Complete Care At Bayshore Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Holmdel, New Jersey.
- Location
- 715 North Beers Street, Holmdel, New Jersey 07733
- CMS Provider Number
- 315252
- Inspections on file
- 17
- Latest survey
- December 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Complete Care At Bayshore Llc during CMS and state inspections, most recent first.
The facility's assessment failed to identify and address the specific services, procedures, and resources required for ventilator-dependent residents. The assessment did not specify the facility's ventilator care bed licensing, nor did it include ventilator-dependent residents in sections covering diseases, care needs, staff training, or equipment. Leadership confirmed the omission during interviews, stating that ventilator care was considered under general respiratory needs.
The facility failed to maintain kitchen equipment in a sanitary manner, with issues including a dirty ice machine, uncovered waste receptacles, and uncleaned cooking equipment. The FSD acknowledged non-compliance with cleaning policies, posing potential contamination risks.
A resident with severe impaired cognition was discharged from a facility without a prescription for clindamycin, an antibiotic needed for an ongoing infection treatment. The omission occurred due to a miscommunication, as the Nurse Practitioner mistakenly believed the antibiotic treatment was completed. The facility's Vice President Clinical acknowledged the error, confirming the resident did not receive their medication on time.
A facility failed to develop an individualized comprehensive care plan for a resident with chronic pain. Despite the resident's frequent pain and administration of pain medications, their care plan lacked a focus on pain management. The resident, who was cognitively intact, expressed the need for an appointment related to shoulder pain. The facility's leadership acknowledged the oversight, which violated their policy and regulatory requirements.
A resident with moderate cognitive impairment and multiple medical conditions experienced a fall in the facility. Despite the incident, the resident's care plan was not updated with new interventions as required by the facility's policy. The Vice President of Clinical confirmed that care plans should be reviewed and updated after a fall, indicating a deficiency in policy adherence.
A resident with a pressure ulcer did not receive a recommended low air-loss (LAL) mattress, as observed by surveyors. Despite a wound care consultant's recommendation and a physician's order for daily wound care, the facility's staff were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy lacked guidance on implementing consultation recommendations, leading to this deficiency.
The facility failed to ensure proper accountability and documentation of narcotic shift count logs and controlled medication administration. Reviews revealed missing signatures and incomplete narcotic counts on shift-to-shift controlled substance count sheets for two medication carts. Additionally, a resident's clonazepam dose was not documented on the declining inventory log, although it was recorded in the electronic MAR. Staff interviews confirmed the lack of adherence to the facility's policy requiring two licensed nurses to account for controlled substances at each shift change.
A surveyor observed improper medication storage on an unattended medication cart in the Vent nursing unit. An LPN left the cart with unsecured medications, including Eliquis and midodrine HCl, visible on an unlockable tray. The DON confirmed that medications should always be secured, aligning with the facility's policy requiring locked storage accessible only to authorized personnel.
The facility failed to follow clinical practice standards by not consistently documenting medication and treatment administration in the MAR and TAR for two residents. This included missing documentation for tube flushes and wound care treatments, with no records to confirm that the care was provided. Interviews with staff confirmed the importance of proper documentation for accountability and continuity of care.
Facility Assessment Lacks Ventilator-Dependent Resident Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment (FA) adequately identified and addressed the required services and procedures necessary for ventilator-dependent residents. Upon review, the FA did not specify that the facility was licensed for 12 ventilator care beds in addition to 220 long-term care beds, nor did it include ventilator-dependent residents under the sections for diseases/conditions, resident support/care needs, staff training/education and competencies, or physical environment and equipment needs. The FA only referenced general respiratory conditions such as COPD, pneumonia, asthma, and respiratory failure, but did not specifically mention ventilator dependency or related requirements. During interviews, facility leadership confirmed that the FA was current but could not identify any vent-specific or related assessments within the document. When asked, the Vice President of Clinical stated that ventilator care was covered under the general respiratory category, and the President of Operations asserted that federal regulations do not require specific mention of ventilator care in the FA. The surveyor noted that the omission of ventilator-specific planning, licensing, and resources in the FA constituted a deficiency, as the facility did not comprehensively address the needs of ventilator-dependent residents as required.
Deficient Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary manner, as observed during a survey. The ice machine was found with stains and debris, and the Food Service Director (FSD) admitted it should be cleaned daily but was not. Two waste receptacles were uncovered, exposing food preparation stations to potential contamination. The eight-burner stove had accumulated burnt food and sludge, indicating non-compliance with cleaning policies. Additionally, a slicer marked as clean was found with crusted debris, and the can opener base had wipeable debris, both acknowledged by the FSD as not cleaned according to policy. The steam tables contained dirty water with floating debris, which the FSD admitted had not been cleaned as required. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged these concerns. The facility's Equipment Cleaning Policy outlined specific cleaning procedures for each piece of equipment, which were not followed, leading to potential cross-contamination and foodborne illness risks. The Ice Machines Sanitation policy also required daily cleaning of the ice machine's exterior, which was not adhered to.
Failure to Provide Antibiotic Prescription at Discharge
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for discharge by not providing a prescription for an active antibiotic treatment. The resident, who had severe impaired cognition and was being treated for an infection related to a hip prosthesis, was discharged to an assisted living facility without a prescription for clindamycin, an antibiotic that was supposed to continue post-discharge. The resident's medical record indicated that clindamycin was administered regularly until the day before discharge, but the prescription was not included in the discharge documents. The deficiency occurred due to a miscommunication between the Nurse Practitioner and the facility staff, leading to the omission of the clindamycin prescription. The Nurse Practitioner mistakenly believed that both antibiotics prescribed to the resident had been completed, resulting in the failure to provide the necessary prescription upon discharge. This oversight was acknowledged by the facility's Vice President Clinical, who confirmed that the resident did not receive their medication on time, and there should have been no missed doses of clindamycin.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan for a resident with chronic pain, which was identified during a survey. The resident, who was admitted with medical diagnoses including diabetes, depressive disorder, and chronic pain syndrome, was observed by the surveyor in bed with eyes closed and later in a wheelchair speaking with the Unit Manager/LPN about needing an appointment for shoulder pain. The resident's medical records indicated frequent pain and the administration of pain medications, including oxycodone, as prescribed by a physician. However, the resident's comprehensive care plan did not include a focus area for pain management, despite the resident being cognitively intact and experiencing frequent pain. The surveyor's review of the facility's policies revealed that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's needs. The Unit Manager/LPN confirmed that a resident with pain should have a pain management plan included in their care plan. During a meeting with the survey team, the facility's leadership acknowledged that the care plan should have been initiated when the resident began experiencing pain. This oversight was a violation of the facility's policy and regulatory requirements.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who had moderate cognitive impairment and multiple medical diagnoses including heart failure and muscle weakness, experienced a fall on December 4, 2023. The fall occurred when the resident slid off their wheelchair in the bathroom, although no injuries were sustained. Despite the incident, the resident's individualized comprehensive care plan was not updated to include new interventions post-fall, which is a requirement according to the facility's policy. The facility's policy on managing falls and fall risks mandates that if falls recur despite initial interventions, staff should implement additional or different interventions or justify why the current approach remains relevant. However, the interdisciplinary team note dated December 5, 2024, indicated that a new intervention of frequent bathroom rounds was added, but this was not reflected in the resident's care plan. During an interview, the Vice President of Clinical confirmed that the care plan should be reviewed and updated with new interventions after a fall, highlighting the deficiency in the facility's adherence to its own policy.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to implement the wound care consultant's recommendations for a resident with a pressure ulcer, leading to a deficiency. The resident, who was cognitively intact and had a history of major depressive disorder, chronic pain, kidney stones, and cerebral infarction, was admitted with an unstageable pressure ulcer. The wound care consultant recommended the use of a low air-loss (LAL) mattress to offload pressure and prevent the worsening of the ulcer. However, during multiple observations by the surveyor, the resident was not provided with the recommended LAL mattress, and the care plan did not include this intervention. Despite the physician's order for daily wound care and the wound nurse practitioner's recommendation, the facility's staff, including the LPN and Unit Manager, were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy did not address the process for implementing wound care consultation recommendations, contributing to the oversight. The Vice President of Clinical acknowledged the oversight and the need for staff education to follow wound care consultant recommendations.
Deficiency in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs and accurately document the administration of controlled medications. During a review of medication storage, it was found that the shift-to-shift controlled substance count sheets for two medication carts had numerous missing signatures from both incoming and outgoing nurses. Additionally, the narcotic counts were not recorded for several shifts, indicating a lack of proper documentation and accountability for controlled substances. Further investigation revealed that a resident's Controlled Drug Administration Record log was incomplete, as the 9:00 AM dose of clonazepam was not signed out on the declining inventory log. An LPN admitted to administering the medication but failing to document it on the log, although it was recorded in the electronic Medication Administration Record. This oversight was acknowledged by the LPN, who confirmed that the declining inventory logs should be completed upon dispensing medication to maintain accurate narcotic counts. Interviews with facility staff, including the Director of Nursing and the Vice President of Clinical, confirmed that the shift-to-shift narcotic count logs were not completed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but this procedure was not consistently followed, leading to missing documentation and signatures on the narcotic count logs.
Improper Medication Storage on Unattended Cart
Penalty
Summary
The facility failed to properly store medications, as observed by a surveyor on the Vent nursing unit's medication cart A. The cart was left unattended by an LPN while administering medication to an unsampled resident. On the cart's unlockable pull-out tray, several packets of individually wrapped medications were visible and unsecured. These included medications such as Eliquis, midodrine HCl, memantine HCl, pravastatin sodium, oxybutynin chloride, levofloxacin, baclofen, metoprolol tartrate, and amiodarone HCl. Upon questioning, the LPN acknowledged that medications should not be left unsecured on the tray, as there was a risk of them being taken. The DON confirmed that medications should always be secured and locked, regardless of the residents' mobility status. The facility's Medication Storage policy, reviewed in November 2022, mandates that all medications be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. The VPC, along with the survey team, LNHA, and DON, confirmed that the medications should not have been stored unsecured on the cart.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to follow acceptable standards of clinical practice by not consistently documenting the administration of medications and treatments in the electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR). This deficiency was identified for two residents. Resident #2 had multiple instances where tube flushes were not documented in the MAR, despite having orders to flush the tube with water every six hours. The review of the MAR and progress notes for various months showed blanks on specific dates, and there was no documentation to confirm that the flushes were administered. The nursing staff responsible for these dates were not available for interview during the survey. Resident #3 had severe cognitive impairment and was at risk for pressure ulcers. The facility discovered a Stage II open wound on the resident's sacrum, and there were orders for wound care treatments, including the application of Santyl and Metrogel. However, the MAR and TAR revealed multiple instances where these treatments were not documented as completed. The review of the progress notes also did not show any documentation that the treatments were performed on the specified dates. The nursing staff responsible for these dates were not available for interview during the survey. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that it is the responsibility of the nurses to document the completion of care in the MAR and TAR. The DON emphasized the importance of signing the MAR and TAR for accountability and continuity of care. The facility's policy on charting and documentation also required that all services provided to residents be documented in their medical records. The failure to document the administration of medications and treatments led to the deficiency identified in the report.
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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