Complete Care At Regent Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hackensack, New Jersey.
- Location
- 50 Polifly Road, Hackensack, New Jersey 07601
- CMS Provider Number
- 315295
- Inspections on file
- 14
- Latest survey
- February 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Regent Llc during CMS and state inspections, most recent first.
The facility failed to maintain proper food safety and sanitation standards, with expired food items, improper personal hygiene practices, and inadequate labeling and storage of food in unit refrigerators. Temperature control issues were also noted, with a refrigerator operating below the acceptable range without corrective actions documented.
The facility's call bell system failed to provide notifications at the nurse's station due to an unplugged annunciator panel, potentially affecting all residents. The issue was confirmed by the DM, who noted that any call bell activation from the fourth floor would not be detected.
The facility was found deficient in maintaining a clean and homelike environment, with surveyors observing dust accumulation on air vents across multiple floors and in residents' rooms, as well as a broken toilet tissue paper holder. The Director of Maintenance acknowledged the lapse in regular cleaning, and the facility's policy did not specifically address vent cleaning.
The facility failed to verify the credentials of newly hired licensed staff, as five out of eight reviewed staff members lacked documented proof of license verification before their hire date. The NJDOH online Public Registry printouts did not include the verification date, and the Director of Human Resources was unaware of this issue. Despite the facility's process to verify licenses before hiring, they could not provide evidence to support this practice.
The facility failed to provide adequate respiratory care for three residents. A resident's BIPAP mask was not replaced as promised, and staff were unaware of the facility's policy on mask care. Another resident's oxygen tubing was improperly stored, violating infection control protocols. A third resident with a tracheostomy lacked a physician order for inner cannula changes, and the facility's policy did not address this aspect of care.
A resident's call light was found inaccessible, tied to a siderail and dangling towards the floor, during a surveyor's observation. The resident, who required assistance for daily activities, expressed difficulty in reaching the call bell, which was confirmed by the RN. The facility's policy mandates call lights be within reach, which was not followed in this case.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in care management. One resident's MDS did not reflect the use of oxygen and BIPAP, another was incorrectly coded for a diabetic foot ulcer instead of a sacral wound, and a third resident's discharge date was inaccurately recorded. The RN/MDSS acknowledged the errors and modified the MDS assessments accordingly.
The facility failed to develop comprehensive care plans for two residents, neglecting to include personal preferences and psychiatric care needs. One resident's preference for a late sleep schedule was not documented, while another's psychiatric diagnoses and medication monitoring were omitted from their care plan. These omissions were contrary to the facility's policy, which mandates the inclusion of measurable objectives and problem areas in care plans.
A facility failed to adhere to professional standards by misdiagnosing a resident, leading to unnecessary antipsychotic medication, and improperly administering a delayed-release medication by crushing it. The misdiagnosis was not documented in the resident's records, and the medication administration did not follow the manufacturer's instructions. The facility's DON and VPoCS acknowledged these errors during a survey.
A resident with intact cognition and a preference for reading materials was observed without these materials in their room, contrary to their care plan. The Activities Aide Recreation acknowledged the absence of subscription reading material since November, attributing it to the new Activity Director's lack of access. The facility's policy to support residents' choices was not followed.
A resident with multiple health conditions, including CHF, did not receive care according to physician orders and recommendations. Daily weights, CHF assessments, and lab tests were inconsistently documented, and the facility failed to follow through on a cardiologist's recommendations for a psychiatric evaluation and medication. Staff interviews revealed a lack of awareness and documentation, and facility policies were not adhered to, leading to deficiencies in resident care.
The facility failed to clarify physician's orders for enteral feedings, leading to potential errors in the care of two residents. One resident had duplicate orders for enteral feeding and water flushes, while another had a piston syringe that was not dated and a yankauer tip not properly stored or discarded. The facility's policies did not provide clear guidance, contributing to these deficiencies.
The facility failed to post the Nursing Home Resident Care Staffing Report daily in a visible and accessible location. On two occasions, the report was either outdated or not visible, with the Director of Nursing and Receptionist acknowledging the oversight. The Staffing Coordinator was responsible for posting, but inconsistencies occurred when she was unavailable.
The facility failed to maintain accurate and complete medical records for two residents. One resident's records lacked a Universal Transfer Form for multiple hospitalizations, while another resident's records showed discrepancies between physician orders and nurse practitioner notes regarding respiratory support. These issues highlight deficiencies in documentation and record-keeping practices.
The facility failed to meet the mandated staffing ratios, resulting in delayed responses to call bells and inadequate incontinence care for residents. A resident reported waiting one to two hours for assistance, while another experienced delays in being put back to bed, leading to a soaked incontinence brief. The staffing coordinator cited callouts and challenges in replacing absent staff as contributing factors.
The facility failed to ensure that TNAs were enrolled in a CNA training program and completed certification as required by CMS and NJDOH. Two non-certified nurse aides were assigned resident care duties without documented training or competency, and the facility lacked a clear policy for hiring and staffing non-certified aides. Missing employee files and job descriptions further complicated verification of staff qualifications.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards, as evidenced by several observations during a survey. In the kitchen, an opened pack of shredded mozzarella cheese was found past its use-by date, indicating a lapse in monitoring and discarding expired food items. Additionally, a dietary staff member was observed with hair not fully restrained by a hairnet while serving food, and another staff member wore a surgical mask improperly, exposing facial hair. These observations highlight a lack of adherence to the facility's policies on food safety and personal hygiene. Further deficiencies were noted in the handling and storage of food items in unit nutrition refrigerators. A nutritional supplement bottle was found without a resident's name, and frozen food items were improperly stored in a refrigerator instead of a freezer. Additionally, a container of blueberries was found without a label, and a refrigerator light fixture was missing, leaving the interior dark. These issues indicate a failure to properly label and store food items, as well as a lack of maintenance and monitoring of equipment. Temperature control issues were also identified, with a refrigerator on the fourth floor operating below the acceptable temperature range. Despite documentation of the issue, no corrective actions were recorded, and maintenance was not promptly notified. This oversight suggests a breakdown in communication and protocol adherence, potentially compromising food safety and quality. The facility's policies on labeling, dating, and temperature monitoring were not consistently followed, contributing to the observed deficiencies.
Call Bell System Malfunction Due to Unplugged Annunciator
Penalty
Summary
The facility failed to ensure that the call bell system was functioning properly, which had the potential to affect all residents. During an observation, it was found that the call bell system did not provide audible or visual notifications at the nurse's station when tested for a specific room. Further investigation revealed that the call bell annunciator at the nurse's station was unplugged. The Director of Maintenance confirmed that with the annunciator panel unplugged, any activation of the call bell system from any room on the fourth floor would not be heard or seen at the nurse's station.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by the accumulation of dust or dirt-like substances on air circulation vent covers across multiple floors and in residents' rooms. During an initial tour, surveyors observed these conditions on the 4th floor nursing unit, as well as on the 2nd and 3rd floors. The Director of Maintenance confirmed that the maintenance department was responsible for cleaning the vents monthly, but acknowledged that the vents were not clean and that the accumulation of material would take a while to build up, indicating a lapse in regular maintenance. Additionally, the surveyor noted a broken toilet tissue paper holder in a resident's room, which was not addressed until after the surveyor's inquiry. The surveyor also observed dusty vents in a resident's toilet and the elevator, which were confirmed by staff to be the result of dust accumulation. The facility's Environment Policy, reviewed in January 2025, did not specifically mention the cleaning of air vents, which may have contributed to the oversight. The policy emphasized maintaining a sanitary, orderly, and comfortable environment, but the observed conditions did not align with these standards. The facility did not provide further documentation to address these deficiencies during the survey process.
Failure to Verify Staff Credentials Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of newly hired licensed staff were verified upon hire, as evidenced by the lack of documented proof for five out of eight reviewed staff members. Specifically, the license verification printouts for these staff members did not include the date of verification, and there was no evidence that their licenses were verified before their date of hire. This issue was identified during a review of ten randomly selected newly hired employee files, where it was found that the New Jersey Department of Health online Public Registry license verification printouts lacked the date of verification for Staff Members #1, #4, #5, #6, and #7. The Director of Human Resources was interviewed and stated that the process involved verifying licenses on the NJDOH online Public Registry before the date of hire. However, the printouts did not show the date of verification, and the Director was unaware of this issue. The Vice President of Clinical Services later confirmed that the website did not print the date, and the computer settings needed to be adjusted to include it. Despite the facility's process to verify licenses before hiring, they could not provide documented evidence to support this practice, leading to the identified deficiency.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for residents using oxygen, as evidenced by deficiencies in the care of three residents. Resident #23 was observed using a BIPAP machine and nebulizer, with the BIPAP mask stored improperly and not replaced as promised. The Registered Nurse was unaware of the facility's policy regarding the frequency of BIPAP mask changes, and there was no care plan addressing the BIPAP mask care and accountability. The resident's medical records lacked evidence of when and how to care for the BIPAP mask, indicating a failure to adhere to the facility's policy. Resident #142 was observed with nasal cannula oxygen tubing not stored in a plastic bag when not in use, contrary to the facility's Oxygen Therapy Policy. The tubing was found laid on the resident's bed and wheelchair seat, which was confirmed by both the Licensed Practical Nurse and the Unit Manager as improper storage. The facility's policy required that oxygen delivery devices be covered in a plastic bag when not in use, highlighting a lapse in infection control practices. Resident #88, who had a tracheostomy, was found to have no physician order indicating the frequency of inner cannula changes or the size of the cannula. The resident's care plan included trach care every shift and as needed, but there was no specific order for inner cannula changes. The Unit Manager confirmed the absence of such an order, and the Director of Nursing acknowledged the oversight. The facility's Tracheostomy Care Policy did not address the frequency of inner cannula changes, contributing to the deficiency in care for this resident.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible within reach, which was identified during an observation by a surveyor. The resident, who was alert and verbally responsive, was found resting in bed with the call light tied to the left siderail and dangling towards the floor, making it inaccessible. When asked about the call bell, the resident expressed difficulty in reaching it and mentioned that they sometimes had to shout or wait for staff assistance. The resident's medical record indicated diagnoses of chronic kidney disease, muscle weakness, and diabetes mellitus, and a care plan intervention required the call light to be within reach. The surveyor's interview with the RN assigned to the resident confirmed that the resident needed assistance with activities of daily living and could use the call bell for help. The RN acknowledged that the call bell should be within reach and took immediate action to rectify the situation. The facility's Call Lights Policy, updated in January 2025, mandates that call lights be positioned conveniently for use and within the resident's reach, which was not adhered to in this instance.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For one resident, the MDS did not reflect the use of oxygen and BIPAP, despite the resident having a physician's order for these treatments due to conditions like sleep apnea and COPD. The Registered Nurse/MDS Supervisor acknowledged the miscoding after reviewing the records and confirmed that the MDS should have been coded to include these treatments. Another resident's MDS was inaccurately coded to indicate the presence of a diabetic foot ulcer, which was not supported by the medical records or treatment orders. Instead, the resident had a sacral wound that was not coded. The RN/MDSS confirmed the error after reviewing the electronic medical record and modified the MDS to reflect the correct wound condition. The third resident's discharge date was incorrectly coded on the MDS. The resident left the facility against medical advice, but the MDS did not reflect the accurate discharge date. The RN/MDSS reviewed the records and confirmed the error, subsequently modifying the MDS to reflect the correct discharge date. The facility staff stated they followed the MDS 3.0 Manual but did not have a separate MDS policy.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in addressing their medical and psychosocial needs. For Resident #8, the surveyor observed that the resident's preferences for sleeping late and waking up late were not documented in the care plan. Despite the resident being cognitively intact and having specific preferences for daily activities, these were not reflected in the care plan, as confirmed by the Activities Aide Recreation and the Certified Nursing Aide. The facility's policy required that such preferences be included in the care plan, but this was not done until after the surveyor's inquiry. For Resident #146, the facility failed to include care plans related to the resident's psychiatric diagnoses and the use of psychotropic medications. The resident had active diagnoses of bipolar disorder and depression and was receiving antipsychotic and antidepressant medications. However, the care plan did not address these psychiatric conditions or the monitoring of side effects from the medications. The Registered Nurse and Unit Manager acknowledged the absence of these critical components in the care plan, which should have been included according to the facility's policy. The facility's Comprehensive Person-Centered Policy required that care plans include measurable objectives and timeframes, describe services to maintain the resident's well-being, and incorporate identified problem areas. Despite these requirements, the care plans for both residents did not initially meet these standards, leading to the identified deficiencies. The surveyor's findings were discussed with the facility's leadership, who acknowledged the issues and initiated updates to the care plans after the surveyor's observations.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in two instances. In the first instance, a resident with a history of major depressive disorder and cardiac issues was misdiagnosed with schizoaffective disorder, depressive type, by an Advance Practice Nurse (APN#1) during a psychiatric follow-up. This diagnosis was not documented in the resident's physician services notes or other relevant records. The misdiagnosis led to the unnecessary prescription of Seroquel, an antipsychotic medication. It was later clarified by another APN (APN#2) that the resident did not have a diagnosis of schizophrenia, and the medication was reduced after the surveyor's inquiry. In the second instance, a Licensed Practical Nurse (LPN) administered Pantoprazole Sodium Oral Tab Delayed Release 40 mg to a resident by crushing the medication and mixing it with applesauce, contrary to the manufacturer's instructions that the medication should be swallowed whole. The resident's profile indicated that they take medications crushed, but the LPN failed to identify any cautionary labels regarding the Pantoprazole. The facility's policy on administering medications did not provide guidance on the crushing of medications, leading to the improper administration of the delayed-release tablets. These deficiencies were identified during a survey, and the facility's Director of Nursing (DON) and Vice President of Clinical Services (VPoCS) acknowledged the errors. The facility did not provide additional information to address these issues during the exit conference with the survey team.
Failure to Provide Resident with Preferred Reading Materials
Penalty
Summary
The facility failed to carry out activities per a resident's care plan, specifically for a resident who was observed without the reading materials that were deemed very important to them. The resident, who had intact cognition and a preference for reading materials such as books, newspapers, and magazines, was observed on multiple occasions without these materials in their room. The resident's care plan included an intervention to greet the resident daily with a morning activity cart offering a beverage of choice and reading material, which was not being followed. The Activities Aide Recreation (AAR) acknowledged the resident's preferences and the absence of the subscription reading material since November. The AAR attributed this to the new Activity Director's lack of access to the subscription reading material. The facility's Activity Policy mandates an ongoing program to support residents' choices based on their comprehensive assessment and care plan, which was not adhered to in this case. The deficiency was discussed with the Licensed Nursing Home Administrator, Director of Nursing, and President of Clinical Services, but no additional information was provided by the facility.
Failure to Follow Physician Orders and Recommendations for Resident Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with multiple health conditions, including congestive heart failure (CHF). The resident had physician orders for daily weights, CHF assessments every shift, and specific laboratory tests, which were not consistently followed. The resident's medical records showed numerous instances where daily weights were not documented, and the physician was not notified of these omissions. Additionally, the CHF assessments were inconsistent, and several laboratory tests, including comprehensive metabolic panels and magnesium levels, were not conducted as ordered. The resident, who had intact cognition, was admitted with diagnoses such as major depressive disorder, cardiac arrhythmia, atrial fibrillation, hypertension, and type 2 diabetes. Despite being followed by a cardiologist, the facility did not adhere to the cardiologist's recommendations, including a psychiatric evaluation and starting a new medication, Mexiletine. The psychiatric evaluation was not scheduled, and the resident was not included on the list of residents to be seen by the psychiatrist, indicating a lack of follow-through on critical medical recommendations. Interviews with facility staff, including a Registered Nurse and the Unit Manager, revealed a lack of awareness and documentation regarding the resident's care orders. The facility's policies on physician orders and laboratory services were not adhered to, as evidenced by the failure to notify the physician of missed lab tests and the lack of documentation for the resident's care. The surveyor's findings were communicated to the facility's leadership, but no additional information was provided to address the deficiencies identified.
Failure to Clarify Enteral Feeding Orders and Equipment Handling
Penalty
Summary
The facility failed to clarify physician's orders for enteral feedings, leading to confusion and potential errors in the care of two residents. For one resident, there were multiple orders for enteral feeding and water flushes that were not clarified, resulting in duplicate entries. The Licensed Practical Nurse (LPN) and Registered Nurse/Unit Manager (RN/UM) acknowledged the duplicate orders but did not take steps to clarify them, which could lead to inconsistencies in the resident's care. The resident was receiving enteral feedings and water flushes, but the orders were not clear, and the facility's protocol was not followed to ensure accurate documentation and administration. Another resident was observed with a piston syringe that was not dated and a yankauer tip that was not stored properly or discarded after use. The LPN confirmed that the piston syringe should have been dated and the yankauer tip discarded, but this was not done. Additionally, there were duplicate orders for enteral feeding and free water infusion, with different rates of infusion, which were not clarified. This lack of clarity in orders and improper handling of equipment could lead to potential errors in the resident's care. The facility's policies on enteral tube feeding and suction equipment did not provide clear guidance on documentation, storage, or dating of equipment, contributing to the deficiencies observed. The surveyor noted that the facility did not provide additional information to address these issues, indicating a lack of adherence to established protocols and procedures for resident care.
Failure to Post Accurate and Visible Staffing Report
Penalty
Summary
The facility failed to post the accurate Nursing Home Resident Care Staffing Report daily in a prominent place that was readily accessible and visible to residents and visitors. On two separate occasions, the surveyor observed that the staffing report was either outdated or not visible. On the first occasion, the report was dated 1/24/25, although the surveyor visited on 1/27/25, and it was obscured by a vase of flowers, making it difficult for residents and visitors to see. The Director of Nursing (DON) and the Receptionist acknowledged the oversight, with the Receptionist admitting she forgot to update the report. On another occasion, the surveyor noted that the staffing report was not posted in the facility's lobby or near the elevators, areas where it would be accessible and visible. The DON explained that the Staffing Coordinator (SC) was responsible for posting the report, but when she was unavailable, the task was left to other staff members, leading to inconsistencies. The SC confirmed that she usually posted the report and left instructions for others to do so in her absence. The facility's policy required the report to be posted daily in a clear and readable format in a prominent place, but this was not adhered to, resulting in the deficiency.
Deficient Medical Record-Keeping for Two Residents
Penalty
Summary
The facility failed to maintain complete, available, accurate, and readily accessible medical records for two residents. For the first resident, the surveyor observed that the resident had been hospitalized multiple times due to a heart condition. Upon reviewing the medical records, it was found that there was no Universal Transfer Form (UTF) available for the resident's transfers in 2024. The Director of Nursing (DON) initially could not provide the UTF and later presented a copy with a handwritten date, admitting that no other UTFs could be found. This indicates a lack of proper documentation and record-keeping for the resident's transfers. For the second resident, the surveyor noted the use of a BIPAP machine and a nebulizer. The resident's medical records showed a physician's order for BIPAP use at night, which was documented as administered in the electronic Treatment Administration Record (eTAR). However, the Progress Notes signed by the Nurse Practitioner (NP) indicated the use of CPAP instead of BIPAP, with no documentation supporting the use of CPAP. This discrepancy between the physician's order and the NP's notes highlights a failure to accurately document the resident's treatment. The facility's Medical Records Policy requires that each resident's medical record accurately represents their experiences and includes complete, accurate, and timely documentation. The surveyor's findings revealed that the facility did not adhere to this policy, as evidenced by the missing UTF for the first resident and the inconsistent documentation regarding the second resident's respiratory support. These deficiencies were discussed with the facility's leadership, but no additional information was provided to address the concerns.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. On the second floor, the resident census was 55, but only 5 Certified Nurse Aides (CNAs) were available, resulting in a ratio of 1 CNA for 11 residents, which is below the mandated ratio of 1 CNA to 8 residents. This staffing shortage was confirmed by the Unit Manager and CNA #1, who reported being assigned to care for 11 residents, indicating that staffing levels varied depending on the number of CNAs available. Resident #93 reported that it sometimes took staff one to two hours to respond to call bells, leading to situations where their incontinence device would be full. This resident, who was cognitively intact with a BIMS score of 15 out of 15, required partial moderate assistance with transfer and toileting. The care plan for Resident #93 included interventions to provide frequent visits to anticipate toileting needs, but the staffing shortage hindered timely assistance. Similarly, Resident #89 experienced delays in receiving assistance, reporting that they had to wait longer than usual to be put back in bed, resulting in a soaked incontinence brief. This resident, also cognitively intact with a BIMS score of 15 out of 15, was dependent on staff for transfer and toileting. The facility's Staffing Coordinator acknowledged the staffing challenges, citing callouts and difficulties in replacing absent staff. Despite efforts to inservice staff on call bell response, the facility's staffing policy and call light procedures were not effectively implemented, contributing to the deficiency.
Facility Fails to Ensure Proper Training and Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that Temporary Nurse Aides (TNAs) were enrolled in a Certified Nurse Aide (CNA) training program and completed their certification as mandated by the Centers for Medicare and Medicaid Services (CMS) and the New Jersey Department of Health (NJDOH). Specifically, the facility did not have documented evidence that TNAs were enrolled in school prior to the deadline and completed their CNA certification by the required date. Additionally, there was no verification that non-certified nurse aides were enrolled and actively taking classes in a state-approved CNA Training Program, nor was there evidence of completion of Module 1 before assigning them independent resident duties. The surveyor's investigation revealed that two non-certified nurse aides, who were previously working as TNAs, were assigned to care for residents without the necessary documentation of their training or competency. The facility's staffing and assignment sheets indicated that these aides were listed as nurse aides, yet there was no evidence that they were working under the supervision of a certified nurse aide. Furthermore, the facility lacked a clear policy or program for the hiring, staffing, and assignments of non-certified nurse aides, contributing to the deficiency. Interviews with facility staff, including the Director of Nursing (DON) and the Director of Human Resources, highlighted a lack of proper documentation and oversight regarding the qualifications and assignments of TNAs and non-certified nurse aides. The facility's transition from a previous company resulted in missing employee files and job descriptions, further complicating the verification of staff qualifications. Despite the DON's efforts to address the issue upon their arrival, the facility continued to utilize TNAs and non-certified nurse aides without ensuring they met the necessary training and certification requirements.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
