New Vista Nursing & Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, New Jersey.
- Location
- 300 Broadway, Newark, New Jersey 07104
- CMS Provider Number
- 315458
- Inspections on file
- 20
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at New Vista Nursing & Rehabilitation Ctr during CMS and state inspections, most recent first.
The facility failed to provide enough linens, such as towels and washcloths, for all residents, resulting in staff being unable to meet basic hygiene needs. Staff and residents reported frequent shortages, with some units receiving only one towel per resident and insufficient blankets during cold conditions. Staff often had to borrow linens from other units or were unable to obtain more when needed, impacting the ability to maintain cleanliness and comfort.
The facility did not report multiple allegations of abuse and misappropriation to the state agency within the required timeframe. Incidents included inappropriate touching between two residents with visual impairments, a resident experiencing a psychotic episode causing fear in a roommate, and a resident with quadriplegia accusing staff of theft. Documentation was present, but staff were unclear about reporting responsibilities, and required notifications were not made.
The facility did not complete required investigations into allegations of abuse and misappropriation involving several residents, including incidents of suspected sexual abuse, theft of money, and resident fear during a roommate's psychotic episode. Although some witness statements and grievances were documented, there was no evidence of thorough investigations as required by facility policy.
The facility did not ensure that POLST forms were fully completed with required dates and physician signatures for three residents, resulting in unclear code status and inconsistent documentation of life-sustaining treatment preferences. Staff interviews confirmed that the process for finalizing these forms was not consistently followed, leading to uncertainty about residents' wishes.
Two residents with complex medical needs reported grievances involving misappropriation of funds, delayed staff response, and transportation issues. Facility records showed no documented follow-up or resolution, and interviews confirmed that the residents were not informed of any investigation outcomes, contrary to facility policy.
A resident with severe cognitive impairment and total dependence on ADLs did not receive a required follow-up appointment after a laparoscopic cholecystectomy, despite hospital discharge instructions specifying the need for a visit in two weeks. Facility staff failed to identify and schedule the appointment, and documentation review confirmed the omission.
A resident with multiple chronic conditions had several instances where medication administration was not properly documented in the MARs, with blank entries and codes indicating missing progress notes or explanations. Staff interviews confirmed that medications were sometimes unavailable due to insurance delays, and required documentation was not consistently completed in the EMR, despite facility policy mandating such records.
The facility failed to maintain proper kitchen sanitation and food storage practices, including unlabeled food items, improper hand hygiene, and unclean equipment. Issues were observed with the juice machine, salad preparation, bread labeling, wet nesting of pans, and storage of items in non-functional ovens. Additionally, items were stored too close to the ceiling in refrigerators and freezers, and the dry storage area had debris on the AC unit and broken ceiling tiles.
The facility failed to ensure the QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies, with the last QAPI Plan being from 2019. The LNHA provided an untitled and undated document that did not reflect a comprehensive QAPI plan, and concerns were identified regarding employee files, non-certified Nursing Aides, staffing, vaccinations, and food temperature.
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly QAPI meetings, as confirmed by the LNHA and a review of attendance records. The IP's absence, crucial for addressing infection control issues, had the potential to affect all 273 residents.
The facility failed to provide a safe, clean, comfortable, and homelike environment. A resident's room was found with unsanitary conditions, including a dirty tube feeding pole, dusty oxygen concentrator, and broken nightstand. In the dining area, a commode with rust-like substances and wood blocks from a broken nightstand were inappropriately placed. The DON and LNHA acknowledged these issues, highlighting a lack of proper cleaning and maintenance protocols.
The facility failed to verify the credentials of newly hired licensed staff before their date of hire. Five out of seven newly hired staff members, including an OT, RN, LPN, and two CNAs, either had their licenses verified after their hire date or lacked documented evidence of verification. Interviews confirmed that verifications should be done before the hire date, but the facility lacked a specific hiring policy beyond a checklist, which was not found in the reviewed files.
The facility failed to develop and implement comprehensive care plans for four residents, including those requiring anticoagulant medication, pain management, smoking safety, and palliative care. The deficiencies were confirmed by the LPN, DON, and MDSC/RN, highlighting a lack of adherence to the facility's policies on care plan development and updates.
The facility failed to provide appropriate respiratory care for three residents. One resident received incorrect oxygen flow, another had an unreadable oxygen concentrator setting, and a third had improperly labeled and stored respiratory equipment. The Director of Nursing confirmed that proper orders and care plans were missing or not followed.
The facility failed to ensure that CNAs received annual performance reviews for five CNAs whose files were reviewed. Despite multiple requests, the facility did not provide the requested performance reviews, and there was no documented evidence that these reviews had been conducted. The issue was discussed with the LNHA and the DON, but no additional information or policy was provided.
The facility failed to maintain infection control standards during a COVID-19 outbreak by not conducting testing according to CDC guidelines, not adhering to proper hand hygiene practices, and improperly storing PPE. Three residents and three staff members were tested on incorrect days, and staff were observed washing hands for less than the required time and storing masks inappropriately.
The facility failed to document and administer influenza and pneumococcal vaccinations for several residents, as per their policies and CDC guidelines. This resulted in multiple deficiencies in resident care, with no proper documentation of vaccine administration or refusal in the medical records.
The facility failed to serve all residents seated at a table their lunch trays in a timely manner, with one resident receiving their tray 16 minutes after others had started eating. Interviews with CNAs revealed no explanation for the delay, and the facility's Meal Service Policy lacked procedures for dining room service.
The facility failed to ensure that a resident with severe cognitive impairment or their representative was offered the opportunity to formulate an Advance Directive, resulting in a default Full code status without documented discussion of end-of-life wishes.
A resident with severely impaired cognition was found with a bump and discoloration on their face, but the facility failed to report the injury of unknown origin to the NJDOH as required. Conflicting accounts and lack of proper documentation led to the deficiency.
A facility failed to thoroughly investigate a fall incident involving a cognitively impaired resident with multiple medical conditions. The initial documentation lacked details on the cause of the fall and preventive interventions, and there were significant delays and discrepancies in updating the care plan. The DON admitted to recent edits and delays in the investigation, and the facility did not provide the fall policy when requested.
The facility failed to accurately code the MDS for three residents, leading to discrepancies in their medical records. Errors included incorrect influenza vaccine dates and missing documentation of oxygen therapy. These issues were identified through observations, interviews, and record reviews.
The facility failed to follow professional standards in medication administration and did not ensure proper care for a resident at risk for wandering. An LPN did not instruct a resident to rinse their mouth after administering an inhalation medication, and the placement of a wander guard was not checked on ten shifts. The resident's Wandering Risk Assessment form was also incomplete.
A facility failed to provide proper wound care for a resident by not adhering to hand hygiene protocols. The Wound Care Registered Nurse (WCRN) missed 12 of 17 hand hygiene opportunities during the wound treatment, including not washing hands after removing gloves and handling supplies with bare hands. The resident had a diagnosis of type 2 diabetes mellitus and chronic obstructive pulmonary disease, and was at risk for pressure ulcers. The facility's policies emphasize the importance of hand hygiene, but these were not followed, leading to the observed deficiency.
The facility failed to monitor and document urinary output for two residents with indwelling catheters, contrary to its policy and procedure. One resident had severe cognitive impairment and multiple diagnoses, while the other had intact cognition and diagnoses including urinary tract infection. The deficiency was confirmed by staff and the Director of Nursing (DON).
The facility failed to ensure that a non-certified Nurse Aide did not continue to work after the specified 120 days and lacked a policy for hiring and staffing non-certified NAs. NA #1 worked for more than 120 days without proper certification, and the facility's administration was unaware of the correct certification requirements.
The facility failed to post the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) in a prominent place, making it inaccessible to residents and visitors for two consecutive days. The responsible staff member had a medical emergency and came in late, and the usual posting location was not readily visible. The facility lacked a policy on posting staffing information.
The facility failed to properly label, store, and administer medications, including undated vials, expired Omeprazole, and unadministered Pneumococcal syringes. Staff interviews revealed awareness of protocols but inconsistent adherence, leading to multiple deficiencies.
The facility failed to maintain a sanitary environment by not keeping the garbage compactor and dumpster area free of garbage and debris. The FSD acknowledged that the area should have been cleaned by the maintenance and dietary departments, and the LNHA admitted that the facility maintenance department is responsible for this task. The facility policy states that outside dumpsters should be kept closed and free of surrounding litter, which was not followed.
The facility failed to ensure timely physician visits and address nutritional issues for a resident with significant weight loss. The resident, with multiple medical diagnoses, had not been seen by the primary physician since 11/19/23, despite a documented 5.2% weight loss over the past month.
The facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. A resident expressed dissatisfaction with the food quality, and observations revealed that lunch had not arrived on time. The delay in delivering meal trays caused the food to lose its temperature, with temperatures recorded below recommended levels. The facility's policies on food quality and meal distribution were reviewed, and it was noted that the policies lacked creation or revision dates.
The facility failed to maintain complete and accessible medical records for two residents. One resident's ADL care documentation was missing, and another resident's physician discharge summary was not present in the medical records. Despite multiple inquiries, the facility could not provide the necessary documentation, indicating a significant lapse in record-keeping.
The facility failed to notify the LTCO of a resident's emergency transfer to the hospital due to vaginal bleeding. The Nursing Clerk responsible for LTCO notifications confirmed the omission, which was attributed to a possible oversight by the previous DON. The facility lacked a specific policy for LTCO notifications, relying on a monthly submission process that contributed to the deficiency.
The facility failed to implement a comprehensive Antibiotic Stewardship Program as per their policy and national standards. The documentation provided was incomplete, lacking essential details such as diagnostic testing and signs/symptoms of residents. Interviews revealed inconsistent documentation of feedback reports, trend reports, and surveillance, leading to the identified deficiency.
Inadequate Linen Supply for Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of linens, including towels and washcloths, for resident care, affecting all residents in the census. Multiple interviews with staff, including CNAs and LPNs, revealed that there were not enough linens available to meet the basic hygiene needs of residents. Staff reported having to borrow linens from other units, make repeated calls to laundry that often went unanswered, and sometimes having to deny residents' requests for additional towels or washcloths. One resident was found in a soiled brief and could not be changed due to the lack of clean linens. The Director of Building Services acknowledged issues with linen disappearance, including being thrown away, hidden, or given to families. The Director of Nursing confirmed that the expectation was for sufficient linen supply to meet resident care needs, especially during the day shift when bathing and frequent brief changes occur. The facility's policy on maintaining a homelike environment specifies the provision of clean bed and bath linens in good condition. However, staff interviews and resident reports consistently indicated that the linen supply was inadequate, with some units receiving only one towel per resident and not enough blankets during colder conditions. The deficiency was observed to impact the facility's ability to maintain cleanliness and comfort for its residents.
Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to report three allegations of abuse involving three residents and one allegation of misappropriation of property involving another resident to the state survey agency within the required two-hour timeframe. For one incident, a resident with paranoid schizophrenia and major depressive disorder was reported by an activities assistant to have inappropriately touched a legally blind roommate. Multiple staff documented the event, but the incident was not included in the facility's Accident and Incident Log, and the Director of Nursing (DON) was unaware of the allegation being classified as sexual abuse. The DON confirmed that such incidents should be reported immediately, but the state agency had not received any reportable incidents from the facility since a date prior to these events. Additionally, the Social Services Director was not aware of his role as Abuse Coordinator and was unfamiliar with the requirements, indicating a lack of clarity in staff responsibilities regarding abuse reporting. Another incident involved a resident with hemiplegia and hemiparesis who became fearful when a roommate, experiencing a psychotic episode, threw objects around the room. The event was documented, but again, there was no evidence that it was reported to the state agency as required. The facility's own policy mandates that all alleged violations involving abuse or misappropriation of property be reported immediately, but this was not followed in these cases. A separate allegation of misappropriation involved a resident with quadriplegia and hypertension who accused staff of stealing money. Progress notes documented the accusation, but the DON was not aware of the allegation and stated it should have been addressed in a morning meeting. Interviews with LPNs revealed uncertainty about the identity of the Abuse Coordinator and the proper reporting process. The facility's failure to report these incidents as required by policy and regulation had the potential to allow continued abuse and misappropriation for all residents.
Failure to Investigate Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to properly investigate multiple allegations of abuse and misappropriation of property involving several residents. For one incident, a resident with paranoid schizophrenia and major depressive disorder was alleged to have inappropriately touched another resident with legal blindness, diabetes, and end stage renal disease. Although witness statements were collected, there were no investigation notes or summary indicating that a full investigation into the suspected sexual abuse was completed. In another case, a resident with quadriplegia and hypertension reported concerns about staff taking his money, and a grievance was filed, but no further investigation was documented by the facility. Additionally, an incident involving a resident with hemiplegia and hemiparesis, who became fearful during a roommate's psychotic episode, was not fully investigated. The Director of Nurses confirmed that investigations were not completed for these incidents by the previous Abuse Coordinator, despite facility policy requiring thorough investigation and documentation of all reports of abuse and misappropriation. The lack of completed investigations for these events constituted a failure to respond appropriately to alleged violations.
Incomplete POLST Documentation and Unclear Code Status for Multiple Residents
Penalty
Summary
The facility failed to ensure that Practitioner Orders for Life-Sustaining Treatment (POLST) forms were properly completed and documented for three residents. For one resident with severe cognitive impairment and diagnoses including dementia and cerebrovascular disease, the paper chart contained two undated POLST forms with conflicting code statuses (DNR and full code), both lacking a date and physician signature. Staff interviews confirmed that the process for obtaining physician signatures and dating the forms was not followed, resulting in unclear code status for the resident. Another resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease, had a POLST form in the paper chart that was signed by the resident but lacked both a date and physician signature. Staff confirmed that this form was incomplete. For a third resident, also cognitively intact and with diagnoses including pneumonia and chronic obstructive pulmonary disease, the EMR documented full code status, but the paper chart contained an advanced directive indicating DNR, signed by the resident and witnesses but not by a physician. Staff interviews revealed uncertainty about the resident's actual code status due to incomplete documentation. Facility policy required that residents' treatment preferences and advance directives be documented and that the plan of care be consistent with these preferences. However, interviews with staff, including the Social Services Director, DON, and Administrator, confirmed that the process for completing and obtaining physician signatures on POLST forms was inconsistent and not reliably followed, resulting in incomplete documentation and unclear communication of residents' wishes regarding life-sustaining treatment.
Failure to Resolve Resident Grievances Related to Misappropriation and Care Concerns
Penalty
Summary
The facility failed to resolve grievances for two residents regarding misappropriation of funds and transportation concerns related to medical appointments. One resident, admitted with diagnoses including type two diabetes, bipolar disorder, hypertension, and bladder cancer, reported ongoing issues with staff mismanaging doctor appointments, including mixing up dates and forgetting transportation arrangements. The resident also expressed frustration that previous grievances about medication administration and other concerns were not addressed, leading to a lack of trust in the grievance process. Documentation of the resident's concern showed no action taken or follow-up recorded. Another resident, admitted with quadriplegia, hypertension, muscle weakness, and benign prostatic hyperplasia, reported two separate grievances: one involving delayed staff response to call lights, resulting in the resident calling 911, and another involving accusations of staff stealing money and not providing proper hygiene care. In both cases, facility documentation lacked evidence of follow-up or resolution. Interviews confirmed that the residents were not informed of any investigation outcomes or corrective actions, and the facility's grievance policy requiring investigation and communication of findings was not followed.
Failure to Schedule Post-Surgical Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medical follow-up appointment was identified and scheduled for a resident following a surgical procedure, specifically a laparoscopic cholecystectomy. The resident, who was severely cognitively impaired and totally dependent on all activities of daily living, was readmitted to the facility after surgery with discharge instructions from the hospital indicating the need for a follow-up appointment in two weeks. However, a review of the facility's records and appointment log confirmed that no such appointment was scheduled or attended during the specified period. Interviews with facility staff revealed that the process for reviewing hospital discharge documents and scheduling follow-up appointments was not consistently followed. The unit clerk, who was not employed at the time of the incident, confirmed that no appointment was logged, and the DON stated that the nurse re-admitting the resident should have reviewed the discharge documentation and relayed recommendations for follow-up to the physician. The RN Supervisor was unaware of the missed appointment, and the facility's policy did not address ongoing treatment requirements. This lapse resulted in the resident missing the recommended post-surgical follow-up care.
Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for one resident by not properly documenting the completion of physician orders on the medication administration records (MARs). The resident, who had a primary diagnosis of diabetes mellitus and multiple comorbidities including bipolar disorder, hyperlipidemia, and major depressive disorder, was prescribed several medications such as atorvastatin, eszopiclone, gabapentin, omeprazole, hydroxyzine, Seroquel, tamsulosin, and trazodone. Review of the resident's MARs for several months revealed multiple instances where medication administration was either left blank or marked as '9', indicating the need for a progress note regarding medication availability or administration, but no such documentation was found in the electronic medical record (EMR). Interviews with the resident and staff confirmed that there were occasions when medications were not available, particularly tamsulosin, due to issues such as insurance authorization delays. The resident reported being told by staff that medications had been ordered but then went without them. LPNs and the DON acknowledged that when medications were unavailable or not given, it was expected that a progress note would be entered, the physician notified, and the situation documented in the EMR. However, this documentation was not consistently present, and the DON was unaware that these documentation errors were ongoing despite previous pharmacy audits identifying similar issues. Facility policy required that all medications administered, withheld, or refused be documented on the MAR, including reasons for any deviations. Despite this policy, the MARs contained blank entries and '9' codes without corresponding progress notes or explanations in the EMR, making it unclear whether medications were administered, withheld, or unavailable. This lack of documentation compromised the accuracy and completeness of the resident's medical record.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store and discard potentially hazardous foods correctly, leading to multiple deficiencies. During a kitchen tour, surveyors observed several issues, including unlabeled rice crispy cereal cups, a juice machine with brown spots on the tubing, and a dietary aide preparing salads without washing the lettuce despite manufacturer instructions. Additionally, multiple loaves of bread and hamburger buns were found without labels, and wet nesting was observed in the dry pots and pans area. The Food Service Director (FSD) also failed to perform proper hand hygiene, using contaminated paper towels to turn off the faucet due to an empty towel dispenser, despite clean towels being available nearby. Crumb-like debris was found between the ovens, and non-functional ovens were improperly used for storage of seasoning and leftover cooking materials. The cast iron griddle was observed with black debris, indicating it had not been cleaned after use. In the walk-in refrigerators and freezers, items were stored too close to the ceiling, and black dust-like debris was found on the light bulb and wiring. Opened seasonings in the dry storage area lacked use-by or discard dates, and the air conditioning unit had a thick layer of black debris on the vent. Additionally, multiple broken, partially moved, and missing ceiling tiles were observed in the dry storage area, with no explanation provided for their condition.
Failure to Update and Implement QAPI Plan
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure had the potential to affect all 273 residents currently living in the facility. During the entrance conference, the surveyor requested information regarding the QAA committee, sign-in sheets for QAPI meetings, and the QAPI plan. The provided documents revealed that the QAPI Policy was last reviewed in December 2021, and the QAPI Plan was last updated in 2019. The Infection Preventionist was not included as a member of the QAA committee, and there was no documented evidence of plans of action developed and implemented to correct identified quality deficiencies for the last four years. Further review showed that the QAPI Program did not have a review date, and the goal descriptions for various departments were outdated, with the last updates being in 2019. When asked about the QAPI plan, the LNHA provided an untitled and undated piece of paper that did not reflect a comprehensive QAPI plan. The LNHA was unable to explain why the QAPI plan was outdated and why certain departments were not included. The surveyor identified concerns about employee files, non-certified Nursing Aides, staffing, vaccinations of staff and residents, and food temperature. The facility management was notified of these concerns, but no additional information was provided to address the deficiencies.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficiency was identified during an interview with the Licensed Nursing Home Administrator (LNHA) and a review of the QAPI attendance records for the last three quarters. The LNHA confirmed that the IP did not attend the QAPI meetings held on 5/11/23, 9/07/23, and 11/30/23. Additionally, the QAA Committee Information provided by the facility did not list the IP as a member of the committee, which is a requirement according to the facility's QAPI policy dated 12/2021. The policy mandates that the QAA Committee must include the Administrator, Director of Nursing (DON), Medical Director, and at least three other staff members, including the IP. During the survey, the LNHA acknowledged the absence of the IP and confirmed that the IP's role is crucial for addressing infection control issues, such as COVID-19 testing and vaccinations for residents and staff. The survey team met with the LNHA and DON multiple times to discuss the deficiency, and the LNHA had no explanation for why the IP was not included in the QAA Committee list. The failure to include the IP in the QAPI meetings had the potential to affect all 273 residents currently living in the facility, as infection control is a critical aspect of resident care and safety.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. In one resident's room, the surveyor observed an air mattress with an indwelling catheter, a tube feeding pump, and an oxygen concentrator, all of which were in unsanitary conditions. The tube feeding pole and the surrounding floor had dried brownish substances, the oxygen concentrator had an accumulation of black and grayish substances, and an electric fan was covered in dust. Additionally, the nightstand table in the room was broken. The LPNs confirmed these observations and acknowledged that the room should have been cleaned and the broken items reported to maintenance. The resident in question was cognitively impaired and required total assistance with activities of daily living, further emphasizing the need for a clean and safe environment. In the dining area on the 4th floor, the surveyor observed a commode with rust-like substances placed in the hallway near a dining table, and two blocks of wood outside a resident's room. The nightstand table in the room was broken, with a missing wood cover for the first drawer. The CNA confirmed that the wood blocks were from the broken nightstand and that the commode should not have been left in the dining area. The LPN also confirmed that the commode should not be in the dining area and asked the CNA to remove it. The presence of these items in the dining area during mealtime was inappropriate and posed a safety concern. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged the issues and stated that there should be no broken supplies or equipment in residents' rooms and that the rooms should be cleaned. The facility had a log for cleaning oxygen concentrators but lacked a cleaning log or accountability for other items such as tube feeding poles and electric fans. The facility's Quality of Life-Homelike Environment Policy emphasized the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Failure to Verify Credentials of Newly Hired Licensed Staff
Penalty
Summary
The facility failed to ensure that the credentials of newly hired licensed staff were verified upon hire. This deficiency was identified for five out of seven newly hired licensed staff members. Specifically, the review of employee files revealed that the license verifications for an Occupational Therapist, a Registered Nurse, a Licensed Practical Nurse, and two Certified Nursing Assistants were either completed after their date of hire or lacked documented evidence of verification prior to their date of hire. The Director of Activities, who previously worked in Human Resources, confirmed that license verifications should be done before the date of hire, but the reviewed files did not include such documentation. During interviews, both the Director of Activities and the Director of Nursing acknowledged that license verifications should be dated and completed before the employees' first physical day at the facility. The Licensed Nursing Home Administrator admitted that the facility did not have a specific policy for new employee hiring other than a checklist, which was not found in the reviewed employee files. The facility's policy on residents' rights to freedom from abuse, neglect, and exploitation stated that individuals with certain negative findings or disciplinary actions should not be employed, but there was no additional information provided to ensure compliance with this policy.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals, addressing their medical, physical, mental, and psychosocial needs. This deficiency was identified for four residents. Resident #19, who was cognitively impaired and required total care, did not have a care plan for anticoagulant medication despite having a physician's order for Apixaban. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed the absence of a care plan for anticoagulants, and it was noted that there had been no Unit Manager for one and a half years to oversee care plan development and updates. Resident #132, who had multiple hospital-acquired wounds and was on pain medication, did not have a care plan for pain management. The LPN and Minimum Data Set Coordinator/Registered Nurse (MDSC/RN) acknowledged the necessity of a pain care plan, but it was not in place. The MDSC/RN stated that the admitting nurse was responsible for initiating care plans, and she would update them during quarterly assessments. However, it was unclear if the nurses were aware of their responsibilities regarding care plan initiation and updates. Resident #36, a smoker with diagnoses including type 2 diabetes mellitus and major depression disorder, did not have a care plan for smoking despite a smoking assessment indicating the need for one. The DON confirmed that all residents who smoke should have an individualized care plan. Additionally, Resident #267, who was placed on palliative care and had a DNR, DNI, and DNH order, did not have a care plan for palliative care. The DON stated that care plans should be created and updated for residents on palliative care. The facility's policies on comprehensive care plans and palliative care were not followed, leading to these deficiencies.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice and physician's order for three residents. For Resident #19, the surveyor observed that the resident was receiving oxygen at 5 LPM via nasal cannula, contrary to the physician's order of 3 LPM. The LPN acknowledged the discrepancy and adjusted the oxygen flow. Further review revealed that there was no current physician's order for oxygen use, and the resident's care plan did not include oxygen use, goals, and interventions. The Director of Nursing confirmed that there should be an order and care plan for oxygen use, which was missing in this case. For Resident #145, the surveyor observed that the oxygen concentrator in use did not have a visible indicator to show the LPM of oxygen being administered. The LPN was unable to read the oxygen setting and acknowledged that the concentrator needed replacement. The resident's medical records showed that there were five unsigned entries for oxygen therapy in the January 2024 electronic Treatment Administration Record. The Director of Nursing acknowledged that the electronic Treatment Administration Record should be signed by the nurses and that the concentrator was replaced immediately. For Resident #235, the surveyor observed that the nasal cannula tubing and nebulizer equipment were not properly labeled with a date, and the face mask was not stored in a bag or labeled. The resident's medical records indicated that the oxygen cannula should be changed weekly, but the observation did not reflect this practice. The LPN confirmed that the tubing should be dated and labeled and that the equipment should be stored properly to prevent infection. The Director of Nursing stated that the oxygen should be administered based on the doctor's order and that the nursing staff is responsible for checking the oxygen concentrator and following the schedule for changing the tubing and storing the equipment properly.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received annual performance reviews for five CNAs whose files were reviewed. This deficiency was identified during a survey when the survey Team Coordinator requested a list of CNAs along with their performance reviews and competencies. Despite multiple requests, the facility did not provide the requested performance reviews, and there was no documented evidence that these reviews had been conducted. The issue was discussed with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing, but no additional information or policy regarding CNA annual performance reviews was provided.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain infection control standards and procedures during a COVID-19 outbreak. Specifically, the facility did not conduct COVID-19 testing according to CDC guidelines and its own policies. Three residents and three staff members were tested on Day 1 and Day 4, instead of the required Day 1, Day 3, and Day 5. The Director of Nursing (DON) and the RN Supervisor acknowledged the discrepancy in testing dates, and the RN Supervisor admitted to conducting tests on incorrect days due to a high volume of testing at the time. The facility's policy required testing on Day 1, Day 3, and Day 5, but this was not followed, leading to a failure in appropriate surveillance for COVID-19 during the outbreak. Additionally, the facility did not adhere to proper hand hygiene practices. A Certified Nursing Aide (CNA) was observed washing hands for only 11 seconds after an incontinence check, contrary to the facility's policy of at least 15 seconds. The CNA admitted to rushing and not following the protocol. Similarly, an LPN was observed washing hands for only 11 seconds after administering medications, and there was no garbage can in the resident's toilet room to dispose of used paper towels. The LPN acknowledged the short duration of handwashing and the absence of a garbage can. The facility also failed to follow appropriate storage of personal protective equipment (PPE). An LPN was observed taking a surgical mask from her uniform pocket before entering a resident's room, which the DON confirmed was inappropriate as it could lead to contamination. The DON stated that infection control education, including hand hygiene and PPE use, was a collaborative effort but acknowledged the lapses in adherence to the facility's protocols. The facility's policies on hand hygiene and PPE use were not consistently followed, contributing to the risk of infection transmission.
Failure to Document and Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and administration of influenza and pneumococcal vaccinations for several residents. For Resident #7, there was no documentation in the hybrid medical records indicating the administration or refusal of the influenza vaccine for the 2023/2024 season. The Director of Nursing (DON) was unable to provide further information, and a declination form was later found in a separate binder, not in the resident's paper chart or electronic medical record (EMR). Similar issues were observed for Residents #132, #149, and #214, where there was no documentation of the influenza vaccine being administered or declined for the current season, despite their severe cognitive impairments and the presence of resident representatives responsible for their care planning. The facility's policies on immunization documentation were not followed, as confirmed by the DON and the MDS Coordinator/Registered Nurse (MDSC/RN) during interviews with the surveyor team. Additionally, the facility failed to ensure the administration of the pneumococcal vaccine for Residents #100 and #127. During a medication storage and labeling observation, pneumococcal syringes labeled for these residents were found, but there was no documentation in their medical records indicating the administration or refusal of the vaccine. The DON acknowledged that the nurse responsible for placing the order should have obtained the informed consent or refusal form from the residents. The facility's policies on immunization documentation were not adhered to, as evidenced by the lack of informed consent/refusal forms in the residents' physical charts. The surveyor team discussed these concerns with the DON and the Licensed Nursing Home Administrator (LNHA), but no additional information was provided to address the deficiencies. The facility's failure to document and administer influenza and pneumococcal vaccinations as per their policies and CDC guidelines resulted in multiple deficiencies in resident care.
Failure to Serve Lunch Trays Timely
Penalty
Summary
The facility failed to serve all residents seated at a table their lunch trays in a timely manner for one of five tables observed, involving a total of four residents. On 1/31/24, the surveyor observed the 4 East dining area during lunch, where three CNAs and one nurse were present with 18 residents. At Table two, only one resident received their lunch tray while the other three residents had not been served. The delay in serving the lunch trays to the remaining residents at Table two was noted, with the last resident receiving their tray at 12:27 PM, 16 minutes after the first resident at the table had started eating. Interviews with the CNAs present during the observation revealed that they could not explain why the residents at Table two were not served simultaneously. The facility's Meal Service Policy, provided later, did not include procedures for serving residents in the dining room. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were informed of the observations and concerns, but no additional information or explanation was provided regarding the issue.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was offered the opportunity to formulate an Advance Directive (AD). This deficiency was identified for a resident with severe cognitive impairment, who was admitted with multiple medical diagnoses including Dementia, Hypertension, Type II Diabetes Mellitus, and Anxiety Disorder. The resident's medical records indicated a Full code status, but there was no documentation showing that the resident's end-of-life wishes had been discussed with the responsible party. The facility's social worker confirmed that the topic of AD had not been discussed with the resident's responsible party, despite the resident's inability to make decisions due to cognitive impairment. The facility's policy stated that if a resident is incapacitated, information about the right to formulate an AD should be provided to the resident's legal representative. However, this policy was not followed in the case of the resident in question. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) acknowledged the issue but did not provide further information. The surveyor noted that the facility defaulted to a Full code status if no AD or POLST form was indicated upon admission, which contributed to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required by federal and state regulations. The deficiency was identified for a resident who was observed with a bump and discoloration on the left side of their face. The resident had a history of falls and severely impaired cognition, making it difficult for them to explain the source of the injury. The injury was first noted by a nurse who observed the resident with a hematoma that was not present the previous day. Despite the resident's confusion and inconsistent explanations about the injury, the facility did not classify it as an injury of unknown origin and failed to report it to the NJDOH. The Director of Nursing (DON) and other staff members provided conflicting accounts of the incident. The DON believed the injury was caused by the resident hitting their head on the side rail, based on statements from staff and the resident's own inconsistent explanations. However, there was no documentation or witness to confirm this. The facility's incident report and investigation did not include all relevant information, such as a physician's progress note that was faxed to the facility after the initial investigation. The DON did not consider the injury to be of unknown origin and therefore did not report it to the NJDOH. The facility's policies on incident reporting and resident rights were not followed correctly. The policies required that all injuries of unknown origin be reported immediately, but the DON and other staff members did not adhere to this requirement. The DON's interpretation of the incident and the lack of proper documentation and communication among staff led to the failure to report the injury as required. The facility did not provide any additional information to justify their actions, and the survey team identified this as a deficiency in the facility's compliance with reporting requirements.
Failure to Complete Thorough Investigation of Fall Incident
Penalty
Summary
The facility failed to complete a thorough investigation of a fall incident involving a resident with multiple medical conditions, including dysphagia, heart failure, and chronic kidney disease. The resident, who was severely impaired in cognitive skills, was found on the floor by a CNA during morning care. The initial progress notes documented that the resident was assessed for injuries, none were noted, and the responsible party and physician were notified. However, there was no documentation on the cause of the fall or interventions to prevent recurrence, and no Fall Risk Assessment was completed at the time of the incident. The care plan interventions were not updated promptly, with significant delays and discrepancies noted in the documentation. The DON provided an investigation report that included additional information not present in the initial report provided by the MDS Coordinator. The investigation was not completed within the facility's stated timeframe of one week, and there were no documented statements from the CNA who found the resident. The DON admitted to editing the information recently, which did not reflect in the initial investigation report. During interviews, the DON confirmed the delays in completing the investigation and acknowledged that the interventions to prevent recurrence should have been documented in the care plan. The surveyor noted discrepancies between the reports provided by the DON and the MDS Coordinator, and the facility management did not provide the facility's fall policy when requested. The surveyor's attempts to contact the CNA for further information were unsuccessful.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their medical records. For Resident #77, the MDS assessment incorrectly reflected the influenza vaccine date as 10/14/22, which was not updated for the 2023 influenza season. The MDS Coordinator/Registered Nurse (MDSC/RN) admitted that the dates auto-populated from the electronic medical record and were not verified for accuracy. Similarly, Resident #242's MDS assessment incorrectly indicated that the resident did not receive the influenza vaccine for the current season, despite medical records showing the vaccine was administered on 11/28/23. The MDSC/RN acknowledged this as a coding error. For Resident #145, the MDS assessment failed to document the use of oxygen therapy, despite the resident being observed with a nasal cannula and a physician's order for oxygen therapy at 2 liters per minute. The MDSC/RN confirmed that this was a data entry error after reviewing the resident's medical records. These inaccuracies were identified through observations, interviews, and record reviews conducted by the surveyor, and were discussed with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), who did not provide additional information.
Medication Administration and Wander Guard Deficiencies
Penalty
Summary
The facility failed to ensure that medication was administered in accordance with manufacturer's cautionary specifications and professional standards of clinical practice. During a medication administration observation, an LPN administered budesonide and formoterol fumarate combination aerosol to a resident without instructing the resident to rinse their mouth afterward, as indicated by the cautionary label on the medication box. The LPN acknowledged the mistake and admitted that the sequencing of the medication administration was not in accordance with professional standards. The resident had a history of type II diabetes, hypertension, and paranoid schizophrenia, and their cognition was intact as indicated by a BIMS score of 15 out of 15. The facility also failed to ensure that care and services were followed for a resident at risk for wandering. The resident was observed with a wander guard bracelet, but a review of the Treatment Administration Record (TAR) revealed that the placement of the wander guard was not checked on ten different shifts in January 2024. The DON confirmed that the TAR had blanks and that the placement should have been checked every shift. Additionally, the resident's Wandering Risk Assessment form was found to be incomplete and inconsistent with the resident's diagnosis of dementia and the use of a wander guard bracelet. The facility's policies on administering medications and elopement did not include specific instructions regarding the issues observed. The DON and LNHA were made aware of the concerns, but no additional information was provided to address the deficiencies. The facility's failure to follow professional standards and ensure proper care for residents at risk for wandering was evident in the observations and documentation reviewed by the surveyors.
Failure to Adhere to Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to provide wound care in accordance with its policy and professional standards of clinical practice for a resident observed for wound care. During the wound treatment observation, the Wound Care Registered Nurse (WCRN) did not perform hand hygiene on 12 of 17 opportunities. This included instances such as not washing hands after removing gloves, not performing hand hygiene before donning new gloves, and handling wound care supplies with bare hands. The WCRN also failed to follow proper hand hygiene protocols when moving from a soiled body site to a clean body site on the same patient and when handling the resident's environment and supplies. The resident involved had a diagnosis of type 2 diabetes mellitus and chronic obstructive pulmonary disease, and was at risk for pressure ulcer development due to immobility and comorbidities. The resident's care plan included specific wound care orders for the left heel, which were not followed correctly by the WCRN. The WCRN admitted to not realizing the missed hand hygiene opportunities and acknowledged that hand sanitizer could have been used more appropriately during the wound care process. The facility's handwashing policy and wound care policy both emphasize the importance of hand hygiene in preventing the transmission of infections. The Director of Nursing (DON) confirmed the necessity of handwashing during wound care to protect against infection. Despite these policies, the WCRN did not adhere to the required hand hygiene practices, leading to the observed deficiency.
Failure to Monitor and Document Urinary Output for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that the urinary output of residents with indwelling catheters (IC) was monitored to ensure patency and prevent infections. This deficiency was observed in two residents. Resident #242, who had severe cognitive impairment and multiple diagnoses including cerebral infarction and type II diabetes mellitus, was transferred to the hospital due to stomach pain and inability to urinate. Upon return, the resident had a new IC, but there were no physician orders to monitor urinary output, and no documentation of urinary output was found in the electronic Medication Administration Record (eMAR) for January and February 2024. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) confirmed that urinary output should be documented every shift, but this was not done for Resident #242, contrary to the facility's policy and procedure for emptying urinary collection bags and documenting the amount of urine emptied from the drainage bag in the resident's medical record. Resident #266, who had intact cognition and diagnoses including urinary tract infection and benign prostatic hyperplasia, was observed with a catheter draining clear yellow urine. The resident's active physician orders did not include monitoring urinary output, and there was no documentation of urinary output in the January 2024 eMAR and electronic Treatment Administration Record (eTAR). Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) indicated that urinary output was previously documented in the computer system but was now recorded in an Activities of Daily Living (ADL) binder, which did not include any amounts of urine output for Resident #266. The DON acknowledged that the facility did not document urinary output but stated that for quality improvement, it should be done. The surveyor discussed these concerns with the facility's Licensed Nursing Home Administrator (LNHA) and DON, who did not provide any additional information. The facility's failure to monitor and document urinary output for residents with indwelling catheters was identified as a deficiency, as it did not comply with the facility's policy and procedure and could potentially lead to undetected issues with catheter patency and increased risk of infections.
Failure to Ensure Proper Certification and Training of Nurse Aides
Penalty
Summary
The facility failed to ensure that a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days. This was identified for one of three NAs reviewed during the Sufficient and Competent Nurse Staffing task. The facility also lacked a delineated policy and/or program for the hiring, staffing, and assignments of non-certified NAs. The deficiency was evidenced by the fact that NA #1, who was hired on 9/15/23, had been working for more than 120 days without proper certification. Despite passing the written exam, there was no verification that NA #1 was licensed or enrolled in a training program during their employment. The surveyor's investigation revealed that the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were unable to provide a complete list of CNAs with their license numbers. The Staffing Coordinator (SC) admitted that the schedule did not differentiate between certified and non-certified NAs, and the Human Resources Clerk (HRC) was unaware of any non-certified NAs working at the facility. The Director of Activities (DoA) and the Human Resources Manager (HRM) both believed that NAs could work for up to a year as long as they were enrolled in a training program and had passed the skills test, which was incorrect according to state regulations. Further interviews with the LNHA, DON, and NA #1 confirmed that there was a misunderstanding regarding the certification requirements. NA #1 had been working at the facility for eight months since passing the written exam but had not received a license. The facility did not have a policy regarding the employment of non-certified NAs, and the LNHA incorrectly believed that NAs could work for a year under the supervision of a Registered Nurse. The facility's failure to ensure proper certification and training of NAs led to this deficiency.
Failure to Post 24-Hour Staffing Report
Penalty
Summary
The facility failed to ensure that the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) was posted in a prominent place within the facility and readily accessible to residents and visitors. On two consecutive days, the survey team observed that the NHRCSR was not posted at the entrance area or elevator area. Interviews with the Security staff and the Staffing Coordinator confirmed that the report was not posted on these days. The Staffing Coordinator admitted that she did not post the report because she was running late, and the Licensed Nursing Home Administrator (LNHA) acknowledged that the usual posting location was not readily visible. The surveyor discussed the issue with the LNHA and the Director of Nursing (DON), who explained that the person responsible for posting the report had a medical emergency and came in late on the days in question. The facility did not have a policy on posting staffing information, and no additional information was provided by the facility. This deficiency was noted as a failure to comply with N.J.A.C. 8:39-41.2 (a)(b)(c).
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by several deficiencies in medication labeling, storage, and administration. During an inspection of a medication cart, an open and undated multiple-dose vial of Lantus was found, which should have been dated once removed from the refrigerator. Additionally, an expired bottle of Omeprazole was found in the medication room, and it was administered to a resident despite being past its use-by date. The pharmacist confirmed that the compounded Omeprazole had a shelf life of 14 days, but the bottle had a beyond-use date of 21 days, leading to its improper use beyond the recommended period. Further deficiencies were observed in the storage and labeling of medications. Two Pneumococcal syringes were found in the medication room, labeled for specific residents but not administered or documented as refused. Additionally, a box of Ipratropium/Albuterol nebules for inhalation was found on a medication cart, despite being discontinued and not included in the active electronic administration record. The facility's policy required that expired and discontinued medications be removed from active inventory, but this was not adhered to. Interviews with nursing staff revealed that they were aware of the requirements for medication labeling and expiration checks but failed to consistently follow these protocols. The Director of Nursing and the Licensed Nursing Home Administrator were informed of these concerns, highlighting the facility's failure to label opened biologicals, remove expired and discontinued medications from active inventory, and ensure proper medication administration practices. The facility's policies on drug storage, labeling, and administration were reviewed, indicating that these deficiencies were in violation of established guidelines.
Failure to Maintain Sanitary Garbage Disposal Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the garbage compactor and dumpster area free of garbage and debris. During a tour of the kitchen and designated garbage area, the surveyor observed garbage debris, including food, cups, bottles, gloves, paper products, and brown paper bags, surrounding the garbage compactor and dumpster. The Food Service Director (FSD) acknowledged that the area should have been cleaned by the maintenance and dietary departments. The Licensed Nursing Home Administrator (LNHA) admitted that the facility maintenance department is responsible for keeping the area clean and free of debris. The facility policy, revised in December 2008, states that outside dumpsters should be kept closed and free of surrounding litter, which was not adhered to in this instance.
Failure to Ensure Timely Physician Visits and Address Nutritional Issues
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits at least once every sixty days and wrote progress notes to address nutritional issues for a resident with weight loss. Resident #77, who had medical diagnoses including dementia, hypertension, type II diabetes mellitus, and anxiety disorder, was observed lying in bed with eyes closed. The resident's medical records indicated a significant weight loss of 5.2% over the past month, as documented by the facility's dietician on 01/16/24. The dietician stated that she would refer any resident with weight loss to the primary physician. However, a review of the interdisciplinary progress notes revealed that the most recent physician visit to Resident #77 was on 11/19/23, and there was no additional documentation that the resident was seen and examined by the primary physician since then. The Licensed Nursing Home Administrator and Director of Nursing were informed of these concerns, but no further information was provided. The surveyor attempted to contact the physician but was unavailable for an interview.
Deficiency in Maintaining Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficiency was identified for one resident complaint and confirmed during the lunchtime meal service for one of three nursing units tested for food temperatures. During the initial tour, a resident expressed dissatisfaction with the food quality. Observations revealed that the lunch had not arrived on time for the residents seated in the main dining area. The meal trucks arrived late, and the process of passing out the meal trays took an extended period, causing the food to lose its temperature. The surveyor observed that the food temperatures were below the recommended levels for hot and cold foods. Further investigation showed that the kitchen equipment was functioning adequately, and the food items were within normal temperature limits before leaving the kitchen. However, the delay in delivering the meal trays resulted in the food cooling down. The facility's policies on food quality and meal distribution were reviewed, and it was noted that the policies lacked creation or revision dates. The policies stated that food should be palatable, attractive, and served at a safe and appetizing temperature, and that meals should be transported and delivered in a timely manner to maintain proper temperatures. The Licensed Nursing Home Administrator acknowledged the issue and stated that the facility is exploring options to improve the timeliness of meal delivery.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for two residents. For one resident, the surveyor found that the Certified Nurse Assistants (CNAs) were documenting Activities of Daily Living (ADL) care on paper forms instead of electronically. However, the facility could not provide any CNA documentation of ADL care for the resident, despite multiple requests and searches by the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). This lack of documentation included important aspects of care such as incontinence and hygiene care, which were not available in either the electronic or paper medical records of the resident. For another resident, the surveyor discovered that there was no physician discharge summary in the medical records after the resident was discharged against medical advice (AMA). The DON confirmed that the discharge summary should have been in the hard medical chart but was not present. The facility's policy on transfer and discharge, which was provided later, indicated that a physician should document the discharge summary. Despite the surveyor's inquiries, the discharge summary was only faxed to the facility after the surveyor's request, raising concerns about the timeliness and accuracy of the documentation. The survey team met with the facility management multiple times to discuss these concerns, but the facility was unable to provide satisfactory explanations or the missing documentation. The lack of proper documentation for both residents indicates a failure to maintain complete and accessible medical records, which is a critical aspect of resident care and regulatory compliance.
Failure to Notify LTCO of Resident Transfer
Penalty
Summary
The facility failed to provide written notification of the emergency transfer to the Office of the Long-Term Care Ombudsman (LTCO) for one resident who was hospitalized. The resident, who had multiple diagnoses including dysphagia, heart failure, chronic kidney disease, bipolar disorder, and anxiety disorder, was transferred to the hospital due to vaginal bleeding. The review of the medical records and the New Jersey Universal Transfer Form confirmed the transfer, but there was no corresponding notification to the LTCO as required by regulations. The Nursing Clerk, responsible for LTCO notifications, confirmed that the notification for this transfer was not submitted and speculated that it might have been missed by the previous Director of Nursing (DON) during the review process. The facility did not have a specific policy for LTCO notifications and followed a monthly submission process, which contributed to the oversight. During the survey, the Nursing Clerk explained the process of LTCO notification, which involved checking electronic medical records, listing residents transferred to the hospital, and preparing a draft report for the DON's review. The DON would then verify the information before the final submission to the LTCO. However, the notification for the resident transferred on 4/19/23 was not found in the provided binder, and the Nursing Clerk could not explain the omission. The Licensed Nursing Home Administrator (LNHA) confirmed the absence of a facility policy regarding LTCO notifications and acknowledged the deficiency. The survey team discussed the concern with the facility management, who confirmed that no additional information was available to address the issue.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive Antibiotic Stewardship Program (ASP) as per their policy and national standards. The Director of Nursing (DON) acknowledged that the newly hired Infection Preventionist (IP) was still in training, and the facility was relying on the previous IP's reports and documentation. However, the documentation provided was incomplete and lacked essential details such as diagnostic testing, type of organism identified, and signs/symptoms of the residents. The facility's policy required a standardized assessment form and comprehensive tracking measures, which were not in place at the time of the survey. The surveyor's interviews with the DON, the former IP, and the Licensed Nursing Home Administrator (LNHA) revealed that infection control was discussed in QAPI meetings, but there was no consistent documentation of feedback reports, trend reports, or surveillance. The provided documentation, including an untitled and undated ABT tracking document and an email summary for the 3rd quarter QAPI for infection control review, lacked detailed information on the specific antibiotics prescribed, diagnoses, and microorganisms of infection identified. The facility's policy outlined the need for regular review of infections, monitoring of antibiotic usage patterns, and reporting on antibiotic resistance patterns, which were not adequately followed. The deficiency was further evidenced by the lack of a standardized assessment form for antibiotic use assessment and the absence of comprehensive documentation for recent antibiotic stewardship activities. The facility's policy required the ASP team to review infections, monitor antibiotic usage patterns, and report on the number of antibiotics prescribed and residents treated each month. However, the facility failed to provide sufficient documentation to demonstrate compliance with these requirements, leading to the identified deficiency in their antibiotic stewardship program.
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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