Careone At Evesham
Inspection history, citations, penalties and survey trends for this long-term care facility in Marlton, New Jersey.
- Location
- 870 East Route 70, Marlton, New Jersey 08053
- CMS Provider Number
- 315464
- Inspections on file
- 15
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Careone At Evesham during CMS and state inspections, most recent first.
The facility failed to maintain an orderly physical environment, with observations of unsanitary conditions and improper storage of personal items and linens in two units. Residents expressed dissatisfaction with the placement of unpackaged incontinence briefs and linens in their rooms. Staff interviews revealed a lack of adherence to proper storage protocols.
The facility failed to obtain physician discharge orders for three residents, did not change a central line catheter dressing as ordered for a resident, and did not follow orders to offload heels or check helmet placement for two other residents. Additionally, medication records for a resident were incomplete, lacking staff signatures for multiple medications.
The facility failed to conduct a new PASRR level 1 assessment after a resident was newly diagnosed with anxiety disorder, depression, psychotic disorder, and schizophrenia. Despite these new diagnoses, no additional PASRR was completed, and the facility lacked a policy on reevaluating PASRRs for new psychological diagnoses.
A facility failed to develop a comprehensive care plan for a resident with pain, despite the resident reporting moderate pain and having relevant medical diagnoses. The care plan was only updated after a surveyor's inquiry, indicating a lapse in proactive care planning.
A facility failed to ensure that a resident with cognitive impairment had an elopement alarm in place as required by a physician's order. The resident was observed multiple times without the alarm, and staff interviews revealed that the order was outdated and not followed.
The facility failed to document urinary output for a resident with an indwelling catheter as per physician's orders and care plan. Multiple instances of non-compliance were observed in February and March 2024, with the Director of Nursing acknowledging that documentation should not be left blank.
The facility failed to maintain respiratory equipment for three residents, including improper labeling and storage of oxygen and nebulizer tubing. Interviews revealed that the facility's practice was to change tubing weekly, but there were no physician orders for these changes, and the observed practices did not align with the facility's policy.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week. For one day during the reviewed week, the previous DON was counted as the RN on duty, which did not meet the facility's policy requirements. This was confirmed by the Licensed Nursing Home Administrator.
The facility failed to ensure proper medication storage, as evidenced by unattended medication carts with medications on top and prescribed medications found in a communal shower room cabinet. Staff confirmed these practices were against facility policies.
The facility failed to handle potentially hazardous foods and maintain sanitation in the pantry on Unit 1. Observations revealed unlabeled and improperly stored food items, including frozen meals, a burger, and a muffin tin with an exposed muffin. Staff interviews confirmed that all food should be labeled, dated, and covered, as per facility policy.
Failure to Maintain Orderly Physical Environment
Penalty
Summary
The facility failed to maintain an orderly physical environment in two units, as evidenced by multiple observations of unsanitary conditions and improper storage of personal items and linens. In the 100 Unit communal shower room, a shelf adjacent to the shower stall contained an unpackaged incontinence brief, a hairbrush with hair entangled in the bristles, and various hygienic bottled toiletries, along with a foul odor. Additionally, the common area across from the nurses' station had food debris, partially consumed beverages, and a single slipper on the floor. Five PVC mobile trash bins, some containing trash, were stored in the shower room, and a scale chair was cluttered with unpacked incontinence briefs, disposable glove boxes, and plastic bags. Resident #72's room had a chair with an unpackaged incontinence brief, towels, a linen sheet, and a hospital gown, which the resident did not want there. Similar issues were observed in other rooms and common areas, including untied bags of linen on the floor and unpackaged incontinence briefs left on chairs in residents' rooms, which residents expressed they did not want there. Interviews with staff, including a housekeeper and the Director of Nursing (DON), revealed a lack of clarity and adherence to proper storage protocols for linens and personal items. The housekeeper stated he was not responsible for removing linens from rooms, while the DON confirmed that linens and incontinence briefs should be stored in closets or carts, not on chairs or in common areas. The facility's policy on laundry and linen, which mandates that clean linen should remain hygienically clean and protected from environmental contamination, was not followed. The DON and the Licensed Nursing Home Administrator confirmed that nursing staff was responsible for removing linens and incontinence briefs from resident rooms and ensuring they were stored appropriately.
Multiple Deficiencies in Physician Orders and Documentation
Penalty
Summary
The facility failed to obtain a physician's order for residents to be discharged from the facility prior to discharge. This deficiency was identified for three residents who did not have discharge orders placed in their medical records before being discharged. Interviews with the Licensed Nursing Home Administrator, Director of Nursing, and nursing staff confirmed that discharge orders were required but were not entered into the computer system due to nursing oversight. The facility policy also required a physician's order to be signed and recorded within 72 hours of discharge, which was not adhered to in these cases. The facility also failed to change a central line catheter dressing as ordered by the physician for Resident #84. The resident's dressing was dated 03/27/24, and the dressing change scheduled for 04/03/24 was not documented as completed. The resident's Treatment Administration Record showed the dressing was changed on 04/10/24, indicating a delay in following the physician's order. Interviews with nursing staff revealed that central catheter dressings should be changed weekly and documented in the Medication Administration Record or Treatment Administration Record, which was not done in this instance. Additionally, the facility did not follow physician orders to offload a resident's heels while in bed for Resident #467. The order was not documented in the Medication Administration Record or Treatment Administration Record, and there was no evidence that the task was completed by the Certified Nursing Assistant. The facility also failed to check helmet placement every two hours for Resident #468, as required by the physician's order. The Treatment Administration Record had multiple instances of missing documentation, indicating that the checks were not performed or not recorded. Furthermore, the facility did not maintain complete medication records with staff signatures for Resident #35, with multiple instances of missing documentation for various medications in the Medication Administration Record.
Failure to Conduct New PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficiency was identified for a resident who had a PASRR level 1 completed in 2019, which was negative for any mental illness. However, subsequent assessments, including the Admission Minimum Data Set (MDS) and quarterly MDS, indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. Despite these new diagnoses, no additional PASRR was completed to reflect the resident's updated mental health status. During interviews, the Social Worker acknowledged that a new PASRR should have been completed following the new diagnoses but was unable to locate any updated PASRR in the electronic medical record. The Administrator confirmed that there was no policy on reevaluating PASRRs for new psychological diagnoses after admission and that audits were conducted without a requirement for annual updates. The facility's policy on Admission Criteria did not address the need for a new PASRR following a new psychological diagnosis, leading to the identified deficiency.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident experiencing pain. During an initial tour, the resident reported right hip and left foot pain, rating it as a seven on a zero to ten scale, indicating moderate pain. Despite having medical diagnoses including sciatica, fibromyalgia, depression, anxiety, and low back pain, the resident's care plan did not initially include a focus on pain management. The Medication Administration Record (MAR) showed that the resident's pain was assessed every shift, with instances of both mild and severe pain recorded. However, the care plan was only updated to include pain management after the surveyor's inquiry, indicating a lapse in proactive care planning for the resident's pain needs. Further review of the facility's policies on comprehensive person-centered care plans and pain assessment and management revealed that the facility did not adhere to its own guidelines. The policies stipulated that services should be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and that pain management interventions should be consistent with the resident's goals for treatment and documented in the care plan. The failure to include pain management in the resident's care plan until prompted by the surveyor highlights a deficiency in the facility's adherence to its policies and procedures for comprehensive care planning.
Failure to Ensure Elopement Alarm in Place
Penalty
Summary
The facility failed to ensure that a safety device used to prevent residents from elopement was in place for a resident identified as not being cognitively intact. The resident, who had diagnoses including paranoid schizophrenia and major depressive disorder, was observed multiple times without the required elopement alarm on their wrist. Despite the physician's order for the elopement alarm to be checked and in place every shift, the resident was found without it on several occasions. Staff interviews revealed that the nurses did not thoroughly check for the elopement alarm, and the Licensed Nursing Home Administrator confirmed that the physician's order was outdated and not followed by the nursing staff. The resident's care plans indicated a focus on wandering and elopement risk due to cognitive impairment, with interventions including checking the security bracelet. However, the facility's policy on wandering and elopements was not adhered to, as the resident was repeatedly observed without the elopement alarm. The failure to ensure the elopement alarm was in place and functioning as ordered led to the deficiency noted in the report.
Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate and sufficient services based on current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). This deficiency was identified for a resident diagnosed with paraplegia and neuromuscular dysfunction of the bladder, who had an indwelling urinary catheter. The physician's order required measuring and recording the catheter output every shift, but multiple instances of non-compliance were observed in both February and March 2024, where the documentation was left blank on several shifts. The Director of Nursing acknowledged that the documentation should not be left blank and suggested that staff might have forgotten to document it. A review of the facility's policy on catheter care revealed that it required following the procedure for measuring and documenting input and output. However, the Medication and Treatment Orders policy did not provide pertinent information regarding this requirement. The failure to document urinary output as ordered by the physician and outlined in the care plan indicates a lapse in adherence to the facility's policies and procedures, potentially compromising the resident's care.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain the necessary care and maintenance of respiratory equipment for three residents. During an initial tour, the surveyor observed that one resident's oxygen tubing was not labeled, and the bag holding the tubing was dated over a week prior. This resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a physician's order for oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath. However, there was no order to change the oxygen tubing weekly. Additionally, two other residents were observed with nebulizer tubing and masks not stored in bags, and their oxygen tubing was improperly placed. These residents had diagnoses of Interstitial Pulmonary Disease and Acute Respiratory Failure with hypoxia, respectively, and had physician orders for oxygen and nebulizer treatments, but no orders to change respiratory tubing weekly were found for one of them. Interviews with the Licensed Practical Nurse Unit Manager (LPN/UM) and the Director of Nursing (DON) revealed that the facility's practice was to change respiratory tubing weekly and store it in bags when not in use. However, there were no physician orders in place for these weekly changes, and the observed practices did not align with the facility's policy. The facility policy required changing oxygen cannulae and tubing every seven days and storing them in plastic bags when not in use. The DON confirmed that the respiratory therapist was responsible for changing the tubing weekly, but acknowledged that there were no orders for the weekly changes, and agreed that the tubing should be stored in bags when not in use.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, for the week of 04/30/2023 through 05/06/2023, the facility did not have an RN on duty for 8 consecutive hours on 05/06/2023. The Nurse Staffing Report indicated that the previous Director of Nursing was counted as the RN on duty, despite the facility's policy requiring an RN to provide services for at least 8 consecutive hours every 24 hours, 7 days a week. This deficiency was confirmed by the Licensed Nursing Home Administrator during an interview with the surveyor on 04/15/2024.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as evidenced by observations on the 100 unit. On two separate occasions, medication carts were left unattended with grey boxes containing individual medication envelopes on top of the locked carts. In one instance, an LPN left the cart in the hallway while taking a resident's vital signs, and in another instance, another LPN left the cart unattended, stating she was new to the facility. Both instances were confirmed by the Registered Nurse/Unit Manager and the Director of Nursing, who acknowledged that the medications should not have been left on top of the carts unattended. The facility's policy explicitly states that no medications should be kept on top of the cart during administration, which was not adhered to in these cases. Additionally, during a tour of the 200 Unit communal shower room, two sealed plastic bottles containing Acetic Acid Irrigation Solution were found in an open cabinet. The labels on the bottles indicated they were prescribed for an unsampled resident. The LPN/Unit Manager and the Director of Nursing confirmed that these medications should not have been stored in the shower room cabinets but rather in a medication cart or medication room. The facility's policy on medication labeling and storage requires all medications to be stored in locked compartments under proper conditions, which was not followed in this instance.
Failure to Properly Label and Store Food in Pantry
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner in the pantry on Unit 1. During observations, the surveyor found three frozen meals and a container of rice pudding in the freezer that were not labeled. Additionally, a burger in the refrigerator was not labeled or dated, and a muffin tin covered with foil had an exposed muffin. A cup with pink liquid without a lid was also found in the refrigerator, neither dated nor labeled. Interviews with the Food Service Director, an LPN, the Director of Nursing, and the Director of Environmental Services confirmed that all food should be labeled, dated, and covered, and any unlabeled food should be discarded. The facility's policy on foods brought by family/visitors also mandates that perishable foods be stored in resealable containers with tight-fitting lids and labeled with the resident's name, the item, and the use-by date. The observations and interviews indicate a failure to adhere to the facility's food handling and storage policies, which are designed to prevent foodborne illnesses. The deficiency was noted in the pantry on Unit 1, where multiple instances of improperly labeled and stored food items were found. The staff members interviewed acknowledged the importance of labeling and dating food items and confirmed that the facility's policy requires such practices to ensure food safety. However, the observed practices did not align with these standards, leading to the identified deficiency.
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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