Excel Care At Wayne
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 296 Hamburg Turnpike, Wayne, New Jersey 07470
- CMS Provider Number
- 315103
- Inspections on file
- 13
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Excel Care At Wayne during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after exiting through an unsecured back door in a construction area where the wander guard system was not functioning. The required daily alarm checks were not completed, and staff were unaware of all residents at risk for elopement due to inconsistent updates to the Neighborhood Watch list. Another resident at risk for elopement was not recognized by some staff as a wanderer or as wearing a wander guard, highlighting failures in communication and supervision.
A resident with severe cognitive impairment and a history of wandering eloped from the facility and was found outside by staff after being reported missing. Although the resident was assessed and returned safely, nursing staff failed to document the elopement event in the medical record, contrary to professional standards and facility policy. Leadership confirmed that such incidents should be recorded to ensure continuity of care.
The facility failed to protect hazardous areas as per NFPA 101:2012 standards. Observations revealed that the kitchen door did not close properly, the storage room by laundry lacked a self-closing device, and the dietary storage room door did not latch. Additionally, the basement medical records room stored combustible materials without a self-closing door.
The facility failed to conduct monthly inspections of the range-hood fire suppression system's wet chemical cylinder, as required by NFPA standards. An observation revealed that while a semi-annual inspection was completed, documentation for monthly inspections from June to November 2024 was missing. This deficiency, confirmed during an interview, had the potential to affect all residents.
The facility failed to maintain its fire system sprinkler heads and ceiling smoke barriers according to NFPA standards. Observations revealed missing escutcheon plates and gaps in ceiling tiles near sprinkler heads in various areas, including the kitchen office, bathrooms, and dining room. These deficiencies were confirmed through interviews and communicated during the Life Safety Code survey exit conference.
The facility did not provide an instructional placard near the Class K fire extinguisher in the kitchen, as required by NFPA standards. This placard should have indicated that the fire protection system must be actuated before using the extinguisher. The deficiency was confirmed through staff interviews and discussed during the Life Safety Code exit conference.
The facility's generator lacked a remote manual stop station, as required by NFPA standards, potentially affecting all residents. Staff were aware of the requirement but could not locate the stop station during the survey.
The facility failed to establish policies and procedures for the maintenance and testing of Patient Care Related Electrical Equipment (PCREE) and did not maintain documentation of testing, inspection, and repairs as required by NFPA 99. During a survey, it was found that there were no comprehensive maintenance programs or inspection reports available, and the facility representatives were informed of this deficiency.
The facility failed to provide a "NO Exit" sign at a stairway door near room 118, which was neither an exit nor a way of exit access. The door was marked with a sign indicating stairs and had an exit sign nearby, making it likely to be mistaken for an exit. This arrangement could affect all first-floor residents, as the stairwell serves as an exit from the second floor to the first floor but not from the first floor.
The facility failed to maintain operational bathroom exhaust fans as required by NFPA standards. During a tour, it was found that 3 out of 7 resident room bathrooms lacked windows and had non-operational exhaust fans, affecting rooms 122, 126, and 218. The main exhaust fan for the section was down, impacting all bathrooms served by that unit, potentially affecting 50 residents.
The facility failed to ensure call bells were within reach for two residents, one with moderately impaired cognition and another with severe cognitive impairment. Both residents had care plans that included using the call bell for assistance, but observations showed the call bells were consistently out of reach, contrary to facility policy.
A facility failed to use a blood pressure monitor correctly, leading to repeated error readings for a resident. Additionally, an antibiotic treatment was not administered as ordered for another resident with a stage 4 pressure ulcer. The facility's policy did not require notifying the physician unless two consecutive doses were missed, but the Director of Nursing acknowledged that the physician should have been informed of the missed doses.
A resident with severe cognitive impairment and frequent urinary incontinence was found with two saturated incontinence briefs, contrary to facility policy. The CNA responsible had not provided care that morning due to a heavy workload, and the resident's care plan lacked incontinence care instructions.
The facility had a medication administration error rate of 7.6%, exceeding the acceptable 5% threshold. Errors included an LPN administering the wrong dosage of Sennoside to a resident and another LPN failing to take a resident's blood pressure immediately before administering Amlodipine, as required by the physician's order. These issues were identified during a survey and discussed with facility leadership.
Failure to Prevent Elopement Due to Inadequate Supervision and System Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to a severely cognitively impaired resident with a known history of wandering and elopement risk, resulting in the resident eloping from the facility. The resident, who had dementia, epilepsy, a history of falls, and a BIMS score indicating severe cognitive impairment, was last seen by staff near the nurse's station and was later found outside the facility by members of the public. The resident was wearing a wander guard, but exited through an unsecured back door in a construction area where the wander guard system was not operational due to a malfunctioning pin pad and disconnected power to the magnet lock. The required daily check of the door alarms had not been completed by the Manager on Duty prior to the incident. Staff interviews and facility records revealed that the resident had been identified as an elopement risk days prior, with a care plan and wander guard in place. However, the resident was able to leave the building through a series of unsecured and unsupervised areas, including a construction zone with an unzipped dust barrier and unlocked doors, ultimately reaching a sidewalk adjacent to a highway. The wander guard system did not alert staff to the resident's exit, and the malfunction was only discovered after the elopement occurred. The facility's elopement and wander guard policies required regular maintenance and testing of the system, as well as supervision in the event of equipment malfunction, but these procedures were not followed. Additionally, the facility failed to ensure that all staff were aware of which residents were at risk for elopement. A second resident, also with severe cognitive impairment and a history of wandering, was not recognized by some staff as a wanderer or as wearing a wander guard. The Neighborhood Watch list, which identified residents at risk for elopement, was not consistently updated or communicated to all staff, leading to confusion and lack of awareness about residents requiring increased supervision. This lack of communication and oversight contributed to the deficient practice in preventing elopement.
Removal Plan
- Resident #2 was located and brought back in building, wanderguard was functional, the resident was assessed with no injuries and placed on 1:1 supervision.
- The Director of Maintenance checked doors, elevators, and wanderguard systems to confirm functional, and identified a possible exit in a non-residential area and secured with alarm.
- The facility began an investigation, and wanderguard devices were tested.
- The Neighborhood Watch list with residents' photos was updated.
- An elopement drill was conducted.
- Certified Nursing Aide (CNA) assignments were updated to include identification of residents at risk for elopement.
- All staff were educated on elopement process.
Failure to Document Resident Elopement in Medical Record
Penalty
Summary
The facility failed to ensure that nursing staff documented a resident's elopement from the facility in the resident's medical record, as required by professional standards of practice. On the date of the incident, a resident with severe cognitive impairment and a history of dementia, epilepsy, and falls was last seen at the nurse's station before being discovered missing from their room. An elopement protocol was initiated, and the resident was found outside the facility by staff after being seen by visitors. The resident was returned to the facility, assessed for injuries, and placed on one-to-one supervision. A review of the resident's medical record revealed that there was no documentation of the elopement incident in the progress notes. The only note present was a nurse's progress note that did not mention the elopement, but instead documented a skin assessment and foot evaluation. Interviews with nursing staff confirmed that the elopement should have been documented in the resident's medical record, and that such incidents are typically charted post-incident to ensure all staff are aware of the event. The facility's own policy on nursing documentation requires that all changes in condition or behavior, as well as nursing interventions and observations, be documented accurately and promptly. The Director of Nursing and other leadership confirmed during interviews that elopement is considered a behavior that should be documented in the medical record. The lack of documentation for this incident was identified as a failure to follow both professional standards and facility policy.
Deficiencies in Hazardous Area Protection
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected in accordance with NFPA 101:2012 Edition, Sections 19.3.2.1, 7.2.1.8, 9.7, and 8.4. During observations, it was noted that the kitchen door, which was on a hold-open device, did not close completely into its frame when released, even after multiple tests. Additionally, the storage room by the laundry had combustible boxes stored without a self-closing or automatic closing device on the door. Similarly, the dietary disposable storage room door failed to positively latch when opened to 90 degrees and released, despite repeated testing. Further observations revealed that the basement medical records room contained combustible paper records with boxes stacked throughout, and the door to this room also lacked a self-closing or automatic closing device. These deficiencies were confirmed through interviews conducted at the time of the observations. The issues were communicated to the relevant personnel during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: A self-closer was added to kitchen door and laundry storage room on 12/14/24. A latch was added to dietary disposable storage room and medical records room on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been serviced on protecting hazardous areas enclosures. The Maintenance Director/designee will conduct monthly walking audits of all doors within hazardous areas for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review audits on a quarterly basis for 12 months to ensure compliance.
Failure to Perform Monthly Inspections of Fire Suppression System
Penalty
Summary
The facility failed to perform monthly inspections of the range-hood fire suppression system's wet chemical cylinder as required by NFPA 17 A: 2009 Edition and NFPA 96: 2011 Edition. During an observation, it was noted that the semi-annual inspection was conducted on December 2, 2024, and the inspection tag was new. However, the facility lacked documentation for the monthly inspections for the previous six months, specifically for June through November 2024. This oversight was confirmed during an interview with a staff member at the time of the observation. The deficiency was identified during a survey conducted on December 12, 2024, and was discussed with facility representatives at the Life Safety Code exit conference on December 13, 2024. The absence of monthly inspection documentation for the range-hood fire suppression system had the potential to affect all residents, as it is a critical component of the facility's fire safety measures. No further documentation was provided to demonstrate compliance with the required monthly inspections.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance director reached the vendor which confirmed that the inspection was completed, however they do not keep previous tags. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in serviced to conduct monthly audits of kitchen hood suppression inspections and automatic sprinkler separations. Maintenance/designee will complete audit inspections and sign off tags of suppression systems the first week of every month. Monthly audit logs will be submitted to the Administrator for review and kept in the Maintenance office. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its fire system sprinkler heads and ceiling smoke barriers in accordance with NFPA 101: 2012 edition and NFPA 25: 2011 edition. During a tour of the facility, several deficiencies were observed, including a missing escutcheon plate on the kitchen office sprinkler head and missing drop ceiling components in the bathrooms of rooms 122 and 126, which caused gaps near the sprinkler heads. Additionally, the storage closet by room 212 had a space along the side of the sprinkler escutcheon cap penetrating through the drop ceiling, and the second-floor dining room had two sprinkler heads missing escutcheon plates. These observations were confirmed through interviews conducted at the time of the survey. The deficiencies were communicated to the relevant staff during the Life Safety Code survey exit conference. The report highlights the potential impact of these deficiencies on all residents, as the facility did not ensure the proper maintenance of its fire protection systems.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance Director received a proposal from the vendor for kitchen office sprinkler head (X1) and second floor dining room (X2) for escutcheons. See attached evidence. The drop ceiling was replaced in the bathroom of rooms 122 and 126 on 12/14/24. The drop ceiling was replaced in the storage closet by room 212 on 12/14/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the Sprinkler Systems. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in-serviced on Sprinkler System Maintenance and Testing. The Maintenance director/designee will conduct monthly walking audits of all sprinkler systems on all floors. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Missing Instructional Placard for Fire Extinguisher
Penalty
Summary
The facility failed to comply with NFPA standards by not providing an instructional placard near the Class K portable fire extinguisher in the kitchen. This placard should have indicated that the fire protection system must be actuated before using the extinguisher. This deficiency was observed during an inspection at 11:26 AM, and the absence of the placard was confirmed through interviews with staff present at the time. The issue was discussed with the relevant personnel during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The K rated fire extinguisher was moved to the proper location next to instruction placard. It is still in the kitchen in an accessible location. See attached evidence. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in-serviced on keeping all monthly placards of portable fire extinguishers. The maintenance Director/designee will maintain a log on all placards monthly. Findings will be submitted to the Administrator for review. Additionally, the maintenance Director will keep onsite placards for a period of at least one year prior to the current year. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audits on a Quarterly basis x 12 months to ensure compliance.
Lack of Remote Manual Stop Station for Generator
Penalty
Summary
The facility failed to ensure the Essential Electrical System (EES) was equipped with a remote manual stop station for the generator set, as required by NFPA 99: 2012 Edition and NFPA 110: 2010 Edition. During an observation on December 12, 2024, it was noted that the facility's generator, located outside the building, lacked a remote manual stop station. This deficiency was identified as having the potential to affect all residents. In an interview conducted on December 13, 2024, a staff member acknowledged awareness of the requirement for a remote manual stop station but was unable to locate one at the time. The absence of this critical safety feature was confirmed during the Life Safety Code Exit conference, highlighting a significant oversight in the facility's compliance with safety regulations.
Plan Of Correction
1/21/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: Powerhouse Generators will be installing the remote manual stop on 1/21/25, due to the recent cold weather and freezing of the ground. Appointment confirmation attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated to maintain remote manual stop and electrical systems. The Maintenance Director/Designee will test remote manual stop during weekly generator testing. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audits on a Quarterly basis x 12 months to ensure compliance.
Deficiency in Electrical Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to provide policies and procedures for Patient Care Related Electrical Equipment (PCREE) and did not conduct maintenance of electrical equipment or maintain a record log of all required testing, test results, and repairs in accordance with NFPA 99: 2012 Edition. This deficiency was identified during a documentation review conducted over three days, where it was revealed that there was no documentation of PCREE testing, inspection, and maintenance available. The surveyor requested the Maintenance Coordinator and Administrator to provide any PCREE documents, but none were provided. In an interview, it was stated that the facility's electrical equipment is inspected and labeled with a sticker, but there were no comprehensive policies or procedures for maintenance, testing, and inspection of PCREE. Additionally, there were no inspection reports available for the facility's patient care-related electrical equipment. This lack of documentation and established procedures was communicated to the facility representatives during the Life Safety Code exit conference.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The VPPO on 12/24/24 updated Electrical Equipment Testing and Maintenance policy and procedure dated 5/1/24, to include Patient Care Related Electrical Equipment (PCREE). 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated on the policy for the maintenance of electrical equipment, and to tag and log all required testing and results and repairs. The Maintenance Director/designee will conduct routine monthly audits of all electrical equipment per manufacturer specifications for results and repairs. Maintenance will tag all inspected equipment. Findings will be submitted to the Administrator for review. 4. Monitoring corrective action: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.
Inadequate Exit Signage at Stairway Door
Penalty
Summary
The facility failed to provide appropriate signage at a stairway door, which was neither an exit nor a way of exit access, as required by NFPA 101: 2012 Edition, Section 19.2.10 and 7.10.8.3.1. During an observation, it was noted that the stairwell door by room 118 was marked with a sign indicating stairs and had an exit sign suspended from the corridor ceiling nearby. The exit sign, positioned approximately 8 inches to the left of the door's opening edge and 7 inches off the corridor wall, featured chevron arrows pointing in both directions. This arrangement made the door likely to be mistaken for an exit, necessitating a "NO Exit" sign on the door. The stairwell serves as an exit from the second floor to the first floor but is not an exit from the first floor, potentially affecting all first-floor residents.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: No Exit sign was placed on stairwell door by room 118 on 12/23/24. 2. Identification of residents who have the potential to be affected by the same deficient practice: All 1st floor residents had the potential to be affected. 3. Systemic changes to ensure that deficient practice does not recur: Maintenance has been in service on Exit signage. Maintenance/designee will conduct monthly walking audits of all exit doors outside for compliance and tracking. Findings of audits will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the audit on a Quarterly basis x 12 months to ensure compliance.
Non-Operational Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain operational bathroom exhaust fans in accordance with NFPA 101:2012 edition, Sections 19.5.2.1, 9.2, and NFPA 90A. During a facility tour, it was observed that 3 out of 7 resident room bathrooms did not have windows, and the exhaust fans were non-operational. These rooms were identified as 122, 126, and 218. An interview confirmed that the main exhaust fan for the section was down, affecting all bathrooms served by that unit. This deficiency had the potential to affect 50 residents.
Plan Of Correction
1/13/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The maintenance Director has repaired exhaust fans in rooms 122, 126 and 218. See evidence attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated in maintaining heating, ventilation, and air conditioning in all patient rooms. The Maintenance Director/ designee will audit HVAC systems throughout the facility, in patient rooms every six months. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the bi-yearly audit on a Quarterly basis x 1 year to ensure compliance.
Failure to Ensure Call Bells Within Reach of Residents
Penalty
Summary
The facility failed to maintain the call bell within reach of residents, which was identified for two residents. Resident #8, who has moderately impaired cognition and requires maximum assistance for Activities of Daily Living (ADL) care, was observed multiple times seated in a wheelchair with the call bell affixed to the right enabler, out of reach. Despite the care plan intervention to encourage the resident to use the bell for assistance, the call bell was consistently placed out of reach by the Certified Nursing Assistants (CNAs) responsible for the resident's care. Resident #11, who has severe cognitive impairment and is dependent on staff for ADL care, was found in bed with the call bell on the floor under the bed, making it inaccessible. The resident's care plan also included an intervention to encourage the use of the call bell for assistance. The facility's policy requires that residents have a means to call staff for assistance, but this was not adhered to, as confirmed by the CNAs and the Licensed Nursing Home Administrator.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #11 call bell was placed within reach immediately. The unit managers ensured the call light was within reach daily. Plan of care reviewed. "Resident #8 call bell was placed within reach immediately. Plan of care reviewed. "Education was conducted with assigned CNAs by Director of Nursing regarding the placement of call bell after care. "Education was completed with all nursing staff regarding the placement of the call bell. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by this deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Ongoing education will be provided to all nursing staff by the Director of Nursing regarding the placement of call bells after care. "Call bell policy reviewed, and education provided to all nursing staff by Director of Nursing. "The Director of Nursing or designee will check the placement of call bells daily at the beginning of each shift. 4. Monitoring corrective actions: "The Director of Nursing or designee will audit 5 call bells placement weekly x 3 months and then monthly x 3 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Deficiencies in Blood Pressure Monitoring and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a blood pressure apparatus was used in accordance with the manufacturer's specifications. During an observation, a Licensed Practical Nurse (LPN) attempted to take a resident's blood pressure multiple times using incorrect techniques, such as placing the cuff on the forearm instead of the upper arm and positioning the rubber tube on the outside of the arm. These errors resulted in repeated error readings. The Registered Nurse/Unit Manager (RN/UM) later confirmed the incorrect technique and stated that the LPN would be educated on the proper use of the device. Additionally, the facility did not administer an antibiotic treatment as ordered by the physician for a resident with a stage 4 pressure ulcer. The resident reported that there were days when the prescribed Gentamicin was not administered. A review of the electronic Medication Administration Record (eMAR) confirmed that doses on two separate days were missed. The facility's policy did not require notifying the physician unless two consecutive doses were missed, but the Director of Nursing acknowledged that the physician should have been informed of the missed doses. The report highlights deficiencies in both the administration of medication and the use of medical equipment, which were not in accordance with professional standards of practice. The facility's failure to adhere to these standards resulted in improper care for the residents involved, as evidenced by the incorrect blood pressure readings and the missed antibiotic doses.
Plan Of Correction
Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident #16). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #20 [R] was taken using the correct method as per manufactures specification. Resident #20 was not affected by the deficient practice. 'US FOIA (b)(6) was educated immediately about proper use of NJ Ex apparatus by unit manager. "Resident #16 was not affected by deficient practice. MD was notified of missed treatments. No new orders were given. "Education was completed by the Director of Nursing with US FOIA (b)(6) regarding the process to be followed when medications are not available. "Medication administration policy was reviewed and updated to reflect communication of missed medication with the physician. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education was provided by the Director of Nursing to all nursing staff regarding proper placement of blood pressure cuff. "Education was provided by the Director of Nursing to all nursing staff regarding the process to be followed when medications are not available and documenting communication with physician. "Blood Pressure cuff placement competency added to orientation and annual training. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit the placement of blood pressure cuff by 2 nurses weekly for 1 month and then monthly for 6 months. "The Director of Nursing or designee will audit 5 residents with treatment orders weekly for 1 month and then monthly for 6 months. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Inadequate Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as Resident #71, who was dependent on staff for assistance. During an observation, the surveyor found the resident seated in a wheelchair in the bathroom with two saturated incontinence briefs, which is against the facility's policy. The Hospitality Aide present was not assigned to provide direct care and had to summon the Certified Nursing Assistant (CNA) responsible for the resident. Upon arrival, the CNA confirmed the inappropriate use of double diapers and admitted to not having provided care to the resident that morning due to having 12 residents on her assignment. Resident #71 was admitted with chronic kidney disease, a fracture of the right femur, and hypertension, and had a severe cognitive impairment with a BIMS score of 7 out of 15. The resident required supervision with toileting and was frequently incontinent of urine. However, the resident's care plan did not address incontinence care, which was a requirement according to the facility's policy. The Director of Nursing acknowledged the oversight and confirmed that the care plan for incontinence care was not initiated until after the surveyor's inquiry.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that NJ Ex Order 26.4b1 was provided to a NJ Ex Order 26.4b1 resident for 1 of 4 residents reviewed for J Exec Order 26.461 care (Resident #71) on 1 of 2 nursing units, X-floor unit. 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #71 was assisted with NJ Ex Order 26.4(b)(1) NJ Ex Ord care immediately. was assessed, no changes in NJ Ex Order 26.4(b)(1) noted. "Education was provided by the Director of Nursing to U.S. FOIA (b) (6) regarding timely NU Ex Order 26.4(b)(1) care. "Plan of care updated for all residents who prefer to use. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All incontinent and dependent residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education provided by Director of Nursing to all nursing staff regarding timely incontinent care as per residents needs. "Residents requesting for two briefs will be evaluated quarterly and annually and preference will be included in the plan of care. "Incontinence rounds added/included in the unit managers daily rounding to ensure incontinence care is provided as per the residents needs. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit 5 incontinent residents weekly for month and then monthly for 6 months to ensure incontinent care is provided in a timely manner. "The Director of Nursing will audit all incontinent residents for preference of two briefs weekly for 1 months and then monthly for 6 months to ensure residents preference is reflected in the plan of care. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 7.6%, which exceeds the acceptable threshold of 5%. During a medication pass observation, two errors were identified involving two residents. The first error occurred when an LPN prepared medication for a resident with a physician's order for Sennosides - Docusate sodium 8.6 mg - 50 mg. Instead, the LPN poured Sennoside 8.6 mg from a house stock bottle, which was incorrect according to the physician's order. This error was acknowledged by the LPN upon review with the surveyor. The second error involved another LPN who prepared medication for a resident with a physician's order for Amlodipine 10 mg, which required holding the medication if the systolic blood pressure was less than 110. The LPN recorded the resident's blood pressure from a notebook into the electronic Medication Administration Record (eMAR) but admitted to taking the blood pressure earlier in the morning rather than immediately before administering the medication, as required by the physician's order. These deficiencies were discussed with the Director of Nursing and other facility leaders during the survey.
Plan Of Correction
Based on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities, and two (2) errors observed which calculated to a medication administration error rate of 7.6%. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20). 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "LPN #1 was educated by the Director of Nursing about verification of correct medication during medication administration and process to follow if a medication is not available. A medication administration observation was completed on LPN #1 by the Director of Nursing. Resident #97 did not receive the wrong medication and was [R] by the deficient practice. LPN #2 was educated by the Director of Nursing about proper medication administration procedure when administering NJ Ex Order 26.4(b)(1) medication with a NJ Ex Order 26.4(b)(1). LPN #2 was educated to complete blood pressure right before administering medication. The LPN #2 completed NJ Exec Order 26.4b1 right after and administered medication as per protocol. Resident #20 was not affected by the deficient practice. A medication administration observation was completed on LPN #2 by the Director of Nursing. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education completed, and the medication administration policy and procedure revised and updated on 12/20/24, with all nurses. The pharmacy consultant will continue with medication administration observations and education monthly to ensure competency of all nurses. 4. Monitoring of corrective actions: "The Director of Nursing or designee will complete medication observation on 3 nurses monthly for 6 months to ensure competency of nurses with an emphasis on medication verification and blood pressure completion right before administering hypertensive medications with BP parameter. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.
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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