Cheshire Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Florham Park, New Jersey.
- Location
- 9 Ridgedale Ave, Florham Park, New Jersey 07932
- CMS Provider Number
- 315383
- Inspections on file
- 13
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cheshire Home during CMS and state inspections, most recent first.
A resident with cognitive intactness but physical limitations was observed twice with their call light out of reach, contrary to their care plan and facility policy. The LPN confirmed the oversight, and facility management acknowledged the deficiency.
The facility failed to complete reference checks for two newly hired staff members, an LPN and an RN. The surveyor found no documented reference checks in their files, despite the facility's policy to seek maximum references. The Acting HR Representative, who took over after the previous HR left, could not provide information on these hires. An inquiry form for the RN was incomplete, and no response was received. The facility's policy, last revised in 1996, was not followed, and the issue was acknowledged by the LNHA and AA.
The facility failed to provide adequate care and documentation for two residents with pressure ulcers. One resident lacked proper documentation and assessment of wounds, and the care plan did not reflect current wound status. Another resident had a Stage 4 pressure ulcer without a formal risk assessment or consistent documentation. Interviews revealed a lack of formal risk assessment processes and inconsistent wound documentation.
A resident using an external urinary catheter managed their own drainage bag, which was observed with uncovered tubing, contrary to infection control practices. Interviews with staff revealed inconsistencies in the understanding of proper storage procedures, and facility documentation lacked specific guidance on the care of external catheters. The care plan did not address the resident's catheter use, and there was no documented education provided to the resident.
A facility failed to change a resident's nebulizer and suction setups as per physician orders, despite having a checklist for respiratory equipment maintenance. The resident, who had a tracheostomy and other health conditions, was observed with outdated equipment. Staff acknowledged the oversight, and the survey team discussed the findings with facility management.
The facility failed to post the Nursing Home Resident Care Staffing Report (NHRCSR) at the beginning of the current shift on two occasions. The Unit Clerk and a nurse were responsible for posting the NHRCSR, but it was not updated for the current day, violating the facility's policy. Interviews confirmed the lapse, with the charge nurse ultimately responsible for ensuring compliance.
A resident with chronic pain was prescribed PRN Oxycodone and Acetaminophen to be administered together for severe pain. However, records showed discrepancies in administration, with Acetaminophen not given as frequently as Oxycodone. Nursing staff confirmed the oversight, and the Consultant Pharmacist failed to identify this irregularity in their monthly review, leading to a deficiency.
A facility failed to provide timely lab services for a resident, neglecting psychiatric recommendations for liver enzyme monitoring and routine lab orders for CBC and CMP. The resident, who was cognitively intact and on medications requiring lab monitoring, did not receive the necessary tests. The DON acknowledged inconsistencies in lab requisition processes, but no explanation or additional information was provided to address the deficiency.
The facility failed to follow proper infection control practices, as a Physical Therapist did not change gloves or disinfect equipment between residents, and laundry areas had issues with dust accumulation and improper storage of soiled clothing. The facility's management was informed, revealing gaps in staff training and monitoring of infection control protocols.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible within reach, which was identified during a survey. The surveyor observed the resident, who was alert and verbally responsive but had slurred speech, sitting in a wheelchair beside the bed with the call light placed on the opposite side of the bed against the wall, out of reach. This observation was made on two separate occasions. The resident's medical record indicated diagnoses of diffuse Traumatic Brain Injury and neuromuscular dysfunction of the bladder, with cognitive intactness but limitations in both upper and lower extremities. The care plan for the resident included an intervention to ensure the call light was within reach, highlighting the facility's failure to adhere to this plan. During an interview, the LPN assigned to the resident confirmed that the call light should be within the resident's reach and acknowledged the oversight when the surveyor pointed it out. The facility's policy on making an open bed also stipulated that the call bell should be within the resident's reach, which was not followed in this instance. The facility management, including the DON and LNHA, acknowledged the findings and the requirement for call lights to be accessible to all residents.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for two out of six newly hired staff members, specifically a Licensed Practical Nurse (LPN) and a Registered Nurse (RN). The surveyor's review of the employee files revealed that there were no reference checks documented for these two staff members. The Licensed Nursing Home Administrator (LNHA) and the Administrative Assistant (AA) were informed of this issue, and the AA indicated that she would follow up with the Acting Human Resources Representative (AHRR). The AHRR, who began covering the HR position after the previous representative left in May 2024, stated that the facility typically requested two references from new employees and used a facility inquiry form to contact previous employers. However, the AHRR could not provide information on the reference checks for the two staff members in question as they were hired before she assumed her role. The surveyor was provided with a copy of an inquiry form that was faxed to a previous employer of the RN, but it was not completed, and no response was received. The facility's policy on Personnel Management Reference Checks, last revised in 1996, stated that the facility would seek the maximum number of references possible to obtain a solid work ethic and character background. Despite this policy, the facility did not have documented reference checks for the two staff members, which was acknowledged by the AA and the LNHA. No additional information was provided by the facility to address this deficiency.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents with pressure ulcers. Resident #8, who was cognitively intact and had diagnoses including quadriplegia, was observed with pressure ulcers but lacked proper documentation and assessment of these wounds. The care plan for Resident #8 did not reflect the current status of the resident's wounds, and there was no consistent weekly documentation of wound assessments, including measurements and descriptions. The Director of Nursing (DON) acknowledged the lack of formal investigation reports for new wounds and stated that there was no formal assessment tool used to assess residents' risks for wounds. Resident #9, who also had quadriplegia and a history of pressure ulcers, was found to have a Stage 4 pressure ulcer that was not present upon admission. The facility did not use a formal assessment tool like the Braden Scale to determine the resident's risk for pressure ulcer development, and there was no documented evidence of a clinical assessment related to the risk of developing pressure ulcers. The care plan for Resident #9 included interventions for monitoring wound healing, but there was no consistent weekly documentation of the pressure ulcer assessments, including measurements and descriptions. Interviews with facility staff, including the DON, Assistant DON, and nursing staff, revealed that the facility did not have a formal risk assessment process for pressure ulcers, and documentation of wound assessments was inconsistent. The facility's policies on wound management and prevention did not include information about risk assessment for pressure ulcer development. The surveyor noted that the facility did not provide additional information or documentation to address the concerns raised during the survey.
Inadequate Storage and Care of Urinary Drainage Bags
Penalty
Summary
The facility failed to provide appropriate care and services for the storage of urinary drainage bags for a resident using an external urinary catheter. The deficiency was identified during observations and interviews conducted by the surveyor. The resident, who was cognitively intact and had a history of paraplegia and neuromuscular dysfunction of the bladder, used an external urinary catheter at night and managed the drainage bag independently. However, the drainage bag was observed hanging at the bedside with uncovered tubing, which was not in line with infection control practices. Interviews with the Certified Nurse Aide (CNA) and Licensed Practical Nurses (LPNs) revealed inconsistencies in the understanding and implementation of proper storage procedures for urinary drainage bags. The CNA acknowledged that the resident preferred to manage their own drainage bag, but noted that the bag should be capped and stored in a plastic bag, which was not done. The LPNs provided conflicting information about the storage and disposal of drainage bags, with one LPN indicating that the bags should be capped and stored, while another suggested they were disposable and should be replaced. The facility's documentation and policies did not adequately address the care and storage of external urinary catheters and drainage bags. The care plan for the resident did not include specific interventions for managing the external catheter and drainage bag, and there was no documentation of education provided to the resident regarding proper care. Additionally, the facility's policy on urinary tract infections did not cover external catheters or the storage of urinary drainage bags, contributing to the deficiency in care provided to the resident.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in changing nebulizer setups and suction tubing as per physician orders. During an initial tour, a surveyor observed a resident with a tracheostomy who reported receiving daily nebulizer treatments. The nebulizer tubing was labeled with a date, indicating it had not been changed as required. The resident's medical history included tracheostomy, paraplegia, hemiplegia, and major depressive disorder, and they were cognitively intact according to a recent assessment. The physician's orders specified that the nebulizer setup should be changed every day shift starting on the 24th of each month, and the suction canister, tubing, and filter should also be changed on the same schedule. However, the electronic Medication Administration Record (eMAR) indicated that these changes were not documented as completed. Interviews with staff, including a Licensed Practical Nurse (LPN) and an Infection Preventionist/Registered Nurse (IP/RN), revealed that the nebulizer and suction setups were not changed as scheduled, which was acknowledged as unacceptable practice. The facility's Respiratory Equipment Set-up checklist required the nebulizer setup to be changed weekly and the suction machine setup monthly, with labeling and dating. Despite these guidelines, the surveyor found that the equipment was not changed according to the schedule, and the staff acknowledged the oversight. The survey team discussed these findings with the facility management, who did not provide additional information during the exit conference.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) at the beginning of the current shift for two out of four days during the survey. On two separate occasions, the surveyor observed that the NHRCSR was not updated for the current day, with reports from the previous day still posted. Specifically, on the morning of 9/03/24 and 9/05/24, the NHRCSR for the current day was missing, indicating a lapse in the facility's compliance with staffing information posting requirements. Interviews with facility staff revealed that the Unit Clerk (UC) was responsible for posting the NHRCSR for the day and evening shifts, while a nurse was tasked with posting it for the night shift. The UC acknowledged that the NHRCSR might be posted late and indicated that the charge nurse was ultimately responsible for ensuring the report was posted for each shift. The facility's policy, titled 'Staffing Nursing Staffing Information,' mandates that the nurse staffing data be posted daily at the beginning of each shift, which was not adhered to on the observed days.
Failure to Administer PRN Medications as Ordered
Penalty
Summary
The facility failed to identify and address an irregularity in the administration of as-needed pain medications for a resident, leading to a deficiency. The resident, who was cognitively intact and had a history of quadriplegia, chronic pain, and other conditions, was prescribed PRN Oxycodone and PRN Acetaminophen to be administered together for severe pain. However, the facility's records showed discrepancies in the administration of these medications, with PRN Acetaminophen not being given as frequently as PRN Oxycodone, contrary to the physician's order. The surveyor's review of the electronic Medication Administration Record (eMAR) for July, August, and September 2024 revealed that PRN Acetaminophen was not administered as ordered alongside PRN Oxycodone on numerous occasions. Interviews with nursing staff confirmed that the medications were not consistently signed off together, and the Licensed Practical Nurse acknowledged the oversight in documentation. Despite the facility's policy requiring a licensed pharmacist to conduct a monthly drug regimen review and report any irregularities, the Consultant Pharmacist did not identify or document this issue in their reports. The deficiency was further highlighted during interviews with the Registered Nurse Supervisors and the Consultant Pharmacist, who admitted to not addressing the irregularity in the monthly Medication Regimen Review. The facility's management was informed of these findings, but no additional information was provided to address the concerns raised by the survey team. The facility's policy mandates that any irregularities be reported in writing to the attending physician, medical director, and Director of Nursing, which was not adhered to in this case.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely and appropriate laboratory services for a resident, specifically regarding psychiatric recommendations and routine lab orders. The deficiency was identified for a resident who was cognitively intact and had multiple diagnoses, including quadriplegia, chronic pain, major depressive disorder, and hypertension. The resident was receiving medications such as Baclofen, Cymbalta, and Trazodone, which required regular monitoring through lab tests. The surveyor found that the facility did not follow the psychiatric recommendation from July 2024 to monitor liver enzymes ALT and AST every 3-6 months. Additionally, routine lab orders for CBC and CMP, scheduled for January and June 2024, were not conducted as required. The facility's Director of Nursing (DON) acknowledged that standing orders for labs should be electronically entered and executed according to physician orders, but inconsistencies in the process were noted, with some requisitions being handled manually. During interviews, the DON could not provide evidence that the lab orders were followed or explain why they were not. Despite being notified of the findings, the facility management did not offer additional information or documentation to address the concerns raised by the surveyor. The deficiency was reported to the Licensed Nursing Home Administrator, DON, and Administrative Assistant during an exit conference.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by the actions of a Physical Therapist (PT) and issues observed in the laundry areas. The PT was observed wearing the same pair of gloves while checking multiple residents' electric wheelchair cushions without changing gloves, performing hand hygiene, or disinfecting the handheld equipment used. This practice was contrary to the facility's policy and CDC guidelines, which require hand hygiene and equipment disinfection between patient interactions. The PT stated that he was instructed by his director to wear the same gloves, indicating a possible gap in staff training or communication. Additionally, during a tour of the laundry areas, deficiencies were noted in the handling and storage of linens and residents' clothing. In one laundry area, an electric fan with visible dust accumulation was blowing air onto uncovered clean linens, which were exposed to potential contamination. In another area, soiled residents' clothing was left uncovered and unattended on top of a washer, contrary to the facility's policy that requires soiled laundry to be bagged and properly stored. The District Manager from the contracted laundry service acknowledged these issues but did not provide a satisfactory explanation for the lapses in protocol. The facility's management, including the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), were informed of these findings. It was revealed that residents using the laundry facilities were not educated on infection control practices, and there was no staff assigned to monitor the laundry area. The facility's policies on hand hygiene and soiled laundry collection were not being followed, contributing to the potential spread of infection within the facility.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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