Gateway Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eatontown, New Jersey.
- Location
- 139 Grant Ave, Eatontown, New Jersey 07724
- CMS Provider Number
- 315177
- Inspections on file
- 15
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Gateway Care Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with a history of wandering eloped from the facility without staff knowledge. The resident was last seen by nursing staff, and a search was initiated after the resident was found missing. Despite existing policies, only wandering risk assessments were performed, and the resident was not placed on frequent monitoring. Staff were unsure how the resident exited, and there was no clear protocol for increased supervision for exit-seeking behavior, resulting in the resident being found by police in a nearby town.
A facility failed to maintain a resident's nutritional and hydration status, resulting in significant weight loss over six months. The resident's dietary preferences were not adequately addressed, and the facility relied on infrequent family visits for nutritional support. Staff did not consistently monitor or record the resident's intake of prescribed supplements, and there was a lack of suitable dietary interventions.
The facility failed to ensure menus were reviewed for nutritional adequacy, leading to discrepancies in dietary care for residents. Menus were not signed by a qualified nutrition professional, and residents received meals that did not match their preferences or physician's orders. The dietitian admitted to a lack of a formal follow-up system to ensure dietary changes were implemented.
The facility failed to ensure the Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program, as the IP was also acting in another role and spent limited time on IP duties. Despite the IP's assurance of up-to-date infection control measures, the facility did not comply with the requirement for a full-time IP dedicated solely to infection prevention and control.
The facility did not maintain clear exit discharges, as ice and snow were observed on pathways at multiple exits, including those by the employee entrance, Kitchen, and Room 105. Staff confirmed awareness of the need for snow and ice removal, affecting all 131 residents.
The facility failed to maintain its sprinkler system per NFPA 25 standards, affecting all 131 residents. Ice buildup was found on a sprinkler head in the freezer, and a missing escutcheon plate was noted in the dishwashing room. The facility lacked documentation for weekly inspections of the dry sprinkler system gauges.
The facility was found to have unsealed penetrations in smoke barriers, including gaps and overcuts in various locations such as near the Dining Room, Room 210, the Korean Office, the Break Room, and the Beauty Salon. This repeat deficiency, previously cited in a past survey, was confirmed by a facility representative who was unaware of the issue, potentially affecting all 131 residents.
The facility failed to maintain smoke barrier doors, affecting 42 residents. A door in the corridor by Room 104 did not close properly due to rubbing the floor, and a door between Rooms 210 and 211 lacked a self-closing device. Staff were unaware of these issues before the survey.
The facility failed to provide documentation of the annual tests and inspections of fire door assemblies as required by NFPA 80. During a record review, it was found that the documentation was missing from the Life Safety Code Survey Binder. Despite requests at various points, the documentation was not provided, and a staff member confirmed the inability to locate it. This deficiency had the potential to affect all 131 residents.
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99. This deficiency could potentially affect all 131 residents, as the facility has a mix of hospital-grade and non-hospital-grade receptacles in resident rooms. An interview confirmed the facility's inability to locate the missing documentation.
The facility failed to maintain its generator according to NFPA 110 standards, as it could not provide documentation of the annual fuel quality test for the diesel generator. This deficiency, confirmed during an interview, had the potential to affect all 131 residents, as the generator is crucial for emergency power.
The facility failed to maintain a sanitary environment, as observed with a resident's recliner and another's wheelchair having dried substances, and an overbed table with brownish spots. Despite a cleaning schedule, these items remained uncleaned, indicating lapses in maintaining a homelike environment.
A facility failed to report and investigate a condition involving a resident until prompted by a surveyor. CNAs noticed the condition but did not report it, assuming it was known. The facility's policies required immediate reporting of such incidents, but there was a lapse in communication. The resident's medical records showed no assessment of the condition until after the surveyor's inquiry.
A registered nurse in an LTC facility borrowed medication from another resident's supply for a resident due to unavailability in the medication cart. The nurse did not follow the protocol of contacting the pharmacy or physician for guidance. Interviews revealed a lack of clarity regarding the policy on borrowing medications, although staff were instructed not to engage in this practice.
A facility failed to maintain a medication error rate below 5%, as observed during a medication pass where a nurse administered the wrong dose of a medication to a resident. The error was identified when the nurse applied a medication patch with incorrect strength to two sites on the resident. Despite inservice training on medication administration, the facility's policy did not ensure the correct dosage was administered.
The facility failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, as observed during rounds on two units. In one case, a staff member checked a resident's condition without a gown, despite signage indicating its necessity. In another instance, a staff member performed care without a gown, later claiming she had stepped out to retrieve an item. Both residents required Enhanced Barrier Precautions due to their diagnoses, highlighting non-compliance with infection control policies.
The facility failed to notify CMS and obtain authorization for a name change from "Gateway Care Center" to "Shore Point Care Center." The surveyor observed the incorrect name on the facility's signage and business cards. Facility representatives admitted the name change was for marketing purposes and had not been reported to CMS or the New Jersey Department of Health. The facility decided to revert to the original name.
The facility failed to meet New Jersey's staffing ratios for CNAs across multiple shifts and did not enforce mask-wearing for employees with medical exemptions from the influenza vaccine. Observations and interviews revealed consistent understaffing and non-compliance with mask policies, indicating lapses in regulatory adherence.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A severely cognitively impaired resident with a history of wandering behaviors eloped from the facility without staff knowledge. The resident, diagnosed with unspecified dementia, mood disturbance, anxiety, and Alzheimer's disease, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The resident was last observed by a registered nurse at approximately 4:45 p.m., and was discovered missing by their assigned certified nurse aide at around 5:05 p.m. Despite a search initiated by staff and the activation of a Code Gray (elopement/missing person code), the resident was not found within the facility. The local police later contacted the facility, having found the resident in a nearby town approximately three miles away, and returned the resident to the facility. The facility's policy required systematic monitoring and management of residents at risk for elopement or unsafe wandering, including identification, assessment, and implementation of interventions to reduce risks. However, interviews with staff and review of facility documents revealed that only wandering risk assessments were conducted, not elopement risk assessments. The care plan for the resident included interventions for wandering and elopement risk, but staff did not place the resident on 15-minute checks, as they were not considered exit-seeking. The Director of Nursing and the Licensed Nursing Home Administrator both stated that the facility did not perform elopement risk assessments, only wandering risk assessments, and that the care plan may have mischaracterized the resident's risk. Staff statements indicated that the resident was known to wander and pace the unit, but there was no clear protocol for increased supervision or monitoring for exit-seeking behavior. The facility was unable to determine how the resident exited the building, as all doors were reported to be locked. The receptionist did not observe the resident leaving through the front entrance, and dietary and housekeeping staff did not recall seeing the resident exit. The lack of adequate supervision and failure to properly assess and monitor for elopement risk led to the resident's unsupervised departure from the facility.
Removal Plan
- All residents were visually checked to be sure they were safe and all staff facility wide were informed to check all residents to ensure safety.
- A complete head count of residents was conducted, and all other residents were accounted for.
- Audit to review the residents at risk of elopement assessments was conducted.
- Full house audit for residents at risk for elopement with review and revision of the care plans was conducted. This included implementation of interventions consistent with the residents' needs, goals and care plans to reflect current risk of elopement.
- The residents were monitored when noted in the common areas such as dayroom, dining rooms, and attending activities.
- The facility has now increased the monitoring to Q 15-minute monitoring Q shift.
- Staff were re-educated on the Elopement Policy and Procedure.
- At risk residents for elopement are identified with a discreet visual indicator listed under special instructions in the residents EMR (Electronic Medical Records).
- Elopement binders located on each unit and front entrance were reviewed and revised with the resident's profile picture in color.
- All exits, windows, and keypads were checked and functioning.
- Keypad codes were changed.
- Facility added monitoring rounds every 15 minutes for identified high-risk residents to maintain safety.
- Audit monitoring tool sheets will be completed by direct care staff and completion reviewed by the DON/Designee.
- Facility implemented a new protocol for Family/Vendors/Visitors to sign in upon entering and sign out prior to exiting the facility.
- Director of Maintenance conducted a full house audit of the keypad doors and windows noted secured, and functioning.
- The facility Director of Maintenance, Director of Housekeeping, and the Administrator will maintain the keypad codes.
- Director of Maintenance will revise the schedule for changing keypad codes, making changes more frequent to monthly to the exit doors located at the end of the units.
- Visitor Communication Signage is located at the vestibule alerting visitors and staff to monitor the surroundings prior to entering the lobby to ensure the safety of the residents.
- Facility Educator provided mandatory re-education for staff (nursing, direct care, dietary, housekeeping, maintenance, and department heads) on elopement prevention, supervision, and emergency response.
- Ongoing training will be provided with any staff on all shifts or vacations prior to the start of the next schedule shift.
- Facility Educator will continue to incorporate the Elopement prevention training into new hire orientation and annual education.
- Facility Educator provided mandatory training on the new implementation of identifying residents at risk for elopement under special instructions in the residents EMR (Electronic Medical Records).
- Facility Administrator conducted QAPI Ad Hoc (Quality Assurance and Performance Improvement) meeting with the Interdisciplinary Team to review the residents at risk for elopement care plans, interventions and elopement assessments.
- Quarterly elopement drills will be conducted to reinforce emergency response.
- Monthly review of elopement risk assessments by the interdisciplinary team will be conducted and revised as needed.
- A QAPI (Quality Assurance and Performance Improvement) has been initiated to report on the above monitoring and auditing procedures.
- Results of the audits and findings, if any, will be presented to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and revised as deemed appropriate.
- Monitoring/Auditing and reporting will continue for a minimum of three months.
Failure to Maintain Resident's Nutritional and Hydration Status
Penalty
Summary
The facility failed to maintain the nutritional and hydration status of a resident, as evidenced by the lack of appropriate interventions and monitoring. The resident experienced significant weight loss over a period of six months, which was not adequately addressed by the facility's staff. Despite the resident's preferences and dietary needs being known, the facility did not provide suitable alternatives or ensure the resident received the necessary nutrition and hydration. Observations revealed that the resident often had untouched meals and supplements, and there were instances where no lunch tray was provided. The facility relied on the resident's family to bring in preferred foods during their infrequent visits, which was not a reliable intervention. The staff failed to consistently monitor and record the resident's intake of physician-prescribed supplements, and there was no evidence of weekly monitoring of the resident's nutritional status. Interviews with staff indicated a lack of awareness and action regarding the resident's nutritional needs. The staff did not implement or document necessary interventions, such as offering suitable substitutes or adjusting the resident's diet to meet their preferences and needs. The facility's policies on weight management and nutritional procedures were not followed, leading to the resident's continued weight loss and inadequate nutritional support.
Plan Of Correction
Element 1 Resident #67's diet was liberalized to regular. [R]NJ Exec Order 26.4b1 was increased from three times a day to four times a day. The physician added an [R]NJ Ex Order 26.4(b)(1) and provided [R]NJ Ex Order 26.4(b)(1) that the resident enjoys based on their [R]EXOT preferences and enjoyment of a [R]. Element 2 [R]NJ Ex Order 26.4(b)(1) All residents have the potential to be affected by this deficiency. Element 3 The facility has hired an experienced Dietician with extensive knowledge in the management of residents with weight loss. Additionally, a Weight Loss audit is being conducted to review newly identified significant weight losses (5% weight loss in 30 days, or 10% weight loss in 180 days) in order to remain in compliance with F692. This audit began on 1/27/2025 and is reviewing all residents in the facility. The results of the audit indicated one newly identified weight loss in the month of January. Element 4 To maintain and monitor ongoing compliance, the Weight Loss audit is being conducted by the Dietician or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Menu Review and Nutritional Adequacy Deficiencies
Penalty
Summary
The facility failed to ensure that menus were reviewed and approved for nutritional adequacy in accordance with nationally accredited standards. During a kitchen tour, it was revealed that the facility followed a three-week cycle menu, but the menus provided were not signed or dated by a qualified nutrition professional to confirm their adequacy. Additionally, the facility's dietitian was unaware of who developed or reviewed the menus, indicating a lack of oversight and accountability in the menu planning process. The surveyors found discrepancies in the dietary care provided to three residents. For instance, one resident's care plan included a physician's order for a specific dietary supplement twice a day, but this was not reflected in the resident's dietary records or meal tickets. Similarly, another resident's preferences and physician's orders were not accurately documented or followed, leading to inconsistencies in the meals served. These issues were compounded by the dietitian's admission that there was no formal system to ensure that dietary recommendations and updates were implemented. Interviews with residents and staff further highlighted the deficiencies. Residents reported receiving meals that did not match their documented preferences, and the dietitian acknowledged the lack of a formal follow-up system to verify that dietary changes were executed. The facility's electronic medical record system was supposed to link with the food service software to automatically update dietary information, but manual errors and communication breakdowns persisted, resulting in unmet nutritional needs and preferences for the residents.
Plan Of Correction
Element 1 This deficiency was corrected by having the NJ Ex Order 26.4(b)(1) and NJ Ex Order 26.4 Menus reviewed and approved by a Licensed Dietitian. Additionally, a Food Preference audit was performed to ensure that all resident food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Food Preference audit was performed on 1/27/2025 to ensure all residents' food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. During the audits, seven residents expressed additional food preferences, which were immediately added to the meal ticket system. Additionally, the food preference audit will continue to ensure that the facility remains in compliance with F803. Element 4 To maintain and monitor ongoing compliance, a Food Preference audit is being conducted by the dietitian or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Inadequate Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program (IPCP) as required by regulations. The IP, who was also acting in another role, indicated that she spent only an hour to an hour and a half each day on her IP duties, with the majority of her time spent on other responsibilities. This was contrary to the requirement that facilities with 100 or more beds must hire a full-time employee in the infection prevention role with no other responsibilities. The surveyor's interviews revealed that the IP position was part-time and temporary, and there was uncertainty about whether the allocated hours were sufficient for the role. Despite the IP's assurance that infection control measures were up to date, the facility did not comply with the directive to have a full-time IP dedicated solely to infection prevention and control, as evidenced by the job description and position action form provided by the facility.
Plan Of Correction
Element 1 Upon identification of the issue regarding the employee covering Infection Prevention (IP) and Unit Manager duties, the employee's role and responsibilities were reviewed. A formal assessment was completed to ensure the employee was properly supported in these dual roles and was provided with the necessary training and resources. The facility transitioned a current staff nurse to the dedicated Unit Manager position effective 1/27/2025, and the employee covering these roles was transitioned back to their original full-time duties as the dedicated Infection Preventionist with no other responsibilities. Element 2 All residents have the potential to be affected. Element 3 The facility has established a more structured planning protocol to ensure continuity of care and leadership in all key roles, including Infection Preventionist and Unit Manager. A permanent, qualified Infection Preventionist and Unit Manager have been appointed immediately to ensure clear leadership and responsibility in these areas. Element 4 The facilities leadership (Administrator and Director of Nursing) will meet with the Infection Preventionist and Unit Manager monthly for continued support in their roles and will be reassessed to ensure they are meeting the requirements of their positions.
Failure to Maintain Clear Exit Discharges
Penalty
Summary
The facility failed to maintain means of egress free of obstructions as required by NFPA 101 Life Safety Code (2012 Edition), Section 7.1. Observations made on January 7, 2025, revealed ice and snow buildup on the pathways from the building to the public way at multiple designated exit discharges, including those located by the employee entrance and 200 Hall, the Kitchen, and Room 105. During interviews conducted at the time of the observations, the staff confirmed the findings and acknowledged awareness that the snow and ice on the sidewalks needed to be removed. This deficiency had the potential to affect all 131 residents of the facility.
Plan Of Correction
Element 1 This deficiency was corrected by shoveling the snow and salting all exit discharge pathways from the building to the public way. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Snow/Ice audit is being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K271. This audit will be completed by making rounds around the facility. Element 4 The Snow/Ice audit is being monitored by the Administrator or designee weekly for four weeks, then every other week for four weeks, and then monthly for one month. If the facility experiences any snow or icy conditions, the audit will be performed on that day, as well as the following day to ensure safe conditions. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for three months to the Quality Assurance Performance Improvement team for review and action as necessary.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, which had the potential to affect all 131 residents. During an observation, ice buildup was found on the deflector of a sprinkler head inside the walk-in freezer. The facility was aware of this issue prior to the survey. Additionally, in the dishwashing room closet, the escutcheon plate was missing from a sprinkler, a fact also known to the facility before the survey. Further review of the facility's sprinkler system records revealed a lack of documentation for weekly inspections of the gauges for the dry sprinkler system. During an interview, the facility confirmed the absence of these records and acknowledged their inability to provide documentation of the weekly inspections during the survey.
Plan Of Correction
Element 1 This deficiency was corrected by removing the ice build up on the sprinkler head deflector located inside the walk-in freezer, replacing the escutcheon plate on the sprinkler head located in the dishwashing room closet, and performed weekly inspections of the gauges for the dry sprinkler system. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Sprinkler Head audit and Dry Sprinkler System Gauge audit are being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K353. This audit is being completed by making rounds within the facility to ensure they are being completed. Element 4 The Sprinkler Head audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. The Dry Sprinkler System Gauge audit will be performed weekly on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Unsealed Smoke Barriers in Facility
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, as required by the NFPA 101 Life Safety Code (2012 Edition) Section 8.5. During observations conducted on January 7, 2025, several unsealed gaps and overcuts were identified in various locations throughout the facility. These included a two-inch unsealed overcut around conduit penetrations near the Dining Room, a similar unsealed overcut around wire penetrations by Room 210, and a six-inch unsealed gap at the top of the wall in the Korean Office. Additional unsealed gaps were found in the Break Room and near the Beauty Salon. The deficiency was confirmed during an interview with a facility representative, who acknowledged the findings and admitted that the facility was unaware of the unsealed gaps and penetrations in the smoke barriers. This issue was a repeat deficiency, having been previously cited during the Life Safety Code Survey conducted on September 29, 2023. The unsealed penetrations in the smoke barriers had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by sealing all openings within the smoke barriers including: the two inch overcut around two conduit penetrations above the ceiling located in the corridor by the dining room, the two inch overcut around the blue wire penetrations above the ceiling located in the corridor by room 210, the six inch gap at the top of the wall above the ceiling located inside the Korean Office, the two inch gap at the top of the wall above the ceiling located inside the break room, and the four inch gap in the wall above the ceiling located in the corridor by the Beauty Salon. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Smoke Barrier audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K372. This audit will be completed by making rounds within the facility to view the smoke barriers. Element 4 The Smoke Barrier audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 (Life Safety Code) 2012 Edition, Section 8.5, which had the potential to affect 42 residents. During an observation, a smoke barrier door located in the corridor by Room 104 did not close smoke tight when released from the magnetic hold open device, stopping halfway between the open and closed position. The facility staff confirmed the door was rubbing the floor and was unaware of this issue prior to the survey. Additionally, another observation revealed that a smoke door located in the bathroom between Rooms 210 and 211 lacked a self-closing device. The facility staff confirmed the absence of the self-closing device and stated they were unaware of this deficiency before the survey.
Plan Of Correction
Element 1 This deficiency was corrected by preventing the door from rubbing against the floor in the corridor near room 104, allowing the smoke barrier door to fully close and latch. Additionally, a self-closing device was installed on the bathroom door between rooms 210 and 211. Element 2 This deficiency has the potential to affect forty-two residents on the East Wing. Element 3 A Smoke Barrier Door audit is being conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K374. This audit will be completed by making rounds within the facility. Element 4 The Smoke Barrier Door audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Missing Documentation for Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual tests and inspections of the fire door assemblies as required by NFPA 80, Section 5.2. This deficiency was identified during a record review conducted on January 7, 2025, at 3:30 PM, where it was discovered that the documentation was missing from the facility's Life Safety Code Survey Binder. The surveyor requested this documentation at multiple points, including the entrance conference, during the record review, and at the exit conference, but it was not provided. During an interview at the same time, a staff member confirmed the finding and stated that the facility was unable to locate the missing documentation during the survey. This deficient practice had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by performing tests and inspections of the fire door assemblies. Element 2 All residents had the potential to be affected by this deficiency. Element 3 A Fire Door Assembly audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K761. This audit is being completed by making rounds within the facility. Element 4 The Fire Door Assembly audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Document Electrical Receptacle Testing
Penalty
Summary
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99 (2012), Section 6.3.4. This deficiency was identified during a review of the facility's Life Safety Code Survey documentation binder, where the necessary documentation was not available. The surveyor requested this documentation at multiple points, including the entrance conference, document review, and exit conference, but the facility was unable to produce it. The deficiency has the potential to affect all 131 residents in the facility, as the documentation pertains to both hospital-grade and non-hospital-grade receptacles in resident rooms. An interview with a facility representative confirmed the finding and revealed that the facility could not locate the missing documentation, indicating a lapse in maintaining required records for electrical system maintenance and testing.
Plan Of Correction
Element 1 This deficiency was corrected by conducting performance tests on the receptacles. Element 2 This deficiency has the potential to affect all residents. Element 3 A Receptacle audit was conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K914. This audit is being completed by making rounds within the facility. Element 4 The Receptacle audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), specifically Section 8.3.8. During a record review, it was discovered that the facility did not provide documentation of the annual fuel quality test for the diesel generator. This documentation was requested multiple times, including at the entrance conference, during the record review, and before the exit conference, but was not provided. An interview conducted on the same day confirmed the finding, with a staff member acknowledging the facility's inability to locate the missing documentation. This deficiency had the potential to affect all 131 residents in the facility, as the generator is a critical component of the facility's emergency power system.
Plan Of Correction
Element 1 This deficiency was corrected by performing the fuel quality test of the diesel generator. Element 2 This deficiency has the potential to affect all residents. Element 3 A Generator audit is being conducted by the Maintenance Director to ensure the facility remains in compliance with K918. This audit is being completed by reviewing the inspection book. Element 4 The Generator audit is being monitored by the Administrator or designee every three months for the next twelve months to ensure that this test is being performed annually. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for twelve months to the Quality Assurance Performance Improvement team for review and action as necessary.
Facility Fails to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations made by a surveyor. Resident #90 was observed in a recliner with dried brown substances on the sides of the chair on multiple occasions. Despite the presence of facility staff assisting the resident with lunch, the recliner remained uncleaned over several days. The resident's admission record and recent Minimum Data Set (MDS) indicated certain diagnoses, but specific details were redacted. Similarly, Resident #125 was observed in a wheelchair with dried brownish and white substances on the left wheel. The surveyor noted this during lunch assistance, and although a staff member acknowledged the issue and promised to notify housekeeping, the wheelchair remained uncleaned the following day. The resident's admission record and MDS also contained redacted information regarding diagnoses. Resident #124 was observed with an overbed table that had multiple dried brownish spots on the bottom. Despite a housekeeper's claim of a cleaning schedule, the table remained uncleaned. The facility's policy on wheelchair and recliner cleaning was reviewed, indicating a monthly cleaning schedule, but the actual practice seemed inconsistent. Interviews with staff revealed that cleaning was often adjusted based on immediate needs, but the observed deficiencies suggested lapses in maintaining a clean environment.
Plan Of Correction
1/27/25 Element 1 It is the practice of the facility to ensure that all residents reside in a safe, clean, homelike environment. The deficiency was corrected by performing a facility wide sanitization audit of all resident care areas, including overbed tables, wheelchair and Geri chairs; all areas that were identified to be dirty were immediately cleaned. Element 2 All residents are potentially affected by this deficiency. Element 3 The systemic changes that were implemented to prevent this deficiency from occurring again include: increasing sanitization rounds on resident care areas and wheelchairs as part of the facilities Guardian Angel Program. The Guardian Angel program is a comprehensive auditing tool used to identify issues throughout the facility. This program was expanded to include all resident care areas, with special attention to wheelchairs, Geri chairs, and overbed tables, in order to remain in compliance with F584. Additionally, the Housekeeping Director and Administrator make daily rounds to ensure identified issues are corrected in a timely manner. Element 4 To maintain and monitor ongoing compliance, the Guardian Angel/Homelike Environment Audit is being conducted by all Department Heads once a week for two months, then once every other week for two months, and then monthly for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Report and Investigate Resident Condition
Penalty
Summary
The facility failed to report and initiate an investigation for a specific incident involving a resident, identified as Resident #47, until prompted by a surveyor's inquiry. The deficiency was identified when the surveyor observed Resident #47 in bed and attempted to interview them, but the resident was unresponsive. Subsequent interviews with Certified Nursing Assistants (CNAs) revealed that they had noticed a condition on the resident but did not report it, assuming it was already known by the staff. Further investigation showed that the facility had not conducted a proper investigation into the incident involving Resident #47, despite having policies in place that required immediate reporting of any suspected abuse, neglect, or injuries of unknown origin. The CNAs involved had received training on these policies, but there was a lapse in communication and reporting, as they did not inform the nursing staff about the resident's condition. The Licensed Practical Nurse (LPN) and other staff members were unaware of the issue until it was brought to their attention by the surveyor. The resident's medical records and individualized plan of care indicated that they required assistance with activities of daily living and had certain medical conditions. However, there was no documentation of an assessment being completed for the resident's condition until after the surveyor's inquiry. The facility's failure to adhere to its own policies and procedures for reporting and investigating incidents led to the deficiency being cited by the surveyor.
Plan Of Correction
Element 1 Upon discovering the NJ Exec Order 26.4b1 on resident #47, immediate steps were taken to assess the injury, ensure the residents' safety, and provide appropriate care (cleaning, applying any necessary treatment). The resident was closely monitored for any further changes in condition. The Ex was promptly documented on in the resident's medical chart. On the same day, an incident report was created to ensure a complete record of the event. An in-service was completed by the Assistant Director of Nursing for all nursing staff regarding notifying the nurse immediately of any skin alterations, as well as Abuse and Neglect policy and reporting. Element 2 The standard was not met for resident #47. All residents that are at risk for skin alterations have the potential to be affected by this deficient practice. Element 3 All nursing staff were re-educated on the facility's Abuse and Neglect policies and procedures for reporting injuries and incidents. In addition, they were re-educated on the facilities abuse reporting and prevention policy. Emphasis will be placed on the importance of documenting every skin alteration. Element 4 Incident audits have been conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance and to ensure all injuries are documented and reported appropriately. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Borrowing from Another Resident's Supply
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by borrowing medication from another resident's supply. This deficiency was identified during a medication administration observation involving a registered nurse (RN#1) and Resident #122. RN#1 was observed administering medication to Resident #122 and admitted to borrowing the medication from another resident's supply because the required medication was not available in the medication cart for Resident #122. The surveyor reviewed the electronic medication administration record (EMAR) and confirmed that RN#1 had administered the borrowed medication without proper authorization. The nurse educator at the facility confirmed that nurses were not allowed to borrow medications from other residents and that the facility had a stock of over-the-counter medications available for residents with physician orders. Despite this, RN#1 did not follow the protocol of contacting the pharmacy or the physician for guidance when the medication was unavailable. Interviews with facility staff, including the nurse educator and other nursing staff, revealed a lack of clarity regarding the policy on borrowing medications. The nurse educator stated that borrowing medications could lead to medication errors and emphasized that nurses were instructed not to engage in this practice. However, there was no documented policy available at the time of the survey to reinforce this directive.
Plan Of Correction
Element 1 Upon identification of the error to resident #122 U.S. FOIA (b)(6), immediate corrective actions were implemented. The resident's condition was assessed for any adverse effects resulting from the NJ Exec Order 26.4b1 administration. The physician was notified and consulted to determine if any additional medical intervention was required. The physician initially provided a one-time order for the NJ Exec Order 26.4b1 that was applied. Additionally, the order was permanently revised to [R]. The nurse who administered the incorrect [R] was counseled and re-educated on the proper administration procedures for [R], including verifying the correct strength per the physician's order. A medication error form was completed right away, and she was successfully re-med passed by the Assistant Director of Nursing. All nurses were educated on the following: not to borrow any medications, NJ Exec Order 26.4b1 are over the counter and [R] is a prescription, and the right of medication pass (right patient, right drug, right dose, right dosage form, right route, right time). A follow-up monitoring plan was implemented to ensure the residents' comfort and safety were maintained and effective with the new order for [R]. A review of all residents receiving NJ Exec Order 26.4(b)(1) treatments, including NJ Exec Order 26.4b1, was conducted. An audit was completed ensuring all residents' [R] were in stock and had the appropriate dose in place. Element 2 All residents receiving topical analgesic treatments, including lidocaine patches, are at risk. Element 3 All nurses were educated on the proper procedure of medication administration by the Assistant Director of Nursing. RN#1 was med passed from the facility's pharmacy consultant with a 0% medication error rate on 1/24/25. A medication error form was completed right away for RN#1, and she was successfully re-med passed by the Assistant Director of Nursing. The Pharmacy consultant will continue to do their monthly unit inspections and medication passes. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance for residents who are receiving patches to ensure the right dosage was applied and available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without a medication error rate of 5% or more. During a morning medication administration observation, a surveyor observed three nurses administering medications to six residents. Out of 27 opportunities, two errors were observed, resulting in a medication administration error rate of 7.4%. The errors were identified for one resident, who was administered medications by one of the three nurses observed. The deficiency was evidenced when a Registered Nurse (RN#1) administered the wrong dose of a medication to a resident. The RN was observed applying a medication patch to two different sites on the resident, but the strength of the medication applied was not as ordered. The RN acknowledged the error after the surveyor pointed it out, and it was confirmed that the physician was contacted regarding the error. The facility's medication administration policy did not reflect procedures for ensuring the administration of the correct dosage. The surveyor's review of the resident's medical record revealed active physician orders for the medication to be applied to two different sites. The facility's staff, including the person responsible for nursing staff education, acknowledged the error and stated that the nurse should have contacted the physician if the correct medication was not available. The facility had provided inservice training on medication administration, but the error still occurred, indicating a lapse in following the correct medication pass procedures.
Plan Of Correction
Element 1 Upon identifying the error with the applied to Resident #122, immediate corrective actions were taken. The resident's condition was assessed to determine if any adverse effects occurred due to the incorrect patch. The physician was promptly notified and consulted to evaluate whether any further medical intervention was necessary. The physician initially issued a one-time order for the [R], which was applied. Following this, the order was permanently revised to the NJ Exec Order 26.4b1. The nurse who administered the incorrect patch was counseled and retrained on the proper procedures for administering lidocaine patches, including verifying the correct strength based on the physician's order. A medication error form was completed immediately, and the nurse was successfully re-med passed. Element 2 All residents receiving topical analgesic treatments, such as lidocaine patches, may be at risk. Element 3 Additionally, all nursing staff were educated on key points, including: not borrowing medications, the distinction between OTC 4% lidocaine patches and prescription 5% patches, and the rights of medication administration (right patient, right drug, right dose, right dosage form, right route, and right time) by the Assistant Director of Nursing. A follow-up monitoring plan was also implemented to ensure the residents' comfort and safety with the newly revised order for the 4% lidocaine patch. A comprehensive review of all residents receiving topical analgesic treatments, including lidocaine patches, was conducted. An audit was completed to ensure that all patches in stock were properly dosed and matched the physician's orders. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance that all medications are administered according to physician orders. All residents receiving patches will be verified to ensure the correct dosage was applied and is available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing, and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Adhere to PPE Protocols for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) as per the facility policy and acceptable standards of infection control practice. This deficiency was observed during rounds on two units, involving two unsampled residents. In the first instance, a staff member approached a resident lying in bed, donned gloves, and checked the resident's condition without wearing a gown, despite a sign indicating that both gloves and a gown were required for high-contact resident care activities. The staff member acknowledged the oversight when questioned by the surveyor. In the second instance, another staff member was observed performing care on a different resident without wearing a protective gown, although a sign indicated that a gown was required. The staff member later explained that she had stepped out of the room to retrieve an item and did not wear a gown upon returning to complete the care. The surveyor noted that there was no evidence of a discarded gown in the room's garbage can, suggesting non-compliance with the facility's policy. Both residents involved had diagnoses that necessitated the use of Enhanced Barrier Precautions, which include donning gowns and gloves during high-contact activities to prevent the transmission of multi-drug resistant organisms. The facility's policy clearly outlines the procedures for managing such infections, yet the staff failed to adhere to these guidelines, leading to the observed deficiencies.
Plan Of Correction
Element 1 Upon discovering the breach in [R], the employees involved were immediately removed from direct care duties and counseled on the proper use of personal protective equipment (PPE) required for residents on NJ Ex Order 26.4(b)(1). On 1/3/25, all staff were retrained by the Assistant Director of Nursing on the facility's protocols regarding the appropriate use of PPE, including gloves and gowns when entering rooms of residents on enhanced barrier precautions. Element 2 All residents on Enhanced Barrier Precautions have the potential to be affected. Element 3 All staff underwent immediate re-education on the facility's enhanced barrier precaution protocols, emphasizing the importance of wearing gowns and gloves when caring for residents on enhanced barrier precautions. Staff were also re-educated on how to identify which residents need these precautions; all re-education was conducted by the Assistant Director of Nursing. Element 4 Enhanced Barrier Precaution spot check audits are being conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance with PPE protocols for residents on enhanced barrier precautions. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and obtain authorization for a change in the facility's name, as required by 42 CFR 424.516. The surveyor discovered this deficiency during a review of the facility's website and physical signage, which displayed the name "Shore Point Care Center" instead of the CMS-licensed name "Gateway Care Center." This discrepancy was confirmed upon arrival at the facility, where the surveyor observed the incorrect name on the building and on business cards provided by facility representatives. During interviews, facility representatives acknowledged that the facility had been operating under the name "Shore Point Care Center" for nearly three years, and they claimed that the state licensing department was aware of this. However, the facility was unable to provide documentation showing that the New Jersey Department of Health Division of Certificate of Need & Licensing or CMS had been notified of the name change. The facility's license, issued by the New Jersey Department of Health, still listed the name as "Gateway Care Center." Further investigation revealed that the facility had not completed the necessary CMS form 855B to report the name change. The facility representatives admitted that the name change was intended for marketing purposes and had not been formally processed with the appropriate regulatory bodies. As a result, the facility decided to revert to operating under the name "Gateway Care Center" and planned to change the signage back to reflect the licensed name.
Plan Of Correction
Element 1 This deficiency was corrected by revising the name listed on facility documents back to Gateway Care Center. Element 2 All residents have the potential to be affected by this deficiency. Element 3 Facility understands that in order to operate under a different name, the Department of Health Division of Certificate of Need must be notified, and the form 855B to CMS must be completed. Element 4 To maintain and monitor ongoing compliance, the Administrator will conduct a Facility Name audit to ensure documents are listed as Gateway Care Center. The Facility Name audit will be conducted by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Staffing and Mask-Wearing Deficiencies
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficiency was observed over multiple periods, including specific weeks in October 2023, June to July 2024, and December 2024. During these times, the facility consistently had fewer Certified Nurse Aides (CNAs) than required for the day shifts, and there were also deficiencies in total staff numbers for evening and overnight shifts. Interviews with the Human Resources director and the Director of Nursing revealed attempts to meet staffing ratios through bonuses and agency staff, but these efforts were not always successful. Additionally, the facility did not ensure that employees with medical exemptions from the influenza vaccine wore surgical or procedural masks when in direct contact with patients and in common areas, as required by New Jersey law. The surveyor observed that two employees, a dietary employee and an activity employee, were not wearing masks despite having medical exemptions from the influenza vaccine. Interviews with these employees indicated a lack of awareness or enforcement of the mask-wearing requirement. The facility's policy on influenza vaccination did not address the use of masks for employees with medical exemptions. The Director of Nursing was unaware of the requirement for these employees to wear masks, which contributed to the deficiency. The facility's failure to comply with staffing ratios and mask-wearing requirements for exempt employees highlights significant lapses in adhering to state regulations designed to ensure resident safety and care quality.
Plan Of Correction
Element 1 It is the practice of the facility to ensure that the minimum direct care staff-to-shift ratios are in compliance with the mandate from the State of New Jersey. The deficiency is being corrected by offering bonuses and overtime to staff to cover openings/callouts in the schedule, offering openings/callouts to staffing agencies, utilizing job search engines (Apploi) to expand the view of job postings, and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, all staff members who are Medically Exempt from receiving the Flu Vaccine were immediately informed they must wear a surgical mask while within the facility, and given masks to wear. Element 2 All residents are affected by this deficiency. Element 3 The deficiency is being corrected by offering bonuses and overtime, utilizing staffing agencies, utilizing job search engines (Apploi), and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, a Staffing Audit is being conducted by the Staffing Coordinator to ensure the facility remains in compliance with S560. Staff were also educated that they must wear a mask while in the facility if they are Medically Exempt from receiving the Flu Vaccine; a Mask Audit is being conducted by the Infection Preventionist to ensure the facility remains in compliance. Element 4 To maintain and monitor ongoing compliance, the Staffing Audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Additionally, the Mask Audit is being monitored by the Director of Nursing or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
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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