Complete Care At Woodlands
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, New Jersey.
- Location
- 1400 Woodland Ave, Plainfield, New Jersey 07060
- CMS Provider Number
- 315273
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Complete Care At Woodlands during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and arterial ulcers did not receive prescribed wound dressing changes as ordered, and nursing staff failed to document the resident's refusals or notify the physician. The wound dressing was not changed according to the schedule, and the medical record did not accurately reflect the missed treatments or refusals, contrary to facility policy.
A resident with hemiplegia, hemiparesis, anxiety, and major depressive disorder experienced vomiting and diarrhea, documented by an LPN. However, there was no RN assessment documented, violating the facility's policy. The RN/Unit Manager admitted to assessing the resident but did not document it, and the DON confirmed the expectation for RN documentation of condition changes.
The facility failed to submit MDS assessments for ten residents within the required timeframes, with delays ranging from three to 26 days. The MDS Coordinator cited being the sole person responsible and waiting on social services as reasons for the delays.
The facility failed to develop baseline care plans within 48 hours for five residents, neglecting to address pain and communication needs for some and not creating plans at all for others. Observations and interviews confirmed these deficiencies.
A resident was served meals with plastic utensils for 14 months despite no assessment indicating she was a danger to herself or others. The resident expressed confusion and frustration, and staff interviews revealed a lack of awareness and communication regarding the reason for the use of plastic utensils.
A resident with respiratory failure, sepsis, and pneumonia was left with unattended medications by an RN, contrary to professional standards. The DON confirmed that medications should not be left unless ordered to be self-administered, which was not the case here.
The facility failed to ensure a safe discharge for two residents who left Against Medical Advice (AMA) by not notifying community agencies and not providing prescriptions for care and medications. Staff did not follow proper procedures, leading to a lack of continuity of care and potential risks for the residents involved.
The facility failed to accurately screen a resident for elopement risk and unnecessarily used a wander guard. Despite the resident's independence and lack of exit-seeking behavior, staff were unsure why the wander guard was in place. The facility's policy on elopement was not followed, leading to the unnecessary use of the wander guard.
The facility staff failed to obtain physician orders for wound care upon admission and when there was a change in treatment for two residents with stage four pressure injuries. The staff did not notify the physician or document the wound treatments properly.
Failure to Follow Wound Care Orders and Document Resident Refusals
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including severe cognitive impairment, diabetes, and arterial ulceration of the right foot, did not receive wound care in accordance with physician orders. The resident's care plan required arterial ulcer dressing changes twice daily and as needed, but documentation showed the dressing was not changed as ordered on several occasions. During an observation, the wound dressing was found to be dated two days prior, indicating it had not been changed per the prescribed schedule. Further review of the medical record and interviews with nursing staff revealed that the resident had refused dressing changes on multiple shifts, but these refusals were not documented in the progress notes as required. Nursing staff admitted to incorrectly marking the treatment as completed on the Treatment Administration Record (TAR) and failing to document the refusal or notify the physician. The Director of Nursing confirmed that the expectation was to attempt the treatment again, document the refusal, and inform the physician if the treatment was not completed. The facility's policies required accurate documentation of wound treatments, including resident refusals and physician notifications. However, there was no evidence that the physician was notified of the missed treatments, and the medical record did not reflect the refusals or the lack of wound care. The physician confirmed not being informed of the refusals and emphasized the importance of notification for continuity of care.
Failure to Document RN Assessment for Change in Resident Condition
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who experienced a change in condition. The resident, who had diagnoses including hemiplegia, hemiparesis, anxiety, and major depressive disorder, was observed by a surveyor in a wheelchair and reported that staff responsiveness was inconsistent. The resident's medical records indicated episodes of vomiting and diarrhea over several days, documented by an LPN. However, there was no documented evidence of an RN assessment during these episodes, despite the facility's policy requiring RN assessment and documentation for changes in a resident's condition. Interviews with the RN/Unit Manager and the Director of Nursing confirmed that the facility's policy was not followed. The RN/Unit Manager acknowledged assessing the resident during the time in question but failed to document these assessments. The Director of Nursing stated that any change in a resident's condition should be reported by an LPN to an RN, who should then verify and document the data. The facility's Charting and Documentation policy, revised in January 2023, mandates that all services and changes in a resident's condition be documented in the medical record, which was not adhered to in this case.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for ten residents were transmitted in a timely manner. According to the facility's policy, resident assessments should be submitted to the CMS QIES ASAP system in accordance with federal and state guidelines. However, the review of the MDS assessments for ten residents revealed significant delays in submission, ranging from three to 26 days late. The assessments were identified as either export-ready or in progress but were not submitted within the required timeframes. During an interview, the MDS Coordinator acknowledged the delays and attributed them to being the sole person responsible for MDS assessments and waiting on social services to input their information. The facility's policy and the CMS Long-term Facility Assessment Instrument 3.0 User's Manual specify that assessments should be submitted no later than 14 calendar days after the assessment reference date (ARD). The failure to adhere to these guidelines resulted in the identified deficiencies.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan for five residents within 48 hours of their admission, as required by policy. For Resident 159, who had multiple pressure ulcers and skin wounds, the baseline care plan did not address her pain and discomfort. Observations revealed that Resident 159 was in visible distress and had several skin tears, yet her care plan lacked interventions for pain management. The Director of Nursing (DON) confirmed that pain should have been included in the baseline care plan. Resident 109, who had diagnoses including toxic encephalopathy and Alzheimer's disease, also did not have her pain and communication needs addressed in her baseline care plan. Observations showed that she experienced pain in her right arm, and her family member expressed concerns about her risk of falling. Despite these observations, the baseline care plan did not include interventions for pain or communication needs. The DON acknowledged that these should have been included. Similarly, Resident 160, who had undergone surgery and had a compression fracture, did not have her pain and communication needs addressed in her baseline care plan. Observations indicated that she experienced pain from her surgery and had difficulty communicating in English. Additionally, Residents 45 and 32 did not have baseline care plans developed within 48 hours of admission. The facility's policy requires that a baseline care plan be developed within 48 hours and provided to the resident or their representative, but this was not done for these residents. The DON and unit managers confirmed these deficiencies during interviews.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident (R87) by serving her meals with plastic utensils for 14 months, despite no assessment indicating she was a danger to herself or others. Observations over several days showed R87 consistently using plastic utensils, and interviews with R87 revealed she was unaware of the reason for this. R87 expressed confusion and frustration about the use of plastic utensils, stating she was not suicidal and found it easier to eat with regular silverware. On one occasion, R87 was observed to be very happy when provided with regular silverware. Review of R87's medical records indicated she was cognitively intact with no serious mental illness or behaviors toward herself or others. The records also showed no ongoing monitoring for behavioral needs and no care plan intervention for plastic utensils. Interviews with facility staff, including the Social Service Director, Dietary Manager, and Unit Manager, revealed a lack of awareness and communication regarding the reason for the use of plastic utensils. The facility's policy on suicide assessment did not support the prolonged use of plastic utensils for R87.
Failure to Follow Medication Administration Protocol
Penalty
Summary
The facility staff failed to follow professional standards of practice by leaving medications at the bedside that were not ordered to be self-administered for Resident 98. Resident 98 was admitted with diagnoses of respiratory failure, sepsis, and pneumonia, and was cognitively intact with a BIMS score of 15 out of 15. An observation on 01/31/24 at 9:38 AM revealed that RN1 left two pills in a medicine cup on the overbed table in Resident 98's room. RN1 returned after five minutes and identified the pills as Lasix and a blood pressure medication, acknowledging that they should not have left the room. The Director of Nursing confirmed that nurses are not to leave medications unattended unless they are self-administered, and a review of the physician orders confirmed that these medications were not ordered to be self-administered.
Failure to Ensure Safe Discharge for Residents Leaving AMA
Penalty
Summary
The facility failed to ensure a safe discharge for residents who left Against Medical Advice (AMA) by not notifying community agencies and not providing prescriptions for care and medications. This deficiency was observed in two residents, R107 and R105, who were reviewed for unplanned discharge. R107, who had severe cognitive impairment and multiple medical conditions, left the facility without proper discharge planning or documentation. The staff did not notify the physician in a timely manner, and R107 was not provided with prescriptions for her medications or wound care supplies. Additionally, there was no evidence of discharge planning or discussions documented in R107's electronic medical record (EMR). R105, who had diagnoses including malignant neoplasm of the cervix and acute kidney failure, also left the facility AMA. The progress notes indicated that R105 left with her daughter, but there was no documentation that the physician had been notified. The staff involved could not recall the specifics of R105's discharge, and the physician confirmed that she was not notified about R105 leaving AMA. The facility's policy required that the physician be notified and that documentation of this notification be entered in the nurses' notes, which was not done in this case. Interviews with staff, including the Licensed Practical Nurse (LPN), Unit Manager (UM), Social Services Director (SSD), and Director of Nursing (DON), revealed inconsistencies in the process of handling AMA discharges. Staff were unsure of the proper procedures and failed to document necessary notifications and actions. The facility's policy on AMA discharges was not followed, leading to a lack of continuity of care and potential risks for the residents involved.
Failure to Accurately Screen for Elopement Risk and Unnecessary Use of Wander Guard
Penalty
Summary
The facility failed to accurately screen residents for elopement risk and ensure that measures were in place for residents with a wander guard. Specifically, Resident 76 was admitted with diagnoses including cerebral infarction, schizophrenia, right bundle branch block, and hemiplegia and hemiparesis. Despite scoring 09 out of 15 on the Brief Interview for Mental Status (BIMS), indicating some cognitive impairment, there was no documented wandering behavior. The resident's care plan included interventions for elopement risk, but the elopement risk assessment indicated that the resident was not at risk for elopement. However, a physician's order required checking the wander guard, which the resident had been wearing for about a year without understanding the reason for it. Staff interviews revealed that the resident was independent, did not exhibit exit-seeking behavior, and staff were unsure why the wander guard was in use. Observations and interviews with staff indicated that Resident 76 was independent in activities of daily living and did not require extra supervision for movement around the facility. The resident was seen walking directly to the TV room without wandering or attempting to exit the facility. Staff, including a CNA and an LPN, confirmed that the resident did not exhibit exit-seeking behavior and were unsure why the wander guard was in place. The Unit Manager and Director of Nursing also acknowledged that the resident was not an elopement risk and that the wander guard was used as a precautionary measure without proper documentation or justification. The facility's policy on elopement and missing residents stated that residents determined to be an immediate risk for elopement would be placed on a wander guard monitoring system. However, the policy was not followed in the case of Resident 76, who was not at risk for elopement but was still required to wear a wander guard. The lack of proper assessment and documentation led to the unnecessary use of the wander guard, causing discomfort to the resident and indicating a failure in the facility's procedures for managing elopement risks.
Failure to Obtain Physician Orders for Wound Care
Penalty
Summary
The facility staff failed to obtain a physician order when there was a change in treatment and failed to obtain a physician order for wound care upon admission for two residents. Resident 45 was admitted with a stage four pressure injury and had a wound vacuum dressing order that was discontinued without a new order for dressing changes. The Unit Manager confirmed that the wound vacuum was stopped and replaced with betadine dressings without notifying the physician or obtaining new orders. The Director of Clinical Services acknowledged the necessity of having an order and notifying the doctor for any change in treatment. Resident 32 was admitted with a stage four pressure injury with eschar present and had no wound care orders documented until four days after admission. The Unit Manager stated that the admitting nurse should follow the orders that come with the resident or use Medi-honey until the wound care team sees them. However, the nurse did not document the wound treatment and did not notify the physician. The Director of Nursing confirmed that the nurse should assess the wound and confer with the doctor for orders upon admission. The LPN admitted to using skin prep and a boot on the wound without documenting or notifying the physician due to being busy with admissions.
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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