Crest Pointe Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pt Pleasant, New Jersey.
- Location
- 1515 Hulse Road, Pt Pleasant, New Jersey 08742
- CMS Provider Number
- 315135
- Inspections on file
- 16
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Crest Pointe Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident reported poor cleanliness in the common shower rooms, and surveyors observed soiled items such as a full trash bin, used bandage, gloves, wet towel, worn socks, and dirty linens left on the floors of two units. Staff interviews and review of job descriptions confirmed that CNAs and housekeeping were responsible for cleaning and removing items after use, but these procedures were not followed, resulting in unclean conditions.
Two residents with mental health conditions experienced verbal abuse in a facility. One resident with PTSD reported inappropriate sexual comments from a CNA, which were not immediately investigated. Another resident with anxiety and ankylosing spondylitis was scolded by a UM/LPN for requesting ADL assistance, leading to increased anxiety. Both incidents were not promptly addressed, violating the facility's abuse policies.
A facility's LNHA failed to implement abuse policies, resulting in two Immediate Jeopardy situations. One resident with PTSD reported inappropriate sexual comments by a CNA, which was mishandled as a grievance. Another resident with anxiety was verbally abused by a UM/LPN, with delayed investigation. Both incidents were not promptly addressed, posing serious threats to resident safety.
The facility failed to ensure non-certified NAs did not work beyond 120 days without certification, affecting five NAs. The LNHA and DON were unaware of the regulatory requirements, and the HR person was new and unfamiliar with the timeframe. NAs worked with resident care assignments past the allowed timeframe, despite having completed schooling and passed tests, due to delays in state background checks and licensing.
The facility failed to report allegations of abuse involving two residents to the NJDOH within the required timeframe. One resident reported inappropriate sexual comments from a CNA, while another resident experienced verbal abuse and neglect after Medicaid discharge. The facility did not adhere to its abuse prevention and reporting policies, resulting in a deficiency citation.
The facility failed to investigate allegations of verbal sexual abuse and verbal abuse involving two residents. One resident reported inappropriate comments by a CNA, and another felt neglected and verbally abused by an LPN after Medicaid discharge. The facility did not follow its abuse prevention and grievance policies, lacking thorough investigations and documentation.
The facility failed to ensure staff were trained to properly assess hemodialysis access sites for two residents, leading to incomplete checks for bruit and thrill. Despite physician orders to check these sites every shift, documentation showed inconsistencies, and staff were unaware of the need to palpate for the thrill. The DON acknowledged the oversight, confirming staff only checked for bruit.
The facility failed to accurately complete DEA 222 forms for narcotic medications, with four out of ten forms missing required information in Part 5. The DON acknowledged the oversight, and the facility's policy lacked guidance on completing these forms.
The facility failed to store potentially hazardous food in a sanitary manner, as observed by a surveyor during a kitchen tour. Food and beverage boxes were found directly on the floor in the dry storage area, contrary to the facility's policy requiring food to be kept at least six inches off the floor. The Food Service Director acknowledged the oversight, and the Regional FSD confirmed the correct procedure.
A resident with multiple health conditions received wound care from an LPN who failed to perform proper hand hygiene between glove changes, as observed by a surveyor. The LPN acknowledged the oversight, and the DON confirmed the facility's hand hygiene policy, which emphasizes its importance in preventing infections.
Failure to Maintain Clean and Homelike Shower Room Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the common shower rooms on two units, as evidenced by direct observations and resident and staff interviews. A resident reported that the shower rooms were poorly cleaned, rating them four out of ten for cleanliness, and stated that staff shortages in housekeeping contributed to the issue. During a facility tour, surveyors observed a full trash bin, a soiled adhesive bandage, disposable medical gloves, and a wet towel left in the Oceanside Unit shower room. In the Bayside Unit shower room, worn socks and a pile of used towels and washcloths were found on the floor. These findings were confirmed by the Housekeeping and Laundry Director (HLD), who described the cleaning schedule but acknowledged the presence of these items during the inspection. Interviews with housekeeping and nursing staff revealed that it was routine for housekeepers to sweep and mop the shower rooms early in the morning and for CNAs to remove dirty linens and ensure nothing was left behind after resident showers. The Unit Manager and LNHA both stated that it was the expectation for CNAs, housekeepers, and unit managers to keep the shower rooms clean and to remove care items promptly. Review of job descriptions and facility policy confirmed that staff were responsible for maintaining cleanliness and proper disposal of items in the shower rooms, but these procedures were not followed, resulting in the observed deficiencies.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by two separate incidents involving residents with mental health diagnoses. In the first incident, a resident with PTSD, anxiety, and depression reported that a CNA made inappropriate sexual comments, which were witnessed by other staff members. Despite the resident's discomfort and the potential exacerbation of their PTSD, the incident was initially handled as a grievance rather than an abuse allegation, and the CNA continued to work for several shifts without suspension or investigation. In the second incident, another resident with depression, anxiety, and ankylosing spondylitis experienced a verbal altercation with a UM/LPN. The resident was scolded and yelled at for requesting assistance with ADLs, leading to increased anxiety and fear. Although the incident was reported to the BOM, the investigation was delayed by two weeks, during which time the resident continued to feel fearful and unsupported. Both incidents highlight the facility's failure to adhere to its abuse policies and procedures, which require immediate reporting and investigation of abuse allegations. The lack of timely action and investigation posed a likelihood of serious harm to the residents involved, as their mental health conditions were negatively impacted by the incidents.
Removal Plan
- Staff education on the facility abuse policy
- Suspension of CNA
- Suspension of the Social Worker
- Suspension of the Nursing Aide
- Suspension of the Director of Therapy
- Suspension of the Certified Occupational Therapy Assistant
- Suspension of the Unit Manager/Licensed Practical Nurse
- Suspension of the Rehab Director
Failure to Implement Abuse Policies Leads to Immediate Jeopardy
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of abuse policies and procedures, resulting in two Immediate Jeopardy (IJ) situations. The first incident involved a resident with PTSD, anxiety, and depression, who reported that a Certified Nursing Aide (CNA) made inappropriate sexual comments. This incident was witnessed by a Nursing Aide and the Rehabilitation Director, but was handled as a grievance rather than an abuse allegation. The LNHA, who was the Grievance Officer, was aware of the incident but did not initiate an investigation, allowing the CNA to continue working for twelve additional shifts. The second incident involved another resident with depression, anxiety, and ankylosing spondylitis, who experienced a verbal altercation with a Unit Manager/Licensed Practical Nurse (UM/LPN). The resident was scolded and yelled at for requesting assistance with activities of daily living, causing increased anxiety and fear. Although the Business Office Manager reported the incident to the LNHA immediately, an investigation was not initiated until two weeks later, during which time the UM/LPN continued to work ten shifts with residents, including the affected resident. The facility's failure to investigate and report these incidents in a timely manner, as required by their policies and federal regulations, posed a serious and immediate threat to resident safety and well-being. The LNHA's lack of action and oversight in both cases resulted in significant emotional harm to the residents involved, highlighting deficiencies in the facility's abuse prevention and grievance handling processes.
Removal Plan
- Suspend the LNHA.
- Appoint the Regional LNHA as the facility's administrator.
- Inservice the Regional LNHA on the facility's policies.
Facility Fails to Ensure Timely Certification of Nursing Aides
Penalty
Summary
The facility failed to ensure that non-certified Nursing Aides (NAs) did not continue to work beyond 120 days without certification, affecting five NAs. During a survey, it was discovered that the facility did not have a system in place to track the certification status of NAs, leading to NAs working with resident care assignments past the allowed timeframe. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were unaware of the specific regulatory requirements, and the Human Resource (HR) person was new and unfamiliar with the timeframe NAs could work without certification. The surveyor's review of the facility's records revealed that five NAs had worked beyond the 120-day limit without certification, with some having their own resident care assignments. Interviews with the NAs confirmed that they were waiting on state background checks and licensing, despite having completed their schooling and passed the necessary tests. The HR/Staffing Coordinator acknowledged the oversight and confirmed that NAs were allowed to have their own assignments after completing a certain amount of training, but should not have continued past 120 days without certification.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the New Jersey State Department of Health (NJDOH) within the required two-hour timeframe. The first incident involved a resident who reported that a Certified Nursing Aide (CNA) made inappropriate sexual comments towards them. Despite the resident's report to the administration, the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), or Assistant Director of Nursing (ADON) did not initially address the incident with the resident. The grievance was documented, but the investigation was not thorough, and the incident was not reported to the NJDOH until the surveyor's involvement. The second incident involved another resident who reported verbal abuse and neglect after being discharged from Medicaid services. The resident claimed that a Unit Manager/Licensed Practical Nurse (UM/LPN) instructed staff not to assist them with activities of daily living, which led to increased physical pain and emotional distress. The Business Office Manager (BOM) was informed of the incident by the resident's representative and reported it to the LNHA. However, the LNHA did not take immediate action to investigate or report the incident to the NJDOH. Both incidents highlight the facility's failure to adhere to its abuse prevention and reporting policies. The facility's policies require immediate reporting of abuse allegations to the appropriate authorities, but in these cases, the facility did not comply with the required protocols. The lack of timely reporting and investigation of these allegations resulted in a deficiency citation for the facility.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse policy to thoroughly investigate allegations of verbal sexual abuse and verbal abuse involving two residents. Resident #79 reported that a Certified Nursing Aide (CNA #1) made inappropriate sexual comments, which made the resident uncomfortable. Despite the resident's report to the administration, there was no thorough investigation, and the resident was not interviewed by the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), or Assistant Director of Nursing (ADON) until after the surveyor's inquiry. The grievance process was initiated by the Social Worker (SW), but it lacked comprehensive documentation, including statements from the resident, witnesses, and CNA #1. In another incident, Resident #60 reported feeling neglected and verbally abused by the Unit Manager/Licensed Practical Nurse (UM/LPN) after being discharged from Medicaid services. The resident expressed that the UM/LPN was angry and scolded them for asking for help with activities of daily living (ADLs), which led to increased anxiety and emotional harm. The Business Office Manager (BOM) was informed of the incident and reported it to the LNHA, but no formal investigation was conducted, and the resident's concerns were not addressed. The facility's policies on abuse prevention and grievance handling were not followed, as evidenced by the lack of thorough investigations and documentation. The LNHA and SW failed to gather necessary statements and evidence, and the facility did not protect the residents from potential abuse. The deficiencies highlight a failure to adhere to established protocols for investigating and addressing allegations of abuse, leaving residents vulnerable and their concerns unaddressed.
Inadequate Training and Assessment of Hemodialysis Access Sites
Penalty
Summary
The facility failed to ensure that staff were adequately trained to assess and document the care of hemodialysis access sites for residents requiring such services. This deficiency was identified for two residents who were receiving hemodialysis treatment. The staff did not properly assess the atrio-ventricular (AV) fistula for both bruit and thrill, which are critical indicators of adequate blood flow and potential complications at the access site. The surveyor observed that the staff only checked for the bruit and not the thrill, which is a palpable sensation that must be felt, not heard. Resident #50, who had a fully intact cognition, reported that the nurses at the facility did not check the hemodialysis site, and this was confirmed by the surveyor's observations and interviews with the staff. The physician's orders required the site to be checked every shift for bleeding, signs of infection, and the presence of bruit and thrill. However, documentation revealed inconsistencies, with some days lacking records of these checks, and on one occasion, the nurse documented the absence of both bruit and thrill. The Licensed Practical Nurse (LPN) responsible for Resident #50's care admitted to not palpating for the thrill and could not recall receiving specific training on the care of dialysis access sites. Similarly, for Resident #4, the staff also failed to palpate for the thrill, as confirmed by the surveyor's observation of another LPN's demonstration. The LPN was unaware that the thrill must be palpated and believed it could be assessed with a stethoscope. The facility's policy on the care of AV fistulas and grafts required palpation for the thrill, but the staff did not adhere to this procedure. The Director of Nursing acknowledged the oversight in the presence of the survey team, confirming that the staff only checked for the bruit and not the thrill.
Incomplete DEA 222 Forms for Narcotic Medications
Penalty
Summary
The facility failed to ensure accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms). During a review of the facility's DEA 222 forms, it was found that four out of ten forms provided were incomplete. Specifically, Part 5 of the forms, which requires the purchaser to fill out the number of packages received and the date received for each line item, was not completed upon receipt of the medications from the provider pharmacy. The forms in question were numbered 231430013, 231430014, 231430015, and 231430016. The Director of Nursing (DON) acknowledged the oversight during a review with the surveyor and admitted that Part 5 should have been completed as instructed on the reverse of the DEA 222 form. The facility's Medication Labeling and Storage policy, revised in February 2023, did not include information related to the completion of the DEA 222 forms, contributing to the deficiency.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure that potentially hazardous food was stored in a sanitary manner. During a kitchen tour, the surveyor observed five stacks of boxes containing food and beverages stored directly on the floor in the dry storage area. These included a case of fruit cup salad, a case of pear juice, a case of coffee, a case of diced pears, two cases of cranberry juice, and a case of ketchup. The Food Service Director (FSD) acknowledged that the food had just been delivered and that mats are usually placed on the floor first, admitting that food should not be stored directly on the floor. The Regional FSD confirmed that the boxes should have been placed on a mat or pallet. The facility's Food Receiving and Storage policy, revised in November 2022, states that food in designated dry storage areas should be kept at least six inches off the floor unless packaged for case lot handling, such as on dollies, pallets, racks, and skids. The surveyor informed the Regional Licensed Nursing Home Administrator (LNHA), who was acting as the facility administrator, of these findings in the presence of the Director of Nursing and the survey team.
Deficient Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to perform proper hand hygiene during wound care for a resident, leading to a deficiency in infection prevention and control. The incident involved a resident with multiple diagnoses, including type 2 diabetes mellitus, chronic pain, end-stage renal disease, and dependence on renal dialysis. The resident was observed in bed, and the surveyor reviewed the medical record, which included a physician's order for wound care on the resident's left great toe. During the wound care procedure, an LPN was observed not performing hand hygiene between glove changes. The LPN initially washed her hands and donned PPE before starting the wound care. However, after removing the dressing and gloves, the LPN did not perform hand hygiene before donning new gloves. This pattern continued throughout the procedure, including when applying ointment and dressing the wound, as well as when applying numbing cream to the resident's hemodialysis injection area. Interviews with the LPN and the DON confirmed the deficiency in hand hygiene practices. The LPN acknowledged the need for hand hygiene between glove changes, and the DON reiterated the facility's policy on proper handwashing techniques. The facility's hand hygiene policy emphasized the importance of hand hygiene in preventing healthcare-associated infections, requiring hand hygiene before and after glove use, and detailed the correct procedure for washing hands.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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