Autumn Lake Healthcare At Salem County
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, New Jersey.
- Location
- 438 Salem-woodstown Road, Salem, New Jersey 08079
- CMS Provider Number
- 315058
- Inspections on file
- 18
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Salem County during CMS and state inspections, most recent first.
A resident with multiple comorbidities and incontinence was not given a complete and accurate skin assessment upon admission, resulting in missed documentation of excoriation and edema. The initial assessment failed to identify skin impairment, and wound care orders were delayed until a subsequent assessment by an LPN. Required incident reporting and documentation were not completed as per facility policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A resident with diabetes experienced a critically low blood sugar, but the LPN did not notify the physician as required by orders and facility policy. Review of records and staff interviews confirmed the lack of notification and documentation, despite clear protocols for such events.
Staff failed to consistently document ADL care provided or refused for three residents with complex medical needs, resulting in missing entries in the DSR and progress notes. Despite the use of a mobile documentation system and clear policy expectations, required ADL documentation was incomplete on multiple shifts, and supervisory checks did not ensure compliance.
A facility failed to develop a comprehensive care plan for a resident with diabetes and elongated toenails, despite the resident's severe cognitive impairment. The facility's policy required a person-centered care plan, but interviews with staff, including the UM and DON, confirmed the absence of such a plan. This oversight was identified during a survey, highlighting a deficiency in the care planning process.
A resident with diabetes and dementia did not have a care plan for their conditions, and there was a delay in podiatry care for elongated toenails. Additionally, there was a significant delay in notifying the physician of abnormal urine culture results, contrary to facility policy. These lapses in care highlight deficiencies in adhering to clinical standards.
A facility failed to provide timely podiatry care for a diabetic resident admitted with elongated toenails, who was not seen by a podiatrist for nearly nine months. Despite the facility's policy for prompt podiatry referrals, the resident's toenails were only addressed after a significant delay. Interviews revealed a breakdown in communication and procedure adherence among staff, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses had an abnormal urine culture result that was not promptly communicated to the physician, contrary to facility policy. The urine culture was collected and reported in early September, but the physician was not informed until several days later, delaying necessary antibiotic treatment. Interviews with facility staff confirmed the expectation for immediate notification of abnormal lab results to prevent potential escalation of the resident's condition.
The facility failed to maintain a homelike environment for three resident rooms on the C/D unit. Observations included damaged furniture, walls, and leaking sinks. Staff confirmed that maintenance issues were reported in a log, but some entries were incomplete, and repairs were not made. The Interim Maintenance Director acknowledged the unresolved issues and the need for repairs.
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. Observations included undated raw chicken, wilted lettuce, undated liquids, unlabeled scalloped potatoes, damaged pork loins, a dented can, a dirty slicer, and a stained cutting board. The Dietary Director acknowledged these issues, which were not in compliance with the facility's policies.
An LPN failed to follow infection control practices and perform hand hygiene during a meal tray pass, handling food and interacting with residents without cleaning her hands. This was confirmed by multiple staff members and a review of the facility's hand hygiene policy.
The facility failed to follow professional standards by not obtaining a diagnosis for the use of an IV antibiotic for a resident admitted with cellulitis and a PICC line. The physician's order for Vancomycin did not include a diagnosis, and the resident and LPN were unaware of the infection being treated. The LPN/UM later confirmed the antibiotic was for MRSA in the blood, but acknowledged the order should have included a diagnosis. The facility's policy requires medication orders to include the clinical condition, which was not followed.
The facility failed to obtain a physician order for a skin tear treatment and did not update a resident's Care Plan with fall prevention interventions after an unwitnessed fall. The resident, who had a history of falls and was cognitively impaired, fell while trying to retrieve something from the closet, resulting in a skin tear. Despite claims in the incident report, no documentation was found in the Care Plan or Electronic Medical Record to support these actions.
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The drainage bag was observed touching the floor and not kept below the bladder level, contrary to the care plan and staff statements. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor.
A resident receiving IV antibiotic therapy for cellulitis had an unlabeled and undated IV medication bag and tubing hanging on the IV pole. The medication was not administered due to a clogged PICC line, and the nurse failed to discard the medication as required. The facility's policies lacked specific instructions on labeling and dating IV tubing, contributing to the deficiency.
A facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall, resulting in a skin tear. Multiple staff members confirmed the absence of documentation in the progress notes, violating the facility's policy on charting and documentation.
Failure to Complete Timely and Accurate Skin Assessment on Admission
Penalty
Summary
The facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission, as required by its Skin Assessment Policy. Upon review, the admission screening indicated the resident's skin was intact, but a subsequent body check performed within 24 hours identified edema in both lower extremities and excoriation to both buttocks. The initial assessment did not document these findings, and the discrepancy was acknowledged by the Director of Nursing, who stated that the excoriation may have been missed during the first assessment. The resident in question had significant medical conditions, including aphasia, hemiplegia, hemiparesis following a stroke, diabetes, and major depressive disorder. The resident required one-person assistance for transfers and was incontinent of urine and frequently incontinent of bowel. Despite these risk factors, the initial skin assessment failed to identify the presence of skin impairment, and the need for wound care with Zinc Oxide was not recognized until the second assessment was completed by another nurse. Interviews with facility staff revealed that if skin issues were identified, an incident report should have been initiated and documented in the electronic medical record, but this was not done. The Treatment Administration Record indicated that a previous skin impairment was present, but there was no corresponding documentation in the progress notes or incident reporting. The delay in identifying and treating the skin impairment resulted in a delay in the administration of prescribed wound care.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Critically Low Blood Sugar
Penalty
Summary
A deficiency was identified when a nurse failed to notify a resident's physician of a critically low blood sugar result, as required by both physician orders and facility policy. The resident, who had intact cognition and a history of diabetes, hypertension, and chronic pain syndrome, had a blood sugar reading of 52, which was below the threshold specified in the physician's orders for mandatory physician notification. Review of the medical record and progress notes revealed no documentation that the physician was informed of this low blood sugar event. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been notified immediately and that documentation of this notification was required. The facility's policy on Notification of Changes also mandates prompt communication with the physician and the resident's representative when significant changes occur. The incident report further confirmed that the responsible nurse did not notify the physician as required.
Failure to Consistently Document ADL Care in Resident Records
Penalty
Summary
Facility staff failed to consistently document Activities of Daily Living (ADL) care in the Documentation Survey Report (DSR) for multiple residents, as required by facility policy. For three out of four residents reviewed, there were missing entries in the DSR and progress notes regarding whether ADL care was provided or refused on specific dates and shifts. The residents involved had significant medical conditions, including quadriplegia, acute respiratory failure, dysphagia, bipolar disorder, dementia, hyperlipidemia, diabetes, hypertension, and chronic pain syndrome. Their cognitive statuses ranged from intact to severely impaired, as indicated by their Brief Interview of Mental Status (BIMS) scores. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for documenting ADLs using a mobile app, and documentation was expected to be completed by the end of each shift. The Director of Nursing (DON) and Unit Manager (UM) confirmed that blank documentation fields did not necessarily mean care was not provided, but acknowledged that documentation should not be left incomplete. The facility's ADL Documentation Policy required all nursing staff and caregivers to document ADLs as part of their daily routines, with supervisors responsible for regular compliance checks. Despite these requirements, the review found multiple instances where ADL documentation was missing, indicating a failure to follow established policy and professional standards.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes and admitted with elongated toenails. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5 out of 15, did not have a care plan addressing these specific needs. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, which was not followed in this case. Interviews with staff, including an LPN, the Unit Manager (UM), and the Director of Nursing (DON), confirmed the absence of a care plan for the resident's diabetes and toenails, highlighting a lapse in the facility's adherence to its care plan policy. The UM was responsible for updating the resident's care plan, typically every quarter and as needed, and acknowledged the oversight in not addressing the resident's toenails. The DON confirmed that the care plan should have included interventions for the resident's diabetes and toenails, as per the facility's policy. The failure to develop and implement a care plan for the resident's specific needs was identified during a survey, revealing a deficiency in the facility's care planning process.
Failure to Follow Clinical Standards for Resident Care
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several areas concerning Resident #2. The resident, who was admitted with diagnoses including Diabetes, Major Depressive Disorder, and Unspecified Dementia, did not have a care plan developed to address their diabetes and elongated toenails. Despite the resident's severely impaired cognition, as indicated by a BIMS score of 5 out of 15, the facility did not create a care plan to manage these conditions, which is a requirement under the facility's care plan policy. Additionally, there was a delay in the resident being seen by a podiatrist. The resident was admitted with elongated toenails, a condition noted in the admission screener, but was not seen by a podiatrist until several months later. The podiatry consult revealed that the resident was at risk for complications without treatment of the toenails, indicating a lapse in timely care. The Unit Manager and Director of Nursing acknowledged that the process for scheduling podiatry visits was not followed, as the nurse should have notified the physician to get a treatment order in place. Furthermore, there was a significant delay in notifying the physician of abnormal urine culture results. The urine culture, collected on September 5, 2024, showed abnormal results reported on September 7, 2024, but the physician was not informed until September 14, 2024. This delay in communication and subsequent treatment initiation was contrary to the facility's policy, which requires immediate notification of abnormal results to the physician. The Director of Nursing confirmed that the facility's procedures for laboratory notifications and care plan initiation were not followed, contributing to the deficiency.
Failure to Provide Timely Podiatry Care for Diabetic Resident
Penalty
Summary
The facility failed to provide timely foot care for a resident with diabetes, who was admitted with elongated toenails and was not seen by a podiatrist until nearly nine months later. The resident, who had severe cognitive impairment, was admitted to the facility with elongated toenails, as noted in the admission records. Despite the facility's policy requiring prompt referral to podiatry for residents with identified foot issues, the resident's toenails were not addressed until a podiatry consult in October, where the toenails were debrided. The delay in podiatric care was noted as a deficiency, particularly given the resident's diabetic condition, which increases the risk of complications. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The LPN responsible for the resident's care did not ensure timely podiatric intervention, and the Unit Manager and Director of Nursing acknowledged the delay in treatment. The facility's policy required nurses to notify the Unit Clerk to schedule podiatry appointments, but this process was not effectively followed. The Director of Nursing confirmed that the delay constituted a lapse in care, especially for a diabetic resident, highlighting a failure to adhere to the facility's podiatry services policy.
Delayed Notification of Abnormal Urine Culture Result
Penalty
Summary
The facility failed to promptly notify the physician of an abnormal urine culture result for a resident, which was a violation of their policy on laboratory services and reporting. The resident, who had severe cognitive impairment and was diagnosed with conditions including diabetes, major depressive disorder, and unspecified dementia, had a urine culture collected on September 5, 2024. The results, which were abnormal, were reported on September 7, 2024, but were not reviewed by the Unit Manager until September 11, 2024. The physician was not informed of these results until September 14, 2024, at which point an antibiotic therapy order was obtained. Interviews with facility staff, including an LPN, the Unit Manager, and the Director of Nursing, revealed that the facility's policy required immediate notification of the physician upon receiving abnormal lab results. The delay in notifying the physician was acknowledged by the staff as a significant lapse, with the Director of Nursing confirming that the expectation was for immediate communication to prevent potential escalation of the resident's condition. The physician also confirmed that they rely on the nursing staff to inform them of any abnormal results, as they do not see long-term care residents frequently.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for three resident rooms on the C/D unit. During the initial tour, the surveyor observed various deficiencies in room 211, including a missing drawer handle, gouged walls, scratched and missing paint, and a leaking sink with water on the floor. Similar issues were found in room 212, where the window blind was broken, and the walls and furniture were damaged. In room 213, the window blind was also broken, and the CNA acknowledged that the room's condition was not homelike. The surveyor interviewed multiple staff members, including a CNA, an LPN, the LPN Unit Manager, the Director of Nursing (DON), and the Interim Maintenance Director (IMD). The staff members confirmed that the process for reporting maintenance issues involved recording them in a maintenance log. However, the log revealed incomplete entries, indicating that some issues, such as the leaking sink in room 211, were not addressed. The LPN and DON acknowledged that the rooms were not homelike and that the maintenance requests had been overlooked. The IMD admitted that he and one other maintenance man were responsible for the facility's repairs and that the maintenance book was checked daily. Despite this, the IMD acknowledged that the issues in the resident rooms had not been resolved and that the maintenance log had blank spots for some entries. The facility's policies on reporting maintenance concerns and repairs were reviewed, revealing that the maintenance book should be checked daily and signed as work is completed. The IMD admitted that the leaking sink in room 211 had not been fixed and that the maintenance issues in the rooms needed to be resolved.
Deficiencies in Food Handling and Kitchen Maintenance
Penalty
Summary
The facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross-contamination. During a kitchen tour, the surveyor observed several deficiencies, including undated raw chicken drumsticks, wilted and blackened lettuce, undated lidded cups of liquids, and an unlabeled bag of scalloped potatoes. Additionally, there were pork loins with unreadable dates and damaged packaging, a dented can of sweetened applesauce, and a slicer with tan debris despite being covered with a plastic bag. A stained cutting board was also found in the dry pots and pans area. The Dietary Director (DD) acknowledged these issues, stating that the food items should have been labeled with pull and use-by dates, and that the equipment should have been cleaned and sanitized to prevent cross-contamination. The facility's policies on food receiving and storage, sanitation, and food preparation and service were reviewed, revealing that the observed practices were not in compliance with the established guidelines. The administrative team was made aware of these concerns during the survey.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to follow appropriate infection control practices and perform hand hygiene during a meal tray pass in the Main Dining area. An LPN was observed handling food and interacting with residents without performing hand hygiene. Specifically, the LPN opened a packet of powder, mixed it into a cup, touched her phone, and continued to handle food items without cleaning her hands. She also touched her nose and various inanimate objects before feeding a resident, all without performing hand hygiene. This was confirmed through interviews with the LPN, the LPN Unit Manager, the LPN Infection Preventionist, and the Director of Nursing, all of whom acknowledged the failure to perform hand hygiene correctly during the meal tray pass. The LPN stated that hand hygiene should be performed between resident contact and when trays were passed, but admitted she did not remember if she had done so during the observation period. The LPN Unit Manager and the LPN Infection Preventionist both confirmed that hand hygiene should have been performed after touching the phone, nose, and before feeding the resident. The Director of Nursing also acknowledged that hand hygiene was not performed correctly and emphasized its importance in preventing the spread of germs. A review of the facility's hand hygiene policy and the Charge Nurse/Staff Nurse job description revealed that all personnel are required to follow handwashing procedures to prevent the spread of infections. The policy specifically states that hand hygiene should be performed after contact with objects in the immediate vicinity of the resident and before and after assisting a resident with meals. The administrative team was made aware of the observation, and the deficiency was documented as a failure to adhere to these established infection control practices.
Failure to Obtain Diagnosis for IV Antibiotic Use
Penalty
Summary
The facility failed to follow professional standards of clinical practice by not obtaining a diagnosis for the use of an antibiotic intravenous medication for a resident. The resident was admitted with IV antibiotic therapy and a PICC line for cellulitis, but the physician's order for Vancomycin did not include a diagnosis. The resident was unaware of the reason for the medication, and the LPN, who was employed through an agency, also did not know the type of infection being treated as it was not documented on the physician's order. The LPN/UM later confirmed that the IV antibiotic was for MRSA in the blood, but acknowledged that the order should have included a diagnosis. The DON explained the policy for residents with a PICC line, emphasizing the need for physician orders to include diagnoses for the IV antibiotic, which was not followed in this case. The LNHA also confirmed that the physician's order should have had a diagnosis associated with the medication use. The surveyor observed that the resident's room had a sign indicating transmission-based precautions/contact isolation, and an IV medication bag labeled with the resident's name was hanging on the IV pole. The resident mentioned that they did not receive the medication the previous night. The facility's policy on medication and treatment orders stated that orders must include the clinical condition or symptoms for which the medication is prescribed, which was not adhered to in this instance. This deficiency was identified through observation, interviews, and review of the resident's medical records and facility documentation.
Failure to Obtain Physician Order and Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to obtain a physician order for the treatment of a skin tear that occurred during a fall and did not update a resident's Care Plan (CP) with fall prevention interventions after the resident fell. This deficiency was identified for one resident who was admitted with diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain. The resident was cognitively impaired and had a history of falls prior to admission. On the date of the incident, the resident had an unwitnessed fall while trying to retrieve something from the closet, resulting in a skin tear on the right elbow. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall. Although the incident report stated that the resident's CP was updated and the physician was notified, the surveyor found no documentation in the CP or the Electronic Medical Record (EMR) to support these claims. Additionally, there was no treatment order for the skin tear in the Physician Order Summary Report (POSR) or the Treatment Administration Record (TAR). Interviews with facility staff, including the Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA), Licensed Practical Nurse Unit Manager (LPN/UM), Registered Nurse (RN), Director of Nursing (DON), and Regional Clinical Director (RCD), confirmed that the required documentation and updates to the CP were not completed. The facility's policies on incidents and accidents, wound treatment and management, and comprehensive care plans were not followed, leading to the deficiency.
Improper Handling of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper handling of a urinary catheter drainage bag for a resident with urinary retention. The surveyor observed the resident's drainage bag touching the floor and not being kept below the level of the bladder on multiple occasions. The resident's care plan specifically included an intervention to keep the drainage bag below the bladder, but this was not followed. The CNA and LPN/UM acknowledged the improper positioning of the drainage bag and corrected it during the surveyor's visit. The facility's Catheter Care policy did not specify that the drainage bag should be kept off the floor, although staff interviews confirmed this practice for infection control reasons. The resident had an intact cognition as indicated by a Brief Interview for Mental Status score of 15 on the admission MDS. The resident's physician had ordered weekly changes of the urinary catheter drainage bag. Despite these orders and the care plan, the CNA initially secured the drainage bag to the resident's waistband, which was level with the bladder, and later left it touching the floor. The LPN/UM and DON confirmed that the drainage bag should be secured below the bladder and not touch the floor to prevent infection and ensure proper urinary flow.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to label and dispose of medications in accordance with accepted professional principles for a resident receiving antibiotic therapy. The resident, admitted in March 2024, was on IV antibiotic therapy for cellulitis and had a PICC line in the right upper arm. During a tour, the surveyor observed an IV medication bag and vial hanging on the IV pole without proper labeling or dating. The resident was unaware of the reason for the medication and mentioned that the nurse had hung the IV the previous night but did not think any medication was administered. The physician's order and Medication Administration Record indicated that the IV Vancomycin was to be administered every 12 hours, but the dose scheduled for the previous night was not given due to a clogged PICC line. The LPN, who was employed through an agency, confirmed that the resident was on IV antibiotics but was unsure of the specific infection being treated. She stated that the previous nurse had reported the clogged PICC line and that the medication should have been discarded when it could not be administered. The LPN/UM confirmed that the IV medication was for MRSA in the blood and that the medication should have been discarded when the nurse realized the PICC line was clogged. The LPN/UM also noted that the IV medication and tubing were not dated or timed, making it unclear how long they had been hanging. The DON explained the facility's policy for residents with a PICC line, including assessing the line for patency and obtaining physician orders for flushing. The DON confirmed that the IV medication should have been labeled and discarded if not administered. The LNHA also confirmed that the medication should have been disposed of after the nurse realized the PICC line was not functional. The facility's policies on discarding medications and intravenous therapy did not include specific instructions on labeling and dating IV tubing, which contributed to the deficiency.
Failure to Document Resident Fall Incident
Penalty
Summary
The facility failed to maintain an accurately documented and complete medical record for a resident who experienced an unwitnessed fall. The resident, who had diagnoses including osteomyelitis, sepsis, and malignant neoplasm of the brain, was found lying on the floor at the foot of the bed. The incident report indicated that the resident was not using a walker and was not wearing shoes or socks at the time of the fall, resulting in a skin tear on the right elbow. However, there was no corresponding documentation in the Nursing Progress Notes (NPN) in the Electronic Medical Record (EMR) regarding the fall and subsequent assessment and care provided to the resident on that date. Multiple staff members, including the LPN, CNA, LPN/UM, RN, and RCD, confirmed the absence of documentation in the progress notes for the fall incident. The facility's policy on charting and documentation requires that all services provided, progress notes, and any changes in the resident's condition be documented in the medical record to facilitate communication between the interdisciplinary team. The lack of documentation in this case represents a failure to adhere to these standards, resulting in an incomplete and inaccurate medical record for the resident. The deficiency was confirmed by the Director of Nursing (DON) and the Regional Clinical Director (RCD), who acknowledged the importance of accurate and complete documentation in the progress notes for legal and communication purposes.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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