Laurel Bay Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Keansburg, New Jersey.
- Location
- 32 Laurel Avenue, Keansburg, New Jersey 07734
- CMS Provider Number
- 315437
- Inspections on file
- 16
- Latest survey
- July 3, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Laurel Bay Health & Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
Three residents with cognitive impairments and elopement risk had care plan interventions, including participation in a walker's club and posting of their pictures at key locations, that were not implemented. Staff interviews confirmed that the interventions were not carried out, pictures were not posted as required, and the walker's club was not conducted, despite these being documented in the care plans.
Nursing staff did not consistently document the placement of a resident's wander guard bracelet on the TAR as required by physician order and facility policy. For several shifts, documentation was missing, despite the expectation that nurses check and record the device's placement every shift. The DON confirmed the lapses in documentation, which were identified through review of medical records and facility policy.
The facility failed to handle potentially hazardous food safely and maintain sanitation, as observed by surveyors. Items in the Drink and Storage Refrigerators, as well as the dry storage area, lacked proper labeling with preparation or use-by dates. The nourishment refrigerator and freezer were unsanitary, with spillage, frost buildup, and unidentified food items. Interviews revealed confusion over responsibilities for cleanliness and expiration checks, and facility policies were not followed.
The facility's call bell system failed to notify staff of activation for a resident's bed, as observed during a survey. The DOM confirmed the system's failure to provide visual or audible alerts, indicating the need for a replacement of the call bell button.
Surveyors identified deficiencies in maintaining a clean and safe environment in the facility. Observations included water and spilled milk on floors, missing trash can liners, brown stains, and missing tiles in shower rooms. The DON and DOH acknowledged daily cleaning routines, but the facility lacked a policy on environmental conditions.
The facility failed to manage and document indwelling catheters properly for two residents. One resident's urinary drainage bag was not in a privacy bag and touched the floor, with no physician orders documented. Another resident's catheter bag was improperly secured, and urinary output was not consistently documented. Staff interviews confirmed the importance of securing drainage bags below bladder level and maintaining documentation, but these practices were not followed.
The facility failed to ensure call devices were within reach for two residents, as required by policy. One resident's device was found on the floor, and the resident had difficulty locating it. Another resident, with moderate cognitive impairment and a fall risk, also had their device out of reach. Staff confirmed the importance of accessible call devices, yet the policy was not followed.
A resident with moderate cognitive impairment was observed with an elopement device, yet their MDS inaccurately indicated no such device was in place. The resident's medical records showed a physician's order for the device, but the MDS was incorrectly coded, failing to reflect this, contrary to facility policy.
A facility failed to update a care plan for a resident with an indwelling catheter. The resident, diagnosed with functional quadriplegia and dementia, was observed with a urinary drainage bag attached to the bed frame. The care plan lacked documentation for catheter care, which the DON acknowledged should have been updated. Facility policy mandates care plan revisions after assessments and significant changes.
A facility failed to follow a physician's order for the placement of an elopement device on a resident at risk for elopement. The device was observed on the left ankle instead of the right, as ordered. Despite this, the Treatment Administration Record was inaccurately signed off, indicating compliance. The resident had a history of breast cancer, anxiety, and depression, with moderate cognitive impairment.
The facility failed to implement fall prevention measures for two residents identified as fall risks. Despite physician orders and facility policy requiring fall mats to be placed beside the beds, observations showed the mats were folded and placed against the wall. Staff interviews confirmed awareness of the protocols, but they were not consistently followed.
The facility failed to adhere to professional standards for respiratory care by leaving masks and tubing uncontained and exposed to air, contrary to infection control protocols. Residents with significant respiratory conditions had their equipment improperly stored, as confirmed by staff interviews and facility policy reviews.
The facility failed to implement Enhanced Barrier Precautions (EBP) on one floor, as observed by surveyors. A room with an EBP sign lacked a designated trash bin for used PPE, contrary to staff interviews and facility policy. Additionally, a treatment cart was improperly brought into a resident's room on EBP for a Multi-Drug Resistant Organism (MDRO), against facility policy. The resident had a wound and a suprapubic catheter, with physician orders to maintain EBP.
The facility failed to document and timely administer influenza vaccinations for two residents, one with Diabetes Mellitus and Metabolic Encephalopathy, and another with Functional Quadriplegia and Dementia. The Infection Preventionist admitted to missing the vaccinations, which were given later than the facility's policy required.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Implement Elopement Risk Interventions for Multiple Residents
Penalty
Summary
The facility failed to implement care plan interventions for three residents identified as being at risk for elopement. Each resident had a care plan intervention that included participation in a walker's club and the posting of their pictures at the first floor, second floor, and reception area to alert staff of their elopement risk. Despite these interventions being documented in the care plans, interviews and observations revealed that the interventions were not carried out. Staff members, including the Activities Director, LPNs, and the Receptionist, were either unaware of the location of the residents' pictures or confirmed that the pictures were not present at the designated areas. Additionally, the Director of Nursing confirmed that the walker's club was not being conducted as indicated in the care plans and that the pictures were not posted as required. The residents involved had significant cognitive impairments and medical conditions such as convulsions, cerebral infarction, hypertension, anxiety disorder, depression, diabetes, and epilepsy, which increased their risk for elopement. The care plans were not updated to reflect the lack of implementation of these interventions, and staff communication regarding the identification of wandering residents was informal rather than following the documented interventions. The failure to implement and update the care plan interventions was confirmed through staff interviews and review of facility documentation.
Failure to Document Wander Guard Placement per Professional Standards
Penalty
Summary
Nursing staff failed to consistently document the placement of a resident's wander guard bracelet on the Treatment Administration Record (TAR) as required by both facility policy and professional standards. Specifically, for one resident with diagnoses including diabetes, epilepsy, and major depressive disorder, there were blank documentation spaces on the TAR for several shifts, despite an active physician's order requiring the wander guard to be checked and documented every shift. The Director of Nursing confirmed that the expectation was for nurses to check the device and sign the TAR accordingly, but this was not done for the identified dates and shifts. The facility's policy on documentation emphasizes that if an action is not charted, it is considered not to have occurred. The deficiency was identified through interviews, medical record review, and examination of facility documentation, which showed that the required checks and documentation for the elopement device were not consistently performed or recorded. This failure was in direct violation of both the facility's own documentation guidelines and the standards set forth by the New Jersey Nurse Practice Act.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the Drink Refrigerator, 35 bowls of butterscotch pudding, 7 cups of applesauce, and 1 cup of cottage cheese were found without preparation or use-by dates. Similarly, in the dry storage area, an open container of peanut butter and a loaf of raisin bread were not properly labeled with open or use-by dates. In the Storage Refrigerator, several items, including butter, macaroni noodles, sauteed onions, and meatballs, were also missing appropriate labeling. These lapses in labeling and dating could compromise food safety and freshness. Additionally, the nourishment refrigerator and freezer on the first floor were found to be unsanitary, with an open milk carton causing spillage, a buildup of freezer frost, and unidentified food items. Interviews with the Dietary Director, LPN, Director of Housekeeping, and Director of Nursing revealed confusion over responsibilities for maintaining cleanliness and checking expiration dates. The facility's policies on labeling, handling food brought in by visitors, and cleaning nourishment refrigerators were not adhered to, contributing to the observed deficiencies.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure that the resident call bell system was properly functioning, as observed during a survey on 12/30/2025. At 12:22 PM, it was noted that the call bell system did not provide visual or audible notification of activation for bed 1 in a specific room when the Administrator pressed the call bell button. This issue was confirmed by the Director of Maintenance (DOM), who acknowledged that the call bell system light did not activate outside the room, and no notification was received at the nurse's station. The DOM indicated that the call bell button required replacement.
Environmental Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by multiple observations made by surveyors. On the first floor, water was found on the floor of a resident's room without a wet-floor sign, and another room had spilled milk on the floor and a trash bin without a liner. Additionally, the first-floor shower room had brown stains on the floor, tile, and caulked areas, and exposed drywall was noted behind a measuring scale. The Director of Nursing acknowledged that resident rooms are cleaned daily and that it is a shared responsibility to manage spills and discarded items. On the second floor, surveyors observed embedded black and gray marks on a bathroom floor, a trash can without a liner, and missing floor tiles in the shower room, which exposed a brown substance around the drain. Missing tiles were also noted at the entrance to the shower area, and several wall tiles around the heater vent and sink were absent, revealing a gray substance. A hole in the wall was observed behind a whiteboard. The Director of Housekeeping stated that general cleaning is conducted daily, and maintenance logs are kept and updated. However, the facility was unable to provide a policy regarding environmental conditions.
Deficiencies in Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of indwelling catheters for two residents, leading to deficiencies in care. Resident #68 was observed with a urinary drainage bag that was not in a privacy bag and was visible from the hallway. Later, the bag was found touching the floor, which is against the facility's policy. Additionally, there were no physician orders in the electronic medical record for the indwelling catheter, which is a requirement for proper care and monitoring. Resident #21 was observed with a urinary catheter drainage bag on top of the bed without a privacy bag and not secured to the bed frame. On another occasion, the drainage bag was in a privacy bag but not properly secured to the wheelchair, causing it to collapse. The resident's medical record showed missing documentation of urinary output on several shifts, and the care plan incorrectly identified the catheter size. Interviews with staff confirmed that the drainage bags should be secured below the bladder level to prevent infection and backflow, and that output should be documented every shift. The facility's policies on catheter care and physician orders were not followed, as evidenced by the lack of documentation and improper handling of urinary drainage bags. The Director of Nursing and other staff acknowledged the importance of securing drainage bags below the bladder level and maintaining proper documentation, but these practices were not consistently implemented for the residents involved.
Failure to Ensure Call Devices are Within Reach of Residents
Penalty
Summary
The facility failed to provide services with reasonable accommodation of resident needs by not ensuring that call devices were within reach of residents. This deficiency was identified in two residents who were reviewed for call devices. During observations, one resident's call device was found on the floor next to the nightstand, and the resident expressed difficulty in locating it. The facility's policy mandates that call devices must be within reach of residents at all times, yet this was not adhered to. Another resident's call device was also found on the floor behind a bedside table, and the resident was unaware of its location. This resident had a history of moderate cognitive impairment and was at risk for falls, with a care plan intervention specifying that the call light should be within reach. Interviews with facility staff, including a CNA and an LPN, confirmed that call devices are considered a fall intervention and should be accessible to residents. Despite this, the facility's policy was not followed, leading to the deficiency.
Inaccurate MDS Assessment for Resident with Elopement Device
Penalty
Summary
The facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), which is an essential tool for managing care. This deficiency was identified for one resident who was observed wandering near the nursing station with an elopement device on their left ankle. Despite the presence of this device, the resident's quarterly MDS inaccurately indicated that there was no wander/elopement alarm in place. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, was unaware of the purpose of the bracelet on their ankle. Further investigation revealed discrepancies in the resident's medical records. The physician's order from August indicated that an elopement device should be placed on the resident's right ankle, and the Treatment Administration Record for December confirmed compliance with this order. However, the MDS Coordinator, upon reviewing the resident's records, confirmed that the MDS was incorrectly coded, failing to reflect the presence of the elopement device. This oversight contradicts the facility's policy, which mandates accurate MDS assessments to ensure comprehensive care plans for residents.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling catheter. During an initial tour, a surveyor observed the resident resting in bed with a urinary drainage bag attached to the bed frame. The resident was admitted with diagnoses including functional quadriplegia and dementia. A review of the resident's current care plan revealed no documentation of a focus area or interventions for the care of indwelling catheters. The Director of Nursing acknowledged that the care plan should have been updated when the resident returned to the facility. The facility's policy requires care plans to be reviewed and revised after annual assessments, quarterly reviews, and any significant changes in condition, including changes in medications or treatments.
Failure to Follow Physician's Order for Elopement Device Placement
Penalty
Summary
The facility failed to adhere to a physician's order regarding the placement of an elopement device for a resident identified as being at risk for elopement. The physician's order specified that the elopement device should be placed on the resident's right ankle, with checks for placement every shift and function checks weekly. However, during the survey, it was observed that the device was placed on the resident's left ankle, contrary to the physician's order. Despite this discrepancy, the Treatment Administration Record (TAR) was signed off, indicating compliance with the physician's order for placement on the right ankle. The resident involved had a history of malignant neoplasm of the breast, anxiety disorder, and depression, with a moderately impaired cognitive status as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The facility's documentation guidelines and policy on the application of the Wanderguard transmitter were not followed, as evidenced by the incorrect placement of the elopement device and the inaccurate documentation in the TAR. This deficiency was confirmed through interviews with facility staff and a review of the resident's medical records.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents at risk of falls. Specifically, the facility did not place fall mats beside the beds of residents who were identified as fall risks. For one resident, the quarterly Minimum Data Set (MDS) indicated a history of falls, and physician orders required an electric low bed with a crash mat every shift. Despite this, observations revealed that the floor mat was folded and placed against the wall while the resident was in bed. Interviews with the Director of Nursing confirmed that the floor mats should not be folded when the resident is in bed. Another resident, with a severely impaired cognitive status and a history of multiple falls, also had physician orders for an electric low bed with a floor mat for safety. However, observations showed that the floor mat was consistently folded and placed against the wall when the resident was in bed. Interviews with staff, including a CNA and an LPN, confirmed that they were aware of the fall prevention protocols, which included placing the mat on the floor when the resident is in bed. The facility's policy on falls also supported this intervention, yet it was not consistently implemented.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for residents by not adhering to professional standards of practice. Specifically, respiratory masks and tubing were left uncontained and exposed to air, which is against infection control protocols. For instance, a resident was observed with a nasal cannula not connected to the humidification bottle, and a nebulizer face mask was left uncovered on a nightstand. Another resident's nebulizer tubing was unlabeled and left open to air, and their nasal cannula had not been changed as per the physician's orders. Additionally, a nebulizer mask was found resting on an oxygen cylinder, unbagged and exposed to air, with the tubing not dated. The residents involved had significant medical histories, including chronic obstructive pulmonary disease, hypoxemia, and other respiratory conditions, necessitating careful management of their respiratory equipment. Interviews with facility staff, including the Director of Nursing and the Infection Preventionist, confirmed that the facility's policy required respiratory equipment to be stored in zip-locked bags when not in use to prevent infection. However, observations during the survey revealed that these protocols were not consistently followed, leading to the identified deficiencies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment regarding Enhanced Barrier Precautions (EBP) on one of its floors. During an initial tour, a surveyor observed a room with an EBP sign but found no designated trash bin for used personal protective equipment (PPE). Interviews with staff, including CNAs and an LPN, confirmed that used PPE should be discarded in a designated bin within the room, but this was not available. The facility's PPE policy also indicated that soiled gowns and other items must be discarded in the appropriate receptacle in the work area, which was not adhered to in this instance. Additionally, a registered nurse was observed bringing a treatment cart into the room of a resident on EBP for a Multi-Drug Resistant Organism (MDRO), which was against the facility's policy. The resident had a wound and a suprapubic catheter, and the physician's orders required maintaining EBP. The Infection Preventionist confirmed that treatment carts should not be brought into rooms of residents on EBP. The facility's policy on MDROs emphasized the importance of EBP to reduce transmission, which was not followed in this case.
Failure to Document and Administer Influenza Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and timely administration of influenza vaccinations for two residents. Resident #34, who was moderately cognitively intact, was admitted with diagnoses including Diabetes Mellitus and Metabolic Encephalopathy. The Minimum Data Set (MDS) for Resident #34 indicated that the influenza vaccine was not received, and no reason was documented for the omission. Similarly, Resident #68, who had severely impaired cognition due to Functional Quadriplegia and Dementia, also did not receive the influenza vaccine as indicated in their MDS, with no documented reason for the omission. During an interview, the Infection Preventionist acknowledged missing the administration of the influenza vaccines for both residents, which were eventually given in January, although they should have been administered by the end of October. The facility's policy stated that the influenza vaccine should be offered annually from October through March unless contraindicated or already administered. This oversight was identified as a deficiency in the facility's vaccination program.
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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