Shore Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toms River, New Jersey.
- Location
- 231 Warner Street, Toms River, New Jersey 08755
- CMS Provider Number
- 315454
- Inspections on file
- 16
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shore Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and communication deficits experienced an unwitnessed fall and complained of left leg pain while found on the floor partially supported by a chair. An LPN documented no visible injury, noted repeated refusals of pain medication, assisted the resident to bed, and did not return to reassess, later stating they needed to complete a med pass and did not inform the physician of the pain complaint, assuming it was due to chronic arthritis. Neurological flow sheets for the post-fall period contained multiple blanks and incomplete entries for level of consciousness, movement, and staff initials. The DON confirmed that required post-injury monitoring, pain assessment, and direct provider notification were not carried out as expected under facility policies, and the resident was later sent to the hospital for evaluation of left hip pain and a femur fracture.
Surveyors found that the facility failed to provide a safe, clean, and homelike environment, with widespread issues such as peeling paint and wallpaper, broken and soiled furniture, stained toilets, and unclean AC units across all nursing units. Staff and residents confirmed that these problems were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction.
Surveyors identified widespread deficiencies in the facility's environment, including peeling paint, broken furniture, soiled floors, stained toilets, and damaged shower areas. Staff and residents confirmed that these issues were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction. Facility leadership acknowledged awareness of the problems, but documentation did not show that repairs or replacements had been completed.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as dirty floors, broken furniture, and unsanitary conditions observed across multiple units. Staff interviews revealed a lack of communication and follow-through on maintenance and housekeeping concerns, with the Maintenance Director confirming that issues should be addressed within 24 hours. Despite acknowledgment of the poor conditions by the DON and LNHA, no concrete plans for improvement were provided.
The facility failed to properly store potentially hazardous foods and maintain kitchen equipment in a sanitary manner. Opened boxes of raviolis and chicken breasts were found unsealed and unlabeled in the freezer, and the steam table contained murky water with food particles. Additionally, cutting boards were deeply pitted and discolored. The FSD acknowledged these issues, and the LNHA and DON were informed but provided no further information.
The facility failed to properly label and store medications and medical supplies, as observed on two medication carts and in a storage room. Expired medications were found, and supplies were improperly stored under a sink, posing infection control risks. Staff confirmed the deficiencies.
The facility failed to provide a dignified dining experience for residents by serving beverages in disposable plastic cups, as observed in one dining room. The LNHA and DON did not refute this concern, and the facility's meal assistance policy did not address the use of non-disposable dinnerware, leading to a deficiency in promoting dignity and respect.
A resident requested a lock for their closet to prevent theft, but the facility failed to install the necessary hardware despite the request being documented. The resident, who was cognitively intact and independent, experienced instances of their closet being found open. Interviews revealed that the facility's policy required residents or families to provide padlocks, while the facility provided hardware, but the lock was not installed.
An LPN failed to secure a medication cart during administration, leaving it unlocked and out of sight while attending to a resident. This action violated the facility's policy, which mandates that medication carts be locked when not in direct view. The incident was confirmed by the LPN/Unit Manager and acknowledged by the facility's administration.
A facility failed to obtain a physician's order for oxygen tubing care and did not develop a comprehensive care plan for a resident receiving oxygen therapy. The resident, with moderate cognitive impairment and multiple medical conditions, had an oxygen concentrator with improperly placed tubing. The physician's order for oxygen administration was present, but there was no order for tubing changes, and these changes were not documented in the EMR. The facility's policy lacked guidelines for oxygen tubing care, and the resident's care plan did not address respiratory care.
The facility failed to ensure proper accountability of narcotic shift count logs on two medication carts. On one cart, a pre-signed outgoing nurse signature was found, while on another, multiple missing signatures were identified for various shifts. The DON and IP confirmed that narcotics should be counted and signed by both incoming and outgoing nurses at shift changes, as per the facility's policy.
The facility failed to properly dispose of garbage and maintain the grounds, leading to potential rodent and pest issues. Observations included construction debris, litter, and numerous cigarette butts scattered across the grounds. The LNHA acknowledged the problem, and interviews revealed that the MD and HD were unaware of their responsibilities for grounds maintenance until recently.
A facility failed to follow proper infection control practices during medication administration. An LPN was observed handling medication tablets with bare hands without performing hand hygiene or wearing gloves. Interviews with other staff revealed inconsistencies in understanding and implementing proper procedures for medication handling, highlighting a lack of adherence to the facility's hand hygiene policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse involving two cognitively impaired residents. The incident was reported by a family member who found one resident partially undressed. The LNHA forwarded the grievance to the SW, but no investigation was initiated, and key staff were not informed. Interviews revealed a lack of awareness and communication about the incident, and facility policies on abuse prevention and investigation were not followed.
A facility failed to address a grievance regarding alleged resident-to-resident sexual abuse. A family member reported finding a resident in a compromised state with another resident, but the grievance was not properly investigated. The Social Worker did not involve key staff or complete the grievance process as per policy, leading to a deficiency.
A facility failed to investigate an allegation of resident-to-resident sexual abuse properly. A resident was found partially undressed and distressed by a family member, who reported the incident. The LNHA did not read the complaint immediately and only forwarded it to the SW, who did not conduct a comprehensive investigation. The facility's policies on abuse prevention and grievance handling were not followed, highlighting lapses in management and oversight.
Failure to Adequately Assess, Monitor, and Communicate After Unwitnessed Fall With Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to properly assess, acknowledge, monitor, and communicate about pain, and to implement appropriate interventions following an unwitnessed fall with a resulting femur fracture for one resident. The resident had dementia and was documented on the MDS as rarely or never understood, with long- and short-term memory problems. On the evening of 4/2/25, an LPN found the resident on the floor in their room, with the upper body leaning halfway on a chair. The resident could not give an accurate statement but complained of left leg pain. The LPN’s assessment documented no visible injury, no swelling, redness, or signs of trauma, and noted that the resident was offered pain medication but refused it three times before being assisted to bed. The LPN later stated in interview that the resident complained of leg pain, was able to take a couple of steps to the bed, and that the LPN did not return to check on the resident after the initial assessment because the resident did not require pain medication and the LPN needed to complete a medication pass. The LPN reported calling and leaving a message for the physician and calling the family, but did not inform the physician that the resident was complaining of pain, explaining that the resident always complained of leg pain from arthritis. There was no progress note identified from the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts documenting the fall beyond the late entry note, and the care plan later reflected that the resident was sent to the hospital for evaluation of left hip pain after the unwitnessed fall. Review of the neurological flow sheet from the time of the fall through the following morning showed multiple incomplete entries. The resident’s level of consciousness was not completed for several time points overnight, with only a notation of sleep, and movement entries were missing or marked as refused, including a blank entry at 3:00 a.m. The initials section was left blank for multiple time slots on the evening and overnight shifts. The DON stated that after an injury the nurse should monitor a resident according to the neurological flow sheet and complete pain monitoring for 48 hours, that no blanks should be present on the neurological flow sheet, and that the LPN should have spoken directly to the provider and explained that the resident was in pain rather than just leaving a message. Facility policies required immediate practitioner notification by phone when a fall results in significant injury or condition change, observation and documentation of delayed complications for approximately 48 hours, and documentation of pain and related signs and symptoms, as well as prompt initiation and documentation of accident/incident investigations and care plan review when desired outcomes are not met.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across all three nursing units. Observations included widespread issues such as peeling wallpaper and paint, cracked and stained ceiling tiles, broken or missing furniture parts, stained and soiled floors, and malfunctioning or dirty air conditioning units. Bathrooms were found with cracked tiles, stained or rusted toilet bowls, missing or damaged grab bars, and peeling paint. Common areas, such as dayrooms and shower rooms, also exhibited soiled and damaged furniture, missing grout, and rusted fixtures. These conditions were confirmed by both staff and residents, with some residents reporting that broken furniture and soiled conditions had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While a computerized work order system was in place, several staff members admitted to being aware of broken or damaged items but did not always submit maintenance requests. Housekeeping staff reported daily cleaning routines, but surveyors observed persistent soiling and debris, particularly in and around AC units and on furniture. Maintenance staff acknowledged that many of the environmental issues predated their employment and that repairs were often limited to what was immediately visible or reported. The Environmental Service Director and other staff confirmed that some cleaning and maintenance tasks, such as cleaning AC units and replacing filters, were not consistently performed as required. The facility had previously been cited for similar deficiencies and had submitted a plan of correction, which included staff education and regular audits of resident rooms and common areas. However, during the current survey, many of the same issues remained unaddressed, and staff acknowledged that corrective actions had not been fully implemented. Facility leadership, including the LNHA, confirmed awareness of the ongoing environmental concerns and acknowledged the poor condition of resident rooms, bathrooms, and common areas during the survey tour.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of the facility's Quality of Life - Homelike Environment policy and procedures, resulting in a failure to provide a safe, clean, comfortable, and homelike environment for residents. During a survey, multiple deficiencies were observed across all three nursing units, including resident rooms with peeling wallpaper and paint, broken or damaged furniture, soiled and stained floors, stained toilet bowls, grab bars coming off the walls, holes in walls, missing trim, and discolored ceiling tiles. In addition, shower rooms were found with rusted fixtures, damaged shower curtains, broken soap holders, and missing grout. These conditions were confirmed by both staff and residents, with some residents reporting that issues such as broken furniture and soiled areas had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While some staff were aware of the process for submitting maintenance requests through a computerized work order system, not all concerns identified by the surveyor were present in the system. Housekeeping and maintenance staff stated that cleaning and maintenance tasks were performed regularly, but acknowledged that certain issues, such as rust stains in toilets and soiled air conditioning units, had not been adequately addressed. The Environmental Service Director and other staff confirmed the presence of these deficiencies during the surveyor's walkthroughs. The LNHA and other facility leadership acknowledged awareness of the environmental issues and confirmed that many of the problems identified by the surveyor were known to them. Despite previous citations for similar deficiencies and a plan of correction that included regular audits and cleaning protocols, the survey found that many of the same issues persisted. Documentation provided by the facility, such as a quote and a check for new furniture, did not demonstrate that corrective actions had been completed, and there was no evidence that the necessary repairs or replacements had been made at the time of the survey.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment across multiple units, as evidenced by several observations made by the surveyor. On the initial tour, the surveyor noted dirty and discolored floors in the lobby and elevators. In resident rooms, there were issues such as soiled and sticky floors, overflowing trash, broken furniture, and missing or damaged fixtures. The Registered Nurse acknowledged awareness of these issues but admitted to not reporting them through the facility's computer system, which is used to notify housekeeping and maintenance departments. Interviews with various staff members, including the Housekeeping Director, Maintenance Assistant, and Licensed Practical Nurse, revealed a lack of communication and follow-through regarding maintenance and housekeeping concerns. The Maintenance Assistant and Housekeeping Director were unaware of specific issues until pointed out by the surveyor, and the Maintenance Director confirmed that maintenance issues should be addressed within 24 hours of receiving a work order. However, the system's effectiveness was questioned as several staff members reported that concerns were not always addressed promptly. Further observations included damaged walls and furniture in the dining room and resident rooms, as well as unsanitary conditions in the shower room. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the poor environmental conditions and mentioned discussions with corporate about replacing furniture, but no concrete plans were provided. The facility's policies on maintenance and housekeeping were not effectively implemented, leading to the observed deficiencies.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner, as observed by the surveyor. In the walk-in freezer, an opened box of raviolis and an opened box of chicken breasts were found in unsealed bags, exposing the contents to air and ice crystals. These items were not labeled with opened or use-by dates, and the Food Service Director (FSD) could not confirm when the packages were opened. Additionally, the steam table contained murky water with food particles, indicating it had not been drained and cleaned as required. The FSD admitted that the steam table water should be changed daily, but there were no work accountability logs to verify when it was last done. Furthermore, four plastic cutting boards were found to be deeply pitted and discolored, suggesting inadequate cleaning and maintenance. The FSD acknowledged that the freezer items should have been labeled and sealed, and that the cooking equipment should have been cleaned to prevent foodborne illness. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were informed of these issues but did not provide additional information. The facility's policies on sanitation and food storage were reviewed, revealing requirements for maintaining cleanliness and proper labeling, which were not adhered to in this instance.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as observed during a survey. On the Third-floor high side nursing unit's medication cart, fourteen individual, single-use vials of ipratropium bromide/albuterol sulfate inhalation solution were found in an opened foil pouch with a hand-written opened date of 1/2/24, despite the manufacturer's instructions indicating the medication should be used within two weeks of opening. Similarly, on the Second-floor low side nursing unit's medication cart, two boxes of the same medication were found with opened foil pouches, one dated 12/7 and the other undated, both exceeding the recommended usage period. The LPNs present confirmed the medications were expired and should have been discarded. Additionally, the Second-floor medication storage room contained improperly stored medical supplies and expired medications. Items such as sterile dressings, feeding tube irrigation sets, and nebulizer machines were stored in a cabinet under the sink, which was confirmed by the LPN/Unit Manager to be an unacceptable storage area due to infection control risks. Expired intravenous solutions were also found in the storage room. The Director of Nursing and the Infection Preventionist acknowledged the deficiencies, confirming that medications should be labeled with the date opened and discarded upon expiration, and that medical supplies should not be stored in areas that pose an infection control risk.
Deficiency in Resident Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of the three dining rooms. On February 13, 2025, during the lunch meal on the third-floor nursing unit, 14 residents were served cold beverages in disposable plastic cups. This practice was observed by the surveyor and was not refuted by the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) during an interview on February 14, 2025. The facility's Assistance with Meals policy, revised in March 2022, emphasized meal assistance with attention to safety, comfort, and dignity but did not address the use of non-disposable dinnerware. This oversight led to a deficiency in promoting dignity and respect for the residents' dining experience.
Failure to Provide Lock for Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident was provided with a lock to prevent the loss or theft of personal items. This deficiency was identified for a resident who was cognitively intact and independent in activities of daily living. The resident had requested a lock for their closet door after being moved to a new room, as they experienced instances where their closet was found open in the morning. Despite the request being documented in the facility's work order system, the lock and necessary hardware were not installed on the closet door. Interviews with facility staff revealed that the Licensed Practical Nurse/Unit Manager was aware of the lock request and had notified maintenance through the TELS system. However, the facility's policy required the family or resident to provide the padlock, while the facility provided the hardware. The Maintenance Director confirmed that he was informed of such requests through the work order system. The Licensed Nursing Home Administrator stated that the facility did not provide locks for residents, indicating a gap in the process that led to the resident's request not being fulfilled.
Medication Cart Security Lapse During Administration
Penalty
Summary
The facility failed to ensure that the medication cart was secured during medication administration, which is a violation of professional standards of clinical practice. This deficiency was observed when an LPN left the medication cart unlocked and out of sight while administering medications to a resident. The incident occurred when the LPN parked the medication cart outside the resident's room, sanitized their hands, and prepared the medications, including oral medications and injectable insulin pens. The LPN then walked to the resident's bedside, leaving the cart unattended and unlocked, despite acknowledging that it should have been locked. The facility's policy on administering medications requires that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. During an interview, the LPN/Unit Manager confirmed that nurses should always lock the cart and minimize the computer screen when stepping away. The surveyor discussed the findings with the Licensed Nursing Home Administrator and the Director of Nursing, who did not dispute the observations. The deficiency was identified for one of the four residents observed during medication administration.
Failure to Obtain Physician's Order and Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the care of oxygen tubing and did not develop a comprehensive care plan for a resident receiving oxygen therapy. During an initial tour, a surveyor observed an oxygen concentrator in a resident's room with nasal oxygen tubing improperly placed. The resident, who had moderate cognitive impairment and medical diagnoses including chronic obstructive pulmonary disease, heart failure, and kidney failure, informed the surveyor that they had removed the oxygen. The physician's order for oxygen administration was present, but there was no order for changing the nasal cannula tubing, and the tubing changes were not being documented in the Electronic Medical Record (EMR). The facility's policy on oxygen administration, last revised in 2010, did not include guidelines for the care of oxygen tubing. Additionally, the resident's comprehensive care plan lacked a focus area for respiratory care or oxygen. When questioned, the Director of Nursing confirmed that a care plan should be in place for any resident receiving oxygen therapy. This deficiency was identified in one of the four residents reviewed for oxygen therapy.
Narcotic Count Log Deficiency
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, as observed by surveyors on two of three medication carts. On the third-floor high side nursing unit's medication cart, a pre-signed outgoing nurse signature was found for the shift-to-shift narcotic count for a specific shift. The LPN confirmed that the log was pre-signed and should have been signed in the presence of the incoming nurse after a narcotic count was completed. On the second-floor low side nursing unit's medication cart, multiple missing nurses' signatures were identified for various shifts throughout January 2025. The LPN confirmed that the incoming and outgoing nurses were supposed to count the narcotics together and sign the log at the time of shift change. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that medication cart narcotics were to be counted and immediately signed by the incoming and outgoing nurses at the time of shift change. They acknowledged that there should not have been any pre-signed spaces or blanks for previous shifts, and missing documentation indicated the count was not done. The facility's Controlled Substance policy, revised in November 2022, requires nursing staff to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses making the count together and documenting any discrepancies.
Improper Garbage Disposal and Grounds Maintenance
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, leading to a potential rodent and pest problem. During a tour of the facility grounds and loading dock area, the surveyor observed construction debris, broken pallets, plastic wrap, Styrofoam panels, and paper litter scattered across the grassy side yard visible from the first-floor residents' windows. Additionally, numerous cigarette butts were found on the ground along the driveway and grassy area, with a cigarette receptacle lying on its side. Behind a short brick wall, more construction debris, metal benches, milk cartons, and tarps were found haphazardly thrown. Further observations behind a large blue storage trailer shed revealed orange milk crates, construction trash, soda cans, and gloves on the ground. Around the facility's three green trash dumpsters, gloves, soda cans, and cigarette butts were also present. The Licensed Nursing Home Administrator (LNHA) acknowledged the concern, stating it was unfair for residents to view such conditions and that the trash could lead to a rodent and pest problem. Interviews with the Maintenance Director (MD) and Housekeeping Director (HD) revealed that both were unaware of their responsibilities for grounds maintenance until recently. The facility's undated policies on grounds maintenance, food-related garbage and refuse disposal, and smoking were reviewed, indicating that maintenance should keep the grounds free of litter and that storage areas should be kept clear at all times.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection control practices during medication administration, as observed by a surveyor. Specifically, an LPN was seen preparing medications for a resident without performing hand hygiene or donning clean gloves. The LPN used their bare fingers to handle a vitamin tablet, which is against the recommended practices for infection control. When questioned, the LPN acknowledged the mistake and admitted that the contaminated tablet should have been discarded. Further interviews with other staff members, including another LPN and the LPN/Unit Manager, revealed inconsistencies in the understanding and implementation of proper procedures for obtaining medications from a bottle. The staff members provided varying responses regarding the use of gloves and hand hygiene, indicating a lack of uniformity in following the facility's hand hygiene policy. The facility's policy states that hand hygiene should be performed before and after handling medications, but this was not consistently practiced by the staff.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident sexual abuse involving two residents, one with severe cognitive impairment and the other with moderate cognitive impairment. The incident was reported by a family member of the alleged victim, who observed the two residents in a compromising situation. The family member's email described finding the alleged victim partially undressed and frazzled, with a staff member allegedly stating that such interactions were common and left unaddressed. The License Nursing Home Administrator (LNHA) received the grievance via email and forwarded it to the Social Worker (SW) with instructions to write a grievance. However, the SW did not initiate an investigation or follow the facility's policies on abuse reporting and investigation. The SW attempted to arrange an Interdisciplinary Care Team (IDCT) meeting to address the grievance but did not complete the grievance process or involve key staff members such as the Director of Nursing (DON) or the Unit Manager. Interviews with facility staff revealed a lack of awareness and communication regarding the alleged incident. The Unit Manager and Behavioral Monitoring Aide were unaware of any resident-to-resident sexual abuse, and the assigned CNA had never observed the two residents together. The facility's policies on abuse prevention and investigation were not followed, as the Administrator did not ensure a thorough investigation or keep the resident and family informed of the investigation's progress.
Removal Plan
- Initiating an investigation related to the grievance/allegation of the resident to resident sexual abuse.
- Completing an assessment related to any signs and symptoms of psycho-social concerns.
- Initiating in-services for the SW and all staff on the facility's policy on Abuse and Neglect, Investigating and Reporting, the Abuse Prevention Program Policy, and the Grievance Policy and Procedure.
- Auditing of incidents and accident reports and grievances to ensure there were not any additional unresolved investigative allegations of abuse, abuse, and neglect identified.
Failure to Address Grievance of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Grievance Policy and Procedure and the Social Worker Job description after a family member of a resident made an allegation of sexual abuse. The incident involved two residents, one with severely impaired cognition and the other with moderate cognitive impairment. The family member reported finding the resident in a compromised state with another resident in the room, and a staff member allegedly stated that such incidents were known but not addressed. The grievance was initially reported via email to the Licensed Nursing Home Administrator (LNHA), who forwarded it to the Social Worker (SW) for investigation. However, the SW did not conduct a comprehensive investigation or involve key personnel such as the Director of Nursing (DON), unit manager, or other nurses. The SW suggested an Interdisciplinary Care Team (IDCT) meeting to address the grievance, but the family member could not attend. The grievance process was not completed as per the facility's policy, and the IDCT did not review the complaint in a timely manner. Interviews with various staff members, including the Unit Manager, Behavioral Monitoring Aide, and Certified Nursing Assistant, revealed a lack of awareness of any resident-to-resident sexual abuse. The facility's policy requires prompt investigation and resolution of grievances, but this was not adhered to in this case. The Director of Nursing was unaware of the grievance, and the LNHA expected a full investigation, which was not carried out, leading to the deficiency.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility's administration failed to conduct a thorough and complete investigation into an allegation of resident-to-resident sexual abuse, as required by their policies. This deficiency was identified during a survey conducted on specific dates in November 2024. The incident involved two residents, one of whom was found in a compromised state by a family member. The family member reported the incident via email, describing how they found their relative partially undressed and distressed, with another resident quickly leaving the room. The family member also mentioned that a staff member had previously observed similar incidents but did not intervene. The facility's policies on abuse prevention, grievance handling, and investigation were not followed. The Licensed Nursing Home Administrator (LNHA) received the complaint but did not read it immediately and only forwarded it to the Social Worker (SW) the following day. The SW, upon receiving the email, attempted to investigate by speaking with Certified Nursing Assistants (CNAs) but did not engage with other key personnel such as nurses, the Director of Nursing (DON), the Unit Manager, or the Administrator. This lack of comprehensive investigation and communication among staff members contributed to the failure to address the serious allegation appropriately. The facility's policies clearly outline the responsibilities of the administration in investigating allegations of abuse, ensuring resident safety, and maintaining open communication with residents and their families. However, these procedures were not adequately implemented in this case. The Administrator's job description emphasizes the importance of directing the facility's functions in compliance with regulations to ensure quality care, which was not achieved in this instance. The failure to follow established protocols and ensure a thorough investigation highlights significant lapses in the facility's management and oversight of resident safety and rights.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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