Complete Care At Inglemoor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Englewood, New Jersey.
- Location
- 333 Grand Ave, Englewood, New Jersey 07631
- CMS Provider Number
- 315349
- Inspections on file
- 13
- Latest survey
- November 7, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Complete Care At Inglemoor, Llc during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses and severe cognitive impairment experienced episodes of sedation and lethargy, with medications being held and changes in treatment occurring. Nursing staff documented these changes but did not notify the physician or the resident's representatives as required by facility policy. The deficiency was confirmed through record review and interviews with the DON.
A resident with severe malnutrition and cognitive impairment was not monitored with weekly weights as ordered by the physician and required by facility policy. Despite clear orders and standards, nursing and dietary staff failed to document or complete weekly weights for four weeks after admission, resulting in noncompliance with professional standards of practice.
A resident with multiple complex diagnoses had several instances where medications were held, but nursing staff failed to document the reasons in the Progress Notes as required. Additionally, unit assignment records for certain dates and shifts were missing, and facility leadership confirmed the incompleteness of the medical records and lack of a relevant policy.
The facility failed to maintain proper kitchen sanitation, resulting in a repeat deficiency. Observations included a stove backsplash with thick grease, a stand-up oven with grease buildup, and a freezer with frost accumulation. The FSD admitted the conditions were unacceptable, and there was no log or schedule for cleaning tasks, contrary to the facility's policy.
The facility failed to clarify physician orders and sequence PRN medications according to pain severity for several residents, leading to medication administration issues. Additionally, during medication pass observations, the facility did not ensure the availability of prescribed medications, resulting in the use of non-equivalent substitutes.
A facility failed to ensure a physician reviewed and signed orders for a resident, resulting in a deficiency. The orders were overdue for 982 days, and the resident had multiple medical conditions, including diabetes and heart failure. The physician's progress notes lacked a medication review, and the LPN was unsure of the process for signing orders. The DON confirmed the oversight, and the facility's policy aimed to ensure quality physician-ordered services.
The facility failed to maintain complete and accurate medical records for several residents, with discrepancies and omissions noted in documentation related to residents' conditions and Facility Reported Events (FREs). For one resident, there was a discrepancy between the DON's and APN's notes regarding extremity limitations. Other residents' records lacked documentation of FREs, with no mention of events or investigations in progress notes, despite facility policy requiring such documentation.
A resident with severe cognitive impairment and requiring maximal assistance was found to have their call bell on the floor, out of reach, after morning care. The CNA confirmed the call bell should have been accessible, but it was not. The facility's policy mandates that call bells be within reach of residents.
A facility failed to accurately document and review a resident's advance directives, resulting in a discrepancy between the resident's EMR, which indicated DNR/DNI, and a POLST form indicating a desire for resuscitation/CPR and DNI. The resident, who was cognitively intact, had diagnoses including respiratory failure and heart failure. The oversight was acknowledged by the DON, highlighting a failure in communication and verification of the resident's wishes.
A resident sustained a cut to the left eyebrow when an overbed table hit them, and the facility failed to conduct a thorough investigation into the incident. The CNA involved reported the incident as accidental, but the investigation lacked individual witness statements and supportive documentation. The facility's administration could not provide comprehensive records, and the investigation did not meet the standards outlined in their policies.
A facility failed to accurately code the MDS for a resident, leading to a deficiency. The resident, with multiple medical conditions including Alzheimer's and a recent fracture, was not accurately represented in the MDS regarding their non-weight bearing status. The facility lacked a specific MDS policy, relying on the RAI manual, which contributed to the error.
A facility failed to update a care plan and clarify a physician's order for a resident with a fractured right 5th metatarsal, leading to discrepancies in weight-bearing status. Additionally, a fall investigation was incomplete as it lacked a statement from the Maintenance Staff who found the resident on the floor. The resident had multiple medical conditions, including Alzheimer's Disease and difficulty walking, with moderately impaired cognition.
The facility failed to obtain weights for a resident according to physician's orders and policy, resulting in unmonitored significant weight loss. Additionally, the facility did not monitor or document fluid intake for another resident with fluid restrictions, as required by physician's orders. These deficiencies were identified through observations, interviews, and record reviews.
A facility failed to properly manage nebulizer equipment for a resident, resulting in a deficiency in respiratory care. The nebulizer mask was found uncovered and not changed since 2/18/25, contrary to the facility's policy of weekly changes. Staff were unsure of the policy, and there was no physician's order for the weekly change or a care plan for respiratory care. The facility's policy did not address proper storage of nebulizer equipment.
A surveyor observed that medication and medical supply storage cabinets on the second floor were not locked, contrary to the facility's policy and standards of practice. The LPN confirmed the cabinets should be locked but was unable to secure them. The Consultant Pharmacist and facility administrators acknowledged the need for secure storage to prevent unauthorized access.
A resident with type 2 diabetes and intact cognition was not offered or documented for influenza and pneumococcal vaccines, despite facility policies requiring such actions. The electronic medical records lacked evidence of vaccine offers, consent forms, or education provided. Interviews with staff confirmed the absence of documentation, and the issue was communicated to the LNHA and DON without additional response.
A resident with intact cognition and medical conditions including diabetes and malnutrition was not offered a COVID-19 vaccine, nor was there documentation of vaccine education or consent in their records. Interviews with facility staff confirmed the lack of documentation and adherence to the facility's vaccination policy.
A nurse in an LTC facility involuntarily confined a resident by attaching a hospital gown to the doorknob and handrail, preventing the resident from leaving their room. The resident, who had moderate cognitive impairment and a history of elopement risk, was found asleep in their room when the door was opened. The nurse claimed the action was to prevent wandering, but it violated the facility's policy against involuntary seclusion.
Failure to Notify Physician and Resident Representatives of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the resident's representatives of significant changes in a resident's condition and status. The resident in question had multiple diagnoses, including type 2 diabetes mellitus, unspecified psychosis, severe protein-calorie malnutrition, and dementia with agitation, and was noted to have severely impaired cognition. Documentation in the medical record showed that the resident experienced episodes of sedation, lethargy, and required assistance with feeding and medication administration. On several occasions, nursing staff documented that the resident was sedated, medications were held, and the resident's condition deviated from their baseline. Despite these changes, there was no documented evidence that the resident's representatives or the physician were notified of the resident's altered condition, including when the resident was sedated, medications were withheld, or when there were changes in medication orders. The facility's own policy required prompt notification of the resident, physician, and resident representative in the event of significant changes in condition or treatment, such as deterioration in health or the need to alter treatment due to adverse consequences. However, the medical record lacked documentation of such notifications during the periods when the resident's condition changed. Interviews with the Director of Nursing confirmed that the expectation was for nursing staff to notify the resident's representatives and physician of any significant change in condition, including lethargy or sedation outside the resident's norm, and to document this communication. The surveyors found no additional information or documentation to indicate that the required notifications had occurred, confirming the deficiency in following notification protocols as outlined in facility policy and regulatory requirements.
Failure to Monitor Weekly Weights for Malnourished Resident
Penalty
Summary
A resident with severe protein-calorie malnutrition, dementia with agitation, persistent mood disorders, and unspecified psychosis was admitted/readmitted to the facility from a geriatric psychiatric hospital. The resident was assessed as severely malnourished and underweight, with a physician's order for weekly weights for four weeks upon admission/readmission, a regular diet, and Ensure Plus twice daily as a supplement. The facility's policy and the Registered Dietitian's standard of practice also required weekly weight monitoring for newly admitted residents. However, a review of the electronic medical and treatment administration records revealed that weekly weights were not documented for the resident as required. Interviews with the DON and RD confirmed that the weekly weights were not completed according to the physician's order and facility policy. The DON acknowledged the omission, and the RD stated that she typically only monitored monthly weights, despite the requirement for weekly monitoring in this case. The facility's weight monitoring policy specified that newly admitted residents should have weights taken on admission and then weekly for four weeks, which was not followed for this resident.
Incomplete Medical Records and Missing Documentation for Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by professional standards. Review of the closed medical record revealed that the resident, who had multiple diagnoses including type 2 diabetes, psychosis, severe malnutrition, and dementia with agitation, had several medication orders documented in the electronic Medication Administration Record (eMAR). However, on multiple occasions when medications such as lorazepam, mirtazapine, trazodone, and Ativan were held, there was no corresponding documentation in the Progress Notes by nursing staff explaining the reasons for holding the medications. Specific dates and times were identified where the eMAR indicated medications were not administered, but the required explanatory notes were missing. Additionally, the facility was unable to provide complete unit assignment records for certain dates and shifts, which the Director of Nursing (DON) confirmed were considered part of the residents' medical records. The DON acknowledged that the medical records should be complete and was unable to provide a policy regarding medical records when requested. The incomplete documentation and missing records were confirmed during interviews with the DON and the President of Clinical Services.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation in the kitchen, leading to a repeat deficiency. During an inspection, the surveyor observed several unsanitary conditions, including a main stove backsplash covered with a heavy, dry, thick brown substance identified as grease, which was not effectively cleaned by the Food Service Director (FSD). Additionally, a stand-up oven had a dry, white substance splattered on its side, and its interior was coated with thick, grease-like substances, particularly around the fan. The FSD acknowledged that the oven should not be in such a condition. Furthermore, a large ice cream freezer was found with frost accumulation around its upper edge, which the FSD admitted should not be present. The facility's cleaning practices were scrutinized, revealing that stoves and ovens were cleaned every two weeks and as needed, but there was no log or schedule indicating when the equipment was last cleaned. The FSD mentioned that cleaning tasks were written on the dietary staff's daily assignments, but the schedule provided did not specify the last cleaning dates for the stove, oven, and freezer. The facility's General Kitchen Cleaning Policy, revised in February 2024, mandates that cleaning and sanitation tasks be recorded, which was not adhered to, contributing to the deficiency.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
The facility failed to clarify physician orders for two residents, leading to medication administration issues. For one resident, the physician's orders for Ibuprofen and Tylenol did not specify the total milligrams for the prescribed doses, which was not clarified until the surveyor brought it to the attention of the Director of Nursing (DON). Another resident had a similar issue with unclear orders for Pantoprazole, Sertraline, and PRN pain medications, which were not clarified until after the surveyor's intervention. Additionally, the resident's enteral feeding order lacked a specified total volume, which was not addressed until the resident returned from the hospital. The facility also failed to sequence PRN medications according to pain severity for three residents. One resident receiving hospice care had PRN orders for morphine and acetaminophen that did not specify the pain level for administration. The Licensed Practical Nurse (LPN) acknowledged the lack of clarity in the orders and intended to discuss it with the DON. Another resident had similar issues with PRN orders for Tylenol and Morphine Sulfate, which were not sequenced according to pain severity, leading to potential confusion in pain management. During medication pass observations, the facility failed to ensure medications were available for two residents. One resident was supposed to receive ACT mouthwash, but it was not available, and a different mouthwash was used instead. Another resident was to receive Lactobacillus Rhamnosus, but a different probiotic was administered due to a lack of availability. These discrepancies were noted by the surveyor, and the facility's Consultant Pharmacist confirmed that the substituted products were not equivalent to the prescribed medications.
Physician Order Review Deficiency
Penalty
Summary
The facility failed to ensure that a physician reviewed and signed the orders for a resident, leading to a deficiency in physician services. The orders, which included medications and treatments, were overdue for review by 982 days. This issue was identified for one resident who had multiple medical diagnoses, including type 2 diabetes mellitus, gastrostomy status, and chronic systolic heart failure. The resident's cognition was severely impaired, as indicated by a BIMS score of 1 out of 15. The surveyor observed that the physician's progress notes did not reflect a review of all medications for the resident. Additionally, the Licensed Practical Nurse was unsure of the facility's process for signing monthly and telephone orders. The Director of Nursing confirmed that the physician had not signed the monthly orders for 982 days, and the notes did not include a medication review. The facility's Physician Services Policy was reviewed, which aimed to provide a reliable process for physician-ordered services according to professional standards of quality.
Deficient Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents, as evidenced by discrepancies and omissions in documentation. For Resident #6, there was a noted discrepancy between the Director of Nursing's (DON) progress notes and those of the Advanced Practice Nurse (APN) regarding the resident's extremity limitations. The DON's notes indicated limitations in the left upper and right lower extremities, which were not reflected in the APN's notes. This inconsistency was acknowledged by the DON, who stated that the limitations had been present since admission. For Resident #40, the medical record lacked documentation related to a Facility Reported Event (FRE) on 11/16/24. Although a nurse's assessment note mentioned a room transfer due to medical necessity, there was no further documentation or investigation related to the FRE in the progress notes from any department. Similarly, for Resident #24, there was no mention of the FRE or any related investigation in the progress notes, despite a psychiatric consult indicating an incident corresponding to the FRE. Resident #36's medical record also lacked documentation of an FRE on 12/23/24, with no mention of the event or investigation in the progress notes. The record did include assessments and a room transfer related to the timeframe, but no specific details about the FRE. For Resident #3, the medical record did not contain any mention of the FRE or related investigation, and the facility could not provide additional progress notes. The facility's policy required staff to document incidents in the electronic medical record, but the investigations were kept in separate files, not integrated into the medical records.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach, which is a requirement for residents who need assistance and can use a call bell. This deficiency was observed for one resident who had severe cognitive impairment and required maximal assistance with activities of daily living. During a survey, the call bell was found on the floor, out of the resident's reach, after morning care was provided by a CNA. The resident indicated that they would call for help by shouting, as the call bell was not accessible. The surveyor confirmed the call bell's position on the floor during multiple visits to the resident's room. The CNA acknowledged the call bell should have been within the resident's reach but did not know how it ended up on the floor. The facility's policy requires call bells to be positioned conveniently for use and within reach of residents. The deficiency was reported to the LNHA and other facility leaders, who acknowledged the expectation for call bells to be accessible to residents.
Failure to Accurately Document and Review Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with diagnoses including respiratory failure, chronic obstructive pulmonary disease, and heart failure. The resident was cognitively intact with a BIMS score of 13 out of 15. The resident's electronic medical record (EMR) indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, while a paper chart contained a POLST form signed by the resident and a physician, indicating a desire for resuscitation/CPR and DNI. This discrepancy was not identified or corrected by the facility staff. The Director of Nursing (DON) and social services staff were responsible for determining and documenting the resident's code status upon admission. However, there was a lack of communication and verification regarding the resident's wishes, as the POLST form completed by the resident was not reflected in the EMR. The DON acknowledged the oversight and the need for clarification of the resident's code status. The facility's policy required that the plan of care be consistent with the resident's documented treatment preferences, which was not adhered to in this case.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who sustained a cut to the left eyebrow. The incident occurred when a Certified Nurse Aide (CNA) attempted to adjust an overbed table that was stuck, resulting in the table hitting the resident's forehead. The resident, who was on blood thinner medication, was assessed for injury and transferred to a hospital emergency room for further evaluation. The facility's initial investigation concluded that the incident was accidental and not intentional, based on interviews with the resident and staff involved. However, the investigation was incomplete as it lacked individual witness statements and additional supportive documentation. The facility's administration, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were unable to provide comprehensive documentation of the investigation, citing difficulties in locating records from the previous administration. The police were involved and took statements from the resident and the CNA, but the facility did not have a complete police report at the time of the survey. The facility's policies required obtaining written documentation from witnesses and direct care staff involved in incidents, but these were not provided. The surveyor noted that the facility's investigation did not meet the standards outlined in their policies for handling allegations of abuse, neglect, or mistreatment. The lack of a comprehensive investigation and documentation was identified as a deficiency by the survey team.
Inaccurate MDS Coding for Resident
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a critical assessment tool used to manage care in accordance with federal guidelines. The deficiency was identified during a survey when it was observed that the MDS did not accurately reflect the resident's status and limitations. Specifically, the MDS with an assessment reference date of January 16, 2025, indicated that the resident had a functional limitation in range of motion and impairment on the upper extremity, but did not accurately capture the resident's non-weight bearing status on the right lower extremity following a fracture. The resident, who was admitted with multiple medical diagnoses including Alzheimer's Disease, dysarthria, osteoarthritis, and contracture of the left hand, had a fall incident resulting in a fracture on December 2, 2024. This incident required the resident to be non-weight bearing on the right lower extremity. Despite these conditions, the MDS did not accurately reflect the resident's current status, as confirmed by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The facility lacked a specific policy for MDS, relying instead on the Resident Assessment Instrument (RAI) manual, which contributed to the inaccurate coding.
Failure to Update Care Plan and Complete Fall Investigation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, there was a failure to clarify a physician's order and revise the care plan (CP) for a resident with a fractured right 5th metatarsal. The physician's order dated 12/11/24 indicated non-weight bearing (NWB) status for the resident's right lower extremity, but a progress note created by the Director of Nursing (DON) on 3/1/25 reflected a change to weight bearing as tolerated (WBAT) with a boot. The DON acknowledged that the CP should have been updated to reflect the WBAT status since 2/12/25, and the order for NWB should have been clarified. Additionally, the facility did not complete a thorough investigation of a fall incident involving the same resident. The fall occurred on 12/2/24, and the investigation report did not include a statement from the Maintenance Staff (MS) who found the resident on the floor. The DON confirmed that it was her responsibility to ensure that the MS's statement was obtained, but this was not done. The facility's policy requires that written documentation of the event be obtained from witnesses and submitted to the DON and/or Administrator. The resident involved had multiple medical diagnoses, including Alzheimer's Disease, dysarthria following a stroke, osteoarthritis, and difficulty walking. The resident's cognition was moderately impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The failure to update the CP and clarify the physician's order, along with the incomplete fall investigation, demonstrate deficiencies in the facility's adherence to professional standards of practice and policy compliance.
Failure to Monitor Resident Weights and Fluid Restrictions
Penalty
Summary
The facility failed to obtain weights for a resident according to the physician's orders and facility policy. Resident #13, who had diagnoses including respiratory failure, chronic obstructive pulmonary disease, and heart failure, experienced significant weight loss. The facility did not obtain weights upon the resident's re-admission on two occasions, and monthly weights were not completed by the expected date. The facility's policy required weights to be taken upon admission and weekly for four weeks, but this was not adhered to, leading to a lack of monitoring of the resident's weight changes. Additionally, the facility failed to monitor and document fluid intake for Resident #28, who had a physician's order for fluid restrictions due to End Stage Renal Disease. The resident's fluid restriction was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the nursing staff was not aware of the fluid restriction. The facility's policy required fluid restrictions to be documented and monitored, but this was not done, resulting in a lack of adherence to the physician's orders. The deficiencies were identified through observations, interviews, and record reviews conducted by the surveyor. The Director of Nursing (DON) and other facility staff acknowledged the issues and indicated that in-service education was being provided to address the deficiencies. However, the report focuses on the failure to follow established protocols for weight monitoring and fluid restriction documentation, which led to the identified deficiencies.
Deficiency in Respiratory Care Due to Improper Nebulizer Equipment Management
Penalty
Summary
The facility failed to ensure appropriate storage and timely replacement of nebulizer equipment for a resident, leading to a deficiency in respiratory care. During an observation, a nebulizer mask was found resting uncovered on a nightstand, with a date indicating it had not been changed since 2/18/25, contrary to the facility's policy of weekly changes. Licensed Practical Nurse (LPN) #1 was unsure of the facility's policy regarding the changing of nebulizer tubing and mask equipment. The Minimum Data Set (MDS) Coordinator confirmed that the equipment should have been changed weekly, and the Director of Nursing (DON) acknowledged that the mask should have been stored in a plastic bag when not in use. The resident involved was admitted with diagnoses including type 2 diabetes mellitus and dysphagia, and had a physician's order for Budesonide Inhalation Suspension for asthma. However, there was no physician's order for the weekly change of nebulizer tubing, nor was there a care plan related to the resident's respiratory care. The DON confirmed that the facility's protocol was not followed, as there was no order for the weekly change of nebulizer tubing, and the equipment was not stored properly. The facility's Oxygen Administration Policy did not address the storage of nebulizer equipment, contributing to the oversight.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications and medical supplies safely and according to standards of practice. This deficiency was identified in one of the two medication storage areas observed on the second floor. During an observation, a surveyor noted that a medication storage cabinet containing various in-house stock medications was not locked. Additionally, two other storage cabinets containing various medical supplies were also found unlocked and did not have locks affixed. The Licensed Practical Nurse (LPN) present confirmed that the cabinets should always be locked and attempted to locate a key to secure them but was unsuccessful. The surveyor further confirmed with the facility's Consultant Pharmacist (CP) that all medications and medical supplies should be stored securely to prevent unauthorized access. The Licensed Nursing Home Administrator (LNHA) and the Regional Vice President of Clinical Services (RVPoCS) were informed of the unsecured medication storage cabinets. They acknowledged that all medications and medical supplies should be kept secured from unauthorized access. The facility's Medication Storage Policy, last reviewed in October 2024, also reflected that all drugs and biologicals should be stored in locked compartments.
Failure to Document and Offer Vaccines
Penalty
Summary
The facility failed to offer and document the administration or refusal of pneumococcal and influenza vaccines for a resident, leading to a deficiency. The resident, who had intact cognition and was diagnosed with type 2 diabetes mellitus with hyperglycemia and moderate protein-calorie malnutrition, did not have documented evidence of being offered the influenza vaccine, although the pneumococcal vaccine was up to date. The electronic medical records lacked documentation of the resident's immunization history, consent forms, or education provided regarding the vaccines. Interviews with the Infection Preventionist Nurse (IPN) and Licensed Practical Nurse (LPN) revealed that the influenza vaccine was supposed to be offered to all residents by the end of September and March, and the pneumococcal vaccine was to be checked for prior administration. However, there was no documentation in the resident's records to confirm that these vaccines were offered or declined, nor was there evidence of education provided. The LPN confirmed the absence of signed consent forms and stated that it was the responsibility of the admitting nurse and IPN to ensure these were completed. The facility's policies for influenza and pneumococcal vaccines required offering the vaccines to residents, documenting education provided, and recording any refusals. Despite these policies, the surveyor found no evidence that the resident was offered the vaccines or that any education was documented. The surveyor's findings were communicated to the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), but no additional information or response was provided by them during the exit conference.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to offer a COVID-19 immunization to a resident, identified as Resident #55, which was discovered during a survey. The resident had been admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia and moderate protein-calorie malnutrition. Despite having an intact cognition as indicated by a BIMS score of 15 out of 15, there was no documented evidence in the resident's medical records that the COVID-19 vaccine was offered, declined, or that education about the vaccine was provided. The electronic record under the immunization tab lacked any information about the resident's COVID-19 immunization status, and there were no consent forms on file. Interviews with the Infection Preventionist Nurse (IPN) and a Licensed Practical Nurse (LPN) confirmed the absence of documentation and consent forms. The IPN stated that vaccines are typically offered when new vaccines are available and upon new admissions, and that all documentation should be recorded in the electronic medical records. The LPN indicated that it was the responsibility of the admitting nurse and the IPN to ensure consent forms are signed and offered. The facility's COVID-19 Vaccination Policy, reviewed by the Licensed Nursing Home Administrator (LNHA), emphasized the importance of educating and offering the vaccine to residents and staff, yet this was not adhered to in the case of Resident #55.
Resident Involuntarily Confined by Nurse
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary confinement. On a night shift, a nurse attached a hospital gown to the doorknob of a resident's room and looped it to the handrail in the hallway, effectively preventing the resident from leaving the room. This action was taken after the resident, who was in a wheelchair, was brought back to their room from another resident's room. The incident was reported by another resident who noticed the door was closed in a way that would prevent the resident from leaving. The resident involved had a history of osteoarthritis, psychosis, bipolar disorder, abnormalities of gait and mobility, gastro-esophageal reflux disease, and atherosclerotic heart disease. The resident's cognitive function was moderately impaired, as indicated by a Brief Interview for Mental Status score of 12. The resident required assistance with activities of daily living but was independent in eating and mobility while in bed and could propel themselves in a wheelchair. The resident's care plan noted a risk for elopement, with interventions to monitor and divert the resident's attention. The nurse involved in the incident stated that she closed the door in this manner to keep the resident safe from wandering during the night. However, when another resident informed her that the door should not be closed in that way, she opened it. The facility's policy on abuse, neglect, and exploitation prohibits involuntary seclusion, which includes confining a resident to their room against their will. The nurse was subsequently terminated for failing to follow facility protocols.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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