Redbank Center For Rehabilitation And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Bank, New Jersey.
- Location
- 100 Chapin Avenue, Red Bank, New Jersey 07701
- CMS Provider Number
- 315286
- Inspections on file
- 13
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Redbank Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to provide activities according to care plans for five residents, affecting their social and mental status. Residents with severe cognitive impairments and physical dependencies were not invited to or engaged in activities, despite care plans indicating the need for scheduled and one-on-one activities. Documentation of activities was inconsistent, and staff were unaware of residents' specific needs, such as broken equipment or language barriers.
A cook in the facility's kitchen failed to change gloves and wash hands after touching his face and contaminated items, then proceeded to handle food directly with the same gloves. Despite being alerted by the Dietary Manager, the cook continued to use his gloved hands improperly, violating the facility's handwashing policy and potentially risking the spread of infection among 132 residents.
The facility failed to follow infection control Enhanced Barrier Precautions (EBP) for two residents and did not handle medications properly for another. Staff did not consistently sanitize hands or use appropriate PPE when entering rooms with EBP signage. An LPN did not wear a gown while administering tube feeding to a resident on EBP, and isolation supplies were not readily available. Additionally, an LPN improperly handled medication by picking up a pill with an ungloved hand. These deficiencies put residents at risk of infection.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential unmet care needs. One resident's MDS inaccurately documented no oxygen therapy or tracheostomy care, despite evidence to the contrary. Another resident's discharge MDS was incorrectly coded, indicating discharge to a hospital instead of a private home. A third resident's MDS failed to reflect existing pressure areas and risk for further ulcers, despite documented skin assessments. These inaccuracies were confirmed through interviews with facility staff.
The facility failed to conduct timely PASARR screenings for two residents with psychiatric diagnoses. One resident was admitted without a psychiatric diagnosis, but later diagnosed with schizoaffective disorder, and no new PASARR Level I screen was completed. Another resident had a positive Level I PASARR screening for mental illness, but the required Level II screening was delayed. The facility's policy mandates reporting and evaluation of such issues by Social Services.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed needs for vision impairment, oxygen use, and protective boots. Despite documented diagnoses and physician orders, care plans lacked necessary interventions, and staff were unaware of these needs. This deficiency highlights a lack of communication and documentation in the facility's care planning process.
A resident with multiple health conditions, including quadriplegia and incontinence, was found to be double briefed on several occasions, contrary to facility policy. Staff confirmed that this practice could lead to skin breakdown and pressure sores. The resident's care plan required pericare after each incontinent episode and immediate changing of wet briefs, which was not followed.
The facility failed to follow physician orders for two residents, leading to risks of skin breakdown and infection. One resident did not receive prescribed heel protector and Multipodus boots, while another had discrepancies in PICC line dressing changes. Staff interviews revealed communication and documentation issues, resulting in non-compliance with care protocols.
A resident with a history of bronchiectasis and acute respiratory failure was not administered oxygen at the physician-prescribed dose of 2 LPM. Observations showed the resident receiving higher doses of 5 LPM and 3.5 LPM. An LPN confirmed the incorrect settings and adjusted them. The DON emphasized the importance of following oxygen orders, as high settings could be problematic for residents with certain conditions.
A resident receiving dialysis three times a week did not receive adequate care, as the facility failed to document vital signs before dialysis and did not provide meals or snacks before early morning sessions. The dialysis communication forms were inconsistently filled out, and staff interviews revealed confusion about responsibilities. The facility's policy for coordinating with the dietary department and maintaining communication with the dialysis center was not effectively implemented.
A facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for a resident with anxiety and depression. The resident's Clonazepam order lacked an end date, and the medication was administered multiple times despite a psychiatric evaluation showing no acute issues. The DON confirmed the oversight, acknowledging the regulatory requirement for an end date.
A resident received medications incorrectly, including late administration of gabapentin, incorrect dosage of estradiol, and discontinued calcium acetate, leading to a medication error rate above 5%. The LPN involved confirmed the errors, and the facility's policy requires adherence to prescribed orders and timing.
Medication carts on multiple floors were left unlocked and unattended by staff, posing a potential risk to resident safety. An RN and an LPN admitted to leaving carts unsecured, contrary to facility policy and expectations. Observations confirmed these lapses, with residents in proximity to the carts.
The facility failed to maintain complete medical records for two residents, leading to deficiencies in documentation related to a death in the facility and a discharge to the community. For one resident, the EMR lacked details about the death, including notifications and a physician's order to release the body. For another resident, the EMR was missing progress notes for the discharge date, and the LPN responsible forgot to document the discharge. The facility's policy requires comprehensive documentation for transfers and discharges, which was not followed.
Failure to Provide Activities According to Care Plans
Penalty
Summary
The facility failed to provide activities according to assessments and care plans for five residents, potentially affecting their social and mental status. Resident 5, who had severe cognitive impairment and was dependent on staff for transfers, expressed a desire to participate in activities but was not invited to any. Despite a comprehensive care plan indicating the need for scheduled activities compatible with her needs, she did not attend any activities in January or February. The Activity Director acknowledged that Resident 5 had not been invited to activities she enjoyed, such as music or dancing, and the Recreation Aid attempted to involve her but faced challenges in getting her up for activities. Resident 87, who was rarely understood and required one-on-one bedside activities, did not attend any activities in January or February. Although room visits were documented, the logs did not specify the activities conducted. Observations revealed that Resident 87 was often lying in bed without any engagement, and family members noted that he enjoyed music but was not involved in activities. The Activity Director and Recreation Aid admitted to inconsistencies in providing and documenting activities for Resident 87. Similarly, Resident 92, who had severe cognitive impairment and a tracheostomy, did not participate in any activities outside his room. Although room visits were recorded, the documentation lacked details on the activities performed. Observations showed that Resident 92 was frequently in bed without engagement, and family members reported that his Geri-chair was broken, preventing him from attending activities. The Activity Director was unaware of the broken chair and the resident's tracheostomy, leading to inaccurate documentation of activities. Residents 112 and 121 also experienced similar issues, with inadequate documentation and lack of engagement in activities, despite their care plans indicating the need for one-on-one visits and activities compatible with their preferences.
Improper Hand Hygiene and Glove Use in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use by kitchen staff, which could lead to the spread of infection and foodborne illness among residents. During an observation, a cook was seen touching his face and nose with gloved hands and then serving food without changing gloves. The cook handled food items directly with his gloved hands, including fried fish filets, sandwiches, and chicken strips, without using utensils. Additionally, the cook used visibly soiled oven mitts over his gloves to handle hot pans and continued serving food without changing gloves or washing hands. The Dietary Manager was informed of the issue and observed the cook's actions, confirming the failure to change gloves. Despite being provided with serving utensils, the cook continued to use his gloved hands to touch food, his pants, and his face. The facility's policy on handwashing requires staff to wash hands before working, after touching any part of the body, and between working with foods, which was not followed in this instance. This deficiency affected 132 of 141 residents consuming food in the facility.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to infection control Enhanced Barrier Precautions (EBP) for two residents, R92 and R107, and did not handle medications properly for resident R101. Observations revealed that staff, including a Certified Nurse Aide (CNA) and Licensed Practical Nurses (LPNs), did not consistently sanitize their hands or use appropriate personal protective equipment (PPE) such as gowns and gloves when entering rooms with EBP signage. Specifically, CNA2 did not sanitize her hands when passing meal trays to rooms with EBP signage, and LPN5 and LPN6 did not follow proper hand hygiene or PPE protocols when providing care to R92, who had a tracheostomy and was on EBP. For resident R107, who had a feeding tube and was on EBP, LPN5 did not wear a gown while administering tube feeding, contrary to the facility's infection preventionist's guidance that a gown should be worn during such high-contact procedures. The facility's Director of Nursing (DON) also confirmed that the expectation was for staff to use EBP, including wearing gowns and gloves when handling feeding tubes. Additionally, the facility failed to ensure that isolation supplies, such as face shields and goggles, were readily available on the third floor, where several residents with tracheostomies were located. In the case of resident R101, an LPN was observed picking up a pill that had fallen onto the medication cart with an ungloved hand and placing it back into the medication cup, which was then administered to the resident. This action was against the facility's policy, which required a no-touch technique for medication administration. The infection preventionist and DON both stated that gloves should be worn if touching medications, and hand hygiene should be performed before putting on gloves. These deficiencies in infection control practices put all residents at risk of infection.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to potential unmet care needs. Resident 107's MDS inaccurately documented that the resident did not receive oxygen therapy or tracheostomy care, despite records and observations indicating otherwise. The resident had a tracheostomy tube with oxygen flowing at 4 liters per minute, and the care plan noted the tracheostomy related to impaired breathing mechanics. Interviews with the Regional Nurse and Director of Nursing confirmed the expectation for accurate MDS coding, which was not met in this case. Resident 129's discharge MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while in reality, the resident was discharged to a private home with home health services. This discrepancy was confirmed through interviews with a Licensed Practical Nurse and the Regional Nurse, who acknowledged the coding error. The resident's actual discharge location was either her mother's or grandmother's home, not a hospital. Resident 92's admission MDS failed to reflect existing pressure areas and the risk for further pressure ulcers. The resident had a documented history of quadriplegia, hypertension, and sepsis, with skin assessments revealing redness and a pressure area on the sacrum. Despite this, the MDS did not indicate any unhealed pressure ulcers or risk for pressure ulcers. The Regional Nurse verified the inaccuracies, noting that the MDS should have included the pressure area on the sacrum and buttock, as well as the risk for further pressure areas. The facility's policy and the Resident Assessment Instrument Manual emphasize the importance of accurate and timely MDS completion, which was not adhered to in these cases.
Failure to Conduct Timely PASARR Screenings for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) for a resident (R20) when a psychiatric diagnosis of schizoaffective disorder was identified. Initially, R20 was admitted without a psychiatric diagnosis, and the hospital's PASARR Level I Screen documented no major mental illness. However, the facility later entered a diagnosis of schizoaffective disorder into the electronic medical record (EMR) without conducting a new PASARR Level I screen. Interviews with the Regional Nurse and the Director of Nursing confirmed that a new PASARR Level I screening should have been completed following the addition of the new psychiatric diagnosis. Another resident (R101) was admitted with a history of mental and behavioral disorders and had a positive Level I PASARR screening for mental illness, indicating the need for a Level II screening. Despite this, the facility did not ensure a Level II screening was conducted in a timely manner. The Social Services Director acknowledged the positive screening and stated that the facility was working to schedule the Level II screening. The Assistant Director of Nursing confirmed that the Level II screening was only requested after the surveyor's inquiry. The facility's policy requires that any issues identified in the PASARR process be reported to the Director of Social Services for further evaluation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which led to deficiencies in addressing their specific needs. One resident, who was admitted with end-stage renal disease and heart failure, had impaired vision documented in their Minimum Data Set (MDS) but lacked a care plan addressing this issue. Despite having an order for an ophthalmology consult due to blurry vision, the care plan did not include interventions for vision impairment, which was confirmed by interviews with the resident and staff. Another resident, who had been hospitalized and returned with a diagnosis of bronchiectasis and acute respiratory failure, required supplemental oxygen. However, their care plan did not document the need for oxygen, even though orders were in place for oxygen delivery. Observations and interviews revealed discrepancies in the oxygen settings, and staff were unaware of the care plan details, indicating a lack of communication and documentation. The third resident had impaired range of motion and was at risk for pressure sores, requiring heel protector boots and Multipodus boots. Despite physician orders for these interventions, the care plan did not include them, and staff were not informed of the need for these boots. Interviews with staff highlighted a lack of responsibility in updating care plans and ensuring that interventions were communicated to those providing direct care. The facility's policies required comprehensive care plans based on thorough assessments, but these were not followed, leading to potential impacts on resident care.
Improper Incontinence Care Due to Double Briefing
Penalty
Summary
The facility failed to provide proper incontinence care for a resident, identified as R92, who was found to be double briefed on multiple occasions. R92, who was admitted with multiple serious health conditions including quadriplegia and incontinence, was dependent on staff for all activities of daily living. The resident's care plan specified that pericare should be performed after every incontinent episode, and briefs should be changed immediately when wet or soiled. However, observations revealed that R92 was double briefed, with the inner brief soaked with urine, which was confirmed by both a family member and facility staff. Interviews with facility staff, including an LPN and CNA, confirmed that double briefing was against facility policy and could lead to skin breakdown and pressure sores. The Director of Nursing also stated that no residents should be double briefed unless requested, and R92 had not made such a request. The facility's policy on incontinence care emphasized the importance of checking residents for incontinence every two hours and changing briefs immediately when wet, which was not adhered to in R92's case.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for two residents, R121 and R89, which put them at risk for skin breakdown and infection. R121 was admitted with multiple fractures and was at risk for pressure sores. Physician orders required R121 to wear heel protector boots while in bed and Multipodus boots when out of bed. However, observations over several days revealed that R121 was not wearing the boots as ordered, and the care plan did not include interventions for the boots. Interviews with staff indicated a lack of communication and documentation regarding the need for the boots, leading to their non-use. R89, who had a PICC line and was diagnosed with conditions including diabetes and MRSA, was observed with a bandage dated 02/14/25, despite orders for weekly dressing changes. The Medication Administration Record showed discrepancies in the dressing change schedule, and interviews revealed confusion about the orders and documentation errors. The facility's policy required verification of physician orders and proper documentation, which was not followed, resulting in the bandage not being changed as required. The deficiencies in both cases were due to failures in communication, documentation, and adherence to physician orders and facility policies. These lapses in care placed the residents at risk for adverse outcomes, such as skin breakdown and infection, due to the non-implementation of prescribed interventions and care protocols.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed dose for a resident, identified as R56, who was reviewed for respiratory care. R56 had a history of bronchiectasis and acute respiratory failure with hypercapnia. The physician's order, dated 01/06/25, specified that R56 should receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. However, observations revealed discrepancies in the oxygen administration. On 02/23/25, R56 was observed receiving oxygen at 5 LPM, and on 02/24/25, the setting was at 3.5 LPM, both of which were higher than the prescribed dose. During an interview, an LPN confirmed the incorrect setting and adjusted the oxygen concentrator to the correct 2 LPM. The Director of Nursing (DON) stated that she expected oxygen orders to be followed, noting that high oxygen settings could be problematic for residents with conditions like COPD. The facility's policy on oxygen administration required staff to verify physician orders and ensure the proper flow of oxygen. The failure to adhere to the prescribed oxygen dose had the potential to cause respiratory distress for the resident.
Inadequate Dialysis Care and Communication for Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as R13, who required dialysis three times a week. R13 was admitted with diagnoses including end-stage renal disease and heart failure. The care plan for R13 included interventions such as taking vital signs before and after dialysis and addressing the risk of altered weight status due to edema and fluid fluctuations. However, the facility did not consistently document vital signs before dialysis, and there was no record of meals or snacks being provided before dialysis sessions, which could affect the resident's nutritional status. The facility's dialysis communication process was also inadequate. The Dialysis binder, which contained communication forms for each dialysis day, was not properly filled out. Of the 19 forms reviewed, 15 lacked documentation of pre-dialysis vital signs, and none recorded any meal or snack provided. Additionally, 17 forms did not have boxes checked regarding medications taken or changes since the last dialysis treatment. Interviews with staff revealed confusion about who was responsible for filling out the forms, and it was noted that dietary staff did not send food for residents to eat before early morning dialysis sessions. The facility's policy required communication with the dialysis center through a communication book and coordination with the dietary department to provide meals or snacks as needed. However, this policy was not effectively implemented, as evidenced by the lack of documentation and communication regarding R13's care. Interviews with various staff members, including LPNs, the Unit Manager, and the Director of Nursing, highlighted inconsistencies in the process and a lack of clarity about responsibilities, contributing to the deficiency in providing safe and appropriate dialysis care for R13.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were not prescribed beyond 14 days without documented rationale for a resident reviewed for unnecessary medications. The resident, who was admitted with diagnoses including depression, anxiety, and end-stage renal disease, had an order for Clonazepam 2MG to be administered as needed for anxiety. This order, which started on February 13, 2024, did not have an end date, contrary to regulatory requirements. The resident's medical records indicated that the medication was administered on multiple occasions in February 2025. Despite a psychiatric evaluation noting no acute behavioral issues or concerns, the facility did not document a rationale for continuing the PRN medication beyond the 14-day limit. The Director of Nursing confirmed the oversight, acknowledging the absence of an end date for the PRN medication, which is a requirement under the regulation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as evidenced by several errors involving a resident identified as R101. R101, who was admitted with diagnoses including hypothyroidism and failure to thrive, had specific medication orders for estradiol, gabapentin, and calcium acetate. During an observation, an LPN administered gabapentin 1 hour and 39 minutes after the scheduled time, gave only one tablet of estradiol instead of the prescribed two, and administered calcium acetate despite it being discontinued. These actions were contrary to the facility's policy, which mandates medication administration within one hour before or after the scheduled time and as per the physician's orders. Interviews with the LPN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed the deviations from the prescribed medication orders. The LPN acknowledged the late administration of gabapentin and the incorrect dosage of estradiol, and was unaware of the discontinuation of calcium acetate. The ADON and DON reiterated the expectation for medications to be administered as ordered and within the specified time frame. The facility's policy on medication administration, reviewed in December 2024, outlines the procedure for verifying and administering medications, emphasizing adherence to physician orders and time frames.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were securely locked when unattended, as observed on multiple occasions across different floors. On the third floor, a registered nurse (RN1) left a medication cart unlocked several times while attending to residents, with residents in close proximity to the cart. This occurred between 11:25 AM and 1:00 PM, during which RN1 admitted to leaving the cart unlocked and acknowledged the potential risk of residents accessing medications. Additionally, on the fourth floor, a medication cart was found unlocked and unattended near the nursing station, with residents nearby, and the unit manager confirmed the cart was not secure. Further observations on the second floor revealed another unattended and unlocked medication cart, which was subsequently locked by the Assistant Director of Nursing (ADON). Interviews with staff, including the ADON, Licensed Practical Nurse (LPN) 11, and the Director of Nursing (DON), confirmed the expectation that medication carts should be locked when unattended. The facility's policy on medication storage, revised in May 2024, also mandates that medication carts be locked or attended by authorized personnel. These lapses in securing medication carts posed a potential risk to resident safety.
Incomplete Documentation for Resident Death and Discharge
Penalty
Summary
The facility failed to maintain complete medical records for two residents, R127 and R129, which led to deficiencies in documentation related to a death in the facility and a discharge to the community. For R127, the electronic medical record (EMR) lacked documentation regarding the circumstances of the resident's death, including how it was discovered, who was notified, and the absence of a physician's order to release the body to the funeral home. Interviews revealed that the LPN on duty forgot to document the death after working a double shift, and the RN who pronounced the death did not document it either, assuming the floor nurse would handle it. For R129, the EMR was missing progress notes for the date of discharge, and the last note did not address the discharge. The LPN responsible for the discharge forgot to document it, including details about the resident's destination and whether discharge instructions or medications were provided. The facility's policy requires comprehensive documentation for transfers and discharges, including reasons for the action, notifications, and a summary of the resident's condition, which was not adhered to in these cases. The lack of documentation for both residents could lead to staff being unaware of the reasons for the residents' absence, whether proper notifications were made, and potential legal issues. The facility's failure to follow its own policy on documentation of transfers and discharges contributed to these deficiencies, as highlighted by the absence of critical information in the residents' medical records.
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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