Complete Care At Ocean Grove Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ocean Grove, New Jersey.
- Location
- 160 S Main St, Ocean Grove, New Jersey 07756
- CMS Provider Number
- 315365
- Inspections on file
- 17
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Complete Care At Ocean Grove Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently document ADL bladder care for two residents, one with spinal stenosis and Parkinson’s disease and another with chronic pulmonary embolism and type 2 DM. Review of the electronic POC records for a specific month showed multiple blank entries for bladder documentation across various shifts, indicating care was not recorded as completed. A CNA and an LPN confirmed that facility expectations require ADL documentation to be completed before the end of each shift, and the DON acknowledged the blanks and reiterated that CNAs are expected to accurately and fully complete ADL logs in accordance with the facility’s ADL policy.
Surveyors found that kitchen staff failed to properly label, date, and store potentially hazardous foods, and did not maintain kitchen equipment in a clean and sanitary manner. Observations included spoiled produce in refrigerators, an ice machine with condensation, unidentified substances, and makeshift repairs, as well as an oven with greasy residue. Opened food items were not labeled or dated as required, and facility policies for cleaning and food safety were not consistently followed.
During incontinence rounds, two residents dependent on staff for ADLs were found wearing double incontinence briefs, both of which were wet. An LPN confirmed this was not appropriate practice. Both residents had significant medical conditions and were assessed as always or frequently incontinent, with care plans lacking specific interventions in one case. Facility policy and staff confirmed that double briefing was not acceptable.
The facility did not have an RN present for at least eight consecutive hours on one day, as required. An RN was scheduled but called out, and although the agency was contacted, an LPN was sent instead. The absence of an RN was not discovered until the next shift, resulting in a lapse in required RN coverage for resident care and assessments.
A resident's medical record was found to be incomplete when the facility could not provide the full Controlled Drug Administration Record (CDAR)/Declining Sheet for a prescribed medication, despite repeated requests and searches by the DON. Only a partial record was available, resulting in a deficiency for failure to maintain complete and accurate documentation as required.
The facility did not meet required CNA-to-resident staffing ratios on multiple day shifts over several weeks, with staffing levels consistently below state-mandated minimums for the number of residents present. This deficiency was identified through interviews and review of facility records, and had the potential to affect all residents.
Two residents in an LTC facility did not receive their medications at the scheduled times, as required by the facility's policy. Despite the late administration of medications for hypertension and pain, there was no documentation of notifying the residents' PCPs or evidence of harm. Interviews with nursing staff confirmed the expectation of timely medication administration and proper documentation, aligning with the facility's policy.
The facility staff failed to document ADL care for two residents as per policy. One resident, with muscle weakness, lacked documentation of necessary interventions like rolling and toileting over several days. Another resident, with severe cognitive impairment, also had missing documentation for bed mobility and toileting care. Staff interviews revealed CNAs were responsible for documenting care in the POC system by shift end, even if care was refused.
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY number for three residents. This omission was identified during a review of the NOMNC forms, and the Director of Social Services was unaware of the requirement.
The facility failed to protect residents from physical abuse, as evidenced by incidents where a resident with severe cognitive impairment hit another resident with a fly swatter, and another incident where a cognitively impaired resident kicked a cognitively intact resident. The facility conducted abuse training and had policies in place, but these incidents still occurred.
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency. Incidents involving a resident being hit with a fly swatter, a resident with a bruised wrist, and a resident with multiple bruises and an abrasion were either reported late or not reported at all. Staff interviews revealed a lack of awareness regarding the required reporting timeframes.
The facility failed to investigate injuries of unknown origin for a resident. Despite reporting the incidents to the DON, no skin audits, resident interviews, or camera footage reviews were conducted. The facility did not follow its policy for thorough investigations.
The facility staff failed to complete a baseline care plan within 48 hours for a resident admitted with diabetes mellitus, spinal stenosis, and quadriplegia. The resident, moderately cognitively impaired, did not have a care plan until 14 days post-admission, contrary to the facility's policy.
The facility failed to provide scheduled showers twice a week for two dependent residents due to staff shortages, despite the residents' preferences and cognitive awareness. Documentation and staff interviews confirmed the inconsistency in providing the scheduled showers.
The facility staff failed to maintain a medication error rate below five percent, as evidenced by two incidents where an LPN administered the incorrect dosage of acetaminophen to a resident and an RN held a dose of spironolactone without physician orders to do so.
The facility failed to ensure medical records were readily accessible for a resident admitted with hypertension, diabetes, and dementia. Despite multiple requests and attempts to retrieve the records from a previous EMR system, the facility was unable to provide the necessary medical information, including critical wound care documentation. This highlights a significant deficiency in maintaining and retrieving resident medical records.
The facility failed to ensure proper infection control practices: a hospitality aide did not wear an N-95 mask and eye protection in a COVID-19 positive room, a CNA doffed PPE outside a room with strict contact precautions, and an LPN cleaned a glucometer without gloves.
Failure to Consistently Document ADL Bladder Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to consistently document Activities of Daily Living (ADLs), specifically bladder care, for two residents. For one resident with spinal stenosis and Parkinson’s disease and a BIMS score of 8/15 indicating moderate cognitive impairment, review of the December 2025 Documentation Survey Report (POC) showed blank entries for bladder documentation on multiple shifts and dates, indicating the task was not documented as completed. For another resident with chronic pulmonary embolism and type 2 diabetes mellitus and a BIMS score of 15/15 indicating intact cognition, the December 2025 POC similarly contained numerous blank bladder documentation entries across day, evening, and night shifts, again indicating the task was not documented as completed. During interviews, a CNA stated that ADL care is documented on the POC and that the expectation is to complete documentation within two hours before the end of the shift, acknowledging that documentation serves as proof of care provided. An LPN stated that all documentation should be completed before staff leave the facility. When presented with the POC records for both residents, the DON acknowledged the blanks and stated that staff are expected to document accurately according to the numerical log and to complete ADL logs in their entirety so the facility can know and perform residents’ needs and expectations. Review of the facility’s ADL policy, implemented 09/01/24, stated that residents unable to carry out ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which the facility failed to follow as evidenced by the incomplete ADL documentation.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper labeling, dating, and storage of potentially hazardous foods, as well as inadequate cleaning and maintenance of kitchen equipment. During kitchen inspections, condensation and an unidentified yellow substance were found on the ice machine, which also had duct tape and a white bonding material applied to damaged areas. The Food Service Director (FSD) was unable to identify the yellow substance or provide a satisfactory explanation for the use of duct tape and bonding material. The oven was observed to have a greasy, brown substance on its inner surface, and the FSD acknowledged that the oven should be kept clean and free of such substances. Additionally, wilted and partially decomposed lettuce, wilted and yellow celery, and cucumbers with visible spoilage and leaking juice were found in the walk-in refrigerators. The FSD stated that produce is checked during meal preparation rather than daily, which contributed to spoiled items remaining in storage. Further observations revealed an opened, unlabeled, and undated box of sausage and a container of cottage cheese in the walk-in refrigerator, both of which lacked required labeling and dating. The FSD confirmed that these items should have been covered and labeled with opened or used-by dates to ensure food safety. Facility policies reviewed by surveyors required regular cleaning and sanitizing of the ice machine and ovens, as well as proper labeling and dating of food items, but these procedures were not consistently followed. The deficiencies were acknowledged by facility leadership during the survey.
Deficient Incontinence Care Due to Use of Double Briefs
Penalty
Summary
Surveyors identified a deficiency in incontinence care during rounds on one of two nursing units, where two residents who were dependent on staff for activities of daily living were found to be wearing double incontinence briefs. In both cases, a staff member exposed the front of the resident's brief, which was wet, and upon further inspection, a second, also wet, incontinence brief was discovered layered underneath. The staff member present acknowledged that applying two briefs was not appropriate. Both residents had significant medical histories, including congestive heart failure, type 2 diabetes mellitus, and acute respiratory failure, and were assessed as always or frequently incontinent and dependent on staff for toileting hygiene. The medical records and individualized care plans for these residents documented their incontinence and dependence on staff, but one care plan did not include specific interventions for incontinence. The facility's policy on incontinence care required appropriate treatment to prevent infections and restore continence to the extent possible. The surveyor confirmed with facility staff and policy that the use of double briefs was not acceptable practice, and the deficiency was cited based on these observations and record reviews.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least eight consecutive hours on one of the days reviewed. Specifically, review of the facility's Nurse Staffing Reports showed that there was no RN coverage for any shift on a particular day. During interviews, facility staff confirmed that an RN was scheduled but called out, and although the agency was contacted to provide a replacement, a Licensed Practical Nurse (LPN) was sent instead. The error was not identified until the next shift, resulting in a full day without RN coverage. The facility's policy requires sufficient staffing, including RNs, to provide nursing care in accordance with resident care plans. However, on the day in question, the absence of an RN meant that there was no RN available to assist with assessments and overall care of the residents, as confirmed by staff interviews. The deficiency was identified through document review and staff interviews, with staff acknowledging the oversight and the failure to ensure RN coverage as required by federal regulations.
Plan Of Correction
1. The facility failed to ensure there was a Registered Nurse working for at least 8 consecutive hours on 1 of 21 days reviewed. 2. All residents have the potential to be affected by this practice. 3. The Facility continues to actively fill all open Registered Nurse positions to comply with Federal Nursing Regulation to have 8 consecutive hours a day, 7 days a week. Staff requirements and facility policy were reviewed with Human Resources and the Staffing Coordinator, who were able to reiterate minimum staffing requirements. The facility will take the following measures to ensure this deficient practice does not occur. The facility will focus on recruitment and retention strategies as follows: identify vacant Registered Nurse positions daily and attempt to fill positions with current Registered Nurses staff or agency; work diligently with the Administrator, Director of Nursing, and Corporate Recruiter to advertise, recruit, and hire sufficient Registered Nurse staff. 4. The Staffing Coordinator will review schedules daily to ensure that at least 8 RN hours are scheduled and will review with the Director of Nursing. The Administrator or designee will audit the schedules weekly for 4 weeks and monthly for 2 months to ensure there is an RN scheduled for 8 consecutive hours 7 days a week. Results and audits will be reviewed at the monthly Quality Assurance Meeting for 3 consecutive meetings. Based upon the results of these audits, a decision will be made regarding the need to continue submission and reporting.
Incomplete Medical Record for Controlled Drug Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of four sampled residents. Specifically, the surveyor requested the complete Controlled Drug Administration Record (CDAR)/Declining Sheet for a resident's medication, but the facility was unable to provide the entire documentation. The only available record was a single sheet with a specific date issued, and despite further requests and searches by the Director of Nursing, the full CDAR/Declining Sheet could not be located. An email response confirmed that the document was still missing at the time of the survey. This deficiency was identified through observations, interviews, and review of medical records and facility documentation. The resident involved had multiple diagnoses and was receiving medication as ordered, but the lack of a complete CDAR/Declining Sheet meant that the facility did not have a full record of the administration of a controlled drug as required by federal and state regulations.
Plan Of Correction
1. Resident #2 was discharged from the facility. 2. All residents who have orders for medications that require a Controlled Drug Administration Record/Declining Sheet have the ability to be affected by this practice. 3. The Medical Record staff was re-educated on the procedure for maintaining accurate, complete, readily accessible, and systematically organized records by the Director of Nursing or designee. The Drug Administration Record Declining sheet will be reviewed for accuracy and placed in residents' charts. 4. The Director of Nursing/Designee will audit the Controlled Drug Administration Record/Declining Sheet on each cart weekly x 4 and monthly x 2. The results of the audit will be reviewed at the Monthly Quality Assurance Meeting for three months. Continuation of the audits, reporting, and frequency after three months will be determined by the QA Committee.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.
Plan Of Correction
1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications in accordance with the acceptable standard of nursing practice and its own policy on administering medications for two residents. Resident #1, who was admitted with diagnoses including hypertension and pain, had medication orders for Clonidine and Gabapentin to be administered at specific times. However, the Medication Administration Audit Report revealed that these medications were consistently administered late, with no documentation indicating that the resident's primary care physician was notified of these deviations. Despite the late administration, there was no documented evidence of harm to the resident. Similarly, Resident #2, admitted with hypertension and dermatitis, had medication orders for Cozaar and Hydroxyzine to be administered at specific times. The Medication Administration Audit Report showed that these medications were also administered late on multiple occasions. Again, there was no indication in the progress notes that the resident's primary care physician was informed of the late administration, and no documented evidence of harm was noted. Interviews with nursing staff, including a registered nurse and a unit manager, confirmed that medications were expected to be administered within one hour of the scheduled time. They also stated that if medications were not administered on time, the physician should be notified, and the incident documented in the medical records. The facility's policy on medication administration, dated October 2022, supports these expectations, emphasizing the importance of timely administration and proper documentation.
Failure to Document ADL Care for Residents
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to two residents, as per the facility's policy and protocol. For one resident, who was admitted with muscle weakness and required assistance with ADLs, the documentation survey report (DSR) did not indicate that necessary interventions such as rolling, turning, repositioning, and toileting were provided during specific shifts over several days in April 2024. This resident had intact cognition and required assistance due to impaired balance and musculoskeletal impairment, as noted in their care plan. Another resident, admitted with Parkinsonism, Alzheimer's Disease, and Dementia, required total assistance with ADLs due to severe cognitive impairment. The DSR for this resident also lacked documentation of bed mobility, turning, repositioning, and toileting care provided during various shifts in May and June 2024. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Unit Manager/Registered Nurse (UM/RN), revealed that CNAs were responsible for documenting ADL care in the Point of Care (POC) system by the end of each shift, even if care was refused. The facility's policy emphasized the importance of documenting all services provided to residents to facilitate communication among the interdisciplinary team.
Failure to Include Required Information on NOMNC Forms
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY (teletypewriters) number for three residents. This omission was identified during a review of the NOMNC forms for three residents, who were either discharged or remained in the facility for long-term care. Specifically, the NOMNC for Resident 23, who was admitted for therapy and discharged home, did not contain the name of the QIO or the TTY number. Similarly, the NOMNCs for Residents 188 and 189, who remained in the facility for long-term care, also lacked this required information. The NOMNC for Resident 188 was issued by phone to the resident's daughter, who handled all business matters, but still did not include the necessary details for filing an expedited appeal. The NOMNC for Resident 189 was issued without the QIO name or TTY number as well. During an interview, the Director of Social Services (DSS) stated she was unaware that the name of the QIO and the TTY number had to be included on the NOMNC. A review of the facility's policy, dated 2022, confirmed that the NOMNC should inform beneficiaries of their right to an expedited review by a QIO. This failure to include the required information could prevent Medicare beneficiaries with hearing impairments from being able to file an appeal in a timely manner.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving four residents. One incident involved a resident with severe cognitive impairment who entered another resident's room and hit her with a fly swatter. The resident who was hit did not sustain any injuries and did not believe the other resident intended to harm her. The staff had attempted a gradual dose reduction of the aggressive resident's psychotropic medication, which led to increased behaviors, and the medication was subsequently resumed at the original dose. Despite the use of a wander guard and staff supervision, the incident occurred, and there were no further incidents reported with this resident. Another incident involved a resident who was cognitively intact and was kicked in the leg by another resident who mistakenly entered her room. The cognitively impaired resident believed he was in his own room and became adamant about staying. The cognitively intact resident attempted to push the other resident out of her room, leading to the altercation. The facility's investigation noted a small purpuric area on the resident's leg as a result of the kick. The cognitively impaired resident was placed on half-hour behavior checks following the incident. Interviews with staff revealed that the facility conducted abuse training annually and in-services throughout the year. Staff were expected to report any concerns to the DON and ensure resident safety. The DON and Regional Administrator both emphasized the expectation for residents to be safe and have an abuse-free environment. The facility's policy on abuse, neglect, exploitation, or misappropriation required all reports of abuse to be thoroughly investigated and documented, with findings reported to relevant agencies.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency for three of six incidents reviewed. In one instance, a resident reported being hit by another resident with a fly swatter, but the incident was not reported to the New Jersey Department of Health (NJDOH) until the following day. In another case, a resident was found with a bruise on her wrist, which was reported to the Director of Nursing (DON) and the former Administrator, but the incident was not reported to NJDOH until three days later. Additionally, a resident was found with multiple bruises and an abrasion, but this incident was not reported to NJDOH at all. Interviews with staff revealed a lack of awareness regarding the requirement to report abuse within two hours if it involves serious bodily injury, or within 24 hours if it does not. The facility's policy on reporting abuse, neglect, exploitation, or misappropriation of resident property was not followed, as incidents were either reported late or not reported at all. The DON admitted to being unaware of the specific reporting timeframes, and the Regional Administrator confirmed that all incidents should be reported within the required two hours. The facility's failure to adhere to these reporting requirements resulted in deficiencies in their handling of abuse and injury incidents.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of an unknown origin for a resident. On one occasion, a resident was found with a bruise on the left wrist, and although the incident was reported to the Director of Nursing (DON) and the former Administrator, no skin audit or resident interviews were conducted. Additionally, the facility did not review camera footage or complete additional body audits. On another occasion, the same resident was found with a bruised finger, a small bruise near the right elbow, and an abrasion on the right elbow. Despite reporting the incident to the DON, no investigation was conducted to determine the cause of the injuries. The facility's policy requires thorough investigations of all reports of resident abuse, including injuries of unknown origin. This includes reviewing documentation, interviewing staff and residents, and observing the alleged victim. However, the facility did not follow these procedures in the cases mentioned. The DON admitted that they were still learning their new electronic medical record (EMR) system and were unsure where to document the incidents. The Regional Administrator also stated that he expected all incidents to be thoroughly investigated, which was not done in these cases.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility staff failed to complete a baseline care plan within 48 hours of admission for one resident. The resident, who was admitted with diagnoses of diabetes mellitus, spinal stenosis, and quadriplegia, was moderately cognitively impaired with a BIMS score of 12 out of 15. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission, the care plan for this resident was not completed until 14 days after admission. Both the Director of Nursing and a registered nurse confirmed the delay during interviews. The facility's policy, dated 10/02/23, mandates the development of a baseline care plan within 48 hours of a resident's admission.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers twice a week as scheduled for two residents, R21 and R51, who were dependent on staff assistance for activities of daily living (ADLs). R21, who was admitted with diagnoses including end-stage renal disease, COPD, hemiplegia, and diabetes mellitus, did not receive scheduled showers on multiple occasions in January and February 2024. Despite being cognitively intact and expressing a preference for showers over bed baths, R21 reported not receiving her scheduled showers due to staff shortages. This was confirmed by the facility's documentation and staff interviews. Similarly, R51, who was admitted with diagnoses of cerebral infarction and hemiplegia, also did not receive scheduled showers on several occasions. R51, who was also cognitively intact, expressed a preference for showers and reported inconsistencies in receiving them as scheduled. The facility's documentation and staff interviews corroborated these claims, indicating that staff shortages were a contributing factor. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) responsible for R21 and R51 confirmed that the residents were scheduled for showers on Mondays and Thursdays but did not always receive them due to staffing issues. The Director of Nursing (DON) acknowledged the problem and stated that residents were supposed to receive bed baths if showers could not be provided. However, the documentation showed that the scheduled showers were not consistently provided, leading to the deficiency.
Medication Administration Errors
Penalty
Summary
The facility staff failed to ensure the medication error rate was below five percent, as evidenced by two observed incidents involving residents R22 and R6. For R22, who has diagnoses including diabetes mellitus, bipolar disease, and schizophrenia, the physician ordered two 500 mg tablets of acetaminophen to be administered in the morning for pain. However, during a medication administration observation, LPN7 was seen administering only one tablet. LPN7 later confirmed the error, acknowledging that she might have given only one tablet despite the order for two. The Director of Nursing (DON) confirmed that all medications should be given as ordered by the physician. In the case of R6, who has diagnoses of hypertension and congestive heart failure, the physician ordered 25 mg of spironolactone to be administered in the morning for edema, with no parameters to hold the medication based on blood pressure readings. During a medication administration observation, RN5 held the medication, citing a low blood pressure reading of 91/53, despite the absence of any such directive in the physician's orders. The DON confirmed that the nurse should have contacted the physician if they felt the blood pressure was too low to administer the medication. RN6 also confirmed that there were no parameters for holding the spironolactone for R6.
Failure to Maintain and Retrieve Resident Medical Records
Penalty
Summary
The facility failed to ensure medical records were readily accessible for one resident (R137) out of a sample of 25. R137 was admitted with diagnoses including hypertension, diabetes, and dementia. Upon review, the facility's current electronic medical record (EMR) system did not contain any information for R137. The Director of Nursing (DON) confirmed that R137's records were not accessible because the facility was previously owned by a different company that used a different EMR system. Despite multiple requests and attempts to retrieve the records, the facility was unable to provide the necessary medical information for R137 in a timely manner. The survey team made several requests for specific medical records, including physician's orders, treatment records, medication administration records, progress notes, and wound care documentation. The facility's Registered Nurse Consultant (RNC) and Administrator made efforts to contact the previous owner and IT department to gain access to the records. However, these efforts were unsuccessful, and the survey team was not provided with the requested information within the expected timeframe. The facility eventually provided a computer tablet containing over 1800 pages of R137's medical record in a portable document format (pdf), but key documents such as wound treatment records and care plans were still missing. Interviews with the facility's staff and a family member of R137 revealed that the resident had a wound care appointment where maggots were found in the foot wound. The family member had a copy of the wound care report, but the facility did not have this report in R137's medical records. The facility's inability to access and provide complete medical records for R137, including critical wound care documentation, highlights a significant deficiency in maintaining and retrieving resident medical records as required by state and federal law.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff members. One hospitality aide entered a COVID-19 positive resident's room wearing a surgical mask instead of the required N-95 mask and eye protection. The aide was unaware of the need for these specific PPE items. Additionally, a certified nursing assistant doffed his gown outside of a resident's room who was on strict contact precautions for Methicillin Susceptible Staphylococcus Aureus (MSSA) in a wound, instead of inside the room as required. The CNA admitted to rushing and not following proper protocol. Furthermore, a licensed practical nurse cleaned a glucometer without wearing gloves after administering insulin to a resident with diabetes mellitus. The nurse stated that he had not considered the need to wear gloves during the cleaning process. The Director of Nursing confirmed that the expectation was for staff to use gloves when cleaning medical equipment. These lapses in protocol could lead to exposure to COVID-19 and bloodborne pathogens among residents and staff.
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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