Excel Care At Manalapan
Inspection history, citations, penalties and survey trends for this long-term care facility in Manalapan, New Jersey.
- Location
- 104 Pension Road, Manalapan, New Jersey 07726
- CMS Provider Number
- 315282
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Excel Care At Manalapan during CMS and state inspections, most recent first.
A resident admitted with pneumonia and acute respiratory failure with hypoxia arrived with discharge instructions for continuous O2 at 2 L/min via nasal cannula and was documented on the admission assessment as having an O2 saturation of 98% while on nasal cannula. However, review of the MAR showed that the physician order for continuous O2 (3 L/min via nasal cannula) was not entered until two days after admission. The DON confirmed that the resident was wearing O2 without a corresponding physician order at admission and that this failed to follow facility policy requiring verification of a physician’s order before administering O2.
A resident admitted with pneumonia and acute respiratory failure with hypoxia had discharge instructions for continuous O2 at 2 L/min via nasal cannula with O2 saturation monitoring, and the admission assessment documented O2 use with a saturation of 98%. However, a formal physician order for O2 and corresponding MAR entry were not made until several days after admission, and the care plan, while noting altered respiratory status, did not include interventions for O2 therapy, the resident’s known non-compliance with O2 use, or O2 saturation monitoring. The UM and DON acknowledged the absence of these care plan elements despite facility policy requiring a comprehensive, person-centered care plan.
Nursing staff did not document notification to a resident's family after the resident, who had Crohn's Disease and Ulcerative Colitis, experienced a significant change in condition involving bloody diarrhea. Although the NP was notified and the resident's representative was present during the emergency, there was no record that staff informed the family as required by facility policy.
The facility did not ensure RN coverage for at least 8 consecutive hours on one day during the review period, as shown by staffing reports indicating no RN services were provided on that day.
Surveyors found that medications were not administered as ordered for three residents, including pain management and routine prescriptions. In several cases, LPNs documented that medications were given when they were not, or marked them as 'awaiting delivery' despite the medications being available in backup supply or in the medication cart. There was also a lack of required documentation and physician notification regarding missed doses, contrary to facility policy and professional standards.
A resident was not provided with food that accommodated their allergies, intolerances, or preferences, and the facility did not consistently offer appealing meal options as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A facility failed to provide food that accommodated a resident's known allergy to eggs and egg-derived products. Despite clear documentation of the allergy in the resident's medical records and meal ticket, the resident was served and consumed a hard-boiled egg. This incident occurred due to the Dietary Aide not adhering to the resident's dietary restrictions, posing a serious health risk.
The facility did not ensure adequate supervision and fall prevention for a resident with a history of multiple falls and major injuries. Despite being identified as a fall risk and having diagnoses requiring assistance with personal care, the resident's care plan lacked comprehensive fall prevention strategies upon readmission. The resident experienced multiple unwitnessed falls, including one resulting in a wrist fracture, due to inconsistent implementation of interventions like bed and chair alarms. Gaps in timely care plan updates and failure to consistently apply recommended safety measures contributed to the ongoing fall risk.
A resident with severe cognitive impairment and a history of chronic UTIs experienced multiple infections requiring hospitalization due to insufficient incontinence care. Despite having a care plan with goals for resolving UTIs, the facility did not update interventions to prevent further infections. Observations revealed the resident wearing two saturated incontinent briefs, and staff acknowledged the practice of using double briefs and pads for heavy wetters. The facility's policies emphasized changing briefs every two hours and monitoring mental status, but these practices were not consistently implemented, contributing to the resident's recurring UTIs.
The facility did not ensure daily administration of antipsychotic medications per physician orders for three residents diagnosed with schizophrenia and psychosis. Two residents missed multiple doses of Clozapine, resulting in increased combative and hallucinatory behaviors, leading to emergency transfers. Additionally, the facility failed to monitor and document behaviors and side effects for a resident on Seroquel, and the care plan lacked individualized non-pharmacological interventions.
The facility failed to address resident grievances regarding access to personal needs account (PNA) funds and food complaints related to the kosher style menu. Residents reported difficulties accessing their PNA funds and dissatisfaction with the repetitive menu options. The facility did not provide adequate documentation or follow-up on these grievances, leading to unresolved issues and dissatisfaction among the residents.
The facility failed to ensure residents could access their Personal Need Account (PNA) funds without restrictions, provide access to at least $50.00 on the same day it was requested, and maintain a system that included receipts for disbursements. Residents confirmed they were unable to access their funds when needed and were restricted to withdrawing only $25.00 at a time. The HRD and LNHA were unable to provide a documented policy or process for handling PNA funds, especially for deceased residents.
The facility failed to ensure residents with Personal Needs Account (PNA) funds received quarterly statements and did not properly manage accounts for deceased residents. The HRD, responsible for handling PNA money, was unaware of deceased residents' accounts and could not provide proof of sending quarterly statements. The LNHA admitted there was no policy in place for managing PNA accounts.
The facility failed to ensure that within 30 days of a resident's death, the resident's funds and a final accounting of those funds were conveyed to the individual or probate jurisdiction administering the resident's estate. Six expired residents were found to have current Personal Needs Account (PNA) balances, and the Human Resources Director (HRD) was unaware of these expired residents and had not closed their accounts. The HRD stated that a remote business office (RBO) handled the accounts, but there was no clear process or policy in place for managing PNA accounts after a resident's death.
The facility failed to maintain a clean, sanitary, and homelike environment for residents, with multiple rooms in the 200 Unit found to have stained curtains, rusted bed frames, chipped furniture, and cracked walls. Despite the LNHA's acknowledgment of the issues, no substantial improvements were observed, and management did not provide specific plans to address the conditions.
The facility failed to provide consistent ADL care, including appropriate incontinent care and scheduled showers. Multiple residents were found wearing double incontinent briefs without consent or documentation, and reports indicated that incontinence care was not provided in a timely manner. Additionally, the facility did not ensure that residents received their scheduled showers, with missing documentation and inconsistent care practices observed.
The facility failed to ensure sufficient and competent staff were available to provide appropriate incontinence care, scheduled showers, and dignified treatment to residents. Observations and interviews revealed delays in assistance, residents left in soiled briefs, and missed showers. Additionally, the facility did not meet the required minimum staffing ratios, affecting the quality of care.
The facility failed to ensure that the DON worked full-time as DON, as the DON was also performing the role of the Infection Preventionist (IP) due to staffing issues. This dual role was confirmed by both the DON and the LNHA during interviews, and the facility's job description for the DON indicated that the primary purpose was to oversee the Nursing Service Department.
The facility failed to serve hot and cold foods at appropriate and appetizing temperatures. Surveyors found that all hot food items were below the required 140°F, and cold food items were above the required 35°F. Residents also reported that their food was often cold and that meal trays sat too long in the hallway before being distributed.
The facility failed to ensure proper food storage, labeling, and sanitation practices. Observations included undated meat, improperly labeled chicken, and a thawed egg product without an open or use-by date. Staff were also seen without appropriate hair restraints, and a pantry refrigerator was non-functioning. These practices did not comply with the facility's policies.
The facility administration failed to implement effective systems to maintain residents' well-being, including providing appropriate food for allergies, timely incontinence care, and treating residents with dignity. Additionally, the facility lacked a comprehensive emergency preparedness program, effective infection control, and adequate staffing levels.
The facility failed to provide timely access to medical records during an on-site survey. The LNHA mentioned that records prior to November 2023 were imported into a new EMR system, but access required a tablet and only one staff member was familiar with the old system. By the fourth day, requested records for several residents from 2022 were still not provided.
The facility's QAPI failed to address multiple issues, including environmental concerns, resident care, and the Antibiotic Stewardship Program. Surveyors observed broken furniture, soiled privacy curtains, and residents wearing double incontinent briefs. Residents also expressed dissatisfaction with kosher-style meals and limited access to PNA funds. The facility did not update care plans for a resident with multiple falls and failed to administer prescribed antipsychotic medications to two residents, resulting in emergency transfers.
The facility failed to ensure the Medical Director (MD) and the Infection Preventionist (IP) attended all quarterly QAPI meetings, compromising the effectiveness of infection control and prevention measures. The review of sign-in sheets and QAPI documentation revealed multiple absences and a lack of required reports from the IP.
The facility failed to follow infection control practices, including improper handling of dirty meal trays, inadequate storage of a nebulizer mask, unclean ice scoop and container, and staff not performing appropriate hand hygiene. These deficiencies were observed by surveyors during various inspections.
The facility failed to ensure proper management of a resident with recurring UTIs and did not consistently follow the Antibiotic Stewardship Program. The DON, also serving as the IP, admitted to not being able to track and review antibiotic use due to time constraints. Incomplete and inconsistent documentation for several months led to gaps in infection control and antibiotic management.
The facility failed to ensure residents were treated with dignity and respect, including ignoring requests for water, serving meals on disposable dinnerware, speaking in foreign languages around residents, conducting personal phone calls during resident interactions, and not providing privacy curtains. These deficiencies were identified through observations, interviews, and document reviews.
The facility failed to notify a resident representative and/or physician for two residents who did not receive their prescribed Clozapine medication on multiple occasions. Both residents exhibited significant changes in behavior, including hallucinations and aggression, but there was no documented evidence of notification as required by the facility's policy.
The facility failed to develop and implement individualized comprehensive care plans with measurable goals for four residents, including those with a history of aggression, falls, psychosis, and allergies. Despite observations and recommendations, the care plans lacked necessary details and interventions.
A resident with severe cognitive impairment and multiple medical conditions, including Type 2 diabetes mellitus, did not receive physician orders for recommended treatments for a diabetic foot ulcer. Despite multiple podiatry consultations, the necessary orders for Bacitracin and Mupirocin were not documented in the resident's medical records, leading to a deficiency in care.
The facility failed to ensure that resident call bells were accessible, as observed during a survey. Three residents were found without accessible call lights, despite care plans and facility policies requiring them to be within reach. The DON and CNAs acknowledged the oversight.
The facility failed to ensure the timely submission of MDS assessments for a resident. The MDS coordinator acknowledged the delay, citing an old medical record system. The quarterly assessment was submitted late, as confirmed by the Director of Nursing.
The facility failed to provide an ongoing activity program that met the needs of all residents, particularly those who enjoyed trips outside the facility. A resident reported that trips had not occurred since December, and the Activity Director confirmed that unpaid transportation invoices prevented scheduling further trips. The LNHA claimed trips were listed as TBD on the activity calendar, but no resolution was provided.
The facility failed to provide consistent pain management for two residents. One resident did not receive a prescribed Lidocaine patch consistently, and the staff did not notify the physician about the missing medication. Another resident did not receive the correct dosage of Percocet for several days due to a lack of communication with the pharmacy and physician. These lapses resulted in unmanaged pain for the residents.
Failure to Obtain Timely Physician Order for Continuous Oxygen Therapy on Admission
Penalty
Summary
Surveyors determined that the facility failed to obtain a physician’s order for oxygen therapy upon admission for a resident who required continuous oxygen. The resident was admitted with diagnoses including pneumonia and acute respiratory failure with hypoxia. Discharge instructions from the sending provider specified oxygen therapy at 2 L/min via nasal cannula on a continuous basis, with monitoring of oxygen saturation and supplemental oxygen as needed to maintain a goal saturation of 92%. The admission/readmission comprehensive nursing assessment documented an oxygen saturation of 98% via nasal cannula, indicating that the resident was receiving oxygen at the time of admission. Review of the Medication Administration Record for the admission month showed an order for oxygen at 3 L/min via nasal cannula, continuous, with a start date two days after the resident’s admission. During interview, the DON stated that an oxygen order should begin on admission when a resident needs it and acknowledged that the resident was wearing oxygen but that the order was not entered into the medical record until two days later. The DON further stated that the facility’s policy on oxygen administration, which requires verification of a physician’s order before the procedure, was not followed by the nurse because there was no oxygen order from admission.
Failure to Develop Baseline Care Plan for Oxygen Therapy and Non-Compliance
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission to address a resident’s oxygen therapy needs and known non-compliance with oxygen use. The resident was admitted with diagnoses including pneumonia and acute respiratory failure with hypoxia. Discharge instructions from the sending provider specified oxygen therapy at 2 L/min via nasal cannula on a continuous basis, with monitoring of oxygen saturation and use of supplemental oxygen as needed to maintain a goal saturation of 92%. The admission/readmission comprehensive nursing assessment documented an oxygen saturation of 98% via nasal cannula, confirming that the resident was receiving oxygen on admission. Despite this, a formal physician order for oxygen was not entered until several days after admission, and the MAR did not show oxygen therapy initiated until that later date. The resident’s care plan, initiated after the oxygen order, identified altered respiratory status related to respiratory failure with hypoxia but did not include any interventions addressing oxygen use, the resident’s non-compliance with wearing oxygen, or any monitoring plan for oxygen saturation. During interviews, the Unit Manager stated that the resident was on oxygen and was non-compliant with its use, and indicated that a care plan would be in place for such non-compliance. The DON acknowledged that there was no care plan for oxygen or for non-compliance with oxygen, despite facility policy requiring a comprehensive, person-centered care plan to meet residents’ needs.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
Nursing staff failed to notify the family of a resident with Crohn's Disease and Ulcerative Colitis when the resident experienced a significant change in condition, specifically an episode of bloody diarrhea. The resident, who was moderately cognitively impaired, was observed by the Nursing Supervisor during the morning shift with this acute symptom. The Nurse Practitioner was notified, and a voicemail was left for the resident's doctor, but there was no documentation that the resident's family was informed of the change in condition as required by facility policy. Interviews and medical record reviews confirmed that while the resident stated they had already called their son, there was no evidence in the medical record that staff had notified the family. The CNA reported that the resident's representative was present at the facility during the emergency, but again, no documentation supported that staff had made the required notification. The facility's policy mandates prompt notification of the resident's representative in the event of a significant change in condition, which was not documented in this case.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Review of the Nurse Staffing Report sheets revealed that there was no RN coverage provided on one of the 28 days reviewed. Specifically, the Nursing Staffing Reports indicated that no RN services were provided on 7/20/25, which is not in compliance with regulatory requirements.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
Surveyors identified that medications were not administered in accordance with professional standards of nursing practice for three residents. In one instance, a resident with diagnoses including anxiety disorder, schizoaffective disorder, and chronic pain did not receive their scheduled pain patch or gel as ordered. The electronic medication administration record (eMAR) indicated the medications were given, but the LPN admitted they had not yet administered them and had signed off in error. The nurse also failed to notify the physician promptly about the missed doses, and the medications were available in the backup supply. Another resident with rheumatoid arthritis did not receive a scheduled dose of Voltaren gel and a newly ordered dose of Methylprednisolone. The eMAR showed the medication was held with a note to see progress notes, but there was no corresponding documentation explaining the omission or any follow-up with the physician. The facility was unable to provide an investigation or further documentation regarding the missed medications, and the consultant pharmacist confirmed that nurses are expected to check backup supplies and notify the physician if medications are unavailable. A third resident with dementia and depression had multiple medications not administered as ordered, with nurses documenting "awaiting delivery" despite the medications being available in the backup supply and in the medication cart. There was no evidence that the physician was notified about the missed doses. The facility's policy requires medications to be administered as prescribed and within one hour of the scheduled time, but this was not followed in these cases.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and preferences.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to provide food that accommodated a resident's known food allergy to eggs and egg-derived products. Resident #32, who had documented allergies to eggs and egg-derived products, was observed eating a hard-boiled egg despite the meal ticket on their breakfast tray clearly indicating these allergies. This incident posed a serious risk to Resident #32's health and well-being, leading to an Immediate Jeopardy situation being declared on 02/27/24. Upon review of Resident #32's medical records, it was noted that the resident had a history of allergies to various substances, including eggs and egg-derived products. Despite these documented allergies in the resident's Admission Record, Physician's Order Summary Report, Comprehensive Care Plans, and various progress notes, the facility failed to ensure that Resident #32's meal was free from allergens. The surveyor's observations revealed that the Dietary Aide responsible for preparing the tray did not adhere to the resident's dietary restrictions, resulting in Resident #32 consuming a hard-boiled egg.
Inadequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent falls for Resident #5, who was identified as a fall risk and had a history of multiple falls resulting in major injuries. Despite being admitted with diagnoses indicating a need for assistance with personal care and a history of falls, the facility did not have a comprehensive care plan in place to address fall prevention upon readmission. The resident sustained multiple falls, including one resulting in a left wrist fracture, without consistent implementation of documented fall prevention interventions. Observations and interviews revealed instances where Resident #5 was found on the floor following unwitnessed falls, indicating a lack of adequate supervision and preventative measures. The facility's failure to consistently implement recommended interventions, such as bed and chair alarms, and to update the care plan in a timely manner after each fall contributed to the ongoing risk of falls for the resident. Despite recommendations from physical therapy for safety measures like alarms and education on calling for assistance, these interventions were not consistently reflected in the care plan or implemented effectively. The facility's documentation also highlighted gaps in assessing and addressing Resident #5's high fall risk status upon readmission and developing a tailored care plan for fall prevention. The lack of timely updates to the care plan, failure to consistently implement recommended interventions, and inadequate supervision to prevent falls for a resident with a history of falls and cognitive impairment contributed to the deficiency identified during the survey.
Inadequate Incontinence Care Leading to Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement interventions to prevent urinary tract infections (UTIs) for a resident with a history of chronic UTIs, leading to multiple instances of UTIs requiring oral and intravenous antibiotic therapy and hospitalization. Resident #51, admitted with diagnoses including Type 2 diabetes mellitus, dementia, overactive bladder, and coronary angioplasty implant, had severe cognitive impairment and required maximum assistance for toileting and hygiene. Despite having a care plan initiated with goals for resolving UTIs, the interventions did not include updated measures to prevent further UTIs or address incontinence care deficits. Observations on 02/23/24 revealed Resident #51 wearing two saturated incontinent briefs, indicating inadequate incontinence care. The facility's staff acknowledged that some residents wore double briefs, and a Certified Nurse Aide (CNA) mentioned placing a pad inside the diaper for heavy wetters. The lack of timely incontinence care, as highlighted by staff interviews, was identified as a risk factor for UTIs. The facility's policies emphasized the importance of changing incontinent briefs every two hours and monitoring for changes in mental status to prevent UTIs related to incontinence. The facility's failure to implement timely incontinence care practices, as indicated by staff interviews and observations, contributed to the deficiency in preventing UTIs for Resident #51. Despite having policies in place to address UTIs and incontinence management, the lack of updated interventions tailored to the resident's needs and history of chronic UTIs resulted in recurring infections requiring hospitalization and antibiotic therapy.
Deficiencies in Antipsychotic Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that antipsychotic medications were administered daily per physician orders for three residents: Resident #19, Resident #45, and Resident #76. Resident #19 and Resident #45 missed multiple doses of their prescribed antipsychotic medications, leading to increased combative and hallucinatory behaviors. Resident #19, diagnosed with schizophrenia, missed 8 out of 31 doses of Clozapine 100 mg, while Resident #45, also diagnosed with schizophrenia, missed 9 doses of Clozapine 200 mg. The deficiencies in medication administration resulted in behavioral escalation, necessitating emergency transfer to Crisis via 911 for both residents. Furthermore, the facility failed to monitor and document behaviors and implement appropriate interventions for Resident #76, who required antipsychotic medication for psychosis. Despite being on Seroquel for psychosis, there was no documented evidence of monitoring specific target behaviors or side effects associated with the medication. The resident's comprehensive care plan lacked individualized non-pharmacological approaches to care, which are essential for maintaining or improving mental, physical, and psychosocial well-being. The facility's failure to adequately monitor and address the resident's behaviors and medication efficacy contributed to the deficiency identified during the survey.
Failure to Address Resident Grievances and Ensure Access to PNA Funds
Penalty
Summary
The facility failed to ensure that all residents were treated with respect and dignity by not promptly addressing ongoing grievances affecting their quality of life. Specifically, the facility did not consistently and uniformly address grievances regarding residents' access to their personal needs account (PNA) funds, food complaints related to the kosher style menu, and the lack of posted menus. This deficiency was identified by six residents who attended a resident council meeting and affected all residents on both units of the facility. During the survey, it was observed that the kitchen operated under a kosher style menu, which was not included in the facility's admission agreement. Residents reported that they no longer received pork products and were limited to chicken and fish, with repetitive menu options. Despite repeated requests for menu changes and the posting of daily menus, these concerns were not adequately addressed. The Food Service Director (FSD) and other staff members were unable to provide documentation or meeting minutes that showed any follow-up on these grievances. Additionally, residents reported difficulties accessing their PNA funds, with restrictions on the amount they could withdraw and delays in receiving their money. The facility's administration did not provide receipts for transactions and failed to ensure that funds were available on weekends. The survey revealed that the facility did not have a clear process for documenting and responding to resident grievances, leading to unresolved issues and dissatisfaction among the residents.
Failure to Ensure Resident Access to Personal Need Account Funds
Penalty
Summary
The facility failed to ensure that residents could access their Personal Need Account (PNA) funds without restrictions, provide access to at least $50.00 on the same day it was requested, and maintain a system that included receipts for disbursements. The deficiency affected all residents with PNA funds. The Licensed Nursing Home Administrator (LNHA) and Human Resources Director (HRD) were unable to provide proof of a system that allowed residents to access their funds as needed, especially on weekends. The HRD admitted that there was no formal policy in place and that the process was communicated verbally to residents. Additionally, the HRD was unaware of the PNA balances for deceased residents, indicating a lack of proper account management. During interviews, residents confirmed that they were unable to access their PNA funds when needed and were restricted to withdrawing only $25.00 at a time. Residents expressed frustration over the delays and excuses given by the staff, and some reported not receiving their money at all. The Resident Council President (RCP) also confirmed that the council never decided on the $25.00 limit and that residents were not provided with receipts for their transactions. The HRD and activity staff corroborated that there was no set amount of money available on weekends and that the process was inconsistent. The surveyor's review of the PNA disbursement logs revealed incomplete records and no disbursements greater than $25.00 on weekends. The HRD and LNHA were unable to provide a documented policy or process for handling PNA funds, especially for deceased residents. The facility's Resident Rights policy stated that residents have the right to manage their personal funds, but the facility failed to uphold this right, leading to the deficiency.
Failure to Provide Quarterly PNA Statements and Manage Accounts
Penalty
Summary
The facility failed to have a system in place to ensure all residents who had the facility manage Personal Needs Account (PNA) funds were provided with a quarterly statement. The Licensed Nursing Home Administrator (LNHA) provided a list of current PNA balances, which included 94 accounts, and noted that six residents with balances over $50 were listed as deceased. The Human Resources Director (HRD), responsible for handling PNA money, confirmed that she did not know about the deceased residents and did not close their accounts. Additionally, the HRD could not provide proof that quarterly statements were sent to residents, as she did not document when statements were mailed out. The LNHA admitted that there was no policy in place for managing PNA accounts and confirmed that residents should receive quarterly statements. The surveyor informed the LNHA and Director of Nursing about the findings related to the PNA, including concerns raised by the resident council. Despite the facility's Resident Rights policy, which guarantees residents the right to manage their personal funds, the facility failed to provide quarterly PNA statements and did not have a proper system to manage and close accounts for deceased residents. The survey team conducted an exit conference with the LNHA, Director of Nursing, and the President of Operations, but no further information was provided regarding PNA statements.
Failure to Convey Resident Funds After Death
Penalty
Summary
The facility failed to have a process in place to ensure that within 30 days of a resident's death, the resident's funds and a final accounting of those funds were conveyed to the individual or probate jurisdiction administering the resident's estate. This deficiency was identified for six expired residents who had current Personal Needs Account (PNA) balances. The Licensed Nursing Home Administrator (LNHA) provided a list of current PNA balances, which included six residents listed as expired but still having balances in their accounts. The Human Resources Director (HRD), who was responsible for the PNA accounts, confirmed that she did not know about the expired residents and had not closed their accounts. The HRD stated that a remote business office (RBO) handled the accounts, but she did not open or close accounts herself and would need to reach out to the RBO for information on closed accounts. The HRD further explained that she contacted the RBO regarding the PNA for the expired residents and was told that paperwork from the family was needed to disperse the money. However, she did not push for specific information and was unable to confirm if the RBO was handling the process or if she was responsible for any part of it. During a pre-exit interview, the LNHA admitted that there was no policy in place for the management of PNA accounts. Despite multiple inquiries, no information regarding the expired resident PNA accounts was provided to the survey team, highlighting a significant gap in the facility's process for managing resident funds after death.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for residents, as observed by surveyors on multiple occasions. Numerous resident rooms in the 200 Unit were found to have visibly stained and soiled privacy curtains, rusted bed frames, chipped furniture, and walls with cracks and splatters. Specific examples include a gray chair with visible stains, a bedside table with missing handles, and a ceiling with brown splatter stains. Additionally, several rooms had missing or damaged furniture, such as a recliner chair with a ripped armrest and a bed frame with a loose piece. During a tour with the Licensed Nursing Home Administrator (LNHA), the surveyors pointed out these deficiencies, and the LNHA acknowledged the issues but did not provide documented rounds or specific plans to address them. The LNHA admitted that the facility was focusing on another unit and had not prioritized the 200 Unit. The surveyors also observed that the day room/dining room had a ripped film over the window, soiled floors, and walls with marks and holes. An activity staff member confirmed that the area did not look clean. Further observations included soiled and stained wheelchairs, a rusted and ripped mechanical lift, and continued issues with cleanliness and maintenance in resident rooms. Despite the LNHA's acknowledgment of the problems and a statement that 4-5 rooms had been painted, the surveyors found no substantial improvements. The LNHA and other management staff did not offer additional information or specific plans to address the observed conditions during a meeting with the survey team.
Failure to Provide Consistent ADL Care and Scheduled Showers
Penalty
Summary
The facility failed to ensure that Activities of Daily Living Care (ADLs) were consistently provided to residents, specifically in providing appropriate incontinent care and scheduled showers. Multiple residents were found wearing double incontinent briefs that were saturated with urine and feces, without their consent or documented care plans indicating the use of double briefs. This practice was observed across several residents, including those with severe cognitive impairments and those who were unable to consent to such care measures. The facility staff, including CNAs and LPNs, confirmed the use of double briefs for residents labeled as 'heavy wetters,' but there was no documentation or care plan interventions supporting this practice. Additionally, the facility had a strong odor of urine, indicating a lack of timely incontinence care. Residents also reported not receiving timely incontinence care, with some stating they were left wet for hours. One resident mentioned that they had to wait from 2:00 PM to 7:00 PM to be changed, despite the facility's policy of providing incontinence care every two hours. The DON acknowledged awareness of the double brief practice and stated that some staff were suspended, but the issue persisted. The facility's documentation was inconsistent, with missing entries for incontinence care and personal hygiene for several residents, further indicating a lack of proper care. The facility also failed to provide scheduled showers to residents. One resident's record showed missed showers on multiple occasions, and the facility could not provide documentation to verify that showers were given as scheduled. The DON admitted that there was no process in place to ensure showers were given on assigned days before January 2024. The facility's policy on ADLs stated that residents would receive services necessary to maintain good nutrition, grooming, personal and oral hygiene, but this was not followed, as evidenced by the observations and interviews conducted by the surveyors.
Staffing and Care Deficiencies
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to provide appropriate incontinence care, scheduled showers, and dignified treatment to residents. Observations and interviews revealed that residents often waited 30 minutes to an hour for assistance, were left in soiled incontinence briefs for extended periods, and were sometimes double-diapered without their consent. This issue was confirmed by multiple residents during a council meeting and through direct observations by surveyors, who noted several instances of residents wearing saturated double briefs and experiencing delays in incontinence care. Additionally, residents reported that their scheduled shower times were not honored, with some being asked to shower late at night or having their showers skipped altogether. The facility's documentation also showed that certain residents did not receive scheduled showers on multiple occasions, and staff cited difficulties in providing care due to the residents' specific needs and time constraints. Furthermore, the facility failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. The staffing records indicated that the facility was consistently understaffed, with several shifts falling short of the required number of CNAs. This deficiency was evident across multiple weeks and months, affecting the quality of care provided to the residents. Interviews with staff confirmed that they were aware of the mandatory staffing requirements but were unable to meet them consistently.
Failure to Ensure Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure that the designated licensed Director of Nursing (DON) worked on a full-time basis as DON to oversee the care of all residents. The DON was also performing the role of the Infection Preventionist (IP) due to the previous IP being a corporate nurse covering multiple facilities and the facility's difficulty in finding a suitable candidate for the IP position. This dual role was confirmed by the DON and the Licensed Nursing Home Administrator (LNHA) during interviews with the survey team. The LNHA acknowledged that the DON was hired to work a scheduled 40-hour week but had taken on the additional responsibilities of the IP a few months ago in the fall. A review of the facility's Director of Nursing Services job description indicated that the primary purpose of the DON was to plan, organize, develop, and direct the overall operation of the Nursing Service Department to ensure the highest degree of quality care. The job description also mentioned assisting the Infection Control Coordinator, but the facility failed to ensure that the DON's full-time schedule was dedicated solely to DON responsibilities. This deficiency was evidenced by the lack of documentation of discussions between the LNHA and the DON regarding the dual roles and the confirmation that the DON was not solely focused on DON duties.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve hot and cold foods at appropriate and appetizing temperatures for residents. During an observation, surveyors, along with the Food Service Director (FSD), tested the temperatures of various food items on a resident's meal tray and found that all hot food items were below the required 140°F, with temperatures ranging from 88°F to 132°F. Cold food items were also found to be above the required 35°F, with temperatures of 51°F and 54°F. Additionally, during a resident council meeting, six residents reported that their food was often cold and that meal trays sat too long in the hallway before being distributed. The facility's Food Temperatures and Holding Policy indicated that hot food should arrive at the resident above 135°F and cold food below 41°F, which was not adhered to in this instance.
Deficiencies in Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and sanitation practices in the kitchen. During an initial tour, the surveyor observed undated meat, improperly labeled chicken, and a thawed egg product without an open or use-by date. Additionally, raw eggs were stored on a middle shelf instead of the bottom shelf, and a large container of potato salad and cottage cheese lacked use-by dates. The surveyor also noted that resident meal trays were visibly wet and dripping, and a can opener was visibly soiled. These observations indicate a failure to adhere to food storage and sanitation policies. Further observations revealed that staff were not wearing appropriate hair restraints. One staff member was seen with hair not fully covered, and a cook's beard was not entirely restrained. Additionally, a pantry refrigerator on the first floor was found to be non-functioning. The facility's policies on food preparation, hair restraints, and food storage were reviewed, and it was found that the observed practices did not comply with these policies. The Administrator was informed of these findings, but no additional information was provided.
Facility Administration Fails to Ensure Resident Well-Being
Penalty
Summary
The facility administration failed to ensure policies, procedures, and effective systems were implemented to maintain each resident's highest practicable physical, mental, and psychosocial well-being. Specific deficiencies included failing to provide appropriate food items to a resident with documented food allergies, failing to provide timely incontinence care to dependent residents, and failing to treat residents with dignity and respect. Additionally, residents were not consistently provided with physician-ordered medications, and interventions were not implemented to prevent falls for a resident with a history of frequent falls and fractures. The facility also failed to address resident council grievances, maintain a homelike environment, ensure residents had unrestricted access to their Personal Needs Accounts, provide transportation for outside trips, maintain a comprehensive emergency preparedness program, and implement an effective infection control program with required antibiotic stewardship and infection surveillance components. Staffing levels were also found to be inadequate to meet resident needs, affecting both resident units in the facility. During the survey, it was observed that a resident with an egg allergy was served and consumed eggs, despite the allergy being documented on the meal ticket. The Medical Director was not made aware of this incident or the concerns regarding incontinence care, where multiple residents were found saturated with urine and wearing double briefs. The Licensed Nursing Home Administrator (LNHA) admitted to not being aware of the antibiotic stewardship not being completed and acknowledged that environmental concerns such as holes in walls, broken furniture, and soiled privacy curtains were not documented during daily rounds. The LNHA also failed to document discussions with the Director of Nursing (DON) regarding infection control and antibiotic stewardship. The survey also revealed that the facility did not have a comprehensive emergency preparedness program, and there were multiple instances of residents not being treated with dignity and respect, such as being served meals on paper plates and disposable silverware, and staff speaking a foreign language in the presence of residents. The facility also failed to follow up on resident council concerns, provide outside trips due to unpaid transportation bills, and manage resident Personal Needs Funds properly. The LNHA admitted to not documenting interactions with the Medical Director or Human Resources Director regarding these issues, and there was no documented process or policy for managing resident funds. The LNHA acknowledged the need for improvement and stated that the facility would strive to do better in the future.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to ensure timely access to medical records during an on-site survey conducted from 02/20/24 through 03/06/24. During the entrance conference, the Licensed Nursing Home Administrator (LNHA) mentioned that the facility had a new electronic medical record (EMR) system since November 2023 and that records prior to this date were imported into the new system. However, when the survey team requested access to these records, they were informed that a tablet was needed to access the prior EMR system. The LNHA was unsure why immediate access to these records was not available and stated that only one person in the facility was familiar with the old EMR system. If this person could not assist, the LNHA would have to contact the former EMR company. By the fourth day of the survey, the facility had still not provided the requested medical records for several residents, including medication and treatment administration records, accidents and incidents, and physician orders from 2022. The survey team specifically noted the missing records for Resident #45, Resident #19, Resident #54, and Resident #51. This failure to provide timely access to medical records was identified as a deficiency in accordance with NJAC 8:39-35.2(k).
QAPI Failures and Resident Care Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAPI) failed to self-identify and address several areas for improvement, including environmental concerns, resident care, the Antibiotic Stewardship Program, and adverse events. During a tour, surveyors observed broken furniture, soiled and missing privacy curtains, and cracked air conditioners. The Licensed Nursing Home Administrator (LNHA) acknowledged these issues but did not document his daily environmental rounds. Additionally, residents expressed dissatisfaction with the kosher-style meals and limited access to their Personal Need Account (PNA) funds, especially on weekends. The Food Service Director (FSD) and LNHA were unaware of the specifics regarding the menu and the contract with the menu company, and there was no follow-up on residents' concerns about the food variety and menu changes. Incontinence care was another significant issue, with multiple residents observed wearing double incontinent briefs saturated with urine. The Assistant Director/Nurse Educator (ADON) admitted that the staff had been in-serviced on this issue two months prior, but no follow-up was conducted to ensure compliance. The facility also failed to implement an effective Antibiotic Stewardship Program (ASP), as there was no system for routine feedback reports and tracking measures of outcome surveillance related to antibiotics. The LNHA was unaware of this lapse and admitted that there was no documentation of any conversations between him and the Director of Nursing Infection Preventionist (DON IP) regarding the ASP. The facility also neglected to update the comprehensive care plan for a resident who sustained 13 falls, including falls with injuries, over a period of time. The Director of Nursing (DON) could not account for missing documents related to the resident's care plan. Additionally, two residents were not administered their prescribed antipsychotic medications, resulting in emergency transfers. There was no documentation explaining why the medications were held or if the attending physician was notified. The LNHA confirmed that the QAPI policy was outdated and that the QAA committee was only aware of the issue with double briefs, failing to address other significant concerns presented by the survey team.
Failure to Ensure Required Members Attend QAPI Meetings
Penalty
Summary
The facility failed to ensure the required members, specifically the Medical Director (MD) and the Infection Preventionist (IP), were present for all quarterly Quality Assurance Performance Improvement (QAPI) meetings. The review of the last four quarterly sign-in sheets revealed that the IP was absent for the meetings on 04/18/23, 10/17/23, and 01/17/24, while the MD was absent for the meeting on 07/08/23. The Licensed Nursing Home Administrator (LNHA) confirmed these absences and noted that the Director of Nursing (DON) was acting as the IP during the 10/17/23 and 01/17/24 meetings. Additionally, the MD stated that he had only attended one QAPI meeting since his appointment in January 2024. This deficiency had the potential to affect all residents in the facility as it compromised the effectiveness of the QAPI meetings in addressing critical health and safety issues, including infection control and prevention measures. The facility's policy did not explicitly require the IP to attend the quarterly meetings, which contributed to the oversight. The LNHA acknowledged that the QAPI quarterly meetings lacked documentation from the IP regarding infection prevention and control, including antibiotic stewardship and infection trends. This was confirmed upon review of the QAPI binder for 2022-2023, which contained no reports from the IP on these critical areas. The facility's Infection Control, Prevention, and Surveillance Plan required quarterly oversight and reporting to the QAPI committee, which was not adhered to, leading to the identified deficiency.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control practices to prevent the spread of potential infection in several instances. On one unit, a staff member placed a dirty meal tray on a food cart with clean trays that had not yet been served. The staff member, identified as the Activity Director, admitted to not following proper procedures for disposing of dirty trays and acknowledged the importance of avoiding the spread of infection. This incident was observed by a surveyor during the breakfast meal service. In another instance, a nebulizer mask used by a resident with chronic obstructive pulmonary disease and acute and chronic respiratory failure was found directly on the bedside table, exposed to the environment. The Licensed Practical Nurse on duty admitted that the mask should have been placed inside a plastic bag when not in use to prevent infection. This observation was made during a care tour by a surveyor. Additionally, the facility failed to ensure the cleanliness of an ice scoop and its container, which were visibly soiled with a black substance. The unit secretary confirmed the contamination and acknowledged the need for regular cleaning. Furthermore, staff members were observed not performing appropriate hand hygiene before and after delivering meal trays and during other care activities. Despite having received in-service education on hand hygiene, staff members did not adhere to the facility's hand hygiene policy, which requires washing hands for at least 20 seconds.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that a resident with recurring urinary tract infections (UTIs) was properly reviewed and managed according to the Antibiotic Stewardship Program (ASP). Resident #51, who had a history of severe cognitive impairment, diabetes, and other medical conditions, was observed to have multiple instances of UTIs and was prescribed various antibiotics over a period of time. However, the facility did not consistently complete or review the Infection Surveillance Checklists for these instances, as required by their policy and national standards. This lack of documentation and review was evident in the resident's medical records and the facility's antibiotic tracking reports. The Director of Nursing (DON), who also served as the Infection Preventionist (IP), admitted to not being able to consistently track and review antibiotic use due to time constraints and other responsibilities. The DON provided incomplete and inconsistent documentation for several months, failing to include necessary details such as onset and end dates, symptoms, pathogens, and outcomes for residents on antibiotics. The facility's ASP policy required regular monitoring, tracking, and reporting of antibiotic use, but these procedures were not followed, leading to gaps in infection control and antibiotic management. The Licensed Nursing Home Administrator (LNHA) was unaware of the deficiencies in the ASP and acknowledged the importance of tracking infections and antibiotic use. The facility's job descriptions and policies outlined the responsibilities for infection control and antibiotic stewardship, but these were not effectively implemented. The surveyor's review of the facility's documentation revealed significant lapses in adherence to the ASP, resulting in the failure to ensure proper antibiotic use and infection control for Resident #51 and other residents in the facility.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect in several ways. Residents' requests for water were not honored, as evidenced by a resident with Alzheimer's who repeatedly asked for water but was ignored by a CNA. The resident did not have a call light to request assistance, and the CNA dismissed the request, citing the resident's repetitive behavior. Additionally, the resident was consistently served meals on disposable dinnerware without any documented rationale for this practice, which was not reflected in the resident's care plan or progress notes. During a resident council meeting, multiple residents expressed concerns about the loud behavior of CNAs in the hallways, long wait times for call bell responses, and inconsistent shower schedules. Residents also reported that staff frequently spoke in foreign languages around them and conducted personal phone calls during resident interactions. These actions were observed by surveyors, including staff referring to residents as 'feeders' and speaking in foreign languages while distributing meals. The use of disposable dinnerware was attributed to a shortage of regular plates and utensils, which was confirmed by the Food Service Director and other staff members. The facility also failed to provide privacy curtains for all residents, as observed during environmental rounds. Two residents were found without privacy curtains for several days, which was confirmed by the maintenance technician and the Director of Maintenance. The facility's policies on dignity and resident rights were not upheld, as staff did not treat residents with the required respect and sensitivity. The deficiencies were identified through observations, interviews, and document reviews conducted by surveyors over a period of several days.
Failure to Notify Physician and Representative of Missed Medication and Change in Condition
Penalty
Summary
The facility failed to notify a resident representative and/or physician for two residents reviewed for a change in condition. Resident #19 did not receive Clozapine 100 mg as ordered by the physician for three consecutive days on two separate occasions. The resident exhibited paranoid behaviors, visual and auditory hallucinations, and refused meals and snacks. There was no documented evidence that the resident's physician or representative was notified of the missed medication or the change in the resident's condition. Similarly, Resident #45 did not receive Clozapine 200 mg as ordered by the physician on two separate occasions. The resident also refused a scheduled complete blood count (CBC) test and exhibited aggressive behavior. Although the doctor was made aware of the resident's behavior, there was no documented evidence that the resident's representative was notified of the missed medication or the change in the resident's condition. The facility's policy requires notification of the resident's physician and representative in such cases, but this was not followed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized resident-centered comprehensive care plans with measurable goals for four residents. Resident #1, who had a history of aggression and was observed being served on disposable dinnerware and cutlery, did not have a care plan addressing this behavior. Despite the Director of Nursing (DON) and Licensed Practical Nurse/Unit Manager (LPN/UM) stating that the behavior was care planned, no documented evidence was found until after the surveyor's inquiry. The resident's care plan only mentioned behaviors of yelling and cursing, with no mention of aggression or the use of disposable dinnerware and cutlery. Resident #5, who had a history of falls, including falls with injury, did not have a care plan addressing fall prevention. The resident sustained a fall resulting in a large bruise and was readmitted to the facility. Despite recommendations from Physical Therapy for bed and chair alarms, there was no documented evidence that these interventions were implemented in the care plan. The Assistant Director of Nursing (ADON) and Licensed Nursing Home Administrator (LNHA) could not provide a care plan for prior falls or comment on the omission of interventions. Resident #76, who had a history of psychosis and was receiving antipsychotic medication, did not have a care plan addressing psychosis or target behaviors. The consulting pharmacy recommended identifying and monitoring behaviors for the use of Seroquel, but there was no documented evidence that this recommendation was followed. The DON and Registered Nurse Unit Manager (RN UM) acknowledged that psychosis was not listed in the care plan, and there were no measurable goals or interventions. Resident #32, who had multiple allergies, did not have a care plan addressing medication and food allergies with measurable goals, possible side effects, and interventions. The facility failed to follow their policies for developing comprehensive care plans.
Failure to Obtain Physician's Order for Diabetic Foot Ulcer Treatment
Penalty
Summary
The facility failed to obtain a physician's order from the attending physician as recommended by the consulting podiatrist for a resident with a diabetic foot ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including Type 2 diabetes mellitus and an acquired absence of the left great toe, was admitted to the facility with no initial skin breakdown. However, an incident report later indicated the presence of a small ulcer on the left great toe, which was subsequently treated by a podiatrist with recommendations for specific topical treatments such as Bacitracin and Mupirocin. These recommendations were not followed up with physician orders in the resident's medical records, leading to a lack of proper documentation and treatment administration as per the podiatrist's advice. The review of the resident's medical records, including the Medication Administration Records (MARs) and Treatment Administration Records (TARs), revealed that there were no physician orders for the recommended treatments from the podiatrist. The facility's handwritten nursing skin assessments and physician progress notes also did not reflect any orders for Bacitracin or Mupirocin. Despite multiple podiatry consultations and recommendations, the necessary physician orders were not obtained, and the treatments were not documented in the resident's records. Interviews with the facility staff, including the LPN Unit Manager and the Director of Nursing, confirmed that the attending physician from 2022 was no longer working at the facility and that the podiatrist who initially treated the resident was also no longer available. The Director of Nursing acknowledged that when a consulting doctor makes a recommendation, the attending physician needs to write an order. The facility's policy on medication administration emphasized that medications should be administered as prescribed, which was not adhered to in this case.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that resident call bells were accessible to residents, as observed during a survey. Resident #1 was found without an accessible call light on two separate occasions. The call light was either blocked by a privacy curtain or behind a nightstand, out of the resident's reach. The care plan for Resident #1 indicated that the call bell should be within reach due to the resident's risk for falls and poor safety awareness. Despite this, the call light was not accessible, and the Director of Nursing (DON) acknowledged that it should have been within reach. Resident #78 was observed with the call light on the floor, out of reach. The CNA acknowledged the issue and stated that the call bell should be within reach of the resident. The resident's care plan included interventions to ensure the call light was within reach to reduce the risk of falls, but this was not followed. Similarly, Resident #288 was found with the call bell on the floor, out of reach. The resident was unable to locate the call bell, and the CNA acknowledged the oversight. The facility's policies and job descriptions for CNAs and LPNs emphasized the importance of ensuring call bells are accessible to residents. The facility's policy on answering call lights required that call lights be within easy reach when residents are in bed or confined to a chair. However, these policies were not followed, leading to the deficiency. The DON confirmed that CNAs and nurses are responsible for ensuring call bells are accessible to residents.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely submission of the required Minimum Data Set (MDS) assessments for a resident. Specifically, the MDS for one resident was found to be over 120 days old. During the survey, the MDS coordinator acknowledged that the quarterly and discharge MDS assessments had not been submitted on time, citing the use of an old medical record system. The Licensed Nursing Home Administrator later provided a report indicating that the discharge assessment was accepted, but the quarterly assessment was submitted late. The Director of Nursing confirmed the late submission with a final validation report.
Failure to Provide Scheduled Trips for Residents
Penalty
Summary
The facility failed to ensure an ongoing activity program that met the needs of all residents, particularly those who enjoyed trips outside the facility. This deficiency was identified for one resident who was cognitively intact and expressed a strong preference for outdoor activities. The resident, who also served as the resident council president, reported that trips used to occur twice per month but had not happened since December. The resident had informed the Licensed Nursing Home Administrator (LNHA) about the desire for more trips, but was told that the bus and trips were too expensive. The resident also mentioned that the LNHA did not conduct meetings regarding changes to the menus as expected. The Activity Director (AD) confirmed that trips were important to the residents but stated that she was unable to schedule them due to unpaid transportation invoices. An invoice for a recreational trip dated several months prior had not been paid despite multiple submissions to corporate. The AD was not informed why the invoice remained unpaid, and the LNHA claimed that trips were listed as TBD on the activity calendar. The surveyor noted that the February activity calendar included a trip marked as TBD, indicating uncertainty about its occurrence. The LNHA and Director of Nursing were informed about the concerns, but no additional information was provided to resolve the issue.
Failure to Ensure Consistent Pain Management for Residents
Penalty
Summary
The facility failed to ensure residents received pain management consistent with professional standards of practice and physician's orders. This deficiency was identified for two residents. Resident #75, who had diagnoses including repeated falls, muscle wasting, and cardiac arrhythmia, was observed to be in pain and reported that a Lidocaine patch, which had been previously ordered, was not consistently applied. The Medication Administration Record (MAR) showed multiple instances where the patch was not applied, and there was no documentation that the physician was notified about the missing medication. The resident repeatedly expressed pain and the lack of the Lidocaine patch, and staff confirmed the inconsistency in applying the patch and the absence of the medication in the facility's stock. The Director of Nursing (DON) acknowledged that the physician should have been notified about the missing medication, but this was not done, leading to the resident experiencing unmanaged pain for several days. Resident #286, who had a fractured ankle and lower tibia, reported that the staff had not provided the correct dosage of Percocet for pain management. The resident was supposed to receive Percocet 7.5/325 mg, but the medication was not delivered until several days after the order was placed. The Treatment Administration Record (TAR) documented elevated pain ratings, and the resident continued to receive the lower dosage of Percocet 5/325 mg, which was ineffective in managing the pain. The facility staff failed to document any contact with the physician or the pharmacy to clarify the order or to inform the physician about the delay in receiving the correct medication. The facility pharmacist confirmed that the delay was due to a lack of communication from the facility staff. The facility's policies and procedures for pain management, administering medications, and handling unavailable medications were not followed. The staff did not notify the physician about the unavailability of the Lidocaine patch for Resident #75 or the delay in receiving the correct dosage of Percocet for Resident #286. The Director of Nursing and the Registered Nurse Unit Manager acknowledged the lapses in communication and documentation, which resulted in the residents experiencing unmanaged pain. The facility's failure to adhere to its policies and procedures led to significant deficiencies in pain management for the residents.
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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