Complete Care At Madison, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Matawan, New Jersey.
- Location
- 625 State Highway 34, Matawan, New Jersey 07747
- CMS Provider Number
- 315015
- Inspections on file
- 18
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Complete Care At Madison, Llc during CMS and state inspections, most recent first.
The facility failed to ensure proper narcotic count and accountability for controlled medications across multiple medication carts and shifts. Narcotic counts were not completed, and nursing signatures were missing for several shifts. Additionally, Individual Patient Controlled Substance Administration Records were incomplete for several residents. The Acting DON confirmed that the narcotic count should be completed at each shift handoff, and missing documentation is unacceptable. Furthermore, a DEA 222 form was pre-signed by the Medical Director, which is against protocol.
A facility failed to conduct timely lithium level testing for a resident with bipolar disorder, despite psychiatric recommendations. The resident, with multiple diagnoses including dementia and bipolar disorder, was on lithium carbonate. Recommendations to check lithium levels were made twice, but tests were delayed or not conducted. Facility staff did not document notifying the physician or obtaining approval for the tests, contrary to facility policies.
The facility failed to prevent staff from using cell phones and speaking non-English languages during resident care, as reported by residents during a council meeting. Residents noted that staff, including CNAs and nurses, used phones and Bluetooth earpieces while providing care, leading to medication errors. Despite awareness and policies against such practices, the facility had not taken recent disciplinary actions.
A facility failed to document complete information on the New Jersey Universal Transfer Form (UTF) for a resident with severe cognitive impairment and multiple diagnoses, including psychosis and depression, during transfers to the emergency room. The UTFs were missing critical information such as date and time of transfer, code status, and primary diagnosis. Interviews revealed no policy for completing the UTF, and staff were not required to fill out all areas of the form. Despite a policy requiring a UTF for transfers, the forms were incomplete, potentially impacting the resident's care.
A facility failed to update a resident's comprehensive care plan to include a stage 4 pressure ulcer on the right elbow. Despite having a physician's order for wound care and being on a repositioning program, the care plan only addressed potential skin integrity issues and not the actual wound. The oversight was confirmed by the UM/LPN and Acting DON, who acknowledged the care plan should have included the elbow wound. The facility lacked a specific policy for updating ICCPs.
The facility failed to follow professional standards in several cases, including not administering pain medication to a resident with chronic pain, not increasing medication doses for a resident with PTSD as ordered, using adhesive tape on a resident's gastronomy tube site against physician orders, and not notifying transport staff of a resident's COVID-19 status during transfer.
The facility failed to properly store medications, with loose, unidentifiable pills found in three medication carts. Inspections revealed two loose pills in the B-Wing's Medication Cart #2, nineteen in the C-Wing's Medication Cart #1, and six in the A-Wing's Medication Cart #1. The RN, UM/LPN, and LVN confirmed that no loose pills should be present, and it was their responsibility to maintain cart organization. The DON stated medications should be stored in their original packaging, as per the facility's policy.
A resident with severe medical conditions and impaired cognition did not receive a timely Speech Therapy evaluation despite a physician's order. The evaluation was missed due to a communication lapse between nursing staff and the Director of Rehabilitation, contrary to the facility's policy requiring prompt initiation and completion of therapy evaluations.
The facility failed to ensure the proper functioning of the resident call bell system. Observations revealed that call bell lights in several rooms did not illuminate, and the system incorrectly identified rooms, with no audible notifications at the nurse's station. The LNHA confirmed the issues, and the RCBSV was updating the system to correct these deficiencies.
Deficiencies in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure proper narcotic count and accountability for controlled medications across multiple medication carts and shifts in August 2024. During a review of the B-Wing nursing unit's Medication Cart #2, it was found that the narcotic counts were not completed for several shifts, and nursing signatures were missing for both incoming and outgoing nurses. Additionally, the Individual Patient Controlled Substance Administration Records for several residents were incomplete, with missing nurse signatures for administered doses of pain and anxiety medications. The Registered Nurse confirmed these discrepancies during the survey. Further examination of the C-Wing nursing unit's Medication Cart #1 revealed similar issues, with narcotic counts left blank for numerous shifts and missing nursing signatures. The Unit Manager/LPN acknowledged the missing documentation and confirmed that all narcotic logs should be complete. The A-Wing nursing unit's Medication Cart #1 also showed incomplete narcotic counts and pre-signed shift-to-shift count logs, which the Licensed Vocational Nurse admitted to doing inappropriately. The Acting Director of Nursing confirmed that the narcotic count should be completed at each shift handoff and that missing documentation is unacceptable. Additionally, the facility failed to properly complete DEA 222 forms, as one form was pre-signed by the Medical Director before submission, which is against protocol. The Acting DON confirmed this error, and the facility could not provide a policy regarding the completion of DEA 222 forms. The facility's Controlled Substances policy requires nursing staff to count controlled medications at the end of each shift, but it did not include guidelines for resident's declining inventory sheets.
Failure to Conduct Timely Lithium Level Testing
Penalty
Summary
The facility failed to ensure timely laboratory testing for therapeutic levels of lithium, a medication used to treat bipolar disorder, for a resident. The psychiatric recommendations to check lithium levels were made on two occasions, but the tests were not conducted promptly. The first recommendation was made on February 7, 2024, but the lithium levels were not tested until March 25, 2024. The second recommendation was made on July 31, 2024, but there was no record of the test being completed. This deficiency was identified during a review of the resident's medical records and interviews with facility staff. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, generalized anxiety disorder, failure to thrive, major depressive disorder, and bipolar disorder. The resident was on medications such as lithium carbonate and fluvoxamine. Despite the psychiatric recommendations, there was no documentation that the nurses notified the physician about the need to check lithium levels, nor was there any record of the physician's agreement or disagreement with the recommendations. The facility's policies required timely laboratory services and physician notification of consultant recommendations, which were not adhered to in this case.
Staff Cell Phone Use and Language Barrier During Resident Care
Penalty
Summary
The facility failed to ensure that staff did not use their cell phones in resident care areas and while performing resident care, and also failed to ensure that staff did not speak in a non-English language while rendering care to English-speaking residents. This deficiency was identified during a Resident Council group meeting with four alert and oriented residents who reported that both certified nursing aides (CNAs) and nurses were using their phones and speaking in a foreign language during care. Two residents specifically mentioned that nurses were on their Bluetooth earpieces while preparing and administering medications, leading to incorrect medications being given, which they refused to take. The residents expressed that the facility was aware of these issues but had not taken any action to address them. The facility's Social Worker confirmed that residents had complained about staff using cell phones, and formal education had been conducted to address this issue. However, observations by the surveyor noted a CNA with a Bluetooth earpiece, and the Licensed Nursing Home Administrator (LNHA) acknowledged that the issue persisted despite reminders to staff. The facility's policy prohibited cell phone use in resident care areas, and the LNHA stated that staff were expected to speak English around English-speaking residents. Despite these policies, no disciplinary actions had been taken recently for cell phone usage, and the facility did not provide any documentation of staff write-ups for such violations.
Incomplete Documentation on Universal Transfer Form
Penalty
Summary
The facility failed to document complete and appropriate information on the New Jersey Universal Transfer Form (UTF) when transferring a resident to the emergency room. This deficiency was identified for a resident with severe cognitive impairment and multiple diagnoses, including unspecified psychosis, depressive disorder, and somatoform disorder. The resident had a history of agitation and aggressive behavior, which led to their transfer to the hospital. However, the UTFs used during these transfers were incomplete, missing critical information such as the date and time of transfer, code status, primary diagnosis, isolation precautions, and contact information for the sending facility. The surveyor's review of the facility's practices revealed that there was no policy or procedure in place for completing the UTF, and staff were not required to fill out all areas of the form, contrary to the instructions. Interviews with the Infection Preventionist/LPN and the Licensed Nursing Home Administrator (LNHA) confirmed that the staff verbally communicated with transport staff but did not ensure the UTF was fully completed. The LNHA also stated that the medical records department or unit clerk was responsible for uploading the UTF to the electronic medical record, but this was not done immediately. The facility's policy on emergency transfer or discharge, revised in December 2022, required the preparation of a universal transfer form to accompany the resident. Despite this policy, the UTFs reviewed were incomplete, indicating a failure to adhere to the established procedures. This lack of documentation and communication could potentially impact the care provided to the resident upon arrival at the hospital, as essential information was not conveyed through the UTF.
Failure to Revise Comprehensive Care Plan for Resident's Elbow Wound
Penalty
Summary
The facility failed to revise an individual comprehensive care plan (ICCP) for a resident with a right elbow wound. The deficiency was identified during a survey when it was observed that the ICCP did not include the resident's actual skin impairment or stage 4 pressure ulcer on the right elbow. The resident, who had been admitted with multiple diagnoses including a stage 3 pressure ulcer and contracture of the elbow, was on a turn and reposition program and had a physician's order for specific wound care treatments. However, the ICCP, last revised in December 2023, only addressed potential skin integrity issues related to immobility and did not reflect the current condition of the resident's elbow wound. Interviews with the Unit Manager/LPN and the Acting Director of Nursing (DON) revealed that the ICCPs were supposed to be updated daily for any changes, including wounds and skin integrity. Despite this, the ICCP for the resident in question did not include the right elbow wound, which was confirmed by both the UM/LPN and the Acting DON. The Acting DON acknowledged that the focus area for the right elbow wound should have remained active, but it was mistakenly marked as resolved when the sacrum wound healed. Additionally, the facility lacked a specific policy for updating ICCPs, relying instead on a baseline care plan policy that did not address care plan revisions.
Failure to Adhere to Professional Standards in Medication Administration and Infection Control
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several instances, impacting the care of multiple residents. One resident with chronic pain did not receive their scheduled dose of dilaudid at 6:00 AM, despite the medication being documented as administered. The Acting Director of Nursing (DON) later explained that the nurse did not want to wake the resident and forgot to document the medication as not given. This oversight left the resident in severe pain, as indicated by their pain level of seven on a numeric scale. Another resident with post-traumatic stress disorder did not receive increased doses of mirtazapine and prazosin as ordered by their physician. The physician had entered new orders to start the increased doses on the same evening, but the nurse did not confirm the orders until the following day. The resident reported not receiving their medications as prescribed, which was confirmed by the Acting DON. The physician had communicated the changes to the nurse, but the follow-up was not adequately managed. Additionally, a resident with a gastronomy tube had adhesive tape applied to their abdomen, contrary to a physician's order to avoid tape due to skin irritation. The resident's representative frequently observed adhesive tape on the resident's abdomen, which caused a rash. The Unit Manager confirmed the presence of adhesive tape and acknowledged that the physician's order was not followed. Furthermore, the facility failed to notify emergency transport staff and the receiving hospital of a resident's COVID-19 positive status during a transfer, as required by their outbreak plan and isolation policy. This lack of communication was confirmed by the Acting DON and Infection Preventionist, who could not provide documentation that the necessary notifications were made.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to properly store medications, as evidenced by the presence of loose, unidentifiable pills in three different medication carts. During an inspection, a surveyor observed two loose pills in the B-Wing nursing unit's Medication Cart #2, nineteen loose pills in the C-Wing nursing unit's Medication Cart #1, and six loose pills in the A-Wing nursing unit's Medication Cart #1. These pills varied in shape, color, and size, and were found in the drawers containing medication blister packages. The Registered Nurse, Unit Manager/Licensed Practical Nurse, and Licensed Vocational Nurse present during the inspections confirmed that there should be no loose pills in the medication carts and that it was the responsibility of the nurses assigned to the carts to maintain their organization and cleanliness. The Acting Director of Nursing was interviewed and stated that all medications should be stored in the packaging in which they were received, and there should be no loose pills in the medication carts. The facility's Medication Storage policy, reviewed in January 2024, mandates that all medications and biologicals be stored in a safe, secure, and orderly manner, in the packaging, containers, or other dispensing systems in which they are received. This deficiency was identified as a violation of NJAC 8:39-29.4.
Failure to Provide Timely Speech Therapy Services
Penalty
Summary
The facility failed to provide timely Speech Therapy (ST) services to a resident, identified as Resident #226, who was admitted with significant medical conditions including hemiplegia, cerebral vascular accident, hypertension, and a gastrostomy tube. The resident's comprehensive Minimum Data Set (MDS) indicated severely impaired cognition and required maximum assistance for eating. Despite a physician's order dated 7/27/24 for evaluations and treatments in Occupational Therapy (OT), Speech Therapy (ST), and Physical Therapy (PT), the resident had not received the ST evaluation by the time of the surveyor's inquiry on 8/22/24. The Director of Rehabilitation (DPT) acknowledged that the ST evaluation was missed and attributed the oversight to a lack of communication from the nursing staff during morning meetings. The facility's policy, revised in February 2020, required evaluations to be initiated within 24 hours and completed within 48 hours of the order. However, the ST evaluation was not conducted until after the surveyor's inquiry, highlighting a failure in the facility's process for managing new therapy orders. The Acting Director of Nursing (DON) confirmed that the evaluation was only completed following the surveyor's intervention.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of the resident call bell system, as observed and determined by surveyors. Specifically, the call bell light outside of Resident Room A-5 did not illuminate when tested, and the system incorrectly identified the room as 0222, with no audible notification at the nurse's station. Additionally, the call bell in Resident Room A-5 (window) did not illuminate or register a signal at the nurse's station. Similar issues were observed in Resident Room A-4, where neither the door nor window call bells illuminated or provided audible notifications at the nurse's station. In Resident Room A-30, although the call bell illuminated and was correctly identified at the nurse's station, there was no audible notification. The Licensed Nursing Home Administrator confirmed the lack of audible notification and discovered that the volume was turned down. The facility's Resident Call Bell System Vendor was in the process of updating the system to correct room identification issues. These deficiencies were noted during the survey and communicated to the Licensed Nursing Home Administrator at the Life Safety Code exit conference.
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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