Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Lake Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to provide care in accordance with professional standards when two residents were observed double diapered, with the inner brief wet and the outer brief dry. A CNA admitted to the practice and said it was done because of short staffing, while the CNA, LPN, ADON, and DON all stated that residents should not be double diapered because it can cause skin breakdown and is not appropriate care. The residents had incontinence-related care needs, and one had documented risk factors for skin impairment.
A staff member failed to immediately report witnessing two residents with cognitive impairments engaged in sexual activity, instead completing her task and taking a lunch break before informing a co-worker. This delay was contrary to facility policy, and staff interviews revealed confusion about the residents' capacity to consent. The incident was not promptly addressed, and the safety of the involved residents and others was not immediately ensured.
A staff member observed two residents engaged in an incident but failed to immediately report it, instead completing her task and taking a lunch break before notifying a co-worker. The delay in reporting was confirmed through interviews, and the residents involved had cognitive and behavioral histories relevant to the event. Facility administration did not ensure staff followed established protocols for immediate reporting and intervention.
The facility was unable to provide its QAPI plan and meeting minutes when requested by surveyors, as the responsible staff member could not access or print the documents due to lack of internet access. This resulted in a failure to demonstrate evidence of an ongoing QAPI program as required by regulations.
A staff member without CNA certification was found performing ADLs for a resident with cognitive impairment, despite facility policy and job descriptions restricting such care to certified personnel. Facility leadership was unaware of the staff member's actions, and documentation confirmed the individual was not authorized to provide direct care.
The facility did not meet required CNA staffing ratios on all reviewed day shifts, consistently providing fewer CNAs than mandated by state law for the number of residents present. This deficiency was identified through a review of staffing records in response to complaints and had the potential to affect all residents.
A review of nurse staffing reports revealed that the facility did not meet the minimum required staffing hours on one day, providing 480 hours instead of the required 484 hours. This deficiency was identified during the investigation of two complaints.
A resident was physically and verbally abused by the DON, who hit the resident with a broom during an altercation. The incident, witnessed by several staff members who failed to intervene or report it, was recorded and circulated on social media, leading to a police investigation. The resident, with a history of major depressive disorder, dementia, and epilepsy, was reportedly agitated and holding a blue disposable razor during the incident.
A facility failed to investigate and report an abuse allegation involving the DON hitting a resident with a broom, as captured in a video posted online. The incident was not reported to the Department of Health, and the DON remained employed until months later. The resident involved had a history of cognitive impairment and aggression, but there was no documentation of the incident in their records. Facility policies requiring immediate action and investigation of abuse allegations were not followed.
A resident with severe cognitive impairment was recorded being hit by the DON, and the video was shared on social media by an LPN, violating privacy and confidentiality policies. Despite training, the LPN was unaware of these policies, leading to a breach of the resident's rights.
A facility failed to report an incident where the DON hit a resident with a broom, as seen in a video on social media. The resident, with severe cognitive impairment, was involved in a verbal and physical altercation with the DON. Several staff members witnessed the event but did not intervene or report it to authorities. The facility's policies on abuse and incident reporting were not followed.
A resident with a history of aggressive behavior and mental health issues was physically abused by a CNA and a Smoking Monitor in a hallway. Despite the resident's pleas, the staff continued to kick and punch the resident until an LPN intervened. The resident was hospitalized with serious injuries. The facility failed to follow its abuse policy, as the staff involved were not immediately removed from care, and the incident was not promptly reported. Surveillance footage was not reviewed in time, and the facility's leadership was not fully informed until police involvement.
A resident with a history of aggression was physically assaulted by staff members, resulting in serious injuries. The facility failed to conduct a timely investigation or report the incident to the police. No incident report was completed on the day of the incident, and witness statements were delayed. The facility's policies on abuse and incident investigation were not followed, placing the resident and others at risk.
A resident with a history of aggressive behavior and multiple diagnoses was harmed due to the facility's failure to implement care plan interventions. The resident was physically assaulted by staff members, resulting in serious injuries. The care plan, which included specific interventions to manage the resident's agitation, was not followed, leading to the incident. The facility's policy emphasizes the importance of care plan implementation to prevent harm, but staff actions contradicted these guidelines.
A resident with a history of aggressive behavior was physically abused by staff members in a LTC facility. The LNHA failed to prevent the abuse, follow the facility's abuse policy, and conduct a timely investigation. The resident sustained serious injuries and was sent to the hospital. The incident was not immediately reported, and staff involved continued to work with other residents. The facility's administration did not follow its own policies, placing all residents at risk.
A facility failed to implement PASARR Level II recommendations for a resident with Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. Despite recommendations for psychiatric consults and other mental health services, the resident was not seen by a psychiatrist, and the facility lacked a policy on PASARR implementation.
The facility failed to update the care plans for two residents who made abuse allegations against staff. Despite investigations and the presence of local authorities, the care plans were not revised with new interventions. Both residents had severe cognitive impairments and a history of making false allegations, but their care plans lacked updates following the incidents.
Double Diapering of Two Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for 2 of 6 residents reviewed by implementing double diapering, which was observed during care for two residents with incontinence needs. Resident #1 had diagnoses including dementia, mild intellectual disabilities, and type 2 diabetes mellitus, and Resident #2 had diagnoses including urinary tract infection, altered mental status, and generalized anxiety disorder. Resident #1’s care plan identified risk for skin impairment related to impulsive scratching, fragile skin, extrapyramidal movements, and peripheral vascular disease, and Resident #2’s care plan identified a potential for altered skin integrity related to incontinence with interventions to keep skin clean and dry and provide prompt incontinence care. During observation, Resident #1 and Resident #2 were each found wearing two incontinence diapers layered on top of each other, with the inner diaper wet with urine and the outer brief dry. The CNA responsible for both residents acknowledged double diapering them, apologized, and stated it was not good practice and was done because of short staffing. The CNA, LPN, ADON, and DON each stated that residents should not be double diapered because it can cause skin breakdown and is not appropriate practice. The facility’s CNA training document stated not to double brief any resident, and the facility policies on perineal care and resident rights emphasized cleanliness, comfort, prevention of skin irritation, and dignified treatment.
Failure to Immediately Report and Respond to Resident-to-Resident Sexual Incident
Penalty
Summary
A deficiency occurred when a staff member failed to immediately report an observed incident involving two residents engaged in sexual activity. The staff member entered the room, witnessed the event, completed her task of collecting hangers, and then left the room without reporting the incident. She subsequently went on her lunch break for approximately 30 minutes before informing a co-worker, who then reported the incident to the appropriate supervisory staff. This delay in reporting was contrary to the facility's policy, which requires prompt reporting of any witnessed abuse or neglect to the charge nurse. Both residents involved had documented cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores. The medical records and care plans showed that one resident had a history of seeking sexual intimacy and related behaviors, while the other also had cognitive limitations. The staff and supervisory interviews revealed uncertainty among staff regarding the residents' capacity to consent to sexual activity, especially given their BIMS scores. Despite the facility's policy allowing sexual intimacy between consenting adults deemed capable by MDS guidelines, staff were unclear about the application of these guidelines in this situation. The failure to immediately report the incident and ensure the safety of both residents, as well as all other residents in the facility, constituted a breach of the facility's abuse/neglect policy. The delay in reporting and lack of immediate intervention placed all residents at risk, as the staff did not promptly assess or secure the safety of those involved or others who might be affected. The deficiency was identified through interviews, medical record reviews, and examination of facility documentation, confirming that the required procedures were not followed.
Plan Of Correction
F 600 Tag F0600 438.12 Free from Abuse, Neglect and Exploitation 1. Corrective Action – On [R] Resident#1 and Resident #2 were [R] and placed on [R] by nursing. – On [R] Resident #1 and Resident #2 were transferred to the local hospital for evaluation. – On [R] the incident was reported to local [R]. – On [R] upon return from the hospital, Resident #1 and Resident #2 were placed on [R]. – On [R] the US FOIA (b)(6) received education from the HR Director on [R] and [R] and timely reporting. – Or [R] the US FOIA (b)(6) received a final discipline from HR Director for lack of timely reporting of the event to the appropriate staff. – On NJ Exec Order 26, the facility orientation for new employees was revised by the HR Director to include education on and NJ Exec Order 26.4 NJ Exec Order 26.4b1 and timely reporting. – Or NJ Exec Order 26.4D, the employee annual orientation requirements have been revised by the HR Director to include sexual abuse, timely reporting, and resident's ability to consent to sexual activity. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: – All residents have potential to be affected by the deficient practice. 3. Measures Put in Place: – The DON/designee will conduct facility education for all staff and assess all staff competency related to abuse and neglect, timely reporting, and facility sexual intimacy policy monthly for 6 months. – The HR and/or designee will randomly audit monthly, for 6 months, 10 employees' comprehension of facility abuse and neglect policy and timely reporting. 4. How Will These Actions Be Measured: – The results of the monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated facility staff on the facility's policy on NJ Exec Order 26.4b1
- Educated staff on the ability for residents to consent to NJ Exec Order 26.4b1 with each other
- Educated staff to report any incidents between residents and ensure the NJ Exec Order 2 residents were safe
- Conducted audits to monitor compliance with education
- Conducted staff assessment and testing to ensure staff had a true understanding of education
Failure to Ensure Timely Reporting and Implementation of Policies Following Resident Incident
Penalty
Summary
A deficiency occurred when facility staff failed to implement policies and procedures regarding an incident between two residents. A staff member entered the room of two residents, observed one resident engaged in an act with the other, and then proceeded to finish her task of collecting hangers before leaving the room. Instead of immediately reporting the incident to a supervisor or nurse as required, the staff member went on her lunch break for approximately 30 minutes. Upon returning from lunch, she reported the incident to a co-worker, who then reported it to the appropriate personnel. The delay in reporting was confirmed during interviews, with the staff member admitting she was aware of the need to report immediately but did not do so out of fear and uncertainty about her supervisor's availability. The residents involved had relevant medical histories and cognitive assessments documented in their records. One resident had a BIMS score indicating impaired cognitive function, and the other also had a care plan noting a history of certain behaviors and interventions. The facility's investigation and interviews with staff revealed that both residents were questioned about the incident, with one denying and the other confirming what was observed. Staff interviews further indicated confusion and inconsistency regarding the residents' capacity to consent to the observed actions, particularly in relation to their BIMS scores. The facility's administration was found to have failed in ensuring that staff followed established protocols for reporting and responding to such incidents. The administrator and department heads were not immediately aware of the delay in reporting, and the staff member's written statement did not accurately reflect the sequence of events. The deficiency was identified as placing all residents at risk due to the failure to ensure prompt reporting and intervention, as required by facility policy and regulatory standards.
Plan Of Correction
F835 Administration 1. Corrective Action: - Effective May 13, 2025, the Administrator of record is no longer employed at the facility. The new Administrator of record began on NJ Ex Order 26.4(b)(1). - On May 15, 2025, the corporate Administrator oriented the new Administrator of record to her job description, previous and current plans of corrections, and statement of deficiencies. 2. Identification of other areas having the potential to be affected due to the nature of this deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put in Place: - The corporate Administrator and/or designees will meet weekly with the new Administrator of record for 4 weeks and then monthly for 6 months to assure that processes and procedures are compliant with company policy. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission of reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated the Administrator on their job description.
- Educated the department heads on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.
- Educated the governing body on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.
Failure to Provide QAPI Documentation During Survey
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its Quality Assurance and Performance Improvement (QAPI) program as required by federal and state regulations. During a survey, the surveyor requested the facility's QAPI plan and the most recent meeting minutes. The staff member responsible for these documents stated she was unable to retrieve or print them due to a lack of internet access, as the documents were stored on her computer and not otherwise accessible. Further interviews confirmed that the QAPI plan and meeting minutes were not readily available to the surveyors upon request. The staff member acknowledged that the QAPI documentation should have been accessible but was not, citing technical limitations as the reason. The facility's own policy requires that minutes of all meetings be recorded and documentation maintained according to internal policy, but this was not achieved at the time of the survey. No information was provided in the report regarding specific residents or their medical conditions in relation to this deficiency. The deficiency was identified solely based on the facility's inability to provide required QAPI documentation and evidence of an ongoing QAPI program during the survey process.
Plan Of Correction
F865 QAPI 1. Corrective Action: On 4/23/25 upon identification, the Administrator printed a copy of QAPI meeting minutes, performance improvement plans, data tracking logs, and related documentation, sent the information to the DOH and placed the printed items in a QAPI binder entitled QAPI 2025. 2. Identification of other residents or areas having the potential to be affected due to the nature of this deficiency: All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: Monthly audits X6 months will be conducted by the Administrator or their designee to ensure the QAPI binder is current and complete. 4. How Will These Actions Be Measured: The results of the monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held June 6, 2025. S 000
Uncertified Staff Member Performed Resident Care Duties
Penalty
Summary
A deficiency was identified when a staff member assigned as a "Monitor" was found performing resident care activities, specifically Activities of Daily Living (ADLs), for a resident. The staff member, referred to as Monitor #1, did not possess a Certified Nurse Aide (CNA) license, as confirmed by a review of her personnel file and her own admission during an interview. Monitor #1 stated that she had attended CNA school and had taken the certification test but failed. Despite this, she reported performing tasks such as changing and caring for residents, which are duties reserved for certified and competent nurse aides. Further investigation revealed that facility leadership, including the Director of Nursing and other administrative staff, were not aware that Monitor #1 was providing direct resident care. The facility's job description for the "Monitor" position did not include providing resident care, but rather focused on supervision, assistance with transportation, and support during mealtimes and leisure activities. The facility was unable to provide an assignment sheet for the relevant date, and interviews confirmed that the Monitor was not authorized to perform CNA responsibilities. The resident involved had a history of cognitive impairment and required significant assistance with daily activities.
Plan Of Correction
F728 Hiring/Use of Nurse Aides 1. Corrective Action - On 4/10/25, monitor #1 received an education and disciplinary action for failure to adhere to their job description. - On [R], monitor #1 was terminated and is no longer employed at the facility. - On 4/10/25, HR Director audited all nursing assistant files to assure they are within their 120 days based on regulatory requirement. All nursing assistants (total of 11) met regulatory criteria for employment as nursing assistants. - On 4/10/25, HR Director audited all nursing assistants to ensure compliance with job description and scope of practice. - On 4/10/25, HR Director educated all monitors (9) on their job description. - On 4/10/25, HR Director audited all monitors' employee files for signed job description and not providing direct care to residents. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: - HR Director and/or designee will audit monthly X6 months all nursing assistants to ensure that they do not work more than 120 days. - Director of Nursing/designee will audit the monitors' performance to assure it is compliant with their job description weekly X4 weeks and then monthly X6 months. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Failure to Meet Mandatory CNA Staffing Ratios on Day Shifts
Penalty
Summary
The facility failed to meet mandatory staffing ratios for Certified Nurse Aides (CNAs) on all 14 day shifts reviewed during the period from 03/23/25 to 04/05/25. According to the New Jersey Department of Health requirements, the facility was required to have one CNA for every eight residents during the day shift. However, staffing records showed that the number of CNAs present each day was consistently below the required minimum, with the facility having between 15 and 18 CNAs for 187 to 192 residents, when at least 23 to 24 CNAs were needed per shift. This deficiency was identified during a review of facility documents in response to complaints NJ182091 and NJ185153. The deficient practice had the potential to affect all residents in the facility, as the staffing shortfall occurred on every day shift reviewed within the two-week period. The report references state law and regulations that specify the minimum staffing requirements and details the exact shortfall for each day, but does not provide information about specific residents or their medical conditions at the time of the deficiency.
Plan Of Correction
S560 Mandatory Access to Care 1. Corrective Action - Staffing coordinator as educated on New Jersey state staffing ratio requirements by the DON on May 19, 2025. - Efforts to hire facility staff will continue until there is adequate staff to meet the minimum staff to resident ratios. Until that time, the facility will use staffing agencies and offer additional shifts to current staff with bonuses as required. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measure Put into Place: - Weekly recruitment, retention and employee appreciation meeting was initiated and will be led by the Director of Human Resources and/or designee. - Hiring and recruitment efforts including pay for experience, online job listing, job fairs, shift differentials and referral bonuses are being utilized to continue to be competitive in the marketplace. - The facility administrator/designee will continue to track and document any recruitment and retention efforts weekly. - The administrator, DON/designee will review staffing schedules weekly to ensure adequate staffing for all shifts. 4. How Will These Actions Be Measured: - The results of the weekly recruitment and retention audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Failure to Meet Minimum Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum required nurse staffing levels for 1 out of 14 days during the review period. Specifically, on one day, the actual staffing hours provided were 480, which was 4 hours less than the required 484 hours. This deficiency was identified through a review of the Nurse Staffing Reports for the weeks of 03/23/25 and 03/30/25, as part of the investigation of two complaints (NJ182091, NJ185153). No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Plan Of Correction
5/22/25 S1680 Mandatory Nurse Staffing 1. Corrective Action: - Staffings coordinator was educated by the DON, on New Jersey state staffing regulation related to nursing services by registered professional nurses, licensed practical nurses, and nurse's aide requirements on May 19, 2025. - Efforts to hire facility staff will continue until there is adequate staff to meet the minimum nursing staff to resident ratios. 2. Identification of other residents or areas having the potential to be affected due to the nature of this deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put in Place: - The administrator, DON/designee will review staffing schedules weekly to ensure adequate nursing staffing for all shifts. 4. How Will These Actions Be Measured: - The results of the weekly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Failure to Prevent and Report Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent physical and verbal abuse towards a resident by a staff member, specifically the Director of Nursing (DON), who was observed hitting a resident with a broom. This incident was recorded by a Licensed Practical Nurse (LPN) and later circulated on social media, prompting a police investigation. The abuse was witnessed by several staff members, including another LPN, a Certified Nursing Assistant (CNA), and a Housekeeper, none of whom intervened or reported the incident. The DON was heard making a threatening statement towards the resident during the incident. The incident occurred when the DON was called to the unit due to the resident's aggressive behavior. The resident, who had a history of major depressive disorder, dementia, and epilepsy, was reportedly agitated and threw a chair at the DON. The DON then used a broom to hit the resident, who was allegedly holding a blue disposable razor. The facility's reportable event documentation did not include a thorough investigation or proper notification to the Department of Health, and the DON remained employed for an extended period after the incident. The facility's policy on abuse was not followed, as the incident was not reported immediately, and the staff involved were not removed from resident care promptly. The DON had received training on abuse prior to the incident, yet failed to adhere to the facility's protocols. The lack of intervention and reporting by the staff present during the incident further contributed to the deficiency, as they did not take appropriate action to protect the resident or notify the authorities.
Plan Of Correction
Immediate Action On NEX OTGOT 20.4161 US. FOLA (was suspended pending investigation. (Terminated) NJ Ex Order 26. 481. Administrator/ADON/HR contacted Board of Nursing on 12/30/2024 to report involvement in incident, and to report the two nurses who observed, recorded video and did not intercede to help, but sent the video to a friend to post. Those nurses no longer work at facility. C.N.A. #1 and C.N.A. #3 were reported to Department of Health for not interceding to help and not reporting. 12/24/24 Education was given to staff C.N.A. #1, and C.N.A. #3, and on how to follow company policy on abuse and report immediately to the abuse coordinator, intervene and call the police. 12/24/24 Morning/clinical meeting audit process started to assure allegations of abuse and neglect and grievances are addressed and investigated within policy. Audits will be completed 3x weekly for the next 4 weeks and monthly for the next 6 months. Other residents having potential to be affected by the same deficient practice All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return. On 12/23/24, (completed 12/25/24) the Assistant Director of Nursing/or designee immediately educated all staff on abuse, neglect and exploitation and deescalating resident behavior, and the importance of reporting all incidents to the abuse coordinator timely, calling police, and intervening. The Interim DON/designee will conduct this education monthly for the next six months. Administrator/DON/ADON/designee will audit education each month to assure all employees have had education. Audits will be conducted 3x's weekly for four weeks and then monthly for the next six months. The Administrator/Interim DON/designee will audit compliance with the education on abuse and conduct 5 random staff assessment and test to assure staff have a true understanding of the facilities abuse policy. Audits will be completed 3x's weekly for four weeks and then monthly for the next four months. The education on the facilities abuse policy and the importance of reporting all incidents to the abuse coordinator immediately, interceding in the situation and calling the police, will become part of our orientation education as well as our annual education. 12/30/2024 Ad Hoc Resident council meeting was held to educate residents on abuse and to ask that if they see something to please say something. Social services/activity director educated them on the signs hanging on units for calling the abuse coordinator, and for calling the ombudsman office. The resident rights were read. How the facility plan to monitor its performance to make sure that solutions are sustained. The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.
Removal Plan
- Education to all staff on abuse, neglect, and exploitation.
- Education on intervening and calling the police if abuse was witnessed.
- Education on what to do when abuse was reported and the process for reporting abuse.
- A third-party consultant company completed an audit that reviewed all incident and accident reports to ensure that each incident included a thorough investigation and appropriate follow-up.
- The third-party consultant company provided the facility with recommendations based on the audits.
- The staff within the video that witnessed the incident between the DON and Resident #1 were no longer working at the facility.
- The Human Resources Director (HRD) received education from the ADON on the proper reporting process when an abuse allegation was reported to her.
- CNA #1 and CNA #3 who witnessed the incident but were not in the video, continue to work at the facility and education was provided to both staff on intervening and calling the police if abuse was witnessed.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of witnessed staff-to-resident physical abuse. The incident involved the Director of Nursing (DON) hitting a resident with a broom, which was recorded by an LPN and later posted on social media. The video showed several staff members present during the incident who did not intervene. The DON was identified as the staff member holding the broom, and the resident involved was identified as Resident #1. The incident was not reported to the Department of Health, and the DON remained employed at the facility until her suspension months later. Resident #1, who was involved in the incident, had a history of major depressive disorder, dementia, and epilepsy. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). The resident's care plan noted a potential for verbal and physical aggression, with interventions to allow verbalization of frustrations and provide diversional activities. However, there was no documentation in the resident's progress notes regarding the incident, police notification, or hospital transfer. The facility's policies required immediate action and thorough investigation of abuse allegations, which were not followed in this case. The DON conducted the initial investigation but failed to report the incident to the appropriate authorities. The facility's policy also required the removal of any employee involved in abusive activity from resident care, which did not occur until the DON's suspension. The lack of intervention by other staff members present during the incident further contributed to the deficiency.
Plan Of Correction
Immediate Action On [R] was suspended pending investigation. (Terminated [R]) On 12/21/24 a third-party consulting company was contracted to conduct an independent investigation of the abuse allegation which comprised of review of documentation, care plans, interviews of staff, observation of resident, review of reportable information from [R]. Audit of all incident and accident reports from Waxed to present was conducted to ensure that each incident included a thorough investigation and appropriate follow up. Audit completed 12/26/2024. 12/24/24 Education was given to staff C.N.A. #1, and C.N.A. #3, and on how to follow company policy on abuse and report immediately to the abuse coordinator, intervene and call the police. 12/24/24 Morning/clinical meeting audit process started to assure allegations of abuse and neglect and grievances are addressed and investigated within policy. Audits will be completed 3x's weekly for the next 4 weeks and monthly for the next 6 months. Administrator/ADON/HR contacted Board of Nursing on 12/30/2024 to report involvement in incident, and to report the two nurses who observed, recorded video and did not intercede to help, but sent the video to a friend to post. Those nurses no longer work at facility. C.N.A. #1 and C.N.A. #3 were reported to the Department of Health for not interceding to help and not reporting. Other residents having potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return. On 12/23/24, (completed 12/25/24) the Assistant Director of Nursing/or designee immediately educated all staff on abuse investigation protocols, importance of collecting all statements, utilizing the social worker to assist in obtaining the residents statements, assuring the original signed statements are turned into the abuse coordinator, Police are called and reporting all incidents to the abuse coordinator immediately and within 5 days turn in all findings of investigation to Administrator. The Interim DON/designee will conduct this education on abuse investigation protocols for the next six months. Administrator/DON/ADON/designee will audit education each month to assure all employees have had education. Audits will be completed 3x weekly for the next 4 weeks and monthly for the next 6 months. The Administrator/Interim DON/designee will audit compliance with the education on abuse investigation and conduct 5 random staff assessment and test to assure staff have a true understanding of our abuse policy. Audits will be completed 3x's weekly for four weeks and then monthly for next four months. The education on the facility protocols on abuse investigations will become part of our orientation education as well as our annual education. Administrator/Interim DON/ADON/designee will audit abuse reportable events to observe and to assure completeness of investigation and that all statements are collected and are in their original signed form, police were called, incident is reported to Department of Health and Ombudsman. Audits will be conducted three times weekly for four weeks, then monthly for the next four months. 12/30/2024 Ad Hoc QAPI meeting was held to review the results of the third-party consulting company's independent investigation of the abuse allegation which comprised of review of documentation, care plans, interviews of staff, observation of resident, review of reportable information from NJ Esx Order 26. 481. In addition, audit of all incident and accident reports from [R] to present was conducted to ensure that each incident included a thorough investigation and appropriate follow up. Audit completed 12/26/2024. The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.
Removal Plan
- Education to all staff on conducting a thorough investigation related to an abuse allegation.
- A third-party consultant company completed an independent investigation of the abuse allegation which was comprised of a documentation review, review of the resident's medical records, staff interviews, resident observations, and a review of the reportable event.
- The third-party consultant company conducted an audit of all incident and accident reports to ensure that each incident included a thorough investigation.
- The Licensed Nursing Home Administrator (LNHA) implemented a daily audit to assure abuse allegations were addressed and investigated according to the facility's policy.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect a resident's right to privacy and confidentiality when a video of a resident being hit with a broom by the Director of Nursing (DON) was recorded by a staff member and subsequently shared on social media. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and diagnoses including Major Depressive Disorder, Dementia, and Epilepsy. The video was recorded by an LPN who was present during the incident and later sent it to a friend who posted it online. This breach of privacy was discovered when local police were notified of the video circulating on social media. Interviews with facility staff revealed that the LPN who recorded the incident was unaware of the privacy and confidentiality policies, despite the facility's policy prohibiting the use of personal electronic devices to record residents without express permission. The Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA) confirmed that staff were trained on these policies upon hire and biannually. However, the LPN did not adhere to these guidelines, resulting in a violation of the resident's privacy and confidentiality rights.
Plan Of Correction
Immediate Action On 12/30/2024 HIPAA privacy and confidentiality education began. U.S. FOIA (b) (6) contacted Board of Nursing on 12/30/2024 to report involvement in incident, and to report the two nurses who observed, recorded video and did not intercede to help, but sent the video to a friend to post. Those nurses no longer work at facility. C.N.A. #1 and C.N.A. #3 were reported to Department of Health as well. Other residents having potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return: On 12/30/2024, education was given to all staff on HIPAA privacy and confidentiality. The interim DON/designee will audit education sign-in sheets to assure all staff have been educated on the HIPAA protocols. The audits will be completed weekly for four weeks and then monthly for the next four months. Education on HIPAA confidentiality and privacy will be given monthly for six months. Education on HIPAA confidentiality and privacy will become part of our orientation education as well as our annual education. The Administrator/DON/designee will audit compliance with the education on HIPAA confidentiality and privacy and conduct 5 random staff assessments and tests to assure staff have a true understanding of HIPAA confidentiality and privacy. How the facility plans to monitor its performance to make sure that solutions are sustained: The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.
Failure to Report and Intervene in Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of witnessed staff-to-resident physical and verbal abuse to the Department of Health and the local Police Department. The incident involved a staff member, identified as the Director of Nursing (DON), hitting a resident with a broom. The event was captured on video and later found on a social media website. Several staff members were present during the incident but did not intervene. The Assistant Director of Nursing (ADON) confirmed the identities of the staff involved and the resident, who was identified as Resident #1. Resident #1, who was admitted with diagnoses including Major Depressive Disorder, Dementia, and Epilepsy, was involved in the incident. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident's care plan noted a history of verbal and physical aggression, with interventions to redirect and provide diversional activities. However, there was no documentation in the resident's progress notes regarding the incident or any notification to the police or hospital transfer on the date of the incident. The facility's policies on abuse and incident reporting were not followed. The DON, who was involved in the incident, was suspended pending an investigation. The ADON and other staff members were unaware of the full details of the incident until the video surfaced. The facility's policy required immediate reporting and intervention in cases of abuse, which did not occur in this situation. The local police were not notified at the time of the incident, and the facility failed to provide evidence of reporting the event to the Department of Health.
Plan Of Correction
Immediate Action On NJ Ex Order 26. 481 US. FOLA (b was suspended pending investigation. (Terminated NJ Ex Order 26. 481. On 12/21/24 a third-party consulting company was contracted to conduct an independent investigation of the abuse allegation which comprised of review of documentation, care plans, interviews of staff, observation of resident, review of reportable information from Wax Order 26. 4B1 12/23/2024 (completed 12/25/24). Education began on abuse and the importance to report any allegation of abuse immediately. Other residents having potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return. On 12/23/24 the U.S. FOIA (b) (6) began education on abuse and the importance to report any allegation of abuse immediately to abuse coordinator, investigation starts immediately and to follow the steps of our accident incident policy to call police and to report to the Department of Health and Ombudsman. Education on our Accident Incident policy will be given monthly for six months. The Abuse and Accident Incident policy education will become part of our orientation education as well as our annual education. The Administrator/Interim DON/designee will audit compliance with the education on Abuse and Accident Incident policy and conduct 5 random staff assessment and test to assure staff have a true understanding of the facility Accident Incident 3 times a week for the first four weeks and then monthly for four months. Administrator/DON/ADON/designee will audit abuse reportable events to observe and to assure the steps in the facility policy are followed such as timeliness of reporting incident, completeness of investigation and that all statements are collected and are in their original signed form, police contacted, and reported to DOH and the Ombudsman office. Audits will be conducted three times a week for one month and then monthly for four months. How the facility plans to monitor its performance to make sure that solutions are sustained. The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.
Failure to Prevent Abuse and Improper Restraint Use
Penalty
Summary
The facility failed to protect a resident from physical abuse and improperly used a physical hold restraint on a resident with a history of aggressive behavior and multiple mental health diagnoses. On the day of the incident, a Certified Nursing Assistant (CNA) and a Smoking Monitor (SM) were observed physically assaulting the resident in the hallway. The resident was found on the floor, being kicked and punched by the staff members, despite the resident's pleas for them to stop. The Licensed Practical Nurse (LPN) who arrived at the scene had to repeatedly instruct the staff to cease their actions before they complied. The resident, who had a history of Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder, was admitted to the hospital with serious injuries, including a splenic laceration and subcapsular hematoma. The facility's records indicated that the resident had been aggressive and had thrown an overbed tray table, leading to a fall. However, the staff's response to subdue the resident was excessively forceful, resulting in significant harm. The facility's investigation revealed that the staff involved had been trained on handling aggressive residents, yet they resorted to inappropriate physical restraint. The facility's policies on abuse and incident reporting were not followed, as the staff involved were not immediately removed from resident care, and the incident was not promptly reported to the appropriate authorities. The facility's leadership, including the Director of Nursing and the Licensed Nursing Home Administrator, were not fully informed of the abuse allegations until the police became involved. Surveillance footage that could have provided clarity on the incident was not reviewed in a timely manner, and the facility's failure to act promptly contributed to the severity of the situation.
Removal Plan
- Re-educating all facility staff on the importance of preventing abuse, ensuring resident safety, and the importance of following the facility's abuse policy.
- Re-education on incident investigations, importance of collecting all written statements, utilizing the Social Worker to assist in obtaining the resident statements, assuring the original signed statements are turned into the abuse coordinator, and reporting all incidents to the abuse coordinator.
- Initiated an audit to monitor compliance with the education.
- Conducted a staff assessment and testing to ensure true understanding of the facility's abuse policy.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of staff-to-resident physical abuse. On the day of the incident, a CNA observed a resident on the floor being physically assaulted by another CNA and a Smoking Monitor. Despite witnessing the abuse, the LPN on duty had to repeatedly instruct the staff members to stop. The resident was subsequently taken to the nursing station and later sent to the hospital, where they were diagnosed with serious injuries, including a splenic laceration and subcapsular hematoma. The facility did not immediately report the incident to the police, and the initial response was inadequate, as the staff involved continued to work their shifts. The facility's documentation and response to the incident were insufficient. The DON confirmed that no incident report was completed on the day of the incident, and witness statements were not collected promptly. The LNHA and other administrative staff were not informed of the full extent of the incident, including the resident's injuries, until the following day when the police were involved. The facility's policies on abuse and incident investigation were not followed, as the RN supervisor did not complete the necessary reports or notify the appropriate authorities in a timely manner. The resident involved had a history of aggression and was diagnosed with Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. Despite these conditions, the facility's care plan for the resident was not effectively implemented, as staff failed to de-escalate the situation before it resulted in physical harm. The lack of immediate and appropriate action placed the resident and others at risk, highlighting significant deficiencies in the facility's handling of abuse allegations and incident investigations.
Removal Plan
- Re-educate all staff on incident investigations
- Emphasize the importance of collecting all written statements
- Utilize the social worker to assist in obtaining the resident statements
- Ensure the original signed statements are turned into the abuse coordinator
- Report all incidents to the abuse coordinator
Failure to Implement Care Plan Leads to Resident Harm
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a history of physically aggressive behaviors and multiple diagnoses, including Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. On a specific date, a Certified Nursing Assistant (CNA) observed the resident on the floor being physically assaulted by another CNA and a Smoking Monitor (SM). Despite the resident's pleas for help, the staff members continued their actions until a Licensed Practical Nurse (LPN) intervened. The resident was subsequently taken to the nursing station and later to the hospital, where they were diagnosed with serious injuries, including a splenic laceration and subcapsular hematoma. The facility's failure to follow the care plan was evident as the staff did not intervene appropriately when the resident became agitated. The care plan outlined specific interventions, such as guiding the resident away from distress and engaging them in calm conversation, which were not followed. Instead, the staff used excessive force, resulting in harm to the resident. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the care plan was not adhered to during the incident. The facility's policy on care plans emphasizes the importance of implementing interventions to prevent harm and maintain residents' functional status. However, the staff's actions during the incident contradicted these guidelines, leading to the resident's injuries. The interdisciplinary team was responsible for ensuring the care plan interventions were implemented, but their failure to do so resulted in a deficiency that placed the resident at risk.
Removal Plan
- Education on ensuring CP interventions were implemented
- Education on the location of the CPs
- Education on how to read the CPs
- Education on the importance of following the CPs
- Education on how to update the CPs
- Audits conducted to monitor compliance with the implementation and following of the CP interventions
- Audits conducted to determine if updates to the CP were required
Failure to Prevent and Investigate Resident Abuse
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to prevent physical abuse of a resident, follow the facility's abuse policy, and conduct a timely and thorough investigation of a reported abuse incident. A resident with a history of aggressive behavior and severe cognitive impairment was involved in an altercation with staff members, resulting in significant injuries. The resident was observed on the floor being physically assaulted by two staff members, a CNA and a Smoking Monitor, who continued their actions despite being told to stop by an LPN. The incident was not immediately reported to the Abuse Coordinator, and the staff involved continued to work with other residents after the event. The facility did not collect accurate and original witness statements, and the investigation was delayed. The resident was sent to the hospital with serious injuries, including a splenic laceration and subcapsular hematoma, after the incident. The facility's failure to implement care plan interventions for the resident's known aggressive behaviors contributed to the situation. The facility's administration did not follow its own policies and procedures for handling abuse allegations. The LNHA did not review camera surveillance until the police were involved, and the incident was initially reported as a regular fall. The DON and ADON did not ensure that an incident report was completed, and witness statements were not properly collected or reviewed. The lack of immediate action and adherence to the facility's abuse policy placed all residents at risk for an Immediate Jeopardy situation.
Removal Plan
- The two staff members identified (CNA #2 and the SM) were terminated from the facility.
- Disciplinary action was initiated for the three employees (CNA #1, LPN#1, and SW#1) who witnessed the incident and did not report it to the Abuse Coordinator.
- Education was provided to all administrative staff about the facility's abuse and investigation policy which included immediate steps taken when an abuse allegation was made and ensuring the safety of all residents.
- Education was provided to all staff on the importance of preventing abuse, ensuring resident safety, and the importance of following the facility's abuse policy to protect all residents.
- Education was provided to all staff on the importance of collecting all truthful statements in their original form, utilizing the SW to assist in obtaining resident statements, and assuring the original signed statements were all submitted to the Abuse Coordinator.
- Education on ensuring implementation of care plan interventions was provided to all the staff.
- Audits were conducted that monitor compliance with the implementation, following of care plan interventions, and if updates to the care plan were required.
- Audits were initiated by the DON that monitor compliance with all staff education.
- The DON conducted staff assessments and testing to ensure that staff have a true understanding of the facility's abuse policy.
Failure to Implement PASARR Recommendations for Resident
Penalty
Summary
The facility failed to implement the recommendations from a resident's Pre-Admission Screening and Resident Review (PASARR) Level II determination. This deficiency was identified for one resident who was admitted with diagnoses including Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. The PASARR Level II determination recommended several actions, including a psychiatric consult upon admission, routine follow-up visits with a psychiatrist, medication monitoring, supportive counseling, and the development of a behavioral modification plan. However, the resident's medical record did not show any visits from a psychiatrist during their stay, and the initial assessment from a psychologist was conducted 25 days after admission. Interviews with facility staff revealed that the PASARR recommendations were included in the resident's baseline care plan, but the interdisciplinary team was responsible for ensuring their implementation. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged that the recommendations were not followed, as the resident was never seen by a psychiatrist. The facility was unable to provide a policy on PASARR recommendations, indicating a lack of structured guidance for implementing these critical care directives.
Failure to Update Care Plans After Abuse Allegations
Penalty
Summary
The facility failed to update the care plans for two residents who made abuse allegations against staff to local authorities. The incidents were reported on 10/17/2024, and investigations were initiated in the presence of local authorities. For one resident, a body check revealed skin alterations on the right side of the body following a fall in the shower, while the other resident showed no skin alterations. Despite these significant events, the care plans for both residents were not updated with new interventions addressing the allegations. The Assistant Director of Nursing acknowledged the importance of updating care plans to ensure all staff are aware of how to care for residents, especially following significant events such as abuse allegations. The facility's policy requires care plans to be revised with any significant changes in a resident's status, yet this was not done for the two residents involved. Both residents had severe cognitive impairments and a history of making false allegations, but their care plans lacked updates following the incidents reported on 10/17/2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tallwoods Care Center | 2 mi | ★★★★★ | 17 | 0 |
| Community Medical Center Tcu | 5.5 mi | ★★★★★ | 0 | 0 |
| Complete Care At Holiday City | 5.6 mi | ★★★★★ | 7 | 1 |
| Complete Care At Bey Lea, Llc | 6.6 mi | ★★★★★ | 13 | 0 |
| Rose Garden Nursing And Rehabilitation Center | 7.4 mi | ★★★★★ | 20 | 1 |
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