Complete Care At Wayne Hills Rehab & Resp Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 130 Terhune Drive, Wayne, New Jersey 07470
- CMS Provider Number
- 315110
- Inspections on file
- 19
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Wayne Hills Rehab & Resp Center during CMS and state inspections, most recent first.
A resident with functional quadriplegia, moderate cognitive impairment, and documented need for 2-person assist with repositioning experienced a fall from bed during care when only one CNA was turning the resident, resulting in the resident’s legs falling off the bed. The care plan identified fall risk but did not specify the resident’s risk level or required number of staff for repositioning, and there was no documentation of interventions implemented after the fall. In the days following, staff later observed bruising, pain behaviors, and swelling, but there was no evidence of ongoing monitoring for pain or injury or documentation of the origin of a right-hand bruise and swelling; hospital imaging ultimately showed bilateral femur fractures and a suspected finger fracture, which the facility’s investigation linked back to the earlier fall.
A resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment developed swelling and bruising of the right hand that was added to the care plan but not reported to the NJDOH as an injury of unknown origin. A facility reportable event submitted days later did not address this hand injury, and the DON confirmed there was no documentation showing it had been reported, despite a facility abuse/neglect policy requiring timely reporting of all alleged violations to state authorities.
The facility failed to conduct thorough, separate investigations into two incidents involving a resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment. During incontinent care, the resident’s legs slid off the bed while the upper body remained on the bed, and later the resident developed right hand swelling and bruising that was added to the care plan. Despite facility policy requiring prompt reporting and same-day, signed witness statements with an investigation initiated by the nursing supervisor, the DON acknowledged that no separate investigation was completed for the first incident and no investigation was conducted to determine how or when the right hand injury occurred.
A resident with severe cognitive impairment and total dependence on staff for eating did not receive the necessary assistance with breakfast, as evidenced by an untouched meal tray at the bedside. Staff failed to provide the required support despite the resident's documented needs and care plan interventions.
Two residents with significant cognitive and physical impairments did not consistently receive or have documented wound care as ordered by their physicians, as shown by multiple blank entries in the Treatment Administration Records for various wound treatments and assessments. The DON confirmed that nursing staff were responsible for implementing and documenting these orders, but the facility's own documentation policy was not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severely impaired cognition and a history of false accusations reported sexual abuse while hospitalized. The facility's DON and LNHA failed to report the allegation to the NJDOH, as required by state and federal regulations, because the report was not made directly to them and the resident was not in the facility at the time. This oversight violated the facility's policy on reporting and investigating abuse allegations.
A resident with severely impaired cognition reported an alleged sexual abuse incident to a hospital social worker, which was not investigated by the LTC facility staff. The DON and LNHA were informed of the allegation during a morning meeting but did not report it to the appropriate agencies, as required by the facility's policy. The social worker also did not investigate, assuming it was the responsibility of the DON and Administrator.
The facility failed to ensure that primary physicians signed monthly orders and wrote progress notes every other month for 10 residents over six months. Despite frequent visits by the physician and NP, records showed inconsistent signage and note-taking. Facility policies did not ensure compliance with regulations for physician visits every 60 days.
The facility failed to submit MDS assessments within the required timeframe for a resident, with delays noted in both Quarterly and Significant Change MDS submissions. A resident, who was cognitively intact and had a history of urinary tract infections, was involved. The Regional MDS Coordinator was consulted but did not provide further information.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care management. One resident's bowel continence was incorrectly coded, and pain presence and fall history were not assessed. Another resident's bowel continence was initially not rated, and CNA documentation was inconsistent. These issues were identified through interviews and record reviews, revealing gaps in assessment and documentation processes.
A facility failed to accurately document a resident's bowel elimination status, despite the resident reporting regular bowel movements. Staff interviews revealed inconsistencies in documentation, with the CNA and RN/UM stating the resident had regular movements, while the MDSC/RN noted the resident was documented as always incontinent. The facility's policy emphasized the need for accurate records to ensure effective communication among the care team.
A resident with severe cognitive impairment and acute respiratory failure was observed receiving oxygen therapy incorrectly, as the nasal cannula was not positioned in the nostrils but on the cheek. The oxygen tubing lacked markings to indicate when it was applied, contrary to facility protocol. The Registered Nurse Unit Manager confirmed the oversight and adjusted the cannula, acknowledging the need for proper dating and regular changing of the equipment.
Failure to Implement Fall-Prevention Interventions and Post-Fall Assessment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement adequate fall-prevention interventions and to thoroughly assess and monitor a resident after a fall and subsequent signs of injury. The resident was admitted with multiple significant diagnoses, including acute respiratory failure, muscle weakness, schizoaffective disorder, seizures, and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A comprehensive nursing assessment documented that the resident’s mobility was very limited, that they were unable to make frequent or significant changes independently, and that they were dependent on others for ADLs. Progress notes prior to the incident documented that the resident required total care with two-person assist for repositioning, but the baseline care plan, while identifying a fall risk focus area, did not specify the resident’s fall risk level or the number of staff required to assist with repositioning in bed. On the date of the fall, the Facility Reportable Event (FRE) stated that while a CNA was providing care, the resident was squirming and holding the side rail while being turned in bed, and the resident’s lower legs fell off the bed while the torso remained on the bed. The CNA and an RN then repositioned the resident back to bed and assessed the resident. However, there was no documented evidence that the facility implemented any interventions following this fall to address the resident’s fall risk or to protect the resident from further injury. An employee statement from the CNA did not indicate that two staff assisted with repositioning during the care at the time of the incident, and in a subsequent interview, the RN confirmed that she did not assist the CNA with repositioning, only assessing the resident afterward and noting no pain. The RN did not provide information regarding follow-up interventions or the required level of care for the resident. In the days following the fall, the facility failed to adequately assess and monitor the resident for pain and injury. The FRE documented that an LPN later noticed bruising on the resident’s bilateral lower extremities, and other staff statements described the resident exhibiting signs of pain, flinching during assessment, and having bruising on both thighs and the lower back. The resident was then sent to the hospital, where imaging revealed acute fractures of the distal shafts of both femurs and a suspicious subtle fracture at the base of the proximal phalanx of the right third finger, associated with pain and bruising. The facility’s FRE did not address the right-hand swelling and bruise, and there was no documentation regarding the origin of the right-hand injury. The facility’s investigational summary concluded that the bilateral femur fractures identified later were the result of the earlier fall, but there was no evidence that the facility monitored the resident for pain and injury after the fall or implemented interventions on the date of the fall to prevent further injury, despite a policy stating that appropriate and immediate interventions and root cause analysis would be conducted for incidents and accidents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) after swelling and bruising were identified on a resident’s right hand. The resident had diagnoses including muscle weakness and functional quadriplegia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. On 12/01/25, the resident’s care plan documented a focus area of swelling and bruising to the right hand, but there was no corresponding report of this injury to NJDOH as required for suspected abuse, neglect, or injury of unknown origin. A review of the facility’s Reportable Event submitted to NJDOH on 12/05/25 showed that it did not address the bruise and swelling on the resident’s right hand. During an interview on 1/29/26, the DON stated that the facility could not provide any documented evidence that the swelling and bruise identified on 12/01/25 had been reported to NJDOH. This failure occurred despite the facility’s Abuse, Neglect and Exploitation policy, revised 9/01/25, which required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, depending on whether abuse or serious bodily injury was involved.
Failure to Conduct Separate and Thorough Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving one resident. The resident was admitted with diagnoses including muscle weakness and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A progress note dated 11/27/25 documented that during incontinent care, while the resident was being turned in bed, both lower extremities slid off the bed and touched the floor while the upper body remained on the side of the bed. A statement from the RN involved indicated the resident was not injured and did not exhibit signs of pain after this fall. The unit manager LPN stated that the facility’s process requires the assigned nurse to report incidents to the nursing supervisor, who is then expected to obtain, on the day of the incident, signed and dated witness statements from all staff involved and to start the investigation. The resident’s care plan included a focus area for right hand swelling and bruising, initiated on 12/01/25. However, the DON reported that there was no separate investigation conducted for the 11/27/25 incident apart from an investigation related to a later incident on 12/03/25. The DON also confirmed that the swelling and bruise identified on the resident’s right hand on 12/01/25 did not have a separate investigation to determine how or when the injury occurred. As a result, the facility did not follow its stated process for timely and complete incident investigation and failed to investigate the origin of the resident’s right hand injury, leading to the cited deficiency under NJAC 8:39-4(f).
Failure to Provide Required Assistance with Meals for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including eating, did not receive the necessary assistance with breakfast. The resident had diagnoses of functional quadriplegia, dementia, and severe protein calorie malnutrition, and was assessed as having severely impaired cognition with a BIMS score of 3 out of 15. The resident's care plan specified total dependence on two staff members for eating. Despite these documented needs, the resident's breakfast tray was found untouched at the bedside, indicating that staff did not provide the required assistance. Interviews revealed that the resident's representative observed the untouched breakfast tray and reported it to the Director of Social Services, who confirmed the tray had not been touched and that the resident required staff assistance to eat. The Director of Nursing stated that residents needing meal assistance were identified on the CNA assignment sheet and that CNAs, nursing staff, and the DON were responsible for providing this assistance. However, in this instance, the necessary support was not provided, resulting in the resident not receiving help with their meal as required by their care plan.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that two residents received wound care as ordered by their physicians, as evidenced by multiple missed or undocumented wound treatments. For the first resident, who was admitted with significant medical conditions including anoxic brain damage, severe contractures, impaired mobility, and incontinence, the care plan identified actual skin breakdown and multiple wounds, including pressure ulcers and arterial injuries. Review of the Treatment Administration Records (TARs) for September, October, and November revealed numerous blank entries where wound care orders were not documented as completed, including treatments for pressure ulcers, arterial ulcers, and skin tears, as well as required weekly skin assessments and offloading interventions. These omissions were confirmed through record review and interviews with the Director of Nursing (DON), who stated that facility nurses were responsible for implementing and documenting wound care orders received from an external wound care company. The second resident, admitted with diagnoses such as functional quadriplegia, dementia, and severe protein-calorie malnutrition, also had a care plan indicating actual skin breakdown, including multiple pressure ulcers and a trauma wound. Review of this resident's November TAR showed blank entries for several physician-ordered wound treatments, including the application of betadine, medihoney, and Triad Hydrophilic wound dressings to various wounds. These treatments were not documented as completed on the specified dates, and the DON confirmed that nursing staff were responsible for carrying out and documenting these orders. The facility's policy on documentation requires licensed staff and interdisciplinary team members to document all assessments, observations, and services provided in the resident's medical record. Despite this policy, the records for both residents showed repeated failures to document or complete ordered wound care treatments, as evidenced by the blank spaces in the TARs and confirmed by staff interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to report an allegation of sexual abuse made by a resident to the New Jersey Department of Health as required. This deficiency was identified for one resident who had a history of false accusations towards staff and utilized nonverbal communication due to severely impaired cognition. The resident was admitted to the hospital with tracheostomy malfunction and respiratory distress, and during this time, the hospital social worker reported the alleged sexual abuse to the facility's Admissions Director via text. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of the allegation during a morning meeting but did not report it to the appropriate authorities. The DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. Both the DON and LNHA acknowledged their failure to report the allegation as per state and federal regulations and did not follow the facility's policy for reporting and investigating abuse allegations.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to investigate an alleged incident of sexual abuse reported by a resident to the New Jersey Department of Health. This deficiency was identified for one resident who had a history of false accusations and severely impaired cognition, as indicated by a BIMS score of 0 out of 15. The resident was admitted to the hospital with a tracheostomy malfunction and respiratory distress. During a morning meeting, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed by the Admissions Director about a text from a hospital social worker stating that the resident reported being sexually assaulted at the facility. However, the DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. The facility's policy requires all allegations of abuse to be reported immediately to the Administrator and appropriate agencies, but this was not followed. The DON and LNHA acknowledged their failure to report the allegation within the required timeframe and did not adhere to the facility's policy for reporting and investigating abuse allegations. The social worker, who heard about the allegation during the morning meeting, did not investigate it, believing it was the responsibility of the Administrator and DON. The facility's policy outlines the need for immediate reporting and investigation of all allegations, but these procedures were not followed in this case.
Deficiency in Physician Order Signage and Progress Notes
Penalty
Summary
The facility failed to ensure that the primary physicians of residents signed and dated monthly physician orders and wrote progress notes every other month, alternating with the nurse practitioner. This deficiency was observed in 10 out of 20 residents reviewed over a six-month period. For several residents, the physician only electronically signed the monthly orders for March 2024, with no other orders signed in the previous months. Additionally, there were no monthly progress notes written by the physician during this period. The surveyor's review of the hybrid medical records revealed that the primary physicians did not consistently sign monthly orders or write progress notes for the residents. Interviews with facility staff indicated that the physician and nurse practitioner were present at the facility multiple times a week. However, the facility's policies and procedures for physician orders and visits, which were provided to the survey team, did not ensure compliance with state and federal regulations requiring physician visits at least every 60 days.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required timeframe for at least one resident. Specifically, the Quarterly Minimum Data Set (QMDS) for a resident was due to be transmitted to the Centers for Medicare and Medicaid Services (CMS) by April 4, 2024, but was not submitted until April 26, 2024. Additionally, a Significant Change MDS (SCMDS) for another resident was due by October 12, 2023, but was not submitted until October 21, 2023. These delays in submission were identified during a surveyor's review of the facility's records. The surveyor observed a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident's electronic medical record showed a history of urinary tract infections. The Regional MDS Coordinator was consulted regarding the late submissions but did not provide further information. The deficiency was noted as a failure to adhere to the timelines set forth by the CMS Resident Assessment Instrument (RAI) Manual, which requires assessments to be transmitted within 14 days of completion.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the management of their care. For Resident #63, the MDS was incorrectly coded as 'not rated' for bowel continence, despite the resident being incontinent and dependent on staff for care. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged the error, noting that the MDS was modified to reflect the resident's incontinence. Additionally, the MDS failed to assess pain presence and fall history, despite documentation indicating no pain and no falls during the relevant period. The MDSC/RN admitted that the assessments were not addressed correctly, highlighting a lack of proper interviews and assessments. For Resident #85, the MDS initially failed to rate bowel continence, which was later corrected to indicate the resident was always incontinent. The resident's care plan confirmed total dependence on staff for incontinence care. However, the CNA documentation for a specific period was either blank or incorrectly coded, failing to reflect the resident's bowel movements accurately. Nursing progress notes did indicate incontinence, but the inconsistency in documentation contributed to the deficiency. These deficiencies were identified through interviews and record reviews conducted by surveyors. The MDSC/RN and other staff members were interviewed, revealing gaps in the assessment and documentation processes. The facility's failure to accurately code and assess the MDS for these residents resulted in a lack of proper care management, as evidenced by the discrepancies in the residents' records and the staff's acknowledgment of the errors.
Inaccurate Documentation of Bowel Elimination Status
Penalty
Summary
The facility failed to maintain the nursing professional standard of clinical practices by not accurately documenting the bowel elimination status of a resident who was reviewed for urinary catheter use. The resident, who was admitted with diagnoses including urinary tract infections, was observed to be cognitively intact and reported having a bowel movement at least once daily without issues. However, the facility's documentation, including the CNA Documentation Survey Report and Progress Notes, did not reflect the resident's bowel elimination status accurately during a specified period in March 2024. Interviews with facility staff, including a CNA, RN/UM, MDSC/RN, and DCS, revealed inconsistencies in the documentation and understanding of the resident's bowel movement schedule. The CNA and RN/UM indicated that the resident had regular bowel movements and would call for assistance when needed. However, the MDSC/RN noted that the resident was documented as always incontinent of bowel elimination, and the DCS highlighted the importance of accurate documentation. The facility's policy on Charting and Documentation emphasized the need for accurate records to facilitate communication among the interdisciplinary team.
Improper Oxygen Administration for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as observed by a surveyor. During an interview with the resident, it was noted that the nasal cannula, intended to deliver oxygen, was not positioned correctly in the resident's nostrils but was instead located on the cheek. Additionally, the oxygen supply tubing lacked any markings indicating when it was applied, which is against the facility's protocol. The resident, who was admitted with acute respiratory failure with hypoxia and essential hypertension, was assessed to have severe cognitive impairment, scoring 7 out of 15 on the Brief Interview for Mental Status (BIMS). Further observations confirmed the nasal cannula was still misplaced, and the Registered Nurse Unit Manager (RNUM) had to adjust it. The RNUM acknowledged the oversight and mentioned that oxygen tubing should be dated and changed weekly or sooner if needed. The facility's policy on oxygen administration specifies that the nasal cannula should be placed approximately one-half inch into the resident's nose. The deficiency was discussed with the facility's administrative team, including the Regional Clinical Registered Nurse, Regional Administrator, Director of Nursing, and Administrator.
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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