Careone At Moorestown
Inspection history, citations, penalties and survey trends for this long-term care facility in Moorestown, New Jersey.
- Location
- 895 Westfield Road, Moorestown, New Jersey 08057
- CMS Provider Number
- 315482
- Inspections on file
- 17
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Careone At Moorestown during CMS and state inspections, most recent first.
A resident with a history of CVA, hallucinations, and moderately impaired cognition reported that a CNA placed both hands firmly on the resident’s shoulders while repositioning a wheelchair, describing the motion as a “hit” but denying pain or intent to harm and expressing not wanting further care from that CNA. Therapy staff and an OT documented the resident’s account, including that the resident felt startled and upset. The CNA denied any inappropriate touching or hitting. The facility’s investigation was limited to statements from the resident, the CNA, and the reporting therapy staff, with no interviews of other residents, additional staff on other shifts, roommates, family, or visitors, despite facility policy requiring a thorough investigation that includes these interviews.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
Two residents were administered medications that had been dropped onto the medication cart by LPNs, who then placed the dropped pills into administration cups and gave them to the residents. Both LPNs later acknowledged that they should have replaced the dropped medications, in accordance with facility policy and infection control procedures. The DON confirmed that administering dropped medications is not permitted by facility policy.
A facility failed to obtain daily weights for a resident with CHF, as ordered by the physician. Despite the resident's need for daily weight monitoring due to their condition, weights were not recorded on seven occasions. This deficiency was confirmed through medical record reviews and staff interviews, highlighting a lapse in following the facility's protocols for weight monitoring.
A facility failed to properly store nebulizer equipment, exposing it to contamination, and did not administer or document incentive spirometry therapy for three residents as ordered. A resident with respiratory issues had their nebulizer mask improperly stored, while three residents requiring IS therapy reported not receiving the device or training, despite records indicating otherwise. Staff acknowledged these discrepancies, confirming the residents' claims.
The facility failed to conduct annual performance evaluations for CNAs, as required for staff improvement and education. During a survey, it was found that four CNAs did not have up-to-date evaluations, and the facility could not provide documentation for the re-hiring of two CNAs. The LNHA and President of Operations confirmed the requirement for annual evaluations, but no additional documentation or policies were provided.
The facility failed to maintain accurate narcotic shift count logs and properly document the administration of controlled medications. Missing signatures and incomplete records were found across multiple shifts, and doses of controlled medications were not signed out on inventory sheets. Additionally, loose pills were found in a medication cart, violating storage policies. LPNs and the DON acknowledged these deficiencies.
The facility failed to obtain weekly weights for a resident as ordered and did not secure a physician's order to hold a tube feeding for another resident. The first resident's weights were not documented on the MAR as required, while the second resident's tube feeding was held without a physician's order due to a scheduled X-ray. Staff acknowledged these oversights, which were contrary to facility policies.
The facility failed to conduct a criminal background check on an LPN before their employment, contrary to its abuse prevention policy. The background check was completed seven weeks after the LPN started working, as confirmed by the LNHA and other officials. No allegations of abuse were reported against the LPN, who no longer works at the facility.
A facility failed to investigate a pressure ulcer on a resident's heel. Despite a physician's order for skin prep and heel elevation, a nurse incorrectly documented no skin breakdown. The resident reported heel pain, but the LPN administered Tylenol without assessing the heel. Later, non-blanchable erythema was observed, indicating a pressure ulcer. The facility's policies on incident reporting and pressure ulcer management were not followed, and an investigation was only initiated after surveyor inquiry.
A resident with a history of falls did not have their comprehensive care plan updated after multiple incidents, despite assessments being conducted. The facility staff showed confusion over who was responsible for revising the care plan, and the facility's policy lacked guidance on care plan revisions.
A facility failed to document catheter care every shift for a resident with an indwelling urinary catheter, as per physician's orders. The resident, with diagnoses including acute kidney failure and obstructive uropathy, had missing documentation for catheter care eleven times in the Treatment Administration Record. Facility policies required documentation of all services, but the Licensed Nursing Home Administrator and President of Operations acknowledged that if care was not documented, it was considered not done.
A resident with end-stage renal disease receiving hemodialysis was not properly assessed or documented according to professional standards. The facility failed to complete dialysis communication forms and incorrectly took blood pressure from the arm with the dialysis access site. Staff acknowledged these oversights, citing rushed procedures.
A facility failed to ensure staff donned PPE before entering the rooms of two residents on COVID-19 isolation. A per diem NP entered without performing hand hygiene or wearing the required PPE, assuming the residents were off isolation due to the absence of visible droplet precaution signage. The interim Administrator confirmed the need for proper PPE use and hand hygiene.
Failure to Thoroughly Investigate Allegation of Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse by a CNA toward one resident. The resident, who had a history of cerebrovascular accident (CVA), hallucinations, and a BIMS score of 9 indicating moderately impaired cognition, was re-admitted shortly before the incident. The admission MDS indicated the resident had no documented behaviors. On the date of the incident, the resident completed an Individual Statement Form describing that while standing beside the bed to get into the wheelchair, the CNA moved the wheelchair to face the door and placed both hands firmly on the resident’s shoulders. The resident stated the CNA did not punch, slap, or shove, denied pain or discomfort, and did not believe the CNA intentionally tried to cause harm, but did not want to work with that CNA. The facility’s Reportable Event Record/Report documented that the resident told therapy staff that the CNA “hit” the resident while attempting to move back into the wheelchair, then clarified that the CNA put hands on the shoulders in a strong manner and denied being struck. The DON assessed the resident with no untoward findings, and statements were obtained from the resident and the CNA. The COTA/L and PT documented that the resident reported being in the room trying to scoot back in the chair when the CNA “hit” the resident, later clarifying that the resident was not used to being touched like that and did not want to return to the current room if that caregiver would be there. An OT email further recorded that the resident used the word “hit” to describe the motion, stated it was not hard and did not cause pain, but that the resident was startled, upset, and unwilling to go back to the room if that caregiver was present. The CNA’s written and verbal statements denied any inappropriate touching or hitting and indicated that after repositioning the wheelchair, the resident made no comments or complaints. During the surveyors’ review of the facility’s investigation, there was no evidence that other residents or additional staff beyond the reporting staff and the CNA involved were interviewed. The Administrator confirmed that only residents and staff directly involved or around the area of the incident were interviewed and acknowledged there were no other resident or staff interviews. This practice did not follow the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, which requires that all allegations be thoroughly investigated, including interviews with the person reporting, any witnesses, the resident, staff on all shifts who had contact with the resident during the period of the alleged incident, the resident’s roommate, family members, visitors, and other residents to whom the accused employee provides care or services.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
During medication administration, two residents were given medications that had been dropped onto the top of the medication cart by two different LPNs. In the first instance, a furosemide tablet was dropped and then placed into the administration cup and given to the resident. The LPN involved acknowledged during an interview that she should have discarded the dropped pill and obtained a new one, as per her training. In the second instance, both a clopidogrel tablet and a sertraline tablet were dropped onto the medication cart and subsequently administered to another resident. The LPN in this case also stated in an interview that she should have replaced the dropped medications. Review of the facility's medication administration policy confirmed that staff are required to follow infection control procedures, including not administering medications that have been dropped. The DON confirmed that it is not facility policy to administer dropped medications.
Failure to Obtain Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure (CHF) as ordered by the physician. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, asthma, chronic kidney disease, and acute on chronic diastolic heart failure, required daily weight monitoring to manage fluid retention. Despite a physician's order dated 9/5/24 for daily morning weights, the facility did not record weights on seven occasions between 9/5/24 and 9/25/24. This oversight was confirmed through a review of the resident's medical records and interviews with facility staff, including a Licensed Practical Nurse and a Charge Nurse, who acknowledged the importance of daily weights in monitoring the resident's condition. The deficiency was further corroborated by the Infection Preventionist/Registered Nurse and the Licensed Nursing Home Administrator, who confirmed the lack of daily weight records. The facility's job descriptions for Licensed Practical Nurses and Certified Nursing Assistants, as well as the Weight Assessment and Intervention policy, emphasize the importance of monitoring resident weight and notifying practitioners of significant changes. However, the facility failed to adhere to these protocols, resulting in missed weight recordings for the resident with CHF, which is critical for preventing fluid overload.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to properly store nebulizer equipment for a resident, leading to potential contamination. During an initial tour, a surveyor observed a nebulizer machine with an attached face mask and tubing lying directly on a resident's nightstand, exposed to air and contamination. The resident, who had a history of acute and chronic respiratory failure, asthma, and other conditions, confirmed receiving a nebulizer treatment that morning. The Licensed Practical Nurse (LPN) and Charge Nurse acknowledged that the nebulizer mask should have been stored in a plastic bag to prevent infection, as per facility policy. Additionally, the facility did not administer or accurately document the use of incentive spirometry for three residents as ordered by their physicians. One resident, who had a displaced fracture and an artificial hip, reported never receiving an incentive spirometer (IS) or being taught how to use one, despite medical records indicating otherwise. The Infection Preventionist/Registered Nurse (IP/RN) confirmed the absence of the IS and acknowledged that the nurses should not have signed off on its use. The Unit Manager/LPN also confirmed the resident's claim and stated that staff should have trained the resident on IS use. Similarly, two other residents with medical conditions requiring IS therapy reported not receiving the device or training. Despite this, their medical records showed that nurses had signed off on the use of IS multiple times a day. The IP/RN and Unit Manager/LPN confirmed the discrepancies, acknowledging that the residents were cognitively intact and would have known if they had received the IS. The Licensed Nursing Home Administrator (LNHA) expected staff to follow facility policies, which were not adhered to in these cases.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct yearly performance reviews for Certified Nursing Aides (CNAs), which is a requirement for staff improvement and education. This deficiency was identified during a survey when the surveyor requested performance evaluations for five selected CNAs. It was found that four out of the five CNAs did not have up-to-date performance evaluations. Specifically, CNA #1's last evaluation was in 2022, CNA #2's was in September 2021, and no evaluations were provided for CNA #3 and CNA #4. The facility was unable to provide documentation for the re-hiring of CNA #3 and CNA #4, which was claimed by the Licensed Nursing Home Administrator (LNHA). During the survey, the LNHA and the President of Operations confirmed that performance evaluations should be completed annually. Despite this acknowledgment, the facility did not provide any additional information or policies to support their compliance with this requirement. The lack of documentation and failure to conduct annual evaluations for CNAs #1, #2, #3, and #4 led to the identification of this deficiency.
Deficiencies in Narcotic Accountability and Medication Storage
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, accurately account for and document the administration of controlled medications, and store medications appropriately according to professional standards. During a review of the medication carts on two nursing units, it was found that the narcotic count logs were incomplete, with missing signatures from both incoming and outgoing nurses across multiple shifts. This lack of documentation was observed for both the day and night shifts, indicating a systemic issue in maintaining accurate records for controlled substances. Additionally, the surveyor identified discrepancies in the documentation of controlled medication administration. Specifically, doses of clonazepam and alprazolam for two residents were not signed out on the declining inventory sheets, although they were recorded as administered in the electronic Medication Administration Record. The LPNs acknowledged the missing documentation and confirmed that the narcotic counts should be conducted and signed by both incoming and outgoing nurses to ensure accuracy and accountability. Furthermore, the surveyor observed loose, unidentifiable pills in the medication cart, which is against the facility's policy for medication storage. The Director of Nursing and LPNs confirmed that there should be no loose pills in the medication carts and that it is the responsibility of the nursing staff to maintain a clean and organized medication storage area. The facility's policies on controlled substances and medication storage emphasize the importance of accurate documentation and proper storage practices to prevent loss or diversion of medications.
Failure to Obtain Weekly Weights and Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to obtain weekly weights for Resident #103 as ordered by the physician. The resident was admitted with several diagnoses, including a fracture of the left femur, osteoarthritis, muscle weakness, and anemia. The physician's order dated 5/21/24 required weekly weights every Tuesday, but the Medication Administration Records (MAR) for May and June 2024 showed blanks for 5/28/24 and 6/6/24. The facility's Infection Preventionist/Registered Nurse and Registered Dietitian confirmed that the weights were not obtained or documented as required, acknowledging the oversight. For Resident #301, the facility did not obtain a physician's order to hold a tube feeding, which was necessary due to a scheduled KUB X-ray. The resident, who had severe cognitive impairment, was observed with a feeding tube that was not connected, and the feeding pump was turned off. The Licensed Practical Nurse (LPN) confirmed that the tube feeding was not being administered and acknowledged the absence of a physician's order to hold the feeding. The LPN later contacted the Nurse Practitioner, who was aware of the situation and intended to issue an order to hold the feeding. The facility's policies and job descriptions require proper documentation and obtaining physician orders for changes in resident care, such as holding tube feedings. The Charge Nurse and Infection Preventionist/Registered Nurse acknowledged that a physician's order should have been obtained before holding the tube feeding. The lack of adherence to these protocols resulted in the deficiencies identified during the survey.
Failure to Conduct Timely Background Checks on New Hires
Penalty
Summary
The facility failed to implement its abuse prevention policy by not conducting criminal background checks on all newly hired employees before their employment commenced. This deficiency was identified during a survey when it was discovered that a Licensed Practical Nurse (LPN), referred to as Staff #4, was hired and began working without a completed background check. The background check for Staff #4 was only initiated seven weeks after their employment start date, which was contrary to the facility's policy that mandates background checks be completed prior to hiring. The surveyor's review of personnel files revealed that Staff #4 began working on December 7, 2023, but the background check was not completed until January 26, 2024. Despite the facility's policy to protect residents from abuse by ensuring thorough screening of potential employees, this lapse in procedure was confirmed by the Licensed Nursing Home Administrator (LNHA) and other facility officials. They acknowledged that Staff #4 did not have a background check prior to hire, although there were no allegations of abuse against this staff member, who no longer worked at the facility.
Failure to Investigate Pressure Ulcer
Penalty
Summary
The facility failed to initiate an investigation when a facility-acquired pressure ulcer was discovered on a resident's heel. The resident, who had a fully intact cognition, was admitted with several medical diagnoses, including a unilateral inguinal hernia. On a specific date, a physician's order was made for skin prep wipes and to float the resident's heels on a pillow due to a red and boggy right heel. However, the Treatment Administration Record indicated that a nurse signed off as having observed no skin breakdown, despite the presence of a pressure-related injury. The surveyor observed the resident in bed with their foot elevated on a pillow, and the resident reported heel pain. The Licensed Practical Nurse (LPN) administered Tylenol for the pain but did not assess the heel before doing so. Upon later assessment in the presence of the surveyor, the LPN noted non-blanchable erythema and swelling on the right heel, indicating the beginning of a pressure ulcer. The resident's feet were not properly offloaded from the pillow, which could contribute to pressure injury. The Unit Manager/LPN stated that the nurse should have reported the pressure injury to the Charge Nurse or Supervisor for an incident report to be completed. The facility's policies on abuse prevention, accidents and incidents, and pressure ulcer management were not followed, as the nurse did not document or report the pressure injury appropriately. An investigation was only initiated after the surveyor's inquiry, revealing a lack of awareness among nurses regarding proper wound staging.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who had diagnoses including cancer, infection following a procedure, and dementia, was observed with a fall mat beside their bed. Despite having a Brief Interview of Mental Status (BIMS) score indicating intact cognition, the resident experienced multiple falls within a short period. These incidents included sitting on the floor, kneeling at the foot of the bed, and being found on the floor near the closet. Although fall evaluations and pain assessments were conducted after each fall, the individualized comprehensive care plan (ICCP) was not updated with specific interventions following each incident. Interviews with facility staff revealed a lack of clarity regarding the responsibility for revising the ICCP. The Charge Nurse indicated that the ICCP should be updated after each fall, but the Infection Preventionist/Registered Nurse and the MDS Coordinator provided conflicting information about who was responsible for these revisions. The facility's policy on comprehensive person-centered care plans did not include guidelines for care plan revisions, contributing to the oversight. Ultimately, it was acknowledged that the ICCP was only revised after the first two falls, leaving the third and fourth falls unaddressed in the care plan.
Failure to Document Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that catheter care was performed and documented every shift as per the physician's order for a resident with an indwelling urinary catheter. The resident, who had medical diagnoses including acute kidney failure and obstructive uropathy, was observed by the surveyor without a visible urinary catheter during the initial tour. However, later observations confirmed the presence of a urinary drainage bag. The resident's medical record indicated a physician's order for catheter care every shift, but the Treatment Administration Record (TAR) showed that catheter care was not documented as rendered eleven times from the beginning of the month through the 23rd. The facility's policies on charting and urinary catheter care required documentation of all services provided to residents. Despite this, the surveyor found missing documentation for catheter care in the TAR, which was acknowledged by the Licensed Nursing Home Administrator and the President of Operations. They stated that if the care was not documented, it was considered not done. This deficiency was identified during a review of the resident's comprehensive care plan and the facility's policies, highlighting a lapse in adherence to the physician's orders and facility protocols.
Deficient Hemodialysis Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident receiving hemodialysis. The resident, who had end-stage renal disease and required dialysis three times a week, was not assessed according to professional standards. The facility's policy required regular monitoring of dialysis treatment sites for complications, including pre and post-dialysis assessments. However, the facility did not complete the necessary dialysis communication forms upon the resident's return from treatment on multiple occasions. Additionally, there were no physician orders related to checking the dialysis access site for a bruit or thrill, which are essential assessments to ensure the functioning of the arteriovenous graft. The surveyor's review revealed that the resident's blood pressure was incorrectly taken from the arm with the dialysis access site 18 times out of 50, despite the known risk of clotting. The Charge Nurse and Registered Nurse acknowledged the oversight, confirming that the dialysis communication forms were not completed and that blood pressures were mistakenly documented from the left arm. The Infection Preventionist and the Licensed Nursing Home Administrator confirmed these deficiencies, noting that staff sometimes rushed, leading to these errors.
Failure to Adhere to PPE Protocols for COVID-19 Isolation
Penalty
Summary
The facility failed to ensure that staff adhered to the infection prevention and control program by not donning personal protective equipment (PPE) before entering the rooms of residents with suspected or confirmed COVID-19. This deficiency was observed during a survey where a per diem Nurse Practitioner (NP) entered the room of two residents who were on isolation for COVID-19 without performing hand hygiene or wearing the required PPE. The NP only wore an N95 face mask and did not use goggles or a face shield, as required by the facility's policy for droplet precautions. The incident involved two residents, one of whom had a medical history that included a diagnosis of COVID-19, and the other had moderate cognitive impairment. The NP assumed the residents were off isolation because the droplet precaution signage was not visible, which led to the oversight. The interim Administrator confirmed that staff should perform hand hygiene and don the appropriate PPE when entering the room of a resident on transmission-based precautions.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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