Complete Care At Fair Lawn Edge
Inspection history, citations, penalties and survey trends for this long-term care facility in Paterson, New Jersey.
- Location
- 77 East 43rd Street, Paterson, New Jersey 07514
- CMS Provider Number
- 315331
- Inspections on file
- 14
- Latest survey
- December 29, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Complete Care At Fair Lawn Edge during CMS and state inspections, most recent first.
A facility failed to implement a procedure for the safe acquisition and receipt of Methadone, a controlled substance, by assigning an unlicensed CNA to pick up and transport Methadone from an outside clinic for several residents. The CNA used a locked box and key, transported the medication in a personal vehicle, and delivered it to nursing staff, despite facility policy requiring controlled substances to be handled by a licensed nurse. Interviews confirmed the absence of a specific policy for this process.
Surveyors observed multiple deficiencies in environmental cleanliness and safety, including stained tiles, peeling safety strips, accumulation of dust and substances on vents, and lack of privacy curtains in shower rooms. Staff interviews confirmed these areas should have been maintained according to facility policy, but required cleaning and repairs were not completed.
Two residents did not receive medications in accordance with physician orders: one did not receive pain medication prior to wound care as ordered, and another received a medication with blood pressure and heart rate parameters without required documentation of those vitals at the time of administration. Nursing staff and management confirmed that orders were not followed or clarified, and facility policy requiring adherence to physician orders and documentation of vital signs was not met.
A resident with COPD and asthma did not receive required follow-up care, including a pulmonology consult and a CT scan, as ordered after hospital discharge. Although physician orders and facility policy required these services, there was no documentation that the consult or scan occurred, nor any explanation for the missed appointments. Facility leadership confirmed the lack of records and were unable to account for the missed follow-up care.
Surveyors identified failures in infection prevention and control, including dusty fans blowing onto uncovered clean linens and resident clothing, cluttered and unclean laundry and linen storage areas, and improper disposal of used items such as a surgical mask and washcloth. Staff confirmed that these practices did not meet facility policy for sanitary handling and storage of linens and waste.
A resident was transferred to another facility without receiving the required Notice of Medicare Non-coverage (NOMNC) within the mandated timeframe. Review of records and staff interviews confirmed that the NOMNC was either missing or dated incorrectly, and staff could not provide a valid explanation for the discrepancy.
The facility failed to supervise and secure two exit-seeking residents, resulting in their elopement. One resident with severe cognitive impairment exited through an unsecured door, while another resident with discontinued out-of-pass privileges was allowed to go outside without verification. Both incidents highlight lapses in supervision and policy adherence.
The facility failed to properly store and label medications, as observed during an inspection of a medication cart. An opened bottle of Acetylcysteine 20% was found without a label or documentation of the date and time it was opened. The medication was believed to belong to a resident with orders for Acetylcysteine inhalation every 6 hours. The Director of Nursing could not explain the improper storage.
The facility failed to provide the mandatory annual dental care services for a resident who had intact cognition and multiple diagnoses, including Depression and Hypertension. Despite being a Medicaid recipient, there was no documentation of dental visits or refusals since the resident's admission.
The facility failed to maintain proper kitchen sanitation and food storage practices. Boxed items were stacked above 18 inches from the ceiling in the walk-in freezer, and a Dietary Chef used a non-disinfected thermometer to check the temperature of ground pork, leading to contamination.
The facility failed to maintain proper infection control practices during medication administration. An LPN on the 3rd floor did not scrub his soapy hands away from running water before rinsing, and another LPN on the 4th floor scrubbed her hands for only 5 seconds instead of the required 20 seconds. Both LPNs could not explain their actions.
The facility failed to adhere to acceptable standards of nursing practice, including improper medication preparation, failure to adjust medication times for a dialysis patient, incorrect oxygen administration, and delayed implementation of dietician recommendations.
The facility failed to maintain proper infection control during a pressure ulcer treatment, did not administer zinc oxide as ordered, and neglected to conduct quarterly Braden Scale assessments for a resident with multiple health issues.
Unlicensed Staff Assigned to Retrieve and Transport Methadone
Penalty
Summary
The facility failed to develop and implement a procedure for the safe acquisition and receipt of physician-ordered Methadone, a controlled substance, from a third-party clinic. Instead, the facility assigned an unlicensed staff member, a Certified Nursing Assistant (CNA), to travel to the outside clinic to pick up Methadone for multiple residents. The CNA transported the Methadone in a locked box with the key in her possession, using her personal vehicle, and delivered it to the facility's nursing staff. Interviews with the CNA, the Director of Nursing (DON), and review of facility documents confirmed that this practice occurred over several weeks, and that there was no specific policy or procedure in place for this process. The facility's existing policy stated that controlled substances should be delivered and signed for by a licensed nurse, but this was not followed in the case of Methadone pickups from the clinic. Further interviews revealed that the consultant pharmacist did not consider the Methadone clinic under his jurisdiction, and the DON acknowledged the lack of a specific policy for Methadone retrieval, relying instead on a general narcotic policy. Nursing staff interviewed stated that CNAs should not handle or deliver narcotics or any type of medication, as they are not licensed to do so. The facility's corporate office also lacked a specific policy for this process. The deficiency was identified through observations, interviews, and document reviews conducted by surveyors, and was cited under relevant state regulations.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by multiple observations on both the 3rd and 4th floors, including both shower rooms. During a tour with the Housekeeping Director, the surveyor observed a shower chair with a ripped cover, a plastic tray on the floor, stained wall tiles and moldings, peeling safety strips in several shower cubicles, and significant discoloration and staining on ceiling tiles. The soiled utility room also had ceiling tiles with brownish discoloration. The 4th floor clean linen room and pantry area were found with heavy accumulations of grayish substances on ceiling vents, and the eyewash area in the nursing station had a heavy accumulation of dust. In the 4th floor dining room, a vent above two residents seated near vending machines was observed with a heavy accumulation of blackish substances, with a total of ten residents and two staff present in the room at the time. Interviews with the Housekeeping Director, RN/Unit Manager, LPN Supervisor, and Assistant Director of Nursing confirmed that these areas should have been cleaned and maintained according to facility policy. Facility documentation, including the Safe and Homelike Environment Policy and Routine Bathroom/Shower Cleaning Policy, outlined requirements for maintaining a sanitary, orderly, and comfortable environment, but these were not followed as evidenced by the observed deficiencies. No specific medical history or conditions of the residents involved were noted in the report.
Failure to Follow Physician Orders and Document Medication Parameters
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice by not adhering to physician orders for medication administration and by not clarifying ambiguous orders for two residents. In the first instance, a resident with Alzheimer's disease, diabetes mellitus, and a stage 4 sacral pressure ulcer had a physician's order for tramadol to be administered before wound care. However, documentation showed that the pain medication was only given once daily in the morning, while wound treatments were performed during the evening and night shifts, contrary to the physician's order. The LPN assigned to the resident's care confirmed that the order should have been clarified since the wound care was not performed on the day shift, and the medication was not administered as intended prior to the wound treatment. In the second instance, another resident with heart failure, hypertension, and benign prostatic hyperplasia had a physician's order for finasteride with specific parameters to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the medication administration records over several months revealed that nurses documented administration of the medication but did not record the required blood pressure and heart rate at the time of administration. Interviews with nursing staff and management confirmed that it was expected for nurses to check and document these vital signs per the physician's order, but this was not consistently done. The lack of documentation meant there was no evidence that the medication was administered in accordance with the specified parameters. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require medications to be administered as ordered by the physician and for vital signs to be recorded when medications have specific parameters. The facility's own policies also state that medications must be given in accordance with orders, including any required time frames, and that vital signs should be documented on the medication administration record when applicable.
Failure to Provide Physician-Ordered Follow-Up Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care as specified by hospital discharge orders and physician instructions, in accordance with professional standards and facility policies. The resident, who had a history of COPD with acute exacerbation and asthma, was discharged from the hospital with instructions for follow-up care, including a pulmonology consult within one month and a follow-up CT scan in July. Physician orders were present in the medical record for these follow-ups, and the facility's policy required timely requests for such services. Despite these orders, there was no documentation that the resident received the required pulmonology consult or the follow-up CT scan. The DON and other facility leadership confirmed that while attempts were made for the pulmonologist to see the resident, there was no record of the resident being unavailable or of the consult being completed. Similarly, there was no documentation explaining why the CT scan was not performed as ordered. The lack of documentation and follow-through on these physician-ordered services constituted a failure to provide care according to the resident's needs and professional standards. Interviews with facility staff, including the DON and the Regional VP of Clinical Services, revealed that they were unaware of the reasons for the missed appointments and acknowledged the absence of required documentation. The facility's own policies emphasized the importance of providing physician-ordered services and maintaining proper records, but these were not followed in this instance, resulting in the identified deficiency.
Deficient Infection Control in Linen, Laundry, and Waste Handling
Penalty
Summary
The facility failed to ensure proper handling and storage of linen and laundry, as well as proper disposal of garbage, in accordance with infection prevention and control standards and the facility's own policies. During a tour of the laundry area, surveyors observed an electric fan with heavy dust accumulation blowing air toward uncovered, clean resident clothing, and a floor littered with crumpled papers, candy wrappers, and dust. The laundry folding table, intended for clean clothes, was cluttered with personal items, food, and miscellaneous objects. Both the laundry staff and the Housekeeping Director confirmed these observations and acknowledged that the conditions did not meet cleanliness expectations. In the clean linen room, another electric fan with significant dust buildup was found blowing air onto uncovered, clean linens, blankets, towels, and gowns. The floor was also dusty, and a used surgical mask was found discarded on the floor. Additionally, three ceiling tiles showed dried brownish discoloration, identified as water condensation, directly above clean, uncovered linens. The Housekeeping Director confirmed that the fan should have been cleaned, garbage should not be on the floor, and the linens were now considered contaminated due to dust exposure. During inspection of a shower room, a wet, used washcloth was found on the floor of a shower cubicle, which the Housekeeping Director stated should have been properly disposed of by the CNA after use. The Infection Preventionist Nurse acknowledged responsibility for environmental rounds but did not provide an explanation for why these deficiencies were not previously identified. The facility's policy requires clean linen to be handled, stored, and transported in a sanitary manner to prevent contamination, which was not followed in these instances.
Failure to Provide Timely Notice of Medicare Non-Coverage Prior to Resident Transfer
Penalty
Summary
The facility failed to issue the required Notice of Medicare Non-coverage (NOMNC) or Form CMS-10123 to a resident who was being transferred to another healthcare facility. Review of the resident's progress notes indicated a transfer occurred, but there was no documented evidence in the electronic medical record that the NOMNC was completed or any explanation for its absence. The physician certification and re-certification form was reviewed, and a NOMNC letter was provided by the Licensed Nursing Home Administrator (LNHA), but the dates on the letter did not align with the resident's actual discharge date. The NOMNC letter was signed by the resident with a date that was after the actual transfer, indicating the notice was not provided within the required timeframe. Interviews with facility staff, including the Director of Social Services (DSS), LNHA, and Director of Nursing (DON), confirmed that the NOMNC should have been signed at least two days prior to discharge, but this did not occur. The DSS could not provide an explanation for the incorrect date, and the LNHA acknowledged that the date should have been checked before the resident signed the form. The DON confirmed that the resident left for another nursing home and that the NOMNC should have been completed, but it was not done in accordance with regulatory requirements.
Failure to Supervise and Secure Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired, exit-seeking resident, resulting in the elopement of Resident #353. The resident, who had severe cognitive impairment and a history of exit-seeking behavior, was able to leave the facility through an unsecured exit door. The door was left unsecured because a staff member deactivated the alarm system to access the dumpster area, allowing the resident to exit the facility. The resident was found several blocks away from the facility, adjacent to a wide, double-lane roadway, posing a serious and immediate risk to their health and safety. Additionally, the facility failed to follow its elopement policy, which resulted in the elopement of Resident #355. Despite the resident's out-of-pass (OOP) privileges being discontinued, the front desk receptionist allowed the resident to go outside to smoke without verifying with the nursing staff. The resident subsequently eloped and was later arrested due to an outstanding warrant. The receptionist did not follow the facility's policy of confirming OOP status with the nursing staff and ensuring that residents only smoked in designated areas. Both incidents highlight significant lapses in the facility's supervision and security measures, as well as failures to adhere to established policies for managing residents at risk of elopement. These deficiencies resulted in immediate jeopardy situations, endangering the residents involved.
Removal Plan
- Door monitor initiated
- Elopement and wandering residents' policy reviewed
- In-service education with all staff on Identification of Residents at Risk for Elopement, Elopement and Wandering policies
- Daily door checks initiated
- Ongoing education to staff regarding elopement precautions and policies, keypad access doors and door safety education
- Weekly inspection of exit doors and function
- Quality assurance performance improvement project to review and interpret all audit findings
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and accurately label medications, as observed during an inspection of the 2nd floor low medication cart. The surveyor found an opened 10ml bottle of Acetylcysteine 20% that was not labeled and lacked documentation of the date and time it was opened. The bottle's label indicated it should be stored in a refrigerator after opening and discarded after 96 hours. The 2nd floor UM/LPN confirmed that the medication should not have been stored without a label, date, or time opened. The Director of Nursing could not explain why the medication was stored improperly. The medication was believed to belong to a resident who had an order for Acetylcysteine Solution 20% 10 ml to be inhaled via nebulizer every 6 hours for mucous secretions. The resident was admitted with diagnoses including Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. The resident's Comprehensive Minimum Data Set (MDS) indicated an intact cognition with a BIMS score of 15 out of 15. The deficiency was noted during a review of the resident's electronic medication administration record (eMAR) and confirmed by the surveyor's interview with the staff.
Failure to Provide Annual Dental Care Services
Penalty
Summary
The facility failed to provide the mandatory annual dental care services for a resident. Resident #56, who was admitted to the facility on 2/9/2023 and was a recipient of Medicaid effective 3/19/23, did not receive an annual examination and treatment by a dentist. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15 out of 15, had diagnoses including Depression, Post Traumatic Stress Disorder, Anorexia, Hypertension, and a Fracture of the left femur. Despite these conditions, there was no documentation of dental visits or refusals of dental visits. This deficiency was confirmed by the facility's Regional Registered Nurse on 4/23/24.
Improper Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store potentially hazardous foods correctly, leading to a risk of foodborne illness. During a kitchen inspection, the surveyor observed multiple boxed items stacked above 18 inches from the ceiling inside the walk-in freezer. The Food Service Director (FSD) acknowledged the issue and stated that the boxes would be rearranged to comply with storage guidelines. Additionally, during lunch meal preparation, the Dietary Chef (DC) checked the temperature of ground pork using a non-disinfected thermometer. The FSD had handed the thermometer to the DC, who then used it without disinfecting the probe. When questioned, the DC assumed the FSD had disinfected the thermometer. The FSD admitted fault and stated that the ground pork would be discarded due to contamination. Facility policies reviewed by the surveyor confirmed the requirement for proper storage and sanitation practices, which were not followed in these instances.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed by the State Surveyor. On the 3rd floor, an LPN was seen putting his soapy hands immediately under running water without scrubbing them away from the water first. The LPN could not explain why he did not follow the proper handwashing procedure. Similarly, on the 4th floor, another LPN scrubbed her soapy hands for only 5 seconds away from the water before rinsing them clean, instead of the required 20 seconds. This LPN also could not explain why she did not adhere to the handwashing policy. The facility's Handwashing/Hand Hygiene Policy requires that hands be vigorously lathered with soap and rubbed together for a minimum of 20 seconds before rinsing thoroughly under running water. The Director of Nursing and the Assistant DON were informed of these observations, and medpass evaluations for the involved LPNs were provided, showing that requirements were met during previous evaluations. However, no further information was provided to explain the deficient practice observed during the survey.
Multiple Deficiencies in Nursing Practice
Penalty
Summary
The facility failed to adhere to acceptable standards of nursing practice, as evidenced by multiple deficiencies observed by the surveyor. One significant issue involved the improper preparation of medications for administration. An LPN was found to have prepared medications for four residents in advance, stacking the medication cups on top of each other without proper labeling. This practice led to confusion and the inability to identify the medications and residents without referring to the electronic medication administration record (eMAR). Additionally, the LPN failed to sign out controlled substances from the inventory sheet when removed, which is against the facility's policy and best practices for medication administration. Another deficiency was identified in the scheduling of medication times for a resident undergoing dialysis. The resident's medication times were not adjusted to accommodate their dialysis schedule, resulting in missed doses. The facility's protocol requires medications to be scheduled around dialysis times, but this was not followed, leading to multiple instances where the resident did not receive their prescribed medication. The facility's policy on hemodialysis did not include guidelines for adjusting medication times, contributing to this oversight. The facility also failed to administer oxygen according to the physician's order for one resident. The resident was observed receiving oxygen at a rate of 8 liters per minute, contrary to the physician's order of 2 liters per minute. The LPN responsible for the resident confirmed the discrepancy but did not provide an explanation for the incorrect administration rate. Additionally, the facility did not act upon the recommendations made by the Registered Dietician in a timely manner for a resident with a feeding tube. The recommendations for adjusting the resident's nutritional intake and hydration were not entered into the electronic medical record as active orders, leading to a delay in the resident receiving the appropriate care.
Failure to Maintain Infection Control and Conduct Required Assessments
Penalty
Summary
The facility failed to maintain proper infection control practices during the treatment of a pressure ulcer for Resident #25. During the treatment, the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) did not perform handwashing prior to the start of the treatment and did not change gloves after cleaning the pressure ulcer before applying the dressing. Additionally, the foam dressing used was not from a new, unopened package, and the overbed table used during the treatment was not disinfected afterward. These actions were confirmed by the ADON during an interview with the surveyor. Resident #25, who was admitted with diagnoses including anemia, Type 2 diabetes mellitus with hyperglycemia, and severe protein-calorie malnutrition, had a significant change in status with an unstageable pressure ulcer that was not present on admission. The resident's Treatment Administration Record (TAR) indicated that zinc oxide was to be applied to the sacrum every shift as a preventative measure. However, there were multiple instances where the TAR was left blank, indicating that the zinc oxide was not administered as ordered. Furthermore, the facility failed to conduct quarterly Braden Scale for Predicting Pressure Sore Risk (BSFPPSR) assessments for Resident #25. The last documented BSFPPSR assessment was in March 2023, with no quarterly assessments recorded for the rest of the year. This was confirmed by the Unit Manager/LPN and the Director of Nursing (DON), who acknowledged that the assessments were not completed as required. The facility's policies on wound care and assessment frequency were not adhered to, leading to these deficiencies.
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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