Big Oak Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsgrove, New Jersey.
- Location
- 849 Big Oak Road, Pittsgrove, New Jersey 08318
- CMS Provider Number
- 315014
- Inspections on file
- 19
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Big Oak Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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 surveyor observed several kitchen sanitation deficiencies, including the misuse of a handwashing sink, rust on shelving units, a black substance in the dishwashing area, and chipped ceramic plates. The Food Service Director and Licensed Nursing Home Administrator acknowledged these issues, which were contrary to the facility's policies on handwashing, food storage, and sanitization.
The facility failed to follow infection control practices during a meal pass, as a CNA did not perform hand hygiene between handling meal trays for different residents. Additionally, the facility lacked a water management program to prevent Legionella growth, with no documented monitoring for waterborne pathogens. The LNHA and DM relied on an outside company's assurance that chemicals used in water treatment would prevent Legionella, but there was no formal process or documentation to support this.
A facility failed to develop comprehensive care plans for a resident on anticoagulant medication and another on hospice care. The first resident's ICCP lacked details on their atrial fibrillation diagnosis and anticoagulant use, despite physician orders for monitoring. The second resident's ICCP included advanced directives but omitted hospice care interventions. Interviews with nursing staff confirmed these omissions, highlighting a failure to follow facility policies and regulatory requirements.
The facility failed to use an infection assessment tool accurately for seven residents prescribed antibiotics, as the criteria for antibiotic use were not met. The Infection Preventionist, who also served as an LPN and Unit Manager, did not document physician notifications when criteria were unmet, despite tracking data on the Infection Log. The facility's policy required review and provider notification, which was not followed.
The facility failed to offer pneumococcal and influenza vaccinations to four residents upon admission, as required by their policies. Despite having intact cognition, these residents were not documented as having been offered the vaccines, and consents or declinations were only obtained after surveyor inquiries. This deficiency highlights lapses in the facility's admission procedures and documentation practices.
The facility failed to offer an updated COVID-19 vaccine to four residents, despite their various medical conditions. The investigation revealed inadequate processes for offering and documenting vaccinations, with records either lacking documentation or showing consents obtained only after surveyor inquiry. The facility's policy required offering the vaccine and documenting refusals, but this was not adhered to, as residents' immunization statuses were not accurately reflected.
A surveyor found the West Wing medication storage room in disrepair, with a musty odor, stained and buckled floors, a cracked ceiling, and detached piping. The sink was nonfunctional for about a month, with water leaking onto the floor, and no hand sanitizer was available. Staff were aware of the issues, but no corrective actions were taken during the maintenance director's absence. The Consultant Pharmacist deemed the environment unacceptable for medication storage.
A resident's room in the facility was found to be in poor condition, with a dirty floor, rusty over bed table, and non-functional television. The resident, who had multiple medical conditions, was tearful and lacked personal effects in the room. Housekeeping and maintenance staff acknowledged the issues, and the facility's policy on maintaining a homelike environment was not followed.
A CNA failed to immediately report an allegation of abuse involving a resident's fingers being twisted by an aide, as required by the facility's policy. The incident involved two residents, one with intact cognition and the other with severe cognitive impairment. The resident with intact cognition initially reported the abuse but later retracted the statement. The facility's policy mandates immediate reporting of any suspected abuse to the administrator and relevant authorities.
A facility failed to notify the State Long-Term Care Ombudsman about a resident's hospitalization for pneumonia, cellulitis, and acute kidney failure. The resident had intact cognition and multiple health issues. The Director of Social Work, responsible for notifications, admitted to not notifying the Ombudsman until months later, missing the resident's case. The Licensed Nursing Home Administrator assumed notifications were sent but did not verify. This oversight violated the facility's policy requiring timely notifications.
A facility failed to ensure a physician's order for monitoring a resident's blood glucose levels, despite the resident being on insulin and having diabetes mellitus. The oversight was identified during a medication administration record review, and the Medical Director acknowledged the need for regular monitoring. The facility's policy did not include blood glucose monitoring, contributing to the deficiency.
A resident with stage 4 pressure ulcers did not receive wound care as per physician's orders in an LTC facility. The LPN responsible failed to change the dressing on the resident's left heel as documented, leading to missed treatments. The DON confirmed the deficiency, acknowledging the risk of infection and improper documentation.
A resident with end-stage renal disease, COPD, and diabetes missed multiple doses of budesonide and Humalog due to the facility's failure to adjust medication administration times around scheduled dialysis sessions. The facility also did not notify the physician of these missed doses, as confirmed by interviews with the LPN and DON. The facility's policies did not address accommodating medication times for dialysis or notifying physicians of missed doses.
A surveyor observed that medications were improperly stored on a treatment cart in the hallway, left unattended by a nurse. An LPN confirmed the medications should have been secured in the cart, and the DON reiterated that medications must be stored in locked compartments as per policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive the adaptive dining equipment specified in their care plan during meal service. Observations revealed missing utensils like a curved spoon and sippy cup, leading to difficulty in eating. Staff interviews confirmed the oversight, despite clear indications on the resident's diet slip and facility policy requirements.
The facility failed to maintain a sanitary garbage disposal area, with two dumpsters left open and loose trash on the ground. The FSD, HD, and DM acknowledged the need for closed lids and a clean area to prevent infection and pests, as per facility policies.
The facility failed to ensure the presence of the LNHA at a QAPI meeting in January 2024, as required by their policy. The LNHA did not sign the attendance sheet, and there was no evidence of their participation in the meeting minutes. The LNHA confirmed their absence and highlighted the importance of their role in the QAPI process.
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.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, as observed by a surveyor on multiple occasions. During an inspection, a dietary staff member was seen removing a fork and spatula from a designated handwashing sink, which lacked signage indicating its exclusive use for handwashing. Additionally, the walk-in refrigerator contained three metal shelving units with rust, and the dishwashing area had a build-up of black substance in the caulking between the counter and the wall. Furthermore, four ceramic meal plates in the storage area were found to be chipped. Interviews with the Food Service Director (FSD) revealed that the dietary staff had not yet cleaned the black substance in the dishwashing area and would require maintenance assistance. The FSD acknowledged that rust on shelving units and chipped dishware should not be present, as they pose contamination risks. The Licensed Nursing Home Administrator (LNHA) confirmed that used utensils should not be stored in the handwashing sink and that maintenance should have been notified about the rust on the shelving units. The LNHA also stated that chipped dishware should have been discarded. The facility's policies on handwashing, food storage, and sanitization were reviewed, highlighting the need for proper maintenance and cleanliness.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during a meal pass on the West Wing unit. A Certified Nursing Assistant (CNA) was observed not performing hand hygiene between handling meal trays for different residents. The CNA handled meal trays and assisted residents with their meals without washing hands or changing gloves, which was confirmed by the CNA, Licensed Practical Nurse (LPN), and the Director of Nursing (DON) as a breach of the facility's hand hygiene policy. The facility's policy, updated in April 2024, required hand hygiene before and after assisting residents with meals. Additionally, the facility did not have a water management program in place to prevent the growth of Legionella, a waterborne pathogen. During the entrance conference, the surveyor requested evidence of a water management program, which the facility could not provide. The Licensed Nursing Home Administrator (LNHA) and the Director of Maintenance (DM) confirmed that while an outside company treated the water, there was no specific monitoring for Legionella. The LNHA later acknowledged that the facility did not have a water management program prior to the surveyor's inquiry and had only recently scheduled testing for Legionella. The facility's failure to implement a water management program was further evidenced by the lack of documented monitoring for waterborne pathogens, despite the facility's policy to maintain a sanitary water supply. The LNHA and DM relied on the outside company's assurance that chemicals used in water treatment would prevent Legionella, but there was no formal process or documentation to support this claim. The facility's Water Supply policy, reviewed in April 2024, emphasized the importance of controlling the spread of waterborne microorganisms, which was not adequately addressed in practice.
Failure to Develop Comprehensive Care Plans for Anticoagulant and Hospice Residents
Penalty
Summary
The facility failed to develop an individual comprehensive care plan (ICCP) for a resident using anticoagulant medication and another resident receiving hospice services. For the first resident, the surveyor observed the resident eating lunch and reviewed their medical record, which showed a diagnosis of atrial fibrillation and the use of anticoagulant medication, apixaban. Despite the presence of physician orders for monitoring potential side effects of the medication, the resident's ICCP did not include their diagnosis or the use of anticoagulant medications. Interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the ICCP should have included these details to ensure proper care. For the second resident, the surveyor observed the resident in bed and confirmed through interview and medical record review that the resident was on hospice care due to multiple cancer diagnoses. The resident's ICCP included advanced directives but lacked a focus area or interventions related to hospice care. Interviews with nursing staff, including LPNs and a Unit Manager, revealed that the care plan should have been developed within 72 hours of the resident being admitted to hospice. The facility's policies on care plans and hospice services were reviewed, indicating that the ICCP should reflect the resident's needs and include hospice care coordination. The surveyor's findings highlighted the facility's failure to adhere to its policies and regulatory requirements for developing comprehensive, person-centered care plans. The absence of specific care plans for residents on anticoagulant medication and hospice services indicated a lack of coordination and communication among the interdisciplinary team responsible for resident care.
Failure to Utilize Infection Assessment Tool for Antibiotic Use
Penalty
Summary
The facility failed to accurately utilize an infection assessment tool for seven residents who were prescribed antibiotics. The Antibiotic Stewardship line list for September, October, and November 2024 revealed that these residents were prescribed antibiotics despite the infection assessment tool indicating that the antibiotic use criteria were not met. The residents were prescribed antibiotics for various infections, including skin infections, tooth infections, and urinary tract infections (UTIs). The Infection Preventionist (IP) confirmed that the criteria for antibiotic use were not met for these residents, and there was no documentation that the physician was notified about the inappropriate antibiotic use. The IP, who also worked as a Licensed Practical Nurse (LPN) and Unit Manager (UM), stated that she used the McGeer criteria for infection surveillance to determine the appropriateness of antibiotic use. Despite tracking the data on the Infection Log and surveillance checklist, the IP did not notice any trends and failed to document physician notifications when criteria were not met. The facility's Antibiotic Stewardship policy required the IP or designee to review antibiotic utilization and notify providers of findings, but this was not done for the seven residents. The Nurse Consultant acknowledged the need to revamp the antibiotic stewardship program to ensure compliance with the criteria.
Failure to Offer Vaccinations Upon Admission
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza vaccinations were offered to residents upon admission, as evidenced by the cases of four residents. Resident #14, who had diagnoses including urinary tract infection and chronic hepatitis C, was not documented as having been offered the pneumococcal vaccine upon admission. Although the resident's cognition was intact, the declination of the vaccine was only documented after the surveyor's inquiry, indicating a lapse in the initial admission process. Resident #70, with a history of immunodeficiency due to drugs, had received a pneumococcal vaccine in 2018 but was not documented as having been offered a subsequent dose upon admission. Despite the resident's intact cognition, the consent for the pneumococcal vaccine was only obtained after the surveyor's inquiry, highlighting a failure in the facility's procedure to ensure timely vaccination offers. Resident #69, who had conditions such as high blood pressure and chronic respiratory failure, was not documented as having been offered the pneumococcal vaccine upon admission. Similarly, Resident #66, with multiple health issues including severe obesity and pressure ulcers, was not documented as having been offered either the influenza or pneumococcal vaccines. The facility's policies required that these vaccines be offered upon admission, but the documentation and follow-up were inadequate, leading to the deficiency noted by the surveyors.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to four out of five residents reviewed for immunizations. This deficiency was identified through interviews, record reviews, and examination of facility documents. The residents involved had various medical conditions, including urinary tract infection, chronic viral hepatitis C, immunodeficiency due to drugs, high blood pressure, pneumonia, chronic respiratory failure, morbid obesity, osteomyelitis, pressure ulcers, diabetes, and depression. Despite these conditions, there was no documentation that these residents received or declined an updated COVID-19 vaccination after 2022. The surveyor's investigation revealed that the facility's process for offering and documenting COVID-19 vaccinations was inadequate. Interviews with the Infection Preventionist (IP), Licensed Practical Nurse (LPN), Director of Nursing (DON), and other staff members confirmed that the administration or declination of vaccinations should have been documented in the residents' electronic medical records. However, the records for the residents in question either lacked documentation of an updated COVID-19 vaccine or showed that consents or declinations were obtained only after the surveyor's inquiry. The facility's policy required that each resident and staff member be offered the COVID-19 vaccine when available, with informed consent obtained prior to vaccination. The policy also stated that refusals should be documented. Despite this, the surveyor found that the facility did not adhere to its policy, as evidenced by the lack of timely documentation and offering of the updated COVID-19 vaccine to the residents. The deficiency was further highlighted by the fact that the residents' immunization statuses were not accurately reflected in their records, and attempts to contact responsible parties for vaccination history were not documented.
Deficient Medication Storage Room Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary medication storage room in the West Wing, as observed by the surveyor. Upon entering the room, a musty odor was detected, and several issues were noted, including discolored and stained floor tiles, a raised and buckled floor, a crack in the ceiling, and detached piping on the floor. Additionally, a moist, soiled blanket with brown stains and debris was found under the sink, and the interior of the cabinet was discolored. The Director of Maintenance acknowledged the issues, stating that the pipes broke three weeks prior and that he had ordered parts for repair but was absent for a week, during which no repairs were made. Interviews with various staff members, including LPNs and the Licensed Nursing Home Administrator, revealed that the sink had been nonfunctional for about a month, with water dripping under the sink and onto the floor. Despite being aware of the issues, no signage was posted to indicate the sink was out of order, and there was no hand sanitizer available in the room. The Consultant Pharmacist confirmed that the medication storage environment was unacceptable and emphasized the need for a clean, dry, and sanitary space. The facility's policies on medication storage and maintenance service were reviewed, highlighting the responsibility of nursing staff and maintenance personnel to ensure safe and operable conditions.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident #66, on the West Unit. Upon entering the resident's room, the surveyor observed a visibly dirty floor with dried paint and debris, a rusty over bed table frame, and a television that was not in service. The resident, who had intact cognition and multiple medical diagnoses including severe obesity, osteomyelitis, and stage 4 pressure ulcers, was found tearful and crying in bed. The room lacked personal effects or decor to offer a homelike environment. Further observations revealed the flooring was heavily soiled with a black substance, and there were red and pink substances identified as ketchup and cranberry juice, respectively, on the floor. The wood around the window frame was peeling and chipped, and the protective cover on the over bed table was chipped with exposed wood. Housekeeping staff claimed the room had been cleaned, but the Housekeeping Director acknowledged the issues and stated that the table should be replaced due to safety concerns. The Director of Maintenance was unaware of the room's condition and had reported the flooring issue to the Licensed Nursing Home Administrator multiple times. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the lack of cleanliness and maintenance in the resident's room. The Licensed Nursing Home Administrator admitted that environmental rounds were conducted twice weekly, but acknowledged that the resident's room should have been maintained in better condition. The facility's failure to provide a clean, comfortable, and personalized environment for the resident was a clear deficiency in meeting the resident's rights and needs.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was immediately reported to a supervisor, as required by the facility's abuse policy. This deficiency was identified during a survey when a Certified Nursing Assistant (CNA) did not report an allegation of abuse involving a resident's fingers being twisted by an aide. The CNA stated that the resident wanted to speak with the state surveyor first, which delayed the reporting process. The facility's policy mandates immediate reporting of any suspected abuse to the administrator and relevant authorities. The incident involved two residents, one of whom had a BIMS score indicating intact cognition, while the other had a severely impaired cognition due to Alzheimer's Disease and other mental health conditions. The resident with intact cognition initially reported the abuse but later retracted the statement, claiming the other resident twisted the staff's fingers. The Licensed Nursing Home Administrator and the Director of Nursing were unaware of the allegation until the surveyor's inquiry, highlighting a lapse in the immediate reporting process as per the facility's policy.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a resident's hospitalization, which was identified during a survey. This deficiency involved a resident who was hospitalized for pneumonia, cellulitis, and acute kidney failure. The resident had a cognitive communication deficit, chronic respiratory failure with hypoxia, and muscle weakness, but their cognition was intact as indicated by a BIMS score of 14 out of 15. The surveyor discovered the omission during a review of the resident's medical records and interviews with facility staff. The Licensed Nursing Home Administrator (LNHA) and the Director of Social Work (DSW) were responsible for ensuring notifications were sent to the Ombudsman's office. However, the DSW, who started in May 2024, admitted to not notifying the Ombudsman's office until September 2024, missing the notification for the resident in June 2024. The LNHA assumed notifications were being sent monthly but did not verify this. The facility's policy required notifications to be sent as soon as practicable, but this was not adhered to, leading to the deficiency.
Failure to Ensure Physician's Order for Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain a professional standard of practice by not ensuring a physician's order was in place for monitoring a resident's blood glucose levels. This deficiency was identified during a medication administration record review for a resident on dialysis. The resident, who was readmitted from an acute care hospital, had diagnoses including end-stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease with acute exacerbation, and diabetes mellitus. Despite the resident's comprehensive care plan indicating a risk for complications related to diabetes mellitus and the need for finger stick monitoring, there were no active physician orders for blood glucose monitoring. The Medical Director acknowledged the oversight, noting that the resident was on insulin and should have their blood glucose levels checked at least three times per week. The facility's Nurse Consultant, in the presence of the Director of Nursing and the Licensed Nursing Home Administrator, stated that if there was a discrepancy with monitoring after the resident's return from the hospital, the expectation would be for the nurse to confirm with the physician whether to reorder the monitoring. The facility's policy on Reconciliation of Medications on Admission did not include blood glucose monitoring, contributing to the oversight.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident with pressure ulcers, as per the physician's orders and facility policy. The resident, who had a history of morbid obesity, osteomyelitis, and stage 4 pressure ulcers, was observed with a dressing on the left ankle and shin that was dated several days prior to the surveyor's visit. The resident also reported having a wound on their bottom. The medical record indicated that the resident had a stage 4 pressure ulcer on the left heel and sacrum, and was on IV antibiotics for osteomyelitis. The facility's care plan included specific interventions for wound care, but these were not followed. The surveyor found discrepancies in the documentation of wound care. The Treatment Administration Record (TAR) showed that the dressing on the resident's left heel was signed out as changed on specific dates, but the dressing observed was dated earlier, indicating it had not been changed as documented. Interviews with the LPN responsible for the resident's care revealed that the dressing change was not performed as required, and the LPN admitted to signing off on the treatment without completing it. The LPN also failed to communicate the incomplete treatment to the oncoming nurse, leading to missed wound care. The Director of Nursing (DON) confirmed that the wound treatment was not administered as ordered, which posed a risk of infection and potential worsening of the wound. The facility's wound care policy required documentation of wound care, including the date, time, type of care, and any changes in the resident's condition, which was not adhered to in this case. The failure to follow the physician's orders and facility policy for wound care was acknowledged by the DON and the Licensed Nursing Home Administrator in the presence of the survey team.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to adjust medication administration times for a resident who required dialysis, leading to missed doses of critical medications. The resident, who had diagnoses including end-stage renal disease, COPD, and diabetes, was scheduled for dialysis on Mondays, Wednesdays, and Fridays with a chair time of 5:15 AM. Despite this schedule, the facility did not adjust the administration times for the resident's medications, including budesonide and Humalog, resulting in multiple missed doses on dialysis days. The facility's comprehensive care plan for the resident did not include interventions to schedule medications around dialysis times. Additionally, the facility did not notify the physician of the missed medication doses. The October, November, and December Medication Administration Records (MAR) showed numerous missed doses of budesonide and Humalog on the resident's dialysis days, with no documented evidence that the physician was informed. Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that medication times should accommodate dialysis schedules and that the physician should be notified of missed doses. However, the facility's policies on dialysis and medication administration did not address these issues.
Improper Storage of Medications
Penalty
Summary
The facility failed to properly store medications, as observed by a surveyor on the East Wing high treatment cart. A tube of Santyl ointment and a bottle of Nystatin External Powder were left unattended on the treatment cart in the hallway next to the conference room. This was confirmed by an LPN/Unit Manager who acknowledged that the medications should have been stored in a plastic bag and secured in the treatment cart. The Director of Nursing also confirmed that medications should be stored inside the locked cart, as per the facility's Storage of Medications policy, which mandates that drugs and biologicals be stored in locked compartments under proper conditions and only accessible to authorized personnel.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment to a resident during meal service as ordered by the physician and indicated on the resident's individual comprehensive care plan (ICCP). This deficiency was observed during a lunch meal where the resident's tray lacked the necessary adaptive equipment, such as a curved spoon and a sippy cup, which were specified in the resident's diet slip. The resident, who has severe cognitive impairment and multiple diagnoses including cerebral palsy and dysphagia, was observed with food droppings on their clothes, indicating difficulty in eating without the proper utensils. Interviews with staff, including an LPN, the Director of Rehabilitation, the Food Service Director, and the Director of Nursing, confirmed the oversight in providing the required adaptive equipment. The staff acknowledged that the resident's diet slip clearly indicated the need for specific utensils, but these were not consistently provided. The facility's policy on assistance with meals, which mandates the provision of adaptive devices for residents who need them, was not adhered to in this instance.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain a sanitary environment in the designated garbage disposal area, as observed by a surveyor on December 4, 2024. During the inspection, it was noted that two out of three garbage dumpsters had one lid open, exposing trash bags inside. Additionally, there was loose garbage on the ground between the dumpsters, including single-use gloves, plastic water bottles, plastic packaging, single-serve juice containers, plastic cup lids, paper debris, and cardboard. The Food Service Director (FSD) acknowledged that the dumpster lids should be closed and that there should not be loose trash surrounding the dumpsters. Further interviews with the Housekeeping Director (HD) and the Director of Maintenance (DM) revealed that dietary, housekeeping, and maintenance staff were responsible for taking their own trash to the dumpsters. Both directors confirmed that the dumpster lids should be kept closed and that there should not be trash and debris surrounding the dumpsters to prevent infection and pest issues. The Licensed Nursing Home Administrator (LNHA) also acknowledged that the dumpster area should be kept clean with the lids closed. The facility's policies on sanitization and food-related garbage disposal, which were reviewed, also stipulated that garbage containers should be kept closed and free of surrounding litter.
LNHA Absence at QAPI Meeting
Penalty
Summary
The facility failed to ensure the presence of the Licensed Nursing Home Administrator (LNHA) at one of the Quality Assurance and Performance Improvement (QAPI) quarterly meetings, specifically the meeting held in January 2024. During the survey, it was discovered that the LNHA did not sign the attendance sheet for this meeting, and there was no documented evidence of their attendance in the QAPI minutes. The LNHA, who was present during the survey, confirmed the absence of their signature and stated that they were not the LNHA at the time of the January meeting. The LNHA emphasized the importance of their role in the QAPI meetings, as they are responsible for chairing the committee and ensuring that all concerns are addressed and presented. The facility's policy on QAPI governance leadership, updated in April 2024, specifies that the administrator is ultimately responsible for the QAPI program and its results. The policy also lists the administrator as a required member of the QAPI committee. Despite this, the LNHA was not present at the January 2024 meeting, which constitutes a deficiency in meeting the regulatory requirements for QAPI committee composition and attendance.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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