Complete Care At Brick Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Brick, New Jersey.
- Location
- 415 Jack Martin Blvd, Brick, New Jersey 08724
- CMS Provider Number
- 315342
- Inspections on file
- 15
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Complete Care At Brick Llc during CMS and state inspections, most recent first.
A survey revealed that a facility failed to provide timely incontinence care to residents, with instances of double or triple briefing noted. One resident was found wearing two briefs, with the inner brief soiled, while another was wearing three briefs, with the inner brief wet and the chux beneath soaked through. A third resident was found wearing two briefs, with the inner brief soaked through. Staff interviews indicated that double briefing was a common practice due to staffing shortages. The DON and LNHA acknowledged the deficiency and stated that double briefing was not acceptable.
A facility was found deficient in maintaining required staffing ratios, leading to inadequate care. Residents experienced insufficient incontinence care, missed showers, and increased falls due to staffing shortages. Instances of double and triple briefing were observed, which can cause skin breakdown. The facility's Volunteer Ombudsman and residents reported unmet needs due to low staffing levels.
A resident with depression and dementia was prescribed Seroquel without documented behaviors justifying its use, and the facility failed to attempt a gradual dose reduction (GDR) or obtain a psychiatric consult. Despite facility policies requiring GDR attempts, there was no documentation of such efforts or clinical contraindications. Interviews revealed a lack of communication and documentation regarding the resident's medication management.
The facility failed to properly label, date, and store potentially hazardous foods and maintain kitchen equipment. Observations included a dirty can opener, a scooper left in a rice bin, uncovered onions near a trash can, a crumb-filled toaster, debris on beef base lids, and an undated, exposed box of bacon. These findings indicate non-compliance with the facility's policies on equipment cleaning and food storage.
The facility failed to maintain complete medical records for three residents, resulting in missing documentation of medication and treatment administration. A resident with multiple diagnoses had several medications not signed off as administered, while another resident at risk for pressure ulcers had missing documentation for wound care treatments. A third resident with a worsening pressure ulcer also had incomplete treatment records. Interviews with staff confirmed that blanks in records indicated non-compliance with treatment orders.
The facility failed to follow infection control protocols, including not using PPE for a resident on contact isolation, lacking a physician's order for contact precautions for a resident with a sacral wound, and not maintaining a urinary catheter bag off the floor. Additionally, during an influenza outbreak, the facility did not test residents for influenza as per CDC guidelines, despite symptoms and hospitalizations.
A resident with dementia and behavioral disturbances was observed with a shower blanket used as a clothing protector instead of a proper one, compromising their dignity. Staff interviews revealed that this practice was common despite the availability of appropriate protectors, and the facility's policy emphasized the importance of dignity.
A resident with acute respiratory failure, Alzheimer's, and COPD experienced a change in condition, including a fever and diminished lung sounds. Despite the facility's policy to notify families in real time, the resident's family was not informed until the following day. Interviews with the DON and LPN/UM confirmed the notification delay, which was identified as a deficiency.
The facility failed to maintain a clean environment by improperly disposing of soiled incontinence briefs and PPE. A resident's room had a soiled brief in a garbage can without a liner, and gloves were left on the floor. An overflowing garbage receptacle with protective gowns was also observed. The Environmental Services Supervisor confirmed these practices were not acceptable, and the facility's cleaning policy was not followed.
A resident with dementia and communication difficulties did not receive the communication support outlined in their Care Plan, such as a communication tablet and Speech Therapy. Staff interviews revealed a lack of awareness and implementation of these interventions, and the Care Plan was not updated to reflect the resident's current needs. The facility's policies on communication and care plans were not followed, resulting in a deficiency.
The facility failed to set an air mattress according to a resident's weight, contributing to the worsening of a pressure ulcer. Despite a physician's order, the mattress was not adjusted to the resident's current weight. Additionally, the facility did not investigate a new pressure ulcer for another resident, as required by policy. Staff interviews confirmed these lapses in following procedures.
A resident with severe protein-calorie malnutrition did not receive appropriate enteral feeding care. The feeding pump was observed running while disconnected, causing formula to drip on the floor. Additionally, dried formula residue was found on the feeding pump pole, and an irrigation syringe was not replaced within the required 24-hour period. The LPN and VPCS confirmed these practices were against facility policy.
The facility failed to ensure proper accountability of narcotic shift count logs on two medication carts, with missing nursing signatures for several shifts. An LPN confirmed the absence of required signatures, indicating a lack of reconciliation of controlled substances at shift changes. Additionally, an LPN administered alprazolam to a resident but did not sign it out on the narcotic inventory sheet, although it was recorded in the electronic MAR. The DON confirmed the necessity of real-time documentation and compliance with the facility's Controlled Substance policy.
The facility failed to secure medications properly during administration and allowed a resident to keep medications in their room without proper assessment or authorization. Two LPNs were observed leaving medication carts unlocked or medications unsecured, and a resident with moderate cognitive impairment had unauthorized medications in an unlockable drawer. Facility policies require medication carts to be locked and unauthorized bedside medications to be secured.
The facility failed to ensure required members attended quarterly QAPI meetings, with the Infection Preventionist absent from one meeting and the DON absent from two meetings, violating policy and regulatory requirements.
Inadequate Incontinence Care and Double Briefing
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed during a survey. Three residents on the Starlight Unit were found to be inadequately cared for, with instances of double or triple briefing noted. Resident #23 was found wearing two briefs, with the inner brief soiled but not soaked through to the outer brief. The resident was fully cognitively intact and had a history of incontinence and potential for skin breakdown. The care plan for Resident #23 included regular incontinence care and monitoring for skin integrity, which was not adhered to. Resident #30 was discovered wearing three briefs, with the inner brief wet and the chux beneath soaked through. The resident was cognitively intact and had a history of pressure ulcers and incontinence. The care plan emphasized frequent position changes and avoiding prolonged pressure on the sacrum, which was not followed. The LPN/UM confirmed the improper care and noted that double briefing was against protocol due to the risk of skin breakdown. Resident #12 was found wearing two briefs, with the inner brief soaked through. The resident was cognitively intact and had a history of urinary tract infection and sepsis. The care plan included regular incontinence care and monitoring for skin breakdown, which was not provided. Interviews with staff revealed that double briefing was a common practice, attributed to staffing shortages and an attempt to reduce the frequency of changes. The DON and LNHA acknowledged the deficiency and stated that double briefing was not acceptable practice.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility was found to be deficient in providing sufficient nursing staff on a 24-hour basis, as mandated by the State of New Jersey. The report highlights that the facility failed to maintain the required minimum direct care staff-to-resident ratios, which resulted in inadequate care for residents. Specifically, the facility did not have enough Certified Nurse Aides (CNAs) on multiple occasions, leading to insufficient incontinence care, missed scheduled showers, and an increase in resident falls. The staffing deficiencies were observed over several weeks, with the facility consistently failing to meet the required CNA-to-resident ratios during day shifts. The report details specific instances of inadequate care due to staffing shortages. For example, a CNA was observed providing incontinence care to a resident who was double briefed, which is against protocol and can lead to skin breakdown. The CNA admitted that double briefing was done due to being short-staffed. Another resident was found to be triple briefed, with the inner brief wet and the chux beneath soaked through, indicating that the resident was not changed regularly. These practices were confirmed by the Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON), who acknowledged that double or triple briefing was not acceptable and could lead to skin issues. Additionally, the report notes that residents did not receive their scheduled showers due to low staffing levels. One resident reported missing a scheduled shower because it was not offered, and the shower log confirmed multiple missed showers. The facility's Volunteer Ombudsman also raised concerns about staffing levels, noting that residents' needs were not being fully met. The report further documents several resident falls, with residents attributing the falls to long wait times for assistance due to staffing shortages. Despite the facility's attempts to schedule staffing according to guidelines, the consistent call-outs and insufficient coverage led to these deficiencies.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to provide a gradual dose reduction (GDR) of psychoactive medication for a resident who was not exhibiting targeted behaviors, and did not obtain a psychiatric consult for the use of a psychotropic medication. The resident, who was admitted with diagnoses including depression and unspecified dementia with behavioral disturbances, was observed to be taking Seroquel, an antipsychotic medication, without documented behaviors that would justify its continued use. The facility's records from June 2023 to April 2024 did not show any episodes of the behaviors for which the medication was prescribed, nor was there documentation of a GDR attempt or a psychiatric evaluation. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's medication management. The Director of Nursing (DON) admitted that the resident had not been seen by the facility psychiatrist and that the psychotropic medications were managed by the primary care physician. The Licensed Practical Nurse (LPN) and the Unit Manager confirmed that there was no documentation of behaviors or a rationale for not attempting a GDR. The facility's psychiatrist had recommended a GDR, but the Nurse Practitioner (NP) did not implement any changes, and the primary care physician was under the impression that the psychiatrist was managing the medication. The facility's policies on psychotropic medication use and tapering required GDR attempts unless clinically contraindicated, but these were not followed. The policies stated that within the first year of starting a psychotropic medication, a GDR should be attempted in two separate quarters, and annually thereafter. However, there was no documentation of such attempts or clinical contraindications for the resident in question, highlighting a significant oversight in medication management and compliance with regulatory requirements.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to properly label, date, and store potentially hazardous foods, as well as maintain kitchen equipment to prevent microbial growth. During an inspection, the surveyor observed several deficiencies in the kitchen. The can opener blade, shaft, and base were found to have sticky brown food particles, indicating it had not been cleaned as per the facility's policy. A large plastic bin of dry rice was found with a scooper left inside, which was against the standard practice. Additionally, a large bin of loose onions, some whole and some cut, were stored uncovered next to a trash can, which is not appropriate storage practice. Further observations included a bread toaster full of crumbs and debris, and three 25-pound tubs of beef base with brown debris on the lids. A 10-pound box of bacon was found without an open date, and the plastic covering was opened, exposing the meat to air. The facility's policies on equipment cleaning and food storage were not adhered to, as evidenced by these findings. The Regional Food Service Director acknowledged these issues during the surveyor's interview.
Incomplete Documentation of Medications and Treatments
Penalty
Summary
The facility failed to maintain complete medical records for three residents, as evidenced by missing documentation of medication and treatment administration. Resident #19, who was cognitively intact and had multiple diagnoses including end-stage renal disease and atrial fibrillation, had several medications not signed off as administered on specific dates in May 2024. These medications included atorvastatin, apixaban, colace, gabapentin, and others, which were left blank in the Medication Administration Record (MAR), indicating they were not given. Interviews with the LPN and DON confirmed that blanks in the MAR suggest the medications were not administered. Resident #131, who was at risk for pressure ulcers, had a deep tissue pressure ulcer on the right buttock. The Treatment Administration Record (TAR) for September and October 2023 showed missing documentation for wound care treatments on several dates. The care plan required treatments to be administered as ordered, and the facility's policy mandated documentation of treatments provided. Interviews with nursing staff and the DON confirmed that blanks in the TAR indicated treatments were not completed. Resident #182, admitted with a Stage III pressure ulcer, had a worsening condition to Stage IV. The TAR for April and May 2024 revealed missing documentation for sacral wound care treatments on multiple dates. The facility's policy required complete and accurate documentation of treatments, which was not adhered to in this case. Interviews with nursing staff and the DON reiterated the importance of documenting treatments to ensure they were completed, and the presence of blanks suggested non-compliance with treatment orders.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to transmission-based precautions (TBP) for infection control, as evidenced by multiple staff members not wearing personal protective equipment (PPE) when entering the room of a resident on contact isolation due to MRSA and VRE infections. Despite clear signage and available PPE, a CNA and a housekeeper entered the resident's room without donning the required gown and gloves. The CNA admitted to not reading the sign, while the housekeeper was unaware of the need for PPE unless performing direct patient care. The Infection Preventionist and Director of Nursing confirmed the importance of following TBP to prevent infection spread, yet staff failed to comply. Another deficiency involved the lack of a physician's order for contact precautions for a resident with a sacral wound infected with antibiotic-resistant bacteria. Although the resident's care plan indicated contact precautions, there was no corresponding physician's order. Staff interviews revealed that nurses should obtain such orders when placing residents on TBP, but this was not done, leading to inconsistencies in the implementation of precautions. Additionally, the facility did not maintain a resident's urinary catheter bag off the floor, as observed during the survey. The catheter bag was found in contact with the floor, contrary to the facility's policy, which requires the bag to be kept off the floor to prevent infection. Staff interviews confirmed the importance of this practice for infection control, yet it was not followed. Furthermore, during an influenza outbreak, the facility failed to test residents for influenza in accordance with CDC guidelines, despite several residents exhibiting symptoms and being sent to the hospital where they tested positive for influenza.
Failure to Provide Appropriate Clothing Protector
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident by not providing an appropriate clothing protector. Resident #24, who was admitted with diagnoses including depression and unspecified dementia with behavioral disturbances, was observed on two occasions with a shower blanket draped around their neck instead of a proper clothing protector. The resident, who was dependent on assistance for activities of daily living and had difficulty communicating, was seen drooling and mumbling, indicating a need for a clothing protector to maintain their dignity during meals. Interviews with staff revealed that the use of shower blankets, sheets, and towels as clothing protectors was a common practice since the new company took over, despite the availability of proper clothing protectors. The CNA and LPN both acknowledged the use of inappropriate items to protect the resident's clothing, and the LPN/UM confirmed that the supplies were accessible to all staff. The Director of Nursing also stated that using a shower blanket was not appropriate and recognized it as a dignity issue. The resident's care plan did not document any preference for using a shower blanket, and the facility's policy emphasized the importance of promoting dignity and self-worth for each resident.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for a resident who was admitted with diagnoses including acute respiratory failure with hypoxia, Alzheimer's Disease, and COPD. The resident's cognition was moderately impaired, and their care plan included an intervention to keep the family informed of changes in condition. On a specific date, the resident experienced a fever and diminished lung sounds, prompting the physician to order a urinalysis, urine culture, chest x-ray, and lab work. Despite these changes, there was no evidence that the resident's family was notified until the following day. Interviews with the Director of Nursing (DON) and the Licensed Practical Nurse/Unit Manager (LPN/UM) revealed that the facility's policy required families to be notified in real time of any change in condition. The DON acknowledged that the family should have been notified earlier, as per the facility's updated notification policy. The policy stated that the nurse or charge nurse must notify the resident's family or representative of significant changes in the resident's status and document this in the medical record. The failure to notify the family in a timely manner was identified as a deficiency by the surveyors.
Improper Disposal of Waste in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the improper disposal of soiled incontinence briefs and personal protective equipment. During a survey, a soiled incontinence brief was found in a garbage receptacle without a bag liner in a resident's room, and disposable gloves were left on the floor. Additionally, an overflowing closed-lid garbage receptacle with yellow disposable protective gowns was observed outside the same room. These observations were confirmed by the Environmental Services Supervisor, who acknowledged that the trash receptacles should have bag liners and that soiled briefs should not be placed in resident garbage cans. Interviews conducted during the survey revealed that the trash receptacle was being emptied by a family member at least once a day, indicating a lapse in the facility's housekeeping responsibilities. The Environmental Services Supervisor confirmed that housekeeping staff were responsible for removing trash bags daily and as needed. The facility's policy on routine cleaning and disinfection was reviewed, which stated the importance of maintaining a safe and sanitary environment to prevent infections. However, the observed practices did not align with this policy, leading to the identified deficiencies.
Failure to Update and Implement Communication Care Plan
Penalty
Summary
The facility failed to provide services according to a resident's communication needs as documented in the Care Plan (CP) and did not update the CP to accurately reflect these needs. The resident, who was admitted with diagnoses including depression and unspecified dementia with behavior disturbances, was observed to have difficulty communicating, with slurred and mumbled speech. Despite the CP indicating the use of a communication tablet and participation in a Speech Therapy (ST) maintenance program, these interventions were not being provided, and no communication devices were observed in the resident's room. Interviews with staff, including a Certified Nursing Assistant (CNA), Licensed Practical Nurses (LPNs), and the Licensed Practical Nurse Unit Manager (LPN/UM), revealed a lack of awareness and implementation of the communication interventions listed in the CP. The Speech Language Pathologist (ST) confirmed no involvement with the resident for communication needs, and the Director of Rehabilitation (DOR) indicated that the interventions were likely added by the Unit Manager without proper evaluation. The resident's Responsible Party also noted the absence of a communication tablet and suggested a need for evaluation by ST for alternative communication methods. The Director of Nursing (DON) acknowledged that the CP should have been updated quarterly to reflect the resident's current needs and confirmed that it was not an accurate reflection of the care being provided. The facility's policies on communication and care plans emphasized the need for accurate, updated CPs tailored to residents' needs, but these were not adhered to in this case, leading to the deficiency.
Failure to Properly Set Air Mattress and Investigate Pressure Ulcer
Penalty
Summary
The facility failed to ensure that an air mattress was accurately set according to a resident's weight, which was a contributing factor to the worsening of a pressure ulcer. Resident #182, who was admitted with a Stage III pressure ulcer and weighed 97 lbs, was observed multiple times with an air mattress set to 280 lbs. Despite a physician's order to monitor the air mattress for proper placement and functioning, the mattress was not adjusted to the resident's current weight of 85 lbs. Interviews with staff, including a CNA, LPN, and the Director of Nursing, confirmed that the responsibility for setting the mattress correctly lay with the nursing staff, yet this was not done, potentially impeding the healing process of the resident's pressure ulcer. The facility also failed to thoroughly investigate a facility-acquired pressure ulcer for another resident, Resident #131. This resident was admitted without any pressure ulcers, but a deep tissue pressure ulcer was identified shortly after admission. Despite the facility's policy requiring incident reports and investigations for new pressure ulcers, no incident report was completed for Resident #131. Interviews with staff, including a CNA, LPN, and the Director of Nursing, indicated that the standard procedure was to complete an incident report and gather statements from staff when a new pressure ulcer was identified, but this was not followed in this case. The facility's policies on support surfaces and incident reporting were not adhered to, leading to deficiencies in the care and investigation of pressure ulcers for the residents involved. The lack of proper mattress settings and failure to investigate new pressure ulcers as per the facility's guidelines contributed to the identified deficiencies.
Inadequate Enteral Feeding Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving enteral feeding, leading to several deficiencies. The resident, diagnosed with unspecified severe protein-calorie malnutrition, had an order for enteral feeding to be administered via a pump. However, the surveyor observed the enteral feeding pump running while disconnected from the resident, causing nutritional formula to drip onto the floor. This was confirmed by the LPN/Unit Manager, who acknowledged that the feeding tube should have been connected to the resident. Additionally, the facility did not adhere to proper hygiene and equipment replacement protocols. The surveyor noted dried formula residue on the base of the pole supporting the enteral feeding pump and an irrigation syringe on the bedside table that had not been replaced within the required 24-hour period. The LPN and the Vice President of Clinical Services confirmed that the syringes should be changed daily and that the feeding formula should not run while disconnected from the resident. These observations indicate a failure to follow the facility's policy on providing adequate nutritional support through enteral feeding.
Deficiency in Narcotic Shift Count Logs and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, as observed by surveyors on two of three medication carts. During medication storage observations, it was found that the narcotic shift count logs for the Seabreeze nursing unit's medication Cart 3 were missing nursing signatures for several shifts in May 2024. Licensed Practical Nurse #1 confirmed that signatures were required to indicate that the incoming and outgoing nurses had counted and reconciled the controlled substances at the change of shift. Similarly, the Starlight nursing unit's medication Cart 1 also had missing signatures for specific shifts, which was acknowledged by Licensed Practical Nurse #2. Additionally, it was noted that LPN #2 administered alprazolam to a resident but failed to sign it out on the narcotic declining inventory sheet, although it was recorded in the resident's electronic Medication Administration Record. The Director of Nursing confirmed that there should be no missing signatures or documentation on the narcotic shift count log and that the declining inventory log should be updated by the administering nurse at the time of dispensing. The facility's Controlled Substance policy requires compliance with laws and regulations related to handling, storage, disposal, and documentation of controlled substances, including the requirement for nursing staff to count controlled medications at the end of each shift.
Medication Security Deficiencies
Penalty
Summary
The facility failed to properly secure medications during administration, as observed with two nurses. One nurse left a bottle of docusate sodium unsecured on top of a locked medication cart while administering medications to a resident. Another nurse left a medication cart unlocked in the hallway while attending to a resident's blood pressure, acknowledging the oversight but continuing with the task before securing the cart. The Director of Nursing confirmed that medication carts should be locked when unattended, and medications should not be left unsecured. Additionally, the facility did not properly secure a resident's home supply medications. A resident was observed with a bottle of Tylenol and an albuterol inhaler in an unlockable drawer in their room. The resident stated that the facility was aware of this arrangement. However, the LPN Unit Manager indicated that residents should be assessed and approved by a physician to self-administer medications, and such medications should be secured. The resident in question had not been assessed or approved for self-administration, and their medical record did not reflect any such authorization. The facility's policies on administering and storing medications require that medication carts be locked when not in use and that unauthorized medications found at the bedside be secured by nursing staff. The resident involved had a moderate cognitive impairment, as indicated by their BIMS score, and there was no care plan in place for self-administration of medications. The facility's failure to adhere to these policies resulted in unsecured medications both during administration and in the resident's room.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Program committee meetings. This deficiency was identified during a review of the quarterly QAPI meeting sign-in sheets and interviews with facility staff. Specifically, the Infection Preventionist (IP) was not present at the QAPI meeting held on April 18, 2024, as confirmed by both the Licensed Nursing Home Administrator (LNHA) and the IP herself, who stated she was conducting wound rounds at the time of the meeting. Additionally, the Director of Nursing (DON) was absent from two of the four meetings reviewed, specifically those held on July 26, 2023, and January 22, 2024. The DON confirmed her absence from the January meeting due to having to leave early. The facility's policy and procedure for the QAPI Program, updated in November 2022, requires the presence of specific individuals, including the Administrator, Director of Nursing Services, Medical Director, and Infection Preventionist, at these meetings. The LNHA acknowledged the absence of the required members and confirmed the discrepancies in the attendance records. The failure to have the required members present at the QAPI meetings is a violation of the facility's policy and regulatory requirements, as outlined in NJAC 8:39-33.1(b).
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.
Trusted data from CMS and state health departments
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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