Millville Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Millville, New Jersey.
- Location
- 54 Sharp Street, Millville, New Jersey 08332
- CMS Provider Number
- 315243
- Inspections on file
- 17
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Millville Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported that a CNA, described as an obese white female with brown hair and arm tattoos, punched and pulled the hair of their nonverbal roommate. The DON and SW limited the investigation to showing the reporting resident small headshot photos of three CNAs, after which no perpetrator was identified, and they did not conduct or document interviews with CNAs or other residents. The CNA who matched the description and was assigned to the alleged victim on the shift in question was neither informed of the allegation nor suspended or removed from duty, despite the facility’s abuse policy requiring immediate removal of an alleged abuser and a thorough, documented investigation.
A resident with clearly documented allergies to mayonnaise, ketchup, and vinegar was repeatedly served meals containing these allergens despite accurate information being present in the EMR, care plan, diet reports, and tray card. The resident, who was cognitively intact and reported prior discussions with dietary staff about these allergies, received a meal tray with mayonnaise and was offered ketchup by a CNA who could not locate the tray card. Later, the same resident was served a meal including creamy coleslaw made with mayonnaise and vinegar, with the coleslaw in contact with other foods on the plate. Dietary leadership and the RD confirmed that these items should not have been provided based on the resident’s documented allergies.
A facility failed to update the PASARR Level One for a resident diagnosed with bipolar disorder, as the existing PASARR from 2017 did not reflect this diagnosis. Despite the resident's medical record indicating the diagnosis in 2023, the PASARR was not updated, which was acknowledged by the Social Services Director and Admissions Director. This oversight could potentially delay necessary assistance for the resident.
A facility failed to create a comprehensive care plan for a resident who began hemodialysis, only noting basic dialysis scheduling without detailed interventions. Despite the resident's intact cognition and specific dialysis needs, the care plan lacked instructions for monitoring the dialysis site or managing the resident's condition. Staff interviews revealed expectations for more detailed care plans, aligning with facility policy and agreements.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols to monitor extended antibiotic use. A resident on long-term doxycycline therapy for septic arthritis was not tracked, as the facility's electronic system did not support monitoring prophylactic antibiotic use. The Infection Preventionist and Medical Director acknowledged the oversight, but no measures were in place before the survey.
The facility failed to report and investigate allegations of verbal abuse by CNAs towards two residents. One resident reported being yelled at by a CNA, which was not investigated or reported as required. Another resident felt belittled by staff, a concern documented in Resident Council minutes without a response. Staff interviews revealed communication gaps and non-compliance with the facility's abuse reporting policy.
Facility staff failed to report allegations of verbal abuse involving two residents to the administration and NJDOH as required by policy. A resident reported being yelled at by a CNA, leading to distress, but the incident was not investigated or reported. Another resident felt belittled by staff, but this concern was not documented or addressed. The facility's policy mandates immediate reporting of suspected abuse, but this was not followed, indicating a breakdown in communication and reporting procedures.
The facility failed to investigate verbal abuse allegations involving two residents. One resident reported being yelled at by CNAs, and another felt belittled by staff. The Social Worker did not collect additional statements, and the DON was unaware of concerns raised in a Resident Council meeting. The facility's abuse policy was not followed, resulting in a deficiency.
The facility failed to meet the required CNA staffing ratios during day shifts, as mandated by New Jersey law. Over several weeks, the number of CNAs on duty was consistently below the required ratio of one CNA to every eight residents, with specific instances showing significant shortfalls in staffing levels.
A facility failed to report an allegation of verbal abuse by a CNA to the SSA within the required timeframe. The incident, initially treated as a grievance, involved a resident being called a liar by a CNA. The delay in reporting occurred because the incident was not immediately recognized as abuse, and it was only reported after the DON spoke with the resident's daughter and received guidance from corporate.
A resident with diabetes and other health conditions did not want an LPN to administer their medication. When the LPN couldn't reach a supervisor or another nurse, she asked a CNA to administer insulin and an oral medication, which the CNA did while the LPN observed. The LPN signed off on the medication administration despite not administering it herself. Other staff confirmed they would not allow a CNA to administer medications.
The facility failed to follow infection control practices during wound care for two residents, leading to potential cross-contamination. A nurse placed supplies on a resident's bed without a protective barrier and did not wear a gown, while another resident's wound care was conducted without a gown and lacked proper signage for Enhanced Barrier Precautions. The facility's policy on PPE and signage was not adhered to, despite previous training.
Failure to Thoroughly Investigate Alleged CNA Abuse and Remove Alleged Perpetrator From Duty
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse and to act in accordance with its abuse prohibition policy after one resident reported witnessing abuse of a roommate. One resident with moderate cognitive impairment (BIMS score 9/15) reported that on a Saturday a CNA hit and pulled the hair of their roommate, who was unable to complete a BIMS due to being unable to speak or be understood. The reporting resident described the CNA as a white, heavyset female with brown hair and arm tattoos and stated that this CNA provided care to the roommate but not to them. The allegation was documented on a reportable event survey, and the facility’s summary noted that the resident reported seeing the CNA punch and pull the roommate’s hair. The facility’s response to the allegation was limited to showing the reporting resident small, headshot photos of three CNAs who fit the general description, including the CNA assigned to the alleged victim on the date in question. The resident did not identify any of the faces, later stating the photos were too small to correctly identify the perpetrator. There was no documentation of interviews with staff or other residents, and no evidence that the CNA who matched the description and was assigned to the alleged victim was suspended or removed from duty during the investigation. The DON stated she did not interview any CNA or other staff because the resident could not identify the alleged perpetrator from the photos and that she ruled out other staff based on the description. Subsequent interviews confirmed that the CNA fitting the description had been assigned to the alleged victim on the shift in question and had not been informed of any allegation, interviewed, or suspended. Other CNAs who worked that shift and one who had switched resident assignments with the implicated CNA reported they were not interviewed and stated that only this CNA matched the description given by the reporting resident. The facility’s abuse policy required immediate removal of the employee alleged to have committed abuse from duty pending investigation, initiation of an investigation within 24 hours, and thorough documentation of interviews in the risk management portal, but the investigation lacked documented staff and resident interviews and did not include removal of the alleged perpetrator from duty.
Removal Plan
- Staff training
- Suspension of staff
Failure to Prevent Allergen Exposure in Resident Meals
Penalty
Summary
The deficiency involves the facility’s failure to prevent a resident with documented food allergies from being served foods containing known allergens. The resident had allergies recorded in the EMR, care plan, diet type report, and tray card to dill, dill oil, mushrooms, ketchup, lactose, radishes, acetic acid (vinegar), and mayonnaise. The resident was cognitively intact with a BIMS score of 15 and reported that their mouth and tongue would swell when consuming allergens. Despite this, the resident stated they had spoken with the Dietary Manager multiple times and continued to receive foods containing allergens. Surveyors observed that during a noon meal, the resident was served a cheeseburger and potatoes with a sealed packet of mayonnaise on the tray, and a CNA offered ketchup, which the resident refused. The CNA confirmed she served the tray, offered ketchup, and that a mayonnaise packet was present, and she was unable to locate the resident’s tray card at that time. The Dietary Manager confirmed the resident’s allergies to ketchup and mayonnaise and acknowledged that mayonnaise should not have been on the plate and ketchup should not have been offered. Later, during the evening meal, the resident was served a cheeseburger, creamy coleslaw, cubed potatoes, and cookies, with the coleslaw in contact with other foods on the plate. Review of the coleslaw recipe showed it contained mayonnaise and vinegar, and the Registered Dietitian confirmed it was an error that the resident received mayonnaise and creamy coleslaw despite allergies documented in Meal Tracker and on the tray slip.
Removal Plan
- Audit of all resident diet orders
- Staff education on checking meal tickets
- Staff education on not providing food items to residents to which they are allergic
Failure to Update PASARR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to initiate a new PASARR Level One for a resident diagnosed with bipolar disorder, which was not reflected in the existing PASARR documentation. The resident, identified as R22, was originally admitted with a PASARR Level One dated 2017, which did not list bipolar disorder as a diagnosis. Despite the resident's medical record indicating a diagnosis of bipolar disorder as of February 2023, the PASARR was not updated to reflect this change. This oversight was confirmed during interviews with the Social Services Director and the Admissions Director, who acknowledged that the PASARR should have been updated to reflect the resident's current mental health diagnosis. The facility's policy requires that all residents with mental disorders or intellectual disabilities receive appropriate pre-admission screenings. However, the policy was not followed in this case, as the PASARR for R22 was outdated and inaccurate. The Admissions Director admitted that the discrepancy should have been identified at the time of admission, and a new PASARR should have been completed. The failure to maintain an accurate PASARR Level One had the potential to delay or limit necessary assistance for the resident should they experience a bipolar episode.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who began receiving hemodialysis. The resident, who had intact cognition, was admitted to the facility after a hospital stay and was diagnosed with encephalopathy, acute kidney failure, and required hemodialysis. Despite the resident's return from the hospital with a permacath placement and a schedule for dialysis on Mondays, Wednesdays, and Fridays, the care plan only included a basic intervention to prepare the resident for dialysis on those days. The care plan lacked detailed interventions related to dialysis care, such as monitoring the dialysis site for complications or specific instructions on managing the resident's condition. Interviews with facility staff, including an LPN, the Unit Manager, and the DON, revealed that the care plan was expected to include detailed information about the resident's dialysis needs, such as the type of line, program, and any dietary or fluid restrictions. The Unit Manager acknowledged that the care plan could be more comprehensive, and the DON expected more detailed information to be included when dialysis started. The facility's policy and the Dialysis Services Agreement also emphasized the need for a comprehensive care plan tailored to the resident's needs, which was not adequately implemented in this case.
Failure to Monitor Extended Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program, specifically lacking protocols to monitor extended antibiotic use. This deficiency was identified during a review of the facility's practices and policies, which revealed that the facility did not track residents on long-term prophylactic antibiotic therapy. The Infection Preventionist (IP) admitted that the current electronic system did not allow for tracking of prophylactic antibiotic use unless it was a new admission with a new antibiotic order. The Medical Director acknowledged the need to track all residents on long-term prophylactic antibiotics, but this had not been implemented before the recertification survey. The deficiency was highlighted in the case of a resident who was on doxycycline for right shoulder septic arthritis. The resident's medical records indicated ongoing suppressive therapy with doxycycline, yet there was no evidence of monitoring or tracking of this extended antibiotic use. The facility's policy on antibiotic stewardship did not address standards for extended antibiotic use, and the responsibility for the program was not effectively executed by the Infection Preventionist, Director of Nursing, and Medical Director, as required by the facility's policy.
Failure to Report and Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy when staff did not report an allegation of verbal abuse by a CNA towards a resident. A resident reported that a CNA yelled at them for requesting their hair to be washed twice, which led the resident to cry. The resident informed the Social Worker about the incident, but no further investigation was conducted, and the incident was not reported as required by the facility's policy. The resident was cognitively intact and dependent on assistance with ADLs, with medical conditions including left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis. Another resident, who was also cognitively intact and required supervision with ADLs, expressed feeling belittled by staff across the facility. This concern was documented in the Private Resident Council minutes, but no response was recorded, and the issue was not reported as verbal abuse. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported, indicating a failure to adhere to the facility's policy on abuse reporting. Interviews with facility staff, including the Social Worker, DON, ADON, and Administrator, revealed gaps in communication and reporting processes. The Social Worker did not collect statements from other residents involved, and the DON was not informed of the concerns raised in the Resident Council minutes. The facility's policy mandates immediate reporting of suspected abuse, but this was not followed, resulting in a deficiency in the facility's handling of abuse allegations.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ Exec Order 26.4[R] during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.4[R] with the reassignment of staff. Resident number 6 was interviewed regarding being belittled and he states he really did not want to talk about it but that it is when they dont let me do what I want to do outside. 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. Staff will be re-inserviced on the Abuse and Neglect policy. Staff will be re-inserviced on the grievance policy. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Report Allegations of Verbal Abuse
Penalty
Summary
The facility staff failed to report an allegation of verbal abuse involving two residents to the administration and the New Jersey Department of Health as required by their Abuse Prohibition policy. Resident #3 reported an incident where a CNA yelled at them for requesting their hair to be washed twice, which led to the resident crying. This incident was reported to the Social Worker, but no further investigation was conducted, and the incident was not reported to the appropriate authorities. Additionally, Resident #6 expressed feeling belittled by staff across the facility, but this concern was not documented or addressed in the Resident Council minutes. Resident #3, who was admitted with conditions such as left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis, was cognitively intact and dependent on assistance with activities of daily living. The Social Worker collected a statement from Resident #3 but did not interview other residents on the staff member's assignment. The Director of Nursing was not informed of the concerns raised in the Resident Council minutes, and no investigation was initiated for the verbal abuse allegations. The facility's policy mandates immediate reporting of suspected abuse, but this was not adhered to in these cases. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident involving Resident #6 was not reported. The Assistant Director of Nursing and the Administrator were also unaware of the concerns raised, indicating a breakdown in communication and reporting procedures within the facility.
Plan Of Correction
Reporting of Alleged Violations 1. Corrective Action CNA 1 and 2 were immediately educated on being considerate during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 is very happy with the reassignment of staff. Partner Rounds were initiated where every patient is assigned to a department head to see several times weekly to handle/report any concerns. Resident number 6 was interviewed regarding being [R] and states really NJ Exec Order 26.4b1 but that it is NJ Exec Order 26.4b1[R]. 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents. Resident #3 reported an incident where a CNA yelled at them for requesting their hair to be washed twice, which led to the resident crying. The resident also reported that another CNA yelled at them, expressing concern about getting people in trouble. Despite the resident's report to the Social Worker, the investigation was incomplete as no additional statements were collected from other residents on the CNAs' assignments. Resident #6, who declined to speak with the surveyor, had previously expressed feeling belittled by staff across the facility during a Private Resident Council meeting. The minutes from this meeting indicated that residents had concerns about staff attitudes, but no response was documented. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported or addressed. Interviews with facility staff, including the Social Worker, DON, and ADON, revealed gaps in the investigation process and communication. The Social Worker did not collect statements from other residents, and the DON was unaware of the concerns raised in the Resident Council minutes. The facility's policy on abuse prohibition requires immediate reporting and investigation of abuse allegations, but these procedures were not followed, leading to the deficiency.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ NJ Ex Order 26.4(b) (1) during patient care and NJ Ex Order 26.4(b)(1). CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.461 with the reassignment of staff. Partner Rounds were initiated where every patient is assigned to a department head to see several times weekly to handle/report any concerns. Resident number 6 was interviewed regarding NJ Ex Order 26.4(b)(1) and states really NJ Ex Order 26.4(b)(1) but that it is when they NJ Ex Order 26.4(b)(1). 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts. The deficiency was identified through a review of facility documentation, which revealed that the facility did not have the required number of Certified Nurse Aides (CNAs) on duty for 18 out of 21 day shifts. This failure to comply with staffing requirements was evidenced by specific instances where the number of CNAs was below the mandated ratio of one CNA to every eight residents. For example, during the week of August 4, 2024, to August 10, 2024, the facility was deficient in CNA staffing on five out of seven day shifts. On August 4, 2024, there were only 13 CNAs for 142 residents, whereas at least 18 CNAs were required. Similarly, in the two weeks prior to the survey from November 24, 2024, to December 7, 2024, the facility was deficient on 13 out of 14 day shifts. On December 7, 2024, there were only 8 CNAs for 127 residents, while at least 16 CNAs were needed. These deficiencies indicate a consistent failure to meet the staffing requirements set forth by the New Jersey Department of Health.
Plan Of Correction
Mandatory Access to Care 1. Corrective Action All residents have the potential to be affected by this deficient practice. Center is currently employing sign on bonuses, referral bonuses, and various other incentives for current staff to meet staffing standards. Nursing employees salaries were increased effective January 1, 2025. 2. All residents have the potential to be affected by this deficient practice. 3. Staffing coordinator was re educated on NJ staffing mandate. Center will continue recruiting functions, which drive various forms of media to increase the number of applicants. Continue to establish external partnerships with schools to train students and transition them into CNAs. Weekly labor management calls with regional support team. 4. The Labor management team will maintain a listing of current recruiting efforts, and document weekly the results of these efforts. The Administrator or designee will audit these efforts weekly x 4 weeks, then monthly x 2 to ensure the Center team is following up on all recruitment tasks. The Administrator or Designee will report findings to the Performance Improvement Committee monthly for three months. The Performance Improvement Committee will evaluate and determine the effectiveness of the plan to ensure substantial compliance is achieved and determine if further monitoring and evaluation is required.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required timeframe for a resident who was verbally abused by a Certified Nursing Assistant (CNA). The facility's policy mandates that any allegations of abuse must be reported no later than two hours after the allegation is made. However, in this case, the incident involving a CNA calling a resident a liar was not reported until nearly a month later. The delay in reporting was due to the incident being initially treated as a grievance rather than abuse, and it was only after the Director of Nursing (DON) spoke with the resident's daughter that the incident was reported to the state. The resident involved in the incident expressed distress over the verbal abuse, which was initially reported to the Social Services staff by the resident. The Assistant Director of Nursing (ADON) was informed, but the incident was not escalated appropriately at that time. The DON, who was on vacation during the initial report, later decided to report the incident as abuse after further discussions and guidance from corporate. This failure to report in a timely manner had the potential to allow suspected abuse to go unreported to the SSA, as noted in the facility's policy and the Elder Justice Act requirements.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided services according to accepted standards of clinical practice with medication administration for one resident. The resident, who was moderately cognitively impaired and had a history of diabetes, cirrhosis of the liver, anemia, and dependence on dialysis, was scheduled for dialysis when the incident occurred. The resident had previously expressed a preference not to have LPN1 as their nurse. On the day of the incident, LPN1 was unable to reach the nursing supervisor or another nurse to administer the resident's medication. With transportation for dialysis on the way, LPN1 asked CNA2 to check the resident's blood glucose and administer insulin and an oral medication, which CNA2 did while LPN1 observed from outside the resident's door. The July 2022 Medication Administration Record (MAR) showed that LPN1 signed off on the medication administration, despite not having administered the medications herself. Written statements from LPN1 and CNA2 confirmed the events as described in the facility's investigation. Interviews with other staff members, including LPNs and CNAs, revealed that they would not ask or agree to a non-licensed employee administering medications, as it was not within their training or scope of practice. The Director of Nursing confirmed the incident and the subsequent termination of both employees involved.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to adhere to basic infection control practices during wound care for two residents, which had the potential to cause the spread of infections. For the first resident, who was moderately cognitively impaired and had a diabetic ulcer on the left foot, the registered nurse (RN) placed wound care supplies directly on the resident's bed without using a protective barrier. The nurse also failed to wear a disposable gown during the procedure and did not post a sign indicating Enhanced Barrier Precautions on the resident's door. After completing the wound care, the nurse improperly placed the used supplies on her medication cart in the hallway. In the case of the second resident, who had a Stage IV pressure sore and severely impaired cognitive status, the RN conducted wound care without wearing a protective gown, despite the presence of a chronic wound. The supplies were placed on a protective barrier on the overbed table, but the nurse did not follow the protocol of wearing a gown. Additionally, there was no sign posted on the resident's door to indicate Enhanced Barrier Precautions, and the nurse mistakenly believed that the absence of the sign meant a gown was not required. Interviews with the RN and the Director of Nursing (DON) revealed that the nurse had received training on Enhanced Precautions and basic infection control practices but failed to apply them correctly. The DON confirmed that the facility had conducted an in-service on Enhanced Barrier Precautions, but the RN was not present at that time. The facility's policy required posting a sign on the patient's room door and using appropriate PPE for wound care, which was not followed in these instances.
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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