Manahawkin Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manahawkin, New Jersey.
- Location
- 1211 Rt 72 West, Manahawkin, New Jersey 08050
- CMS Provider Number
- 315206
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 19 (3 serious)
Citation history
Health deficiencies cited at Manahawkin Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain a complete facility assessment (FA) that accurately reflected the behavioral and mental health needs of its resident population and the resources available to meet those needs. The FA referenced psychiatric and mood disorders and indicated that behavioral and mental health services and contracted mental health professionals were used, but it did not identify the specific contracted providers or list any psychiatrists, psychologists, or licensed counselors. The section stating that behavioral health staffing was adequate for residents with dementia, mental health conditions, or trauma history contained no supporting evidence. During interviews, the LNHA and DON acknowledged that the FA was incomplete, despite a large population of residents with mental health and behavioral issues and a facility policy requiring a comprehensive, regularly updated FA addressing resident needs, services, staff competencies, and staffing patterns for all shifts.
The facility did not maintain required RN coverage for at least eight consecutive hours a day, seven days a week, as shown by review of the Nurse Staffing Report for a two-week period prior to survey. On four separate days within that period, there was no RN coverage for any shift. The administrator acknowledged awareness of the lack of RN coverage and attributed it to staff call outs, resulting in noncompliance with regulatory requirements for RN staffing and RN leadership.
The facility failed to provide breakfast at a regular time and allowed more than 16 hours to elapse between the evening meal and the next morning’s breakfast. On one morning, breakfast, normally served around 8:00 AM, was not delivered until late morning, during which residents requested food and were only offered available pantry snacks by an LPN and a CNA. The delay stemmed from a scheduled cook reporting car trouble and not arriving, a dietary aide without a kitchen key waiting in the lobby without notifying others, and limited key access restricted to certain staff, while the night supervisor with a key was unaware of the issue. The FSD confirmed the extended interval between dinner and breakfast and that existing meal service policy described how to serve meals but did not address meal timing or the 16-hour maximum interval between meals.
A resident with schizoaffective disorder, bipolar disorder with psychotic features, muscle weakness, difficulty walking, and cognitive deficits eloped after observing staff enter a keypad code and exiting when the door lock indicator turned green. The resident, who was only supposed to leave with family, was last seen inside by an LPN and a CNA while walking the halls, then left alone in pajamas, clog-style shoes, and no coat, without a cane. A passerby later found the resident on the roadside, took them to a convenience store, and police ultimately returned the resident to staff. The facility’s elopement policy required systematic identification and assessment of elopement risk and individualized care planning, but the record showed only one prior low-risk elopement assessment and no targeted elopement interventions before the incident. Staff interviews and documentation confirmed that no one knew the resident had left until police returned them, and surveyors cited the facility for failing to provide adequate supervision, develop appropriate elopement-prevention interventions, and follow its elopement and wandering policy, resulting in Immediate Jeopardy under F689.
Surveyors found that the facility allowed a resident with intact cognition and using a motorized wheelchair to leave independently through the front door multiple times without any physician order (PO) authorizing out-of-pass (OOP) or leave of absence (LOA) or specifying supervision needs, and without any related focus or interventions in the care plan. Another cognitively intact resident with multiple medical conditions had POs permitting LOA with medications and with a responsible party, but the care plan did not include any OOP/LOA-related focus, goals, or interventions. The Receptionist described a process in which nursing staff notified her when the independently leaving resident was coming to the lobby so she could unlock the door and assist with the wheelchair, and the DON acknowledged that OOP/LOA status and instructions should have been reflected in both orders and care plans to meet professional standards of quality.
Staff failed to document ordered wanderguard checks for a resident with intact cognition but multiple diagnoses, including schizoaffective disorder, bipolar disorder with psychotic features, diabetes with mononeuropathy, muscle weakness, and difficulty walking, who had been assessed as at risk for elopement and care planned for elopement prevention with a wanderguard. Physician orders required every-shift checks of wanderguard placement, function, expiration, and skin integrity under the device, but the TAR showed blank entries for these orders on a night shift, and progress notes documenting the resident’s elopement and return by police contained no evidence that the wanderguard or related skin integrity were checked. A facility memo on timely and accurate MAR/TAR documentation, signed by the assigned LPN, required prompt and complete documentation, and the DON confirmed that blank TAR spaces meant there was no way to know if the care was provided.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors found that two shower rooms and an elevator had temperatures above the required range, with readings over 84°F. Although no residents were present in the shower rooms or elevator during the checks, residents, visitors, and staff were observed using the elevator. Facility leadership reported no known issues with the air conditioning system following a recent power outage.
A resident with dementia had missing clothing and personal items after a closet lock was removed, and the family raised concerns to staff. Although the Administrator acknowledged the issue and indicated reimbursement would be requested, no formal grievance was filed, no investigation was conducted, and no reimbursement was provided, contrary to facility policy.
A nurse failed to observe a resident taking prescribed medications, leaving a cup of pills at the bedside instead of ensuring consumption. The resident, who was cognitively intact and had multiple chronic conditions, did not take the medications as intended. Facility policy and leadership confirmed that nurses are expected to watch residents take their medications to ensure proper administration and safety.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple wounds, including an unstageable heel ulcer and a stage IV knee ulcer, did not receive pressure ulcer treatments as ordered by the NP/CWS. Facility staff documented only generic wound care for several weeks, and the specific treatment orders were not implemented until later. The DON confirmed that ordered treatments were only completed when the NP/CWS was present, and the Unit Manager could not explain the lapse.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week. On two occasions, there was no RN coverage, and the DON stepped in as a supervisor, which did not meet the requirement. The facility's policy mandates daily RN coverage, which was not met.
The facility failed to follow the planned menu and notify residents of changes for three consecutive meals. Residents received incorrect desserts and vegetables, and the Food Service Director did not contact the Registered Dietitian/Nutritionist for approval of substitutions. The facility lacked a policy for menu substitutions.
The facility failed to maintain kitchen sanitation, with issues such as uncovered coffee filters, exposed frozen pizza, unrecorded dish machine temperatures, wet nesting of pans, and unsanitized thermometer use. Additionally, refrigerator temperatures were not logged, and portion control cups lacked dates, violating facility policies.
Surveyors observed unsanitary conditions in a facility, including hair and debris on equipment wheels, a sandwich under a bed, and a protruding nail in a resident's room. Additionally, shower rooms lacked liners for trash cans and linen carts, and had missing tiles and stained surfaces. The Director of Maintenance and Director of Nursing acknowledged the issues, noting the absence of a formal cleaning schedule.
The facility failed to accurately complete the MDS for several residents, leading to discrepancies in their assessments. A resident's use of a hand splint was not documented, another's discharge was incorrectly coded, and a third resident's wander alarms were not recorded. Additionally, a resident using a Merry Walker was not coded for restraint, and two residents' use of splints and handrolls were omitted from their MDS. These errors were acknowledged by the MDS Coordinator.
The facility failed to develop comprehensive care plans for four residents, each with specific medical needs. A resident on anticoagulant medication, another requiring oxygen therapy, a third using a splint for a contracted hand, and a fourth at risk of elopement with a wander alarm, all lacked appropriate documentation in their care plans. The LPN and DON acknowledged these omissions, confirming that such treatments and interventions should be included in the care plans.
The facility failed to provide appropriate treatment for range of motion limitations for three residents. One resident was observed with a splint that was not included in the care plan or physician orders. Another resident with cerebral palsy was not wearing a prescribed hand roll or splint, and documentation was lacking. A third resident with a contracture was not using a splint, and the care plan did not address its use. The facility lacked a policy for therapy services and treatment for range of motion limitations.
The facility failed to obtain physician's orders for supplemental oxygen for three residents, leading to deficiencies in respiratory care. A resident with COPD used oxygen without a current order, another resident had an oxygen concentrator without an order and improper storage of equipment, and a third resident's oxygen use was not documented despite having a PRN order. Staff interviews confirmed these lapses in compliance with facility policy.
A resident with severe cognitive impairment was inappropriately transported backward in a wheelchair without footrests, causing their feet to drag on the floor. The facility's policy lacked guidance on proper transportation methods, and staff acknowledged the inappropriateness of the action.
The facility failed to issue the required beneficiary notices for two residents reviewed for SNF Beneficiary Protection Notification. The CSW admitted to not providing the necessary forms due to a lack of awareness and recent changes in staff. Two residents remained in the facility without receiving the required SNFABN Form 10055, as indicated in the surveyor's review.
A facility failed to implement a baseline care plan within 48 hours of admission for a resident with fractures requiring a splint and CAM boot. The care plan lacked necessary instructions for these devices, and physician orders did not reflect their use. The LPN acknowledged the oversight, indicating a lapse in care planning.
A facility failed to document a discharge summary for a resident who was planned for discharge to a hospital. The resident's medical record lacked documentation of the hospitalization or discharge, and no discharge summary was provided, contrary to the facility's policy. The DON and LNHA acknowledged the oversight.
The facility failed to address Consultant Pharmacist recommendations in a timely manner for two residents, leading to a deficiency in medication management. Recommendations for discontinuing or clarifying medication orders were delayed, with responses taking up to 40 days. Interviews with staff revealed a lack of adherence to the facility's policy for addressing these recommendations within 10 days.
A resident with acute kidney failure and sinusitis had a urinalysis conducted, but the facility failed to promptly notify the physician of abnormal results. The results were received on one day, but the physician only discovered them six days later, delaying necessary antibiotic treatment. Interviews confirmed the lack of documentation and adherence to the facility's policy for timely notification.
A facility failed to document medication administration in the EMAR for a resident with multiple diagnoses, including hemiplegia and bipolar disorder. The resident's EMAR showed blank spaces for several medications, indicating a failure to document administration. Interviews with an LPN and the DON confirmed that the nurse responsible did not initial the EMAR as required by facility policy.
Incomplete Facility Assessment of Behavioral and Mental Health Needs and Resources
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive facility assessment (FA) that accurately identified the mental and behavioral health needs of its resident population and the resources necessary to provide appropriate care. On 2/11/26, a surveyor requested and reviewed the FA dated 7/22/25, which stated its purpose was to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. The FA’s scope referenced resident population characteristics, including physical and behavioral health needs, and required staff competencies, as well as facility resources such as behavioral health services and contracted personnel. Upon review, the FA listed certain psychiatric and mood disorders (schizophrenia, depression, anxiety) under diseases/conditions and referenced a vendor retained to provide psychiatric and psychological services, as well as behavioral and mental health services such as psychological, psychiatric, and PESS (Psychiatric Emergency Screening Services) unit. However, the FA did not identify the contracted mental health professional under Social Services, and none of the behavioral and mental health providers (psychiatrists, psychologists, licensed counselors) were named; the areas to identify these providers were left blank. Under staffing patterns for behavioral health services, the FA stated that staffing was adequate for residents with dementia, mental health conditions, or a history of trauma, but no evidence or supporting information was documented. During an interview with the LNHA, DON, and DOO, the surveyor asked them to identify where psychiatric and behavioral issues were addressed in the FA. The LNHA pointed to the sections referencing behavioral and mental health services and the contracted mental health professional but acknowledged that information for mental health providers was not available and that no evidence was listed under behavioral health staffing patterns. When asked if the FA reviewed was fully complete, the DON stated it was not, and confirmed that the facility had a large population of residents with mental health, behavioral, and psychiatric issues. Both the LNHA and DON acknowledged that several necessary components of the FA were missing, and the LNHA stated she had attempted to review the FA but had not had the chance to do so. The facility’s own policy required a comprehensive, documented facility-wide assessment addressing resident population needs, including physical and behavioral health, staffing competencies, services (including behavioral health), and shift-specific staffing, to be reviewed and updated at least annually, which was not met in this instance.
Failure to Maintain Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. On 2/3/26, a surveyor requested the Nurse Staffing Report (NSR) for the two weeks prior to the survey, covering 01/18/2026 to 01/31/2026. Review of the NSRs completed by the facility for this period showed there was no RN coverage for any shift on four specific dates: 1/18/26, 1/21/26, 1/28/26, and 1/31/26. During a telephone conversation on 2/11/26 at 8:06 AM, the Licensed Nursing Home Administrator confirmed awareness that there was no RN coverage on those dates and stated that the lack of coverage was due to call outs. The deficiency was cited under NJAC 8:39-25.2(h), which requires an RN on duty eight hours a day and a full-time RN director of nurses.
Delayed Breakfast Service and Excessive Interval Between Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide breakfast at a regular time and to ensure no more than 16 hours elapsed between the evening meal and the next morning’s breakfast. On the morning in question, staff interviews indicated that breakfast, which was usually delivered between approximately 7:45 AM and 8:30 AM, was not delivered until about 10:30 to 11:00 AM. The second-floor LPN and CNA reported that residents asked for food while waiting, and they provided snacks from the pantry. The LPN stated she did not notify a supervisor or manager about the delay and confirmed that nursing staff did not have a key to the kitchen. The Food Service Director reported that the scheduled cook called at 4:00 AM about car trouble and later failed to arrive on time, leaving the dietary aide, who arrived at 6:30 AM, unable to access the locked kitchen. The dietary aide did not inform others that he could not get into the kitchen and waited in the lobby. The FSD stated that only two cooks, the FSD, and the director of maintenance had keys to the kitchen, and dietary aides did not. The night shift cook with a key did not arrive until 9:30 AM, and the FSD arrived at 10:45 AM to assist with breakfast, resulting in approximately 17 hours between dinner at 5:45 PM the previous evening and breakfast service. The Administrator confirmed that the night supervisor had a key but was unaware of the problem. Review of the facility’s “Serving a Meal” policy showed it addressed how to serve meals but did not include a process to ensure meals were provided at regular times or that no more than 16 hours elapsed between meals, and no additional relevant policies were provided.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Door Security
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident with poor decision-making abilities. The resident had multiple diagnoses, including schizoaffective disorder, bipolar disorder with psychotic features, muscle weakness, difficulty walking, and cognitive deficits with confusion. An Elopement Risk Review earlier in the year had assessed the resident as low or no risk for elopement, and no additional elopement risk assessments were documented between that time and the date of the incident. The resident’s care plan identified a self-care deficit related to cognitive deficits and confusion, and a separate focus that the resident was at risk for falls, accidents, and incidents, but there were no documented care plan interventions specifically addressing elopement risk prior to the incident. On the night of the incident, staff accounts and documentation showed that the resident was last observed inside the facility around 1:00 AM by an LPN and again around 1:30–1:45 AM by a CNA, who reported that the resident was walking around the facility, which was described as usual behavior. The resident later reported that they exited the facility by watching staff enter a code into a keypad at an exit door and then waiting for the door’s locking mechanism light to turn green before going through the door. The Nursing Supervisor on duty stated that the front door lock did not lock immediately upon closing and that it was possible for someone to get out when the door was in that condition. The resident stated that they were only allowed to leave with family, yet left the building alone wearing pajamas, rubber clog-style shoes, no coat, and without their cane. External documentation from the police incident report indicated that a caller observed an elderly person in pajama pants and no jacket on the side of the roadway, identified by first name and an identification bracelet. The caller transported the resident to a convenience store, gave them money, and then left. Police then picked up the resident from the store and returned them to the facility around 2:00–2:08 AM. Facility documentation, including the Facility Reportable Event and progress notes, confirmed that staff were unaware the resident had left until police returned the resident and reported finding them at the convenience store. Interviews with the Unit Manager and DON confirmed that such an unsupervised departure met the facility’s definition of elopement and that the resident was not considered safe to go out independently. The surveyors determined that the facility failed to provide adequate supervision, failed to develop appropriate interventions to prevent elopement for this resident, and failed to follow its elopement and wandering policy, resulting in an Immediate Jeopardy situation under F689. The facility’s elopement and wandering policy stated that residents at risk for elopement would receive adequate supervision to prevent accidents and care according to individualized care plans, and that the facility would use a systematic approach to identify and assess elopement risk. However, the record showed only one Elopement Risk Review earlier in the year, with no subsequent reassessments until after the elopement occurred. The DON described that, following an elopement, the expectation was for assessment, completion of a risk management form, collection of staff statements, and notification of family and physician to support a thorough investigation and root cause analysis. At the time of the survey, only limited staff statements were available, and the survey findings concluded that the facility did not adequately implement its own policy or maintain sufficient supervision and environmental controls to prevent the resident’s unauthorized exit.
Removal Plan
- Safely returned Resident #2 to the facility and placed on one-to-one supervision.
- Applied a wander guard for Resident #2 and verified its functionality, placed the resident on enhanced supervision, and moved the resident to a room closer to the nurse's station.
- Updated Resident #2's care plan.
- Reassessed Resident #2 for elopement risk.
- Conducted a facility headcount.
- Inspected facility exit doors, keypads, alarms, and the wander guard system to validate proper functioning.
- Updated the facility's front door to eliminate delay in opening and closing.
- Reviewed the facility elopement policy.
- Re-educated facility-wide staff on elopement prevention and emergency protocols and validated competency.
- Completed reassessments of at-risk residents.
Failure to Obtain OOP/LOA Orders and Update Care Plans for Resident Leaves
Penalty
Summary
Surveyors determined that the facility failed to obtain a physician order (PO) for one resident to go out of the facility on pass (OOP) or take a leave of absence (LOA), and failed to include OOP/LOA status and related interventions in the care plans of two residents. Observations in the lobby showed residents interacting with the Receptionist, who controlled the front door. The Receptionist reported that only one resident was allowed to leave independently and that nursing staff would call her when this resident was coming to the lobby to go out, after which she would assist the resident with getting their wheelchair through the front doors. For the first resident, medical record review showed admission with diagnoses including injury from a motor-vehicle accident and polyneuropathy, with a Quarterly MDS indicating intact cognition (BIMS score of 15) and use of a motorized wheelchair or scooter. The Resident Responsibility/Sign Out Sheet documented multiple instances in which this resident signed out of the facility, listing self as the responsible party. However, the Order Summary Report contained no PO authorizing OOP or LOA or specifying the level of supervision required, and the Care Plan Report contained no focus, goals, or interventions related to the resident going OOP or on LOA. In an interview, this resident stated they went out independently once or twice a week, notifying a nurse, signing out in a logbook, and then having the nurse notify the Receptionist to unlock the front door. For the second resident, the Admission Record documented diagnoses including cellulitis of a limb, benign neoplasm of the meninges, cirrhosis of the liver, generalized muscle weakness, and difficulty walking, with a Comprehensive MDS showing intact cognition (BIMS score of 14). The Order Summary Report for this resident did contain POs allowing LOA with medications and LOA with a responsible party, each with specified start dates. Despite these orders and the resident’s report that they had gone out with family in the past, the Care Plan Report lacked any focus, goals, or interventions related to going OOP or on LOA. In an interview, the DON confirmed that the first resident did not have a PO for OOP/LOA and stated that such an order and corresponding care plan information were necessary so staff would know if and how the resident could go out, consistent with the facility’s Comprehensive Care Plans policy and professional standards of quality.
Failure to Document Ordered Wanderguard Checks for Elopement-Risk Resident
Penalty
Summary
Facility staff failed to document ordered interventions intended to prevent elopement for a resident with a known history and risk of elopement. The resident, who had intact cognition per a recent MDS but diagnoses including diabetes with mononeuropathy, schizoaffective disorder, bipolar disorder with psychotic features, muscle weakness, and difficulty walking, was assessed as at risk for elopement on an Elopement Risk Review that noted verbalized desire or plans to leave without authorization, cognitive impairment, decreased safety awareness, and disturbances in judgment or history/risk of wandering. The resident’s care plan identified elopement risk related to attempts to leave the facility and a prior incident, and included use of a wanderguard tag as an intervention. Physician orders directed staff to check placement of the wanderguard every shift, check skin integrity under the wanderguard on the left ankle every shift, and check skin integrity, function, placement, and expiration of the wanderguard every shift, replacing it immediately if expired, in ill repair, or not functioning. Review of the Treatment Administration Record revealed blank boxes for these wanderguard-related orders on the night shift of a specified date, indicating no documented checks were performed that shift. Progress notes for that period documented that a police officer informed nursing staff that the resident had been picked up by a passerby on a nearby road, taken to a convenience store for coffee, and then returned to the facility by another officer; the resident stated they knew the code to the facility door and refused to further discuss the elopement. The progress notes contained no documentation that skin integrity, placement, or function of the wanderguard were checked. A facility document regarding timely and accurate MAR/TAR documentation, signed by the LPN assigned that night, emphasized that all entries must be signed promptly and accurately and that records should be reviewed for completeness at the end of the shift. The DON confirmed that the wanderguard should have been checked every eight hours and that blank spaces on the TAR meant there was no way to know if the care was provided, stating that if nurses did not document something, it did not happen.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Safe Room Temperatures in Shower Rooms and Elevator
Penalty
Summary
Surveyors identified that the facility failed to maintain safe and comfortable room temperature levels in two of four resident shower rooms and in one facility elevator. During temperature checks conducted in the presence of the Maintenance Person, the second-floor East shower room and another second-floor shower room were both found to have temperatures of 84.4 degrees Fahrenheit, which exceeds the required range of 71 to 81 degrees Fahrenheit. The elevator car was also found to have a temperature of 84.6 degrees Fahrenheit. At the time of these observations, no residents were present in the affected shower rooms or elevator, but residents, visitors, and staff were observed using the elevator throughout the day. Interviews with the Maintenance Director and the Licensed Nursing Home Administrator revealed that there had been a recent power outage, but both stated that the air conditioning and generator systems functioned properly during and after the outage. The Maintenance Director was not aware of any work orders related to room temperatures, and the Administrator confirmed there was no known interruption in air conditioning. The deficiency was cited under NJAC 8:39 -31.6(p)4 for failing to ensure a safe, clean, and comfortable environment for residents.
Failure to File and Investigate Grievance for Missing Resident Belongings
Penalty
Summary
The facility failed to ensure that a family member's concern regarding missing clothing and personal items for a resident diagnosed with dementia was filed as a grievance and properly investigated. The facility's policy requires that grievances, including those about lost clothing or personal items, be documented and responded to within five days. Documentation review showed that the family expressed concern about the resident's closet lock being removed and missing items, but there was no evidence that a grievance was filed or investigated for this incident. The resident's progress notes indicated the family raised the issue during a visit, and the nurse acknowledged the concern but did not initiate the grievance process. Interviews with facility staff confirmed that the concern was not formally documented or investigated as a grievance. The Administrator acknowledged awareness of the family's concern and stated that an email was sent to the family indicating a request for reimbursement would be submitted. However, no reimbursement was provided, and no formal grievance or investigation was completed. The Administrator confirmed that a grievance should have been filed to ensure a thorough investigation and resolution for the family.
Failure to Observe Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer medications according to professional standards of nursing practice. During a survey, a resident with diagnoses including spondylosis, depression, anxiety disorder, and chronic pain was found with a cup containing multiple pills left on their overbed table. The resident, who was cognitively intact, stated that the nurse handed them the medication, which they then placed on the table and forgot to take. The nurse confirmed that she did not observe the resident taking the medication and left the room in a rush, deviating from the usual process of watching residents take their medications. Facility leadership, including the Unit Manager and Director of Nursing, stated that the expectation is for nurses to observe residents consuming their medications to ensure proper administration and safety. Review of the facility's policy also confirmed that nurses are required to observe residents taking their medications. The nurse involved acknowledged the importance of this practice and admitted to not following it during the incident.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and record review, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered treatments for pressure ulcers were completed as prescribed for one resident with multiple wounds related to peripheral vascular disease and gangrene. Upon admission, the resident had an unstageable pressure ulcer on the right heel and a stage IV pressure ulcer on the right medial posterior knee, with specific treatment orders documented by a Nurse Practitioner/Certified Wound Specialist. However, review of the Treatment Administration Record (TAR) revealed that from the beginning of June through June 23, only a generic wound care treatment was documented as completed, rather than the specific treatments ordered. The correct treatment orders were not implemented until June 26, and there was no evidence that any wound care was provided on June 24 and June 25. Weekly wound assessments and treatments were performed by the NP/CWS, but facility staff did not follow the prescribed orders on other days. The Director of Nursing confirmed that the facility's documentation did not reflect completion of the ordered treatments except when the NP/CWS was present. The Unit Manager was unable to provide an explanation for why the ordered treatments were not completed by staff. This failure to follow the care plan and physician orders for pressure ulcer management was identified through record review, interviews, and review of facility policy.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the Nurse Staffing Reports for the period from 11/17/2024 to 11/30/2024, which revealed that there was no RN coverage for all shifts on 11/18/2024 and 11/23/2024. During an interview, the Director of Nursing (DON) acknowledged that staffing needs were not fully met and that when an RN was unavailable, the DON would step in as a supervisor, which does not fulfill the requirement for RN coverage. The Licensed Nursing Home Administrator confirmed that the DON cannot be counted as the RN on duty. The facility's policy requires RN coverage for 8 hours daily, which was not adhered to on the specified dates.
Failure to Follow Planned Menus and Notify Residents of Changes
Penalty
Summary
The facility failed to adhere to the planned, written menu and did not notify residents in advance of menu changes for three consecutive meals observed by the surveyor. On December 3, 2024, during the lunch meal on the 2nd floor, eight residents, including Resident #48, were served diced peaches instead of the scheduled yellow cake for dessert, and no dinner rolls were provided as per the menu. The Food Service Director (FSD) admitted that the kitchen staff did not prepare the yellow cake and had run out of dinner rolls the previous Friday, with deliveries occurring only once a week. On December 4, 2024, Resident #84, assisted by a staff nurse, received Salisbury steak with gravy, white rice, and mixed vegetables, which were the same as the previous day, instead of the scheduled scalloped corn and baked apple dessert. The FSD and cook confirmed the substitution of mixed vegetables due to a shortage of corn and admitted that the Registered Dietitian/Nutritionist (RDN) was not contacted for approval of these substitutions prior to the meal. The FSD acknowledged that the facility's process required contacting the RDN for menu substitutions and documenting them in the meal substitution log. On December 5, 2024, the surveyor observed the same mixed vegetables being served for the third consecutive day, contrary to the menu that specified different vegetables for each day. The FSD acknowledged the oversight and agreed to change the menu. Additionally, on December 6, 2024, diced fruit was served instead of the scheduled sherbet, and the FSD admitted to not completing the menu substitution process in advance. The facility was unable to provide a policy and procedure for menu substitutions, indicating a lack of proper protocol adherence.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, leading to several deficiencies observed by the surveyor. In the dry storage area, a previously opened pack of coffee filters was left uncovered, exposing the usable surface to potential contamination. Similarly, in the walk-in freezer, a box of frozen pizza was found open, with the pizza exposed to air and possible contamination. Additionally, the dish machine temperature logs were not recorded for the month of December, indicating a failure to ensure that dishwashing temperatures met the required minimums before use. Further observations revealed issues with wet nesting, where pans were stacked while still wet, creating conditions conducive to microorganism growth. A can opener attached to a prep table was found with a brown/black sticky substance on its cutting blade and stem, indicating it was not included in the cleaning schedule. In the nourishment rooms, refrigerator temperatures were not recorded for several days, and there was no monitoring of freezer temperatures due to the absence of an internal thermometer. Portion control cups containing applesauce and diced fruit were found without dates, contrary to facility policy. During a tray line observation, the Food Service Director (FSD) failed to properly sanitize a digital thermometer between checking food temperatures, using a paper towel instead of an approved sanitizer. This practice was against the facility's policy, which requires thermometers to be clean, sanitized, and calibrated. The facility's policies on food brought in by family and visitors and dishwasher temperature recording were not adhered to, contributing to the overall deficiency in maintaining kitchen sanitation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment, as evidenced by multiple observations made by surveyors. On two separate units, surveyors noted hair and debris wrapped around the wheels of medication carts and a Hoyer lift. Additionally, a half-eaten sandwich was found under a bed in one of the rooms. In another instance, a resident's room had a disattached bed rail and a protruding nail from a chair rail, posing a potential hazard. The Director of Maintenance acknowledged the oversight, admitting that such occurrences were common in rooms where beds were placed against the wall. Further observations revealed unsanitary conditions in the shower rooms, including trash cans and linen carts without liners, missing floor tiles, stained wall tiles, and a bulging ceiling tile. The Director of Nursing and Licensed Nursing Home Administrator were informed of these issues, and it was noted that there was no formal cleaning schedule in place. The facility's policies on routine cleaning and cycle cleaning were reviewed, but they were undated and lacked specific implementation details.
Inaccurate MDS Documentation Across Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) for several residents, leading to discrepancies in their assessments. For Resident #35, the MDS did not reflect the use of a resting hand splint on the right hand, despite a physician's order for its application during daily activities. The MDS Coordinator (MDSC) acknowledged the oversight during an interview, confirming that the splint should have been coded in section O of the MDS. Resident #107's discharge status was inaccurately coded as returning home, although the resident was sent to the hospital via 911 due to a fall. The MDSC admitted that the discharge should have been coded as a hospital transfer. Similarly, Resident #99 was observed with wander alarm bracelets, yet the MDS did not document the use of these alarms, which was confirmed by the MDSC as an error. Additional discrepancies were noted for Resident #67, who was observed using a Merry Walker, which was not coded as a restraint in the MDS despite the resident's inability to release it independently. Resident #102 was not coded for wearing a splint, although it was observed and documented in the nurse's notes. Lastly, Resident #1's MDS failed to reflect the use of a handroll and splint, despite physician orders for their use. These inaccuracies highlight a pattern of incomplete and incorrect MDS documentation across multiple residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for four residents, each with specific medical needs. Resident #8, who was on an anticoagulant medication, did not have this treatment documented in their care plan, despite having diagnoses of acute embolism and thrombosis of deep veins. Both the LPN/UM and the DON acknowledged that anticoagulants should be included in the care plan, but this was not done. Resident #18, who required oxygen therapy, was observed using oxygen via nasal cannula on multiple occasions. However, their care plan did not reflect the use of oxygen therapy, even though there was a physician order for PRN oxygen for shortness of breath. The LPN/UM confirmed that oxygen therapy should be care planned and documented in the Treatment Administration Records. Resident #35, who had a contracted right hand, was ordered to use a resting hand splint, but this was not included in their care plan. The LPN/UM and DON both agreed that the use of a splint should be documented in the care plan. Similarly, Resident #99, who was at risk of elopement and wore a wander alarm bracelet, did not have any interventions noted in their care plan for elopement risk, despite having a care plan focus area for this issue. The LPN/UM and DON confirmed that interventions for a wander alarm should be included in the care plan.
Failure to Provide Range of Motion Treatment
Penalty
Summary
The facility failed to provide appropriate treatment for range of motion limitations for three residents. Resident #102 was observed with a black splint on the left lower arm and wrist, which was supposed to be worn daily. However, the resident's care plan did not include specific instructions for the use of the splint or CAM boot, and there were no physician orders for these devices. The orthopedic notes recommended physical therapy and the use of a splint, but these were not reflected in the resident's care plan or physician orders. Resident #1, diagnosed with cerebral palsy, was observed without a hand roll or splint on the right hand, despite physician orders for their use. The resident's care plan did not include the hand roll or splint, and the MAR and TAR did not document their application or removal. The LPN/UM confirmed that the resident should be care planned for these devices, and a physician's order is required. Resident #35, with a diagnosis of cerebral infarction, was observed with a contracture in the right hand but without a splint. The care plan did not address the use of a splint, and the MARs/TARs lacked documentation of its application or removal. Occupational therapy notes indicated that the resident received passive range of motion exercises and that nursing staff was informed about the splint. The DON confirmed that documentation should be on the TAR, but the facility could not provide a policy regarding therapy services and treatment for range of motion limitations.
Failure to Obtain Physician's Orders for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen for three residents, which is a requirement according to the facility's policy. Resident #54, who has COPD, was observed using oxygen without a current physician's order. The resident's medical records did not include an active order for oxygen use, and the staff confirmed the absence of such an order. Despite the resident's need for oxygen, as evidenced by low oxygen saturation levels, the facility did not ensure the necessary documentation was in place. Resident #261 was observed with an oxygen concentrator in their room, but there was no physician's order for its use. The nasal cannula was improperly stored, being left on the floor and exposed to contamination. The resident's medical records and care plan did not reflect the use of supplemental oxygen, and staff interviews confirmed the lack of an order and improper storage practices. The facility's policy requires oxygen equipment to be bagged when not in use and tubing to be changed weekly, which was not adhered to in this case. Resident #18 was observed using oxygen via nasal cannula, but the administration of oxygen was not documented in the treatment records. Although there was a physician's order for PRN oxygen, the facility failed to document its administration and did not ensure the oxygen tubing was dated weekly as per policy. Interviews with staff revealed a lack of compliance with the facility's procedures for oxygen administration and documentation, contributing to the deficiency.
Inappropriate Wheelchair Transportation of Resident
Penalty
Summary
The facility failed to ensure a resident was transported in a dignified manner, as observed by a surveyor. A Licensed Practical Nurse/Unit Manager (LPN/UM) was seen pulling a resident backward in a wheelchair from the nurse's station to the dining/recreation room. The resident's feet, clad in slippers, were dragging on the floor due to the absence of footrests on the wheelchair. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status score of 4/15, was not capable of following instructions, which contributed to the inappropriate method of transportation. The facility's policy on Safe Resident Handling/Mobility/Transfers, implemented in November 2023, did not provide guidance on transporting residents from one area to another. During interviews, the LPN/UM acknowledged the inappropriateness of pulling a resident backward in a wheelchair, and the Director of Nursing (DON) stated that residents should be pushed forward and provided with leg rests if they cannot lift their feet. The lack of specific guidance in the facility's policy and the staff's actions led to the deficiency in maintaining the resident's dignity during transportation.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required beneficiary notices for two residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification (SNF BPN). The certified social worker (CSW) at the facility admitted to the surveyor that she had only started issuing the SNF BPN forms in October after her predecessor left. During the survey, it was revealed that the CSW was unaware of the requirement to provide two forms, Notice of Medicare Non-Coverage (NOMNC) - Form CMS 10123 and SNF Advanced Notice of Non-Coverage (SNFABN) - Form CMS-10055, to residents discharged with Medicare A time remaining. Resident #9, who started Medicare A coverage on 10/17/2024 and had coverage until 11/26/2024, remained in the facility but did not receive the required SNFABN Form 10055. Similarly, Resident #22, with a Medicare A start date of 8/6/2024 and coverage until 9/19/2024, also remained in the facility without receiving the necessary SNFABN Form 10055. The surveyor's review of the SNF BPN forms indicated that the facility did not provide the required documentation, as noted under Section 1 of the forms.
Failure to Implement Baseline Care Plan for Resident's Immediate Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which included the necessary healthcare information to address the resident's immediate needs. This deficiency was identified for a resident who was observed with a black splint on the left lower arm and wrist, provided by an orthopedic doctor due to a broken left arm and ankle. The resident mentioned that they no longer wore the CAM boot, which was initially provided along with the splint. However, the physician orders did not include any current or discontinued orders for a cast, splint, or CAM boot, and the care plan did not address or include specific instructions for these medical devices. The resident's medical records indicated a history of fractures, with a cast initially placed on the right lower extremity and left upper extremity. Subsequent notes revealed that the resident returned from an orthopedic appointment with a brace on the left arm, and later, the cast was replaced with a CAM boot. Despite these changes, the care plan failed to reflect the necessary care instructions for the cast, splint, or CAM boot. During an interview, the LPN/Unit Manager acknowledged that the resident should have had a care plan for these medical devices, highlighting the oversight in the facility's care planning process.
Failure to Document Discharge Summary for Hospitalized Resident
Penalty
Summary
The facility failed to document a discharge summary for a resident who was reviewed for hospitalization. The resident, who had been admitted with medical diagnoses including myocardial infarction, anxiety, and adult failure to thrive, was planned for discharge to a short-term general hospital. However, the resident's progress notes and electronic medical record did not reflect any documentation or note of the hospitalization or discharge, nor did they include a discharge summary. Upon review, the Director of Nursing and the Licensed Nursing Home Administrator acknowledged that there should have been progress notes entered by a nurse or social worker regarding the resident's discharge or hospitalization. Additionally, they confirmed the absence of a required discharge summary. The facility's discharge summary policy, implemented in October 2023, mandates that a discharge summary be provided upon a resident's discharge, detailing the resident's clinical status and care instructions to ensure a safe transition. However, this policy was not adhered to in this instance.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist (CP) in a consistent and timely manner for two residents, leading to a deficiency in medication management. For Resident #22, the CP recommended discontinuing the PRN Ativan order unless a clinical rationale and anticipated duration of therapy were documented, as per CMS requirements. Despite these recommendations being made on two separate occasions, the facility did not address them promptly, with the nursing staff acknowledging that recommendations should be addressed within 10 days but failing to do so. For Resident #90, the CP made several recommendations over a period of months, including clarifying medication orders and adjusting administration times. However, the facility consistently delayed responding to these recommendations, taking up to 40 days to address them. This included recommendations to clarify the Glucagon order, update the Prostat order, and adjust the administration of Coreg. The facility's policy required that recommendations be addressed within 10 working days, but this was not adhered to. Interviews with facility staff, including the LPN/Unit Manager and the DON, revealed a lack of adherence to the facility's policy for addressing CP recommendations. The DON and LPN/UM both acknowledged that recommendations should be completed before the next month's pharmacy consultant review, yet this was not consistently achieved. The facility's failure to act on the CP's recommendations in a timely manner resulted in a deficiency in medication management for the residents involved.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal urinalysis results for a resident, leading to a delay in treatment. The resident, who was admitted with acute kidney failure and acute ethmoidal sinusitis, had a urinalysis conducted on October 17, 2024, with results received by the facility on October 18, 2024. However, the physician was not informed of these results until October 24, 2024, when he discovered the abnormal findings while reviewing lab slips. This delay resulted in the resident not receiving the necessary antibiotic treatment until six days after the results were available. Interviews with the Unit Manager and the Director of Nursing confirmed that there was no documented evidence in the resident's electronic medical record that the physician had been notified of the abnormal results on the day they were received. The facility's policy requires prompt notification of lab results to the physician, which was not adhered to in this case. The physician confirmed that the protocol was for the nurse on duty to promptly notify him of any abnormal lab results, which did not occur, leading to a lapse in timely medical intervention.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice for documenting medication administration in the electronic Medication Administration Record (EMAR). This deficiency was identified during a survey conducted on June 26 and 27, 2024, for one of the three residents reviewed for medication administration. The resident in question, who was admitted with conditions including hemiplegia, hemiparesis, bipolar disorder, and hypertension, had a cognitively intact status as indicated by a BIMS score of 14 out of 15. The review of the resident's EMAR for June 2024 revealed blank spaces for several medication orders on June 6, 2024, at 9:00 P.M., indicating a failure to document the administration of prescribed medications such as Levetiracetam, Ferrous Sulfate, Lisinopril, and Oxycodone. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the nurse responsible for administering medications should have initialed the EMAR after administration. Both the LPN and DON acknowledged that blank spaces on the EMAR indicated that the medications were either not given or the task was not completed. The facility's policy on medication administration requires that the Medication Administration Record (MAR) be signed after medications are administered, which was not adhered to in this instance. This oversight in documentation was confirmed by the DON, who verified the blank spaces on the resident's EMAR for the specified date and time.
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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