Complete Care At Monmouth, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Branch, New Jersey.
- Location
- 229 Bath Avenue, Long Branch, New Jersey 07740
- CMS Provider Number
- 315284
- Inspections on file
- 18
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Monmouth, Llc during CMS and state inspections, most recent first.
A resident with complex medical needs did not have complete documentation of medication administration, including controlled substances, as staff failed to sign the eMAR and properly record medication refusals. The facility was also unable to provide required controlled substance administration records when requested, and both the LPN and DON confirmed that facility policies for medication documentation were not followed.
A facility failed to administer and document Lorazepam for a resident as per physician orders, violating professional standards and its own medication administration policy. The resident, with chronic pain syndrome and anxiety, did not receive the medication on two occasions, and there was no documentation or notification to the physician or family. Interviews with the LPN and DON confirmed the lapses in following the expected procedures.
The facility failed to maintain kitchen sanitation and proper food storage standards, as observed by a surveyor. Unlabeled and undated opened food items were found in the freezer and refrigerator, exposing them to air and potential contamination. Additionally, dented cans were improperly stored, contrary to facility policies. These deficiencies were acknowledged by the facility's administration.
The facility was found to have deficiencies in egress door accessibility and signage. The main entrance's sliding doors had a lockset that could restrict emergency use, contradicting the evacuation plan. Additionally, three egress doors with a delayed 15-second egress feature lacked required signage, potentially affecting all residents during an emergency.
The facility failed to ensure emergency illumination along the means of egress was automatic, as required by NFPA 101:2012. Observations in multiple areas showed that wall switches could shut off all ceiling lights, leaving the areas without necessary illumination. This deficiency was confirmed by the US FOIA (b)(6) during the survey.
The facility failed to maintain sprinkler heads in optimal condition as required by NFPA 25. An observation revealed that a fire sprinkler head in the laundry exit/egress corridor had a towel with electrical tape wrapped around it. This was confirmed by a staff member who was unsure of the reason for this condition.
An observation revealed that an extension cord was improperly used to power an ice machine in the facility kitchen, violating NFPA electrical safety standards. The cord was installed through a concrete wall into a GFCI outlet, which was confirmed during an interview with a US FOIA representative.
The facility failed to conduct reference checks for five new hires before their start dates, violating its abuse policy. The HR Director confirmed that reference checks are required before employment, and the LNHA acknowledged the oversight. This deficiency was identified during a review of personnel files and interviews with facility staff.
The facility failed to provide proper respiratory care for three residents, as observed by surveyors. A resident had unlabeled and improperly stored oxygen tubing, another had tubing in use for twelve days without a storage bag, and a third resident received oxygen without a physician's order. The facility's policies for respiratory equipment management and physician orders were not followed, leading to these deficiencies.
The facility failed to maintain a dignified dining experience by serving some residents on disposable plates due to a shortage of reusable ones. An LPN noted the lack of reusable plates, and the Chef confirmed using disposables as a backup. The CCO and LNHA acknowledged the dignity issue, and the facility's policy emphasized a home-like dining environment.
A resident was transferred to another LTC facility without a complete New Jersey Universal Transfer Form (UTF) and without a physician discharge summary. Only 9 of the 29 required sections of the UTF were filled out, omitting critical information such as code status and reason for transfer. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged these deficiencies.
A facility failed to create an individualized comprehensive care plan for a resident with a new left below knee amputation, who was receiving wound care. The resident's medical record showed diagnoses including acquired absence of the left leg, diabetes, repeated falls, and acute kidney failure. Despite these conditions, the care plan did not address the amputation, surgical wound, or impaired skin integrity. The DON confirmed these should have been included, as per facility policy.
The facility failed to update the care plans for two residents after falls, despite policies requiring such updates. One resident, with a history of hip fracture and high fall risk, had their care plan revised only after surveyor inquiry. Another resident, with multiple falls and medical conditions, did not have new interventions added to their care plan after falls. The DON acknowledged the oversight, which was against the facility's policies.
A facility failed to administer medications timely and properly manage medication supplies. A resident received medications late, contrary to physician orders, risking potential overdose. Additionally, an LPN borrowed medications from other residents due to lack of backup, violating protocol. Interviews with nursing leadership confirmed the correct procedure involves checking the pyxis and notifying the physician and pharmacy, emphasizing that borrowing medications is not allowed.
A resident with a stage three pressure ulcer did not receive prescribed skin protective devices, such as a low air loss mattress and heel boots, despite physician orders and wound care recommendations. The resident and staff confirmed the absence of these devices, indicating a failure to implement necessary measures to prevent further skin breakdown.
A resident admitted with multiple health conditions, including tobacco use, did not sign a Smoking Contract/Agreement upon admission, which was identified as a deficiency. The facility's policy required smoking contracts to be signed upon admission, but the contract was not signed until months later. Interviews with staff confirmed the oversight, acknowledging that the contract should have been completed upon admission.
A resident with end-stage renal disease and dependent on dialysis experienced a medical emergency due to a bleeding dialysis shunt. The facility failed to have a physician's order for assessing the dialysis access site, and there was no documentation of site assessments in the resident's records. Interviews with nursing staff confirmed the presence of an AVF but revealed that assessments were not documented, which was acknowledged by the DON.
The facility failed to accurately count and reconcile controlled substances, specifically Oxycodone/Acetaminophen, on Medication Cart A, 2nd floor. The IPCSAR reconciliation sheet was incorrect for eight shifts, with a missing tablet not properly documented. The Narcotic Shift Count log showed discrepancies and missing signatures, indicating non-compliance with the facility's policy for narcotic counts during shift changes.
The facility failed to act on Consultant Pharmacist recommendations for two residents. A resident with COPD had multiple medication recommendations unaddressed over several months, while another resident with hemiplegia had a PRN medication discontinuation suggestion ignored. The facility's policies required timely action on such recommendations, but these were not followed, as acknowledged by the DON and LNHA.
A resident with Type 2 diabetes and moderately impaired cognition did not receive mandatory annual dental care, resulting in brown, discolored, chipped, and missing teeth. Despite the resident's oral health issues being noted in assessments, the facility failed to order a dental consultation or document dental care services. The facility's policy required a physician order for dental consults, which was not followed, leading to the deficiency.
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey law. On three separate day shifts, the facility did not meet the required staffing levels, having fewer CNAs than required for the number of residents. Interviews with the Staffing Coordinator and the Licensed Nursing Home Administrator confirmed awareness of the staffing regulations, but the facility still fell short on the specified days.
Failure to Document Medication Administration and Maintain Controlled Substance Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including ALS, anxiety disorder, chronic pain syndrome, schizoaffective disorder, bipolar disorder, and adult failure to thrive. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Physician orders were in place for several controlled substances, including lorazepam, methadone, and morphine sulfate, with specific administration times documented in the resident's order summary report. On multiple occasions, staff did not sign the electronic Medication Administration Record (eMAR) to indicate whether medications were administered or refused. Specifically, there were blanks on the eMAR for scheduled doses of lorazepam, methadone, and morphine sulfate. Progress notes indicated that the resident refused some medications, but these refusals were not properly documented on the eMAR as required by facility policy. Interviews with the LPN/Unit Manager and the DON confirmed that the nurse responsible for medication administration did not follow the facility's documentation policy, resulting in missing signatures and incomplete records. Additionally, the facility was unable to provide the Individual Patient Controlled Substance Administration Record sheets for the resident's controlled medications for certain dates when requested by the surveyor. The DON acknowledged that these records should have been available and that the facility failed to adhere to its own policies regarding medication administration and documentation. Facility policies required all assessments, observations, and services to be documented in the medical record, and for refusals to be reported and documented, which was not done in this case.
Failure to Administer and Document Medication as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice for medication administration and care plan interventions for a resident. Specifically, the facility did not follow physician orders for administering Lorazepam to a resident diagnosed with chronic pain syndrome, anxiety, and other conditions. The resident's electronic Medication Administration Record (eMAR) showed that Lorazepam was not administered on two occasions, and there was no documentation of the medication being given or any reason for its omission. Additionally, the facility's policy on medication administration, which requires immediate documentation of administered medications, was not followed. Interviews with the LPN and the Interim Director of Nursing (DON) confirmed the expectation that medications should be administered and documented as ordered. Both acknowledged the missing documentation in the eMAR, indicating that the medication was not administered. The facility's policy also mandates notifying the physician and family if a medication is not administered, which was not done in this case. The deficiency was identified during a survey, which included observations, interviews, and a review of medical records and facility documentation.
Failure to Maintain Kitchen Sanitation and Food Storage Standards
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, as observed during a surveyor's visit. In the kitchen freezer, an unlabeled and undated opened box of hotdogs/kielbasa was found with the plastic bag inside also opened, exposing the contents to air and freezer burn. Similarly, an opened 15-pound box of single slice bacon was found with the plastic bag inside opened, exposing the bacon to air. In the walk-in refrigerator, sliced turkey deli meat was wrapped in clear plastic wrap and labeled with a use-by date of the previous day, indicating it should have been discarded. Additionally, on the spice/dry storage rack, a four-quart plastic container with a green lid was found unlabeled and undated, containing an unidentifiable white powder identified as instant mashed potato mix. Other items such as garlic powder, paprika powder, and browning seasoning sauce were also found opened and undated. The facility's policies for frozen, refrigerated, and dry food storage were not adhered to, as evidenced by the lack of labeling and dating of opened food items. Furthermore, dented cans of mandarin orange slices and grape jelly were found on the canned goods rack, contrary to the facility's policy that dented cans should be stored separately. These observations were acknowledged by the Licensed Nursing Home Administrator, Director of Nursing, Assistant LNHA, and the Regional Director of Operations during the survey. The facility's policies, revised in late 2024, clearly outlined the requirements for labeling, dating, and proper storage of food items to prevent contamination and maintain food quality, which were not followed in this instance.
Plan Of Correction
1. Corrective Action The Facility was deficient in its practice of storing and handling food items. The unlabeled, undated, opened box of Kielbasa was discarded. The unlabeled, undated, and opened fifteen # box of bacon was discarded. The sliced turkey deli meat with an expired used by date of 12/2 was discarded. The unlabeled, undated 4-quart plastic container containing a white powder was discarded. The unlabeled, undated spices, garlic powder, paprika powder, and bottle of browning sauce were discarded. The two dented cans containing grape jelly and mandarin oranges were moved to the dented can rack in a separate location. 2. Identification of other residents having potential to be affected by the deficient practice The deficient practice has the potential to affect all residents. 3. Measures put in place • Dietary Staff received in person re-education on the Frozen Food Storage Policy, the Dry Food Storage Policy and the Dented/Compromised Cans Policy by the Regional Dietary Director. 4. How facility will monitor corrective actions to ensure the deficient practice does not recur Dietary Director/ Designee will conduct audit weekly x4 and monthly x2 and will report to the Quality Assurance Meeting for the duration of the audit period.
Deficiencies in Egress Door Accessibility and Signage
Penalty
Summary
The facility was found to have deficiencies related to egress doors, which are critical for safe evacuation during emergencies. Observations revealed that the main entrance's outer set of sliding doors had a lockset with a hook-type deadbolt that could restrict emergency use of the exit. Although signs indicated that the doors could be pushed open in an emergency, the engaged thumb-latch locks would prevent this action, contradicting the evacuation plan that designated these doors as an exit/egress route. Interviews confirmed that the lockset could impede exit from the egress side during an emergency. Additionally, the facility failed to label three out of six egress doors equipped with a delayed 15-second egress feature with the required signage. These doors, located on the second floor near various offices and resident rooms, lacked signs indicating "Push Until Alarm Sounds, Door Can Be Opened in 15-Seconds," as required by NFPA 101 standards. This oversight was confirmed during a building tour, and the absence of proper signage could potentially affect all residents in the event of an emergency.
Plan Of Correction
1. The lock on the front door was removed on December 24, 2024. Signs were installed on all doors with a 15 second delayed egress stating "Push until alarm sounds. Door can be opened in 15 seconds." 2. All residents in the Facility are at risk from Egress doors not meeting the requirements of the National Fire Protection Association. 3. The ability for the front door to open when pushed in case of emergency will be confirmed on the weekly checklist. The presence of signage stating to push until alarm sounds will be confirmed on weekly door checks. The Maintenance Director or designee will be responsible for completing and signing off on weekly rounds. The checklist will be audited monthly by the Administrator for 3 months. 4. The Director of Maintenance or designee will report on the status of daily door rounds to the Administrator at Quarterly QA meeting x 3.
Failure to Provide Automatic Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination that would operate automatically along the means of egress, as required by NFPA 101:2012 Edition, Sections 19.2.8 and 7.8.1.3* (2). This deficiency was observed in four areas and had the potential to affect all residents. Specifically, observations revealed that in the #3 nurse station dining room, #3 nurse station day room, floor #1 dining room, and the day room by resident room 321, sets of wall switches were able to shut off all ceiling light fixtures, leaving the areas without any illumination of the means of egress that was continuously in operation or capable of automatic operation without manual intervention. These findings were confirmed by the US FOIA (b)(6) during the observations and were discussed at the Life Safety Code survey exit conference.
Plan Of Correction
1. Two switches in each of the three dining rooms were disabled, allowing for light fixtures to be on in each room at all times. The dining room lights will be powered by the Emergency generator during a power outage. 2. All residents can be at risk of illumination of means of egress not meeting requirements of the National Fire Protection Association. 3. The ability of one light staying on at all times will be added to weekly tasks on Facility Maintenance Software and will be confirmed by the Maintenance Director or Designee on weekly rounds. 4. The Director of Maintenance or designee will report to the Administrator on the status of Emergency illumination at Quarterly QA Meeting x 3. Completion date
Deficient Maintenance of Sprinkler Heads
Penalty
Summary
The facility failed to maintain sprinkler heads in optimal condition as required by NFPA 25. During an observation, it was found that one of the two fire sprinkler heads in the laundry exit/egress corridor had a towel with electrical tape wrapped around the pipe and sprinkler head. This observation was confirmed by the US FOIA (b)(6), who was unsure why the pipe and sprinkler head were in this condition. The deficiency was noted during an interview and observation on 10/16/24 and was discussed at the Life Safety Code exit conference on 12/12/24.
Plan Of Correction
1/17/25 1. The rag covering the sprinkler head was immediately removed on December 11, 2024. All other sprinkler heads in the Facility were visually inspected to ensure they were not covered. 2. All residents are considered at risk of sprinkler heads not meeting the requirement of the National Fire Protection Association. 3. The Maintenance, dietary, and housekeeping staff were all in-serviced on not placing any barrier in the path of any sprinkler head. The Maintenance director or designee will follow behind any vendor to ensure they do not leave any obstruction in the path of any sprinkler heads. The Director of Maintenance or designee will perform a visual inspection of all sprinkler heads on a weekly basis. 4. The Director of Maintenance or designee will report to the Administrator on the status of all sprinkler inspections at the Quarterly QA Meeting for three consecutive meetings.
Improper Use of Extension Cord for Ice Machine
Penalty
Summary
The facility was found to be in violation of electrical safety standards as outlined in NFPA 101, NFPA 70, and NFPA 99. During an observation, it was noted that an extension cord was used beyond temporary installation, serving as a substitute for fixed wiring. This practice was identified in the exit/egress corridor, where a black wire with a modified yellow plug was connected through a concrete wall into a GFCI duplex wall outlet. This setup was used to supply power to the ice machine in the facility kitchen. The deficiency was confirmed during an interview with the US FOIA representative present at the time of the observation. The issue was formally acknowledged during the Life Safety Code exit conference. The improper use of the extension cord had the potential to affect all residents within the facility, as it did not comply with the required electrical safety standards.
Plan Of Correction
1. A new outlet was installed for the ice machine inside the kitchen area. 2. All Residents are at risk of electrical equipment not meeting the requirements of the National Fire Protection Association. 3. A visual Electrical receptacle inspection to ensure no use of extension cords will be added to Monthly tasks on Facility maintenance task software and will be confirmed by The Director of Maintenance or designee on Monthly rounds. 4. The Director of Maintenance or designee will report to the Administrator on the status of all Electrical receptacle inspections at Quarterly QA Meeting x 3.
Failure to Conduct Pre-Employment Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing reference checks on employees before their start date. This deficiency was identified for five out of ten employees reviewed for new hires. The facility's Abuse Policy, dated September 1, 2024, mandates that verification of references should be conducted on potential employees before they begin working with residents. However, upon review of personnel files, it was found that Employees #3, #6, #8, #9, and #10 did not have evidence of reference checks conducted prior to their employment start dates. During interviews, the Human Resources Director confirmed that the facility's hiring policy requires all new hires to have completed reference checks before their first day of employment. The Licensed Nursing Home Administrator, along with the Director of Nursing and Regional Director of Operations, acknowledged the missing pre-employment checks when interviewed by the survey team. The failure to conduct these checks was a violation of the facility's policy and the New Jersey Administrative Code.
Plan Of Correction
1. The U.S. FOIA (b) (6) was in-serviced by the Administrator on ensuring Reference Checks prior to hire or documenting if unable to obtain. 2. All residents have the ability to be affected by this deficient practice. An audit was done on all current employee files to ensure reference checks were completed with no further concerns identified. 3. The Administrator provided in person education to Department Heads and the Human Resource Director pertaining to documents required upon hire, per policy. 4. The Human Resources Director will audit all new hire files weekly for four weeks and then Monthly for two months. The Human Resources Director will submit to the Administrator the status of all New Hire Reference Checks for the past month at Monthly QAPI meeting for three months and then at Quarterly for the next three Quarters.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, as observed by surveyors. Resident #19 was found with an oxygen concentrator and nasal cannula tubing that was not labeled, dated, or stored in a protective covering. The resident's medical records indicated a need for oxygen therapy, but the tubing was not managed according to the facility's policy, which required weekly changes and proper labeling to prevent contamination and infection. Interviews with the LPN/UM and the Infection Preventionist confirmed that the facility's policy was not followed, as the tubing was not labeled or stored correctly. Resident #54 was observed receiving oxygen through nasal cannula tubing that had been in use for twelve days without being changed, contrary to the physician's order for weekly changes. The tubing was labeled and dated, but there was no storage bag observed, which is required to prevent contamination. The facility's policy mandates that respiratory equipment be stored in a labeled and dated bag when not in use, but this was not adhered to, as confirmed by interviews with the LPN/UM and the Infection Preventionist. Resident #239 was found with a tracheostomy tube connected to an oxygen concentrator, but there was no physician's order for oxygen administration in the resident's medical records. The facility's policy requires a physician's order for oxygen use, except in emergencies, but this was not obtained for Resident #239. The DON confirmed the absence of the necessary order, acknowledging the oversight. The facility's failure to follow its own policies and obtain the required physician's orders for oxygen administration contributed to the deficiencies identified by the surveyors.
Plan Of Correction
1. Residents affected by deficient practice: The facility failed to ensure NU Ex Order 26.4(b)(1) equipment was stored and dated properly and ensure a physician's order was in place for a resident who received Exer. Resident #19's NJ Exec Order 26.461 was replaced, correctly labeled, dated, and stored in a protective covering on 12/3/24. Resident #54's NJ Exec Order 26.461 was replaced, correctly labeled, dated, and a dated storage bag was provided on 12/3/24. Resident #239 was discharged from the facility. 2. Identifying other residents who could be affected by the deficient practice: Residents that require oxygen therapy could be affected by this deficient practice. An audit of all residents who require oxygen was completed to ensure orders in place, care plan in place, and all equipment dated and bagged. No other concerns were identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed nurses were in-serviced by the Assistant Director of Nursing on the policy/process of residents requiring oxygen therapy. The in-service included that respiratory tubing gets changed, bagged, and dated each Wednesday on the 11-7 shift, and licensed nurse is to ensure the oxygen liter flow on the concentrator matches the oxygen order in PCC. 4. Monitoring the continued effectiveness of the systemic change: Unit Managers/Designee will conduct audits of residents requiring oxygen to ensure orders, care plans, and all equipment is in place weekly x 4 then Monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Use of Disposable Plates in Dining Room
Penalty
Summary
The facility failed to serve meals in a dignified, home-like manner by using disposable containers for some residents dining in one of the main dining rooms. During an observation, it was noted that four out of fourteen residents were served lunch on red plastic disposable plates, while others received their meals on reusable plates and silverware. The Licensed Practical Nurse (LPN) present explained that there were not enough reusable plates available from the kitchen. Additionally, desserts were served on disposable plates, and residents were not assisted in removing the plastic wrap from their cake slices. The Chef admitted to using disposable plates as a backup due to an insufficient supply of regular plates from the kitchen. The Corporate Compliance Officer (CCO) and the Licensed Nursing Home Administrator (LNHA) acknowledged that serving meals on disposable plates was a dignity issue and that all residents should have been served in the same manner. The facility's Dining Service Tray Presentation policy, revised in October 2023, stated that residents should eat in a dignified, home-like environment and that disposable items should not be used for meal service. The LNHA also noted that the kitchen should have provided more plates and that the Chef should have requested additional plates if needed.
Plan Of Correction
1. Corrective Action The USFFOLAT and nurse were educated by the Food Service Director that the residents should not have received a plastic plate and that all residents in the dining room must be served all courses of the meal on non-disposable plates. 2. Identification of other residents having potential to be affected by the deficient practice The deficient practice has the potential to affect all residents receiving meals. 3. Measures put in place Staff, including nursing and dietary, were in-serviced on dignity with regards to meal service and the Facility's policy on Tray presentation. This included education on serving prepared desserts on reusable plates. 4. How facility will monitor corrective actions to ensure the deficient practice does not recur The Dietary Director (or designee) will complete weekly audits for four weeks and monthly for two months. • Dietary Director will submit Audit results to the QAPI Committee monthly for three months.
Incomplete Transfer Documentation for Resident
Penalty
Summary
The facility failed to ensure the New Jersey Universal Transfer Form (UTF) was completed when transferring a resident to another long-term care facility. Specifically, for Resident #289, only 9 out of the 29 required sections of the UTF were filled out, leaving critical areas such as code status, reason for transfer, and medical records attachments blank. Additionally, the facility did not complete the physician discharge summary for the resident, which is a necessary document to accompany the transfer. Resident #289 was admitted with diagnoses including cerebral infarct, hemiplegia, hemiparesis, and dysphagia. The resident was transferred to a facility closer to a family member, but the transfer documentation was incomplete. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged the deficiencies in the UTF and the absence of a discharge summary during the surveyor's review.
Plan Of Correction
1. Resident affected by the deficient practice: The facility failed to ensure the New Jersey Universal Transfer form and physician discharge summary was completed for resident #289. Resident #289 was discharged from the facility [R]. Individual nurse who discharged the resident was provided with individual education on the process for discharging residents to another LTC facility, including the New Jersey Universal Transfer Form. 2. Identifying other residents who could be affected by the deficient practice: Residents being discharged to another LTC facility could be affected by this deficient practice. Discharges for December were audited and no residents were discharged from the facility to another LTC during this period. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses and U.S. FOIA (b) (6) were in-serviced on the policy/process for discharging residents to another facility that includes the New Jersey Universal Transfer Form, beginning 12/4/24 by the Director of Nursing and Assistant Director of Nursing. The Clinical Management team and The Medical Records Director in-serviced on completion of Physician discharge summary for all residents discharged, beginning on 12/4/24 by the Director of Nursing and Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing or Designee will conduct audits of discharged residents charts to ensure accurate completion of the New Jersey Universal transfer form and discharge summaries weekly x 4 weeks then monthly x 2 months. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Develop Comprehensive Care Plan for Amputee Resident
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan (ICCP) for a resident who had a new left below knee amputation and was receiving wound care for a surgical site. This deficiency was identified during a survey when the resident, who was observed sitting in a wheelchair, mentioned receiving therapy on the left leg. The resident's medical record indicated diagnoses including acquired absence of the left leg below the knee, diabetes mellitus, repeated falls, and acute kidney failure. Despite these conditions, the ICCP did not include the left below knee amputation, surgical wound, or impaired skin integrity. The Director of Nursing (DON) confirmed that the surgical wound should have been noted in the admission assessment, physician orders, and included in the ICCP, with a focus on impaired skin integrity. However, the review of the ICCP revealed that these critical aspects were missing. The facility's policy, dated 9/1/24, mandates the development and implementation of a comprehensive person-centered care plan for each resident, consistent with their medical, nursing, and psychosocial needs as identified in the comprehensive assessment. This policy was not adhered to in the case of the resident with the new amputation.
Plan Of Correction
1. Resident affected by deficient practice: The facility failed to develop an individualized comprehensive care plan for a resident with a new NJ Exec Order 26.4b1 who was receiving care to a NJ Exec Order 26.4(b)(1). Resident #189 care plan was updated to reflect NJ Exec Order 26.4b1 related to NJ Exec Order 26.4(D). 2. Identifying other residents who could be affected by the deficient practice: Residents who are admitted to the facility with a surgical site could be affected by this deficient practice. Other residents with surgical sites were audited. No other residents with surgical sites were found. 3. Measures or systemic changes to ensure that the deficient practice does not recur: Unit Managers, Nursing Supervisors, and Licensed Nurses in-serviced on Comprehensive Care Plans to include surgical wound care by Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: Director of Nursing/designee will conduct audits of all new admissions to ensure accurate completion of comprehensive care plans for surgical sites/wounds weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise the individual comprehensive care plans (ICCP) for two residents following falls, which is a deficiency in care planning. Resident #55, who was hospitalized and later readmitted, had a history of a right hip fracture and was completely dependent on staff for mobility. Despite being identified as a high risk for falls after a fall incident, the resident's care plan, which was last revised months prior, was not updated with new interventions until after the surveyor's inquiry. Resident #14, who had multiple diagnoses including chronic obstructive pulmonary disease and congestive heart failure, experienced several falls over a few months. The resident's care plan, which identified them as at risk for falls due to impaired mobility and other factors, did not include new interventions after falls on specific dates. The Director of Nursing acknowledged that the care plan should have been updated with new interventions following these incidents. The facility's policies on fall prevention and care plan revisions require that care plans be updated with new interventions following a fall. However, the care plans for both residents were not revised in accordance with these policies, leading to the identified deficiency. The Director of Nursing confirmed that the care plans should have been updated with new interventions as changes occurred.
Plan Of Correction
1. Residents affected by the deficient practice: Resident #55's care plan was updated with interventions upon readmission on 12/6/24. Resident #14 had no NJ Exec Order 26.4b1 requiring further care plan intervention. 2. Identifying other residents who could be affected by the deficient practice: All Residents who have a fall or who have an incident could be affected by this deficient practice. Current residents with a fall were audited for care plan updates with no noted issues. 3. Measures or systemic changes to ensure that the deficiencies will not recur: U.S. FOIA (b) (6) Unit Managers, Nursing Supervisors and Licensed Nurses in-serviced on the Policy for Incidents/Accidents and the process by Director of Nursing. Emphasis placed on the timing of completing the care plan with a new intervention at the time of the incident. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing/Designee will audit five resident incident reports to ensure timely completion of CarePlan interventions weekly x 4 then monthly x 3. Results of audit will be reviewed at Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Medication Administration and Management Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of practice by not administering medications in a timely manner according to physician orders for a resident. During an initial tour, it was observed that a resident received their scheduled medications late. The resident had a history of chronic pain syndrome, anxiety disorder, bipolar disorder, and adult failure to thrive. The review of the Medication Admin Audit Report revealed multiple instances where medications such as morphine sulfate, methadone HCL, and lorazepam were administered outside the prescribed time frames. The Director of Nursing acknowledged that medications given outside the one-hour window before or after the scheduled time were considered late, and emphasized the importance of timely administration to prevent potential overdose. Additionally, the facility failed to ensure proper medication management by borrowing medications from one resident's supply to administer to another. During medication administration observations, an LPN was seen borrowing medications from other residents when the required medications were not available in the medication cart. This occurred for two residents, where medications such as escitalopram oxalate and metformin HCL were borrowed from other residents' supplies. The LPN admitted to the surveyor that borrowing medications was against protocol, but justified the action due to the lack of backup medications in the cart. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the proper procedure when a medication is unavailable is to check the pyxis for backup, notify the physician, and contact the pharmacy for a STAT order if necessary. Both emphasized that medications should not be borrowed from one resident for another, as it could lead to the original resident running out of their prescribed medication. The facility's Medication Administration policy also outlined the requirement to administer medications within a specific time frame and to verify medication details before administration.
Plan Of Correction
1. Residents affected by the deficient practice: The facility failed to maintain professional standard of practice by ensuring medications were administered in a timely manner in accordance with the resident's physicians order and ensuring proper medication management by borrowing medications from one resident supply to administer to another resident. Resident #48 had not had further cited concerns of receiving medications outside of parameters since [R] Resident #60 and Resident #4 received medication as ordered. Licensed nurse who administered medication as cited to resident #60 and #4 received individual education. 2. Identifying other residents who could be affected by the deficient practice: All residents can be affected by this practice. Residents #48, #60, and #4 were audited for medication administration outside of parameters with no further issues identified. Five other residents were audited to ensure that all medications were available with no issues identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed nurses in-serviced on the Medication Administration Policy and the process if a resident is out of their supply of medication beginning 12/5/24 by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Unit Managers/Designee will conduct an audit of medication availability and administration time parameters for five residents weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for a resident, as evidenced by the lack of prescribed skin protective devices and interventions. The resident, who was admitted with multiple medical diagnoses including a stage three pressure ulcer, was observed without a low air loss mattress or heel boots, despite physician orders and wound care consultant recommendations for these interventions. The resident reported not receiving the special mattress or boots and was using a pillow for offloading instead. The Licensed Practical Nurse confirmed the absence of these prescribed devices, indicating a failure to implement the necessary measures to prevent further skin breakdown. The resident's medical records and care plan highlighted the need for specific interventions to manage and prevent pressure ulcers, including the use of a customized shoe, foam heel protector boots, and a low air loss mattress. Despite these documented needs and recommendations, the facility did not provide the required equipment, as confirmed by both the resident and staff interviews. The Director of Nursing acknowledged the purpose of these interventions was to prevent worsening of the wound or new pressure ulcers, yet the facility's actions did not align with the established care plan and physician orders.
Plan Of Correction
1. Residents affected by the deficient Orders were discontinued for NuExec Order 26.461 and no NJ Exec Order 26.4b1 was in place per recommendation as NJ Exec Order 26.4b1 had been NU EX Order 26. as of NJ Exec Order 26.4b1 rounds and NJ Exec Order 26.4b1 rounds, NJ Exec Order 26.4b1 was NJ Ex Order 26.4. 2. Identifying other residents who could be affected by the deficient practice: All residents with wounds and that are at risk for wounds. Residents with wounds were audited to ensure that all orders and recommendations were carried out. No further issues identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Unit Managers and Licensed nurses were educated on the Administration of Wound treatments by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing/designee will conduct an audit of all wound consults to ensure all orders/recommendations were followed weekly x 4 weeks then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Obtain Smoking Contract Upon Admission
Penalty
Summary
The facility failed to have a resident who smoked sign the Smoking Contract/Agreement upon admission, which was identified as a deficient practice for one of the three residents reviewed for accidents. The resident, who was admitted with diagnoses including hypertension, anxiety disorder, bipolar disorder, and polyneuropathy, was observed ambulating in the hallway and later in their bedroom. The resident's medical record indicated an intact cognition and current tobacco use, with a comprehensive care plan noting the resident as a smoker. However, the Smoking Contract/Agreement was not signed until several months after admission, and the facility could not provide a smoking contract from the time of admission. Interviews with facility staff, including the Activities Director and the Director of Nursing, revealed that smoking assessments and contracts were supposed to be completed upon admission. The Director of Nursing stated that Smoking Contracts should be completed within 72 hours of admission, but could not confirm when they should be completed other than upon admission. The Licensed Nursing Home Administrator acknowledged that a Smoking Contract should have been completed upon the resident's admission. The facility's Smoking Policy required all residents who smoke to sign a smoking agreement contract upon admission, which was not adhered to in this case.
Plan Of Correction
1. Resident affected by deficient practice: Resident #82 had a NJ Exec Order 26.4b1 completed on [R]. 2. Identifying other residents who could be affected by the deficient practice: Residents who smoke could be affected by this deficient practice. All other residents who smoke were audited for smoking contracts and no further issues were identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Smoking policy/process re-education provided to clinical team ([R], Unit Managers, Nursing Supervisors, Licensed Nurses, and the [R] in person by Director of Nursing. The Smoking Policy was reviewed in person with all residents who smoke require a smoking assessment and contract upon admission to the facility. 4. Monitoring the continued effectiveness of the systemic change: The Activities Director/Designee will audit up to five smokers to ensure adherence to smoking policy and procedure have been completed weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Document Dialysis Access Assessment
Penalty
Summary
The facility failed to ensure a physician's order was in place to properly assess a resident's dialysis access site. This deficiency was identified for a resident who was dependent on renal dialysis and had a recent medical emergency involving their dialysis shunt, which started to bleed, necessitating emergency surgery. Upon review, it was found that the resident's medical records did not include a physician's order to assess the dialysis access site, nor were there any documented interventions in the individualized comprehensive care plan to monitor or assess the site. Further investigation revealed that the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November and December 2024 did not show any documentation of the dialysis site being assessed or monitored by the nursing staff. Interviews with the nursing staff, including the Licensed Practical Nurse/Unit Manager and another LPN, confirmed the presence of an arteriovenous fistula (AVF) in the resident's arm, but also revealed that assessments were not documented. The Director of Nursing acknowledged the lack of documentation and confirmed that there was no physician's order for assessing the dialysis access, highlighting a lapse in following the facility's Hemodialysis policy.
Plan Of Correction
1. Resident affected by deficient practice: The facility failed to ensure a physician's order was in place to properly assess a resident's Exec Order 26.4NJ Ex Order 26. site. Order was entered for resident #81 to check for NJERECOR. 2. Identifying other residents who could be affected by the deficient practice: Residents with a dialysis access site have the potential to be affected. Other residents with a dialysis access site were audited with no negative findings noted. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses in-serviced on the policy/process of resident requiring dialysis to include assessing bruit and thrill by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: Unit Manager/designee will audit up to four dialysis resident's charts and ensure orders/care plan is in place weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Inaccurate Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the accurate counting and reconciliation of controlled substances. During a survey, it was observed that the Individual Patient Controlled Substance Administration Record (IPCSAR) reconciliation sheet was incorrect for eight shifts with 16 occurrences on Medication Cart A, 2nd floor. The surveyor noted that a tablet of Oxycodone/Acetaminophen 5/325 mg was missing from the blister pack, despite the IPCSAR indicating one tablet should remain. The December 2024 Medication Administration Record (MAR) showed the missing pill was administered and signed off on the resident's MAR but not correctly on the IPCSAR. Further investigation revealed discrepancies in the Narcotic Shift Count log, with inaccurate counts recorded for multiple shifts and missing reconciliation signatures for the 11pm-7am shift on 12/4/24. Interviews with the LPN/UM and the DON confirmed that the facility's policy for narcotic counts during shift changes was not followed. The facility's policy requires controlled substances to be accounted for by two licensed nurses at the end of each shift, which was not adhered to, leading to the identified deficiencies.
Plan Of Correction
1. Resident affected by the deficient practice: The facility failed to provide pharmaceutical services in accordance with professional standards to ensure dispensed and administered controlled substance medication was accurately counted, and the individual patient NJ Ex Order 26.4(b)(1) administration record sheet was incorrect for 8 shifts with 16 occurrences on medication Cart on the floor. Investigation was initiated. Nurse who signed MAR was interviewed and indicated that medication was administered but was not documented on Individual Patient Controlled Substance Administration Record (IPSCAR). Individual nurse who did not accurately document on IPSCAR received in person education on the Controlled Substance Administration and Accountability Policy. Nurses who completed the shift counts for 12/2/24 (11pm-7am shift), 12/3/24 (11p-7am, 7a-3p, and 3p-11p), 12/4/24 (11p-7a, 7a-3p and 3p-11p) and 12/5/24 (11p-7a and 7a-3p) received in person education on the Controlled Substance Administration and Accountability. 2. Identifying other residents who could be affected by the deficient practice: Residents who receive narcotic medication could be affected by this deficient practice. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses received in person education on the Medication Administration Policy and the process of end of shift narcotic count by Director of Nursing / Designee by reviewing the Medication Administration Policy and the end of shift count with the Nurses. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing or Designee will complete an audit of all narcotic count sheets to ensure accuracy weekly x4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Act on Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist (CP) were acted upon in a timely manner for two residents. Resident #54 was admitted with chronic obstructive pulmonary disease and was cognitively intact. The CP made several recommendations regarding the resident's medication regimen, including potential risks of serotonin syndrome and duplicate therapy, which were not addressed by the attending physician or reflected in the Medication Administration Record (MAR). These recommendations were made in June, August, September, and October, but none were completed by the facility. Resident #35, admitted with hemiplegia and hemiparesis following a stroke, had a discontinued order for a medication used to treat lung disease. The CP recommended discontinuing a PRN medication that had not been used for over 60 days, but this recommendation was not addressed in a timely manner. The Director of Nursing (DON) acknowledged that pharmacy consultant recommendations should be addressed within one to two weeks, but this was not done. The facility's policies required that CP reports be acted upon and submitted to the DON within 10 working days. However, the reports for both residents were not signed or dated by the attending physician, and the recommendations were not completed. The Licensed Nursing Home Administrator (LNHA) and other staff acknowledged the failure to address the pharmacy consultant recommendations timely, as per the facility's policies.
Plan Of Correction
1. Residents affected by the deficient practice: For residents #54 and #35, provider and nursing reviewed and addressed pharmacy consultant recommendations for six months for both residents. 2. Identifying other residents who could be affected by the deficient practice: All residents with recommendations from the pharmacy consultant are at risk if the Consultant Pharmacy Report is not followed up with in a timely manner. All pharmacy recommendations for December were audited by the Director of Nursing to confirm that provider and nursing recommendations were completed, with no issues noted. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Beginning on 12/6/24, Unit Managers and U.S. FOIA (b) (6) received education on Pharmacy Recommendations by Director of Nursing. Monthly Pharmacy recommendations are to be completed within one week of receiving from Pharmacy Consultant. DON/or designee will follow up to ensure all recommendations have been addressed by the Physician. 4. The Director of Nursing will review/ensure accurate completion of the Monthly Pharmacy Consultant reports x3 months and Quarterly x2. Results will be reviewed during Quality Assurance Meeting over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Provide Annual Dental Care
Penalty
Summary
The facility failed to provide mandatory annual dental care and services for a resident, identified as Resident #15. The deficiency was observed when the surveyor noted the resident's teeth were brown, discolored, chipped, and some were missing. The resident was admitted with a diagnosis of Type 2 diabetes mellitus and had a moderately impaired cognition with a BIMS score of 10 out of 15. Despite the resident's oral health issues being noted in the Nursing Comprehensive Assessment, the comprehensive Minimum Data Set (cMDS) inaccurately reflected the resident's oral condition, indicating no issues with dentures or natural teeth. Furthermore, there was no order for a dental consultation in the resident's Order Summary Report, and the electronic medical record (eMAR) lacked documentation of offered or refused dental care services. The facility's Care Plan for the resident included interventions for oral/dental health problems related to poor hygiene, yet there was no evidence of dental visits for the resident in the records provided by the Director of Nursing. Interviews with the Licensed Practical Nurse Unit Manager and the Director of Nursing revealed that the facility's policy required a physician order for dental consults based on admission assessments, which was not followed in this case. The facility's Dental Services Policy and Agreement were in place, but the resident's dental needs were not addressed as required, leading to the identified deficiency.
Plan Of Correction
1. Residents affected by deficient practice The facility failed to provide the annual [R] and services to Resident #15. On 12/5/24, Resident #15 was requested to be seen by [R] during next scheduled visit. 2. Identifying other residents who could be affected by the deficient practice: All residents have the potential to be affected by this deficient practice. 3. Measures or systemic changes to ensure that the deficiencies will not recur: The Dental Services Policy was reviewed with the Unit Managers, Unit Secretary and Director of Social Services by the Assistant Director of Nursing. Audit conducted for long-term residents to ensure they received a dental consult. 4. Monitoring the continued effectiveness of the systemic change: The Social Worker will complete an audit of five residents to ensure they have been seen by the Dentist. This audit will be completed Monthly x 3 months. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.
Failure to Meet Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified during a review of the facility's Nurse Staffing Reports, which revealed that on three separate day shifts, the facility did not meet the required staffing levels. Specifically, on one day shift in March 2024, the facility had 11 CNAs for 93 residents, falling short of the required 12 CNAs. Similarly, in November 2024, the facility had 10 CNAs for 85 and 86 residents on two separate day shifts, where at least 11 CNAs were required. Interviews with the facility's Staffing Coordinator and the Licensed Nursing Home Administrator, along with the Director of Nursing, confirmed awareness of the staffing regulations. The Staffing Coordinator mentioned that when staffing was deficient, they would send out "massive" texts to employees and, if necessary, use agency staff. Despite these efforts, the facility still failed to meet the mandated staffing ratios on the specified days, leading to the identified deficiency.
Plan Of Correction
1. There was no care issues reported on the three-day shifts of the twenty-one reviewed that the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. The Director of Nursing/designee reviewed the last 30 days of the Certified Nursing Assistant staffing report. The interdisciplinary team reviewed the grievance logs and care conference meetings, and no care issues were identified. 2. All residents have the potential to be affected by staffing below state mandated minimum levels. 3. Administrator in-serviced the staffing coordinator regarding the requirement for S560 to ensure Certified Nursing Assistant staffing needs are reviewed daily and addressed as needed to meet the staffing requirement. Recruitment efforts are in place to assist the facility in recruiting. Certified Nursing Assistant receive sign-on bonuses, referral bonuses, reimbursement for Certified Nursing Assistant tuition, and transportation service from certain locations. Facility also has contracts with agencies to recruit Certified Nursing Assistants. The Director of Nursing/designee also reviews staff attendance records to ensure that excessive absences are addressed accordingly. 4. The Administrator/designee will have weekly meetings with the staffing coordinator to audit staffing schedules, needs, and the efficacy of the systems in place to fill needs weekly. The findings of the audits will be presented at the QAPI meetings for three months.
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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