight and verification of training completion led to the NAs providing care without adequate preparation, placing residents at risk.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, leading to potential foodborne illness risks. During a kitchen tour, a food service staff member was observed washing dishes with bare hands, handling both dirty and clean dishes without performing hand hygiene. The dish machine temperature log was outdated, and the Food Service Supervisor (FSS) was unaware of the required temperatures, relying on a weekly check by the dish machine company. Expired and unlabeled food items were found in the refrigerator and freezer, and various food items lacked proper labeling with use-by dates. The kitchen environment was unsanitary, with debris, a dead insect, and a malfunctioning prep sink. The FSS admitted to the absence of a cleaning schedule, and the Human Resources Director (HRD) confirmed that the kitchen was not clean. Additional observations included soiled food preparation tables, a can opener with debris, and a sticky metal table by the ice machine. The ice machine baffle had pinkish debris, and personal beverages were improperly stored. The facility's Food Receiving and Storage Policy required clean storage areas and proper labeling of dry foods, which was not adhered to. The HRD acknowledged that the dry storage room was not clean, contradicting the policy's requirements. The facility's failure to maintain cleanliness and adhere to food safety protocols was evident throughout the kitchen and storage areas.
Deficiency in Addressing Resident Concerns and Staff Training
Penalty
Summary
The facility failed to identify and implement interventions to address resident concerns regarding staffing issues, staff training, grievances, abuse, issues with medications, incontinence care, staff competency, and the use of uncertified nurse aides through their Quality Assurance and Performance Improvement (QAPI) program. This deficiency was observed across all four resident care units. During a care tour, surveyors noted that several residents were left soiled in their excrement for extended periods, with some wearing multiple soaked incontinent briefs. Residents also had long, jagged, and soiled fingernails. Interviews with alert residents revealed that the facility was understaffed, and staff were not adequately trained to care for the residents. One resident reported expressing concerns about the lack of training to the Licensed Nursing Home Administrator (LNHA), but no action was taken. During a Resident Council Meeting, eight out of eleven residents expressed concerns over staffing and staff incompetence. They reported that many Certified Nursing Assistants (CNAs) were agency staff who seemed untrained and lacked communication skills. Residents noted that incontinence care was not provided in a timely manner, particularly by the 3:00 PM to 11:00 PM staff, leading to malodorous odors in the hallways. The facility's QAPI program did not address these issues, as confirmed by the LNHA, who stated that there was no data-driven QAPI program for concerns identified with incontinence care, staff training, restorative care, and grievances. The facility's QAPI attendance logs and meeting notes did not reflect any actions taken to address these significant concerns.
Failure to Designate a Full-Time Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Prevention and Control Nurse solely responsible for the infection prevention and control program, as required by the State of New Jersey Department of Health Executive Directive No 20-026-1. During an interview, the facility's Infection Preventionist (IP) revealed that she has been performing dual roles as both the IP and the Assistant Director of Nursing (ADON) since 2019. Despite completing her CDC training and receiving certification as a Nursing Home Infection Preventionist in 2020, she continues to work full-time in both capacities. The Director of Nursing (DON) confirmed that the facility is licensed for 130 beds, which mandates a full-time IP with no other responsibilities. The DON acknowledged the requirement but did not provide further information to address the deficiency.
Incomplete Investigations and Documentation in LTC Facility
Penalty
Summary
The facility failed to follow its policy for Abuse Investigation and Incidents and Accidents, resulting in incomplete investigations and documentation for two separate incidents involving residents. In the first case, a resident alleged verbal abuse by staff, stating that staff made fun of them and ignored their needs. The grievance form filed by the resident was incomplete, lacking documentation of review, action taken, and resolution. The Director of Nursing (DON) admitted that no thorough investigation was conducted, and only a brief conversation with the resident was documented, without interviewing other potential witnesses or staff involved. In the second incident, a resident was found on the floor, unresponsive, and saturated with urine, requiring emergency transport to the hospital. The investigation into this incident was also incomplete, with no witness statements or a comprehensive analysis of the circumstances leading to the fall. The DON acknowledged the lack of documentation and stated dissatisfaction with the new investigation process, which contributed to the incomplete investigation. The facility's policies on incident reporting and abuse investigation require thorough documentation and investigation of all incidents, including interviewing all involved parties and providing complete documentation. However, in both cases, the facility failed to adhere to these policies, resulting in inadequate investigations and unresolved grievances.
Inadequate Incontinence and Hygiene Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate incontinence and personal hygiene care for several residents, as evidenced by multiple observations and interviews conducted by surveyors. Residents were found sitting or lying in soiled conditions for extended periods, with some residents wearing multiple incontinence briefs that were saturated with urine and feces. This was observed across different units and involved residents who were dependent on staff for care, including those with cognitive impairments and limited mobility. The surveyors noted strong malodorous odors in the hallways and rooms, indicating a lack of timely incontinence care. Specific incidents included a resident who had not been changed since the morning, resulting in soaked bedding and clothing, and another resident who was found with three saturated briefs. The care plans for these residents did not adequately address their needs for activities of daily living (ADLs) or incontinence care. Staff interviews revealed inconsistencies in care provision, with some staff members acknowledging the use of double briefs and others unable to confirm when residents were last changed. The facility's policy required incontinence care every two hours, but this was not consistently followed. Additionally, residents expressed concerns about inadequate staffing and delayed responses to call lights, which contributed to the deficiencies in care. A resident council meeting highlighted these issues, with residents reporting that incontinence care was often delayed until shift changes. The facility's management was reportedly unaware of the extent of the issues, despite the pervasive odors and resident complaints. The surveyors documented these deficiencies and discussed them with facility management during the survey process.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, specifically in the administration and monitoring of cardiac medications. For Resident #88, the facility did not have a procedure in place for administering Milrinone, an intravenous medication for heart failure, which required specific monitoring. The resident's blood pressure was not consistently monitored every four hours as ordered, with only 28 out of 84 required readings documented. Additionally, there was no policy in place for the administration of Milrinone, and the staff were not adequately trained to monitor and administer the medication according to the physician's order. For Resident #296, the facility failed to provide timely administration of physician-ordered cardiac medications upon admission. The resident was admitted with several diagnoses, including paroxysmal atrial fibrillation and COPD, and required medications such as Amiodarone and Advair. However, these medications were not administered on the ordered date, and there was no documentation of communication with the physician regarding the missed doses. The facility's process for acquiring medications from the pharmacy was not effective in ensuring timely administration. Similarly, for Resident #297, the facility did not administer Magnesium Oxide as ordered on the date of admission. The medication was not documented as administered, unavailable, or refused, and there was no evidence of communication with the physician regarding the missed dose. The facility's failure to acquire and administer routine medications without delay was a recurring issue, as evidenced by the lack of documentation and timely action for multiple residents.
Failure to Address Wandering and Inappropriate Urination Behaviors
Penalty
Summary
The facility failed to accurately assess and address the behavior management needs of a resident, identified as Resident #74, who exhibited wandering and inappropriate urination behaviors since December 2023. Despite these behaviors being documented in the resident's clinical records and reported by other residents and staff, the care plan was not revised to include meaningful interventions to manage these behaviors. The care plan focused on cognitive function and elopement risk but did not address the specific behaviors of wandering into other residents' rooms and urinating in inappropriate places. The resident, who has diagnoses including vascular dementia and major depressive disorder, was noted to have a severely impaired cognitive status with a BIMS score of 00 out of 15. Despite this, the Minimum Data Set (MDS) did not reflect the wandering behavior, and the care plan lacked specific interventions for the resident's nighttime wandering and urination issues. The facility's interventions, such as placing stop signs at door entrances, were ineffective, and there was no evidence of non-pharmacological interventions being implemented. Interviews with staff and residents confirmed the ongoing issues, with reports of the resident entering other rooms, displacing belongings, and urinating in trash cans. The facility did not provide adequate supervision or scheduled activities at night to address these behaviors. Additionally, the facility failed to investigate incidents thoroughly, such as when the resident was found on the floor in another resident's room, which could have indicated potential abuse. The lack of a comprehensive behavior management plan and appropriate interventions contributed to the deficiency.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate services for a resident with limited mobility, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, identified as having contracted hands and no assistive devices, was observed without splints or hand rolls. The Temporary Nurse Aide confirmed the absence of assistive devices, and the Assistant Director of Nursing (ADON) was unable to open the resident's hands fully. The Licensed Practical Nurse/Unit Manager (LPN/UM) admitted that the restorative book, which documents services provided, had been missing for two months, indicating a lack of proof that the restorative program was functional. The resident's electronic medical record lacked orders for ambulation or assistive devices to prevent further decline in ROM. The LPN/UM confirmed the absence of hand rolls for the past two years and was unable to provide documentation for Passive Range of Motion (PROM) or Active Range of Motion (AROM) exercises. Despite the resident's fall, there was no referral to therapy services for skilled interventions, as indicated in the care plan. The resident's diagnoses included arthropathy, Parkinson's disease, mood disturbance, and hypotension, with a moderately impaired cognition score. The Physical Therapy Director (DPT) confirmed that restorative nursing was recommended post-discharge from physical therapy to prevent decline, but the nursing department was responsible for its implementation. The PT discharge summary indicated that the resident had achieved maximum potential and was to continue with a restorative ambulation program. However, the facility's policy on resident mobility and ROM, which was undated, stated that residents should not experience an avoidable reduction in ROM and should receive appropriate services and equipment to maintain or improve mobility. The lack of documentation and implementation of the restorative program contributed to the deficiency.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident received oxygen as ordered, which was identified during a survey. The deficiency involved a resident who was admitted with acute respiratory failure and hypoxia, requiring continuous oxygen administration at 3 liters per minute (LPM) via nasal cannula to maintain oxygen saturation above 94%. However, observations by the surveyor revealed that the oxygen concentrator was set between 2 and 2.5 LPM on multiple occasions, contrary to the physician's order. The resident was cognitively intact and had a care plan in place that included providing oxygen as ordered. Further review of the electronic Treatment Administration Record (eTAR) showed that the order for oxygen was not consistently signed off by nurses on certain shifts. During a follow-up observation, the Licensed Practical Nurse (LPN) confirmed the oxygen was set to 2 LPM, which was not in accordance with the physician's order. The issue was escalated to the Registered Nurse/Unit Manager, who instructed the LPN to check the resident's blood oxygen level and contact the physician. Despite discussions with the survey team, the facility's corporate nurse, Director of Nursing (DON), and Licensed Nursing Home Administrator (LNHA) did not provide additional information to address the concerns raised.
Failure to Post Accurate and Timely Nursing Home Staffing Report
Penalty
Summary
The facility failed to ensure that the posted Nursing Home Staffing Report (NHSR) was up to date and accurate. On multiple occasions, surveyors observed that the NHSR was outdated, with the report dated 7/12/24 still posted on 7/14/24 and 7/15/24. The report was supposed to reflect the current resident census and the number of nursing staff on duty, but it was not updated for several days. The Director of Nursing confirmed that the resident census was 97, differing from the outdated report which showed a census of 101. The Human Resources Director (HRD) acknowledged that the receptionist was responsible for posting the NHSR daily, but the report was not printed over the weekend, and the Monday report was delayed. The HRD admitted that the NHSR should have been up to date for the benefit of residents and their families. During discussions with the survey team, the corporate nurse, the Director of Nursing, and the Licensed Nursing Home Administrator did not provide further information to address the concerns. Additionally, the facility's staffing policy did not include procedures to ensure the NHSR was posted accurately and timely.
Failure to Acquire Routine Medications Timely
Penalty
Summary
The facility failed to acquire routine medications without delay for timely administration to a resident. On a specific date, a surveyor observed an LPN preparing medications for a resident, which included a physician's order for Cholecalciferol. The LPN stated that the medication was not in stock for administration, and a review of the order audit report revealed that a pharmacy supply order was created but not received. The electronic Medication Administration Record (eMAR) indicated that the medication was documented as administered on several dates, except for one date where it was noted that the facility was awaiting delivery. The RN/UM stated that when a medication is out of stock, the nurse can order it through the electronic Medication Record, call, or fax the pharmacy. The ADON confirmed that the expectation was for the nurse to inform the supervisor, check with the pharmacy, and inform the doctor if there was an issue. However, the RN/UM was not informed that the medication was not received since the order date. The ADON also confirmed that a stat immediate order was a service provided by the pharmacy, and a call should have been made to inform the prescriber. The deficiency was discussed with the survey team, corporate nurse, DON, and LNHA, but no further information was provided regarding the concerns.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of controlled substances and other medications, as observed during a survey. In one of the medication rooms, a narcotic box containing a resident's sealed Lorazepam medication was found to be not permanently affixed within the refrigerator. The box was easily removable, which was acknowledged by a Registered Nurse (RN) as a safety concern to prevent theft or misuse. This issue was identified during an inspection conducted in the presence of the RN, who stated that the narcotic box should have been bolted for security. Additionally, during an inspection of a medication cart, it was observed that prescription ointments, creams, and over-the-counter (OTC) medications were intermingled in the drawers. An LPN confirmed that the OTC medications were house stocked and used for any resident, and that prescription ointments should have been separated by resident and indication to avoid cross-contamination. An unlabeled Mupirocin Ointment with white creamy seepage was found among the medications, and the LPN could not explain its presence. The LPN/Unit Manager confirmed that prescription medications should have labels and be stored separately, acknowledging the failure to maintain the pharmacy's provided separation of medications.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
