Autumn Lake Healthcare At Memorial Bridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Penns Grove, New Jersey.
- Location
- 201 Fifth Avenue, Penns Grove, New Jersey 08069
- CMS Provider Number
- 315271
- Inspections on file
- 15
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Memorial Bridge during CMS and state inspections, most recent first.
The facility did not ensure that physician visit progress notes were documented in a timely manner for three cognitively intact residents with multiple medical conditions. Medical records lacked required physician documentation at the time of review, and staff interviews revealed uncertainty about the process for entering or forwarding physician notes, resulting in missing documentation as required by facility policy.
A resident admitted with multiple medical conditions did not have weekly weights consistently monitored or documented as required by facility policy. Staff interviews confirmed awareness of the weight monitoring protocol, but gaps in documentation and a significant unaddressed weight gain were identified. Additional weights were added to the record after the surveyor's review, highlighting inconsistencies in record-keeping and failure to follow established procedures.
A cognitively impaired resident with a history of refusing care and at moderate fall risk sustained a head laceration after a CNA attempted to enter the resident's room against their wishes, resulting in a fall. Staff interviews and facility policies confirmed that residents' rights to refuse care and privacy were known and trained, but these were not followed during the incident, leading to the injury.
Surveyors identified widespread deficiencies in maintaining a safe, clean, and homelike environment, including peeling paint, missing tiles, unclean shower rooms, broken equipment, and cluttered common areas. Staff and leadership acknowledged these issues, which affected residents' access to amenities and contributed to an institutional atmosphere.
The facility did not develop or implement complete, person-centered care plans for several residents, omitting essential interventions such as oxygen therapy, PASARR Level 2 mental health needs, hand orthotic use, and incontinence care. These omissions were confirmed through record review, staff interviews, and direct observation, despite facility policy requiring all identified needs to be addressed in the care plan.
Surveyors found that multiple residents dependent on staff for incontinence care were left in saturated or soiled briefs, with some waiting extended periods for assistance despite facility policy requiring care every two hours or as needed. Staff interviews confirmed awareness of the policy, but delays in care and unaddressed call lights were observed, resulting in residents not being kept clean and dry as required.
Surveyors found that two residents with cognitive impairments and fall risks did not have their nurse call bells within reach, contrary to facility policy and care plan interventions. Staff interviews and document reviews confirmed that call bells should be accessible, but in these cases, one call bell was on the floor and another was wrapped around a wall unit, making them inaccessible.
The facility did not ensure that State Survey results were readily accessible, as required. Alert and oriented residents reported not knowing the location of the survey results or being informed about them. The binder with the results was kept inside a buffet cabinet in the lobby, requiring a door to be opened, and residents in a locked unit could not access it. Both the UM and LNHA confirmed the results were not easily accessible, contrary to facility policy.
A resident with an indwelling urinary catheter was observed without a securement device on the leg and with a drainage bag that was not properly covered for privacy or secured to the bed frame. The DON confirmed that securement devices and privacy covers are facility practice, but these were not in place for the resident, resulting in a failure to provide appropriate catheter care.
Surveyors found that medications were not properly stored and the medication room was not maintained in a sanitary manner. Opened beverage containers and personal bags were present in the medication room, and loose tablets were discovered in two medication carts. Facility policy requires medications to be stored in original packaging and storage areas to be kept clean and organized, but these standards were not met.
A housekeeper entered a resident's room under Contact Precautions for VRE UTI without wearing required PPE, despite clear signage and available gowns and gloves. The staff member believed PPE was only necessary for aides, not housekeeping. Both the Infection Preventionist and DON confirmed that all staff should use PPE per facility policy and posted instructions.
A resident with dementia and psychotic disturbances experienced a fall during an incident involving a CNA, but the facility failed to conduct a thorough investigation as required by policy. Key witnesses, such as roommates, were not identified or interviewed, and the care plan was not updated to reflect the allegation. The DON and LPN acknowledged gaps in the investigation, including uncertainty about reviewing available security footage and incomplete documentation.
A resident who was not cognitively intact did not receive prescribed medications, including diabetes, blood pressure, and seizure/mood disorder treatments, within the required time frame on multiple occasions. Medications scheduled for morning administration were given significantly late, contrary to facility policy and prescriber's orders. The RN acknowledged the late administration and the need to prioritize timely medication delivery.
The facility did not meet the required CNA staffing ratios on four day shifts, as mandated by New Jersey law. The facility was short of the required number of CNAs for the number of residents present, potentially affecting all residents.
Failure to Ensure Timely Physician Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure that the attending physician responsible for supervising the care of residents documented physician visit progress notes at the time of each required visit. This deficiency was identified for three residents, all of whom were cognitively intact and had various medical diagnoses, including fracture of the left pubis, hypertension, myocardial infarction, cellulitis, obstructive sleep apnea, asthma, spinal stenosis, type II diabetes, and anxiety disorder. For each of these residents, a review of their electronic medical records did not show documentation of a visit from the attending physician during the relevant period. During interviews, the DON stated that some providers entered notes directly into the electronic system while others forwarded notes to be scanned, and was unsure of the attending physician's process. The attending physician, who also served as the facility's Medical Director, reported that due to a recent change in the login system, he had been dictating and handwriting notes to be faxed to the facility for inclusion in the medical record, but was unsure why the documentation was missing for these residents. The facility's policy required timely and pertinent documentation, with notes to be written or entered at the time of the visit or returned to the facility within a week if prepared later. The absence of these notes at the time of the survey constituted the deficiency.
Failure to Monitor and Document Weekly Weights Upon Admission
Penalty
Summary
The facility failed to implement and monitor weekly weights upon admission in accordance with professional standards of practice for one resident. The resident was admitted with multiple diagnoses, including a fracture of the left pubis, hypertension, and a history of myocardial infarction, and was cognitively intact at the time of admission. The facility's policy required weights to be taken upon admission, the next day, and then weekly for four weeks, but documentation showed gaps in recorded weights, with missing entries between certain dates and a significant weight gain not being identified or addressed in a timely manner. Interviews with staff, including CNAs, LPNs, the Unit Manager, the Registered Dietitian, and the Nursing Supervisor, revealed that all were aware of the weight monitoring policy and the importance of regular weight checks. However, there was a lack of clarity and follow-through regarding the actual documentation and monitoring of the resident's weights. The staff could not account for the missing weights, and there was no documentation of refusals or reasons for the omissions. The Registered Dietitian and Medical Director were not aware of the significant weight change until it was brought to their attention by the surveyor. A review of the facility's documentation practices showed inconsistencies, with additional weights being added to the record after the surveyor's initial review, based on information from a former employee. The Director of Nursing acknowledged that weights should have been entered promptly and that missing weights were only discovered during the survey process. The facility's policies required accurate and timely documentation of weights and maintenance of accurate medical records, which was not followed in this case.
Failure to Honor Resident Refusal and Ensure Safety Leads to Fall and Injury
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of refusal of care and at moderate risk for falls sustained a head injury after a fall. The incident took place when a CNA attempted to enter the resident's room despite the resident's refusal, resulting in the resident falling backward and sustaining a laceration to the back of the head. The resident was subsequently sent to the hospital for evaluation. The resident's care plan documented severe cognitive impairment, destructive and intrusive behaviors, and a risk for falls, with interventions to redirect negative behaviors and monitor for changes in gait status. The CNA involved in the incident reported attempting to check on the resident, who persistently refused and tried to shut the door. The CNA continued to insist on entering, leading to the resident losing balance and falling. Statements from other staff confirmed that the resident was particular about care and could become upset if things were not done according to their preferences. Staff interviews indicated that training had been provided on respecting residents' rights, including the right to refuse care and the importance of not violating privacy, especially for those with cognitive impairments. Facility policies reviewed by the surveyor emphasized treating residents with dignity and respect, honoring refusals of care, and implementing fall prevention interventions based on risk assessments. Despite these policies and staff training, the CNA's actions did not align with established protocols, directly resulting in the resident's fall and injury. The deficiency was identified through observation, interviews, and review of medical records and facility documentation.
Failure to Maintain a Safe, Clean, and Homelike Environment Across Multiple Units
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment across three units. On A Unit, there were repeated findings of peeling and chipped paint, missing floor tiles, black debris and discoloration, broken equipment, and cluttered areas such as the shower room and nurse's station. The presence of medical equipment and wheelchairs stored in front of the fish tank further detracted from the homelike atmosphere and limited residents' access to recreational features. Staff interviews confirmed that these issues were known and that storage space was insufficient, leading to institutional-like conditions. On B Unit, surveyors found personal items and grooming tools left unattended in the shower room, and a resident room lacking basic amenities such as a bathroom mirror and toilet paper. These observations indicated lapses in housekeeping and attention to residents' daily living needs. Staff acknowledged the need for improved housekeeping and maintenance services to address these concerns. C Unit was noted to have significant maintenance and cleanliness issues, including peeling paint, missing drawers, broken fixtures, cracked walls and moldings, and unclean shower areas with hair and debris. Damaged furniture and equipment, such as a ripped geriatric chair and a loose door handle, were also observed. Facility leadership and maintenance staff acknowledged the ongoing challenges in maintaining the unit, citing factors such as the resident population and environmental conditions, but confirmed that the observed deficiencies required repair and attention.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. For one resident with asthma who was observed receiving oxygen via nasal cannula, there was a physician's order and documentation in the medical record indicating the need for oxygen therapy, but no corresponding care plan addressing the use of oxygen was found. The Assistant Director of Nursing confirmed that oxygen use should have been included in the care plan, and the facility's policy requires measurable objectives and timeframes for all identified needs. Another resident with a state-level 2 PASARR determination for serious mental illness had documentation of depression and anxiety in the care plan, but the positive PASARR Level 2 status and associated specialized services were not identified or addressed in the care plan. Social workers acknowledged that this information was missing and should be included, and the Director of Nursing confirmed that the care plan should reflect PASARR Level 2 status and related services, as outlined in facility policy. Additional deficiencies were noted for residents requiring a hand orthotic and for a resident with frequent incontinence. In both cases, physician orders and assessment data indicated the need for specific interventions (hand roll and incontinence care), but these were not documented in the residents' care plans. Staff interviews confirmed that such needs should be included as focus areas in the care plans, in accordance with facility policy, but were omitted.
Failure to Provide Timely and Adequate Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide proper incontinence care to several residents who were dependent on staff for activities of daily living. During initial rounds, one resident was found in bed with a saturated incontinent brief and was unable to recall the last time they had been changed. The resident's medical record indicated frequent incontinence of bowel and bladder, and their care plan required regular incontinence checks and assistance. Another resident was observed with a saturated brief that had soaked through to their gown, and staff acknowledged that care was delayed as they were attending to other duties. Additional observations included two residents with visibly soiled briefs, one with urine and the other with both urine and feces. In both cases, staff confirmed the need for incontinence care but did not provide it immediately. One of these residents had their call light on for 20 minutes requesting assistance, but no staff responded during that time. Medical records for these residents documented diagnoses such as cerebral infarction, impaired mobility, and always being incontinent, with care plans specifying the need for routine and as-needed incontinence care to maintain skin integrity. Interviews with CNAs, LPNs, and the DON confirmed that facility policy and staff expectations were to provide incontinence care every two hours or as needed, and to respond promptly to call lights. Despite these policies, residents were found unclean and wet, and staff acknowledged that sometimes it took a while to reach all residents. Facility policy stated that incontinent residents should be maintained clean and dry, but this was not consistently achieved as evidenced by the surveyors' observations.
Failure to Ensure Call Bells Were Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to accommodate the needs of two residents by not ensuring that nurse call bells were within their reach. During an initial tour, one resident's call bell was found on the floor underneath the head of the bed, while another resident's call bell was wrapped around the wall unit of the nurse's call bell system, making them inaccessible. A CNA present at the time confirmed that call bells should be on the bed within the resident's reach but expressed an inability to address all issues. Both residents had significant cognitive impairments and were at risk for falls, as documented in their care plans, which included interventions to encourage the use of call bells for assistance. Further interviews with facility staff, including a CNA and the DON, confirmed that facility policy requires call bells to be easily accessible to residents and that staff are expected to ensure this when passing by rooms. Review of facility documents, including job descriptions and policies, reiterated the requirement for call bells to be within easy reach of residents when in bed or confined to a chair. The deficiency was cited under NJAC 8:39-27.1 (a).
Survey Results Not Readily Accessible to Residents and Public
Penalty
Summary
The facility failed to maintain the most recent State of New Jersey inspection results in a location that was readily accessible to residents, families, and the public. During a Resident Council Meeting, all four alert and oriented residents interviewed stated they were unaware of where the State Survey results were kept and had not been informed about them. Observations during a tour revealed that while signs indicated the survey results were in the lobby, the binder containing the results was stored inside a buffet cabinet that required opening a door to access. The C-wing unit, which is locked, also had residents who could not readily access the results. Interviews with the Unit Manager and the Licensed Nursing Home Administrator confirmed that the survey results were not readily accessible to residents, particularly those on the C-wing. Facility policy requires that survey reports and plans of correction be readily accessible to residents and the public.
Failure to Provide Appropriate Catheter Care and Securement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed without appropriate catheter care. The surveyor noted that the resident's urinary catheter drainage bag contained tinged, red urine and was not covered for privacy. Additionally, the resident did not have a securement device on their leg to stabilize the catheter tubing, as confirmed by both observation and the resident's statement. On a subsequent observation, the drainage bag was found unsecured from the bed frame and instead left in a privacy cover, contrary to proper catheter management protocols. Interviews with the Director of Nursing confirmed that the facility's practice is to use privacy covers and securement devices, but these were not in place for the resident at the time of observation. The resident's medical record included orders for catheter maintenance due to urinary retention, and the care plan acknowledged the presence of an indwelling catheter. Facility policy requires daily evaluation of catheter necessity and prompt removal when no longer needed, but the observed lack of securement and privacy measures constituted a failure to provide appropriate treatment and care.
Improper Medication Storage and Unsanitary Medication Room
Penalty
Summary
Surveyors identified that the facility failed to properly store medications and maintain a sanitary environment in one of three medication rooms and two of seven medication carts reviewed. During an inspection of the B Unit Medication Room, six opened beverage containers and two personal bags were found on the counter, despite the availability of a staff breakroom for such items. The LPN/Unit Manager confirmed that staff should not keep beverages and bags in the medication room. Additionally, the Director of Nursing acknowledged that there are lockers available for staff belongings on the B-Wing. Further inspection revealed loose tablets in medication carts: two loose tablets were found in the drawer of B wing medication cart 2, and eleven loose tablets were found in the drawer of A wing medication cart 2. The Director of Nursing stated that medication carts are audited monthly for loose tablets. A review of the facility's policy indicated that drugs and biologicals should be stored in their original packaging and that medication storage and preparation areas must be kept clean, safe, and sanitary. The policy also requires that each resident's medications be stored separately to prevent mixing.
Failure to Use PPE During Contact Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices when a housekeeper was observed mopping the floor in a resident's room that was under Contact Precautions for Vancomycin Resistant Enterococcus (VRE) urinary tract infection. Despite clear signage and the availability of personal protective equipment (PPE) such as gowns and gloves at the room entrance, the housekeeper did not wear any PPE while inside the room. The signage specifically instructed all providers and staff to don gloves and gowns before entering and to discard them before exiting the room. The housekeeper stated that PPE was only required for aides providing direct care, not for housekeeping staff. The resident in question had an active order for special contact isolation precautions due to a VRE UTI, with all services to be provided in the resident's room. The care plan also included an intervention to maintain contact isolation precautions for the duration of antibiotic treatment. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that housekeeping staff should have been wearing PPE in accordance with facility policy and the posted instructions. Facility policy required staff and visitors to wear disposable gowns upon entering rooms under contact isolation and to avoid contaminating surfaces after gown removal.
Failure to Conduct Thorough Abuse Investigation and Maintain Documentation
Penalty
Summary
The facility failed to maintain adequate documentation and conduct a complete and thorough investigation into an alleged abuse incident involving a resident with significant cognitive impairment and a diagnosis of dementia with psychotic disturbances. The incident in question involved a Certified Nursing Assistant (CNA) entering the resident's room, after which the resident fell to the floor. Statements from staff indicated that the CNA was attempting to enter the room to check on the resident's roommate, and the resident, who was blocking the door, lost balance and fell. The facility submitted a Facility Reported Event (FRE) to the Department of Health, but the investigation documentation was incomplete. Upon review, it was found that the facility did not identify or interview all potential witnesses, including the resident's roommates, despite statements indicating that at least one roommate was present during the incident. The Licensed Nurse Practitioner Unit Manager (LPN/UM) and the Director of Nursing (DON) both acknowledged that the investigation did not confirm who was present in the room at the time of the incident, nor did it include attempts to interview the roommates. Additionally, the DON confirmed that the care plan was not updated to reflect the allegation, and there was uncertainty about whether available security camera footage was reviewed as part of the investigation. The facility's own policies require that all involved persons, including the alleged victim, perpetrator, witnesses, and others with knowledge of the incident, be identified and interviewed. The policies also specify that the investigator should review completed documentation forms and interview roommates, family members, and visitors. The failure to follow these procedures resulted in an incomplete investigation and insufficient documentation regarding the alleged abuse incident.
Failure to Administer Medications Within Required Time Frame
Penalty
Summary
A deficiency was identified when a resident, who was not cognitively intact as indicated by a Brief Interview of Mental Status score of 0, did not receive medications within the required time frame as per physician's orders and facility policy. The resident had orders for Jardiance 10mg once daily, metoprolol tartrate 25mg twice daily, and Depakote Sprinkles 125mg (three capsules in the morning). On two separate occasions, these medications, scheduled for administration at 8:00 AM, were instead given significantly later—at 9:36 AM and 10:08 AM, respectively. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. During an interview, the RN acknowledged administering the medications late and stated that the resident should have been prioritized for timely medication administration. The failure to follow the prescriber's orders and the facility's medication administration policy resulted in the resident not being free from significant medication errors.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels for nursing homes. During a review of staffing records from December 1, 2024, to December 14, 2024, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on four separate day shifts. On December 2 and 3, 2024, the facility had 17 CNAs for 143 residents, falling short of the required 18 CNAs. On December 5, 2024, there were 17 CNAs for 141 residents, again requiring at least 18 CNAs. Finally, on December 13, 2024, the facility had 16 CNAs for 138 residents, when at least 17 CNAs were needed. This deficiency had the potential to affect all residents in the facility.
Plan Of Correction
1) Efforts to hire more facility staff to allow us to have adequate or more than adequate staff to serve our residents have been ramped up. In the meantime, the facility will utilize agencies to fill open slots in the schedule. 2) All residents in the Facility have the potential to be affected by the deficient practice. 3) The Administrator and Director of Nursing shall continue to review the daily Certified Nursing Assistant (CNA) staffing schedules to ensure compliance with the state's minimum CNA staffing requirement. Furthermore, the facility will review its recruitment program and hiring efforts to attract and hire CNAs, as evidenced by placing advertisements on Indeed, contacting recruitment agencies, and offering referral bonuses to current staff for securing additional staff. The center shall offer overtime, incentive pay, and bonuses to current staff when a staffing shortage is identified or occurs throughout the day and/or week. The facility staffing coordinator will work with sister facilities staffing coordinator for CNAs/License Nurses for daily backup when call outs occur. CNAs will receive free meals and incentives on top of their regular pay. The facility will offer overtime, bonuses, or incentives to Licensed Nurses to work as Nursing Assistants when warranted. The facility also maintains an agreement with nursing staffing agencies in the event of any staffing shortage. A meeting was conducted on Tuesday with Staffing Company, HR, and DON to discuss current needs. 4) The Administrator and Director of Nursing or designee shall review/audit the Certified Nursing Assistant (CNA) staffing schedule daily for 4 weeks, then monthly x 2 months, and then quarterly for 3 quarters to determine compliance with the state's minimum CNA staffing requirement. The Administrator shall continue to monitor the facility's recruitment and retention practices to identify potential areas of improvement. The results of these audits will be submitted monthly to the Quality Assurance and Performance Improvement (QAPI) committee for the next 6 months. This will be a part of the Quarterly Quality Assurance Program ongoing. Staffing Coordinator and DON will check staffing sheets the next day and initiate progressive discipline for those who are calling out. Weekend call outs will mandatorily be made up the following weekend. This will be ongoing.
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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