Plaza Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabeth, New Jersey.
- Location
- 456 Rahway Avenue, Elizabeth, New Jersey 07202
- CMS Provider Number
- 315483
- Inspections on file
- 12
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Plaza Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Laundry staff handled soiled and clean linens without appropriate PPE, such as gowns or aprons, and demonstrated confusion about proper procedures for handling isolation and regular laundry bags. Facility policies required the use of gloves and gowns when handling soiled linens, but these practices were not followed or understood by staff.
The facility did not include a plan in its emergency preparedness policy for maintaining generator power and fuel during emergencies. Staff confirmed there was no documented procedure for ensuring emergency power systems would remain operational or for supplying power if the generator failed, as required by federal regulations and referenced standards.
The facility did not meet the required CNA-to-resident staffing ratio for one day shift, providing only 10 CNAs for 87 residents when at least 11 were required. This deficiency was identified through staffing records and confirmed during an interview with the Staffing Coordinator, who stated she was aware of the staffing requirements.
The facility did not ensure that new employees, including RNs, LPNs, and CNAs, received required health examinations by a physician, APN, or PA within the mandated timeframe, as shown by missing or incomplete documentation in 6 out of 10 newly hired staff files. The DON confirmed the lack of proper records and could not provide additional information to demonstrate compliance.
The facility failed to monitor and maintain bed side rails, resulting in a loose and leaning side rail for a resident with severely impaired cognition. The Maintenance Supervisor did not conduct regular bed checks or document side rail inspections, and the facility's policy did not address the risk of entrapment.
The facility failed to update a resident's PASARR level one screening upon receipt of new serious mental health diagnoses. The resident had additional diagnoses added over time, but the PASARR screening was not resubmitted or updated, placing the resident at risk for unmet care needs and not receiving appropriate mental health support.
The facility failed to develop comprehensive care plans for three residents reviewed for side rail use and one resident reviewed for limited range of motion. The care plans did not address the use of bed rails or document refusals to wear a hand splint, despite observations and staff confirmations.
The facility failed to document attempts of alternatives before using bed rails, complete quarterly and annual side rail assessments, and obtain informed consent from residents or their representatives. This deficiency involved three residents, leading to potential risks of injury or entrapment due to improper bed rail use.
The facility failed to inform the NJDOH of an abuse allegation within the mandated two-hour period. The incident involved two residents and occurred on a specific date. The investigation was delayed, and the report was faxed to the NJDOH beyond the required timeframe. Interviews indicated that the abuse protocol was initiated late, and the Administrator was not informed until the following Monday. The facility's policy mandates immediate reporting, but this was not followed, constituting a deficiency.
Failure to Ensure Proper PPE Use in Laundry Handling
Penalty
Summary
The facility failed to ensure that laundry staff had the proper personal protective equipment (PPE) necessary to handle linens in a manner that would prevent the spread of infection. During a survey, it was observed that laundry aides were emptying dryers and handling both clean and soiled linens without the use of gowns or aprons. When questioned, one laundry aide was unaware of any PPE requirements when handling dirty linens, and no gowns or aprons were observed in the laundry area. Another staff member, who was new to laundry and housekeeping, also did not know if PPE was required and attempted to look up the information online during the survey. Further interviews revealed inconsistencies in the use of laundry bags for soiled and isolation linens. While some staff described using water-soluble bags for isolation linens, others were observed using clear plastic bags that were not biodegradable for dirty laundry. There was confusion among staff regarding which bags should be used for isolation and whether PPE was necessary when handling soiled linens. Additionally, laundry aides were seen folding clean linens in a manner that allowed the linens to touch their clothing, and no PPE aprons were available in the area. A review of the facility's policies indicated that standard precautions, including the use of gloves and gowns when handling potentially infectious materials or soiled linens, were required. The policies also specified that soiled linen should be handled with gloved hands and an apron or gown, especially for residents on transmission-based precautions. Despite these written policies, the observed practices in the laundry area did not align with the facility's infection prevention and control program requirements.
Plan Of Correction
483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Element #1. The Policy on Linen Management was updated on 6/4/2025. The laundry room personnel and the [R] were immediately in-serviced by the Infection Preventionist/Director of Nursing on the updated Linen Management Policy, especially regarding PPE and apron/gown use while handling soiled linens. Laundry personnel also received instructions on PPE supplies, gowns, and aprons. These items are readily available in the washing machine area for use by laundry personnel by the Infection Preventionist and the housekeeping director. Element #2 All residents have the potential to be affected by these deficient infection control practices. Element #3. All housekeeping and laundry personnel and the [R] were in-serviced on 6/19/2025 and educated by the Infection Preventionist on laundry and linen handling, and use of PPE/gowns/aprons. A PPE sign-off log will be present for the laundry staff to sign off daily that they are using proper PPE for infection control purposes. Element #4. For three (3) months (from 6/6/25 till 9/6/25), the Housekeeping Director and Infection Preventionist will monitor linen handling (3) times weekly for (4) weeks, then weekly for (2) months, then monthly thereafter for laundry personnel's compliance with infection prevention over the next two quarters. The Infection Preventionist and Nursing Director or designee will review the results of these audits, including any actions taken for correction. All findings to be reported and discussed by the next two QAPI meetings.
Deficiency in Emergency Generator Fuel and Power Maintenance Planning
Penalty
Summary
The facility failed to ensure that its emergency preparedness policy included a plan for maintaining generator power and fuel during an emergency. During a record review, it was found that the Emergency Preparedness Policy did not reference any procedures or strategies for keeping the emergency power systems operational in the event of a power outage or other emergency situations. This omission was specifically noted in the documentation provided by the facility. At the time of the survey, an interview with facility staff confirmed that there was no plan in place to maintain fuel sources for the emergency generator during an emergency. Additionally, there was no documented plan for supplying power to the building if the generator failed to operate during such an event. This lack of planning was acknowledged by the staff member interviewed by the surveyor. The deficiency was communicated to the facility's leadership during the Life Safety Code exit conference. The absence of a comprehensive emergency power and fuel maintenance plan was identified as a failure to meet the requirements set forth by federal regulations and referenced standards, including NFPA 99 and NFPA 110.
Plan Of Correction
Element #1 On 6/6/2025 the Administrator and the Maintenance Director went to do an audit on the facility contract and reports with our vendor Powerhouse, which services our generator. In the binder of contracts, we found the contract dated 1/1/2025, stating clearly that Powerhouse will service our facility with fuel throughout the time the generator is on during an emergency and will replace it with a rental if the current generator malfunctions (see policy attached). Element #2 All residents have the potential to be affected by this deficient practice when life safety reports and contracts are not handy and not in the right binder. Element #3 The administrator in-serviced the US FOIA (b)(6) the same day 6/6/25 about the importance of having all reports and contracts related to lift safety, to be stored in the emergency preparedness binder and to check monthly contract and report from the Vendor Powerhouse who services the generator, that they are up to date with life safety compliance. In addition, the administrator in-serviced the maintenance director on the responsibility of having a contracted vendor service the generator throughout the emergency and having a backup generator in case it malfunctions. Element #4 The Administrator will monitor the Maintenance Director for three (3) months starting 6/9/2025-9/9/2025 weekly on having all life safety reports and contracts handy and placed in the Emergency preparedness binder for all life safety compliance. All findings will be reviewed and discussed in the next Quarterly QAPI committee meeting.
Failure to Meet Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for one out of fourteen day shifts reviewed. Specifically, on one day shift, there were only 10 Certified Nurse Aides (CNAs) present for 87 residents, whereas the required minimum was 11 CNAs. This deficiency was identified through a review of the facility's "Nursing Staffing Report" for the specified weeks. During an interview, the Staffing Coordinator stated she was familiar with the CNA staffing ratios and believed the facility was able to meet them. The facility's staffing policy, reviewed in January 2025, indicated that staffing assignments were developed in accordance with resident needs and relevant regulations. However, the documentation and staffing records reviewed by the surveyor demonstrated that the facility did not meet the mandated CNA-to-resident ratio for at least one shift.
Plan Of Correction
Element #1 The staffing coordinator was in-serviced on 6/20/2025 by the Administrator and Nursing Director; education provided included the importance of meeting the minimum staffing requirements and utilizing all possible avenues to proactively increase staffing in the facility. Element #2 All residents have the potential to be affected by this deficient practice when staffing regulations are not met. Element #3 The staffing coordinator continues to utilize all possible means to increase facility staff, including offering bonuses to staff that refer to CNAs. The staffing coordinator will review the scheduled monthly staffing; any shift not adequately staffed, the staffing coordinator will reach out to our contracted staffing agencies, who assure us they will make all efforts to supply the necessary staff. In addition, the staffing coordinator can offer part-time/per-diem employment to our sister facility's CNA that may be seeking additional working hours. Staffing Coordinator, Nursing Director, and Administrator have listed job opportunities/openings on Indeed and Apploi for hiring nursing staff. Element #4 The Administrator or designee will monitor daily staffing levels with the staffing coordinator for the next 4 months (6/20/2025-10/20/2025). Weekly for the first 4 weeks and after 4 weeks, bi-weekly for 12 weeks. All findings to be reported and discussed by the next two QAPI meetings.
Failure to Ensure Timely Employee Health Examinations for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees received a required health examination by a physician, advanced practice nurse, or New Jersey licensed physician assistant within two weeks prior to employment or upon employment, or within thirty days if a registered nurse assessment was completed upon hire. During a review of 10 randomly selected newly hired employee files, it was found that 6 did not have documentation of a completed physical examination as required by regulation. Specifically, one LPN had no pre-employment health screen or documentation of a physical, and other staff had only partial or incomplete health reports. Interviews with the Director of Nursing (DON) confirmed that the facility's process was to have new hires receive a physical 1 to 2 weeks prior to starting work, typically performed by the facility's medical director. Upon review of the files, the DON acknowledged the missing or incomplete documentation and was unable to provide additional information to demonstrate compliance. The facility's policy also required a health review and physical examination for all new employees, but the records reviewed did not consistently meet these requirements.
Plan Of Correction
Element #1. On 6/5/2025 The facility Human Resource Manager (HR), Administrator and Director of Nursing began an audit on all new hire within the last (1) year to schedule date for each new hire to complete a Register Nurse (RN) assessment or physical examination. The Facility Administrator in-serviced on 6/6/2025 the director of nursing to follow the facilitys policy on completing an Registered Nurse assessment upon prior to hire date and schedule health physician exam with the facilitys medical director for all new employees in the required time frame. Element #2. All residents have the potential to be affected by this deficient practice by not completing registered nursing assessment or physician assessment within the required time frame. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting.
Failure to Monitor and Maintain Bed Side Rails
Penalty
Summary
The facility failed to have an ongoing monitoring of bed side rails as part of their routine maintenance program for one resident and 86 of 87 occupied beds reviewed for side rails. Resident 71, who had severely impaired cognition and was dependent on mobility, was observed with a loose and leaning side rail that created a hand-size gap between the mattress and the rail. The Maintenance Supervisor confirmed that bed checks were not conducted regularly, and side rail inspections were not documented. The side rail was tightened only after the issue was pointed out by the surveyor. The facility's maintenance log for January 2024 did not include entries for bed rail maintenance, and the Maintenance Supervisor admitted to not checking for gaps between the side rail and mattress. The facility's policy on the use of side rails did not address the risk of entrapment, and the Administrator could not provide a bed maintenance/inspection policy. The facility's failure to properly monitor and maintain bed side rails was evident in the condition of Resident 71's bed and the lack of documented inspections. Additionally, the facility's review of a resident roster revealed that 86 of 87 occupied beds had side rails in use, yet there was no evidence of a systematic approach to ensure their safety. The facility's policy on side rails emphasized avoiding their use as physical restraints but did not include measures to prevent entrapment. The lack of proper maintenance and monitoring of bed side rails posed a significant risk to residents' safety, as demonstrated by the observations and interviews conducted during the survey.
Failure to Update PASARR Level One Screening
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASARR) level one was updated upon receipt of new serious mental health diagnoses. Specifically, one resident, who was admitted with diagnoses of bipolar disorder and acquired absence of limb, had additional diagnoses of insomnia, bipolar disorder in partial remission, unspecified psychosis, and schizoaffective disorder depressive type added over time. However, the PASARR level one screening completed prior to admission did not identify any serious mental health diagnoses, and it was not resubmitted or updated to reflect the new diagnoses after admission. During interviews, both the Administrator and the Social Services Director acknowledged that the PASARR level one should have been resubmitted with the updated diagnoses. The facility's policy on PASARR did not address the procedure for correcting an incorrect admission screening or resubmitting the screening if a serious mental health diagnosis was received after admission. This oversight placed the resident at risk for unmet care needs and not receiving appropriate and necessary mental health support and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with goals and approaches for three residents reviewed for side rail use and one resident reviewed for limited range of motion. For Resident 32, the care plan did not address the use of bed rails despite the resident being totally dependent on staff for bed mobility and having bilateral full quarter upper rails in the up position during multiple observations. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 33, who was cognitively intact and required staff supervision for bed mobility, also had bilateral upper full quarter bed rails that were not addressed in the care plan. The resident was not advised of the risks and benefits of side rails. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 71, who had severe cognitive impairment and limited range of motion, had side rails included only as an intervention and not as a full care plan with goals and objectives. Additionally, the resident's refusal to wear a hand splint was not documented in the care plan, despite observations and staff interviews confirming the refusals. The MDS Coordinator and Director of Nursing confirmed that the refusals should have been care planned. The facility's policies on comprehensive care plans and side rail use were not followed, leading to these deficiencies.
Failure to Document Alternatives and Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that three residents (R32, R33, and R71) had documented attempts of alternatives before using bed rails, completed quarterly and annual side rail screen assessments according to facility policy, and informed consent from the resident or their representative regarding the risks and benefits of bed rail use. This deficiency was identified through observations, record reviews, interviews, and facility policy reviews. The lack of proper documentation and informed consent could potentially put residents at risk for injury or entrapment due to bed rail use. For Resident 32, the facility did not provide documentation of alternative measures utilized prior to the use of side rails. The resident had severe cognitive impairment and was observed with bed rails up on multiple occasions. The side rail assessment form dated 10/02/19 indicated the need for side rails but did not include any recent assessments or informed consent documentation. Similarly, Resident 33, who was cognitively intact, had been using bed rails for nine years without being informed of the risks and benefits. The side rail assessment form dated 08/14/15 was the only documentation provided, and no recent assessments or informed consent were available. Resident 71, who had severe cognitive impairment and physical limitations, was observed with loose and improperly installed side rails. The side rail assessment dated 07/07/22 did not include the risk of entrapment or the specific condition for side rail use. No informed consent was found in the resident's records. Despite the facility's policy requiring side rail assessments upon admission, quarterly, and annually, as well as informed consent, these procedures were not followed for the three residents reviewed, leading to the identified deficiency.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to inform the New Jersey Department of Health (NJDOH) of an abuse allegation within the mandated two-hour period. The incident involved two residents, R73 and R41, and occurred on 05/20/23. The investigation summary provided by the facility revealed that the residents were questioned on 05/22/23, and the investigation concluded on 05/23/23. The report was faxed to the NJDOH on 05/25/23, which was beyond the required reporting timeframe. Interviews with the Social Service Director (SSD) and the Licensed Practical Nurse (LPN) indicated that the abuse protocol was initiated on 05/22/23, and the Director of Nursing (DON) was informed immediately after the incident. However, the Administrator was not informed until the following Monday, and the NJDOH was not notified within the required two-hour window. The facility's policy on abuse and neglect, revised in December 2023, mandates immediate reporting of any abuse allegations to the appropriate authorities. Despite this policy, the facility did not adhere to the required reporting timeframe. The Administrator acknowledged that the NJDOH should have been informed within two hours of the accusation of physical contact between the residents. The reportable event record indicated that the alleged abuse occurred at 4:20 PM on 05/20/23, but the event was not deemed significant and was not called in immediately. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
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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