Manhattanview Ctr For Rehabilitation And Healthcar
Inspection history, citations, penalties and survey trends for this long-term care facility in Union City, New Jersey.
- Location
- 3200 Hudson Avenue, Union City, New Jersey 07087
- CMS Provider Number
- 315465
- Inspections on file
- 22
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Manhattanview Ctr For Rehabilitation And Healthcar during CMS and state inspections, most recent first.
The facility failed to conduct monthly drug regimen reviews for several residents in March and April 2024. A resident received an incorrect dosage of Seroquel due to a physician's order error, which was not identified by the Consultant Pharmacist. The absence of reviews was attributed to staffing changes and oversight lapses.
The facility failed to maintain proper kitchen sanitation and food storage, with opened and unlabeled food items in the freezer, unclean steamer tables, and unsanitary conditions in nursing unit pantries. The issues were acknowledged by the FSD, DON, and IP/RN, emphasizing the need for adherence to facility policies to prevent bacteria and illnesses.
A resident with a history of PTSD did not receive appropriate treatment and services in a facility. Despite having PTSD indicated in the Pre-Admission Screening and Resident Review, it was not included in the resident's care plan or addressed in psychiatric evaluations. The facility's records lacked documentation of emotional counseling or interventions for PTSD, and the Monthly Psychotropic Summary did not identify triggers or interventions. The Director of Nursing acknowledged the oversight, stating the diagnosis was not identified or treated appropriately.
The facility failed to maintain accurate reconciliation and accountability of narcotic medications for a resident, with discrepancies in transaction logs and unauthorized access to the electronic back-up machine (EBM). Expired medications were not removed from active inventory, leading to potential administration errors. The Director of Nursing was unaware of these issues, and facility policies on medication management were not effectively implemented.
A resident reported that a nurse threw coffee at them, but the facility's investigation was incomplete, lacking statements from key individuals and details about the alleged nurse. The resident, with a history of diabetes and bipolar disorder, was cognitively intact. The facility's report contained inconsistencies, and the Director of Nursing admitted to not including necessary information in the report.
The facility failed to provide written notification to two residents and/or their representatives regarding the reason for hospital transfers, as required by regulations. The Director of Social Services acknowledged that notifications were not sent, although notices were sent to the ombudsman monthly. The facility's policy requires informing residents and their representatives of transfer reasons and appeal rights, which was not followed.
The facility failed to provide written notification of its bed hold policy to residents or their representatives prior to hospital transfers. This deficiency was identified during a review of medical records for two residents, which lacked the necessary documentation. Interviews revealed that the Admissions Director acknowledged the omission, despite the facility's policy requiring written notification at each transfer.
A facility failed to document a resident's death properly, omitting vital information such as the time of death, physician and family notifications, and changes in clinical condition. The resident, admitted with cancer and chronic kidney disease, had their body pick-up documented, but essential details required by facility policy were missing. The DON confirmed the importance of this documentation for the electronic death registration system.
The facility failed to post an accurate daily Nursing Home Resident Care Staffing Report, as observed by surveyors. The report in the lobby was outdated and showed incorrect census numbers compared to the facility's records. The HR/BOM, responsible for posting the report, acknowledged the need for accuracy and timely updates, especially for weekends. Facility management was informed of the discrepancy but did not provide further information during the exit conference.
The facility failed to offer updated pneumococcal vaccinations to two residents as per CDC and ACIP guidelines. One resident with chronic obstructive pulmonary disease and another with major depressive disorder did not receive the PCV 15 or PCV 20 after having received the Pneumovax. The facility's policy was outdated, leading to this deficiency.
A facility failed to transmit a resident's discharge MDS assessment within the required 14-day period, completing it 99 days late. The MDS Coordinator admitted to missing the deadline, and the facility's policies lacked specific timelines for MDS completion and transmission. The issue was identified during a survey, and management did not provide further information.
The facility staff failed to document the administration of medication in accordance with professional standards and the facility's Medication Administration policy for a resident with anemia. The medication was scheduled to be administered at 6:00 pm but was documented as given at 11:30 am two days later, with no explanation provided. Both the UMLPN and DON were unable to explain the discrepancy.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to provide oversight by a licensed Consultant Pharmacist (CP) for several residents during March and April 2024. Specifically, the facility did not conduct a monthly drug regimen review (MRR) for four out of five residents in March and for all five residents in April. This oversight was identified during a survey when the surveyor reviewed the hybrid medical records and found missing MRR reports for the specified months. The Director of Nursing (DON) acknowledged the absence of these reviews and stated that the facility was unaware of the issue until the surveyor's inquiry. One significant irregularity involved a physician's order for Seroquel, an antipsychotic medication, for a resident. The order was for a dosage of 0.5 mg, which was below the usual recommended dose. Despite this, the medication was administered as ordered from March 26 to May 8, 2024. The Progress Notes indicated that the order was outside the recommended dose, but there was no Pharmacy Consultant Note for March 2024. A late entry note dated April 30, 2024, stated that medications were reviewed, but it did not address the irregularity. The surveyor's investigation revealed that the regular CP left in early March 2024, and the designated CP was on leave, leading to a lack of MRRs for the 3rd, 4th, and 5th floors. The facility's Medication Regimen Review Policy requires a monthly review for all residents, which was not adhered to. The DON admitted responsibility for ensuring timely MRRs and confirmed that the resident received the correct dose of Seroquel despite the incorrect order.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and food storage, as observed during a survey. In the kitchen, several opened food items in the walk-in freezer were found unlabeled and exposed, with freezer burn and frost, indicating improper storage. The food preparation area had an uncovered trash can filled with garbage and food debris. Additionally, the steamer tables had opaque water with sediment, which was not cleaned as per policy, as acknowledged by the Food Service Director (FSD). The surveyor also found unsanitary conditions in the nursing unit pantries on the 3rd, 4th, and 5th floors. The 3rd-floor pantry had a build-up of white sediment and a yellowish film on the ice machine, and the ice scoop was sitting in stagnant water with an orange film. The 4th-floor pantry had similar issues, with white sediment, a yellowish/orange film, and black sediment on the ice machine. The ice scoop holder was not equipped with drainage holes, leading to stagnant water and sediment buildup. The sink in the 4th-floor pantry had black sediment around it, which was acknowledged by the Housekeeping Director (HD). The Director of Nursing (DON) and the Infection Preventionist/Registered Nurse (IP/RN) acknowledged the issues in the pantries, emphasizing the importance of maintaining cleanliness to prevent bacteria and possible illnesses. The facility's policies on food storage, steam table cleaning, garbage disposal, and ice machine maintenance were reviewed, highlighting the need for adherence to these protocols to ensure a safe and sanitary environment for residents.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of PTSD, as identified during a survey. The resident, who was observed in a fetal position with a monitoring device, had diagnoses including major depressive disorder, psychotic disorder, anxiety disorder, mild cognitive impairment, and unspecified dementia. However, PTSD was not listed in the resident's Admission Record or the most recent quarterly Minimum Data Set. The Pre-Admission Screening and Resident Review indicated PTSD, but the facility did not include it in the resident's care plan or provide related services. The Director of Social Services, a Certified Social Worker, was responsible for scheduling meetings but did not engage in clinical social work services. The psychiatric evaluations conducted by the facility's Psychiatric Mental Health Nurse Practitioner did not address PTSD, despite it being part of the resident's chief complaint. The facility's records, including the electronic Medical Record and Social Services Progress Notes, lacked documentation of emotional counseling or non-pharmacological interventions for PTSD. Additionally, the Monthly Psychotropic Summary did not identify triggers or interventions for PTSD. The facility's policies required that all residents have adequate person-centered care plans, including recommendations from the PASRR Level 2 determination. However, the facility did not develop an individualized care plan for the resident's PTSD, nor did it monitor or assess the resident's behavior related to PTSD. The Director of Nursing acknowledged the oversight, stating that the diagnosis was not identified or treated appropriately. The facility's failure to address the resident's PTSD needs was a significant deficiency in providing the highest practicable mental and psychosocial well-being for the resident.
Deficiencies in Narcotic Medication Management
Penalty
Summary
The facility failed to maintain accurate reconciliation and accountability of controlled substances, specifically narcotic medications, for a resident. The Director of Nursing (DON) admitted that narcotic reconciliation was not conducted daily, particularly on weekends when she was not present. The facility lacked a paper log for the electronic back-up machine (EBM) inventory, and there were discrepancies in the transaction logs, such as missing witness names and unexplained inventory changes. The Controlled Substance by Container Report (CSCR) revealed that morphine tablets were removed and administered without a physician's order, involving multiple nursing staff members. Additionally, the facility did not detect, remove, or dispose of expired narcotic medications from the active inventory stored in the EBM. During an inspection, expired medications such as Oxycontin and Zolpidem were found in the EBM. The DON acknowledged the presence of expired medications and stated that they could not be removed until a letter from the Drug Enforcement Agency was received. The facility's policy required expired medications to be removed from storage, but this was not adhered to, leading to potential medication administration errors. The report highlights the facility's failure to ensure proper tracking and reconciliation of narcotic medications, as well as the failure to remove expired medications from active inventory. The DON was unaware of the unauthorized access to the EBM and the administration of medications without a physician's order. The facility's policies on medication storage and loss or theft of drugs were not effectively implemented, contributing to the deficiencies observed during the survey.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to timely and thoroughly investigate allegations of abuse involving a resident who reported that a nurse threw coffee at them. The incident was reported to the state agency, but the investigation was incomplete and lacked critical information. The resident, who had a history of type 2 diabetes mellitus and bipolar disorder, was cognitively intact and did not exhibit behaviors such as psychosis or rejection of care. The resident alleged that a nurse was verbally abusive and threw coffee at them, prompting the resident to call the police. The facility's investigation was found to be deficient as it did not include statements from key individuals involved, such as the resident, the alleged nurse perpetrator, and other staff members present during the incident. Additionally, the investigation summary did not provide the full name, license information, or background check details of the alleged nurse involved. The facility's report also contained inconsistencies, such as a typographical error in the date of the reported event. The Director of Nursing acknowledged that the alleged nurse's name should have been included in the report and admitted that a background check was not conducted because the allegation was deemed unsubstantiated. The Vice President of Operations noted that the nurse was an agency nurse, but could not explain why education on behavior and abuse prevention was not maintained in the file. The facility's policy on abuse prevention required detailed reporting and investigation protocols, which were not fully adhered to in this case.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reason for hospital transfers, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital on multiple occasions. A review of Resident #93's electronic and hybrid medical records showed that there was no written notification provided for the transfers that occurred on specific dates. Similarly, Resident #97's closed medical record also lacked written notification for hospital transfers. During interviews, the Director of Social Services admitted that the facility did not send written notifications to residents or their representatives when transfers occurred, although notices were sent to the ombudsman monthly. The facility's policy on Transfer/Discharge Notification, last reviewed in February 2024, outlines the requirement to inform residents and their representatives of transfer reasons and appeal rights, which was not adhered to in these cases.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives prior to hospital transfers, as required by their own policy and state regulations. This deficiency was identified during a review of the medical records for two residents who were transferred to the hospital. The records for both residents did not include the necessary written notification of the bed hold policy, which should have been provided at the time of each transfer. Interviews with facility staff revealed that the Admissions Director acknowledged that residents received the bed hold policy upon admission but did not receive written notification at the time of transfer. The facility's policy mandates that a written notification, signed and dated by the resident or their representative, must be given at each transfer for hospitalization or therapeutic leave. Despite this requirement, the facility did not adhere to its policy, resulting in the deficiency noted by the surveyors.
Deficient Documentation of Resident's Death
Penalty
Summary
The facility failed to adhere to acceptable standards of nursing practice regarding the documentation of a resident's death. This deficiency was identified for a resident who was admitted with diagnoses including malignant neoplasm of the bladder and chronic kidney disease. The electronic medical record lacked documentation of a change in the resident's clinical condition, vital signs, time of death, physician notification, and family notification. The nurse documented the body pick-up but omitted critical information such as the time of death and notifications, which are essential for the electronic death registration system. During an interview, the Director of Nursing (DON) confirmed the missing documentation and acknowledged its importance. The facility's policies on Nurse's Notes and Death of a Resident/Patient require detailed documentation upon a resident's death, including the time of death, physician and family notifications, and post-mortem care details. The facility management admitted that the electronic medical record did not provide sufficient information to determine the resident's death, who pronounced it, and whether the physician and family were informed.
Inaccurate Posting of Daily Staffing Report
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily, as required. On a Tuesday, surveyors observed that the NHRCSR posted in the front lobby was dated from the previous Thursday, indicating a discrepancy in the census numbers. The posted report showed a census of 120 residents, while the facility's submitted Nurse Staffing Report for that week indicated a census of 119 on the same date. This inconsistency was brought to the attention of the facility management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), during meetings with the survey team. The Human Resource and Business Office Manager (HR/BOM) was responsible for posting the NHRCSR and stated that it should be updated and posted before 8 AM each day. However, the HR/BOM acknowledged that the report should have been accurate and updated, especially for weekends when it is prepared in advance. The facility's policy requires the NHRCSR to include the facility name, current date, census, and staffing details, but the failure to update the report as per policy led to the deficiency. The facility management did not provide additional information during the exit conference with the surveyors.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal vaccination according to the current CDC and ACIP recommendations. This deficiency was identified for two residents who were reviewed for immunization status. The surveyor found that the facility did not offer the appropriate pneumococcal conjugate vaccine (PCV 15 or PCV 20) to residents who had previously received the Pneumovax (PPSV 23) vaccine, as per the guidelines. Resident #75, who was admitted with chronic obstructive pulmonary disease and hypertensive heart disease, was found to have not received the pneumococcal vaccine update. The resident's medical records indicated that they received the Pneumovax on a previous date, but there was no record of being offered the PCV 15 or PCV 20. Similarly, Resident #80, with diagnoses including major depressive disorder and mild cognitive impairment, also did not have a record of being offered the updated pneumococcal vaccine, despite having received the Pneumovax. The facility's Infection Preventionist/Registered Nurse acknowledged the oversight and confirmed that the residents should have received the PCV 20 one year after the PPSV 23. The facility's policy, which was supposed to follow CDC guidelines, was outdated and did not reflect the current recommendations for pneumococcal vaccination. This lack of adherence to updated guidelines led to the deficiency noted by the surveyors.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit the discharge Minimum Data Set (MDS) assessment for a resident within the required timeframe. The surveyor identified that the MDS record for a resident was over 120 days old. Upon review, it was found that the discharge return not anticipated (DRNA) MDS was completed and transmitted 99 days after the assessment, which is beyond the 14-day requirement set by the Centers for Medicare & Medicaid Services (CMS). The MDS Coordinator, a Licensed Practical Nurse, acknowledged the delay and stated that the oversight was due to missing the deadline. The facility's policies, including the RAI Process Policy and the Completion of MDS Policy, did not specify the timeline for completing and transmitting the MDS. The MDS Coordinator admitted to not having a report for April 2024, which could have identified the missing MDS. The surveyor noted that the facility's adherence to the RAI manual was insufficient in ensuring timely MDS completion and transmission. The deficiency was discussed with the facility management, who did not provide additional information during the exit conference.
Failure to Document Medication Administration as per Facility Policy
Penalty
Summary
The facility staff failed to document the administration of medication in accordance with professional standards of practice and the facility's Medication Administration policy for one resident. Resident #2, who was admitted with a diagnosis of anemia, had an order for Epoetin Alfa Injection Solution to be administered subcutaneously every Monday, Wednesday, and Friday at 6:00 pm. However, a review of the Medication Administration Record (MAR) for September 2023 showed that the medication was administered on 9/6/23 at 6:00 pm, but the Location of Administration Report (LAR) indicated it was administered on 9/8/23 at 11:30 am by the Unit Manager Licensed Practical Nurse (UMLPN), which was not according to the MAR schedule. There was no documentation in the progress notes explaining why the medication was not administered or documented on 9/6/23 as scheduled. The UMLPN and the Director of Nursing (DON) were unable to provide an explanation for the discrepancy. The facility's policy on Medication Administration, revised in April 2023, states that medication administration should be documented on the MAR as soon as medications are given. The UMLPN stated that the nurse should document the administration of medication immediately before moving to the next resident. Despite this, the UMLPN's signature appeared on the LAR on 9/8/23 at 11:30 am, indicating a failure to follow the facility's protocol. The DON confirmed that the protocol requires the administering nurse to sign the MAR to show that the medication was administered according to the doctor's order but could not explain the discrepancy in the administration times.
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.
Trusted data from CMS and state health departments
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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