Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 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 resident with a known history of suicidal ideation cut their wrist after obtaining a razor from a shower area, while staff had no self-harm precautions in the care plan or orders and were unaware of the resident’s history. The facility also failed to keep other residents on 1:1 monitoring under continuous observation, complete behavior monitoring sheets, or remove sharp objects and metal utensils from residents identified as suicide risks.
A resident with severe cognitive impairment, total ADL dependence, and hospice services developed a sacral pressure injury that progressed from redness to a large full thickness wound. Staff documentation was inconsistent, with multiple SOTs missing skin descriptions or measurements, the care plan lacked interventions for the actual breakdown, and hospice recommendations for a gel cushion and foam mattress were not communicated or reflected in the record.
Kitchen Sanitization and Sanitizer Testing Deficiency: The surveyor observed the three-compartment sink quaternary sanitizer at 200 ppm, but the FSD could not verify the concentration because test strips were not available. The FSD stated the kitchen should never run out of sanitizer strips, and the LNHA stated that proper sanitizing of kitchen equipment and dishware was expected for infection prevention and safety.
Failure to Protect Residents, Manage Wounds, and Secure Medications A resident with a known history of suicidal ideations and a prior plan to cut their wrist was found with a bleeding wrist laceration after disassembling a razor found in the shower, and the record did not include safety interventions to protect the resident from self-harm. Another cognitively impaired resident developed a sacral skin injury that progressed to a full thickness wound, while the record lacked consistent skin assessment documentation and follow-up related to wound progression. Surveyors also found Morphine house stock not properly accounted for in the EBM and medications left unsecured at a resident's bedside, which staff acknowledged should not have occurred.
Unsafe and Unkempt Resident Areas: Multiple resident rooms, shower areas, and a nourishment room had broken toilet paper holders, damaged walls, rusted and chipped fixtures, duct-taped and frayed equipment, broken doors, and visible soil or black substance in showers and bathrooms. Staff and the LNHA acknowledged the conditions were not presentable or homelike, and a CNA stated he would not want to use the fifth-floor showers.
The facility failed to consistently document and reconcile controlled substances in the EBM. During survey observation, cycle count documentation was missing, morphine was not listed on the inventory despite being stored in the EBM, and staff could not explain where the bottles were kept or how to access the EBM during a power outage. The surveyor also found incomplete oxycodone, alprazolam, and lorazepam documentation, with missing resident names, dates, times, and signatures, and the DON acknowledged there was no process to audit narcotic reconciliation.
An RN poured a medication into an ungloved hand during med pass, an LPN/UM performed wound care without disinfecting the bedside table, changing gloves after wound cleansing, or dating the dressing, and CNAs distributed meal trays without hand hygiene between residents. The resident receiving wound care had severe cognitive impairment, was dependent for ADLs, and was receiving hospice services.
A resident with morbid obesity, schizophrenia, anxiety, depression, glaucoma, and severely impaired cognitive skills had a fall risk care plan that noted an actual fall, but the record did not show new interventions were added after the fall. The fall investigation documented the resident lost balance while trying to get out of bed and struck the right shoulder and upper arm against a dresser, and staff interviews confirmed the care plan was only dated after falls rather than revised with new interventions.
An LPN and CNA were observed caring for a resident with severe cognitive impairment, total ADL dependence, and wound risk, but the resident’s ordered right forearm wound treatment was not consistently performed or documented. The TAR showed signatures for some days and a blank entry for another, while the dressing remained dated earlier than the documented care; the LPN said the treatment may have been overlooked and that a blank TAR entry meant the treatment was not done as ordered.
Urinary Catheter Care and Output Documentation Deficiencies: The facility failed to provide proper Foley care for two residents with indwelling catheters. One resident’s drainage bag was observed on the floor and visible from the doorway despite care plan directions to keep it below bladder level and out of view, and staff including a CNA, LPN, RN/UM, and DON acknowledged the bag should be kept off the floor for infection prevention and privacy. For another resident with diagnoses including UTI, urinary retention, and neuropathic bladder, the TAR contained blank entries for ordered urine output documentation, and the LPN and DON stated blanks meant the output was not recorded.
A resident with COPD and severe cognitive impairment was observed receiving oxygen at 3L to 3.5L via concentrator even though the MD order was for 2L/min PRN. The resident's BiPAP machine was also found not stored in a plastic bag when not in use, despite staff confirming that it should be bagged for infection control and that nurses are responsible for following the MD order and monitoring oxygen settings.
Failure to timely act on CP recommendations for a resident with COPD, schizophrenia, anxiety, depression, and impaired cognition. The resident was ordered Fluticasone Furoate-Vilanterol, but the CP recommended clarifying the diagnosis and adding instructions to rinse the mouth after use; interviews with the LPN/UM and DON confirmed the recommendations were not acted upon effectively.
Unsecured medications were found at a resident’s bedside when surveyors observed a clear liquid and a medicine cup with two pills on the nightstand. The CNA said the meds should not have been left there, the LPN said she had given meds in the hallway and that the pills were not from her pass, and the RN/UM and DON confirmed meds should not be left unsecured at the bedside. The pills were identified as aspirin 81 mg and vitamin B12 100 mcg.
Improper Garbage Disposal Area Maintenance: Surveyors observed food waste, utensils, wood, cardboard, used gloves, face masks, and container tops discarded on the ground near the garbage disposal containers, along with low-lying black tubing in the area. The FSD, DOM, and LNHA all stated that trash should be placed inside the containers and that the area should be kept sanitary and free of debris; the facility’s Waste Disposal policy required waste to be disposed of in a safe, controlled, and compliant manner.
The facility failed to ensure required QAPI committee members were present at quarterly meetings. Review of sign-in sheets showed the ICP was on LOA for one meeting and had no attendance documentation for another, while the LNHA and current DON signed the July meeting sheet despite stating they were not employed there at that time. The LNHA later stated that the Medical Director, LNHA, DON, and ICP were all required to attend the quarterly QAPI meetings.
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 Protect Residents at Risk for Self-Harm and Ensure Ordered Supervision
Penalty
Summary
The facility failed to protect a resident from self-harm and failed to provide adequate supervision for a resident with a known history of suicidal ideations and a prior plan to cut themself with a razor. The resident had been admitted with diagnoses including depression, schizophrenia, and intellectual disabilities, and the prior facility’s records showed that the resident had called 911 and told police they were having suicidal ideations and wanted to cut themselves with a razor. Despite that history, the resident’s current care plan and physician orders did not include safety interventions related to self-harm, and facility staff stated they were unaware of the resident’s suicidal history. On the night of the incident, the resident was found during routine rounding with a two-inch laceration to the right wrist that was bleeding profusely. Staff reported that the resident was holding the wrist with toilet paper to slow the bleeding, and the resident stated, “I thought that I was going home, but they said I was not.” A nurse later observed a disassembled shaving razor on the bedside table, with the blade nearby and the handle broken off. The resident stated they had found the razor in the shower. The resident was also taking Eliquis and aspirin, and staff stated the resident should not have had access to a razor and should have used an electric razor because of bleeding risk. The facility also failed to ensure that residents identified with suicidal ideations were monitored as ordered and kept free from sharp objects. One resident on 1:1 monitoring was observed alone in the room with metal utensils on the overbed table, and the behavior monitoring sheet was blank for the day. Another resident ordered for 1:1 monitoring was observed without staff present, and a monitor stated she had not been instructed on her responsibilities or on environmental checks. A third resident identified as at risk for suicidal ideation was found with a razor, unopened razor blade packages, and a large nail clipper in the bathroom, while the assigned monitor stated she had not received instructions on monitoring duties or environmental checks.
Incomplete pressure injury monitoring and prevention
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for a cognitively impaired resident who was dependent on staff for all ADLs and receiving hospice services. The resident was identified with a reddened sacral area that later progressed to a full thickness wound measuring 10 cm x 7.5 cm x 7.5 cm on the wound care NP’s initial assessment. The resident’s admission and MDS documentation showed severe impairment in decision making, dependence on staff, and risk for pressure ulcers, yet the care plan did not include interventions for the actual skin breakdown or pressure-relieving devices when the wound first appeared. The record showed inconsistent and incomplete skin monitoring. Although a physician order required skin assessments twice weekly with completion of the Skin Observation Tool (SOT), many of the SOT entries lacked descriptions of the resident’s skin condition, and several assessments did not document the wound or its measurements. The first documented reddened sacral area on the SOT did not include measurements, and the next SOT did not mention the area. Later, when treatment orders were in place for the sacral wound, only one SOT documented the condition, and it still lacked measurements or a detailed description. The facility also documented a treatment order for the sacral area while physician progress notes later described the skin as normal, creating conflicting documentation. Hospice documentation noted redness on the resident’s back and recommended a gel cushion for the wheelchair and a foam mattress because the mattress was not functioning properly, but there was no documentation that these recommendations were communicated to the physician or implemented by the facility. The care plan was not updated to reflect these recommendations or to add protective skin interventions when the resident’s skin breakdown was first identified. By the time the wound care NP evaluated the resident, the sacral wound had progressed to a large full thickness wound, and the surveyor observed the wound encompassing the entire sacral area with yellow, black, and brown tissue, foul odor, and scant brown drainage.
Kitchen Sanitization and Sanitizer Testing Deficiency
Penalty
Summary
The facility failed to follow proper sanitation practices for dishware and kitchen equipment to prevent microbial growth in accordance with professional standards for food service safety. During a kitchen tour, the surveyor observed the three-compartment sink quaternary chemical sanitization solution at 200 parts per million (ppm). When asked to verify the sanitizer concentration with a test strip, the FSD was unable to do so because test strips were not available, and he stated he would obtain them immediately. The FSD also stated that the kitchen should never run out of sanitizer strips because the chemical sanitization process destroys harmful bacteria and prevents foodborne illnesses. The LNHA later stated that she expected kitchen staff to properly sanitize kitchen equipment and dishware and that sanitizing was important for infection prevention and safety. The facility’s Sanitization policy, updated February 2025, stated that all equipment, food contact surfaces, and utensils shall be sanitized using hot water and/or chemical sanitizing solutions, and that quaternary ammonium compound chemical sanitizing solutions may consist of 150-300 ppm. The deficiency was cited under NJAC 8:39-17.2(g).
Failure to Protect Residents, Manage Wounds, and Secure Medications
Penalty
Summary
The facility failed to protect a resident with a known history of suicidal ideations and a prior plan to cut their wrist. After admission, the resident was found with a two-inch laceration to the right wrist that was bleeding profusely. Facility staff reported that the resident had disassembled a razor found in the shower, and the resident stated, "I thought that I was going home, but they said I was not." The resident's current record did not include safety interventions to protect the resident from self-harm, despite the prior history documented in the admitting paperwork. The facility also failed to properly manage a resident's skin breakdown and wound care. A cognitively impaired resident who was dependent on staff for ADLs was first identified with a reddened area on the sacrum that later progressed to a full thickness wound. The wound was measured by the Wound Care NP as 10 cm x 7.5 cm x 7.5 cm at the initial assessment. The record did not show that ongoing skin assessments were completed and documented in accordance with a physician's order, that hospice recommendations for pressure-reducing devices were communicated to the physician, or that follow-up documentation consistently tracked the progression or resolution of the skin breakdown. The facility further failed to maintain medication security and controlled substance accountability. Surveyors found Morphine sulfate house stock in the EBM cycle count process that was not listed in the machine's drug inventory, and two boxes were found in the non-narcotic portion of the EBM with empty boxes and no accessible bottles. The DON stated the facility had no process to audit the cycle count and could not explain why the Morphine was not included in the EBM drug list. In a separate observation, medications were found left unsecured at a resident's bedside in a cup on the nightstand, later identified as Aspirin 81 mg and Vitamin B12 100 mcg. Staff acknowledged that medications should not have been left there and should have been secured.
Unsafe and Unkempt Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on multiple nursing units. During an initial tour, the surveyor observed numerous environmental deficiencies on the third floor, including broken toilet paper holders in several resident bathrooms, a frayed protective mat wrapped with duct tape at the end of a bed, brown substance in bathroom tile creases, a rusted and flaking light switch box, wall areas that appeared water damaged, holes and other damaged areas in walls, and toilet paper placed next to a soiled trash bin or on a covered bathtub instead of in a holder. On the sixth floor nourishment room, the right pantry side door was broken. On the third floor shower room, chipped paint and a rusty metal shower room organizer were also observed. Staff interviewed during the tour stated that restroom toilet paper holders should be functioning, toilet paper should not be placed on the bathtub cover, rooms should be more presentable, and the broken pantry door should not be broken for resident access control and infection control purposes. In addition, the fifth-floor south shower room contained a chipped and cracked plastic shelf, a dark caked-on substance in the shower drain, black substance on the shower walls, missing, chipped, and cracked floor tiles, and chipped white paint on a wooden shelf. A CNA stated the shower should not have broken or damaged equipment and said he would definitely not want to shower in either fifth-floor shower. The LNHA stated she was aware of the condition of the showers and that the facility was in the process of updating all shower rooms, and acknowledged the showers were not homelike. The facility policy stated residents are to be provided with a safe, clean, comfortable homelike environment.
Controlled Substance Reconciliation and EBM Inventory Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice for controlled substances and emergency medications in the electronic backup machine (EBM). The Director of Nursing (DON) stated that daily cycle counts were supposed to be completed by two nurses, but during observation the surveyor did not see cycle count documentation. Review of the pharmacy transaction log showed that the cycle counts had not been conducted daily, and the DON acknowledged that the facility did not have a process to audit the narcotic medication reconciliation process. During the EBM observation, two empty morphine sulfate 20 mg/ml boxes were found stored in the non-narcotic portion of the EBM, while the corresponding inventory list did not include morphine 20 mg/ml. The RN/IP, DON, and LPN/UM could not explain where the two bottles of morphine were located, and the DON stated she could not access the top drawer where the pharmacy representative later said the bottles had been placed. The DON also stated she did not know how to use the EBM keys in the event of a power outage or electrical failure, and the pharmacy representative stated staff should have been oriented to the process. The facility’s cycle count records did not show morphine 20 mg/ml as part of the required count, and the facility policy required manual override keys to be assigned and kept secured. The surveyor also found controlled substance documentation problems with oxycodone, alprazolam, and lorazepam. On the oxycodone declining inventory sheet, several lines were missing required information such as date, time, resident name, and signatures, and some removals were flagged as discrepancies. The facility could not provide packing slips and transaction reports requested during the investigation, and the DON acknowledged unresolved discrepancies. For alprazolam and lorazepam, some entries documented removal by two nurses but did not include the resident’s name. The DON confirmed that the facility did not have a process in place to audit narcotic medication reconciliation, and the facility policy stated that discrepancy resolution should be clearly addressed and unresolved discrepancies reported.
Infection Control Failures During Medication Pass, Wound Care, and Meal Service
Penalty
Summary
The facility failed to follow infection control practices during medication administration, wound care, and meal tray distribution. During medication pass observation, an RN prepared medications for a resident and opened a bottle of Vitamin D3, poured a tablet directly into her open palm, and then placed it into the medicine cup. When questioned, the RN stated she had used alcohol-based hand rub before starting the pass and initially thought the practice was acceptable. The RN then donned a glove, removed the tablet from the cup, discarded it in the medication eliminator solution, and re-poured all of the oral medications. The DON later acknowledged that the nurse should not have poured medications into an ungloved hand and identified it as an infection control issue. During wound care observation, an LPN/UM performed sacral wound treatment for a resident who had severe cognitive impairment, was dependent on staff for all ADLs, was at risk for pressure ulcers, and was receiving hospice services. The nurse placed wound care supplies directly on the resident’s bedside table without disinfecting the surface or using a protective barrier. After removing the soiled dressing and washing hands, the nurse applied clean gloves, cleansed the wound, and then continued the dressing change without washing hands or changing gloves after wound cleansing. The nurse also did not date the new dressing and attempted to return contaminated wound supplies to the treatment cart. The IP stated that treatment supplies should not be brought into the room in original containers, the work surface should be disinfected and covered with a barrier, hands should be washed and gloves changed after removing the soiled dressing and again after wound cleansing, and dressings should be dated for continuity of care. During dining observation, CNAs distributed lunch trays on the 6th floor and went from one resident to another without performing hand hygiene between residents. A CNA interviewed during the observation did not know that hand hygiene should be performed between residents during tray pass. An LPN/UM confirmed that hand hygiene was required between residents during food tray distribution to prevent the spread of infection. An Activities Monitor assisting with tray distribution also appeared unaware of the need for hand hygiene between residents. The IP stated that CNAs must perform hand hygiene between residents during meal tray distribution because they are in close contact with residents and touch objects while setting up trays.
Care plan not updated after resident falls
Penalty
Summary
The facility failed to revise a resident’s care plan with related goals and interventions each time the resident sustained a fall. Resident #135 had diagnoses including morbid obesity, schizophrenia, anxiety disorder, depression, and bilateral primary open-angle glaucoma. The quarterly MDS dated 1/2/26 indicated the resident had short-term and long-term memory problems, severely impaired cognitive skills for daily decision-making, and one fall since admission, entry, reentry, or the prior assessment without injury. The resident’s comprehensive care plan identified the resident as at risk for falls or injury related to psychotropic drug use, behaviors, poor safety awareness, and decreased mobility related to COPD and morbid obesity. The care plan included an actual fall on 11/15/25, but there was no documented evidence that interventions were implemented to prevent recurrence of falls. The fall investigation documented that the resident lost balance while trying to get out of bed, landed on the right shoulder and upper arm against a dresser, and sustained redness to the right upper arm; the resident did not hit the head. Staff interviews showed RN #2 stated that after a fall, the supervisor or he was responsible for updating the care plan, but he only documented the date of the fall, while the unit manager reviewed the care plan and implemented interventions. The LPN/UM stated new interventions were required after each fall and that the interventions were supposed to be updated with every fall, and the DON stated every new fall or event should result in a new intervention on the care plan and that it should have been updated immediately after the fall.
Ordered wound treatment not performed or documented
Penalty
Summary
The facility failed to provide necessary treatment services consistent with professional standards of clinical practice by not performing a physician-ordered wound treatment as directed for Resident #194. The resident was admitted with diagnoses including dementia, bipolar disorder, and heart failure, and the quarterly MDS dated 3/5/26 indicated severe cognitive impairment with a BIMS score of 3 out of 15, dependence on all ADLs, and risk for pressure ulcers. During interview, the LPN stated that the only treatment being performed was for a skin tear on the right forearm, while the primary care CNA stated the resident was incontinent, required complete care, and had a wound on the right buttock that had been present for a couple of weeks. On observation, the resident had an anti-pressure cushion in the chair, an air mattress on the bed, and a dressing on the right forearm dated 3/12/26. The TAR contained a physician order dated 3/6/26 to cleanse the right forearm with NSS, apply honey gel, and cover with a clean dry dressing every day for wound healing. The TAR showed nursing signatures on 3/13/26 and 3/14/26, but the 3/15/26 entry was blank. When interviewed, the LPN stated he signed the TAR on 3/14/26 and said he did not remember whether the wound care was completed that day, adding that it was probably overlooked; he also stated that a blank signature block meant the treatment was not done as ordered. The ADON, DON, and LNHA were informed of the findings and did not have a response as to why the dressing remained dated 3/12/26 while staff were signing or not signing the TAR.
Urinary Catheter Care and Output Documentation Deficiencies
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for two residents with indwelling catheters. For one resident, the surveyor observed the Foley catheter drainage bag contained within a privacy bag but positioned on the floor and visible from the hallway during two separate observations. The resident had diagnoses including uninhibited neuropathic bladder, a BIMS score of 2 out of 15, and a care plan that directed staff to position the catheter bag and tubing below the level of the bladder and away from the room entrance. The resident also had an active order for Foley catheter care every shift. During interviews, a CNA, an LPN, the RN/UM, and the DON all acknowledged that the drainage bag should be kept off the floor and positioned away from the doorway for infection prevention and resident privacy. The facility policy titled Catheter Care, Urinary stated that catheter tubing and the draining bag should be kept off the floor. Despite this, the drainage bag was observed on the floor and visible from the doorway, contrary to the resident’s care plan and the facility policy. For the second resident, the record showed diagnoses including urinary tract infection, urinary retention, and neuropathic bladder, with an indwelling catheter and a care plan directing staff to monitor and document intake and output as per facility policy. The order summary included an order to empty and measure Foley catheter urine output every shift. Review of the TAR showed multiple blank documentation entries for urine output, and an LPN stated that there should not be any boxes left blank because that meant the nurse did not record the amount of urine output. The DON also stated that there should be no blanks on the TAR and that blanks meant the work was not done.
Incorrect Oxygen Setting and Improper BiPAP Storage
Penalty
Summary
The facility failed to assess a resident's oxygen setting to ensure the resident was receiving the correct amount of oxygen as ordered by the physician, and failed to properly store the resident's BiPAP machine in a bag when not in use. Resident #191 had diagnoses including COPD and a quarterly MDS dated 12/26/25 showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. During the initial tour on 1/15/26 and again on 1/16/26, the surveyor observed the resident in bed receiving 3L and then 3.5L of humidified oxygen via an oxygen concentrator, while the physician order dated 1/13/26 specified oxygen at 2L/min PRN every shift. The resident's BiPAP machine was also observed not stored in a plastic bag as ordered when not in use, despite several dated plastic bags being present in the room. Record review showed the resident's care plan directed staff to administer oxygen per MD orders, document respiratory status every shift as needed when not within baseline, and notify the MD promptly as needed. The resident's oxygen levels from 7/25/25 to 1/20/26 showed oxygen was provided on multiple occasions even when oxygen saturation was greater than 94%, and progress notes from 12/28/25 to 1/2/26 did not show nurse communication with the MD regarding oxygen levels or oxygen settings. During interviews, CNA #7 and LPN #4 confirmed the oxygen concentrator was set to 3L and that the BiPAP machine should be stored in a bag when not in use. The DON stated nurses were responsible for notifying the MD and family of changes in oxygen settings and oxygen levels, and confirmed the BiPAP machine should be cleaned and stored in a dated plastic bag.
Failure to Timely Act on Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon Consultant Pharmacist recommendations in a timely manner for one resident reviewed for medications. Resident #135 had diagnoses including morbid obesity, schizophrenia, anxiety disorder, depression, acute and chronic respiratory failure, and COPD exacerbation. The resident's quarterly MDS dated 1/2/26 indicated short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making. During observation on 1/16/26, the resident was seen ambulating independently in the hallway without an assistive device and appeared confused when the surveyor attempted to interview them. The resident's order summary included Fluticasone Furoate-Vilanterol inhalation aerosol powder, ordered on 10/20/25. The Consultant Pharmacist's comments report showed that on 11/29/25 the pharmacist recommended clarifying and updating the diagnosis for the inhaler, and on 12/31/25 recommended that the resident rinse their mouth after using the medication and to clarify and update the diagnosis. Interviews with the LPN/UM and DON confirmed that the recommendations were received through the facility process, but were not acted upon effectively, and the DON stated the nurse should have documented that the recommendations were conveyed to the physician and whether any physician orders were received.
Unsecured Medications Left at Resident Bedside
Penalty
Summary
Medication was left unsecured at the bedside of Resident #13 on the 5th floor. Surveyors observed the resident lying in bed with eyes closed and a clear plastic cup containing a clear liquid and a medicine cup with two pills on the bedside table. The resident did not respond to surveyor inquiry, and the privacy curtain was pulled to the side of the footboard, limiting access to the nightstand. At that time, no residents were observed ambulating independently near the room without staff present. When the CNA arrived and was shown the pills, she stated the medication should not have been left there and that the resident was supposed to take medication while the nurse was in the room. The LPN acknowledged giving the resident medications in the hallway and stated the pills in the cup were not from her morning medication pass. The RN/UM confirmed there should be no medications left unsecured at the bedside and stated the nurse must observe the resident taking the medication. Later review by the DON identified the pills as Aspirin 81 mg and Vitamin B12 100 mcg, and the DON confirmed medications should not be left at the bedside because they must be secured for the safety of all residents.
Improper Garbage Disposal Area Maintenance
Penalty
Summary
The facility failed to provide a sanitary environment in one garbage disposal area by allowing garbage and refuse to be improperly disposed of on the ground adjacent to the disposal containers. On 1/15/26 at 10:25 AM, the surveyor and the Food Service Director observed container tops, food waste, plastic utensils, pieces of wood, cardboard boxes, used gloves, and face masks discarded on the ground near the garbage disposal containers. The surveyor also observed low-lying black tubing and additional black tubing running along the ground in the same area. During interviews, the FSD stated that maintenance of the garbage disposal areas was a shared responsibility between dietary and maintenance and confirmed that trash and discarded items were expected to be placed inside the containers, not on the ground, to maintain a safe and sanitary environment. The Director of Maintenance later stated that trash should be properly disposed of inside the containers and that the black tubing should always be maintained in a safe manner. The LNHA also stated that it was unacceptable for the garbage disposal area to be littered with trash, used items, or tubing on the ground, and the facility’s Waste Disposal policy required infectious and regulated waste to be disposed of in a safe, controlled, and compliant manner.
QAPI Committee Meetings Lacked Required Member Attendance
Penalty
Summary
The facility failed to ensure that the required members were present during quarterly QAPI Committee Meetings. Review of the last four quarters of QAPI sign-in sheets showed that during the 4/24/25 meeting, the Infection Control Preventionist (ICP), a mandatory participant, was documented as being on leave of absence. The July 2025 QAPI sign-in sheet did not contain any entry in the ICP signature panel to show whether the ICP attended that meeting. During interview, the LNHA stated that the QAPI meetings reviewed occurred before she and the current DON were hired. However, the July 2025 sign-in sheet showed that both the LNHA and the current DON signed as attending that meeting. The Director of Human Resources and Staffing stated that the ICP was on leave of absence for both the April 2025 and July 2025 quarters and did not attend those meetings. The LNHA later stated that the Medical Director, LNHA, DON, and ICP were all required to attend the quarterly QAPI Committee Meetings.
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 | ★★★★★ | 11 | 0 |
| Rose Garden Nursing And Rehabilitation Center | 7.4 mi | ★★★★★ | 1 | 1 |
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