Avalon Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, New Jersey.
- Location
- 1059 Edinburg Road, Hamilton, New Jersey 08690
- CMS Provider Number
- 315223
- Inspections on file
- 19
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Avalon Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that residents were seen by their attending physician or NP at the required intervals, nor that progress notes were consistently documented in the EMR. Several residents, including those with severe cognitive impairment and complex medical needs, lacked physician notes for extended periods, and staff confirmed that expected documentation and visits were missing. Facility policy required timely visits and documentation, but these requirements were not met for multiple residents.
A resident with dementia and diabetes was repeatedly observed in bed without the required fall mat in place, despite a care plan and physician order mandating its use. Nursing staff confirmed the fall mat should have been on the floor whenever the resident was in bed, but it was found leaning against the wall on multiple occasions.
A resident with ESRD and multiple comorbidities repeatedly missed scheduled medications, supplements, and blood glucose monitoring because administration times conflicted with dialysis appointments. Nursing staff documented missed doses due to the resident being out for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule, contrary to facility policy and professional standards.
A resident with hypertension and heart failure did not receive 14 doses of a prescribed antihypertensive medication due to unavailability, with missed doses documented in the MAR and no evidence that the physician was notified. The resident was later transferred to the hospital for uncontrolled hypertension and diagnosed with a hypertensive emergency. Nursing staff confirmed the medication was not available, and facility leadership was unaware of the issue until the survey.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive an initial comprehensive visit from a physician within the required 30-day period after admission. Review of records and staff interviews confirmed that only a "HISTORY AND PHYSICAL" by an APN was available, with no timely physician documentation, in violation of both federal regulations and facility policy.
Staff did not consistently document care provided to a resident in the Point of Care (POC) system, leaving multiple blank entries across several shifts. Interviews confirmed that CNAs are expected to record all ADLs in the POC, and that missing documentation means the policy was not followed. The facility's policy requires complete documentation of care, but this was not done for the resident in question.
The facility did not meet the required CNA-to-resident staffing ratios for 14 consecutive day shifts, consistently scheduling fewer CNAs than mandated by state law for the number of residents present. This deficiency was identified through review of staffing records and interviews, and had the potential to affect all residents.
A resident with respiratory failure and COPD did not receive prescribed continuous oxygen therapy when the oxygen concentrator was found off, resulting in the resident being unresponsive with low oxygen saturation. The care plan lacked documentation of oxygen supplementation, and staff did not ensure the concentrator was operating as ordered.
A resident with severe cognitive impairment required assistance with bathing and dressing but frequently refused care, leading to family concerns about hygiene. Although staff were aware of the refusals and communicated with the family, the facility failed to document the grievance or follow its policy for investigating and responding to complaints, and the Administrator was not informed.
A resident with respiratory diagnoses and an order for oxygen therapy did not have their care plan updated to reflect the use of oxygen, despite documentation in the medical record and physician orders. Staff interviews confirmed that the care plan should have been revised to include this intervention, in accordance with facility policy.
A resident with severe cognitive impairment and multiple respiratory diagnoses was found to be receiving oxygen at 3 L/min instead of the physician-ordered 2 L/min. The discrepancy was identified when the nasal cannula was observed out of the nostrils and the concentrator set incorrectly. Staff interviews revealed that the oxygen flow rate was not checked as required by facility policy, resulting in a failure to follow the physician's order.
A resident in a long-term care facility reported being pushed by a CNA, causing hot coffee to spill on them. Despite the resident's cognitive intactness and clear report of the incident, the facility failed to investigate or report the abuse in a timely manner, allowing the CNA to continue working. This failure to follow the facility's abuse prevention policy resulted in Immediate Jeopardy.
Two residents suffered burns due to inadequate supervision and safety measures while handling hot liquids. One resident experienced burns on two occasions while heating coffee in an unlocked nutritional room, and another resident sustained a burn while transporting coffee from the dining room. Both residents had intact cognition, but the facility failed to enforce safety policies, leading to these incidents.
The facility failed to secure a medication cart and remove expired items from a storage room. An unlocked cart was left unattended at a nurses' station, and several expired medical supplies were found in a storage room. The RN responsible was unaware of the unlocked cart, and the Unit Manager missed the expired items during routine checks.
The facility failed to accurately complete Medicare Part A forms for a resident and two residents, omitting essential information such as TTY numbers, QIO names, and facility contact details. The facility's policy lacked instructions on completing these forms, leading to deficiencies in notifying residents about their Medicare coverage and potential liabilities.
A resident, who was cognitively intact, was involved in an altercation with a CNA, resulting in a coffee spill. The resident alleged that the CNA pushed him, causing the spill. Despite the facility's policy requiring immediate reporting of such incidents, the alleged abuse was not reported to the state agency or Ombudsman within the required timeframe. The DON and Administrator confirmed the incident was not reported, citing an internal conclusion of the investigation.
A resident accused a CNA of pushing him, causing hot coffee to spill on his lap. The facility failed to conduct a thorough investigation, as required by policy, leading to a deficiency finding. The Director of Nursing initially dismissed the need for further investigation but later acknowledged the oversight.
A facility failed to ensure the PASARR Level I screen was completed correctly for a resident with schizoaffective disorder. The resident was admitted with a diagnosis of schizoaffective disorder and a BIMS score indicating moderately impaired cognition. However, the PASARR form incorrectly stated there was no major mental illness, which was acknowledged by the Social Services Director. This oversight potentially failed to identify necessary specialized services and appropriate placement.
A resident with major depressive disorder and other health issues did not have an activity care plan reflecting their preference for one-to-one activities. Despite being cognitively intact and dependent on staff for daily activities, the resident's care plan did not include their desire for individualized activities, as revealed through staff interviews and record reviews.
A resident with a complex medical history sustained a second-degree coffee burn while transporting hot coffee in a wheelchair. The facility failed to update the resident's care plan to include necessary interventions, such as reminders for the resident to seek assistance and staff education on cooling hot liquids. Interviews with staff confirmed the oversight, which did not align with the facility's policy on revising care plans as resident conditions change.
A resident with multiple diagnoses, including anoxic brain injury and diabetes, was not weighed according to physician orders, leading to unmonitored weight changes. The facility failed to document weights on several occasions, and the RD was not informed of any weight issues due to the lack of documentation. The Unit Manager's abrupt leave contributed to the oversight, and the facility's policy on weight documentation was not followed.
A resident on Enhanced Barrier Precautions due to an open wound was not provided care with the appropriate PPE by staff. A CNA and an LPN were observed not wearing gowns while providing direct care, despite clear signage and available PPE. The LPN admitted to forgetting the gown in a rush to administer pain medication.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by their attending physician or nurse practitioner at the required intervals, and that appropriate progress notes were documented in the electronic medical record (EMR). For four residents reviewed, there were significant gaps in physician documentation and visits. One resident with severe cognitive impairment and multiple diagnoses, including diabetes and asthma, had no progress notes from the attending physician for a ten-month period. Another resident, also severely cognitively impaired, lacked both a history and physical (H&P) note upon initial admission and re-admission, as well as progress notes from the attending physician for several months. A third resident, who was cognitively intact and had diagnoses of low back pain and anemia, had an H&P and a single progress note from the attending physician, but there were no physician or nurse practitioner notes for several consecutive months, nor evidence of consistent alternating monthly visits as required. This resident also experienced two hospitalizations, after which the expected H&P documentation upon re-admission was missing. The fourth resident, with moderately impaired cognition and diagnoses including anxiety disorder and anemia, had an H&P and a progress note from the physician, but no further notes from either the physician or nurse practitioner for multiple months, and no evidence of the required visit schedule being followed. Interviews with nursing staff and review of facility policy confirmed that the expectation was for physicians to see new admissions within 24-48 hours, complete H&P documentation, and make regular progress notes during rounds. However, staff were unable to locate the required documentation in the EMR for the residents reviewed, and confirmed that the expected physician visits and notes were not present for extended periods. The facility's policy aligned with state and federal regulations, but was not followed in practice for these residents.
Failure to Follow Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the resident's care plan and physician orders. Specifically, a resident with diagnoses including unspecified dementia and Type 2 Diabetes Mellitus with chronic kidney disease was observed multiple times in bed without the required fall mat in place. The care plan and physician order both specified that a fall mat should be positioned on the exit side of the bed at all times when the resident was in bed. However, on several occasions, the fall mat was observed leaning against the wall rather than on the floor as required. Interviews with nursing staff, including an RN and the DON, confirmed that the fall mat should have been in place whenever the resident was in bed, in accordance with the physician's order. The RN stated that the mat was not on the floor due to a broken bed, but could not explain why this prevented the use of the fall mat. The DON and LPN/Unit Manager both affirmed that the fall mat was necessary for resident safety and should be used as ordered. The deficiency was identified through observations, interviews, and review of the resident's medical record and care plan.
Failure to Adjust Medication and Supplement Administration for Dialysis Schedule
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident requiring dialysis by not adjusting medication administration times, nourishment supplementation, and monitoring to accommodate the resident's scheduled dialysis sessions. The resident, who had multiple diagnoses including end stage renal disease (ESRD), diabetes, heart failure, and was dependent on hemodialysis, had medication and supplement orders that conflicted with the times the resident was out of the facility for dialysis. Despite the resident's dialysis schedule being known (Tuesday, Thursday, and Saturday afternoons), there were no physician orders specifying alternative administration times for these days, and medications and supplements were repeatedly not administered as ordered on at least nine dialysis days during the resident's stay. Review of the electronic medication administration record (EMAR) and nursing progress notes revealed that medications such as Hydralazine, Novolog, Coreg, Gabapentin, Prosource, and Nepro, as well as blood glucose monitoring, were not given at scheduled times because the resident was out of the facility for dialysis. Documentation codes and nursing notes indicated the reason for missed doses was the resident's absence for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule. The facility's own policies required that medication administration times be determined by resident need and benefit, and that staff be educated on timing and administration of medications, particularly before and after dialysis. Interviews with nursing staff, the unit manager, the DON, and the administrator confirmed that nurses were expected to review and adjust medication orders with the physician for residents attending dialysis, and that documentation should not simply state that medications were missed due to dialysis. The DON acknowledged that the physician should have been notified to obtain appropriate orders and that the EMAR should not reflect missed medications for scheduled dialysis absences. The deficiency was identified through review of records, interviews, and facility policy, and was specific to one resident reviewed for dialysis services.
Failure to Administer Antihypertensive Medication Resulting in Hospital Transfer
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension and heart failure did not receive 14 doses of a physician-ordered antihypertensive medication, Entresto, over several days. The medication was documented as not administered or unavailable on multiple occasions, with corresponding entries in the Medication Administration Record (MAR) and progress notes. Despite the repeated lack of administration, there was no documentation that the physician was notified about the unavailability of the medication, and the medication was not obtained from the pharmacy or backup supply in a timely manner. The resident subsequently experienced uncontrolled hypertension, presenting with symptoms such as dizziness, generalized weakness, and markedly elevated blood pressure, which led to an emergency hospital transfer. Hospital records indicated a diagnosis of hypertensive emergency, and the medical team questioned compliance with prescribed medications, noting the absence of an exact substitute for Entresto. Interviews with nursing staff confirmed that the medication was not available and not administered, and that there was no documentation of physician notification regarding the missed doses. Further review revealed inconsistencies in MAR documentation, such as doses being marked as administered when the medication was not available, and the use of codes without corresponding physician orders. The Director of Nursing and other facility leadership acknowledged that medication should not be checked off as administered if not given and that the physician should be contacted if a medication is unavailable for several days. However, there was no evidence that the facility conducted a timely review or investigation of the incident prior to the survey, and leadership was unaware of the missed medication administration until informed by surveyors.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Complete Timely Initial Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of a resident conducted an initial comprehensive visit within the required 30-day time period after admission. Review of the electronic medical record and progress notes revealed that the initial physician visit for the resident was not completed within 30 days of admission, as required by federal regulations. The only available documentation was a "HISTORY AND PHYSICAL" signed by an advanced practice nurse, with no further documentation from the physician since the resident's arrival. Interviews with facility staff confirmed that there were no additional physician notes available for the resident during the required timeframe. The facility's own policy, which aligns with federal requirements, states that the attending physician must visit patients at least once every 30 days for the first 90 days following admission. This policy was not followed in the case of the resident identified in the report.
Plan Of Correction
1. Resident #2's initial comprehensive physician visit was completed on 01/07/2024, and as recently as 6/11/25, no negative concerns were identified. 2. All residents have the potential to be affected by this practice. An audit was completed of all current residents to ensure that physician visits occurred within the required time frame. Any inconsistencies were addressed immediately. 3. The facility's admission process has been updated to include a physician visit tracker that flags any upcoming 30-day deadlines for new admissions. U.S. FOIA (b) (6) educated Ex Order 26. 4B1 and medical staff, on facility policy regarding the timeliness of physician visits. 4. The DON or designee will monitor all new admissions weekly for 4 weeks, followed by a monthly audit for 3 months to ensure a physician visit occurs in accordance with facility policy and reported to the Committee for review and action. The QAPI Committee, including the NHA, DON, Medical Director, and Admissions Coordinator, will evaluate trends and determine whether additional interventions or education are needed.
Failure to Document Resident Care in Point of Care System
Penalty
Summary
Facility staff failed to consistently document care provided to a resident in the "Documentation Survey Report v2 (DSR)" and did not follow the facility's policy on Point of Care (POC) documentation. Specifically, for one resident, there were multiple instances where documentation was missing for care provided across several dates and shifts. The electronic medical record review revealed blank spaces in the POC documentation, indicating that care was either not provided or not recorded as required. Interviews with staff, including LPNs and other facility personnel, confirmed that the expectation is for CNAs to document all activities of daily living (ADLs) in the POC system for every shift. Staff stated that refusals of care should be documented in both the care plan and progress notes, and that blank spaces in the POC indicate a failure to document. The staff also acknowledged that the facility's policy was not followed, as documentation was missing for the identified periods. The facility's policy requires CNAs to document resident care in accordance with each resident's individualized plan of care, including self-performance and support for ADLs such as toileting and personal hygiene, as well as bowel and bladder continence. The lack of documentation for the resident in question was confirmed by both record review and staff interviews, establishing that the required documentation was not completed as per policy and regulatory requirements.
Plan Of Correction
1. Resident #2 was assessed that NJ Ex Order 26. 4B1 was provided by licensed nursing staff. The residents continue to receive appropriate care per the plan of care. 2. All residents have the potential to be affected by incomplete or inconsistent documentation by not documenting that incontinent care was provided. A facility-wide audit was completed to ensure POC is completed for all current residents. Any inconsistencies were addressed immediately, and all charts were updated accordingly. 3. All Certified Nursing Assistants were re-educated on the facility's policy titled "Point of Care (POC) Documentation," with emphasis on timely and complete documentation of care tasks, including incontinence care and toileting hygiene. Education will be completed on orientation and as part of annual competencies. 4. The Director of Nursing (DON) or designee will conduct daily audits of POC documentation prior to CNA end of shift for all residents for 5 consecutive days, followed by weekly audits for 3 weeks, and then monthly audits for 3 months. Results of the audits will be documented and reviewed during the facility’s monthly QAPI (Quality Assurance and Performance Improvement). The QAPI Committee, comprised of the NHA, DON, Infection Preventionist, and Medical Director, will oversee the effectiveness of these interventions and recommend additional actions if necessary.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during a 14-day review period. According to the findings, the facility was required to have at least one CNA for every eight residents on the day shift. However, for each of the 14 day shifts reviewed, the number of CNAs scheduled was consistently below the required minimum. For example, on multiple days, only 15 or 16 CNAs were present for 141 to 145 residents, when at least 18 CNAs were needed to meet the mandated ratio. This deficiency was identified through interviews and a review of facility staffing documents. The shortfall in CNA staffing was present on every day shift reviewed within the specified two-week period, affecting all residents in the facility. The report does not provide specific details about individual residents or their medical conditions, but it notes that the deficient practice had the potential to affect all residents due to the facility's failure to comply with state staffing requirements.
Plan Of Correction
1. Corrective Action for Residents Found to Have Been Affected: All staffing coordinators, unit managers, and scheduling personnel were re-educated on state staffing mandates and compliance tracking by the DON on 06/20/2025. 2. Identification of Other Residents Who May Be Affected: All residents in the facility during the day shift may have been affected by insufficient CNA staffing. 3. Measures and Systemic Changes to Prevent Recurrence: Staffing Recruitment: The facility has entered a new collective bargaining agreement as of 06/01/2025 with its union to increase wages $2.00 per hour. Daily Staffing Audits: The Director of Nursing (DON) or designee will review staffing ratios daily by shift and maintain a record to ensure compliance. Recruitment Campaign: A CNA recruitment initiative was launched including sign-on bonuses, referral incentives, job fairs, and outreach to local training programs including tuition sponsorship of nursing assistants, which has had successful outcomes. Through the sponsorship of Nursing Assistant training programs, the facility has successfully recruited and retained nursing assistants who received their Certified Nursing Assistant certification. A new recruiter started on 06/09/2025 who is actively engaging applicants through social media and on-the-spot interviews including weekends. Daily weekday meetings are held to discuss recruitment efforts. Retention Campaign: An employee survey was conducted of 95% of all staff, and results were received to facilitate feedback on actionable insights that help the facility understand, predict, and improve employee satisfaction and engagement to improve staff retention. Additionally, the facility has deployed human resource software through Retain. This software plays a proactive role in keeping employees engaged, utilized, and aligned with organizational goals. It minimizes turnover by addressing the root causes of attrition—overwork, disengagement, lack of growth, and misalignment between employee goals and business needs. Additionally, the facility has an active Employee of the Month program as well as team-building events to foster camaraderie and employee satisfaction. 4. Monitoring of Corrective Actions to Ensure Effectiveness: QAPI Oversight: Staffing ratio compliance will be tracked as a monthly Quality Assurance Performance Improvement (QAPI) indicator and results forwarded to the facility’s QAPI committee. Weekly Review: The DON will present a weekly staffing compliance summary to the Administrator for validation by 06/24/2025 for 30 days. 30-Day Audit: A 30-day audit (ending 07/24/2025) of CNA staffing ratios will be completed and submitted to the QAPI Committee for review and validation.
Failure to Provide Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure, pneumonia, and COPD did not receive care in accordance with physician orders and professional standards. The resident was admitted with an order for continuous oxygen at 5 liters per minute via nasal cannula, but the care plan did not mention oxygen supplementation. On the morning in question, the resident was found unresponsive, diaphoretic, and with blue nailbeds; the pulse oximeter showed an oxygen saturation of 50%. The oxygen concentrator was discovered to be off, though it was plugged in, and had to be turned on by the LPN. The resident required two-person assistance for repositioning and was reportedly unable to reach the concentrator, which was located at the bedside. Staff interviews revealed that the LPN received a report from the previous shift indicating no changes overnight, and the CNA observed the resident with oxygen tubing in place during morning rounds. However, the oxygen concentrator was not operating at the time the resident was found unresponsive. Facility policy required nursing staff to follow physician orders and document care accordingly, but the care plan lacked documentation of the oxygen order, and the facility's oxygen administration policy did not include guidelines for concentrator use. This series of actions and omissions resulted in the resident not receiving prescribed oxygen therapy.
Failure to Address Family Grievance Regarding Resident Hygiene
Penalty
Summary
The facility failed to properly address a family member's concern regarding a resident's bathing and changing of clothes. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1/15, and required supervision and assistance with bathing and dressing. Documentation showed that the resident frequently refused showers and changes of clothing, and staff reported that the resident would only accept care from a specific CNA. Despite these refusals, the family expressed concerns about the resident's hygiene, which were communicated to the Social Worker (SW). The SW informed the family that efforts were being made to resolve the issue, including working with the CNA to assist the resident. However, the SW did not document the conversation with the family, and the Administrator, who served as the facility's grievance officer, was not made aware of the family's concern. The facility's grievance policy required that all grievances be investigated, documented, and responded to in writing, with findings reported to the Administrator within five working days. This process was not followed in this case. Interviews with various staff members, including the Unit Manager, LPN, CNA, and DON, confirmed that the resident often refused showers and changes of clothing, and that refusals were to be documented and communicated. However, there was a lack of documentation regarding the family’s grievance and the facility’s response, and the required notification and investigation procedures outlined in the facility’s grievance policy were not followed. This resulted in the facility failing to honor the resident's right to have grievances addressed without discrimination or reprisal.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, pneumonia, and COPD, was admitted and re-admitted to the facility on multiple occasions. Despite physician orders and progress notes indicating the resident was receiving oxygen at 5 liters per minute via nasal cannula, the care plan did not reflect the use of oxygen. The omission was confirmed during interviews with the Unit Manager, Director of Nursing, and Licensed Nursing Home Administrator, all of whom acknowledged that the care plan should have been updated to include oxygen therapy upon the resident's admission or return to the facility. A review of the facility's policy on comprehensive person-centered care plans indicated that care plans are to be revised as information about the resident and their condition changes. However, the care plan for this resident did not include any mention of oxygen use, despite clear documentation in the medical record and physician orders. The failure to update the care plan was identified through observation, record review, and staff interviews during the survey.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute and chronic respiratory failure, hypoxia, hypercapnia, and COPD was observed receiving oxygen at a rate of 3 liters per minute via nasal cannula, despite a physician's order specifying 2 liters per minute. The surveyor and unit manager found the nasal cannula out of the resident's nostrils and the oxygen concentrator set at 3 liters per minute. The unit manager confirmed the discrepancy after checking the physician's order and adjusted the oxygen flow to the correct rate. The resident's pulse oximeter reading was 99% at the time of observation. Further interviews revealed that the LPN had seen the resident earlier with the nasal cannula in place but did not check the oxygen flow rate. The CNA reported that the oxygen concentrator appeared to be working during rounds. The facility's policy requires nursing staff to follow physician orders and verify oxygen administration procedures, including checking the flow rate. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported that the CNA pushed them, causing hot coffee to spill on their lap. This incident was not properly investigated or reported by the facility, leading to a situation of Immediate Jeopardy. The incident occurred when the resident was in the nutrition room heating up food and coffee. The CNA entered the room to get ice for other residents, and a confrontation ensued. The resident accused the CNA of pushing them, which resulted in the coffee spill. Despite the resident's report of physical abuse, the facility did not suspend the CNA or report the incident to the appropriate authorities in a timely manner. The facility's policy on abuse prevention was not followed, as the incident was not reported within the required two-hour timeframe, and the CNA continued to work for several days after the allegation. The Director of Nursing (DON) acknowledged the failure to act appropriately and confirmed that the incident should have been reported and the CNA suspended immediately.
Removal Plan
- Suspending CNA #1 pending investigation
- Notifying the New Jersey Department of Health of the allegation of abuse
- Educating all staff on the facility abuse policy
Inadequate Supervision and Safety Measures for Hot Liquids
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents handling hot liquids, resulting in multiple burn incidents. Resident #13 suffered burns on two occasions while attempting to heat coffee in a microwave located in an unlocked nutritional room. On the first occasion, Resident #13 experienced a first-degree burn on the pelvic area after an altercation with another resident. On the second occasion, Resident #13 sustained more severe burns, including second-degree burns on the left thigh and penis, when a door bumped into their wheelchair, causing the hot coffee to spill. Resident #40 also suffered a second-degree burn while attempting to transport hot coffee from the dining room to their room. The resident placed the coffee cup inside their wheelchair, which led to the spill and subsequent burn. The incident occurred despite the facility's policy that hot beverages should be served with a lid to prevent spills. Both residents involved had intact cognition, as indicated by their BIMS scores, and were capable of making decisions regarding their activities of daily living. However, the facility's lack of supervision and failure to implement adequate safety measures for handling hot liquids contributed to these incidents. The facility's policies and procedures were not effectively enforced, leading to these preventable accidents.
Removal Plan
- Resident education and care plans updated as indicated.
- The interdisciplinary care team met to discuss hot beverages policy, microwave use, and reviewed trends surrounding hot beverage spills.
- Microwaves were removed from the common area by Maintenance staff/designee.
- The resident council president and residents were made aware by unit managers/interdisciplinary team that microwaves were removed from common areas by maintenance staff/designee and that requests should be made to staff for reheating of food and beverages.
- The resident council/food committee was held. Residents were educated on hot beverage safety and the removal of microwaves from common areas. The residents were educated that dietary staff would reheat meals and beverages upon request to minimize the risk of injury and validate appropriate beverage temps before resident consumption and/or transporting of hot beverages.
- Staff education was initiated and remained ongoing.
- Education on monitoring during meals and during resident transport of hot beverages to assist in minimizing the risk of potential injury and following plan of care.
- Staff were educated to request reheating of meals and beverages from dietary staff. Education to dietary staff regarding reheating food and beverages per policy and facility-initiated process.
- A review was completed of resident incidents with identified residents reviewed. Care plans were in place, and no further variances were noted.
- Kitchen audits related to test trays remain ongoing. Variances addressed as indicated.
Medication Security and Expired Items Deficiency
Penalty
Summary
The facility failed to ensure the security of one of its medication carts and did not remove expired supplements and blood equipment from a medication storage room. An unlocked medication cart was observed at the nurses' station between the 800 and 700 halls. During this time, two staff members were in the office with their backs to the window, and the cart was not in their line of sight. Several staff members and two unidentified residents passed by the unlocked cart, and a CNA accessed it for a straw. The RN responsible for the cart was unaware it was unlocked and reported the incident to the Unit Manager. In the medication storage room between the 700 and 800 halls, several expired items were found, including intravenous catheters, a nutritional supplement, specimen collection instruments, and a viral access spike. The Unit Manager, who usually checks the room twice a week, admitted to missing these expired items during her last inspection. The facility's policy requires that expired medications and biologicals be returned or destroyed, and that all compartments containing medications be locked when not in use.
Inaccurate Completion of Medicare Beneficiary Notices
Penalty
Summary
The facility failed to accurately complete the Medicare Part A form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one resident and the CMS Skilled Facility Nursing Advanced Beneficiary Notice (SNFABN) CMS-10055 form for two residents. For Resident 6, the NOMNC form was missing the TTY number, which is essential for residents who are hard of hearing or deaf to assist them in filing an appeal. Additionally, the form did not include the name of the Quality Improvement Organization (QIO), which is responsible for reviewing appeal information. The SNFABN form issued to Resident 6 by phone was also incomplete, lacking the facility's telephone number and providing insufficient information in the sections for care, reason Medicare might not pay, and cost. Similarly, for Resident 79, the SNFABN form was completed in the same inadequate manner, missing the facility's phone number and providing vague descriptions in the care, reason Medicare might not pay, and cost sections. The facility's policy on Medicare Advance Beneficiary and Medicare Non-Coverage Notices did not provide instructions on how to complete these forms. The 2018 instructions for the SNFABN form and the undated instructions for the NOMNC form specify the necessary information that should be included, such as the facility's contact details and clear, understandable language for the beneficiary.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident, identified as R13, to the state agency within the required two-hour timeframe. R13, who was cognitively intact with a BIMS score of 14 out of 15, was involved in an altercation with a Certified Nursing Assistant (CNA1) in the nourishment room. During the incident, R13 reportedly blocked the entranceway and threatened to pour coffee on CNA1. In the ensuing struggle, R13 spilled coffee on himself and later alleged that CNA1 pushed him, causing the spill. Despite these allegations, the incident was not reported to the state agency or the Ombudsman as required by the facility's policy. The Director of Nursing (DON) and the Administrator confirmed that the incident was not reported, with the DON stating that the staff concluded the investigation internally and did not find it necessary to notify the state agency. However, upon reviewing the statements where R13 reported alleged physical abuse, the DON acknowledged that the incident should have been reported within two hours of staff's knowledge. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or exploitation to the Administrator and relevant authorities, which was not adhered to in this case.
Inadequate Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident, identified as R13, who was cognitively intact with a BIMS score of 14 out of 15. The incident occurred when R13 was in the nourishment room heating coffee, and a CNA entered the room to get ice. R13 accused the CNA of pushing him, causing hot coffee to spill on his lap. The CNA provided a written statement indicating that R13 blocked her path and threatened her, leading her to squeeze past him, which she claimed resulted in the coffee spill. The investigation into the incident was inadequate, as it lacked comprehensive interviews and documentation. The facility's policy required thorough investigation procedures, including interviews with all involved parties and witnesses, which were not fully conducted. The Director of Nursing initially decided not to pursue the investigation further, citing R13's tendency to fabricate stories, but later acknowledged the need to restart the investigation. Interviews with staff and the resident revealed inconsistencies in the accounts of the incident. The CNA denied returning to the nourishment room a second time, contrary to her written statement. The resident, R13, maintained that the CNA pushed him, causing the spill. The facility's failure to adhere to its abuse investigation policy and the lack of a comprehensive investigation placed R13 at risk and resulted in a deficiency finding.
Failure to Complete PASARR Screening Correctly
Penalty
Summary
The facility failed to ensure the Pre-Admission Screen and Resident Review (PASARR) Level I screen was completed correctly prior to the admission of a resident diagnosed with schizoaffective disorder. The resident, identified as R112, was admitted to the facility from the hospital with a diagnosis of schizoaffective disorder and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. Despite this, the PASARR Level I screen submitted by the hospital case worker incorrectly indicated that the resident did not have a diagnosis or evidence of a major mental illness disorder. During an interview, the Social Services Director acknowledged that the PASARR form was filled out incorrectly by the hospital and confirmed that the resident had a long-standing diagnosis of schizophrenia. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process, which was not adhered to in this case. This oversight created a potential failure to identify the specialized or rehabilitative services needed by the resident and whether the placement in the facility was appropriate.
Failure to Develop Activity Care Plan for Resident
Penalty
Summary
The facility failed to develop an activity care plan for a resident, identified as R49, which included the resident's preference for one-to-one activities. This oversight was identified during a review of the resident's records and interviews with facility staff. R49 was admitted with several diagnoses, including major depressive disorder, and was noted to be cognitively intact but dependent on staff for all activities of daily living. The resident's admission activities assessment indicated a preference for one-to-one activities rather than group activities, but this preference was not reflected in the care plan. Interviews with facility staff, including an LPN and the Activity Director, revealed a lack of awareness and follow-through regarding the resident's activity preferences. The LPN was unsure if the resident was on the list for one-to-one visits, and the Activity Director, who was new to the position, admitted to not having developed a care plan that reflected the resident's desires. The facility's policy on comprehensive person-centered care plans was not adhered to, as the care plan did not describe the services needed to maintain the resident's well-being.
Failure to Revise Care Plan After Resident Sustains Coffee Burn
Penalty
Summary
The facility failed to revise the care plan for a resident who sustained a second-degree coffee burn while attempting to transport hot coffee from the dining room to his room. The resident, who had a medical history including diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarct, was not provided with an updated care plan to reflect the incident and the necessary interventions to prevent recurrence. The care plan, last revised in 2014, did not include reminders for the resident to ask for assistance when carrying hot items or the staff education to ensure hot liquids were cooled before being offered to residents. Interviews with facility staff, including an LPN and the DON, confirmed that the care plan should have been updated to include these interventions. The facility's policy on care plans, which mandates ongoing assessments and revisions as resident conditions change, was not adhered to in this case. The failure to update the care plan posed a potential risk to resident safety, as it did not reflect the necessary precautions to prevent similar incidents in the future.
Failure to Document Resident Weights as Ordered
Penalty
Summary
The facility failed to provide quality care in accordance with physician orders for a resident, identified as R78, by not adhering to the prescribed schedule for weighing the resident. R78 was admitted with several diagnoses, including anoxic brain injury and type II diabetes mellitus, and had a feeding tube providing the majority of daily calories. The care plan required weekly weights for four weeks, then monthly weights, to monitor for unplanned weight loss. However, the facility did not document weights as ordered, with missing entries for several dates in May and June. This lack of documentation meant that significant weight changes were not communicated to the Registered Dietitian (RD), who was unaware of any issues due to the absence of recorded weights. Interviews revealed that the RD was not notified of any weight changes because the weights had not been entered into the system. The Unit Manager responsible for documenting weights had left abruptly, leaving work undone, which contributed to the lack of documentation. A Licensed Practical Nurse (LPN) stated that weekly weights were supposed to be recorded by the Unit Manager, and any significant weight differences should have been reported. The facility's policy required weights to be recorded in the medical record, which was not followed, leading to the deficiency.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions. The resident, who was admitted with multiple diagnoses including aftercare for hip replacement surgery, hemiplegia, hemiparesis, diabetes, major depressive disorder, seizures, and cerebral infarct, had an open area on the right buttocks. This condition necessitated Enhanced Barrier Precautions, as indicated by signage outside the resident's room, which instructed staff to perform hand hygiene and don gloves and gowns while providing direct care. During an observation, a Certified Nursing Assistant (CNA) was seen providing a bed bath to the resident without wearing a gown, and a Licensed Practical Nurse (LPN) entered the room to administer pain medication and assist with the bed bath, also without donning a gown. The LPN later admitted to forgetting to wear a gown in the rush to provide timely pain relief. The incident was noted by another LPN, who confirmed the failure to adhere to the PPE requirements. The Infection Preventionist was informed of the incident and conducted a staff in-service on Enhanced Barrier Precautions.
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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