Excel Care At Dover
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, New Jersey.
- Location
- 65 North Sussex Street, Dover, New Jersey 07801
- CMS Provider Number
- 315355
- Inspections on file
- 15
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Excel Care At Dover during CMS and state inspections, most recent first.
A resident with CHF, atrial fibrillation, and hypertension developed loose, foul-smelling dark stools and acute hypotension, with BPs in the 70s/40s and later in the 60s/30s, while on 2 L/min O2. Nursing staff notified an ADON, who obtained orders for STAT labs, X-ray, and urinalysis and told staff they were waiting on the physician, despite a telephone/verbal order from the physician to immediately call 911 and transfer the resident to the ER for a change in condition and low BP. The physician arrived later that morning expecting the resident to have been transferred, learned from an LPN that the resident was still in the building and more hypotensive, and again ordered immediate ER transfer, at which point 911 was called. Documentation and interviews revealed discrepancies between the ADON’s late-entry notes, the order audit report, and staff accounts, as well as lack of timely notification to the DON and a minimal, nonspecific internal investigation summary. The resident was ultimately transported to the ER, admitted with shock, anemia, and hyperkalemia, and expired the same day.
A resident with cardiac comorbidities and moderate cognitive impairment developed loose, foul-smelling dark stools and hypotension. Nursing staff obtained a BP of 73/47 mm Hg and notified an ADON, who, according to the MD, was verbally ordered to call 911 and send the resident to the ER. The MD later found the resident still in the facility with a further decreased BP of 64/34 mm Hg after staff reported they were waiting for her arrival and for labs to be drawn before calling 911. The resident was eventually sent to the hospital and expired there the same day. Facility leadership reported they were not informed of the delay until after the death, and the LNHA acknowledged the event was not reported to the state despite policies requiring prompt reporting of suspected neglect and resident safety events.
A resident with CHF, AFib, and hypertension developed hypotension, loose foul-smelling dark stools, and disorientation, with BPs in the 70s/40s and later in the 60s/30s while on 2 L O2. Nursing staff notified an ADON, who ordered STAT labs and diagnostics and stated she would contact the MD. The MD reported giving a verbal order around 9:30 AM to call 911 and send the resident to the ER, and an order audit showed an ER transfer order entered earlier than documented in the ADON’s late entry note. Staff interviews and MD statements indicated the resident remained in the facility while the ADON waited for labs and for the MD to arrive, despite the order for immediate transfer, and the resident was only sent out after the MD arrived on-site and again ordered 911 to be called; the resident later died in the hospital the same day. The DON stated she was not informed at the time, and the ADON later wrote back-dated notes and resigned. The administrator produced only an undated, generic one-page investigation summary without the resident’s name, incident date, detailed timeline, staff statements, or root cause analysis, which did not meet the facility’s own policies for thorough investigation of suspected neglect and serious reportable events.
The facility failed to develop and implement comprehensive policies and procedures to prevent and investigate abuse, resulting in inadequate handling of sexual abuse allegations involving two residents. The investigation lacked proper documentation, interviews, and assessments, and the facility did not ensure contracted staff were pre-screened or trained on abuse policies.
The facility failed to conduct thorough investigations into allegations of abuse involving residents. One resident reported bruises after a lab technician allegedly ordered a CNA to hold them down for blood work. In another case, two residents alleged sexual abuse by a staff member, but the facility's investigation lacked documented statements from key witnesses and comprehensive assessments. The facility's failure to adhere to its abuse investigation policy resulted in an incomplete response to serious allegations.
The facility failed to address lab values and notify physicians of changes in residents' conditions. A resident with severe cognitive impairment had a skin tear that was not properly monitored, leading to a foul odor, and a low blood sugar level that was not reported for five days. Another resident with moderate cognitive impairment had a low potassium level that went unreported for 26 days. A third resident with a pressure ulcer did not receive ordered wound care, leading to worsening conditions and removal from the facility.
The facility failed to provide sufficient nursing staff, leading to inadequate supervision and documentation for two residents with multiple falls. One resident experienced falls without proper investigation or interventions, while another suffered a fatal injury due to insufficient supervision. The facility also did not meet the required CNA staffing ratios, as acknowledged by the LNHA.
The facility failed to report allegations of abuse and an injury of unknown origin to the NJDOH within the required timeframe. Two residents reported sexual abuse by a male nursing assistant, and another resident alleged being hit by a staff member. Additionally, a resident was forcibly removed from a meeting by the Director of Activities. The facility did not report these incidents as required by their policy.
The facility failed to maintain a homelike environment on the 2nd floor Unit, with surveyors observing persistent odors and frayed, stained carpets. The Director of Maintenance and Housekeeping acknowledged the issues but lacked documentation of repairs or audits, despite the facility's policy to ensure a safe and comfortable environment.
A facility failed to document medications and treatments for a resident with multiple diagnoses, including MS and glaucoma, as per physician's orders. Additionally, the facility did not consistently document urinary catheter output for another resident, despite physician's orders. The DON and facility management acknowledged these deficiencies, which were not in line with the facility's policies.
The facility failed to administer medications on time for multiple residents, as observed during a medication pass. The EMAR showed overdue medications, and the MAR confirmed that medications were consistently administered late. There was no documentation that the PCPs were notified, nor was there evidence of harm recorded in the progress notes.
The facility failed to remove expired medications from the medication cart and ensure that medication cabinets and refrigerators were locked. A surveyor observed an RN accessing unlocked cabinets and using expired Aspirin. The DON confirmed that both current and discontinued medications were stored in these unlocked compartments, contrary to the facility's policy.
Failure to Follow Physician Order for Immediate ER Transfer After Acute Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to carry out a physician’s order to immediately transfer a resident to the emergency room (ER) following a significant change in condition and hypotension. The resident had multiple diagnoses including systolic congestive heart failure, atrial fibrillation, and hypertension, and had a BIMS score of 11/15 indicating moderate cognitive impairment. On the morning in question, nursing staff documented that the resident had loose, foul-smelling, dark stools and was encouraged to increase oral hydration, with SpO2 at 95% on 2 L/min oxygen via nasal cannula. At 8:54 AM, the resident’s blood pressure was recorded as 73/47 mm Hg, which is below the normal range. A physician telephone order was entered at 9:20 AM to send the resident to the ER for emergency transfer due to low blood pressure and change in condition. The physician later documented a late entry stating that at 9:33 AM she had given a verbal order to nursing (to the ADON) to send the resident to the ER due to low blood pressure. The physician reported that she instructed the ADON to call 911 and send the resident out immediately. However, the resident remained in the facility. Nursing notes documented that during morning rounds the resident appeared disoriented, with blood pressure 71/47 mm Hg, heart rate 64 bpm, temperature 97.7°F, respiratory rate 18, and SpO2 95% on 2 L/min oxygen. The LPN documented that the ADON was made aware, obtained orders for STAT labs, X-ray, and urinalysis, and was waiting for a response from the physician. The physician stated that when she arrived at the facility at 10:00 AM for scheduled rounds, she believed the resident had already been transferred. At approximately 10:10 AM, an LPN informed her that the resident was still in the building and that the blood pressure had decreased further to 64/34 mm Hg, and that they had been told to wait until the physician arrived. The physician then reiterated that the resident needed to be sent to the ER immediately, and 911 was called. Nursing documentation later that day indicated that the resident was transported to the ER and was admitted with diagnoses including unspecified shock, anemia, and hyperkalemia, and that the resident expired at the hospital the same day. The facility’s records and interviews showed discrepancies between the ADON’s late-entry note and the order audit report, as well as conflicting statements about whether the DON had been notified, and the facility’s investigation documentation was limited and lacked specific resident identifiers and incident details. Interviews with facility staff further described the sequence of events leading to the deficiency. The ADON was reported by the Assistant DON and nursing staff to have been notified of the resident’s low blood pressure and change in condition, to have ordered STAT labs and diagnostic tests, and to have indicated that they were waiting on the physician or on lab results before calling 911, despite the physician’s order for immediate transfer. The physician stated that waiting for labs was not appropriate for the resident’s condition. The DON reported that she was not made aware of the situation until after the resident expired and that a late-entry note by the ADON claiming DON notification was not accurate. The LNHA acknowledged that there appeared to have been a delay in sending the resident to the ER and provided an undated, generic investigation summary that did not include the resident’s name, date of incident, or attached statements. The surveyors concluded that the facility failed to implement its abuse, neglect, physician notification, and change in condition policies when staff did not promptly carry out the physician’s order for immediate ER transfer, resulting in a finding of neglect and an Immediate Jeopardy situation.
Removal Plan
- The VP of Clinical Services and VP of Human Resources met with the DON to review and reinforce the facility's acute transfer review process, unit rounding procedures, and clinical oversight of residents experiencing an acute change in condition.
- The Chief Nursing met with the DON and reinforced expectations related to timely and accurate documentation, physician notification, and escalation of care when residents experience an acute change in condition.
- The LNHA and DON provided ongoing education to all licensed nursing staff on physician notification of residents' changes in condition, documentation of physician's orders, carrying out a physician's order, change in condition assessment and emergency response, resident neglect, abuse, and prevention.
- The LNHA will provide ongoing oversight of the DON to ensure continued monitoring of changes in condition, physician/provider notification, and documentation of clinical interventions.
- The clinical team reviewed all sub-acute charts and there were no additional discrepancies identified.
Failure to Report Alleged Neglect After Delay in Following MD Transfer Order
Penalty
Summary
The facility failed to report an allegation of neglect to the New Jersey Department of Health (NJDOH) after a resident with multiple cardiac conditions experienced a significant change in condition and a physician’s order to send the resident to the hospital was not promptly carried out. The resident had diagnoses including systolic congestive heart failure, atrial fibrillation, and hypertension, and a comprehensive MDS showed moderate cognitive impairment with a BIMS score of 11/15. On the morning in question, nursing documentation reflected that the resident had loose stools with very foul-smelling, dark fluid, and vital signs showed a blood pressure of 73/47 mm Hg, which is below the normal adult range. According to a late-entry physician progress note, the physician gave a verbal order at 9:33 AM to the Assistant Director of Nursing (ADON #2) to send the resident to the emergency room due to low blood pressure. A late-entry provider note by ADON #2 stated that after being notified by a float nurse, ADON #2 assessed the resident, found them responsive without labored breathing, repositioned them, attempted to contact the physician, notified the DON for assessment, and documented that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated and the resident was transferred while still responsive. However, in an interview, the physician stated that when ADON #2 called around 9:30 AM, she instructed that 911 be called and the resident be sent to the ER, and when she arrived at the facility at 10:00 AM, she assumed the resident had already left. The physician further reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a further decreased blood pressure of 64/34 mm Hg, and that staff told her they were waiting for her to come in. The physician stated that ADON #2 told her they were waiting for labs to be drawn before calling 911, which the physician indicated was not appropriate for the resident’s condition, and only then was 911 called. The DON reported that facility leadership was not made aware of the delay in sending the resident to the hospital until after the resident expired at the hospital, and that ADON #2 had not informed her despite documenting in a late-entry note that the DON had been notified. The Licensed Nursing Home Administrator acknowledged that the event should have been reported to NJDOH, and review of facility policies showed that allegations or suspicions of neglect and resident safety events were required to be promptly reported to regulatory authorities, which did not occur in this case.
Failure to Investigate Delayed ER Transfer After Physician Order and Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an unexpected resident death and to rule out neglect after a physician’s order for immediate transfer to the ER was not followed. A resident with systolic congestive heart failure, atrial fibrillation, and hypertension had a recent MDS showing a BIMS score of 11, indicating moderate cognitive impairment. On the morning in question, nursing documentation showed the resident had loose, foul-smelling dark stools and was encouraged to increase oral hydration, with SpO2 at 95% on 2 L O2 via nasal cannula. At 8:54 AM, the resident’s BP was documented at 73/47 mm Hg, well below normal. A physician progress note, entered later as a late entry, recorded that at 9:33 AM the physician gave a verbal order to nursing (to the ADON) to send the resident to the ER due to low BP. Subsequent nursing notes documented that during morning rounds the resident was awake, responsive but disoriented, with BP 71/47, HR 64, temp 97.7°F, RR 18, and SpO2 95% on 2 L O2. Nursing staff notified the ADON, who ordered STAT labs, X‑ray, and urinalysis and indicated she would contact the physician. A provider progress note by the ADON, entered as a late entry, stated that she was initially unable to reach the physician, that the DON was immediately notified, and that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated. However, the facility’s order audit report showed a telephone order at 9:20 AM to send the resident to the ER for emergency transfer due to change in condition, contradicting the ADON’s late entry note about the timing and sequence of events. The physician later stated she had instructed the ADON around 9:30 AM to call 911 and send the resident to the ER and that she assumed the resident had already left when she arrived for rounds at 10:00 AM. Interviews with staff revealed conflicting accounts and suggested a delay in carrying out the physician’s order to transfer the resident. The physician reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a BP of 64/34 mm Hg and that staff told her they were told to wait until she came in. The physician stated that the ADON told her they were waiting for labs to be drawn before calling 911, which the physician considered inappropriate for the resident’s condition. Nursing notes documented that when the physician arrived, the resident’s BP was 63/36, SpO2 could not be obtained, and the physician again ordered transfer to the ER, after which 911 was called and the resident was transported and later expired in the hospital that day. The DON stated she was not made aware of the situation until after the resident’s death, despite the ADON’s late entry note claiming the DON had been notified, and that the ADON resigned after writing the back‑dated note. The administrator provided an undated, untitled, one‑page “investigation” summary and conclusion with no resident name, incident date, or attached statements, which did not reflect the detailed events, conflicting timelines, or staff interviews described elsewhere in the record. This minimal document did not meet the facility’s own Abuse Investigation and Reporting and Reportable Events policies, which require prompt, thorough investigations, interviews, medical record review, and root cause analysis for serious events. The facility’s policies required that all reports of suspected neglect and serious reportable events be promptly identified, thoroughly investigated, and documented, including interviews of involved staff and witnesses, review of the medical record and care plans, evaluation of contributing factors, and root cause analysis for serious events. The DON reported that corporate was made aware and conducted an investigation but that she herself was not interviewed. The administrator acknowledged there appeared to have been a delay in sending the resident to the ER and attributed the situation in part to interpersonal conflict between two ADONs. The only investigation document produced consisted of a brief, generic summary and conclusion describing hypotension with stable heart rate and oxygen saturation, ongoing monitoring, physician communication, and eventual transfer to the ER, without specific identification of the resident, the date, the sequence of orders and actions, or any analysis of the delay or conflicting documentation. As a result, the surveyors determined that the facility failed to thoroughly investigate the unexpected death and the apparent failure to promptly follow a physician’s order for emergency transfer, and therefore failed to rule out neglect as required by facility policy and regulation.
Inadequate Abuse Prevention and Investigation Procedures
Penalty
Summary
The facility failed to develop comprehensive policies and consistently implement procedures to prevent and investigate abuse. This deficiency was identified during a survey following allegations of sexual abuse by a contracted certified nurse aide involving two residents. The facility did not have a system in place to pre-screen contracted staff timely or provide training on current facility abuse policies. Additionally, the facility failed to identify all residents who may have been abused and did not have a documented system to rule out abuse. The investigation into the allegations was inadequate. The facility did not ensure that all involved persons, including potential witnesses, were identified, and a documented interview was completed per facility policy. The investigation summary lacked individual statements from other residents, staff, or family members, and there were no attached police reports. The education for the accused CNA was based on an abuse policy from a different facility, indicating a lack of proper documentation and adherence to the facility's own policies. The medical records of the involved residents did not reflect any documentation related to the allegations of abuse. There were no nurses' notes or physician documentation regarding the incident, and no physical or psychosocial assessments were found in the electronic or paper medical records. The facility's failure to document and investigate the allegations thoroughly contributed to the deficiency, as evidenced by the lack of a comprehensive investigation and proper documentation.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct and document thorough investigations into several allegations of abuse involving residents. In one case, a resident reported bruises on their arms after a lab technician allegedly ordered a CNA to hold the resident down for blood work. The resident, who was on a blood thinner, expressed frustration and confusion over the repeated blood draws. Despite the resident's complaints and visible bruising, the facility did not complete a comprehensive investigation, as evidenced by the lack of employee statements and a detailed incident report. In another incident, two residents alleged sexual abuse by a staff member. One resident reported being washed roughly by a CNA, while the other claimed the same CNA performed inappropriate actions. The facility's investigation was incomplete, lacking documented statements from key witnesses, including the residents, their family members, and other staff. The facility's documentation did not include a comprehensive assessment of the residents involved, nor did it provide evidence of psychological support as claimed in the investigation summary. The facility's investigation process was further compromised by the absence of documented interviews with other residents who may have been affected or witnessed the incidents. The facility's failure to adhere to its own abuse investigation policy, which requires thorough documentation and interviews, resulted in an incomplete and inadequate response to serious allegations of abuse. The lack of a comprehensive investigation and documentation raises concerns about the facility's ability to protect its residents and ensure their safety.
Failure to Address Lab Values and Notify Physicians
Penalty
Summary
The facility failed to address laboratory values in a timely manner and notify physicians of changes in residents' conditions, as evidenced by the cases of two residents. Resident #109, who had severe cognitive impairment and was a high fall risk, had a skin tear on the right arm that was not properly monitored or reported to the physician. The wound developed a foul odor, indicating possible infection, but there was no documentation of follow-up care or physician notification. Additionally, a health alert system indicated a low blood sugar level for Resident #109, but the physician was not informed until five days later. Resident #6, with moderate cognitive impairment and chronic kidney disease, experienced a health alert system notification due to a low potassium level. Despite the alert, the facility did not review the lab results or notify the physician for 26 days. The APN and physician were unaware of the abnormal lab results, which could have been addressed to prevent potential complications. Resident #330, who had muscle wasting and dysphagia, was admitted with a stage 2 pressure ulcer. The facility failed to provide wound care as ordered, with multiple instances of missed documentation in the electronic Treatment Administration Record. The resident's condition worsened, leading to complaints from the resident's representative and eventual removal from the facility. The facility administration could not provide documentation or rationale for the lack of communication with the physician regarding the residents' conditions.
Inadequate Staffing and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate supervision and documentation for residents with multiple falls. Specifically, two residents with severely impaired cognition experienced multiple falls, and the facility did not conduct thorough investigations or implement appropriate interventions. For one resident, the investigation reports were incomplete, lacking staff statements and necessary details, and the interventions were not suitable given the resident's cognitive impairment. The facility's Director of Nursing acknowledged the incomplete investigations and the need for more detailed documentation. Another resident, also with severely impaired cognition, experienced multiple falls, including one that resulted in a fatal injury. The care plan for this resident included interventions such as educating the resident to ask for assistance and keeping the resident in a supervised area. However, these interventions were not effectively implemented, as evidenced by the resident's frequent falls and the lack of adequate supervision. The resident's family member reported that the resident was sent to the hospital for a shoulder injury, which ultimately led to the resident's death. The facility was also found to be deficient in meeting the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. During the two weeks prior to the survey, the facility consistently failed to provide the required number of Certified Nursing Aides (CNAs) for the day shifts, resulting in insufficient staffing to meet the needs of the residents. The Licensed Nursing Home Administrator admitted awareness of the staffing requirements and acknowledged that the facility did not always meet these requirements.
Failure to Timely Report Abuse and Injury Allegations
Penalty
Summary
The facility failed to report allegations of abuse and an injury of unknown origin to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe. This deficiency involved four residents. In one instance, two residents reported allegations of sexual abuse by a male nursing assistant. Resident #85 reported that the aide washed their private area roughly, and Resident #42 alleged that the aide performed an inappropriate act. The facility's Director of Nursing (DON) submitted the Reportable Event Record (RER) to the NJDOH one day after the incidents were reported, which was not within the required timeframe. Another incident involved Resident #104, who reported being hit by a staff member about a year ago. The resident, who had dementia and Alzheimer's Disease, alleged that a male registered nurse banged their knees into a wall. The facility initiated an investigation, but there was no evidence that the incident was reported to the State Agency within the two-hour timeframe. The investigation was ongoing, and the facility had not concluded the investigation into the bruises found on the resident's knees. Additionally, Resident #35 filed a grievance after being forcibly removed from a meeting by the Director of Activities (DA). The resident reported being pushed against their will, and the incident was allegedly captured on camera. However, the facility did not retain the video footage, and the DA resigned shortly after the incident. The facility did not report this incident to the NJDOH, as they did not consider it necessary. The facility's policy required immediate reporting of alleged abuse, neglect, or mistreatment, but this was not adhered to in these cases.
Failure to Maintain Homelike Environment on 2nd Floor Unit
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for resident rooms on the 2nd floor Unit, as observed by surveyors. During multiple visits, surveyors noted a persistent odor of wet carpet and urine in several rooms, as well as visibly frayed and stained carpets. The Director of Maintenance acknowledged awareness of wet carpets due to a toilet overflow but did not document these issues in the Daily Maintenance Log. The Director of Housekeeping also conducted environmental rounds but reported maintenance issues verbally without written documentation. The Licensed Nursing Home Administrator and other facility leaders were unable to provide documentation of environmental and housekeeping audits or maintenance logs that addressed the carpet conditions. Despite the facility's policy to provide a safe, clean, and homelike environment, there was no evidence of systematic documentation or follow-up on the observed deficiencies, indicating a lapse in maintaining the residents' right to a comfortable living space.
Failure to Document Medications and Catheter Output
Penalty
Summary
The facility failed to document medications and treatments according to physician's orders for a resident who was reviewed for medication and treatment administration. The resident, who had multiple diagnoses including Multiple Sclerosis, glaucoma, and neuromuscular dysfunction of the bladder, had several medications and treatments marked as 'not addressed' in the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) on a specific date. There was no documentation in the Progress Notes explaining why these medications and treatments were not administered, nor was there any communication with the physician or family regarding the missed medications and treatments. Additionally, the facility did not consistently document catheter urinary output according to physician's orders for another resident who was reviewed for urinary catheters. This resident, who had diagnoses including urinary tract infection and benign prostatic hyperplasia, had a physician's order for urinary catheter care every shift, which included documenting the output. However, the electronic Treatment Administration Record (eTAR) showed that the urinary catheter output was not documented on several occasions throughout the month. The Director of Nursing (DON) and other facility management acknowledged the deficiencies during interviews with the surveyors. They confirmed that the expectation was for nurses to document reasons for not administering medications or treatments and to follow physician's orders for documenting urinary output. The facility's policy on infection control and indwelling urinary catheter use also required documentation of urine output and monitoring for signs and symptoms of infection, which was not adhered to in this case.
Failure to Administer Medications on Time
Penalty
Summary
The facility failed to administer medications in accordance with the acceptable standard of nursing practice and did not follow the facility policy on Medication Administration and Physician Services. This was observed during a medication pass on one of the nursing units, where multiple residents' medications were not administered at the scheduled times. Specifically, the Electronic Medication Administration Record (EMAR) showed overdue medications for several residents, indicating that the medications were not given within the required time frame. The Registered Nurse (RN) confirmed that the red color on the EMAR screen signified overdue medications, and the medications were subsequently administered late to the residents. Resident #1, who had multiple diagnoses including Diabetes Mellitus type 2, Atrial Fibrillation, and Hypertension, had several medications scheduled at specific times. However, the Medication Administration Report (MAR) showed that these medications were consistently administered late on numerous occasions throughout January 2024. There was no documentation indicating that the resident's Primary Care Physician (PCP) was notified about the late administration of medications, nor was there any evidence of harm documented in the progress notes. Similarly, Resident #2, who had diagnoses including Hypertension, Type 2 Diabetes Mellitus, and Dementia, also had medications administered late on multiple occasions in March 2024. The MAR indicated that medications such as Acetaminophen, Amlodipine, Clonidine, Lisinopril, and Metformin were not given at the scheduled times. Again, there was no documentation that the PCP was informed about the late administration, and no harm was recorded in the progress notes. This pattern of late medication administration and lack of proper documentation was also observed for Residents #3, #4, and #5, who had various medical conditions and required timely medication administration as per their care plans and physician orders.
Medication Storage and Expired Medication Deficiency
Penalty
Summary
The facility failed to ensure that expired medications were removed from the medication cart and that medication cabinets and refrigerators were locked. During a medication administration observation, a surveyor noted that a registered nurse (RN) accessed medication cabinets without using a key and left them unlocked. The RN also found and used an expired bottle of Aspirin from the medication cart. The surveyor observed that the medication cabinets and refrigerator on Unit 2B were unattended and unlocked for an extended period, and the Director of Nursing (DON) confirmed that both current and discontinued medications were stored in these unlocked compartments. The DON also noted that the refrigerator had a sign indicating it should not be left unlocked, but it was found unlocked during the surveyor's visit. Interviews with the RN and DON revealed that the cabinets and refrigerator should always be locked to prevent unauthorized access to medications. The RN admitted that she did not check her cart for expired medications that day, which led to the expired Aspirin being available for use. The facility's policy on medication storage, dated February 2024, mandates that all drugs and biologicals be stored in locked compartments when not in use, but this policy was not followed during the surveyor's observation. The DON acknowledged the oversight and indicated that an audit would be conducted to ensure compliance with the policy.
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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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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