Peace Care St Joseph's
Inspection history, citations, penalties and survey trends for this long-term care facility in Jersey City, New Jersey.
- Location
- 537 Pavonia Avenue, Jersey City, New Jersey 07306
- CMS Provider Number
- 315452
- Inspections on file
- 16
- Latest survey
- November 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Peace Care St Joseph's during CMS and state inspections, most recent first.
The facility failed to maintain proper pharmaceutical services, with deficiencies in DEA Form-222 record-keeping, lack of policies for controlled substances, and improper medication storage. Missing and incomplete forms, unremoved medications of a discharged resident, and undated blood glucose test strips were observed, highlighting issues in tracking and accountability.
The facility did not ensure the Infection Preventionist attended the required quarterly QA meetings, as evidenced by sign-in sheets showing the IP's absence from four meetings. The Administrator could not explain the absence, despite policies requiring the IP's participation.
The facility failed to maintain infection control standards during wound care for two residents with pressure ulcers. An RN and an LPN did not adhere to proper hand hygiene and wound care procedures, leading to potential contamination. Additionally, personal care items were shared between residents, and a linen cart was improperly used, compromising the sanitary environment. CNA #2 also failed to perform proper hand hygiene.
The facility failed to offer updated pneumococcal vaccinations to residents according to CDC and ACIP guidelines. A resident with heart failure and COPD, another with colon cancer and COPD, and a third with severe cognitive impairment were not documented as having been offered the updated vaccine, despite having received previous vaccinations. The facility's policy to offer immunizations per CDC guidelines was not followed, as confirmed by the RN/IP and DON.
The facility failed to provide timely incontinence care to three residents on the 4th floor unit. A resident was found with two saturated briefs, another with a saturated brief due to lack of two-hourly care, and a third with a wet brief and bladder pad. All three residents had cognitive impairments and required assistance, yet lacked care plans for incontinence. The DON confirmed the need for two-hourly rounds and proper use of briefs and pads.
A resident with Alzheimer's and a stage 3 pressure ulcer was observed receiving oxygen therapy at 4 LPM, contrary to the physician's order of 2 LPM. The LPN and DON confirmed the discrepancy, acknowledging the failure to adhere to the physician's order.
The facility failed to meet the required CNA staffing ratios on several day shifts, as mandated by New Jersey state law. Additionally, a resident was found to have not received timely incontinence care, with a CNA confirming the lapse in care. The DON stated that incontinence care should be provided every two hours, highlighting a deficiency in the standard of care.
A facility failed to accurately relay medication orders for a newly admitted resident, resulting in the administration of six discontinued medications. The resident, with intact cognition, refused the medications, stating they were not ordered. Facility staff interviews revealed a lack of communication with the AP, who was unaware of the discontinued medications. The facility's policy required resolving medication discrepancies on the day of admission, which was not followed.
A facility failed to maintain an accurate and complete list of a resident's discharged medical records, missing crucial medication instructions. The resident had multiple diagnoses, and the hospital's After Visit Summary was incomplete, leading to unawareness of six discontinued medications. The facility's policy on maintaining accurate medication information was not effectively implemented.
Deficiencies in Pharmaceutical Services and Record-Keeping
Penalty
Summary
The facility failed to maintain proper pharmaceutical services, as evidenced by several deficiencies related to the handling and documentation of controlled substances. The surveyor found inconsistencies in the record-keeping of DEA Form-222, which is crucial for the accurate reconciliation of narcotic medications. Specifically, several forms were missing, had incorrect addresses, or were not properly completed, with missing information such as the number of packages received and the date received. These discrepancies were identified during a review of the facility's records and were acknowledged by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). Additionally, the facility lacked a comprehensive policy and procedure for handling controlled substances, including the DEA Form-222. The DON admitted that there were no existing policies to address the discrepancies found, nor were there procedures for the accurate ordering, receiving, and administration of narcotic medications. This lack of policy contributed to the facility's inability to ensure proper tracking and accountability of narcotic medications. The surveyor also observed issues with medication storage and labeling. In one instance, medications belonging to a discharged resident were not removed from active inventory, posing a risk for medication administration errors. Furthermore, an opened bottle of blood glucose test strips was found undated, contrary to the manufacturer's instructions, which require dating upon opening to ensure proper usage within the specified timeframe. These observations were confirmed by the nursing staff and acknowledged by the DON.
Infection Preventionist Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the required staff attended the quarterly Quality Assurance (QA) meetings, specifically the Infection Preventionist (IP), who was absent from all four reviewed meetings. The surveyor, upon entrance, requested the QA meeting sign-in sheets and found that the IP did not attend the meetings held on 10/17/24, 7/18/24, 4/18/24, and 1/18/24. During an interview, the Administrator could not provide a reason for the IP's absence, stating that the IP would attend if present in the building. The facility's policies, reviewed by the surveyor, indicated that the IP is required to participate in the QA committee, highlighting a failure to adhere to these policies.
Infection Control Deficiencies in Wound Care and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper infection control standards during wound care treatments for two residents with pressure ulcers. For Resident #181, the RN did not adhere to the correct hand hygiene protocol, washing hands for only 10 seconds instead of the required 20 seconds, and turning off the faucet with bare hands. During the wound care procedure, the RN contaminated the wound by wiping from the wound bed back into the peri-wound area and used soiled gloves to handle clean supplies, including placing a contaminated gauze pad into the wound bed. For Resident #6, the LPN also failed to follow proper wound care procedures. The LPN used the same gloves to handle both clean and contaminated supplies, and improperly cleansed the wound by wiping from the peri-wound area back into the wound bed. Additionally, the LPN did not apply Periguard to the peri-wound before covering it with a bordered dressing and returned contaminated supplies to the treatment cart instead of discarding them. The facility also failed to provide a safe and sanitary environment by allowing the sharing of personal care items between residents and bringing a linen cart into a resident's room, which was then returned to the hallway. CNA #1 acknowledged the error in sharing personal care items and bringing the entire linen cart into the room. Furthermore, CNA #2 did not perform proper hand hygiene by failing to lather hands for 20 seconds outside the stream of water, as required by the facility's policy.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered to residents according to the current CDC and ACIP recommendations. This deficiency was identified during a survey where three out of five residents reviewed for immunization status were not offered the pneumococcal vaccine as per the updated guidelines. The Registered Nurse/Infection Preventionist acknowledged awareness of the new guidelines but confirmed that the facility had not offered the newest pneumococcal vaccine to residents who had previously received the vaccine. Resident #23, who was diagnosed with type 2 diabetes, heart failure, and chronic obstructive pulmonary disease, was observed to have an intact cognitive status with a BIMS score of 15 out of 15. Despite having received the Pneumovax vaccine in 2022, there was no documentation in the resident's medical records indicating that the updated pneumococcal vaccine was offered or declined, nor was there evidence of education provided in 2023. Similarly, Resident #36, with diagnoses including colon cancer and chronic obstructive pulmonary disease, also had a BIMS score of 15 out of 15. This resident received the Pneumovax vaccine in 2021, but again, there was no documentation of the updated vaccine being offered or declined, or any educational efforts in 2023. Resident #83, who had severe cognitive impairment with a BIMS score of 6 out of 15, was also not documented as having been offered the updated vaccine, despite having received the Pneumovax vaccine in 2022. The facility's policy stated that immunizations should be offered in accordance with CDC guidelines, but this was not adhered to, as confirmed by the Director of Nursing and the Licensed Nursing Home Administrator.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to three residents on the 4th floor unit, as observed by the surveyor. Resident #22 was found with two saturated incontinence briefs, which CNA #1 attributed to the night CNA's practice of double-diapering, a practice acknowledged as incorrect by CNA #1. Resident #22 had severe cognitive impairment and required extensive assistance for personal hygiene, yet there were no care plans addressing bowel and bladder incontinence. Similarly, Resident #109, who also had severe cognitive impairment and required maximum assistance, was found with a saturated brief, and CNA #1 admitted to not providing the necessary two-hourly incontinence care due to being too busy. Resident #87, with moderate cognitive impairment, was found with a wet incontinence brief and an inserted bladder pad, which CNA #2 stated was placed by the night CNA. Resident #87 expressed a desire to be changed and washed, indicating a lack of care throughout the morning. The Director of Nursing confirmed that incontinence rounds should occur every two hours and that residents should not have two briefs or bladder pads unless requested. None of the three residents had care plans addressing their incontinence needs, despite their conditions requiring such care.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident. The resident, who was admitted with diagnoses including Alzheimer's disease, a stage 3 pressure ulcer, and gastrostomy status, was observed receiving oxygen therapy at a rate of 4 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 2 LPM. This discrepancy was noted during observations on two separate occasions, where the resident was found in bed with the oxygen concentrator set at 4 LPM. The Licensed Practical Nurse (LPN) confirmed the incorrect oxygen setting and acknowledged that the physician's order should have been followed. The Director of Nursing (DON) also confirmed that the physician's order for oxygen administration was not adhered to. The facility's policy on oxygen therapy specifies that oxygen should be administered only as ordered by a physician, with the rate of oxygen flow specified in the order.
Deficient Staffing Ratios and Resident Care Lapses
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. Specifically, the facility was deficient in Certified Nurse Aide (CNA) staffing for residents on four out of fourteen day shifts during the two-week period from October 13, 2024, to October 26, 2024. On these days, the number of CNAs on duty was insufficient to meet the state-mandated ratio of one CNA to every eight residents for the day shift. This staffing shortfall was documented in the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports (AAS-11 and AAS-12). Additionally, the surveyor observed a specific incident involving a resident who had not received necessary care. On November 4, 2024, a resident reported not being changed or bathed all morning. The CNA responsible for the resident confirmed that she had not yet provided care to the resident, who was found with a wet incontinence brief and a bladder pad inserted by the night CNA. The Director of Nursing stated that incontinence care should be provided every two hours, indicating a lapse in the standard of care expected. The surveyor informed the facility administration of these staffing ratio concerns, but no further information was provided by the facility.
Failure to Accurately Relay Medication Orders for New Admission
Penalty
Summary
The facility failed to ensure that medication orders for a newly admitted resident from the hospital were completely and accurately relayed to the Attending Physician (AP). Upon admission, there were six medications that had been discontinued by the hospital, but this information was not clarified with the AP for continuance. This oversight was identified during a review of admission orders for one of three newly admitted residents. The resident in question had a range of diagnoses, including Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. The resident's After Visit Summary (AVS) from the hospital indicated changes in medication, including the discontinuation of six specific drugs. However, these changes were not reflected in the facility's Order Recap Report (ORR) or the Medication Administration Record (MAR), which showed that the discontinued medications were still being administered. The resident, who had an intact cognitive status as per the Minimum Data Set (MDS), refused the medications, stating they were not ordered. Despite this, the facility's records showed that the medications were administered on multiple occasions. Interviews with facility staff revealed a lack of communication and verification of the medication list with the AP. The Licensed Nursing Home Administrator (LNHA) and a House Supervisor Registered Nurse (RN) acknowledged that the facility's procedure was to follow the hospital's medication list and confirm it with the AP. However, the AP was not aware of the discontinued medications and typically did not see the patient until two days post-admission. The facility's policy required discrepancies in medication orders to be resolved by consulting the resident's physician on the day of admission, which was not adhered to in this case.
Incomplete Medical Records for New Admission
Penalty
Summary
The facility failed to maintain an accurate and complete list of a resident's discharged medical records from the hospital, which included crucial medication discharge instructions. This deficiency was identified in one of the three residents reviewed for admission orders. The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis. The Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact. However, the After Visit Summary (AVS) from the hospital, which should have contained detailed discharge instructions, was incomplete, missing pages 4 through 7. This incomplete documentation led to a lack of awareness regarding the discontinuation of six medications for the resident. During an interview, the House Supervisor RN stated that the facility follows the medication list from the hospital for newly admitted residents and that the nurse responsible for the admission would review the medication list with the physician. However, the RN was unaware of the six medications that were discontinued at the hospital and could not provide an explanation for the missing pages in the AVS. The facility's policy on new admissions emphasizes maintaining and communicating accurate resident medication information, but in this case, the policy was not effectively implemented, resulting in the deficiency.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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