Autumn Lake Healthcare At Southgate
Inspection history, citations, penalties and survey trends for this long-term care facility in Carneys Point, New Jersey.
- Location
- 449 S Pennsville-auburn Road, Carneys Point, New Jersey 08069
- CMS Provider Number
- 315237
- Inspections on file
- 16
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Southgate during CMS and state inspections, most recent first.
A resident with quadriplegia, a stage 4 pressure ulcer, and an indwelling catheter did not receive proper infection control measures during wound care. An LPN failed to wear a gown as required by Enhanced Barrier Precautions, used soiled gloves to handle multiple medication tubes, and returned these containers to a shared cart without disinfection. The urinary drainage bag was also observed resting on the floor and then placed on the bed, contrary to infection control protocols.
A resident with multiple chronic conditions did not receive a physician-ordered dose of Xarelto for atrial fibrillation because the medication was unavailable, and staff were unable to borrow it from other units. There was no documentation that the physician was notified of the missed dose, and pharmacy records showed a delay in resupply. Facility policy requires nurses to follow physician orders, but this was not followed in this instance.
The facility failed to maintain proper food safety and sanitation practices, with issues such as unlabeled food, improper cooling of meatloaf, inadequate handwashing, and malfunctioning dishwashing equipment. Observations revealed multiple sanitation lapses, including personal items in food prep areas and unclean kitchen equipment, highlighting significant lapses in compliance with health regulations.
The facility failed to maintain a clean and safe environment across three resident units, with issues such as grime on water coolers, unclean ice carts, and cobwebs in windows. Housekeepers confirmed that certain cleaning tasks were not part of their routine, and the facility's policies on cleaning and disinfection were not being followed. The Licensed Nursing Home Administrator and Director of Maintenance acknowledged the deficiencies, including unclean windows and inadequate staffing in the housekeeping department.
The facility failed to document reference checks for 10 employees, including RNs, LPNs, CNAs, and other staff, as required by its abuse policy. The DHR admitted to not documenting verbal references and often relied on current employee references or did not pursue references for re-hires or agency staff. The LNHA was aware of the DHR's responsibility but was unsure about the need for checks for re-hires or agency staff. This lack of documentation led to the deficiency.
The facility failed to develop comprehensive care plans for three residents, neglecting critical areas such as tube feeding, pain management, and oxygen use. One resident with a gastrostomy tube lacked a care plan for PEG tube management, another with rib fractures and cancer had no pain management plan, and a third with COPD did not have a plan for oxygen use. Interviews with staff revealed a lack of clarity and responsibility in updating care plans to reflect residents' needs.
A resident with chronic pain and a history of rib fractures and esophageal cancer experienced a delay in receiving a recommended pain management consultation. Despite frequent administration of oxycodone, the facility failed to secure an appointment with a specialist who accepted the resident's insurance. Interviews revealed a lack of communication and follow-through in scheduling the necessary appointment, contrary to the facility's policy for prompt medical follow-ups.
The facility failed to maintain dryer machines safely, as two out of four machines had lint accumulation due to incomplete cleaning logs. The Interim Housekeeping Director noted that staff should clean lint traps every two hours, but logs were last completed in August without a specified year. The Licensed Nursing Home Administrator expressed concern over the lack of documentation, which is crucial for preventing fire hazards.
A facility failed to follow a physician's order for a resident at risk of pressure ulcers by not providing prescribed heel boots. Instead, the resident's feet were placed on pillows, contrary to the order. Staff interviews revealed a misunderstanding of the order, and the DON confirmed the requirement for heel boots, which were not initially provided.
A resident with COPD was observed with a nasal cannula connected to an empty oxygen tank, contrary to a physician's order for continuous oxygen therapy. Facility staff, including a CNA and LPN, confirmed the oversight, highlighting a failure to ensure the resident received the prescribed oxygen. The resident's care plan and facility policy emphasized the need for continuous oxygen, which was not adhered to.
The facility failed to maintain safe and palatable food temperatures, as observed during a survey. Residents reported receiving cold meals in their rooms, and surveyors confirmed that food temperatures were inconsistent, with some items falling below the safe holding temperature. The facility's policy on food temperatures was not followed, potentially allowing for bacterial growth.
A facility failed to minimize infection spread during incontinence care rounds due to inadequate hand hygiene by a CNA. The CNA, responsible for eight residents, washed her hands for only 10 and 9 seconds after providing care, contrary to the facility's policy of at least 20 seconds. This occurred despite some residents being on Enhanced Barrier Precautions due to medical conditions. Interviews with staff confirmed the expectation of proper hand hygiene, which was not met.
Failure to Follow Infection Control Practices During Wound Care and Catheter Management
Penalty
Summary
A deficiency was identified when a resident with quadriplegia, a flaccid neuropathic bladder requiring a urinary drainage bag, and a stage 4 pressure ulcer did not receive care in accordance with infection control protocols. During wound care, an LPN failed to don a gown as required under Enhanced Barrier Precautions (EBP) for hands-on care of residents with open wounds. The LPN also used the same pair of soiled gloves to handle multiple medication tubes and returned these medication containers to a shared wound cart without disinfecting them. Additionally, the LPN brought medication containers into the resident's room, contrary to facility policy, which states that such items should not enter resident rooms to prevent cross-contamination. Further observations revealed that the resident's urinary drainage bag was resting on the floor rather than being secured to an appropriate holder, and was subsequently placed on the resident's bed prior to wound care. Facility staff, including the Infection Preventionist and Director of Nursing, confirmed that these actions were inconsistent with established infection control practices, which require the use of gowns and gloves for EBP, proper handling of medication containers, and ensuring urinary drainage bags are kept off the floor to prevent infection.
Failure to Provide Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic kidney disease, aneurysm of artery of lower extremity, and peripheral vascular disease did not receive a physician-ordered medication, Xarelto 20mg, for atrial fibrillation. The resident was cognitively intact, as indicated by a BIMS score of 15/15. On the specified date, the medication was not administered during the 3:00 p.m. to 11:00 p.m. shift, as shown by a blank entry on the Medication Administration Report. The Director of Nursing confirmed that if a medication is not available, nurses are expected to check backup supplies and contact the pharmacy, and if a dose is missed, the physician should be notified. The Infection Preventionist nurse stated that attempts to borrow the medication from other units were unsuccessful. There was no documentation in the resident's progress notes that the physician was notified of the missed dose. Pharmacy records indicated that a resupply request for the medication was made the following day, and the medication was received from the contracted pharmacy over the next two days. Facility policy requires nurses to follow physician orders and recommendations. The failure to ensure the medication was available and administered as ordered, and the lack of physician notification regarding the missed dose, led to the cited deficiency.
Plan Of Correction
Corrective Action: On 5/22/25, notified PCP that Resident #2 missed a dose of NJ Exec Order 26.4b1; no new orders were given. NJ Exec Order 26.4b1 from not receiving medication. Resident #2 resumed the medication as ordered on NJ Exec Order 26.4b1. On 5/23/25, director of nursing received approval from medical director to have NJ Exec Order 26.4b1 added to back-up box. An audit was conducted on 6/11/25, by the director of nursing on all EMAR progress notes of medications not administered. Discrepancies were identified, addressed, and individual counseling was provided to each nurse. Identification of Residents at Risk: All residents prescribed medication(s) have the potential to be affected by this deficient practice; residents can be identified by reviewing physician's orders. Systemic Change: Facility-wide in-service on proper procedure on requesting a refill for medication in a timely manner & when a prescribed medication is not available was conducted on 6/11/25 with all nurses, by the director of nursing. "Medication Not Available" form was initiated to be completed by nurses and turned into the director of nursing. Quality Assurance: Unit managers, or designee, will conduct an audit on EMAR progress notes to assure proper procedure taken on any medication not administered. Audits will be completed weekly for 2 months, then monthly for 1 year. Any discrepancies will be corrected/ addressed immediately. These audits will be turned into the director of nursing. The results of the EMAR audits will be reviewed by the DON, or designee, weekly for 2 months, then monthly. The findings will be reported to the LNHA and QAA committee quarterly for one year. The QAA committee will review the effectiveness of the implemented corrective actions and determine if further action is needed. If necessary, adjustments to protocols or corrective actions will be made to assure continued compliance and improvement.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. Observations revealed multiple issues, including unlabeled and undated food items, improper handwashing techniques, and inadequate food storage practices. For instance, containers of pudding were found without labels or dates, and a staff member washed her hands for only nine seconds, contrary to the facility's hand hygiene policy. Additionally, frozen meatballs were left exposed to air, and temperature logs for the walk-in refrigerator and freezer were incomplete, with no temperatures recorded on a specific date. Further deficiencies were noted in the cooling and storage of meatloaf, which was not properly cooled to the required temperatures, posing a risk of bacterial growth. The meatloaf was found at 48.6°F, above the safe holding temperature of 41°F, and there were no temperature logs to demonstrate the cooling process. The facility's Regional Food Service Director confirmed that the meatloaf should have been discarded due to improper cooling. Other sanitation issues included a can opener with a dried black substance, personal items in the food preparation area, and a lack of cleanliness in various kitchen areas, such as the tilt skillet and deep fryer. The facility also failed to adhere to policies regarding food labeling, cleaning schedules, and equipment maintenance. Several items, including hot dogs and grape jelly, were found unlabeled and undated, and a thermometer was missing from a refrigerator. The dishwashing machine was not functioning correctly, with gauges not moving during use, indicating improper sanitization of dishes. Additionally, personal items were found in unit nourishment room refrigerators, and there were issues with cleanliness and maintenance, such as stained ceiling tiles and clogged drains. These deficiencies highlight significant lapses in food safety and sanitation practices within the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment across three resident units, as evidenced by multiple observations and interviews. On the 300 unit, a water cooler was found with a build-up of white streaks and grime, an ice cart had a plastic liner with rips and brown stains, and trash can lids were covered in white and brown substances. Housekeeper #5 confirmed that her cleaning routine did not include the water cooler or trash can lids. The Infection Preventionist stated that the water cooler should be cleaned twice per shift, and the Food Service Director noted that ice carts should be cleaned weekly, but some units never bring them for cleaning. Resident council feedback and further observations revealed additional deficiencies. Residents reported unclean windows with cobwebs, and the housekeeping department was noted to be short-staffed. Observations on the 200 and 100 units showed large cobwebs in atrium windows, a cracked window, and black debris on doors. Resident #89's shower had a black substance on the floor, and a shower chair with washcloths was left hanging. Housekeepers on the 200 and 100 units confirmed that high dusting was not part of their routine, and the Interim Director of Housekeeping admitted that outside windows had not been cleaned in over five years. The Licensed Nursing Home Administrator confirmed the presence of cobwebs and acknowledged the difficulty in maintaining the exterior of the building. The Director of Maintenance stated that the facility should be kept in good repair, but the housekeeping department was responsible for dusting the lounges. Facility policies reviewed indicated that trash cans should be disinfected daily, and ice machines should be cleaned regularly, but these procedures were not being followed. The Routine Cleaning and Disinfection policy emphasized the importance of maintaining a clean environment to prevent infections, but the facility failed to adhere to these standards.
Failure to Document Employee Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing reference checks for 10 out of 10 employee files reviewed. The surveyor found that the files of various staff members, including registered nurses, licensed practical nurses, certified nursing assistants, housekeepers, and dietary aides, lacked documented evidence of reference checks. The Director of Human Resources (DHR) admitted to not documenting verbal references and stated that she often relied on current employee references or did not pursue references for re-hires or agency staff who became employees. The DHR also acknowledged that reference checks were not completed for some employees due to unsuccessful attempts to reach references or because the employees were re-hires. The Licensed Nursing Home Administrator (LNHA) was aware that the DHR was responsible for reference checks but was unsure if checks were needed for re-hires or agency staff. The facility's policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, which included conducting reference checks. However, the DHR confirmed that she did not have documented evidence of completed reference checks for the employees reviewed, and blank forms were provided instead. This lack of documentation and adherence to policy led to the deficiency identified by the surveyor.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop an individual comprehensive care plan (ICCP) for three residents, addressing critical areas such as tube feeding, pain management, and oxygen use. Resident #85, who had a gastrostomy tube for enteral feeding, did not have a care plan that included the management of the PEG tube. Despite having physician's orders for enteral feeding and tube maintenance, the ICCP lacked a focus area for the PEG tube. Interviews with the Director of Nursing (DON) and the Regional Nurse revealed a lack of clarity and responsibility in updating the care plan to reflect the resident's needs. Resident #108, who suffered from pain due to multiple rib fractures and esophageal cancer, did not have a care plan addressing pain management. The resident frequently experienced pain that affected daily activities, and the medication administration record showed regular administration of oxycodone for pain relief. However, the ICCP did not include a plan for managing the resident's pain, which was acknowledged as necessary by both the LPN and the DON during interviews. Resident #391, who had COPD and required continuous oxygen therapy, also lacked a care plan related to oxygen use. The resident's treatment records indicated consistent oxygen administration, but the ICCP did not reflect this critical aspect of care. Interviews with nursing staff highlighted the expectation that oxygen use should be included in the care plan, yet this was not done. The facility's policy on comprehensive care plans emphasized the need for timely development and regular updates, which were not adhered to in these cases.
Failure to Schedule Timely Pain Management Appointment
Penalty
Summary
The facility failed to follow up on a healthcare provider's recommendation for a pain management appointment for a resident with chronic pain. The resident, who had a history of rib fractures and esophageal cancer, reported severe back pain and expressed dissatisfaction with the management of their pain. Despite a recommendation from a Nurse Practitioner for a pain management consultation in October, the facility did not make timely arrangements for the appointment. The resident's medical records indicated that the recommendation for a pain management appointment was made in October, but the first documented attempt to schedule the appointment was not until December. The Unit Clerks responsible for scheduling appointments were aware of the recommendation but failed to secure an appointment with a specialist who accepted the resident's insurance. The resident's pain was managed with oxycodone, which was administered frequently, but the underlying issue of securing a specialist consultation was not addressed. Interviews with facility staff, including Licensed Practical Nurses, Unit Managers, and the Director of Nursing, revealed a lack of communication and follow-through in scheduling the necessary appointment. The Unit Clerks had a list of specialists who accepted the resident's insurance but had not contacted any of them. The facility's policy required medical follow-up appointments to be scheduled promptly, but this was not adhered to, resulting in a delay in the resident receiving appropriate pain management care.
Failure to Maintain Safe Dryer Conditions
Penalty
Summary
The facility failed to maintain dryer machines in a safe operating condition, as evidenced by the observation of lint accumulation in two out of four dryer machines. During a tour of the facility's laundry room, the Interim Housekeeping Director (IDH) revealed that the laundry staff were responsible for cleaning the dryer lint traps every two hours and documenting the completion in a logbook. However, upon reviewing the logbook, it was found that the logs were not completed according to the facility's policy, with the last entries dated 8/20 and 8/21, without indicating the year. This lack of documentation raised concerns about adherence to the facility's policy. Further inspection of the dryer machines revealed a moderate amount of lint accumulation in the lint traps of two machines, which contradicted the IDH's statement that the traps should have been cleaned two hours prior. The IDH acknowledged that the staff should follow the facility's policy to prevent fires. The Licensed Nursing Home Administrator (LNHA) expressed concern about the lack of documentation related to lint trap cleaning, which is a critical safety measure to prevent fire hazards. The facility's updated policy from 1/2025 mandates that lint traps be cleaned every two hours and that all cleaning activities be logged, highlighting the importance of maintaining these records for safety and compliance.
Failure to Follow Physician's Order for Heel Boots
Penalty
Summary
The facility failed to adhere to a physician's order for the use of bilateral heel boots for a resident at risk of developing pressure ulcers. During an observation, the surveyor noted that the resident was not wearing the prescribed heel boots and instead had their feet resting on green pillows. The resident expressed a desire to wear the heel boots, which were not present in the room at the time. The resident's medical record indicated a history of conditions such as hemiplegia, morbid obesity, and mild protein calorie malnutrition, and the resident was identified as being at risk for skin breakdown. The physician's order specified the use of heel boots when in bed to prevent pressure ulcers, which was not being followed. Interviews with facility staff, including an LPN and a CNA, revealed that the heel boots were supposed to be offered to the resident, and there was no record of the resident refusing them. The CNA admitted to using a green pillow instead of the heel boots. The Director of Nursing confirmed that the heel boots should have been used as per the physician's order. The facility's policy mandates that all nurses follow physician orders, which was not adhered to in this instance, leading to the deficiency.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for a resident who required continuous oxygen therapy. During an initial tour, a surveyor observed the resident resting in bed with a nasal cannula connected to an empty portable oxygen tank. This observation was confirmed by a Licensed Practical Nurse (LPN), who then connected the nasal cannula to an oxygen concentrator and replaced the portable oxygen tank. The resident's medical record indicated a diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation, and a physician's order required continuous oxygen at two liters via nasal cannula. Interviews with facility staff, including a Certified Nurse Aide (CNA), LPN, and the Director of Nursing (DON), revealed that the staff was responsible for ensuring the resident received continuous oxygen as per the physician's order. The resident's comprehensive care plan also highlighted the need for continuous oxygen therapy. Despite this, the resident was found without the necessary oxygen supply, indicating a lapse in following the physician's orders and facility policy, which mandates adherence to physician orders and recommendations.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature, as evidenced by observations and resident feedback. During a Resident Council Meeting, four out of five residents reported that meals served in their rooms were cold, with only the dining room receiving warm meals. One resident noted that meals were delivered on open racks that did not maintain warmth, particularly affecting the last unit served, which received cold food. Observations by surveyors confirmed that food temperatures on the steam table were inconsistent, with some items exceeding the desired temperature and others falling below the safe holding temperature of 135 degrees Fahrenheit. Further investigation revealed that during the lunch meal service, trays were prepared and placed on an uncovered food truck, leading to temperature discrepancies by the time they reached the residents. The Regional Food Service Director confirmed that the puree foods did not meet the desired temperatures, and cold items were not maintained at 41 degrees Fahrenheit or below. The facility's policy on food temperatures was not adhered to, as evidenced by the recorded temperatures of the meal trays, which were outside the safe range, potentially allowing for bacterial growth. This deficiency was noted on one of the three nursing units observed.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to minimize the spread of infection during incontinence care rounds on one of its nursing units. This deficiency was observed when a Certified Nursing Assistant (CNA) was seen performing hand hygiene inadequately after providing care to residents. The CNA was responsible for eight residents, four of whom required incontinence care. During the rounds, the CNA was observed washing her hands for only 10 seconds after changing a resident's brief, which was contrary to the facility's policy requiring at least 20 seconds of handwashing. This inadequate hand hygiene was repeated after providing care to another resident, where the CNA washed her hands for only nine seconds. The issue was further compounded by the fact that some residents were on Enhanced Barrier Precautions (EBP) due to their medical conditions, such as having a tracheostomy or gastrostomy tube, which necessitated additional infection control measures. Despite the presence of signs indicating the need for gowns and gloves, the CNA's failure to adhere to proper hand hygiene protocols posed a risk of spreading infection. Interviews with the Licensed Practical Nurse/Unit Manager, Infection Preventionist, and Director of Nursing confirmed that the facility's expectation was for staff to wash their hands for a minimum of 20 seconds to prevent the spread of germs, which was not met in this instance.
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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