Llanfair House Care & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 1140 Black Oak Ridge Road, Wayne, New Jersey 07470
- CMS Provider Number
- 315142
- Inspections on file
- 15
- Latest survey
- December 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Llanfair House Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of diabetes and vascular disease developed a pressure ulcer that was not reported or managed according to facility policy. Initial treatment with Zinc Oxide cream was ordered, but documentation was inconsistent, and the condition worsened. The resident was eventually hospitalized with an unstageable pressure ulcer, revealing lapses in the facility's adherence to pressure ulcer prevention and management policies.
The facility failed to follow physician orders for bolus feeding for a resident and did not document medication and treatment administration for several residents. This included incorrect administration of Jevity 1.2 and missing documentation for medications like Levothyroxine and Protonix. Staff acknowledged the errors, which were observed over multiple days.
The facility failed to ensure accurate dating of physician progress notes for several residents, leading to a deficiency. Residents with various medical conditions had progress notes documented as late entries, indicating a systemic issue with documentation. The facility's policy required physicians to date, write, and sign progress notes at each visit, but this was not adhered to.
The facility failed to issue the required SNF Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents who remained in the facility after their Medicare Part A coverage ended. The Director of Social Services was unaware of the requirement to provide the SNF ABN, resulting in a lack of communication to the residents or their representatives about potential financial liability. This deficiency was noted during a survey and discussed with the facility's administration.
The facility failed to update care plans for two residents, leading to deficiencies in care management. One resident's care plan did not reflect a current physician order for nutritional formula, while another resident's care plan lacked interventions for a newly identified pressure ulcer. These oversights were confirmed by facility staff and highlighted during a surveyor's review.
A facility failed to maintain respiratory equipment in a sanitary manner for a resident receiving continuous oxygen therapy. The resident's oxygen tubing had not been changed since 11/5/24, despite a physician's order for weekly changes. Interviews with staff confirmed the oversight, and the facility's policy also required weekly changes. No further explanation was provided by the facility's administration.
The facility failed to ensure required physician visits and documentation of progress notes for two residents. One resident, admitted with respiratory issues, had no progress notes despite being cognitively intact. Another resident, with heart failure and diabetes, also lacked documentation after the initial admission note. The facility's policy mandates regular physician visits and documentation, which were not adhered to.
A facility failed to timely respond to a Consultant Pharmacist's recommendations for a resident with multiple diagnoses, including anemia and diabetes. The CP advised against crushing Sucralfate tablets and suggested alternative administration methods, but the facility re-ordered the medication without changes. Further recommendations regarding administration timing and evaluation with feedings were also ignored. An LPN continued to crush the tablets for G-tube administration, and the DON admitted to not understanding the CP's advice. The facility's policy lacked a specified timeframe for responding to such recommendations.
The facility failed to properly label, dispose, and secure medications in inspected medication and treatment carts. An unlocked treatment cart was found unattended, and a medication cart contained undated blood glucose test strips and an unnecessary Humalog insulin pen. The LPNs acknowledged these oversights, which were against the facility's medication storage policy.
The facility failed to maintain complete and accessible medical records for two residents, leading to deficiencies in documentation and care coordination. One resident's hospice care binder lacked necessary progress notes, while another resident's physician did not document an admission assessment in the medical records. These actions were contrary to the facility's policies, resulting in incomplete documentation and potential gaps in care management.
Failure to Report and Manage Pressure Ulcer
Penalty
Summary
The facility failed to report and appropriately manage a newly developed pressure ulcer for a resident, leading to the worsening of the condition. The resident, who had a history of Peripheral Vascular Disease and type 2 Diabetes Mellitus with diabetic neuropathy, was admitted with severely impaired cognition. Initially, an excoriation was identified on the resident's sacral area, and treatment with 40% Zinc Oxide cream was ordered. However, there was no documented evidence that the facility reported the development of a pressure ulcer to the wound doctor or updated the resident's medical records accordingly. The facility's records showed inconsistencies and omissions in documenting the resident's condition. Despite the presence of excoriation, the Skin/Wound Note and Progress Notes did not reflect the development of a pressure ulcer. The Pressure Ulcer Flow Sheet also failed to document the excoriation identified earlier. The resident's condition worsened, leading to a new physician's order for a different cream, but the facility did not update the list of residents with facility-acquired wounds to include this resident. Interviews with facility staff revealed that the excoriation was not reported immediately to the wound doctor, which contributed to the worsening of the condition. The facility's policies on pressure ulcer prevention and management, as well as skin checks, were not followed, resulting in a lack of timely intervention and documentation. Ultimately, the resident was transferred to the hospital with a diagnosis of an unstageable pressure ulcer, highlighting the facility's failure to adhere to its own policies and procedures.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering tube feeding and documenting medication and treatment for several residents. For one resident, the facility did not follow the physician's order for bolus feeding, administering only one carton of Jevity 1.2 instead of the prescribed two cartons at midnight. This discrepancy was noted over multiple days in November and December, and the error was acknowledged by the facility's staff, including the Registered Dietician and Licensed Practical Nurse. Additionally, the facility failed to document the administration of medications and treatments for four other residents. This included missing signatures on the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for various medications and treatments, such as Levothyroxine, Tylenol, Protonix, and wound care treatments. The lack of documentation occurred on multiple occasions, indicating a pattern of non-compliance with the facility's policy on medication and treatment administration. The surveyor's observations and interviews with facility staff, including the Director of Nursing and Infection Preventionist, confirmed these deficiencies. Despite the facility's policy requiring verification and documentation of medication and treatment administration, the staff failed to consistently adhere to these protocols, resulting in repeated deficiencies in maintaining professional standards of care.
Inaccurate Physician Documentation in Progress Notes
Penalty
Summary
The facility failed to ensure that the primary physicians accurately dated their progress notes during visits, resulting in a deficiency. This issue was observed in 8 out of 16 residents, where the physicians did not document the progress notes on the effective date of service. The residents involved had various medical conditions, including schizophrenia, chronic kidney disease, epilepsy, diabetes, peripheral vascular disease, multiple sclerosis, and dementia, among others. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyors. For Resident #41, the progress notes were not documented on the effective date, with several entries being recorded as late entries. The resident, who was cognitively intact, could not recall the last time they were assessed by their physician. Similarly, Resident #51, who had severely impaired cognition, had multiple progress notes inaccurately dated, with late entries spanning several months. Resident #110, also with severely impaired cognition, had progress notes that were not written on the date of service, indicating a pattern of late documentation. The surveyors also found that Resident #45, who had moderate cognitive impairment, had inaccurately dated progress notes, with several entries recorded as late entries. Resident #66, with moderate cognitive impairment, had a significant number of progress notes inaccurately dated, indicating a systemic issue with documentation. Resident #71, with severe cognitive impairment, and Resident #84, with moderate cognitive impairment, also had inaccurately dated progress notes. The facility's policy required physicians to date, write, and sign progress notes at each visit, but this was not adhered to, leading to the deficiency.
Failure to Issue SNF ABN to Residents
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents who were reviewed during the survey. The SNF ABN is essential for informing beneficiaries about their potential financial liability for services not covered by Medicare and their standard claim appeal rights. The surveyor found that the facility did not provide the SNF ABN to Resident #30, Resident #83, and Resident #27, who were discharged from Medicare Part A coverage but remained in the facility. The Director of Social Services (DSS) had filled out a form titled SNF Beneficiary Notification Review, which indicated that the SNF ABN was not provided to these residents, and there was no additional documentation about the communication of these forms to the residents or their representatives. During an interview, the DSS admitted to the surveyor that he was unaware of the requirement to issue the SNF ABN when residents remain in the facility after Medicare Part A's last covered day of service. The DSS acknowledged that he did not issue the SNF ABN to the residents or their representatives. The surveyor discussed these concerns with the facility's Licensed Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing, but no additional information was provided. This deficiency was noted under NJAC 8:39-4.1(a)(8).
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, leading to deficiencies in their care management. Resident #51, who was admitted with conditions including anemia, type 2 diabetes, and a nontraumatic subdural hemorrhage, had a physician order for Jevity 1.2 formula feeding that was not updated in the care plan. The Registered Dietician acknowledged the oversight, as the care plan still reflected an outdated order for Jevity 1.5. This discrepancy was noted during a surveyor's review of the resident's medical records and was confirmed in an interview with the Registered Dietician. Resident #110, admitted with peripheral vascular disease and diabetic neuropathy, had a newly identified unstageable pressure ulcer on the buttocks that was not reflected in the comprehensive care plan. The care plan failed to include interventions for the pressure ulcer, despite physician orders for topical treatments. The Director of Nursing stated that nurses were responsible for updating care plans, but the facility's policy required audits to ensure care plans were current. The surveyor's review highlighted the lack of updates in the care plan, which was confirmed during a meeting with facility leadership.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for a resident receiving continuous oxygen therapy. The deficiency was identified when a surveyor observed the resident using oxygen via a nasal cannula with tubing that had not been changed since 11/5/24, despite a physician's order to change the oxygen setup weekly. The resident, who was cognitively intact, had been admitted with diagnoses including pneumonia, chronic respiratory failure, and pulmonary fibrosis. Interviews with facility staff, including the LPN/Unit Manager and the Infection Preventionist/Assistant Director of Nursing, confirmed that the oxygen tubing had not been changed according to the physician's order. The facility's policy on oxygen administration also required weekly changes of the oxygen tubing and mask/cannula. Despite discussions with the Licensed Nursing Home Administrator, Director of Nursing, and Infection Preventionist/Assistant Director of Nursing, no further information was provided to explain the failure to adhere to the policy and physician's order.
Failure to Conduct Required Physician Visits and Document Progress Notes
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes as required. This deficiency was identified for two residents. Resident #95, who was admitted with diagnoses including pneumonia, chronic respiratory failure, and pulmonary fibrosis, did not have any Physician Progress Notes (PPN) documented since admission. Despite being cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), there were no PPNs found in the resident's hybrid medical records. The Licensed Practical Nurse Unit Manager confirmed the absence of PPNs and noted a change in the primary physician from MD#2 to MD#1, effective 11/15/24. MD#2, who was responsible for the resident's care, last visited the facility in October 2024 but could not explain the lack of documentation. Similarly, Resident #103, admitted with chronic systolic heart failure, type 2 diabetes mellitus, and hypertension, also lacked PPNs since admission. The resident, who was cognitively impaired with a BIMS score of 7 out of 15, had only an initial physician's admission note dated 10/2/24, with no subsequent PPNs documented. The facility's policy requires physicians to see residents within 30 days of admission and at least every 30 days for the first 90 days, then every 60 days thereafter. The Director of Nursing acknowledged the documentation concern but provided no further information.
Failure to Respond to Pharmacist's Recommendations
Penalty
Summary
The facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for a resident. The resident, who was admitted with multiple diagnoses including anemia, type 2 diabetes mellitus, nontraumatic subdural hemorrhage, and gastrostomy, had a physician's order for Sucralfate to be administered via G-tube. The CP recommended not to crush the Sucralfate tablets and suggested preparing a slurry or changing to a suspension formulation. Despite this, the facility re-ordered the medication without changes and did not respond to the CP's recommendations. Further recommendations by the CP included administering Sucralfate on an empty stomach and evaluating its use with feedings due to the risk of bezoar formation. The facility did not respond to these recommendations either. During an interview, an LPN described crushing the tablets and administering them via G-tube, contrary to the CP's advice. The Director of Nursing (DON) admitted to not understanding the CP's recommendation. The facility's policy did not specify a timeframe for responding to CP recommendations, contributing to the deficiency.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label, dispose, and secure medications in one of five medication carts and one of five treatment carts inspected. During an observation of medication administration, a treatment cart on the 1st floor was found unlocked and unattended, containing ointments and creams. Although no residents were near the cart at the time, the LPN acknowledged that the cart should always be locked when unattended. Additionally, during an inspection of a medication cart on the 1st floor, an opened bottle of blood glucose test strips was found without a date, and an unopened Humalog insulin pen was also undated. The LPN confirmed that the blood glucose test strips should have been dated upon opening, and the Humalog pen should have been dated once removed from the refrigerator. The Humalog pen was also noted to be unnecessary as the resident was no longer on this medication. The manufacturer's specifications indicated that the blood glucose test strips expire 90 days after opening, and the Humalog insulin pen expires 28 days after opening.
Deficiencies in Medical Record Maintenance and Hospice Coordination
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents, leading to deficiencies in documentation and coordination of care. For one resident, the surveyor observed that the hospice care binder lacked progress notes from hospice nurses and aides, which were supposed to be included according to the facility's policy. The Licensed Practical Nurse acknowledged the absence of these notes, and the Hospice Registered Nurse/Director of Operation confirmed that while notes were entered into the hospice's electronic system, they were only printed and filed in the binder if action was required by the facility. The facility's policy required communication and documentation of hospice interventions, which was not adhered to in this case. For another resident, the surveyor found that the resident's primary physician had not documented an admission assessment in the hybrid medical records. The resident, who had moderate cognitive impairment, could not recall their last visit with the physician. The Licensed Practical Nurse unit manager was unsure where the physician documented their progress notes, and the physician later confirmed that the admission assessment was kept in their office rather than in the resident's medical records. This was contrary to the facility's policy, which required that all physician assessments be included in the medical records. The survey team discussed these concerns with the facility's Licensed Nursing Home Administrator and Director of Nursing, who acknowledged the issues. The facility's policies on coordination of hospice services and maintenance of medical records were not followed, resulting in incomplete documentation and potential gaps in resident care management.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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