Morris View Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Morristown, New Jersey.
- Location
- 540 West Hanover Avenue, Morristown, New Jersey 07960
- CMS Provider Number
- 315303
- Inspections on file
- 22
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Morris View Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses reported missing vapes, with a roommate alleging that an LPN accessed the resident's belongings. The incident was investigated internally and by local police, and the items were later found and returned. However, the facility did not report the allegation of misappropriation to the state health department as required, nor was the incident documented in the resident's progress notes.
Two residents' care plans were not updated after significant incidents: one involving a family member altering a resident's prescribed liquid consistency, and another involving a resident reporting missing vapes and contacting police. Despite staff awareness of these events and the residents' complex medical histories, care plan interventions were not revised to address the new issues.
The facility failed to maintain the confidentiality of resident health information when two residents with intact cognition were referred to an external preventive care program without proper notification or consent. The administrator entered referrals and granted the external group access to electronic health records, resulting in the disclosure of protected health information and contact details to the outside provider, despite residents' objections.
An LPN documented completion of a physician-ordered mist humidifier for a resident with severe cognitive and physical impairments, but the device was found empty, dry, and unplugged during observation. The LPN admitted to signing off the order in the eMAR without actually performing the required task, resulting in a failure to meet professional nursing standards.
A resident with a history of spinal stenosis and stroke experienced an unwitnessed fall, leading to increased pain and limited mobility. The facility failed to timely assess the resident and provide adequate pain management, as the resident's complaints of pain were not effectively addressed or communicated to the physician. Additionally, the injury was not reported to the NJDOH, and the facility's policies on fall management and pain assessment were not properly implemented.
The facility failed to maintain proper kitchen sanitation and staff attire, risking foodborne illness. Expired juice boxes were found in use, and dietary aides wore inappropriate jewelry and lacked proper hair restraints. The FSD acknowledged these issues, which violated facility policies on food storage and staff attire.
The facility failed to verify licenses, conduct criminal background checks, and obtain reference checks for several staff members before their hire date. A CNA, LPN, and RN had issues with license verification, while a Unit Clerk started work before a background check was completed. Additionally, several staff members lacked documented reference checks. The Director of Human Resources acknowledged these deficiencies, and the facility lacked a policy for the new hire process.
The facility failed to ensure attending physicians signed and dated monthly orders and conducted required visits for several residents. For instance, a resident's attending physician did not document visits for several months, with only the APN covering some months. Another resident's records lacked signed monthly orders and documented visits for June and July. The facility's policy requires timely documentation and regular visits, which were not met, leading to deficiencies.
The facility failed to follow proper hand hygiene and transmission-based precautions, as observed by surveyors. A housekeeper did not perform hand hygiene after glove removal, and residents were not offered hand hygiene before and after meals. Additionally, staff did not consistently use PPE for residents on contact precautions, and a physician did not follow enteric contact isolation procedures. Room assignments for residents requiring isolation were also mishandled, with a resident with C. difficile sharing a bathroom with another resident not on isolation.
The facility failed to maintain a clean and safe environment, with issues such as a loose safety railing in a public toilet, uncleaned blood stains in the chapel, and disrepair in a resident's room. These deficiencies were reported by residents and confirmed by surveyors, highlighting a lack of adherence to the facility's policy for maintaining a sanitary and comfortable environment.
A facility failed to serve meals in a dignified manner when a resident was not served a lunch tray at the same time as others at their table. Despite the CNA's request, the tray was missing from the initial delivery. The RN acknowledged the issue, and the facility's policy requiring simultaneous service was not followed.
The facility failed to complete comprehensive assessments in a timely manner for three residents, as required by the RAI Manual. The MDS for a resident was completed 32 days after the ARD, another 15 days after, and a third 31 days after, all exceeding the 14-day requirement. The MDS Coordinator and facility management acknowledged the issue, but no additional information was provided during the exit conference.
The facility failed to complete quarterly MDS assessments within the required timeframe for two residents. The assessments were completed 19, 26, and 17 days after the ARD, exceeding the 14-day completion requirement. The MDS Coordinator and DON acknowledged the issue, but the facility did not provide additional information or refute the findings during the exit conference.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in their assessments. A pdMDS/RN completed assessments remotely without interviewing residents, resulting in inaccurate health condition documentation. One resident's hospice care was not coded, and another's pain assessment was inaccurately recorded. These issues highlight the facility's failure to ensure accurate resident assessments as per CMS guidelines.
A facility failed to provide an accurate discharge summary for a resident, including a documented medication reconciliation. The resident's discharge instructions listed Aspirin EC 81 mg to be taken twice a day, conflicting with the physician's prescription and notes, which specified once a day. The RN acknowledged the discrepancy and the need for clarification with the physician, which was not done, violating the facility's policy.
Two residents in an LTC facility experienced deficiencies in respiratory care. One resident had an unbagged nebulizer mask that was not changed as per policy, while another had an oxygen concentrator with a nasal cannula improperly stored and not in use despite a continuous oxygen order. The facility's records and care plans were incomplete, and staff interviews confirmed lapses in following procedures.
The facility failed to post the Nursing Home Resident Care Staffing Report (NHRCSR) daily as required. The report was missing for the day shifts on three separate occasions. The surveyor informed the DON and LNHA, but no additional information or refutation was provided by the facility management.
A medication nurse failed to securely store medications during a medication pass, leaving a card containing Xarelto unattended on top of a cart. This action was against the facility's policy, which requires all medications to be stored securely. The incident was confirmed by the RN/Unit Manager and acknowledged by the LNHA and DON.
A facility failed to follow physician's orders for a resident's hypertension medication by not documenting required blood pressure and pulse readings before administration. Additionally, the facility did not specify a site for a Lidocaine patch application for another resident, leaving the decision to the nurse or requiring resident input. These deficiencies were identified during a survey, and the facility management was informed but did not contest the findings.
A resident with dementia and hypertension experienced multiple unwitnessed falls, and the facility failed to conduct a comprehensive root cause analysis or implement new non-pharmacological interventions after each fall. Despite having a care plan, the facility repeatedly used psychiatric consults as interventions without introducing new strategies to prevent further falls. Interviews with staff revealed inconsistencies in the process for handling unwitnessed falls, and the facility's policy did not require documentation of interdisciplinary team discussions.
A resident received both Warfarin and Xarelto due to a documentation error, which the Consultant Pharmacist failed to identify during a drug regimen review. This led to the resident's health decline and hospital admission. The facility's policy on medication errors was not followed, resulting in this deficiency.
A resident in an LTC facility was hospitalized after receiving both Xarelto and Coumadin due to a transcription error by an RN. The resident, with a history of chronic conditions, became symptomatic and was diagnosed with an upper GI bleed. The error was discovered after 18 doses were administered, highlighting a failure to adhere to medication error policies.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident's missing personal items to the New Jersey Department of Health (NJDOH) as required. The incident involved a resident with multiple diagnoses, including achalasia of cardia, narcolepsy with cataplexy, anxiety disorder, PTSD, major depression, and bipolar disorder, who was assessed as cognitively intact. The resident's vapes were reported missing, and the resident's roommate stated that an LPN was seen entering the room and accessing the resident's belongings. The resident notified the local police, who responded and interviewed both the resident and the LPN, who denied taking the items. The facility conducted an internal investigation, including review of video footage and interviews with involved parties. The video showed the LPN entering and exiting the resident's room, but there was no visual evidence of the LPN taking any items. The missing vapes were later found in a soiled utility room and returned to the resident by social services. Despite the investigation and the involvement of local law enforcement, the facility did not document the incident in the resident's progress notes as an allegation of misappropriation, nor did they report the allegation to the NJDOH as required by regulation. Interviews with facility leadership confirmed that the previous administration did not report the incident to the NJDOH, citing that the investigation was unsubstantiated and the items were eventually found. The facility was unable to provide documentation or video evidence to support their statements regarding the notification of the resident or the outcome of the investigation. The facility's own abuse prevention policy requires reporting of all allegations of abuse or misappropriation within required timeframes, which was not followed in this case.
Failure to Update and Revise Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans in response to significant events for two residents. For one resident with cerebral palsy, aphasia, and quadriplegia, the care plan did not include new interventions after the resident's father was observed altering the consistency of the resident's liquids and confronting staff about it. Despite this incident, there were no updates to the care plan to address the tampering of liquids, and the Director of Nursing acknowledged that best practice would be to update interventions following such incidents. For another resident with multiple diagnoses including achalasia, narcolepsy with cataplexy, anxiety disorder, PTSD, major depression, and bipolar disorder, the care plan identified the resident as a smoker and included interventions for managing smoking supplies. However, after the resident reported missing vapes and accused a staff member of taking them, and subsequently called the police, there was no evidence that the care plan was revised to address these new developments. Interviews with staff confirmed the resident's smoking status and use of vapes, but the care plan did not reflect updated interventions following the incident.
Failure to Protect Resident Health Information During Introduction of External Care Program
Penalty
Summary
The facility failed to protect the confidentiality of residents' health information when it introduced an external medical practice, Newave Care, to residents without proper notification or consent. The program involved the collection and disclosure of residents' protected health information (PHI) for preventive care purposes. In two cases, residents with intact cognition reported that they were approached by Newave Care staff without prior warning from facility administration. One resident stated that their medical records were accessed to determine eligibility for the program, and that the referral was made by facility administration rather than their physician. The resident did not consent to participation and expressed concern about a potential HIPAA violation. Documentation confirmed that the facility administrator entered orders referring residents to Newave Care for various programs. Another resident reported that Newave Care staff persistently contacted both the resident and their family member, despite the resident's clear refusal and capacity to make their own decisions. The resident questioned how the external group obtained their family member's contact information and medical details. Interviews with facility staff revealed that the external group was given access to the electronic health record system (PCC) and that referrals were made for all eligible residents by the administrator. The social worker indicated that the external group had access to resident information prior to direct contact. These actions resulted in the unauthorized disclosure and use of residents' PHI.
Failure to Follow Physician Order and Accurate Documentation for Respiratory Device
Penalty
Summary
A deficiency occurred when an LPN failed to follow a physician's order for a mist humidifier for a resident. The order required the mist humidifier to be turned on and filled with distilled water to the appropriate level every shift while the resident was in the room. During an observation, the resident was seen in their room with the mist humidifier present but it was empty, dry, and not plugged in. When questioned, the CNA indicated that the nurse was responsible for the device. Upon review of the electronic Medication Administration Record (eMAR), it was found that the LPN had signed off as if the order had been completed for that shift, despite the device not being in use or filled as required. The LPN confirmed in the presence of the surveyor that she had documented the order as completed in the eMAR without actually performing the task. The resident involved had significant medical conditions, including cerebral palsy, aphasia, quadriplegia, seizures, and microcephaly, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. The failure to carry out the physician's order and the inaccurate documentation constituted a breach of professional nursing standards and facility policy.
Failure to Timely Assess and Manage Pain After Resident Fall
Penalty
Summary
The facility failed to timely assess a resident after an unwitnessed fall, which occurred on 9/16/23 at 01:20 AM. The resident, who had a history of spinal stenosis, stroke, and unsteadiness on feet, was found on the floor by a CNA. The RN conducted a body assessment, and the resident initially denied pain. However, the resident later experienced increased pain and limited mobility, which was not adequately addressed by the facility. The resident's pain was not effectively managed, as evidenced by the lack of timely administration of appropriate pain medication and failure to notify the physician of the resident's persistent pain. The facility's documentation revealed multiple instances where the resident complained of pain, but the nursing staff did not provide adequate pain management or notify the physician for further intervention. The resident's pain was documented at various levels, ranging from mild to severe, yet the facility continued to administer only Tylenol, which was ineffective. The resident's complaints of pain were not consistently communicated to the physician or adequately documented by the therapy staff, leading to a delay in appropriate medical evaluation and treatment. Additionally, the facility did not report the injury to the New Jersey Department of Health, as required. The Director of Nursing and other staff members were interviewed, and it was noted that there was a lack of communication and documentation regarding the resident's fall and subsequent pain management. The facility's policies on managing falls, pain assessment, and incident reporting were not effectively implemented, contributing to the deficiency in care provided to the resident.
Deficiencies in Kitchen Sanitation and Staff Attire
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could lead to foodborne illness. During an inspection, the surveyor observed that the juice dispenser machine was connected to several large juice boxes with expired 'Best if Used by' dates. Specifically, an unsweetened black iced tea juice box had a date of 5/20/2024, a cranberry juice fusion box had a date of 11/28/2023, and a thickened water nectar consistency juice box had a date of 4/19/2024. The Food Service Director (FSD) acknowledged that these boxes should have been disposed of and could not explain why they were still in use. Additionally, the surveyor noted issues with staff attire that could compromise food safety. Dietary Aide #1 was observed wearing drop earrings more than an inch long, and Dietary Aide #2 was wearing medium hoop earrings. Both aides were unsure of the facility's policy regarding earrings in the kitchen. The FSD confirmed that ServSafe guidelines indicated such jewelry should not be worn. Furthermore, another dietary aide, DA #3, was observed with exposed facial hair, which was not covered with a beard restraint as required by the facility's policy. The FSD instructed DA #3 to put on a beard cover. The facility's policies on food storage and staff attire were reviewed, indicating that all foods should be consumed within their use-by dates and that dietary staff should wear hair restraints and minimal jewelry.
Deficiencies in Staff Hiring Process
Penalty
Summary
The facility failed to ensure proper verification of licenses, criminal background checks, and reference checks for several staff members, leading to deficiencies in their hiring process. Specifically, three out of seven licensed staff members did not have their licenses verified before their date of hire, and one out of ten staff members did not have a criminal background check completed before starting work. Additionally, six out of ten staff members did not have reference checks from past employers documented in their files. During the survey, it was revealed that a Certified Nursing Assistant, a Licensed Practical Nurse, and a Registered Nurse had issues with license verification, either lacking documentation or having verification completed after their hire date. Furthermore, a Unit Clerk began working before their criminal background check was completed, and several staff members, including a Recreation Aide and an Occupational Therapist, lacked documented reference checks. The Director of Human Resources acknowledged the deficiencies, stating that license verifications were sometimes completed after the date of hire and that reference checks were supposed to be in the file. The facility did not have a policy for the new hire process, and the Licensed Nursing Home Administrator confirmed that the date of hire was not always the date the employee started working. The facility's policy on abuse prevention requires background checks and prohibits hiring individuals with certain findings or disciplinary actions, but these procedures were not consistently followed.
Deficiency in Physician Documentation and Visits
Penalty
Summary
The facility failed to ensure that the attending physicians signed and dated monthly physician orders and conducted required visits for several residents. Specifically, the attending physician did not document visits for Resident #18 for March, April, May, or June 2024, with only the Advanced Practice Nurse (APN) documenting visits in April and June. Similarly, Resident #80's attending physician did not document visits for March, April, May, or June 2024, with the APN only documenting a visit in March. Resident #227's attending physician also failed to document visits for April, May, or June 2024, with the APN documenting only in May. Resident #257's attending physician did not document visits for May or June 2024, although the APN covered these months. The surveyor's review of Resident #466's electronic medical record revealed that the attending physician and APN had not signed monthly orders for June and July 2024. Additionally, there was no documentation of visits by the attending physician for these months, nor was there a history and physical or progress notes documented. The Registered Nurse (RN) interviewed was unsure of the process for signing orders and could not locate the necessary documentation in the electronic medical record. The Director of Nursing (DON) was also unable to find the required documentation upon review. The facility's policy and procedure for physician responsibilities, signatures, and visits require that all physician orders and progress notes be signed and dated in a timely manner. Physicians are expected to conduct initial visits within 48 hours of admission and regular visits every 30 days for the first 90 days, then at least once every 60 days thereafter. The surveyor's findings indicated that these requirements were not met for the residents reviewed, leading to the identified deficiencies.
Infection Control Deficiencies in Hand Hygiene and Precautionary Measures
Penalty
Summary
The facility failed to adhere to proper hand hygiene and transmission-based precautions, as observed by surveyors. In one instance, a housekeeper was seen wearing gloves while cleaning a toilet room and then proceeded to move through the hallway without removing the gloves or performing hand hygiene. This was contrary to the facility's policy and CDC guidelines, which require hand hygiene after glove removal and before leaving a room. Additionally, during a dining observation, residents were not offered hand hygiene before and after meals, which is a requirement according to the facility's hand hygiene policy. The facility also failed to implement appropriate transmission-based precautions for residents on contact precautions. For instance, a resident with MRSA in the urine was placed on contact precautions, but the necessary signage and PPE bins were not consistently present or utilized by staff. A housekeeper entered the resident's room without wearing a gown, despite the contact precaution signage indicating the need for gown and gloves. Furthermore, a physician was observed exiting a room under enteric contact isolation without removing PPE or performing hand hygiene, which is against the facility's infection control policy. There were also issues with room assignments for residents requiring isolation. A resident with C. difficile was placed in a room with another resident who was not on isolation, and both residents shared a bathroom. The infection preventionist was not aware that the non-isolated resident used the shared bathroom, which could pose a risk of infection transmission. The facility's policy requires residents on contact precautions to be placed in private rooms or assessed for appropriate roommate placement, which was not adequately followed in this case.
Deficiencies in Facility Cleanliness and Safety
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in both resident and common areas. In one instance, a resident reported a loose safety railing in a public toilet room, which was confirmed by the surveyor and the Licensed Nursing Home Administrator (LNHA). Additionally, the chapel, used for religious services, had blood stains on the carpet from an incident a month prior, which had not been cleaned despite being reported. Housekeeping staff were unaware of the stain, and the Infection Preventionist/Registered Nurse (IP/RN) confirmed the presence of the stain and observed additional black stains and discolored ceiling tiles. In another instance, a resident's room was found to have chipped and faded paint with black streaks on the walls, and the floor tiles were discolored. The resident, who was dependent on a wheelchair and had conditions such as obesity and osteoarthritis, pointed out these issues to the surveyor. The Housekeeping staff acknowledged the need for cleaning and maintenance, while the Director of Maintenance admitted the room's condition was unacceptable and noted a previous leak that had not been addressed. The facility's Safe and Homelike Environment Policy mandates maintaining a sanitary, orderly, and comfortable environment, which was not upheld in these cases. The policy requires prompt reporting and addressing of maintenance issues, which did not occur as evidenced by the unresolved environmental concerns in both the resident's room and common areas. The facility management was informed of these findings during the survey, but no additional information or refutation was provided.
Failure to Serve Meals Dignifiedly
Penalty
Summary
The facility failed to ensure that residents were served their meals in a dignified manner during meal service, as observed by a surveyor. On the specified date, the surveyor noted that a lunch food truck was parked in front of the nursing station and then taken into the dining room where five residents were present. However, one resident was not served a lunch tray at the same time as the other residents at their table. The Registered Nurse (RN) was questioned by the surveyor about the missing tray and acknowledged that the Certified Nursing Aide (CNA) had already requested it, but it was not included in the initial delivery. The CNA eventually received and set up the lunch tray for the resident, but this delay was noted as a failure to serve all residents at a table together, as per the facility's Dining Environment Policy. The surveyor informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other facility management of the issue, and the facility did not provide additional information or refute the findings. The policy review confirmed that all residents seated at a table should be served together when feasible, which was not adhered to in this instance.
Failure to Timely Complete Comprehensive Assessments
Penalty
Summary
The facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for three residents. The deficiency was identified through interviews and record reviews, revealing that the facility did not adhere to the required timeline for completing the Minimum Data Set (MDS) assessments. Specifically, the MDS for Resident #6 was completed 32 days after the Assessment Reference Date (ARD), and for Resident #135, it was completed 15 days after the ARD. Both assessments exceeded the mandated completion period of no later than 14 days after the ARD. Additionally, the MDS for Resident #14 was completed 31 days after the ARD, further indicating non-compliance with the required timeline. The surveyor's interviews with the part-time MDS Coordinator/RN and facility management confirmed awareness of the issue, with the MDS Coordinator acknowledging previous similar concerns. Despite being informed of these findings, the facility did not provide additional information or refute the surveyor's observations during the exit conference.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required timeframe for two residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the quarterly MDS should be completed within 92 days after the Assessment Reference Date (ARD) of the previous MDS, and the completion date should be no later than 14 days after the ARD. However, for Resident #6, the quarterly assessment was completed 19 days after the ARD, and for Resident #135, the assessments were completed 26 and 17 days after the ARD for two separate quarters. During the survey, the part-time MDS Coordinator/RN acknowledged the late submissions and stated that the facility follows the RAI Manual guidelines. The Director of Nursing also recognized the issue of late completion and submission of MDS assessments. Despite these acknowledgments, the facility did not provide additional information or refute the findings during the exit conference with the survey team, which included the Licensed Nursing Home Administrator, Chief Nursing Officer, Corporate Compliance Officer, and Regional Administrator.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. For Resident #135, the MDS was inaccurately completed by a per diem MDS/Registered Nurse (pdMDS/RN) who worked remotely and did not interview the resident in person. The MDS Coordinator RN (MDSC/RN) acknowledged that the pdMDS/RN did not conduct the necessary interviews, resulting in an inaccurate assessment of the resident's health conditions, particularly regarding pain management. Resident #138's MDS assessments contained inconsistencies in coding related to the resident's ability to understand and the omission of hospice care. The resident was coded as sometimes able to understand, yet the Brief Interview for Mental Status (BIMS) was not conducted. Additionally, the resident was not coded as receiving hospice care despite a physician's order indicating hospice admission. The MDSC/RN acknowledged these discrepancies and noted that different staff completed sections B and C at different times, contributing to the inconsistency. For Resident #198, the MDS was completed by the pdMDS/RN, who recorded a pain assessment without directly interviewing the resident. The MDS indicated that the resident experienced pain, but the assessment was completed remotely, raising concerns about the accuracy of the information. These deficiencies highlight the facility's failure to ensure accurate and reliable resident assessments, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines.
Failure to Provide Accurate Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to provide an accurate discharge summary for a resident at the time of discharge, which included a documented medication reconciliation, post-discharge instructions, and a physician's prescription. The deficiency was identified during a review of the closed medical records of a resident who was admitted with multiple diagnoses, including cellulitis, hypothyroidism, major depressive disorder, cerebrovascular disease, and seizures. The resident's discharge instructions listed a medication regimen that was inconsistent with the physician's prescription and progress notes, specifically regarding the dosage frequency of Aspirin EC 81 mg. The discrepancy was noted between the discharge instructions, which indicated the medication should be taken twice a day, and the physician's prescription and notes, which specified once a day. The RN interviewed acknowledged that the discharge instructions are what the resident or family follows and stated that the nurse should have clarified the order with the physician. The physician confirmed the correct dosage was once a day. The facility's policy required a medication reconciliation as part of the discharge summary, which was not properly conducted in this case.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of respiratory equipment for two residents. Resident #111 was observed with an unbagged nebulizer mask that had a foggy appearance and was dated two months prior, indicating it had not been changed as per facility policy. The resident's physician orders did not include instructions for changing the nebulizer mask, and the facility's electronic records did not reflect any such orders. Interviews with the LPN/Unit Manager and the Infection Preventionist confirmed that the mask should be changed weekly and stored properly to prevent infection. Resident #466 was observed with an oxygen concentrator at the bedside, and the nasal cannula was not stored in a bag when not in use. The resident's medical records indicated a physician's order for continuous oxygen therapy, but observations showed the oxygen was not in use, and the nasal cannula was improperly stored. The resident's care plan was incomplete, lacking specific goals and interventions for respiratory care. Interviews with the Assistant Director of Nursing and the assigned LPN revealed inconsistencies in following the physician's orders and proper storage procedures. The facility's Oxygen Administration Policy required the replacement of the entire setup every seven days and proper storage of equipment when not in use. However, the surveyor's findings indicated that these procedures were not consistently followed, leading to potential risks for infection and non-compliance with physician orders. The facility management was notified of these deficiencies, but no additional information was provided to refute the findings.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) as required. During the survey, it was observed that the NHRCSR was not posted for the day shifts on three separate occasions. On 7/08/24, the report for the day shift was not posted, with the previous day's report still displayed. Similarly, on 7/09/24, the report for that day's shift was missing, and on 7/12/24, the report for the day shift was also absent. The surveyor informed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) about these concerns, and it was noted that the Assistant Administrator was responsible for posting the NHRCSR. However, no additional information or refutation of the findings was provided by the facility management during the exit conference.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and appropriately, as observed during a medication pass on the South Side of the 2A Unit. A surveyor noted that a medication nurse placed medication cards on top of a medication cart while preparing and administering medications to a resident. After administering the medications, the nurse left a medication card containing Xarelto, a blood-thinning medication, unattended on top of the cart. This was contrary to the facility's policy, which mandates that no medications should be left on top of the cart and that all medications should be stored securely. The surveyor confirmed with the medication nurse and the RN/Unit Manager that leaving medications unattended was inappropriate and against the facility's policy. The facility's policies, reviewed by the surveyor, emphasized the importance of storing all drugs and biologicals in a safe, secure, and orderly manner. The incident was acknowledged by the Licensed Nursing Home Administrator and the Director of Nursing during a discussion with the survey team.
Failure to Follow Physician's Orders and Specify Medication Application Site
Penalty
Summary
The facility failed to adhere to physician's orders for a resident regarding the administration of Metoprolol Succinate ER, a medication prescribed for hypertension. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure was less than 100 or if the pulse was less than 60. However, from June 10 to June 14, 2024, the medication was administered without documenting the resident's systolic blood pressure and pulse in the electronic Medication Administration Record (eMAR). The Registered Nurse responsible for administering the medication on several of these days admitted to the oversight but could not provide an explanation for the lack of documentation. In another instance, the facility did not specify a site for the application of a Lidocaine patch for a resident who frequently complained of pain. The physician's order for the Lidocaine patch, intended for pain management, did not include instructions on where to apply the patch on the resident's body. The Director of Nursing confirmed that the order was incomplete and acknowledged that the location for patch placement should have been specified to ensure the correct pain site was treated. The absence of specific instructions left the determination of the application site to the discretion of the nurse or required consultation with the resident or their medical history. These deficiencies were identified during a survey, and the facility's management, including the Licensed Nursing Home Administrator and Director of Nursing, were informed of the findings. Despite being notified, the facility did not provide additional information or contest the findings during the exit conference with the survey team.
Failure to Implement Non-Pharmacological Interventions After Falls
Penalty
Summary
The facility failed to ensure a comprehensive investigation and implementation of non-pharmacological interventions following unwitnessed falls for a resident. The resident, who had medical diagnoses including dementia and hypertension, experienced multiple unwitnessed falls. The facility's investigation into these falls did not include a documented conclusion for the root cause analysis, which is a critical step in understanding and preventing future incidents. The facility's care plan for the resident included interventions such as keeping personal items within reach and providing a safe environment. However, after each fall, the interventions were not adequately updated to include new non-pharmacological strategies. For instance, after a fall on 4/25/24, the intervention was a psychiatric consult, but no additional non-pharmacological intervention was implemented. Similarly, after a fall on 6/04/24, the same intervention of a psychiatric consult was repeated without introducing a new strategy to prevent further falls. Interviews with facility staff, including the LPN, Unit Manager, ADON, and DON, revealed inconsistencies in the process for handling unwitnessed falls. The staff acknowledged that while an incident report was initiated, there was no documented conclusion or root cause analysis. Additionally, the facility's policy on managing falls did not explicitly require documentation of an interdisciplinary team meeting or discussion, which contributed to the lack of comprehensive follow-up on the resident's falls.
Consultant Pharmacist Fails to Identify Medication Error
Penalty
Summary
The facility's Consultant Pharmacist (CP) failed to identify and report a medication irregularity for a resident, leading to a significant health decline. On January 11, 2024, a nurse mistakenly documented a physician's order for Warfarin Sodium, a blood thinner, for a resident who was already prescribed Xarelto, another blood thinner. This error resulted in the resident receiving 18 doses of Warfarin from January 12 to January 29, 2024. During this period, the CP conducted a drug regimen review on January 15, 2024, but did not document any recommendations regarding the concurrent administration of both blood thinners. The resident, who had a history of chronic kidney disease, atrial fibrillation, and other health issues, became symptomatic and experienced a decline in health due to the administration of both medications. The resident's condition worsened, leading to an admission to an acute care hospital with a diagnosis of an upper gastrointestinal bleed and diarrhea. The CP admitted to seeing the new medication order but did not take action to clarify or stop the administration of Warfarin, as she thought it was for a short period and did not confirm with the nursing staff or the Director of Nursing (DON). The facility's policy on adverse consequences and medication errors emphasizes the importance of monitoring residents for potential adverse effects and ensuring that medication regimens do not include incompatible drugs. Despite this policy, the CP did not adhere to the guidelines, resulting in the resident's adverse health event. The deficiency was identified during a surveyor's review of the resident's medical records and interviews with the CP and facility staff.
Medication Transcription Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in a serious health decline. A registered nurse incorrectly transcribed a medication order for Coumadin, a blood thinner, intended for another resident, into the medical record of Resident #2, who was already prescribed Xarelto, another blood thinner. This error led to Resident #2 receiving both medications concurrently from January 12, 2024, to January 29, 2024, for a total of 18 doses. Resident #2, who had a history of chronic kidney disease, atrial fibrillation, and other significant health conditions, became symptomatic and experienced a decline in health due to the medication error. On February 5, 2024, the resident was found to be weak, lethargic, and unable to be safely transferred back to bed. The resident was subsequently sent to the hospital, where they were diagnosed with an upper gastrointestinal bleed and diarrhea, conditions likely exacerbated by the concurrent administration of two blood thinners. The error was discovered on January 30, 2024, when Resident #2 exhibited significant bleeding and hypotension. The Director of Nursing confirmed the transcription error during an investigation, noting that the registered nurse responsible could not recall the incident or provide an explanation. The facility's policy on medication errors emphasizes monitoring for adverse consequences and ensuring that residents are not taking incompatible medications, which was not adhered to in this case.
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.
Trusted by long-term care providers and associations.
