Careone At Wellington
Inspection history, citations, penalties and survey trends for this long-term care facility in Hackensack, New Jersey.
- Location
- 301 Union Street, Hackensack, New Jersey 07601
- CMS Provider Number
- 315152
- Inspections on file
- 19
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Careone At Wellington during CMS and state inspections, most recent first.
A cognitively impaired resident with a known history of elopement was allowed to leave their unit unescorted after an LPN deactivated the elevator's wander guard system. Upon reaching the lobby, the resident exited the facility through a rear door after a receptionist disengaged the wander guard alarm, enabling the resident to leave unsupervised. The absence was not discovered until hours later during rounds, and the resident was eventually found in a nearby town and returned to the facility.
The facility failed to maintain proper sanitation and labeling practices in the kitchen and nutrition refrigerators. Observations included soiled and wet pans, an unlabeled oatmeal cup, and unlabeled food items in refrigerators. The CSD and nursing staff acknowledged these issues, which were not in compliance with facility policies.
The facility exhibited deficiencies in infection control practices, including improper use of PPE and inadequate hand hygiene. An LPN entered a COVID-19 positive resident's room without full PPE, and housekeeping staff failed to remove PPE inside rooms. A Unit Secretary wore her mask improperly, and CNAs did not perform hand hygiene during meal service. These actions occurred despite prior staff education on proper procedures.
The facility failed to properly document the receipt and administration of controlled substances, as evidenced by incomplete DEA 222 Forms and discrepancies in Controlled Drug Administration Records (CDAR). An LPN admitted to not signing the CDAR immediately after administering medication, and the facility's policies lacked guidance on DEA 222 forms and CDAR documentation.
The facility failed to maintain a medication error rate below 5%, with a surveyor observing three errors out of twenty-six opportunities. Errors included administering Docusate Sodium in tablet form instead of capsules and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened. The nurse did not follow medication orders or cautionary instructions, and the DON confirmed that medications should be administered as ordered.
The facility failed to properly store medications on two medication carts, as observed by a surveyor. On Cart 2, a foil package of budesonide inhalant suspension and a foil package of DuoNeb were found without dates indicating when they were opened. Similarly, on Cart 1, a DuoNeb solution was also undated. Both the UM/LPN and the LPN confirmed that these medications should have been dated. The facility's policy did not include information on dating opened nebulizer solutions, leading to the deficiency.
The facility failed to maintain resident dignity during a meal service, as CNAs left trays and garbage on tables and one CNA stood while feeding a resident, which was acknowledged as inappropriate.
A facility failed to accurately document and review a resident's advance directives, as the EMR did not reflect the DNH status indicated on the resident's POLST form. Despite the resident's severe cognitive impairment and multiple diagnoses, there was no care plan related to advance directives, and staff interviews revealed lapses in the process for updating and ensuring the accuracy of these directives.
A facility failed to accurately code the MDS for two residents, resulting in incorrect gender identification. One male resident was coded as female, and one female resident was coded as male, contrary to their Admission Records. The RN MDS coordinator acknowledged the errors, which were identified during a surveyor's review.
A facility failed to follow infection control standards for a resident's respiratory care. The nasal cannula tubing was not changed as per policy and was found on the floor instead of being stored in a plastic bag. The resident, with a history of congestive heart failure and other conditions, was receiving oxygen therapy. Staff acknowledged the lapses in protocol, which were confirmed by the DON.
A resident was administered Tamsulosin, a medication not approved for use in women, without proper documentation or justification. Despite the resident's cognitive intactness and the presence of a urinary catheter, the facility failed to provide a rationale for the off-label use of the medication, leading to a deficiency in medication management practices.
A resident returned from hemodialysis with syringes still attached to their catheter, which should have been removed at the clinic. The oversight was discovered by the resident's family, and the facility failed to conduct a proper post-treatment assessment. Documentation and communication lapses were identified, as the dialysis communication report was not consistently returned, and the nurse did not thoroughly check the catheter site.
A resident was inadvertently given Dakin's solution, a wound cleanser, instead of water to take with oral medication after an RN prepared the solution in a drinking cup and mistakenly handed it to the resident. The resident experienced a burning sensation upon ingestion and reported it immediately. The incident occurred due to failure to follow facility procedures for wound care preparation and medication administration, as confirmed by staff interviews and policy review.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with a history of elopement and a severely impaired BIMS score was identified as being at risk for wandering and elopement. The resident's care plan included interventions requiring staff to accompany them to meals and scheduled activities. Despite these interventions, the resident was allowed to leave the unit unescorted in their wheelchair after an LPN deactivated the elevator's wander guard system, permitting the resident to travel alone to the lobby. Upon arrival in the lobby, the resident approached the rear exit door, which was equipped with a wander guard alarm. The receptionist at the desk disengaged the alarm, allowing the resident to exit the facility through the rear door. Video footage confirmed that the resident left the building unaccompanied and was last seen on camera propelling their wheelchair through the parking lot and out of view. Staff did not notice the resident's absence until a dinner tray was found untouched during rounds several hours later. The facility's failure to provide adequate supervision and to follow the care plan interventions for a resident at high risk for elopement resulted in the resident leaving the premises unsupervised. The resident was not located until several hours later, when they were found in a nearby town and returned to the facility. The incident occurred despite the wander guard system being operational and no equipment malfunctions being reported.
Sanitation and Labeling Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain proper sanitation practices in the kitchen and nutrition refrigerators, leading to potential foodborne illness risks. During a kitchen tour, the surveyor observed that some half sheet pans were soiled with white debris and others were wet when they should have been dry before stacking. Additionally, an undated and unlabeled paper cup containing oatmeal was found on a countertop, which the Culinary Service Director (CSD) acknowledged should not have been there and removed it. In the nutrition refrigerators on the second and third floors, several items were found unlabeled, including tubs of sea salt caramel ice cream, a jar with an unknown food item wrapped in foil, and a carton of eggnog. The Registered Nurse Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) acknowledged that these items should have been labeled with the resident's name and date. The CSD confirmed that these were not facility-stocked items and stated that they would follow up to identify the owners or dispose of the items if necessary. The facility's policies on sanitization and food brought by family/visitors were reviewed, revealing that equipment and utensils should be cleaned and sanitized, and food items should be labeled and stored properly. However, the policies did not address specific drying protocols for dishware and cookware. The Licensed Nursing Home Administrator (LNHA) acknowledged the expectation for personal food items to be labeled and stored correctly, indicating a team effort was needed to ensure compliance with these standards.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to appropriate infection control practices, particularly in the use of Personal Protective Equipment (PPE) and hand hygiene. An LPN entered the room of a COVID-19 positive resident without wearing the required PPE, which included an N-95 respirator mask, gown, and gloves. Despite being aware of the facility's policy, the LPN only wore a surgical mask and gloves, failing to don a gown. Additionally, housekeeping staff were observed exiting rooms of residents on Transmission-Based Precautions (TBP) without removing their PPE, which included gowns and gloves, inside the room as required. Further observations revealed that a Unit Secretary was wearing her surgical mask improperly below her nose and mouth while in the hallway. This was attributed to her not being re-inserviced after returning from vacation. Similarly, during a meal service, four Certified Nursing Assistants (CNAs) did not perform hand hygiene before distributing lunch trays or assisting residents with meal setup, which is a critical step in preventing the spread of infection. The report also highlighted multiple instances where housekeeping staff did not follow proper PPE doffing procedures, such as removing soiled PPE in the hallway instead of inside the resident's room. These actions were observed despite the staff having been previously educated on the correct procedures. The Infection Preventionist and Director of Housekeeping confirmed that staff had been in-serviced on these protocols, yet compliance was not consistently observed during the surveyor's visit.
Deficient Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the documentation and handling of controlled substances. The deficiency was identified through a review of DEA 222 Forms and Controlled Drug Administration Records (CDAR). The DEA 222 Form used to order controlled substances was not properly filled out, as the section for recording the number received and the date received was left blank. This form was associated with an order for Schedule II controlled substances, including oxycodone tablets, intended for emergency backup supply. Additionally, discrepancies were found in the CDAR forms for two controlled substances on a medication cart, where the documented available doses did not match the physical quantity present. During the survey, a Licensed Practical Nurse (LPN) admitted to not signing the CDAR immediately after administering medication, citing being in a rush as the reason. The facility's Director of Nursing (DON) confirmed that the staff should document on the CDAR when the medication is removed from the packaging. The surveyor also noted that the facility's policies on medication labeling and storage, as well as administering medications, did not include pertinent information regarding DEA 222 forms or CDAR documentation. This lack of proper documentation and adherence to procedures led to the identified deficiencies.
Medication Administration Errors Exceeding 5% Error Rate
Penalty
Summary
The facility failed to ensure that medications were administered with an error rate of less than 5%, resulting in a medication error rate of 15.38% during an observation. The surveyor observed three nurses administering medications to six residents, with three errors occurring out of twenty-six opportunities. The errors involved two residents, one of whom was unsampled, and were administered by one nurse. The errors included administering Docusate Sodium in tablet form instead of the prescribed capsule form and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened, for a resident with difficulty swallowing. The surveyor noted that the nurse did not adhere to the medication orders and failed to follow cautionary instructions, such as separating Phenytoin from calcium by at least two hours. Additionally, the nurse left a vial of Budesonide on top of a medication cart while searching for other medications, indicating a lack of proper medication management. The Director of Nursing confirmed that medications should be administered as ordered and that staff should follow medication cautions or warnings, contacting the physician or pharmacy if there are any issues or questions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications on two of the three medication carts inspected, as observed by the surveyor. During the inspection of Cart 2 on the 2nd floor, the surveyor, accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN), found a foil package of budesonide inhalant suspension and a foil package of albuterol/ipratropium inhalant solution (DuoNeb) without dates indicating when they were originally opened. The UM/LPN confirmed that these medications should have been dated upon opening. Similarly, on Cart 1, the surveyor, in the presence of the LPN on duty, found a foil package of DuoNeb solution also lacking an opening date. The LPN acknowledged that the vial should have been dated. The surveyor reviewed the facility's policy on Medication Labeling and Storage, which did not include information on dating opened packaging of nebulizer solutions. Additionally, the manufacturer packaging information for both DuoNeb and budesonide specified the time frames within which the medications should be used once opened. The facility's failure to adhere to these guidelines and properly label the medications led to the deficiency noted in the report.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during a dining observation on the third floor, involving four Certified Nursing Aides (CNAs). During a lunch meal, the CNAs distributed trays to residents and left them on the table underneath each resident's plate. Additionally, three insulated lids were left in the middle of the tables, and the CNAs placed wrappers and garbage inside those lids, which remained on the tables throughout the entire meal. Furthermore, one CNA was observed standing while feeding an unsampled resident, which was acknowledged by the CNA as inappropriate, as she should have been seated while feeding the resident.
Failure to Accurately Document and Review Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, heart failure, and atrial fibrillation. The resident's paper chart included a POLST form indicating DNR, DNI, and DNH directives, signed by the resident's representative and an advance practice provider. However, the electronic medical record (EMR) did not reflect the DNH status, and there was no care plan related to advance directives. Interviews with facility staff revealed that the process for updating and ensuring the accuracy of advance directives was not followed. The LPN/UM confirmed the discrepancy in the EMR and stated that nursing staff should have ensured the EMR was updated. The Assistant Director of Social Services indicated that social services assess residents for advance directives, but the responsibility for ensuring the POLST directives are carried out lies with the nursing staff. The facility's policy requires that information about advance directives be prominently displayed and communicated to direct care staff, which was not adhered to in this case.
Inaccurate MDS Gender 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 gender identification. Resident #67, who is male according to the Admission Record, was incorrectly coded as female in both the entry and comprehensive MDS assessments. Similarly, Resident #70, identified as female in the Admission Record, was inaccurately coded as male in the MDS assessments. These errors were identified through a review of the electronic medical records and the MDS assessments by the surveyor. The Registered Nurse (RN) MDS coordinator, responsible for ensuring the accuracy of MDS assessments, acknowledged the inaccuracies upon review with the surveyor. The MDS coordinator stated that the guidance from the MDS 3.0 Manual was followed, yet the errors persisted. The surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about these concerns, highlighting the facility's failure to adhere to federal guidelines requiring that resident gender on the MDS match the information in the Social Security system.
Failure to Adhere to Infection Control Standards in Respiratory Care
Penalty
Summary
The facility failed to adhere to infection control standards in the management of respiratory care for a resident. Specifically, the nasal cannula (NC) tubing used for oxygen delivery was not changed according to the facility's policy, which required a change every Tuesday on the night shift. The NC tubing was observed to be dated 12/18/24, indicating it had not been changed by 12/24/24 as required. Additionally, the NC tubing was found on the floor and not stored in a plastic bag, which is against infection control measures. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) acknowledged these lapses in protocol. The resident involved had a medical history that included congestive heart failure, schizophrenia, and major depressive disorder, and was receiving oxygen therapy as part of their care plan. The resident's cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's Director of Nursing (DON) confirmed that the policy required NC tubing to be changed every 7 days and stored properly when not in use. The surveyor's observations and interviews with staff highlighted the failure to follow these established procedures, leading to the deficiency noted in the report.
Unnecessary Medication Administration in Female Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving the administration of Tamsulosin (Flomax) to a female resident. The resident was admitted with diagnoses including COVID-19, heart disease, and a urinary tract infection, and was cognitively intact with a BIMS score of 15 out of 15. The resident had a urinary catheter inserted, and Tamsulosin was prescribed for urinary retention management after the catheter was placed. However, the use of Tamsulosin, which is indicated for benign prostatic hyperplasia in men and not approved for use in women, was not supported by documentation in the resident's medical record regarding its off-label use or a benefit versus risk assessment. The Nurse Practitioner acknowledged the off-label use of Tamsulosin in the female resident but did not document the rationale or any potential benefits in the medical record, considering it a common practice. The surveyor's interview with the Director of Nursing and the Licensed Nursing Home Administrator revealed that the facility did not provide further pertinent information to justify the use of Tamsulosin in this case. The lack of documentation and justification for the off-label use of Tamsulosin in a female resident constitutes a deficiency in the facility's medication management practices.
Failure to Ensure Proper Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received services consistent with professional standards of practice. The deficiency was identified when a resident returned from an HD clinic with two empty syringes still connected to their dialysis access site, a permanent intravenous catheter in the upper chest. These syringes, used to flush the catheter with saline post-treatment, should have been removed at the clinic. The oversight was discovered by the resident's family member the following day, who alerted facility staff. The resident, admitted with conditions including end-stage renal disease and dependence on HD, had moderate cognitive impairment. Facility records indicated that the resident's dialysis site was to be assessed for infection or bleeding every shift. However, documentation revealed that the post-treatment assessment was not properly conducted or recorded. The nurse who received the resident back from HD did not perform a thorough check of the catheter site and failed to notice the syringes. Additionally, the dialysis communication report, which should accompany the resident to and from the clinic, was not consistently returned to the facility nurse. Interviews with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved highlighted discrepancies in the documentation and communication processes. The facility's policies required documentation of dialysis treatment and post-treatment observations, but these were not adhered to in this instance. The DON acknowledged the need for proper assessment and documentation upon the resident's return from HD, which was not adequately performed, leading to the deficiency.
Resident Given Wound Cleanser Instead of Water with Oral Medication
Penalty
Summary
A deficiency occurred when a resident was given a clear liquid by mouth to take with their medication, which was later identified as Dakin's solution (Sodium Hypochlorite 0.25%), a wound cleanser, instead of water. The registered nurse responsible for the incident had prepared the Dakin's solution in a drinking cup at the treatment cart and, after being interrupted by the resident requesting pain medication, inadvertently handed the cup containing the wound cleanser to the resident along with their oral medication. The resident immediately reported a burning sensation upon swallowing the liquid, and the incident was reported to the nurse practitioner, primary care physician, and poison control. The resident involved had a history of right femur fracture, hypertensive heart disease, bacteremia, repeated falls, and was cognitively intact according to the most recent assessment. The resident required supervision or assistance with activities of daily living. Facility records and interviews confirmed that the nurse did not follow established procedures for wound care preparation, which require pouring liquid solutions directly onto gauze and not into drinking cups, and also failed to adhere to medication administration protocols that prohibit keeping treatment supplies on medication carts and using inappropriate containers for wound solutions. Observations and interviews with staff revealed that medication carts were to be used exclusively for medications, while treatment carts were designated for wound care supplies. The director of nursing and unit manager both confirmed that the nurse's actions were not in line with facility policy or professional standards. The nurse involved was terminated following the incident and did not respond to follow-up inquiries from facility leadership.
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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