Dellridge Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Paramus, New Jersey.
- Location
- 532 Farview Ave, Paramus, New Jersey 07652
- CMS Provider Number
- 315129
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Dellridge Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain proper sanitation and food safety standards, with expired beverage boxes, improper hair restraint use, and inadequate cleaning practices observed. A dietary staff member was found without a beard restraint, and clean dishes were improperly stored, raising contamination concerns. Additionally, food items in the nutrition refrigerator lacked proper labeling, and the cleaning log was not signed, indicating lapses in protocol adherence.
A survey revealed deficiencies in a facility's adherence to professional standards, including failure to follow meal tickets for residents, improper medication administration, and inadequate disposal of excess medication. A resident did not receive a prescribed supplement, and another was given medication without following the manufacturer's guidelines. The facility's policies lacked guidance on proper medication disposal.
The facility failed to follow proper hand hygiene and PPE practices, as observed in multiple instances involving staff members. A Recreation Aide improperly wore a mask and reused hand wipes, a Physician did not disinfect equipment or perform hand hygiene, and housekeeping and dietary staff changed gloves without washing hands. These actions violated the facility's infection control policies.
The facility failed to provide meals in a dignified manner for two residents. One resident did not receive hand hygiene assistance before their meal, while another had to wait ten minutes for their meal, which lacked a diet slip. The Director of Nursing acknowledged that residents should eat simultaneously and that hand hygiene should be offered. Facility policies on food service and hand hygiene were not followed, leading to these deficiencies.
A facility failed to document a resident's advance directives, leaving a POLST form undated and unsigned, with no indication of the resident's desired status. Interviews revealed ongoing efforts to ensure documentation, but difficulties in obtaining physician signatures for full code residents. A progress note was added after surveyor inquiry, updating the resident's code status.
A resident with dysphagia, dementia, and malnutrition was readmitted without wounds, but later developed multiple wounds, including a DTI. The facility failed to notify the Resident's Representative (RR) of this change in condition, as required by policy. Documentation of the notification was missing from the medical record, and the investigation form where it was allegedly recorded was not part of the medical record.
The facility failed to maintain a safe, clean, and homelike environment for residents, as observed in several deficiencies. A resident's room had peeling wood on dressers, a missing heater grill cover, and a soiled bed frame, with no maintenance records for these issues. Another resident's room was missing a closet door, with no work order submitted for replacement. Additionally, a resident reported persistent cobwebs and dust, despite previous complaints. The facility lacked formal maintenance and cleaning policies, leading to delays and unaddressed issues.
A resident with severe cognitive impairment and a history of cerebral infarct and vascular dementia was observed unshaven on multiple occasions, indicating a failure by the facility to provide necessary grooming services. Despite requiring substantial assistance for personal hygiene, inconsistencies in care were noted, with staff citing occasional refusal by the resident but also acknowledging that proper explanation could lead to compliance.
A facility failed to complete a stat chest x-ray (CXR) and notify a physician of a resident's low blood pressure (BP). The resident, with multiple diagnoses including diabetes and dementia, had a stat CXR ordered for congestion, but it was not completed, and no results were documented. Additionally, low BP readings were not communicated to the physician, contrary to facility protocols requiring notification of acute condition changes. This deficiency highlights a lapse in following professional standards and facility policies.
A facility failed to document the date and time of oxygen tubing changes for a resident receiving oxygen therapy. The resident, with a history of chronic respiratory failure, was observed using oxygen without a label indicating when the tubing was last changed. Despite a physician's order for weekly tubing changes, there was no evidence of compliance on the specified date. The facility suggested the label might have fallen off, but their policy did not specifically require labeling the tubing.
A resident with end-stage renal disease did not receive consistent care for dialysis, as the facility failed to ensure proper documentation and administration of Zofran for nausea. The medication was sent with the resident to the dialysis center without a physician's order, and there were discrepancies in the documentation of its administration. The facility's policies on medication administration and dialysis care were not followed, leading to this deficiency.
The facility failed to ensure the 24-hour staffing report was accurate and prominently posted. Surveyors found outdated reports and inadequate visibility in accessible areas. The DON and UC were responsible for postings, but inconsistencies were noted, especially on weekends. The LNHA acknowledged the issue, and additional posting areas were added, but no specific policy was in place.
A facility failed to maintain complete medical records for a resident with multiple wounds. The resident's medical record lacked documentation of wound care for a three-week period, despite weekly visits by a wound PA. The missing notes were only uploaded after a surveyor's inquiry, highlighting a lapse in maintaining accessible medical records.
A facility failed to accurately code the MDS for a resident, indicating an unplanned discharge to a hospital when the resident was actually discharged to home. The discrepancy was identified through a review of medical records and confirmed by the MDSC/LPN and MDSC/RN, who acknowledged the mistake. The issue was discussed with the facility's administration, but no further information was provided.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards, as evidenced by several observations during a kitchen tour. Expired beverage boxes were found in the juice dispenser area, with the Food Service Director (FSD) acknowledging that the diet lemonade was expired. Additionally, a fiber-like strand was found on a food processor machine in the food preparation area, which was identified as part of a hairnet. The FSD and Regional FSD confirmed that the items on the table were being prepared for the next meal. Furthermore, a small veggie steam pan was found soiled with dry, hard food-like debris, indicating a lapse in cleaning procedures. The surveyor also observed a dietary staff member with facial hair not wearing a beard restraint, which is required to prevent contamination. The FSD was unable to provide beard restraints for the staff member, and the staff member was instructed to wear a face mask instead. In the dishwashing area, clean dishes were improperly stored above a three-compartment sink filled with sanitizing solution, and a crumpled washcloth was found next to clean dessert bowls, raising concerns about cross-contamination. Additionally, several uncovered food bins were found with discolored stains and an accumulation of clear liquid, further indicating inadequate sanitation practices. In the nutrition refrigerator, food items were found without proper labeling, including the resident's name, room number, and date of storage. This lack of labeling made it difficult to determine the freshness and safety of the food items. The Housekeeping Director (HKD) admitted to not signing the cleaning log for the refrigerator, which is supposed to be cleaned every Friday. The facility's policies on hair restraints, cleaning, and food storage were reviewed, revealing gaps in adherence to these protocols. The facility failed to provide documentation supporting the use of expired beverage boxes, further highlighting deficiencies in food safety management.
Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice in several areas, as observed during a survey. During meal observations, it was noted that the facility did not follow the residents' meal tickets. Resident #41 did not receive a prescribed magic cup supplement during lunch, and the electronic Medication Administration Record (eMAR) was inaccurately signed as administered without noting the resident's refusal. Additionally, the physician's order for the magic cup was not clarified to include the amount or percentage of intake, which is considered best practice. Similarly, Resident #43 did not receive the specified nectar-thickened orange juice, and Resident #44 did not receive the two cups of coffee as indicated on their meal tickets. The facility staff, including the Food Service Director and the Director of Nursing, were unable to provide satisfactory explanations for these discrepancies. The survey also revealed issues with medication administration. During a medication pass observation, it was found that excess medication was not disposed of properly. LPN#1 was observed pouring excess guaifenesin DM into a second dose cup and disposing of it in the trash receptacle instead of the approved medication disposal system. Additionally, Resident #339 was administered Sucralfate without adhering to the manufacturer's specifications, which require the medication to be taken on an empty stomach. The resident had consumed at least 50% of their breakfast shortly before the medication was administered, which does not align with the requirement of taking the medication one hour before or two hours after a meal. The facility's policies and procedures were found lacking in guidance regarding the proper disposal of unused or excess medications. The surveyor's interviews with the Director of Nursing and the Consultant Pharmacist confirmed that medications should be disposed of in the approved medication disposal system, which was not followed in the observed instances. The facility's failure to adhere to professional standards in meal service and medication administration was documented, and the facility management was notified of these findings during the survey process.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) practices, as observed in multiple instances involving various staff members. A Recreation Aide was seen distributing lunch trays with a surgical mask improperly worn, not covering the nose, and using hand wipes without discarding them after use. The aide acknowledged the improper use of PPE and hand hygiene practices, despite having received education on these protocols. A Physician was observed performing an eye examination without following proper infection control practices. The Physician did not disinfect the table used for equipment placement, failed to perform hand hygiene after glove removal, and was unaware of the enhanced barrier precautions (EBP) posted in the resident's room. The Infection Preventionist Nurse and the Regional Director of Nursing acknowledged the Physician's failure to adhere to hand hygiene protocols and the facility's responsibility to inform providers and vendors about infection control practices. Housekeeping and dietary staff also demonstrated lapses in hand hygiene. A Housekeeper was observed changing gloves without performing hand hygiene between glove changes, despite acknowledging the requirement to do so. Similarly, dietary staff members were seen changing gloves without washing their hands during meal service. The facility's hand hygiene policy, which emphasizes handwashing as the primary means to prevent infection spread, was not followed by these staff members.
Failure to Provide Dignified Meal Service
Penalty
Summary
The facility failed to ensure that meals were consistently provided in a dignified and homelike manner, and that resident meal assistance was provided in a dignified manner. This deficiency was observed in the recreation dining room for two residents. During the survey, it was noted that one resident did not receive hand hygiene assistance before their meal, while another resident had to wait for ten minutes to receive their meal after others at the same table had already started eating. Additionally, the meal provided to the second resident lacked a diet slip, and there was confusion regarding the resident's room number and dietary requirements. The surveyor observed that the staff did not offer hand hygiene to one resident, and the staff proceeded to set up the resident's meal without it. When questioned, a recreation aide acknowledged that the resident should have been provided an opportunity for hand hygiene. For the other resident, the surveyor noted that the resident did not have a meal tray while others were eating, and there was a delay in providing the meal. The tray eventually delivered to the resident did not have a diet slip, and there was a mix-up with the room number, leading to potential confusion about the resident's dietary needs. The facility's Director of Nursing (DON) explained the process for dining services, which includes the recreation staff distributing trays and verifying meal tickets. The DON acknowledged that residents should eat simultaneously and that hand hygiene should be offered and assisted by the staff. The facility's policies on food service and hand hygiene were reviewed, indicating that staff should assist residents with hand hygiene before meals and verify meal accuracy. However, these procedures were not followed, leading to the observed deficiencies.
Failure to Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's advance directives, specifically for one resident who was admitted with chronic respiratory failure, anxiety disorder, and type 2 diabetes mellitus. The resident's medical records, both electronic and paper, lacked a completed New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, which was undated and unsigned by the resident, attending physician, or facility staff. There was no documentation indicating the resident's desired advance directive status, and the physician's orders did not reflect any advance directive status either. Interviews with the Director of Social Services and the Licensed Social Worker revealed that the facility had an ongoing project to ensure all residents had completed advance directives and POLST forms, but there were difficulties in obtaining physician signatures for residents who were full code. The Licensed Social Worker acknowledged that the missing documentation for the resident could have been inadvertently missed. A progress note was later added to the resident's electronic medical record, updating the code status to full code after the surveyor's inquiry. The facility's Advance Directive Policy did not specifically address full codes and POLST/advance directives.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the Resident's Representative (RR) of a change in condition for a resident who was admitted with diagnoses including dysphagia, dementia, and protein-calorie malnutrition. Upon readmission from hospitalization, the resident did not have any wounds, but a Physician Assistant (PA) noted multiple wounds, including a deep tissue injury (DTI), on 9/5/23. There was no documented evidence in the resident's medical record that the RR was notified of these DTIs, nor were there wound measurements or appearance documented for three weeks following the initial note. The Assistant Director of Nursing (ADON) confirmed that the notification of the RR was not documented in the electronic medical record, and the Facility Acquired Pressure Injury Investigation Form, where the notification was allegedly documented, was not part of the medical record. The facility's policy on acute condition changes required that the physician discuss the situation with the staff and the resident and/or family, but there was no evidence provided that this occurred. The surveyor's findings were confirmed by the ADON, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other facility representatives.
Deficiencies in Maintaining a Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In one instance, a resident's room was found with dressers that had peeling wood, exposing rough surfaces, and a heater unit without a front grill cover. Additionally, the bed frame was visibly soiled with a dry, brown substance. The resident, who had impaired cognition due to dementia and Alzheimer's, was unable to communicate these issues. Despite a maintenance log entry for a jammed drawer, there was no record of the peeling wood or missing grill cover being reported or addressed. Another deficiency involved a resident's room missing a closet door. The resident, who had severely impaired cognition due to vascular dementia, was unable to communicate the issue. The Unit Manager was unaware of the missing door, and there was no work order submitted for its replacement. The Director of Maintenance acknowledged the door was removed for replacement but was not logged in the maintenance book. The door was eventually replaced after a delay, highlighting a lack of formal maintenance policy and procedure. A third deficiency was reported by a resident during a Resident Council meeting, where they complained of cobwebs and dust in their room. Despite a previous grievance form being filled out, the issue persisted, with the surveyor observing dust and cobwebs in the resident's room. The resident, who had intact cognition, had previously reported the issue, but it was not adequately addressed. The facility's policy on cleaning and disinfecting residents' rooms was not followed, as surfaces were not cleaned regularly or when visibly soiled.
Failure to Provide Necessary Grooming Services for a Resident
Penalty
Summary
The facility failed to provide necessary grooming services for a resident who was unable to perform activities of daily living (ADL) independently. This deficiency was observed when the surveyor noted that the resident was unshaven on multiple occasions. The resident, who has severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 2 out of 15, requires substantial assistance for personal hygiene. Despite the resident's need for total care, the Certified Nursing Assistant (CNA) responsible for the resident's care was not the regular aide and mentioned that the resident sometimes refused shaving, which contributed to the lack of grooming. The resident's medical records indicated a history of cerebral infarct, vascular dementia, adjustment disorder, and delusional disorders, which may affect their ability to communicate and cooperate with care. Interviews with staff revealed inconsistencies in the provision of grooming care, with some staff noting the resident's occasional refusal of care but also acknowledging that the resident would allow shaving if explained properly. The facility's policy requires that residents unable to perform ADLs receive necessary services to maintain grooming, which was not consistently adhered to in this case.
Failure to Complete Stat CXR and Notify Physician of Low BP
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, as evidenced by the lack of documentation and follow-up on a stat chest x-ray (CXR) order and low blood pressure (BP) readings. The resident, who had diagnoses including type 2 diabetes mellitus with chronic kidney disease, dementia, colostomy, and anxiety disorder, was assessed to have moderate cognitive impairment. A physician's order for a stat CXR due to congestion was not completed, and there was no documentation of the CXR results in the resident's paper chart or electronic medical record (EMR). Additionally, the resident's BP readings were notably low on one occasion, but there was no documentation indicating that the physician was notified of this change in condition. The facility's Registered Nurse/Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) stated that any change in a resident's condition should be communicated to the physician using the SBAR tool, but this protocol was not followed. The facility's policies required that the physician be notified of acute changes in condition and that appropriate treatments be authorized and monitored, but these steps were not documented. The facility's failure to ensure the stat CXR was completed and to notify the physician of the resident's low BP readings represents a deficiency in providing care according to professional standards and facility policies. The facility's Acute Condition Changes-Clinical Protocol Policy and Lab and Diagnostic Test Results-Clinical Protocol Policy did not adequately address the protocol for when a diagnostic test could not be performed, contributing to the deficiency.
Failure to Document Oxygen Tubing Change
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident receiving oxygen therapy, as evidenced by the lack of documentation regarding the date and time the oxygen tubing was changed. During an initial tour, a surveyor observed a resident using oxygen via nasal cannula without any label indicating when the tubing was last changed. The resident, who was in the process of weaning off oxygen, was unsure about the frequency of tubing changes. The facility's policy required weekly changes of the oxygen tubing, with the date, time, and nurse's initials documented, but there was no evidence of this documentation for the observed date. The resident involved had a medical history that included chronic respiratory failure, anxiety disorder, and type 2 diabetes mellitus. The resident's cognitive assessment indicated no impairment, and the care plan noted the use of oxygen for breathing difficulties. Despite the physician's order for weekly tubing changes, the facility's records did not show that the order was followed on the specified date, as the PRN order for the tubing change was not signed. The facility's response to the surveyor's findings suggested that the missing label was an isolated incident and might have fallen off. However, the facility's oxygen administration policy did not specifically mention labeling the tubing with a date. The surveyor's inquiry into the labeling process revealed that the date was written on surgical tape, which could potentially become detached. The facility did not provide further documentation to support their claim that the label had been replaced.
Deficiency in Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate care consistent with professional standards. The deficiency was identified for a resident with end-stage renal disease who was dependent on renal dialysis. The resident was alert, oriented, and verbally responsive, attending dialysis three times a week. However, there were issues with the administration of Zofran, a medication prescribed for nausea, which was not consistently documented or administered as per the physician's orders. The Licensed Practical Nurse (LPN) and Registered Nurse/Unit Manager (RN/UM) were responsible for documenting the dialysis communication forms (DCF) and ensuring the medication was sent with the resident to the dialysis center. However, there were discrepancies in the documentation and administration of Zofran. On multiple occasions, the medication was noted as sent but not administered, and there was no physician's order (PO) for sending the medication with the resident. The RN/UM acknowledged the lack of documentation and the absence of an active order for Zofran to be sent to dialysis. The facility's policies on end-stage renal disease care and medication administration were not followed, leading to a lack of accountability and documentation for the Zofran medication. The surveyor noted that the administration time of the medication was unknown, and there was no PO for sending the medication with the resident. The facility's failure to adhere to its policies and ensure proper documentation and administration of medication resulted in the deficiency.
Inaccurate and Inaccessible Staffing Report Posting
Penalty
Summary
The facility failed to ensure that the 24-hour staffing report was accurate and prominently posted, as required by regulations. On multiple occasions, surveyors observed that the staffing report was not updated or visible in a location accessible to all residents and visitors. Specifically, on 12/15/24, the staffing report was outdated and not visible in the initial hallway or nursing station, and on 12/17/24, the report had not been updated for that day. The Director of Nursing (DON) and Unit Clerk (UC) were responsible for posting the reports, but there was a lack of clarity and consistency in their process, particularly on weekends when supervisors were supposed to manage the postings. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue and stated that there was no specific facility policy for posting the staffing report, relying instead on general regulations. The LNHA and other staff members, including the Regional DONs and COO, discussed the visibility and accuracy of the postings, with the LNHA adding an additional posting area. Despite these discussions, the facility did not provide any additional information or documentation to address the deficiency noted by the surveyors.
Incomplete Medical Records for Resident's Wound Care
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for a resident, which was identified during a survey. The resident, who had been admitted with conditions including dysphagia, dementia, and protein-calorie malnutrition, had a gap in their medical records concerning wound care. After returning from a rehospitalization, the resident was noted to have multiple wounds, but there were no documented wound notes for a three-week period in the medical record. The Assistant Director of Nursing (ADON) acknowledged that the wound Physician Assistant (PA) visited weekly but did not document the wound care notes in the electronic medical record during that time. The ADON later uploaded the missing wound notes into the electronic medical record after the surveyor's inquiry. The facility's policy on medical records, which was reviewed in November 2024, requires that medical records be retained in accordance with applicable laws, but the facility did not provide additional information on the retention period. The surveyor's investigation revealed that the wound notes were not accessible in the computer system until after the surveyor's inquiry, indicating a lapse in maintaining complete medical records as per professional standards.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a tool used to manage care in accordance with federal guidelines. The deficiency was identified during a review of the medical records of a resident who was admitted with diagnoses including a wedge compression fracture of an unspecified lumbar vertebra, pain in an unspecified joint, and surgical aftercare. The resident's most recent Discharge Return Not Anticipated (DRNA) MDS indicated an unplanned discharge to a short-term general hospital. However, a late entry in the progress notes, signed by the Director of Nursing (DON), revealed that the resident was actually discharged to home and picked up by the resident's representatives. Upon interviewing the MDS Coordinator/Licensed Practical Nurse (MDSC/LPN), it was confirmed that the facility followed the Resident Assessment Instrument (RAI) manual for MDS coding. The MDSC/LPN acknowledged the discrepancy and stated that the MDS and medical records should match. Further review by the MDSC/Registered Nurse (MDSC/RN) confirmed that the MDS should have been coded as a discharge to the community, not to the hospital, indicating a mistake in the coding process. The survey team discussed these findings with the facility's administration during an exit conference, but no additional information was provided.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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