Crystal Lake Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bayville, New Jersey.
- Location
- 395 Lakeside Blvd, Bayville, New Jersey 08721
- CMS Provider Number
- 315125
- Inspections on file
- 19
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Crystal Lake Healthcare And Rehabilitation during CMS and state inspections, most recent first.
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.
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.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
