Birchwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranford, New Jersey.
- Location
- 205 Birchwood Ave, Cranford, New Jersey 07016
- CMS Provider Number
- 315091
- Inspections on file
- 18
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Birchwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in the Memory Care Unit, including missing or broken furniture components, damaged surfaces, and unaddressed maintenance issues in both resident rooms and common areas. Staff interviews confirmed these problems and described a logbook system for reporting repairs, but the environment was not maintained in good repair as required by facility policy.
A resident with dementia and diabetes, who was at risk for nutritional problems, did not receive a physician-ordered Ensure Plus supplement at the scheduled time because it was not available on the medication cart. Staff interviews confirmed the supplement was not administered as ordered due to stocking issues, and the DON stated staff are expected to follow physician orders.
The facility was found to have deficiencies in food storage and kitchen equipment maintenance, potentially leading to foodborne illnesses. Observations included ice accumulation in the walk-in freezer, inconsistent temperature readings in refrigerators, and unclean kitchen equipment. Interviews with staff confirmed these issues, acknowledging the risk of foodborne illnesses and degraded food quality.
The facility failed to consistently document post-dialysis access site assessments for two residents with end-stage renal disease, despite orders to monitor for complications every shift. Observations and interviews revealed inconsistent documentation practices, with missing records over several months. The Director of Nursing acknowledged the documentation issues, and the facility was unable to provide additional evidence of assessments.
A resident with hypotension was prescribed Midodrine with instructions to hold the medication if SBP exceeded 130. Despite this, the medication was administered multiple times without adhering to the SBP parameter. The LPN responsible admitted to errors in the EHR system and was unaware of the need to document held medications. The consultant pharmacist's recommendations to reevaluate the medication were not followed, leading to continued administration outside prescribed parameters.
A surveyor observed infection control deficiencies during medication administration in an LTC facility. An RN failed to perform hand hygiene before and after administering medications, despite Enhanced Barrier Precautions signage. Additionally, a House Keeper did not follow proper handwashing procedures. The facility's policies align with CDC guidelines, but staff did not adhere to them.
The facility failed to maintain a sanitary and homelike environment, with surveyors observing dirty areas in hallways and an unsanitary shower room on the 400 wing. The porter and Director of Housekeeping acknowledged issues with floor maintenance, citing years of wax buildup. The shower room was found with used items left behind, and staff interviews revealed uncertainty about cleaning responsibilities and frequency. Despite some maintenance efforts, issues persisted.
The facility failed to ensure accurate MDS assessments for three residents. A resident with chronic MASD was inaccurately documented as having no skin conditions. Another resident with rectal cancer was not coded for cancer in the MDS, despite medical records indicating its presence. Additionally, a resident who suffered a fall resulting in a fracture was incorrectly reported as having no falls in the discharge MDS. These errors highlight a pattern of oversight in documenting residents' conditions.
A facility failed to create a comprehensive care plan for a resident prescribed an anticoagulant medication. The resident, diagnosed with Atrial Fibrillation, had a physician's order for Apixaban. However, no care plan was in place to address the medication needs. An LPN indicated that the Unit Manager should have completed the care plan, but it was unclear why it was not done. The issue was discussed with the Administrator and DON, but no further information was provided.
A resident admitted with conditions like spinal stenosis and diabetes was identified as high risk for skin breakdown, but the facility failed to document detailed skin assessments and implement a care plan. Despite noted discolorations, preventive interventions were not initiated, and required documentation was incomplete, as confirmed by facility staff interviews.
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Medical records showed that physicians did not sign the monthly orders for April, May, or June 2024. The Wing 2 Unit Manager and the DON confirmed that physicians should sign orders electronically, but this was not done.
Failure to Maintain Homelike Environment and Good Repair in Memory Care Unit
Penalty
Summary
The facility failed to provide a homelike environment in good repair for six residents residing on the Memory Care Unit. Observations revealed multiple deficiencies in resident rooms and common areas, including missing covers on air conditioner/heating units, broken drawers in closets and nightstands, missing or chipped laminate on windowsills and cabinets, partially detached privacy curtains, chipped and missing paint on overbed table stands, and missing baseboards. Additionally, common area issues included missing heating unit covers, torn vinyl on chair cushions, and dried substances on walls. These deficiencies were directly observed by surveyors during their inspection of the unit. Interviews with facility staff, including the Maintenance Director, LPN, CNA, and DON, confirmed the presence of these issues and described the process for reporting and addressing maintenance concerns through a logbook system. The facility's policy requires the maintenance department to keep the building and equipment in safe and operable condition at all times, and to maintain the building in good repair and free from hazards. The observed failures to maintain the environment in good repair had the potential to affect the psychosocial needs of the residents.
Failure to Administer Physician-Ordered Nutritional Supplement
Penalty
Summary
Nursing staff failed to follow physician dietary orders for a resident with dementia and type II diabetes who was identified as having a potential for nutritional problems. The resident's care plan included an intervention to provide an Ensure supplement as ordered, and physician orders specified Ensure Plus twice daily at 9:00 AM and 5:00 PM for protein calorie malnutrition. On the evening of 12/09/25, observation revealed that the resident was not provided the 5:00 PM Ensure Plus supplement with dinner. Interviews with staff indicated that the Ensure Plus supplement was not available on the medication cart at the time it was due. The unit manager obtained the supplement and gave it to the LPN, but the LPN confirmed that the supplement had not been administered because it was not on the cart. The LPN stated it was the nurse's responsibility to ensure the cart was stocked. The Director of Nursing stated that staff are expected to follow physician orders and administer supplements in a timely manner.
Deficiencies in Food Storage and Kitchen Equipment Maintenance
Penalty
Summary
The facility was found to have several deficiencies related to food storage and kitchen equipment maintenance, which could potentially lead to foodborne illnesses. During the survey, it was observed that the walk-in freezer had sheets of ice on the floor and icicles hanging from the ceiling, condenser fans, and food boxes. Additionally, several boxes of opened food items, such as croissants, turkey burgers, and breaded eggplant, were not labeled with open or expiration dates and were unsealed, covered with snow, frost, and ice crystals. The walk-in refrigerator #1 had inconsistent temperature readings from different thermometers, and a box of bacon was found opened, unsealed, and unlabeled. Walk-in refrigerator #2 was out of service, and there was no plan for its repair, despite communication from the repair service. Further observations revealed that the temperatures of potentially hazardous foods in walk-in refrigerator #1 were above the safe range, with heavy cream and cottage cheese measuring 46.7 degrees F and 50.4 degrees F, respectively. The facility's kitchen equipment was also not maintained in a clean and sanitary manner. The microwave's interior ceiling was covered with multi-color splatter debris, the meat slicer was found with caked-on brown debris despite being covered with a plastic bag indicating it was clean, and the shelf under the griddle had sediment and debris. Interviews with the Food Service Director, kitchen supervisor, clinical dietary manager, and licensed nursing home administrator confirmed the issues with the freezer and refrigerator, acknowledging that these conditions could lead to foodborne illnesses and degrade food quality. The facility's policies on food safety, physical environment, and monitoring of cooler/freezer temperatures were reviewed, highlighting the need for proper labeling, dating, and maintenance of equipment to prevent contamination and ensure food safety.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to properly assess and document the condition of dialysis access sites for two residents, leading to a deficiency in providing safe and appropriate dialysis care. Resident #55, who has end-stage renal disease and severe cognitive impairment, was observed refusing dialysis due to feeling unwell. Despite having orders to monitor the dialysis access site on the left arm for signs of complications every shift, the facility's records showed inconsistent documentation of these assessments over a two-month period. Similarly, Resident #146, also diagnosed with end-stage renal disease and severe cognitive impairment, had orders to monitor the dialysis access site for complications every shift. However, the nursing progress notes revealed missing documentation for post-dialysis access site assessments over a three-month period. The facility's policy required nurses to monitor and document the status of the resident's access site upon return from dialysis, but this was not consistently done. Interviews with the facility's staff, including the Director of Nursing and registered nurses, confirmed the lack of documentation for post-dialysis assessments. The Director of Nursing acknowledged the poor documentation practices, and the registered nurse admitted to the absence of required documentation in the electronic health records. Despite requests for additional documentation, the facility was unable to provide evidence of consistent post-dialysis assessments, leading to the deficiency finding.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring the accurate administration of Midodrine, a medication used to increase blood pressure, according to the physician's order for a resident with hypotension. The resident, who had severe impaired cognition, was prescribed Midodrine to be administered at bedtime with the condition to hold the medication if the systolic blood pressure (SBP) was greater than 130. However, the medication was administered multiple times over several months without adhering to the SBP parameter, despite the resident's blood pressure readings exceeding the prescribed limit on several occasions. The deficiency was identified through a review of the electronic medication administration records (eMARS) and interviews with facility staff. The LPN responsible for administering the medication admitted to making errors in the electronic health record (EHR) system, stating that they were unaware of the need to document when the medication was held and to notify the appropriate personnel. The LPN had been working with the EHR system for three years but was not familiar with the process of canceling a medication in the system when it was held. The facility's consultant pharmacist had noted the issue in the Medication Review Reports (MRR) for two consecutive months, recommending reevaluation of the resident's need for Midodrine. However, the recommendations were not followed up by the unit manager, leading to continued administration of the medication outside the prescribed parameters. The facility's policy on medication administration required obtaining and recording vital signs and holding medications for vital signs outside the physician's prescribed parameters, which was not adhered to in this case.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration, as observed by a surveyor. A Registered Nurse (RN) was seen preparing and administering medications to residents without performing hand hygiene before or after the process. This occurred despite the presence of Enhanced Barrier Precautions (EBP) signage, which required hand hygiene before entering and exiting rooms. The RN acknowledged the oversight when questioned by the surveyor. Additionally, a House Keeper (HK) was observed improperly washing hands by not following the facility's hand hygiene policy. The HK washed hands for only 12 seconds, turned off the faucet with bare hands, and dried hands on pants, contrary to the policy that requires using a towel to turn off the faucet and drying hands with a single-use towel. The Infection Preventionist (IP) confirmed that the HK had been educated on proper hand hygiene. The facility's policies on medication administration and hand hygiene were reviewed and found to be in line with CDC guidelines, which emphasize the importance of hand hygiene to prevent infection spread. The Director of Nursing (DON) acknowledged the expectation for staff to perform hand hygiene as per the guidelines, especially when dealing with residents on precautions.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for residents, as evidenced by observations of dark, dirty areas in the hallways and doorways of the 400 hallway over several days. The porter responsible for cleaning stated that he had not yet cleaned the 400 wing and was usually the only porter, with a floor technician working only on weekends. The Director of Housekeeping acknowledged the issue, attributing it to years of wax buildup and stated that the floors had only been waxed once in the past three years. She also admitted to not having seen a policy regarding floor maintenance. Additionally, the shower room on the 400 wing was found in an unsanitary condition with used towels, gloves, a clothing item, a used mask, and an opened adult brief left on a shower chair. Interviews with a CNA and an LPN revealed that CNAs were expected to clean up after showers, but there was uncertainty about how often the shower room was checked. The Director of Housekeeping and the Maintenance Director both acknowledged the poor condition of the shower room, with the Director of Housekeeping suggesting the need for new tiles and caulking. Despite some maintenance efforts, dark brown areas remained in the shower stall.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments of residents using the Minimum Data Set (MDS) assessment tool, as evidenced by deficiencies identified in three residents. Resident #94 was observed with chronic moisture-associated skin damage (MASD) in the sacral area, yet the MDS assessment on 7/14/24 inaccurately indicated no skin conditions were present. The MDS Coordinator acknowledged the error, noting that the MASD should have been documented. Resident #37, diagnosed with rectal cancer, had an MDS assessment on 5/17/24 that failed to reflect cancer as an active diagnosis, despite medical records and care plans indicating its presence. The MDS Coordinator admitted the oversight in coding the cancer diagnosis. Resident #586, who suffered a left femur fracture due to an unwitnessed fall, had a discharge MDS on 3/26/24 that incorrectly reported no falls since the prior assessment. Progress notes and a facility investigation confirmed the fall, yet the MDS did not reflect this incident. The MDS Coordinator was informed of the discrepancy and acknowledged the need to address the coding error. These inaccuracies in MDS assessments highlight a pattern of oversight in documenting residents' conditions accurately.
Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed an anticoagulant medication. During an observation, the resident confirmed taking an anticoagulant medication. A review of the resident's Electronic Medical Records showed that the resident was admitted with a diagnosis of Atrial Fibrillation and had a physician's order for Apixaban, an anticoagulant, to be taken orally every two days. However, the surveyor found no care plan addressing the resident's anticoagulant medication needs. An interview with an LPN revealed that the Unit Manager is responsible for completing care plans, and there should have been a care plan for the resident receiving anticoagulant medication. The LPN was unsure why the care plan was not created. The issue was discussed with the Administrator and Director of Nursing, but no additional information was provided.
Failure to Assess and Plan for High-Risk Skin Breakdown
Penalty
Summary
The facility failed to thoroughly assess a skin discoloration identified on an admission assessment and did not implement a care plan for a resident at high risk for skin breakdown. Resident #585 was admitted with conditions including spinal stenosis, muscle wasting, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) indicated the resident was frequently incontinent and required maximum assistance with activities of daily living. Despite being identified as at risk for pressure ulcers, no skin or ulcer injury treatments were documented. The admission assessment noted discolorations on the resident's groin and sacrum, but lacked details such as size and color. The Braden scale score indicated a high risk for skin breakdown, necessitating immediate prevention protocols and care plan documentation. However, the care plan did not include interventions to prevent skin deterioration. The Treatment Administration Record (TAR) lacked documentation of preventive skin care treatments, and a physician's order for weekly skin checks was not properly documented in the electronic medical record. Interviews with facility staff, including the wound care nurse, Director of Nursing (DON), and other nursing staff, revealed a lack of detailed documentation and care planning. The DON confirmed that the admission nurse should have provided a more descriptive assessment and initiated a care plan with preventive interventions. The facility's policy required a pressure risk injury assessment and a full body skin assessment upon admission, with findings documented in the medical record, but these protocols were not followed for Resident #585.
Failure to Sign Monthly Medication Orders
Penalty
Summary
The facility failed to ensure that physicians signed and dated monthly medication orders for five residents over a three-month period. Specifically, the medical records for five residents showed that their physicians did not hand sign or electronically sign the monthly physician's orders for April, May, or June 2024. This deficiency was identified during a review of hybrid medical records for the residents. The Wing 2 Unit Manager and the Director of Nursing confirmed to the surveyor that physicians should be signing their monthly orders electronically, but this was not done for the specified months.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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