Preferred Care At Hamilton
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton Square, New Jersey.
- Location
- 1501 State Hwy 33, Hamilton Square, New Jersey 08690
- CMS Provider Number
- 315111
- Inspections on file
- 18
- Latest survey
- February 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Preferred Care At Hamilton during CMS and state inspections, most recent first.
A resident at risk for skin breakdown developed a stage 3 pressure ulcer due to the facility's failure to implement and document necessary interventions. The care plan was not updated with recommended treatments, and there was a delay in starting wound care. Staff failed to document the resident's skin condition consistently, and the primary care physician and nurse practitioner did not address the issue in a timely manner.
The facility failed to maintain proper kitchen sanitation and food handling practices, with issues such as improper handwashing, incorrect use of beard nets, unsanitary storage, and unlabeled food items. Staff members were observed not following infection control protocols, including inadequate hand hygiene and sweating over food. The Infection Preventionist confirmed that education on these practices was provided, and the Licensed Nursing Home Administrator acknowledged the deficiencies.
A facility failed to follow professional standards for PICC line dressing changes for a resident with a PICC line in the left chest wall. The dressing was observed to be unlabeled and undated, and the resident reported it had not been changed since insertion. Medical records lacked orders for PICC line observation or dressing changes. Interviews with staff confirmed the facility's process was not followed, and the survey team acknowledged the concerns.
A facility failed to document pain assessments before administering morphine sulfate to a resident with thoracic discitis and cervical spondylopathy. Despite the resident's regular pain medication schedule, 84 out of 131 doses lacked documented pain level assessments. The DON and LPN confirmed the absence of required documentation, contrary to the facility's pain management policy.
A facility failed to adequately monitor a resident's use of psychoactive medications, despite the resident's moderate cognitive impairment and dependence on staff for daily activities. The resident was prescribed multiple psychotropic medications, but there was no documentation of behavior or side effect monitoring as required by the facility's policy. Interviews with staff revealed inconsistencies in monitoring practices, and the Director of Nursing acknowledged that monitoring was not conducted daily as the policy specified.
The facility failed to maintain resident dignity during feeding assistance and catheter management. An LPN stood while feeding a resident, despite available seating, and meal slips labeled residents as 'feeders,' which staff acknowledged as undignified. Additionally, a resident's catheter drainage bag was exposed without a privacy bag, visible from the hallway. Facility policies lacked guidance on these dignity concerns.
The facility failed to maintain a clean and homelike environment on the South Side nursing unit. Observations revealed dirty linen on the floor, a cracked trash can without a liner, and a toilet with a brown substance. A bag with used Foley catheter leg bags was improperly tied to a handrail. The DON, IP, and ESD acknowledged these issues, which violated the facility's policies on linen handling and routine cleaning.
A resident with severe cognitive impairment and a history of falls had a care plan that was not updated to include the use of a fall mat and bed positioning against the wall, despite these interventions being in place. The facility's policies required care plan updates following falls, which were not followed in this instance.
A facility failed to properly manage respiratory care for two residents, leading to deficiencies in labeling, dating, and storing oxygen equipment. One resident's oxygen tubing was found unbagged and exposed, while another's equipment lacked proper labeling. Both residents' care plans did not include necessary respiratory interventions, contrary to facility policies. Staff interviews confirmed these oversights, highlighting gaps in infection control and care planning.
The facility failed to adhere to professional standards in pharmaceutical services and documentation, as evidenced by missing signatures and incorrect narcotic tablet counts on medication carts. LPNs confirmed these discrepancies, and the DON acknowledged the need for immediate documentation as per policy.
The facility failed to maintain the kitchen garbage dumpster area, as observed by a surveyor with the FSD and LNHA. Food debris and disposable gloves were scattered on the ground, and a half-full garbage compactor was left open and unused. The FSD and LNHA acknowledged the area should have been clean and containers closed. The facility's policy requires the trash area to be clean, odor-free, and pest-free, with sealed and covered containers.
A facility failed to properly store soiled linen and sanitize medical equipment, leading to potential cross-contamination. A CNA was observed using the same bags for dirty linen and briefs across multiple residents, while soiled medical equipment was improperly stored in a medication room. These actions violated the facility's infection control policies, as confirmed by the LPN, Unit Manager, and Infection Preventionist.
A facility failed to conduct a new PASRR level one assessment for a resident newly diagnosed with psychosis. Initially admitted in 2021, the resident's PASRR assessment did not indicate a mental illness, but a 2024 MDS assessment showed severe cognitive impairment and a psychotic disorder. The social worker admitted a level two PASRR was not completed after the new diagnosis, and the DON confirmed the oversight.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development and worsening of a stage 3 pressure injury for a resident. The resident, who was admitted with Parkinson's disease and protein calorie malnutrition, was identified as being at risk for skin breakdown due to bladder incontinence and immobility. Despite this, the facility did not update the resident's care plan to reflect the need for a moisture barrier cream after it was discontinued, nor did they document regular skin checks as required. The resident developed moisture-associated skin damage (MASD) on the right buttocks, which progressed to a stage 3 pressure injury. The facility did not update the care plan with new interventions recommended by the Wound Care Consultant, such as using an alternating pressure mattress and specific cushions to reduce pressure. Additionally, there was a delay in starting the recommended wound treatment, and the facility failed to document the resident's skin condition consistently. The facility's staff, including the Licensed Practical Nurse, Infection Preventionist, and Director of Nursing, were unable to provide explanations for the lack of documentation and updates to the care plan. The primary care physician and nurse practitioner also failed to document and address the resident's skin condition in a timely manner. The facility's policies on skin assessment and wound treatment management were not followed, contributing to the deficiency.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation and proper food handling practices, leading to potential risks of foodborne illness. During an initial tour of the kitchen, the surveyor observed several deficiencies, including improper handwashing techniques by the Food Service Director and the Licensed Nursing Home Administrator, who did not meet the required 20 seconds of lathering with soap. Additionally, a staff member with a long beard wore a beard net incorrectly, leaving beard hair exposed, which was confirmed by the Food Service Director as inappropriate. Further observations revealed unsanitary storage practices, such as scoopers stored inside bins of powdered mashed potatoes and flour, causing the lids to remain open and potentially allowing rodent access. Several containers of dried herbs were opened and not dated, and an apple pie in the walk-in freezer was not labeled or dated. Clean dessert bowls were stored uncovered near a dusty exhaust fan and refrigerator cooling system, and cutting boards on the drying rack were pitted and had deep cut marks. During a follow-up tour, additional issues were noted, including a staff member washing hands without proper lather time and another staff member sweating over a tray of mashed potatoes, with sweat dripping into the food. The Infection Preventionist confirmed that infection control education, including proper hand hygiene and the use of hair and beard nets, was provided to all staff. The Licensed Nursing Home Administrator acknowledged the deficiencies in personal hygiene, hand hygiene, and kitchen sanitation, as well as the need for proper labeling and dating of kitchen supplies.
Failure to Follow PICC Line Dressing Change Protocol
Penalty
Summary
The facility failed to ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. This deficiency was identified for one resident who had a PICC line located in the left chest wall. The surveyor observed that the dressing on the PICC line was not labeled or dated, and the resident reported that the dressing had not been changed since it was inserted. The medical records, including the Order Summary Report, Medication Administration Record (MAR), and Treatment Administration Record (TAR), did not reflect any orders for PICC line observation or dressing changes. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility's process was not followed, as the PICC line data set should have been discussed with the physician, and orders should have been placed in the electronic medical record. The facility's policy required that the PICC dressing be changed weekly or if soiled, and the dressing should be labeled with the date, time, and initials of the person who changed it. The survey team, including the Licensed Nursing Home Administrator (LNHA), DON, IP, and the Regional Nurse, acknowledged the surveyor's concerns regarding the deficiency.
Failure to Document Pain Assessments Before Administering Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring and assessment of pain prior to administering pain medication to a resident. This deficiency was identified for 84 out of 131 doses of morphine sulfate administered to a resident who was prescribed the medication for moderate to severe pain. The resident, who had diagnoses including thoracic discitis and cervical spondylopathy, was observed wearing a back brace and using a cane, indicating ongoing pain management needs. Despite the resident's intact cognition and regular pain medication schedule, the facility did not document pain level assessments prior to administering the medication as required. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) confirmed that pain level assessments were not documented for each dose of pain medication administered. The facility's pain management policy required pain management to be consistent with professional standards, including recognition, assessment, treatment, and monitoring of pain. However, the Medication Administration Record (MAR) showed that pain assessments were not conducted for numerous doses across November, December, and January, as indicated by the absence of documented pain levels. The DON acknowledged the lack of proper documentation, and the LPN confirmed that the MAR was marked with an X where pain assessments were missing.
Inadequate Monitoring of Psychoactive Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychoactive medication for Resident #85, as identified during a survey. The resident, who was admitted with chronic respiratory failure and diabetes mellitus, had a moderate cognitive impairment with a BIMS score of 7 out of 15. The resident was dependent on staff for activities of daily living and was prescribed multiple psychotropic medications, including trazodone, lorazepam, buspirone, and valproic acid, for conditions such as depression, anxiety, and mood disorder. Despite these prescriptions, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that the facility was monitoring the resident's behavior or side effects related to these medications. Interviews with facility staff, including a CNA, LPN, and LPN/Unit Manager, revealed inconsistencies in the monitoring practices for psychotropic medication use. The CNA noted that the resident required complete care and occasionally became anxious and confused but did not exhibit aggressive behavior. The LPN confirmed that the resident's behaviors were not consistently documented, and there were no physician's orders for behavior or side effect monitoring. The LPN/Unit Manager stated that monitoring was typically done for 14 days following a new medication or change, but was unsure of the facility's behavior monitoring protocol. The facility's policy on Behavior Management, Intervention, and Monitoring required daily monitoring and documentation of drug side effects for residents on psychotropic medications. However, the Director of Nursing (DON) stated that monitoring was only done by exception or during gradual dose reduction, not daily as the policy specified. This lack of consistent monitoring and documentation for Resident #85's psychotropic medication use constituted a deficiency in the facility's care practices.
Failure to Maintain Resident Dignity in Feeding and Catheter Management
Penalty
Summary
The facility failed to promote and maintain resident dignity during feeding assistance and for a resident with a urinary catheter. During a dining observation, an LPN was seen standing while feeding a resident with severe cognitive impairment, despite available seating. This was confirmed by both the CNA and the LPN, who acknowledged that proper feeding assistance should involve sitting alongside the resident to maintain eye contact and dignity. Additionally, meal slips for three residents labeled them as 'feeders,' a term considered undignified by the facility's staff and administration. In another instance, a resident with a suprapubic catheter was observed with their catheter drainage bag exposed and not placed in a privacy bag, allowing the contents to be visible from the hallway. The facility's policy did not include storing Foley catheter bags in privacy bags, although staff acknowledged the importance of using privacy bags for maintaining resident dignity. The resident involved was cognitively intact and aware of their catheter status. The facility's policies on dining and urinary catheter management were reviewed, revealing gaps in ensuring resident dignity. The Dining and Meal Assistance policy emphasized not standing over residents while assisting them with meals and avoiding undignified labels. However, the Urinary Catheters policy lacked guidance on using privacy bags for catheter drainage bags, which was identified as a dignity concern by the staff.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the South Side nursing unit. During an observation, a surveyor identified several environmental concerns, including a bag of dirty linen left on the floor near a resident's dresser, a cracked trash can without a liner, and a toilet with a brown substance splattered around the rim. Additionally, a clear bag filled with used Foley catheter leg bags was tied to a handrail in a resident's bathroom. The resident confirmed that they did not place the bag there, and the Unit Manager/LPN acknowledged the inappropriate placement of the bag due to infection control concerns. Interviews with the Director of Nursing (DON), Infection Preventionist (IP), and Environmental Services Director (ESD) revealed that the facility's policies were not followed. The DON and IP confirmed that soiled linen should be immediately taken to the soiled utility room and not left in resident rooms. The ESD stated that housekeepers follow a daily schedule and that CNAs should notify housekeeping for immediate cleaning if a resident has an accident. The facility's Linen Handling and Routine Cleaning and Disinfection policies emphasize the importance of handling and cleaning to prevent contamination and infection, which were not adhered to in this instance.
Failure to Update Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls who used a fall mat. This deficiency was identified during a survey when the resident was observed in bed with a fall mat on the floor and the bed pushed against the wall. Despite these observations, the resident's care plan did not include interventions for the use of fall mats or the bed being against the wall. The resident, who had severe cognitive impairment and a history of falls, was admitted with diagnoses including failure to thrive, hypertension, chronic pain, and anxiety. The care plan was last updated following a fall on 11/17/24, but it did not reflect the current interventions in place. The facility's policies required that care plans be reviewed and updated following a resident fall, which was not adhered to in this case. During a meeting with the Director of Nursing, Licensed Nursing Home Administrator, Regional Director of Nursing, and Infection Preventionist, it was confirmed that the care plan should have included the fall mat and bed positioning. This oversight was a violation of the facility's Fall Policy and Care Plan Process policy, which mandates timely updates to care plans based on assessments and reassessments.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to properly label, date, and store respiratory equipment, leading to potential contamination risks. During an initial tour, a surveyor observed a resident with an oxygen concentrator and nasal cannula tubing that was unbagged and exposed to air. The resident's medical records indicated a need for oxygen due to shortness of breath, but the individualized comprehensive care plan (ICCP) did not include a focus area for respiratory care or interventions for oxygen administration. Interviews with the Unit Manager and Infection Preventionist confirmed that the tubing should be stored in a bag when not in use to prevent contamination. Another resident was observed receiving oxygen via nasal cannula at 4 liters per minute, but the oxygen tubing and humidification bottle were not labeled or dated. The resident, who had chronic respiratory failure and diabetes mellitus, was unsure when the equipment was last changed. The surveyor noted that the oxygen tubing had illegible writing, and the humidification bottle lacked labeling. The facility's policy required weekly changes and dating of the tubing, but there was no physician's order for the humidification bottle. The Director of Nursing confirmed that the ICCP for this resident did not include oxygen administration. The facility's policies on oxygen administration and care plan processes were reviewed, revealing gaps in labeling and dating requirements for humidification bottles and the storage of oxygen tubing. The care plan policy emphasized the need for individualized plans based on assessments, but the deficiencies in the residents' care plans indicated a failure to adhere to these guidelines. The Director of Nursing acknowledged these oversights during interviews with the survey team.
Deficiency in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice and did not accurately document the administration of controlled medications. This deficiency was identified during a review of two out of three medication carts. On one occasion, the surveyor, accompanied by an LPN/Unit Manager, found that the Individual Patient Controlled Substance Administration Record sheet for a resident's morphine extended release tablets was not signed by the nurse who administered the medication. The inventory sheet indicated there should be 10 tablets, but only 9 were present. Similarly, another resident's morphine ER tablets were not properly documented, with the inventory sheet showing a discrepancy between the expected and actual tablet count. Further observations revealed similar issues with another medication cart, where the declining inventory sheet for a resident's oxycodone immediate release tablets was not signed by the administering nurse, and the tablet count was incorrect. Interviews with the LPNs confirmed the missing signatures and incorrect narcotic tablet counts. The Director of Nursing acknowledged that the declining inventory sheets should be completed immediately when medication is dispensed, as per the facility's Medication Administration policy.
Improper Waste Disposal in Kitchen Dumpster Area
Penalty
Summary
The facility failed to properly dispose of and maintain waste in the kitchen garbage dumpster area. During an initial tour, the surveyor, along with the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA), observed food debris, including bread slices and other unidentifiable disposed food and disposable gloves, scattered on the ground. Additionally, a half-full garbage compactor was found with its door wide open and not actively being used by staff. The FSD acknowledged that the dumpster area should have been maintained and cleaned, and that leaving the garbage compactor open and having food debris on the ground was unacceptable and could promote rodents. The LNHA later acknowledged that the dumpster area should have remained clean, and the garbage containers should have been closed when not in use. A review of the facility's Dumpster Area policy, revised in November 2024, stated that the trash area should be clean, odor-free, and free from pest infestation, with trash containers sealed, leak-proof, and covered at all times to prevent exposure to waste. The policy also required that all trash be placed inside the dumpster.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
The facility failed to ensure that soiled linen and soiled incontinent briefs were properly stored in a sanitary manner, as observed on the South Unit. During a dining observation, a surveyor noted a bag of dirty linen and a bag of trash containing dirty protective briefs on the floor of a resident's room. A Certified Nursing Assistant (CNA) was seen feeding a resident with these bags placed in front of the bed. The CNA admitted to using the same bags for multiple residents to avoid wasting bags, which was against the facility's policy. The Licensed Practical Nurse (LPN) and the Unit Manager confirmed that this practice was inappropriate and posed an infection control issue due to the risk of cross-contamination. Additionally, the facility failed to ensure that soiled medical equipment was sanitized prior to storage, as observed in the North Medication Storage Room. A surveyor found a soiled oxygen concentrator with a humidification bottle and three soiled tube feeding pumps stored in the medication room. The LPN/Unit Manager acknowledged that the soiled equipment should have been placed in the soiled utility room for housekeeping to process, as storing it in the medication room could lead to cross-contamination with sterile supplies and medication preparation areas. The facility's policies on linen handling and cleaning and disinfection of nursing equipment were not adhered to, contributing to these deficiencies. The Infection Preventionist and the Director of Nursing confirmed that the staff should not have been taking dirty linen and equipment from room to room and that soiled equipment should be processed in the soiled utility room. These lapses in protocol were identified as infection control issues that could potentially lead to cross-contamination and the spread of infection within the facility.
Failure to Conduct New PASRR Assessment for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment for a resident who was newly diagnosed with a mental illness. The resident, initially admitted in 2021, had a new diagnosis of psychosis in December 2022. The initial PASRR level one assessment, completed in June 2021, did not indicate a mental illness diagnosis. However, the most recent Minimum Data Set (MDS) assessment in October 2024 showed the resident had severe cognitive impairment and a diagnosis of anxiety and psychotic disorder. During the survey, the social worker acknowledged that a level two PASRR was not completed following the new diagnosis. The social worker stated that the psychiatrist communicated the new diagnosis to the nurse, who then informed the social worker. The Director of Nursing confirmed that the PASRR should have been completed, indicating a lapse in the facility's process for coordinating assessments with the PASRR program.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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