Careone At The Highlands
Inspection history, citations, penalties and survey trends for this long-term care facility in Edison, New Jersey.
- Location
- 1350 Inman Avenue, Edison, New Jersey 08820
- CMS Provider Number
- 315132
- Inspections on file
- 19
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Careone At The Highlands during CMS and state inspections, most recent first.
A resident with an unstageable pressure ulcer received wound care from an RN who failed to follow infection control protocols, including not cleaning the overbed table, not changing gloves between tasks, and not performing hand hygiene after the procedure. Unused supplies were returned to the treatment cart without sanitization, and the RN acknowledged these breaches when interviewed by surveyors.
A resident with COPD did not receive multiple doses of prescribed Breo Ellipta inhaler and Triamcinolone cream because the medications were not available, and there was insufficient documentation that the pharmacy or physician was contacted as required. An LPN noted intentions to follow up, but could not provide evidence of communication, and the DON confirmed that backup inhalers and steroid creams were not stocked. The facility's policy required timely administration and documentation, which was not met in this case.
A resident with severe cognitive and mobility impairments was found unresponsive on the floor after a fire alarm, and the facility failed to conduct a thorough investigation as required by policy. Only one witness statement was collected despite multiple staff being present, and other staff were not interviewed about the incident. The DON and administrator determined the fall was cardiac in origin, but the required comprehensive investigation, including gathering all witness accounts, was not completed.
A resident with multiple health conditions, including severe malnutrition and impaired cognition, was not weighed weekly as ordered by a physician and as required by facility policy. Only the admission weight was documented, with no further weights recorded during the required period. Staff interviews and record reviews confirmed the absence of weekly weight documentation.
The facility failed to report injuries of unknown origin for two residents with severe cognitive impairment to the NJDOH, as required by their policy. One resident had multiple skin tears, and another had an unexplained injury in the perineal area. Despite documentation by nursing staff, there was no evidence of reporting to the authorities.
The facility failed to revise care plans for two residents after incidents indicating changes in their conditions. One resident experienced multiple skin tears, and another had a skin opening in the perineal area. Despite these incidents being documented, care plans were not updated to include new interventions. Staff acknowledged the oversight, contrary to facility policy requiring care plan updates after significant condition changes.
The facility failed to maintain dignity during mealtime for two residents needing assistance with eating. One CNA was observed standing while feeding a resident and using her cellphone, while another CNA was seen sitting on a resident's bed and using a facility tablet instead of interacting with the resident. Both residents had severe cognitive impairments and required assistance with meals.
The facility failed to maintain the confidentiality of resident information when a paper with resident photos, names, room numbers, and vital signs was left on top of a medication cart, accessible to anyone passing by. The RN assigned to the cart incorrectly believed there were no HIPAA violations, but the facility's administration later agreed that private medical information was improperly exposed.
The facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment for a resident within the mandated timeframe. The MDS Coordinator acknowledged the oversight, and the facility's administration was informed of the issue.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their medical records. One resident was incorrectly coded as discharged to a hospital instead of home, and another resident's fall was inaccurately documented as having a major injury. These errors were confirmed by the MDS Coordinator and discussed with the facility's administration.
The facility failed to accurately document and clarify the administration of medication for three residents, leading to deficiencies in care. Conflicting orders for hand splints, unavailability of prescribed Lidocaine patches and Miconazole powder, and incorrect dosage of Sertraline were observed.
A resident with multiple diagnoses was observed receiving oxygen at 4 LPM instead of the prescribed 2 LPM. The LPN confirmed the incorrect setting but could not explain the deviation from the physician's order. The facility's policy on oxygen administration was not followed.
The facility failed to ensure that the primary physician signed and dated monthly physician orders for four residents, resulting in orders being 70 days overdue. This was confirmed through interviews and record reviews.
The facility failed to ensure that the responsible physician conducted face-to-face visits and wrote progress notes at least once every sixty days for a resident with multiple diagnoses, including End Stage Renal Disease and Major Depressive Disorder. All visits were conducted by an APN, with no documented evidence of the physician's visits.
The facility failed to remove expired and discontinued medications from active inventory, as evidenced by the presence of outdated drugs in medication carts and improper storage conditions. Staff were unable to explain the discrepancies, and the facility's policy on medication removal was not consistently followed.
A CP failed to clarify the medication dosage for a newly admitted resident, who reported receiving an incorrect dose of sertraline for anxiety. The resident had been receiving 75 mg prior to admission but was given only 50 mg daily since admission. The CP did not receive the hospital discharge medication list and only reviewed the medications entered in the electronic medical record, leading to the discrepancy.
The facility failed to maintain proper kitchen sanitation practices and discard potentially hazardous foods. An opened bottle of expired molasses was found, and dietary aides were observed with improper hair restraints and jewelry, violating facility policies. The Culinary Director and other officials acknowledged these deficiencies.
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through multiple periods where the facility did not meet the minimum staffing requirements for CNAs on both day and evening shifts. Specific instances included days with significantly fewer CNAs than required, such as only 1 CNA for 97 residents on certain shifts. The issue was discussed with the facility's administration, who did not provide further information.
The facility failed to maintain complete and accessible medical records for a resident. The resident's primary physician's progress notes were not documented in the hybrid medical records, and the physician was out of the country, making the notes inaccessible. The facility's policy requires that physician progress notes be maintained and documented upon each visit.
A CNA was observed holding a soiled bag while assisting a resident with their meal, touching the resident's meal tray and utensils. The CNA then placed the bag on a bedside table, sanitized her hands, and discarded the bag. The Administrator and Clinical Lead RN acknowledged the infection control breach.
Infection Control Breach During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain proper infection control standards during wound care treatment for a resident with an unstageable pressure ulcer. The RN gathered wound care supplies and placed them directly on the overbed table without cleaning the surface or using a clean barrier. During the dressing change, the RN removed the soiled dressing and, without changing gloves, proceeded to cleanse the wound, apply ointment, and pack the wound, all with the same contaminated gloves. The RN also used the same gloves to handle a pen from her pocket to date the dressing and did not sanitize the overbed table after completing the procedure. The resident involved had multiple diagnoses, including cognitive communication deficit, peripheral vascular disease, depression, and anxiety disorders, and was admitted with a severe, unstageable pressure ulcer on the sacrum. The resident was on Enhanced Barrier Precautions, as indicated by signage on the door. The RN's actions during the wound care procedure did not align with the facility's policy, which requires cleaning the bedside stand, establishing a clean field, performing hand hygiene at multiple steps, and using clean technique throughout the dressing change. After completing the wound care, the RN removed her gloves but did not perform hand hygiene before leaving the resident's room. Unused supplies that had been brought into the resident's room were returned to the treatment cart without being sanitized. The RN acknowledged these breaches in infection control when interviewed, and the Director of Nursing confirmed the observed deficiencies.
Failure to Provide Timely Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that two prescribed medications, Breo Ellipta Aerosol and Triamcinolone topical cream, were obtained and administered in a timely manner for one resident. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD), had physician's orders for both medications, but multiple doses were not administered over several days. The electronic medication administration record (EMAR) showed that the medications were repeatedly marked as not available, with documentation indicating follow-up with the pharmacy, but there was no evidence that the pharmacy or physician was consistently contacted as required. Progress notes documented by an LPN indicated intentions to follow up with the pharmacy when the medications were unavailable, but there was a lack of documentation confirming that the pharmacy or physician was actually contacted. The LPN stated during interview that she would call the pharmacy and physician if medications were out of stock for more than three days, but could not provide evidence of these communications in the progress notes. Additionally, the LPN acknowledged that there were no backup medications available in the facility for inhalers or steroid creams, and that they had to wait for the pharmacy to deliver the medications. The Director of Nursing (DON) confirmed that while some backup medications were available in the facility, there were no backup inhalers or steroid creams. The DON stated that nurses should call the physician for follow-up orders or alternative medications when a medication is not available, and that all such actions should be documented in the progress notes. Upon review, the DON acknowledged that there was insufficient documentation of pharmacy and physician notification, and that continued documentation of medication unavailability without further action was not appropriate. The facility's policy required medications to be administered in a safe and timely manner as prescribed.
Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to follow its Accidents and Incidents - Investigating and Reporting policy by not conducting a thorough investigation after a resident was found on the floor following a fire alarm. The resident, who had severe cognitive impairment, significant mobility limitations, and multiple medical diagnoses including atrial flutter and diabetes, was found unresponsive with low blood oxygen and blood pressure, requiring emergency transport. Documentation showed that the fall was unwitnessed, and only one witness statement was collected, despite several staff being present on the unit at the time of the incident. Interviews with other staff members who were on duty revealed that they were not interviewed or asked to provide statements regarding the incident. The facility was unable to provide additional witness statements or documentation about the circumstances of the fall. The Director of Nursing and the Administrator determined the fall was cardiac in origin after reviewing hospital records, but the facility did not complete a comprehensive investigation as required by policy, which mandates prompt initiation and documentation of investigations, including collecting witness accounts and other pertinent data.
Failure to Document and Perform Weekly Weights for At-Risk Resident
Penalty
Summary
The facility failed to follow its policy on Weight Assessment and Intervention and did not adhere to physician orders for weekly weights for one resident. The resident in question was admitted with multiple diagnoses, including anemia, Type 2 diabetes, severe protein-calorie malnutrition, muscle weakness, dysphagia, and cognitive communication deficit. The resident's Minimum Data Set indicated severely impaired cognition and a therapeutic diet, with a care plan identifying risk for malnutrition and an intervention to be weighed as ordered. Physician orders specified weekly weights for four weeks, but documentation showed only an initial weight recorded on admission, with no further weights documented during the required periods. Interviews with facility staff, including a CNA, DON, and RD, confirmed that the only documented weight for the resident was on admission, and no evidence was provided to show that weekly weights were obtained as ordered. The facility's own policy required weights to be recorded upon admission and at intervals established by the interdisciplinary team or as ordered, with documentation in the medical record. The lack of documented weekly weights was confirmed through review of the electronic medical record, weight summary, and weekly weight sheets, as well as by staff interviews.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents to the New Jersey Department of Health, as required by their policy on Abuse, Neglect, Exploitation, or Misappropriation. Resident #2, who had severe cognitive impairment due to dementia, was found with multiple skin tears on different occasions. These incidents were documented by various nursing staff, but the facility could not provide evidence that these injuries were reported to the NJDOH. The facility's policy mandates immediate reporting of such injuries to the administrator and relevant authorities, but this was not adhered to. Similarly, Resident #4, who also had severe cognitive impairment and was dependent on assistance for all activities of daily living, was found with an unexplained injury in the perineal area. This incident was documented by an LPN, but again, there was no evidence that it was reported to the NJDOH. The facility's policy clearly states that all injuries of unknown origin must be reported immediately to the appropriate authorities, but this procedure was not followed in these cases.
Failure to Revise Care Plans After Incidents
Penalty
Summary
The facility failed to ensure that the care plans (CP) for two residents were revised following incidents that indicated a change in their condition. Resident #2, who was admitted with diagnoses including dementia and muscle weakness, experienced multiple skin tears over several months. Despite these incidents being documented in incident reports (IR), the CP was not updated to include new interventions to prevent recurrence. The Registered Nurse (RN) responsible acknowledged that the CP should have been revised at the time of the incidents but admitted it was an oversight. Similarly, Resident #4, who had severe cognitive impairment and required assistance with activities of daily living, experienced a skin opening in the perineal area. This incident was reported, but the CP was not updated to reflect this change in condition. The Unit Manager and Director of Nursing both stated that the CP should be updated immediately following such incidents, but they could not explain why it was not done in this case. The facility's policy requires CPs to be revised when there is a significant change in a resident's condition, which was not adhered to in these instances.
Failure to Maintain Dignity During Mealtime
Penalty
Summary
The facility failed to maintain dignity during mealtime for two residents who needed assistance with eating. For Resident #27, a CNA was observed standing while feeding the resident a supplement and simultaneously holding her personal cellphone. The CNA admitted to standing because she was assisting another resident in the same room. Resident #27 had severe cognitive impairment and required assistance with meals. The facility's policy mandates that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, which includes not standing over them while assisting with meals. The facility's Administrator and Clinical Lead RN acknowledged that the CNA should have been seated and attentive while feeding the resident. For Resident #72, a CNA was observed sitting at the end of the resident's bed, looking at an electronic device instead of interacting with the resident during mealtime. The ADON confirmed that the device was a facility tablet used for documentation. The CNA admitted to completing documentation while supervising the resident's meal, which was against the facility's policy. Resident #72 had severe cognitive impairment and required set-up or clean-up assistance for meals. The ADON and VPSCP acknowledged that the CNA should not have been sitting on the resident's bed or using the tablet at that time and should have been interacting with the resident.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of resident information on the Electronic Health Records system. This deficiency was observed when a surveyor noticed a paper with resident photos, names, room numbers, and vital signs placed on top of a medication cart. The paper was accessible to anyone passing by, including family members, which compromised the privacy of the residents' medical information. The Registered Nurse (RN) assigned to the medication cart confirmed that the paper was a roster used to document important information about the residents. Despite being informed by the surveyor that the paper contained private medical information, the RN incorrectly believed that there were no HIPAA violations. The facility's Licensed Nursing Home Administrator and the President of Special Clinical Projects later agreed that the nurse had revealed private medical information that should have been covered from view.
Failure to Complete and Transmit MDS - Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines for one resident. The deficiency was identified during a review of the facility's assessment tasks and the resident's electronic medical record. The resident was discharged to the community, but the required Discharge Assessment MDS was not completed or transmitted within the mandated timeframe. The MDS Coordinator acknowledged that the Discharge MDS for the resident was missed. The surveyor reviewed the resident's MDS 3.0 Assessment History and found no Discharge Assessment MDS for the discharge date. According to the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual, a Discharge Assessment must be completed and transmitted within specific timeframes. The facility's Licensed Nursing Home Administrator and the President of Clinical Special Project were informed of the concern, but no further information was provided.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For Resident #105, the discharge MDS was incorrectly coded as a discharge to a short-term general hospital, while the patient was actually discharged home. This error was confirmed by the MDS Coordinator upon review. The resident had diagnoses including Chronic Kidney Disease, Hematuria, Anemia, and Muscle Weakness, and the error was identified during a review of the patient's discharge summary and instructions form dated 11/3/23. The issue was brought to the attention of the facility's President of Special Clinical Projects and Licensed Nursing Home Administrator, who acknowledged the need for accurate MDS coding but provided no further information at the time of the surveyor's inquiry. For Resident #47, the MDS was inaccurately coded to reflect a fall with a major injury, which did not occur. The resident, who had diagnoses including Metabolic Encephalopathy, Urinary Tract Infection, Severe Protein-Calorie Malnutrition, and Dysphagia, was observed in the day room and had a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The MDS Coordinator admitted that the section documenting falls was coded in error, as the resident only experienced one fall with no injury. This discrepancy was also discussed with the facility's LNHA and VPSCP, who did not provide additional information to the surveyor.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately document and clarify the administration of medication for three residents, leading to deficiencies in care. Resident #39 had conflicting physician orders for the application of hand splints, with one order stating the splints should be applied from 12:00 PM to 4:00 PM and another from 4:00 PM to 10:00 PM. Despite the conflicting orders, the splints were observed on the resident outside of these times, and the facility staff could not explain the discrepancy. Resident #43 reported that a Lidocaine 5% Patch, prescribed for daily application, was not available and had not been applied as documented. The surveyor confirmed with the pharmacy that the patch had never been sent, yet the facility's records falsely indicated it had been applied. Additionally, Resident #43's Miconazole Antifungal Powder, also prescribed for daily use, was not available until a specific date, despite documentation showing it had been applied daily. Resident #21, who was prescribed Sertraline for anxiety, reported receiving a lower dosage than prescribed prior to admission. The facility's records did not reflect any change in dosage, and attempts to contact the responsible physician and nurse were unsuccessful. The facility's policies on medication management were not followed, leading to the resident receiving an incorrect dosage of medication.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders related to the use of continuous oxygen therapy for a resident. The resident, who had diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Chronic Systolic Heart Failure, was observed receiving oxygen at 4 Liters per minute (LPM) instead of the prescribed 2 LPM. This discrepancy was noted during two separate observations by the surveyor on the same day. The resident's care plan and physician's orders clearly indicated that oxygen should be administered at 2 LPM, but this was not adhered to by the facility staff. When the surveyor brought this to the attention of the Licensed Practical Nurse (LPN) caring for the resident, the LPN confirmed the incorrect oxygen setting but could not provide an explanation for the deviation from the physician's order. The facility's policy on oxygen administration, which requires verification of physician orders and proper documentation of oxygen settings, was not followed. The Director of Nursing (DON) and the President of Special Clinical Project were informed of the issue, and it was acknowledged that oxygen should be administered according to physician orders.
Failure to Ensure Monthly Physician Order Reviews
Penalty
Summary
The facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was current and accurate. This deficiency was observed for four residents. Resident #76, who had diagnoses including End Stage Renal Disease and Major Depressive Disorder, had physician orders that were 70 days overdue for review. Similarly, Resident #51, with diagnoses such as Heart Failure and Alzheimer's Disease, also had physician orders 70 days overdue. Resident #47, with diagnoses including Metabolic Encephalopathy and Dysphagia, and Resident #27, with diagnoses such as Fracture of the right clavicle and Dementia, both had physician orders overdue by the same duration. The surveyor's review of the residents' electronic medical charts revealed that the primary physician had not signed the Order Summary Reports for these residents. Interviews with the Nurse Practitioner and the facility's Regional Registered Nurse confirmed that the physician orders must be reviewed and signed electronically every month, which had not been done. The facility's Licensed Nursing Home Administrator and the President of Special Clinical Projects acknowledged the deficiency but provided no further information.
Failure to Ensure Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for one resident, who was admitted with diagnoses including End Stage Renal Disease, Major Depressive Disorder, Cognitive Communication Deficit, and Muscle Weakness. The resident had a Brief Interview for Mental Status score indicating moderately impaired cognition. The review of the physician's progress notes revealed that all visits were conducted by an Advanced Practice Nurse (APN) and not by the physician, with no documented evidence of the physician visiting and examining the resident at least every 60 days. During an interview, the APN confirmed that the physician orders must be reviewed and signed electronically every month but admitted that she had not reviewed and signed the resident's physician orders. The Licensed Nursing Home Administrator and the President of Special Clinical Projects acknowledged that the physician failed to conduct a face-to-face visit at least every 60 days, as required.
Failure to Remove Expired and Discontinued Medications
Penalty
Summary
The facility failed to ensure that expired and discontinued medications were removed from active inventory in accordance with professional standards of clinical practice. During an inspection, the surveyor found that the [NAME] Unit Nursing Station lacked an Emergency Kit, and the staff could not explain its absence. Additionally, the surveyor discovered an opened Humalog Kwik pen that should have been discarded after 28 days and a Mucomyst solution that should have been discarded after 96 hours, both of which were still in use past their recommended disposal times. The refrigerator storing these medications was also found to be at an incorrect temperature of 28 degrees Fahrenheit, instead of the required 36 to 46 degrees Fahrenheit range. The surveyor observed an LPN removing discontinued medications from a medication cart, which included medications for multiple residents who had either been discharged or moved to different rooms. These medications were not removed from the cart in a timely manner, leading to the accumulation of expired and discontinued drugs. Specific examples included medications for residents who had been discharged as far back as several months prior, yet their medications were still present in the cart. Further inspection revealed expired medications in the medication carts, including bottles of Aspirin Enteric Coated 81 mg with expiration dates that had either passed or been obscured. The facility's monthly Consultant Pharmacist Unit Inspection Reports indicated that expired medications were a recurring issue. Despite the facility's policy requiring the removal of expired and discontinued medications, these practices were not consistently followed, as evidenced by the surveyor's findings and the inability of staff to provide explanations for the discrepancies.
Consultant Pharmacist Fails to Clarify Medication Dosage for New Admission
Penalty
Summary
The Consultant Pharmacist (CP) failed to clarify the medication dosage for a newly admitted resident, Resident #21, during the initial medication review. Resident #21, who was admitted with diagnoses including sepsis, anxiety, and muscle weakness, reported receiving an incorrect dose of sertraline (Zoloft) for their anxiety. The resident had been receiving 75 mg of sertraline prior to admission but was given only 50 mg daily since admission. Despite reporting this discrepancy to a staff member, no corrective action was taken, and the issue remained unresolved for about a week before the surveyor's interview with the resident. The surveyor's review of Resident #21's medical records confirmed the discrepancy. The hospital records indicated that the resident was receiving 75 mg of sertraline, while the facility's physician orders documented a 50 mg dose. The CP's initial medication review noted that the hospital discharge medication list was not available at the time of review, and the CP only reviewed the medications entered in the electronic medical record. The CP admitted to not questioning the 50 mg order observed in December 2023, as the hospital discharge medication list was not provided. Interviews with the CP and the facility's President of Special Clinical Projects (VPSCP) revealed that the process for reviewing new admissions' medication regimens was not followed correctly. The CP stated that a remote pharmacist would review the hospital discharge medication list if the CP could not visit within 48 hours of admission. However, the CP did not receive the necessary hospital discharge medication list for Resident #21. The VPSCP acknowledged the error and stated that the medication regimen should have been reviewed with the resident and physician, and the hospital medication list should have been faxed to the CP group. The facility could not explain why the CP did not receive the discharge medication record.
Failure to Maintain Kitchen Sanitation and Discard Expired Foods
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and discard potentially hazardous foods in a manner to prevent foodborne illness. During a kitchen tour, the surveyor observed an opened one-gallon bottle of molasses with an expired use-by date on a storage shelf below Chef Preparation Table #3. Additionally, dietary aide #1 was observed with hair not fully restrained under their hairnet, and dietary aide #2 was wearing large, hooped earrings, both of which are against the facility's policies. The Culinary Director (CD) confirmed that the molasses should have been discarded and that dietary staff should have their hair fully restrained and not wear large, hooped earrings. The facility's policies, including the Food and Nutrition Services Department Employee Uniform Policy and the Food Receiving and Storage policy, were reviewed and found to be in violation. The policies clearly state that jewelry should be kept to a minimum and that foods should be labeled, dated, and monitored to ensure they are used by their use-by date or discarded. The Licensed Nursing Home Administrator (LNHA) and the President of Special Clinical Projects (VPSCP) acknowledged the deficiencies and confirmed that the observed practices were not in compliance with the facility's policies.
Failure to Maintain Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports for four distinct periods. During these periods, the facility consistently did not meet the minimum staffing requirements for Certified Nursing Assistants (CNAs) on both day and evening shifts. For example, during the two-week period beginning 09/12/2021 and ending 09/25/2021, the facility was not in compliance for 8 of 14 day shifts and 2 of 14 evening shifts. Similar deficiencies were noted in the periods from 12/19/2021 to 01/01/2022, 5/14/2023 to 5/27/2023, and 12/17/2023 to 12/30/2023, with multiple shifts falling short of the required CNA staffing levels. The specific instances of non-compliance included days where the number of CNAs was significantly below the required minimum. For example, on 12/27/2021, there was only 1 CNA for 97 residents on the day shift, whereas at least 12 CNAs were required. Similarly, on 12/26/2021, there were only 3 CNAs for 97 residents on the day shift. These staffing shortages were observed across multiple shifts and dates, indicating a pattern of insufficient staffing that could potentially impact the quality of care provided to the residents. The surveyor discussed the lack of required staff with the Registered Nurse VP Special Clinical Projects and Acting Licensed Nursing Home Administrator, who did not provide any further information. The facility's failure to meet the mandated staffing ratios was documented as a violation of NJAC 8:39-5.1(a) and NJAC 8:39-27.1(a), highlighting a significant deficiency in the facility's ability to provide adequate care to its residents as per state regulations.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for one of the residents reviewed. During an observation, the resident was found to be awake, alert, and verbally responsive. However, a review of the resident's hybrid medical records revealed that there were no physician progress notes documented by the resident's primary physician. The Regional Clinical Nurse confirmed that the physician was out of the country and the notes were in the physician's office, making them inaccessible to the facility. The facility's policy requires that physician progress notes be maintained for each resident and that the attending physician must write, sign, and date the notes upon each visit. The Regional Clinical Nurse and the Licensed Nursing Home Administrator acknowledged that the physician's documentation should be stored in the resident's hybrid medical record, but no additional documentation was provided. This failure to maintain complete and accessible medical records was identified as a deficiency by the surveyor.
Infection Control Breach During Dining Observation
Penalty
Summary
The facility failed to maintain proper infection control practices during a dining observation. A Certified Nursing Assistant (CNA) was observed holding a clear plastic bag containing a dirty bib while assisting a resident with their meal. The CNA touched the resident's meal tray and utensils while holding the soiled bag. After placing the bag on a bedside table in the hallway, the CNA sanitized her hands and then discarded the bag in the dirty utility room. The Administrator and the Clinical Lead RN acknowledged the CNA's failure to adhere to infection control practices when informed of the incident.
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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