Dwellside Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherry Hill, New Jersey.
- Location
- 3025 Chapel Avenue West, Cherry Hill, New Jersey 08002
- CMS Provider Number
- 315068
- Inspections on file
- 18
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Dwellside Care And Rehab during CMS and state inspections, most recent first.
A resident with chronic pain and intact cognition, receiving scheduled extended-release morphine for moderate pain, experienced a period when the facility ran out of the ordered narcotic and it was not refilled in a timely manner. The MAR showed multiple scheduled doses marked with chart codes indicating "other" or "hold" and references to nurse notes, but corresponding progress notes were missing or incomplete, with only some entries noting that the medication was out of stock or awaiting pharmacy delivery. There was no documented evidence that the provider was contacted promptly for a refill, despite later verbal reports that multiple attempts had been made, and an RN confirmed entering a code for a missed dose without documenting follow-up. Pharmacy records showed delays related to obtaining a correct script, while facility policies required complete, accurate documentation of all services and physician communications in the medical record, which was not met in this case.
A severely cognitively impaired resident with a known history of wandering and elopement risk was able to leave the facility undetected after the alarm systems on the elevator and employee entrance failed to activate. Staff did not recognize or intervene as the resident exited, and previous reports of alarm malfunctions were not effectively addressed, resulting in the resident being missing for several hours before being found by police.
A resident with dementia and behavioral issues repeatedly physically assaulted other residents and staff, resulting in injuries such as bruising, swelling, and a head hematoma. The facility failed to consistently implement effective supervision or interventions, did not always maintain required 1:1 monitoring, and did not complete recommended staff training or interviews after incidents. Affected residents reported feeling unsafe and traumatized.
A resident with dementia and diabetes returned from the hospital with a cast after a wrist fracture. Facility staff failed to monitor or assess the skin around the cast for nearly two months. When necrotic skin and an opening were eventually found, there was a delay in notifying the physician. The resident later developed a foul odor, was diagnosed with a wrist infection, and was found to have a maggot infestation under the cast after hospital admission.
Multiple residents with intact cognition reported that the only shower room on their unit was used for storage of equipment, clothing, and soiled incontinence briefs, resulting in odors and an unclean environment. Observations confirmed sticky spills and debris on common area floors, clutter and garbage in the shower room, and food carts with partially eaten meals left in hallways. Staff acknowledged that cleaning and storage practices were not followed, and that cleanliness concerns had been raised by residents.
Multiple residents reported that meals were served without necessary condiments and were often bland, cold, or unappetizing, with staff and committee meeting minutes confirming ongoing issues with food quality, temperature, and missing items. Observations showed that condiments were not consistently provided in the dining room, and staff interviews revealed frequent resident complaints about food and condiment availability.
The facility did not conduct thorough abuse investigations or maintain complete documentation in multiple incidents involving resident altercations. Key actions such as interviewing all involved parties, obtaining signed witness statements, and documenting resident assessments were not completed, despite facility policy requiring these steps. The DON confirmed missing documentation and incomplete investigation records.
A medication cart was left unlocked and unattended in front of the nurse's station, with the computer screen displaying resident names. An LPN acknowledged not securing the cart during the overnight shift due to the absence of visitors or residents, despite facility policy requiring carts to be locked when not attended. The DON confirmed that the cart should have been secured and resident information kept private.
Failure to Maintain Complete and Accurate Documentation for Narcotic Pain Medication Refill
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record in accordance with professional standards for one resident receiving chronic pain management. The resident was admitted with diagnoses including osteoarthritis of the knee, spinal stenosis, abnormalities of gait, major depressive disorder, and anxiety, and had a comprehensive MDS showing a BIMS score of 15/15, indicating intact cognition, and frequent pain. The resident had an active order for Morphine Sulfate Oral Tablet Extended Release 15 mg to be given every 12 hours for moderate pain. In an interview, the resident reported that in August there was a time when the facility ran out of morphine, it was not refilled timely, and that oxycodone and Percocet were given as substitutes during the period when morphine was unavailable. Review of the August MAR showed multiple scheduled morphine doses on specific dates and times marked with chart codes "#9" (Other/See Nurse Notes) and "#5" (Hold/See Nurse Notes). However, corresponding progress notes for those dates did not consistently document the reasons for these codes or the actions taken. Progress notes that were present included a physician note on one date ordering a lidocaine patch after a report of left knee pain, and several EMAR notes on later dates indicating "awaiting pharmacy delivery," "waiting on pharmacy delivery," and "med [out of stock] awaiting order." There was no documented evidence in the medical record that the facility contacted the resident’s medical provider to request a refill for the morphine from the time the medication first became unavailable until two days later. Interviews and external documentation further highlighted gaps in charting. The contracted pharmacy provided a timeline showing that an electronic refill request was received, a fax was sent to the physician for a needed script, a script with missing information was received, clarification was requested from facility staff, and the correct script was eventually received and the medication delivered. An RN stated that nurses were responsible for monitoring narcotic counts, that narcotics required a written script rather than electronic re-ordering, and that all related actions should be documented. The RN confirmed entering a "#9" code for a missed morphine dose without a corresponding progress note and could not recall calling the physician, acknowledging that such a call and its documentation should have occurred. The DON reported that an LPN had verbally stated multiple attempts were made to reach the physician, but these efforts were not documented in the medical record, contrary to the facility’s policies requiring complete, accurate documentation of services and all communication with physicians and supervisory staff in the resident’s record.
Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Alarm Systems
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking and previous elopement attempts was able to elope from the facility. The resident, who had diagnoses including dementia and Alzheimer's disease and a BIMS score indicating severe cognitive impairment, was known to require supervision for locomotion off the unit and was identified as an elopement risk on their care plan. The resident was equipped with a Wander Guard (WG) device intended to prevent unauthorized exit by triggering alarms and disabling elevator and door access. On the day of the incident, the resident exited the facility through an employee entrance after using an elevator, both of which were supposed to be secured and alarmed for residents with a WG. The alarm system failed to activate when the resident used the elevator and exited through the employee door. A CNA observed the resident leaving but did not intervene, mistaking the resident for a visitor due to their appearance and the absence of an alarm. Multiple staff interviews revealed that the elevator and alarm system had a history of malfunctioning, with several staff members reporting prior incidents where the resident accessed the elevator and left the unit, as well as reporting these issues to management. However, there was no evidence that these concerns were effectively addressed or escalated to facility administration. The facility's policies required adequate supervision and a systemic approach to monitoring residents at risk for elopement, but staff practices and system failures allowed the resident to leave the building undetected. The resident was missing for several hours before being located by police and returned to the facility. Staff interviews indicated a lack of clear responsibility for supervising residents not assigned to them and inconsistent communication regarding malfunctioning safety systems. The failure to provide adequate supervision and maintain functional safety systems resulted in a situation of Immediate Jeopardy.
Removal Plan
- Resident was sent to the hospital for evaluation, returned to the facility, and immediately placed on 1:1 supervision that was maintained.
- Resident had a skin and pain assessment with no injury.
- The physician and family were notified.
- Resident's Wander Guard (WG) was checked every shift for placement and function.
- The facility's vendor serviced the WG system.
- Staff were stationed at employee entrance/exit until the system was repaired and the WG vendor increased the system's sensitivity.
- All residents with WG were checked.
- Updated resident photos for residents with WGs were posted in both elevators and employee entrance.
- All receptionists were educated on the process of buzzing employees in and out of the facility.
- All staff were educated on the facility's elopement policy, wandering binders and identification process.
- Elopement drills were conducted.
Failure to Protect Residents from Physical Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect three residents from physical abuse by another resident, who had a history of Alzheimer's disease, dementia, and behavioral disturbances. The resident in question exhibited escalating aggressive behaviors, including multiple incidents of physical altercations with both residents and staff. These incidents included hitting, punching, and choking, resulting in injuries such as bruising, swelling, and a hematoma. Despite these events, the facility did not consistently implement or maintain effective supervision or interventions to prevent further abuse. The aggressive resident was involved in several documented incidents over a period of months, including unprovoked attacks on other residents and staff members. In one instance, a resident was found with significant injuries after being attacked, including facial bruising, scratches, and swelling, and required hospital evaluation. Another resident reported being pushed and falling, resulting in a head injury and subsequent trauma. Staff members were also physically assaulted while attempting to redirect the aggressive resident, with one LPN sustaining a cut to the nose and another being punched and placed in a chokehold. The facility's response to these incidents was inconsistent and, at times, inadequate. There were lapses in supervision, such as the removal of increased monitoring after serious incidents and failure to provide 1:1 observation as ordered. Staff were not always interviewed or provided statements following incidents, and recommended staff training on managing resident aggression was not completed. Additionally, some staff and the medical director were unaware of the full extent of the incidents, and residents affected by the abuse reported feeling unsafe and traumatized, with one resident keeping their door closed out of fear.
Failure to Monitor and Timely Notify Physician of Cast-Related Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to monitor and assess a resident's skin condition around a cast and did not notify the physician in a timely manner after necrotic skin was discovered. The resident, who had dementia, diabetes mellitus, and severe cognitive impairment, had sustained a right wrist fracture and returned to the facility with a cast following surgery. There was no documentation of any assessments or monitoring of the resident's arm, wrist, or skin around the cast for nearly two months after the cast was applied. On one occasion, the resident complained of arm pain, and necrotic skin with an opening was found under the cast, but there was no immediate physician notification or further assessment documented for two days. Subsequent documentation noted a foul odor from the cast, at which point the physician was notified and an antibiotic was ordered. Two days later, the resident was sent to the emergency room and admitted with a wrist infection. Upon return to the facility, the resident was diagnosed with a right wrist infection, status post hardware removal, and maggot infestation. Attempts to interview the nursing staff involved were unsuccessful, and the DON declined to comment on expectations for care at the time of the incident.
Failure to Maintain Clean, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for residents on the second floor, as evidenced by multiple observations and resident interviews. Several residents with intact cognition reported that the only shower room on their unit was used as a storage area for equipment, discharged residents' clothing, and soiled incontinence briefs, resulting in unpleasant odors and an unclean environment. Residents also described the shower room as cluttered and dirty, with unclean shower pads and chairs, and reported that the common area floors had not been mopped for several days, leaving them sticky and covered in debris. Direct observations confirmed these concerns, with surveyors noting sticky food and beverage spills, white particles, and large spills in the hallways and dining areas. The shower room contained soiled pads, garbage, missing floor drains, and piles of clothing and equipment, all of which were verified by staff as inappropriate. Housekeeping and nursing staff acknowledged that the shower room and common areas were not being cleaned as required, and that extra equipment and residents' clothing should not be stored in the shower room. The Housekeeping/Laundry Supervisor and DON both stated that cleanliness issues had been raised by residents in council meetings. Additionally, food carts with partially eaten meals from the previous day were left in the hallway outside the dining room on the first floor, accessible to residents. Staff interviews revealed that the carts should have been stored in a locked area and not left in the hallway. The DON confirmed that staff should be rounding every hour to prevent such occurrences and acknowledged that leaving the carts in the hallway was a hazard and put residents at risk.
Failure to Provide Palatable Food and Appropriate Condiments
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered food and drink to eight out of 32 sampled residents. Multiple residents with intact cognition reported that meals were served without necessary condiments, such as sweetener, salt, pepper, ketchup, or mustard, and described the food as bland, overcooked, dry, or unappetizing. Specific complaints included dry noodles, overcooked vegetables, inedible fish sticks, and soup with minimal ingredients. Several residents also reported that their meals were served cold or at an unappetizing temperature, and that condiments were inconsistently provided or missing entirely, despite being indicated on tray cards for certain diets. Resident Council and Menu Committee meeting minutes documented ongoing concerns from residents regarding the taste, temperature, and appearance of food, as well as the lack of condiments and missing menu items. These concerns were raised repeatedly over several months, with some meeting minutes lacking any documented response or action. Observations during meal service confirmed that while food temperatures on the tray line were within acceptable ranges, by the time meals reached residents, some items were cold, dry, or bland, and condiments were not provided in the dining room as required. Staff interviews corroborated these findings, with LPNs and CNAs reporting frequent resident complaints about food quality and the inconsistent availability of condiments. The Dietary Manager acknowledged issues with staffing and the failure to prepare condiment containers for the dining room, as well as ongoing problems with food temperatures and menu satisfaction. The Regional Dietitian was unaware of the extent of resident complaints. The facility's own Food Preparation Guidelines policy requires food to be prepared in a manner that preserves or enhances nutrition, flavor, and appearance, and to be served at safe and appetizing temperatures, but these standards were not met as evidenced by resident reports, staff interviews, and direct observations.
Failure to Conduct Thorough Abuse Investigations and Maintain Complete Documentation
Penalty
Summary
The facility failed to ensure that abuse investigations were thoroughly conducted for three out of five reviewed cases, affecting four residents. Specifically, the facility did not interview all involved parties, including alleged victims, perpetrators, and witnesses, nor did it determine whether abuse occurred, its extent, or cause. Documentation of the investigations was incomplete, with missing or undated witness statements, lack of resident interviews, and absent or incomplete skin assessments following incidents. In one incident, a resident with Alzheimer's disease and moderate cognitive impairment attempted to enter another resident's room, resulting in a physical altercation. Staff statements were present but lacked proper identification and signatures, and there was no documentation of interviews with the residents involved or complete skin assessments. In another event, a resident was observed with hands on another resident's neck, resulting in visible injuries and hospitalization, but only one unsigned witness statement was present, and no statements from the residents or other staff were included. The investigation summary did not indicate whether abuse was substantiated. A third incident involved a resident entering another's room, leading to a physical altercation and injury. Only one staff statement was present, with no documentation from the involved CNA or the resident who was cognitively intact. The DON confirmed that no additional documentation or statements were available for these incidents. These failures in investigation and documentation were contrary to the facility's own abuse policy, which requires thorough interviews and complete records.
Unsecured Medication Cart and Exposed Resident Information
Penalty
Summary
A medication cart on A Hall was observed unsecured and unattended in front of the nurse's station, with the computer screen open and displaying the names of 14 residents. At the time of observation, only a certified nurse's aide was present in the hallway, and no licensed nursing staff were at the cart. During an interview, an LPN admitted to knowingly leaving the cart unlocked during the overnight shift, citing the absence of families and residents as the reason for not being as careful with securing the cart. The facility's policy requires medication carts to be secured during medication pass to prevent unauthorized access, and the Director of Nursing confirmed that the cart should have been locked unless a nurse was present. The incident was found to be in violation of the facility's policy and regulatory requirements for medication security and resident information privacy.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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