Mount Holly Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, New Jersey.
- Location
- 62 Richmond Avenue, Lumberton, New Jersey 08048
- CMS Provider Number
- 315128
- Inspections on file
- 16
- Latest survey
- February 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mount Holly Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was neglected by a CNA who refused to supervise them and was found sleeping. The resident fell and sustained a hip fracture, requiring hospital transfer and surgical repair. The facility's investigation and documentation were inadequate, and the incident was not properly reported or documented in staff files.
A resident with severe cognitive impairment and a high risk for falls experienced two falls within one hour, resulting in severe injuries requiring hospitalization. Despite being on one-to-one monitoring, the resident sustained multiple fractures and contusions. The facility failed to implement effective interventions following previous falls, contributing to the incident.
The facility failed to maintain a clean and sanitary kitchen environment, as observed by a surveyor and the Regional Dining Director (RDD). Deficiencies included a soiled gasket and debris in the walk-in refrigeration unit, debris on the floor and shelf liner in the dry food storeroom, and a meat slicer with debris on the base and blade. The RDD acknowledged these issues and mentioned that a new Food Service Director was developing a cleaning schedule.
The facility failed to ensure residents understood the binding arbitration agreement before signing it. Three residents with cognitive impairments were documented to have signed the agreement without proper assessment of their understanding. Facility staff lacked training and documentation processes to ensure comprehension, leading to this deficiency.
The facility failed to address a gas leak in the kitchen, where staff used a lighter to ignite stove burners due to a malfunctioning pilot light. The Regional Director of Dining confirmed the gas smell and regular use of a lighter, but the Licensed Nursing Home Administrator was unaware of the issue. A repairman found several failed pilot lights causing gas leaks, creating an Immediate Jeopardy situation.
The facility failed to provide adequate staffing and care, resulting in deficiencies such as delayed incontinence and nail care, insufficient resident supervision, and communication barriers for non-English speaking residents. Observations revealed residents left in soiled briefs, with long, dirty nails, and without access to call bells. An incident involving a resident's fall highlighted inadequate supervision, and the facility did not meet required staffing ratios, affecting care across multiple units.
The facility failed to serve food at appetizing temperatures and taste, as observed during a survey. Residents reported consistently cold and unpalatable food. A test meal revealed breakfast and lunch items not meeting required temperatures, with the FSD acknowledging the issue. The facility's policy lacked specific temperature requirements, contributing to the deficiency.
The facility failed to follow physician orders for medication administration and safety measures. A resident received Hydralazine despite low blood pressure, another lacked required bilateral floor mats, and others had issues with medication timing and availability. These deficiencies indicate non-compliance with established protocols.
A facility failed to provide a communication board for a Spanish-speaking resident, leading to ineffective communication with staff. Despite the care plan's requirement for an interpreter and communication board, staff relied on hand gestures, and the board was not found in the resident's room. The DON acknowledged the oversight.
The facility failed to ensure call bells were accessible for two residents, leading to deficiencies in care. One resident had the call bell out of reach on multiple occasions, despite their cognitive and physical limitations. Another resident also had the call bell out of reach, impacting their ability to request assistance. Staff interviews confirmed the expectation for call bells to be within easy reach, as per facility policy.
The facility failed to provide consistent incontinence and personal hygiene care for residents, as observed in multiple cases. Residents were found with soaked briefs, long and jagged nails, and unshaven, despite having care plans in place. Staff interviews revealed a lack of adherence to responsibilities, contributing to these deficiencies.
The facility failed to provide proper pressure ulcer care and prevention for two residents. One resident had a sacral wound without a dressing, and the dressing order was not transcribed correctly. Another resident returned from the hospital with a pressure injury that was not documented or treated promptly. The facility did not adhere to professional standards, leading to deficiencies in wound care and prevention.
A facility failed to develop a baseline care plan for pain management for a resident admitted for rehabilitation after hip surgery. The resident, with a history of a fall and hip fracture, was discharged from the hospital with a plan for pain control and specific medications. However, the facility's care plan did not address pain management, despite the resident's reported pain level. The DON acknowledged the oversight, which was contrary to the facility's Pain-Clinical Protocol Policy.
A facility failed to conduct a timely pain assessment and provide appropriate pain management for a resident with a hip fracture. Despite a documented pain level of 6 upon admission, pain medication was not administered until nearly 20 hours later. The DON indicated that pain medication is only given if requested by the resident, contrary to the facility's protocol requiring proactive pain assessment and management.
The facility failed to consistently address concerns raised by residents during monthly Resident Council Meetings. Five residents reported being unaware of any follow-up to their concerns, and a review of the October 2024 meeting minutes showed no documented resolutions. The DON acknowledged the lack of follow-up, despite the facility's policy requiring a response form to track issues and resolutions.
Two medication administration errors were observed in an LTC facility, resulting in a 5.8% error rate. One resident did not receive their prescribed Midodrine due to unavailability and lack of timely follow-up by an LPN. Another resident was given Esomeprazole for GERD while eating, contrary to the physician's order to administer it 30 minutes before meals. These errors indicate a failure to adhere to medication administration protocols.
A resident with multiple medical conditions, including a sacral decubitus ulcer, did not receive proper wound care monitoring and documentation as per their care plan. Despite a Wound Care Specialist's recommendations, the facility failed to document daily assessments or monitor the wound, leading to the resident's hospital admission with cellulitis and an infected sacral wound. The facility did not follow its protocol for notifying changes in the resident's condition to the physician.
Neglect Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect and received adequate supervision, resulting in a fall and injury. The resident, who was severely cognitively impaired and required extensive assistance with activities of daily living, was found lying on the floor complaining of severe pain. The resident had a history of falls and required a one-person physical assist with toileting. Despite these needs, the assigned Certified Nurse Aide (CNA) neglected to supervise the resident and was found sleeping at the nurse's desk. The incident occurred when a loud thud was heard, and staff found the resident on the floor by their room door. The resident stated they needed to go to the bathroom and was in pain, holding their left leg. The on-call Medical Doctor assessed the resident via video chat and ordered an emergency transfer to the hospital, where the resident was diagnosed with a closed fracture of the left hip requiring surgical repair. The facility's investigation revealed that the CNA assigned to supervise the resident refused the assignment and was sleeping instead of watching the resident. The facility's documentation and investigation were inadequate, as the Director of Nursing (DON) was unaware of the CNA's refusal to supervise the resident. The facility's report to the New Jersey Department of Health lacked statements and a signed conclusion. Additionally, the incident was not documented in the employee files of the staff involved, and the facility's policy on reporting and investigating abuse and neglect was not followed. The facility failed to provide adequate supervision and documentation, leading to the resident's fall and injury.
Inadequate Supervision Leads to Resident's Severe Fall Injuries
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent falls with injury for a resident assessed as high risk for falls. On 12/23/24, a resident who was on one-to-one monitoring experienced two falls within one hour, resulting in severe injuries that required emergency services and hospitalization. The injuries included multiple fractures to the facial bones, contusions, and a laceration requiring sutures. Despite being on one-to-one observation, the resident sustained a second fall shortly after the first, indicating a lapse in supervision. The resident had a history of multiple falls, with fifteen documented incidents prior to the severe fall on 12/23/24. The resident was admitted with diagnoses including unspecified dementia, major depressive disorder, restlessness, agitation, and gait abnormalities. The resident's comprehensive Minimum Data Set (MDS) indicated severe cognitive impairment and a high risk for falls, requiring supervision or assistance for mobility and transfers. Despite this, the care plan often lacked new interventions following falls, and the resident continued to experience frequent falls with injuries. The facility's Director of Nursing (DON) acknowledged the resident's impulsivity and need for constant redirection but could not explain the failure in supervision that led to the second fall on 12/23/24. The facility's Falls-Clinical Protocol required staff to identify causes of falls and implement interventions, but this was not consistently done. The lack of effective interventions and supervision contributed to the resident's repeated falls and the severe injuries sustained on 12/23/24.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain the kitchen environment and equipment in a clean and sanitary manner, which could potentially lead to bacterial growth and foodborne illness. During an initial tour of the kitchen, the surveyor, accompanied by the Regional Dining Director (RDD), observed several deficiencies. The first walk-in refrigeration unit had a soiled gasket and debris on the ceiling and fan, which the RDD acknowledged needed immediate attention. Additionally, debris was found throughout the floor and on a shelf liner in the dry food storeroom. The RDD mentioned that a new Food Service Director was in place and a cleaning schedule was being developed. Furthermore, a meat slicer, which was covered and presumed clean, was found to have debris on the base and by the blade upon inspection. The RDD admitted that it was not as clean as it should be. The facility's Sanitization Policy, revised in November 2022, states that the food service area should be maintained in a clean and sanitary manner, which was not adhered to in this instance.
Failure to Ensure Residents' Understanding of Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents were explicitly informed of and understood the binding arbitration agreement (AA) before entering into it as part of the Admission Agreement. This deficiency was identified for three residents who were reviewed for arbitration agreements. The facility's Admission Agreement included an Alternative Dispute Resolution Agreement, which was legally binding and required residents to waive their right to a trial. However, the facility did not adequately assess the residents' understanding of this agreement, particularly for those with cognitive impairments. Resident #71, who had severe cognitive impairment with a BIMS score of 07, was documented to have signed the AA. However, the resident's power of attorney was unaware of the agreement, indicating a lack of proper communication and understanding. Similarly, Resident #123, with moderately impaired cognition, and Resident #370, with severe cognitive impairment, were also documented to have signed the AA without a clear assessment of their understanding. The facility staff responsible for presenting the AA did not have a formal process or documentation to ensure residents comprehended the agreement. Interviews with facility staff revealed that there was no specific training or documentation process in place to assess residents' understanding of the AA. The staff relied on verbal presentations and informal assessments of cognition, such as asking general questions, without documenting the residents' comprehension. The facility lacked a policy or procedure to guide this process, leading to the deficiency in ensuring residents were informed and understood the binding nature of the arbitration agreement.
Failure to Address Gas Leak in Kitchen
Penalty
Summary
The facility failed to address a significant safety hazard in the kitchen, where a strong smell of natural gas was detected. During an inspection, surveyors observed that the staff used a lighter to ignite the stove burners due to a malfunctioning pilot light. The Regional Director of Dining (RDD) confirmed the presence of the gas smell and admitted that the lighter was used regularly to light the stove, although he could not recall informing the Licensed Nursing Home Administrator (LNHA) about the issue. Further investigation revealed that the Maintenance Director (MD) was aware of the lighter being used but was not informed about the stove's malfunction. A repairman later confirmed that several pilot lights had failed, causing gas to leak. The repairman indicated that the stove required new parts to fix the issue, and the gas leak was confirmed to be a result of the failed pilot lights. The facility's failure to promptly address the gas leak and reliance on a lighter to ignite the stove created an Immediate Jeopardy situation, posing a risk of explosion or fire. The LNHA was not aware of the problem until the surveyors brought it to his attention, highlighting a breakdown in communication and safety protocols within the facility.
Removal Plan
- The staff were instructed to stop manually lighting the pilot light.
- The gas line was disabled to prevent further manual lighting until repairs were made.
- The stove was replaced.
Inadequate Staffing and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff to meet the needs of residents, resulting in multiple deficiencies. Observations revealed that residents were not receiving timely incontinence care, with some residents left in soiled briefs for extended periods. Additionally, nail care was neglected, with several residents having long, jagged, and dirty nails, which were not addressed despite repeated observations and requests from residents. The lack of adequate staffing was evident, as the facility did not meet the required staffing ratios on numerous occasions, leading to inadequate care and supervision. Resident supervision was also insufficient, as evidenced by an incident where a resident fell and sustained a hip fracture. The fall occurred after a CNA was found sleeping instead of supervising the resident, and the facility's investigation into the incident was incomplete, lacking necessary statements and documentation. Furthermore, communication barriers were present for a resident who primarily spoke Spanish, as the facility failed to provide a communication board or effective means for the resident to express their needs, relying instead on hand gestures. The facility's failure to maintain required staffing levels and provide adequate care and supervision affected all residents across multiple units. The report highlights specific instances where residents were left without access to call bells, further compromising their ability to request assistance. The deficiencies were compounded by the facility's inadequate response to staffing shortages and lack of adherence to established care protocols, as outlined in the job descriptions for CNAs and LPNs.
Deficiency in Food Temperature and Taste
Penalty
Summary
The facility failed to consistently serve food to residents at an appetizing temperature and taste, as evidenced by observations and interviews conducted during a survey. During a resident council meeting, five residents reported that the food was always cold and tasted bad. On a subsequent day, a surveyor observed the delivery of breakfast meal trays to the Maple Unit, noting a delay of 26 minutes from the time the meal cart arrived to when the last tray was distributed. A test meal conducted by the surveyor and the Food Service Director (FSD) revealed that the breakfast items, including sausage, juice, and milk, were not at acceptable temperatures, with the FSD acknowledging that the cold temperatures were not okay. Further investigation during lunch meal preparation showed similar issues with food temperatures. The surveyors and FSD tested a meal that included fish, rice, zucchini, and a hamburger patty, finding that none of the hot items met the required temperature of 135 degrees Fahrenheit. Additionally, the zucchini and rice were described as bland and mushy. The facility's Food Temperature Log confirmed that hot foods must be above 135 degrees before service, and cold foods below 41 degrees, but the policy provided by the Licensed Nursing Home Administrator did not specify these temperature requirements. This deficiency was documented under NJAC 8:39-17.4(e).
Non-Compliance with Physician Orders and Safety Measures
Penalty
Summary
The facility failed to consistently follow physician orders for medication administration and safety measures for several residents. For Resident #82, the facility did not adhere to the physician's order to hold Hydralazine when the systolic blood pressure (SBP) was less than 120. Despite the order, the medication was administered on multiple occasions when the resident's SBP was below the specified threshold. Interviews with the LPN and Unit Manager revealed a lack of adherence to the holding parameters, which could potentially lead to adverse effects such as further lowering of blood pressure. Resident #19, who was at risk for falls, had a physician's order for bilateral floor mats to be placed on both sides of the bed. However, observations revealed that only one floor mat was consistently placed on the left side of the bed, contrary to the physician's order. The LPN and CNA acknowledged the discrepancy, indicating a failure to ensure the safety measures were properly implemented and documented. Additionally, Resident #23's medication administration was not in compliance with the physician's order, as the required blood pressure and heart rate monitoring prior to administering Olmesartan was not documented. Similarly, Resident #44 received Esomeprazole after beginning their meal, despite the order to administer it at least half an hour before meals. Furthermore, Resident #89 did not receive the prescribed Midodrine due to unavailability, and there was a delay in notifying the physician and obtaining the medication from the backup supply. These instances highlight a pattern of non-compliance with medication administration protocols, as outlined in the facility's policy.
Failure to Provide Communication Means for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide adequate communication means for a resident with a language barrier, identified as Resident #122, who primarily spoke Spanish. The deficiency was observed when the surveyor noted that the resident was unable to communicate effectively with staff due to the absence of a communication board, which was supposed to be provided as per the resident's care plan. Despite the resident's care plan indicating the need for an interpreter and a communication board to assist with daily needs, staff members relied on hand gestures to communicate, which was insufficient for understanding the resident's needs. Interviews with staff members, including CNAs and an LPN, revealed that they were aware of the resident's language barrier but did not have effective tools to facilitate communication. The CNAs admitted to using hand gestures, and the LPN mentioned occasionally using a Spanish-speaking CNA to assist. However, the communication board, which was part of the facility's policy for residents with language difficulties, was not present in the resident's room. The Director of Nursing acknowledged the oversight during a meeting with the survey team, confirming that the communication board should have been available to the resident.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that the call bell was accessible and within reach for all residents, as evidenced by observations and interviews with staff and residents. Resident #29 was observed multiple times with the call bell out of reach, either on top of the bedside table or tucked underneath the mattress. Despite the resident's ability to use the call bell, their severe cognitive impairment and physical limitations made it difficult for them to locate it. The care plan for Resident #29 included ensuring the call bell was within reach, but this intervention was not consistently implemented by the staff. Similarly, Resident #22 was observed with the call bell hanging from the bed frame, out of reach, during multiple observations. This resident also had severely impaired cognition and required maximal assistance with toileting hygiene. The care plan for Resident #22 included encouraging the use of the call bell for assistance, but the resident was unable to reach it when needed. Interviews with the Director of Nursing and other staff confirmed that the call bell should have been secured and within easy reach of the residents, as per facility policy.
Deficiencies in Incontinence and Personal Hygiene Care
Penalty
Summary
The facility failed to consistently provide appropriate incontinence care and personal hygiene for residents, as evidenced by multiple observations and interviews. Resident #100 was found in bed with a soaked brief and a call device on the floor, indicating a lack of timely assistance. Despite having a care plan for incontinence care, the resident reported not being changed since the previous night. Similarly, Resident #89 was observed with long, jagged nails and unshaven, despite expressing a desire for nail trimming and shaving. The care plan for Resident #89 indicated a need for assistance with activities of daily living due to weakness and deconditioning, yet these needs were not met. Resident #132 was also observed with thick facial hair and a soaked brief, indicating a lack of personal hygiene care. Despite having a care plan for assistance with activities of daily living, the resident's needs were not addressed. Resident #150 was found with long, discolored nails and unshaven, despite a care plan goal for being clean and well-groomed daily. The Unit Manager confirmed the need for nail trimming and shaving, yet these actions were not taken. Other residents, such as Resident #370, #123, #71, #122, #82, #77, and #35, were observed with similar deficiencies in personal hygiene and incontinence care. These residents had long, jagged nails with substances underneath, and some were found with soaked briefs. The facility's policies and job descriptions for nursing staff and CNAs outlined the responsibilities for providing daily care, including nail care and incontinence care, but these were not consistently followed. Interviews with staff revealed a lack of awareness and adherence to these responsibilities, contributing to the deficiencies observed.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For Resident #10, the surveyor observed a deep wound to the sacral area without a dressing during an incontinence tour. The dressing was found dislodged in the resident's brief, and the CNA stated it might have come off during repositioning. The nurse confirmed that the dressing was to be changed every three days and as needed, but the order was not transcribed correctly. Additionally, the LPN was observed using scissors without disinfecting them, which was corrected by the Unit Manager during the surveyor's observation. Resident #29 was transferred to the facility and initially assessed with no skin issues. However, upon readmission from the hospital, the resident was found to have a deep tissue injury surrounding an open skin pressure injury, which was not documented or treated in a timely manner. The facility failed to measure the wound or notify the physician and resident representative promptly. The wound care was not initiated until several days after the resident's return, and there was no documentation of wound care prior to the wound care team's initial visit. The facility's failure to adhere to professional standards of practice in wound care and prevention of pressure ulcers was evident in both cases. The lack of timely and appropriate wound care, failure to transcribe physician orders, and inadequate communication and documentation contributed to the deficiencies observed by the surveyor.
Failure to Develop Pain Management Care Plan
Penalty
Summary
The facility failed to develop an initial baseline care plan for pain management for a resident admitted for rehabilitation following hip surgery. The resident, who had a history of a fall resulting in a non-displaced intertrochanteric fracture of the right femur, was discharged from the hospital with a primary diagnosis of a right intertrochanteric fracture proximal femur. The hospital discharge summary included a plan for pain control as needed, and the discharge medication list specified oxycodone-acetaminophen for pain management. Upon admission to the facility, the resident's pain level was recorded as 6, with an acceptable pain level of 3. Despite the resident's need for pain management, the facility's care plan did not include a focus area for pain management. The care plan only addressed areas such as activities of daily living, risk for falls, skin breakdown, leisure activities, and nutrition. During an interview, the Director of Nursing acknowledged that the resident should have been care planned for pain. The facility's Pain-Clinical Protocol Policy, revised in October 2022, outlines the need for establishing goals of pain treatment with input from the resident, physician, and staff, which was not adhered to in this case.
Failure to Conduct Timely Pain Assessment and Management
Penalty
Summary
The facility failed to ensure a pain assessment was completed and documented for a resident who required pain management services. The resident, who had a history of a fall resulting in a non-displaced intertrochanteric fracture of the right femur and Type 2 Diabetes Mellitus, was admitted to the facility for sub-acute rehabilitation following surgery for an open reduction and internal fixation of the right hip. Upon admission, the resident's pain level was documented as 6, with an acceptable pain level of 3. However, the Medication Administration Record (MAR) showed that the pain medication order for Oxycodone-Acetaminophen was not administered until nearly 20 hours after admission, despite the resident's documented pain level. The Director of Nursing (DON) stated that pain medication is only administered if the resident requests it, indicating a lack of proactive pain assessment and management. The facility's Pain-Clinical Protocol Policy requires nursing staff to assess pain upon admission and monitor the use of analgesics, but this was not followed. The surveyor's review found no pain assessment or documentation of medication administration in the MAR until much later, highlighting a deficiency in the facility's pain management practices.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure a consistent process for addressing concerns raised by residents during monthly Resident Council Meetings (RCM). This deficiency was identified for all five residents who attended the RCM, as they reported being unaware of any follow-up to their expressed concerns. The surveyor's interview with these residents revealed that they were not provided with documented follow-up at subsequent meetings. A review of the RCM minutes from October 2024 showed that residents had requested staff to refrain from wearing earbuds while providing care, and the Director of Nursing (DON) had stated an intention to reeducate staff on phone usage. However, there was no evidence of resolution or follow-up on this issue. The facility's policy, revised in February 2021, requires the use of a Resident Council Response Form to track issues and their resolution, with the relevant department responsible for addressing concerns. Despite this policy, the DON acknowledged the absence of documented resolutions from the RCM and stated that concerns should be addressed and revisited as old business in subsequent meetings. During the exit conference, facility management did not provide additional information or refute the findings, indicating a lack of adherence to the established process for addressing resident concerns.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to ensure that medications were administered without error, resulting in a medication administration error rate of 5.8%. During a morning medication administration observation, two surveyors noted errors involving two residents. The first error involved Resident #89, who did not receive their prescribed dose of Midodrine for hypotension because the medication was unavailable. The LPN responsible did not follow up with the physician or attempt to retrieve the medication from the facility's backup supply in a timely manner, leading to the resident missing their dose. The second error involved Resident #44, who was administered Esomeprazole, a medication for GERD, while actively eating breakfast. The physician's order specified that the medication should be given at least half an hour before meals. Despite being aware of the order, the LPN administered the medication incorrectly, which was not in accordance with the prescribed instructions. Both errors were observed during the same medication pass, highlighting a failure in adhering to medication administration protocols. The facility's policies and procedures for medication administration were not followed, as evidenced by the lack of timely follow-up for unavailable medications and the incorrect timing of medication administration relative to meals.
Failure to Monitor and Report Changes in Wound Condition
Penalty
Summary
The facility failed to provide quality wound care in accordance with professional standards for a resident, leading to a significant deficiency. The resident, who was non-verbal and totally dependent on staff, had a history of multiple medical conditions including advanced multiple sclerosis, adult failure to thrive syndrome, and a sacral decubitus ulcer. The care plan for the resident included monitoring and documenting changes in skin status, administering treatments as ordered, and reporting to a physician as clinically indicated. However, there was no documentation that the wound was assessed daily or monitored, and no nursing progress notes were made regarding the resident's wound or possible infection from 2/09/23 to 2/15/23. On 2/9/23, a Wound Care Specialist noted that the resident's wound was deteriorating, with 20% slough and 80% granulation tissue, and recommended specific treatment changes. Despite these recommendations, the facility did not document any follow-up or monitoring of the wound. On 2/15/23, the resident was transferred to the hospital at the request of a family member, but there was no assessment indicating the reason for the transfer. The hospital admission revealed that the resident had cellulitis of the neck and chest, an infected sacral wound, and a fever, requiring treatment with intravenous antibiotics and a wound VAC. The Director of Nursing, who was on vacation at the time, later indicated that the nurse should have assessed the resident and contacted the physician before the hospital transfer. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their representative, and the attending physician, but this protocol was not followed. The lack of documentation and failure to monitor and report changes in the resident's wound condition led to the deficiency.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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