Riverside Health And Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Trenton, New Jersey.
- Location
- 325 Jersey Street, Trenton, New Jersey 08611
- CMS Provider Number
- 315235
- Inspections on file
- 18
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Riverside Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
A Social Worker Assistant did not receive required annual in-service training on abuse and neglect, as evidenced by a lack of documentation in her employee file and confirmation from both the Social Worker and Assistant Director of Nursing. The facility's policy mandates annual education for all staff, but records showed only initial orientation training for the SWA, resulting in noncompliance with regulatory requirements.
A resident with multiple medical conditions and intact cognition alleged verbal abuse by the ADON. Although staff reported the incident to the Social Worker, no immediate investigation was initiated, and the event was not reported to facility leadership, contrary to the facility's abuse policy.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by a surveyor. Egg salad sandwiches lacked a made-on date, and expired marshmallows and water were found in storage. Staff, including a Speech Therapist and an Administrator, were seen in the kitchen without required hair restraints, indicating a need for reeducation.
The facility's call bell system was found to be deficient, with issues including inaudible notifications and non-functioning devices, affecting all residents. Observations revealed that call bell activations did not register at the nurse's station, and visual notifications were obstructed. In one instance, a call bell did not function due to broken pins, as confirmed by the DOM, with residents present during testing.
Surveyors identified multiple deficiencies in the facility, including unclean and unsafe environments, non-functional equipment, and inadequate resident care. Observations included dirty washcloths, worn mattresses, non-working lights and televisions, missing furniture, and improper meal service. Staff interviews revealed a lack of communication and reporting, contributing to unresolved issues.
Facility staff failed to follow infection control practices during wound care and meal service. A resident on Enhanced Barrier Precautions did not receive proper gown use by the Unit Manager during wound care. Additionally, CNAs on the 4th floor did not perform or assist with hand hygiene during meal service. These actions were contrary to the facility's policies on Enhanced Barrier Precautions and hand hygiene.
A resident's privacy and personal property rights were violated when a housekeeper accessed their bedside drawer without permission. The resident, who is cognitively intact, expressed distress over the intrusion. Facility staff, including the DON and LNHA, confirmed that such actions were against policy, which emphasizes respect and dignity for residents.
A resident's call bell was repeatedly found on the floor, out of reach, despite their care plan and facility policy requiring it to be accessible. Staff interviews confirmed the expectation for call bells to be within reach, yet the deficiency persisted, as acknowledged by the facility's administration.
A resident with a history of stroke and dementia experienced a witnessed fall in the facility, but the investigation was incomplete. The assigned nurse failed to provide a statement, and there was no documentation in the progress notes. The facility's policy lacked specific guidance on conducting thorough investigations, leading to the deficiency.
The facility failed to accurately assess two residents in the MDS. One resident with a Wander guard was incorrectly coded as having no wander alarm, and another resident using continuous oxygen was incorrectly coded as not using oxygen. These errors were confirmed by the MDS Coordinator and other staff.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. One resident's care plan lacked specific details on mood impairment and medication use, while another resident's care plan did not address significant weight loss. The Registered Dietitian and Director of Nursing acknowledged the omissions, which were contrary to the facility's policy on comprehensive care plans.
A resident with severe cognitive impairment experienced a fall in the facility, which was witnessed by a CNA. Despite the incident, there was no documentation in the resident's medical record, violating the facility's protocol for documenting falls. The lack of documentation was confirmed by multiple staff members, including an LPN Supervisor and the DON.
Two residents with indwelling urinary catheters were not provided appropriate care, leading to potential infection risks. A resident's catheter bag was found on the floor and unsecured, with missing documentation for catheter care. Another resident's catheter bag was improperly positioned above the bladder and lacked a privacy cover. Staff interviews confirmed these practices were against facility policy.
The facility failed to properly store respiratory equipment for two residents, leaving nebulizer masks and nasal cannulas unsecured and exposed to air. One resident's equipment was found in an open drawer and another's on a nightstand and floor. Staff acknowledged that equipment should be stored in bags, as confirmed by the Infection Preventionist and Director of Nursing.
A facility failed to timely address a CP's recommendation to clarify a resident's medication order for liquid Colace, despite repeated notices. The ADON and DON acknowledged the delay, which contradicted the facility's policy for timely communication and response to CP recommendations.
Failure to Provide Annual Abuse and Neglect Training to Social Services Staff
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation policy by not ensuring that all existing staff received annual education on abuse and neglect. Specifically, the Social Worker Assistant's (SWA) employee file only contained documentation of an in-service on resident neglect and abuse from her orientation in 2009, with no evidence of any additional or annual in-services on this topic. During interviews, the SWA could not recall the last time she received such training, and the Social Worker (SW) confirmed she had never provided or reviewed any in-services on abuse and neglect for the SWA. The Assistant Director of Nursing (ADON) stated that while she maintained in-service records for the nursing department, other department heads were responsible for their own staff, and she was unable to locate any recent training records for the SWA. The facility's undated Abuse, Neglect, and Exploitation policy requires that existing staff receive annual education through planned in-services. The SW's job description also assigns responsibility for checking the competence of social services personnel. Despite these requirements, there was no documentation of annual abuse and neglect training for the SWA, indicating a failure to follow facility policy and regulatory requirements for staff education on this critical topic.
Failure to Investigate Alleged Verbal Abuse and Implement Abuse Policy
Penalty
Summary
The facility failed to immediately initiate an investigation into an allegation of verbal abuse and did not implement its Abuse, Neglect and Exploitation policy as required. A resident with diagnoses including paraplegia, acute pyelonephritis, anxiety, and depression, and who was cognitively intact, was involved in an incident where the Assistant Director of Nursing (ADON) was alleged to have been verbally abusive. Documentation showed that the resident accused the ADON of speaking inappropriately to them. Despite this, there was no immediate investigation initiated at the time of the allegation. Interviews revealed that the Social Worker (SW) was informed by multiple staff members that there had been a verbal altercation between the resident and the ADON, and that the ADON later apologized to the resident. However, the SW did not follow up with either party or report the incident to the Administrator or Director of Nursing. The facility's policy required immediate investigation of any suspected or reported abuse, but this was not followed in this case.
Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the reach-in cooler, two egg salad sandwiches were found without a made-on date, only a use-by date, which the Dietary Director (DD) acknowledged should be discarded due to the risk of causing illness. Additionally, in the dry storage area, four bags of unopened marshmallows were found with an expired manufacturer's date, and the DD confirmed they should be discarded. Furthermore, in the overstock storage area, 70 cases of water were found with an expired manufacturer's date, and the DD noted that the Licensed Nursing Home Administrator (LNHA) was aware and working on obtaining a new supply. The surveyor also observed sanitation issues related to staff not wearing hair restraints in the kitchen area. The Speech Therapist (SP) and the Administrator of Pediatric Medical Daycare (APMC) were both seen without hairnets, despite acknowledging the requirement to wear them. The District Dietary Director (DDD) confirmed that staff should wear hair restraints and mentioned that the APMC frequently enters the kitchen without a hairnet, indicating a need for reeducation. The facility's policy on labeling food requires all products to be marked with a made-on and use-by date, which was not adhered to in the observed instances.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of the resident call bell system, which had the potential to affect all residents. During observations and interviews conducted in the presence of the Director of Maintenance (DOM), it was found that the call bell system's volume was not set to a level that could be heard, and the devices used to identify call bell notifications were not functioning properly. Specifically, in two separate rooms, the call bell light turned on when tested, but there was no audible notification, and the activation did not register at the nurse's station call bell annunciator. Additionally, visual notification of the activation was obstructed by a hallway wall. In another room, the call bell did not function at all due to broken pins in the call bell box, as confirmed by the DOM. Residents were present in the rooms during these tests, highlighting the immediate impact of the deficiency.
Deficiencies in Environmental Safety and Resident Care
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by several observations made by surveyors. On the Fourth Floor, a surveyor found dirty washcloths and a hairbrush in a central bath, a worn mattress in a resident's room, and a non-functional bathroom light and television in another resident's room. Interviews with staff revealed that these issues were known but not addressed, with the CNA and RN responsible for reporting such deficiencies to the unit manager, who in turn would use a computerized system to log maintenance requests. However, the system was not accessible to CNAs, and the issues remained unresolved. On the Third Floor, a surveyor noted a missing drawer in a resident's wardrobe, which had not been reported to maintenance. The Unit Manager was unaware of the missing drawer, and the Maintenance Director stated that room rounds were conducted every three to six months, with the last one in July 2024. The Director of Nursing confirmed that there should be no broken furniture in resident rooms, and the Licensed Nursing Home Administrator acknowledged the oversight after it was brought to their attention. On the Second Floor, a surveyor observed a trash can without a liner, disposable gloves in a whirlpool tub, and a full sharps bin that had not been emptied. Additionally, hair was found tangled in the wheels of medication carts, and residual stains and wrappers were present in the glove holder. During meal service observations, staff served residents on meal trays without removing items or inquiring about preferences, contrary to the facility's policy on providing a homelike environment and treating residents with dignity and respect.
Infection Control Deficiencies in Wound Care and Meal Service
Penalty
Summary
The facility staff failed to adhere to appropriate infection control practices in two specific instances. Firstly, during the provision of wound care to a resident with a sacral pressure ulcer, the Unit Manager did not wear a gown despite the resident being on Enhanced Barrier Precautions, which required gown and glove use for high-contact activities such as wound care. The absence of a bin containing personal protective equipment outside the resident's room was noted, and the Unit Manager acknowledged the oversight. The facility's policy on Enhanced Barrier Precautions, which mandates gown and glove use for residents with wounds or indwelling medical devices, was not followed. Secondly, during meal service on the 4th floor, three CNAs distributed meal trays to residents without performing hand hygiene beforehand, nor did they assist residents with hand hygiene before, during, or after the meal. Interviews with the CNAs, the Registered Nurse Unit Manager, the Infection Preventionist, and the Licensed Nursing Home Administrator confirmed that hand hygiene should have been performed by staff and assisted for residents. The facility's policies on hand hygiene and assistance with meals, which emphasize the importance of hand hygiene to prevent infection, were not adhered to.
Violation of Resident Privacy and Personal Property Rights
Penalty
Summary
The facility failed to maintain an environment that protected and valued a resident's private space and personal property, as observed during a survey. A housekeeper was seen wiping the inside of a resident's bedside drawer without permission, which was confirmed by the Registered Nurse Unit Manager (RN/UM#1) and the Housekeeping Director (HD) as inappropriate since the room was not scheduled for terminal cleaning. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed distress and did not give permission for the drawer to be accessed. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that residents have an expectation of privacy regarding their personal property. The facility's Environmental Services Operational Manual and Resident Rights policy emphasize treating residents with kindness, respect, and dignity, which was not upheld in this instance. The incident involved a resident with diagnoses including paranoid schizophrenia, anxiety disorder, and bipolar disorder, highlighting the importance of respecting their personal space and belongings.
Failure to Maintain Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call bell within reach for a resident, leading to a deficiency. During a survey, it was observed multiple times that the resident's call bell was on the floor under the bed, and the resident was unaware of its location. The resident had a BIMS score indicating intact cognition and was at risk for falls due to impaired balance and mobility. The resident's care plan specified that the call bell should be within reach at all times, yet this was not adhered to. Interviews with facility staff, including a CNA, RN, RN Unit Manager, and the DON, confirmed that call bells should be within reach and secured to the bed. The facility's policy also required staff to ensure call lights are accessible to residents. Despite these guidelines, the call bell was repeatedly found on the floor, indicating a failure to follow established procedures and policies, as acknowledged by the Licensed Nursing Home Administrator.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to maintain proper documentation and conduct a thorough investigation following a witnessed fall involving a resident. The incident occurred when a resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, and dementia, fell after their shoe came off while walking. The fall was witnessed by a certified nursing assistant, and the resident was found sitting on the floor with the back of their head having hit the wall. Despite the fall being witnessed, the facility did not complete a comprehensive investigation as required. The investigation was incomplete because the assigned nurse did not provide a statement detailing the fall, and there was no nurse's note in the electronic medical record progress notes regarding the incident. Interviews with the LPN Supervisor and LPN Unit Manager confirmed that the necessary documentation and witness statements were not gathered, and the Director of Nursing acknowledged the lack of a thorough investigation. Additionally, the facility's Accidents and Supervision policy did not offer specific guidance on conducting a thorough investigation, contributing to the deficiency.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the status of two residents in the Minimum Data Set (MDS), an essential assessment tool for facilitating care. For Resident #98, the surveyor observed a Wander guard on the resident's left ankle, which was ordered by a physician and documented in the Medication Administration Record. However, both the Quarterly and Annual MDS assessments incorrectly indicated that there was no wander/elopement alarm. The MDS Coordinator and the Director of Nursing confirmed the coding errors during interviews. For Resident #41, the surveyor observed the resident using oxygen via nasal cannula, which was consistent with the resident's medical history of Chronic Obstructive Pulmonary Disorder (COPD) and a physician order for continuous oxygen use. Despite this, the most recent Quarterly MDS assessment incorrectly coded the resident as not using oxygen. The MDS Coordinator and the Licensed Nursing Home Administrator acknowledged the error, confirming that the resident's oxygen use should have been accurately reflected in the MDS.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the care plan did not specify the focus areas related to their risk for mood impairment, use of psychotropic medications, anti-anxiety medications, and antidepressant medications. The care plan lacked details on what the mood impairment was related to and did not specify the medications involved. Additionally, the resident could not recall if the facility had ever discussed their care plan with them, indicating a lack of communication and involvement in the care planning process. For another resident, the facility failed to include a care plan focus area or interventions for significant weight loss, despite the resident experiencing a weight loss greater than 5% in a month or 10% in six months. The Registered Dietitian acknowledged that a focus should have been added to the care plan for the significant weight change, and the Director of Nursing confirmed that the dietitian should have been responsible for updating the care plan. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain thorough documentation following a witnessed fall, which is a deficiency in meeting professional standards of clinical practice. This issue was identified for one resident who experienced a fall without injury. The fall occurred when the resident's shoe came off while walking, causing them to fall and hit the back of their head against the wall. Despite the incident being witnessed by a certified nursing assistant, there was no documentation in the resident's medical record regarding the fall. The resident involved in the incident had a medical history that included cerebral infarction, hemiplegia, hemiparesis, and dementia. The resident's cognitive function was severely impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The lack of documentation was confirmed by multiple staff members, including a Licensed Practical Nurse Supervisor, a Registered Nurse, and a Licensed Nurse Unit Manager, all of whom acknowledged that the assigned nurse was responsible for entering the assessment into the progress notes. The facility's protocol required detailed documentation of falls, including vital signs, range of motion, and any injuries or changes in condition. However, the surveyor found that there was no progress note or electronic medical documentation from the assigned nurse detailing the fall. The Director of Nursing and the Licensed Nursing Home Administrator both acknowledged the absence of necessary documentation, which was a clear deviation from the facility's established protocols for assessing and documenting falls.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. For Resident #120, the catheter drainage bag was observed resting on the floor and unsecured to the bed, contrary to the physician's order to document catheter output every shift. The Treatment Administration Record for Resident #120 showed blank sections on multiple dates, indicating a lack of documentation for catheter care. During an interview, the Licensed Practical Nurse acknowledged that the bag should not be on the floor, and the Director of Nursing confirmed that the bag should be secured to the bed frame and not in contact with the floor for infection control reasons. Resident #21 was observed with a urinary catheter drainage bag laying on top of the bed without a privacy bag and visible from the hallway. The bag was also hooked onto the right arm of the resident's wheelchair, positioned above the bladder, which is against the facility's policy. The Treatment Administration Record for Resident #21 also showed blanks for monitoring Foley catheter output. Interviews with the Unit Manager and Infection Preventionist confirmed that the catheter bags should be below the bladder level and covered with privacy bags to prevent infection. The facility's policy on catheter care emphasizes the importance of maintaining the drainage bag below the bladder level and ensuring privacy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment, specifically nebulizer masks and nasal cannulas, in accordance with professional standards of practice. For Resident #72, a nebulizer mask was observed unsecured and exposed to air in an open drawer, and nebulizer tubing was found extending into a closed drawer without a date label. The Registered Nurse/Unit Manager acknowledged that the equipment should normally be stored in a bag, and the Infection Preventionist confirmed that all equipment should be stored in a bag with the resident's name and date on it. Similarly, for Resident #19, a nebulizer mask and nasal cannula were observed unsecured and exposed to air on a nightstand and hanging from an oxygen concentrator. The nasal cannula was also found on the floor and hanging from the back of the resident's chair. Resident #19 had a medical history of acute respiratory failure and chronic obstructive pulmonary disease (COPD), with orders for nebulization and continuous oxygen therapy. The Unit Manager and Infection Preventionist both stated that the equipment should be stored in bags when not in use, and the Director of Nursing confirmed that it should not be left open to air or on the floor.
Delayed Response to Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident admitted with Alzheimer's Disease and Protein-Calorie Malnutrition. The CP had recommended clarifying the resident's liquid Colace order to include specific concentration and dosage details. This recommendation was initially made on May 22, 2024, and reiterated on June 24, 2024, but was not acted upon until July 6, 2024, when the original order was discontinued and a new order was written. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for handling CP recommendations was not followed as intended. The ADON stated that recommendations are typically sent to the doctor for review and completed within a day or two, but could not recall why this particular recommendation was delayed. The DON acknowledged that the recommendation should have been completed sooner, despite the facility's policy stating that CP recommendations should be communicated and responded to in a timely fashion.
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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