Silver Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherry Hill, New Jersey.
- Location
- 1417 Brace Road, Cherry Hill, New Jersey 08034
- CMS Provider Number
- 315280
- Inspections on file
- 30
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Silver Healthcare Center during CMS and state inspections, most recent first.
A high fall-risk resident with dementia, prior fractures, muscle weakness, and a history of recent unwitnessed falls was placed on 1:1 supervision. During an evening shift change, the CNA assigned as the 1:1 monitor reported telling an LPN that the resident required continuous supervision and stated that the LPN asked another CNA to watch the resident, but no clear handoff or acceptance of responsibility was documented. The LPN later stated no one spoke with him about the resident’s care, and another CNA who arrived shortly after observed the resident in a wheelchair near the nurse’s station, then saw the resident stand and fall against the wheelchair before she could intervene, without indicating she had been assigned as the 1:1 monitor. The resident sustained a skin tear and forehead bruise, later developed new-onset aphasia, and was admitted to the hospital with a subdural hematoma. Facility leadership and policy required that a designated 1:1 monitor remain within eyesight of the resident and not discontinue supervision until another staff member confirmed taking over, but assignment records did not identify who was responsible for 1:1 monitoring on the overnight shift.
A cognitively impaired resident with a known history of exit-seeking behaviors eloped from the facility after staff failed to maintain adequate supervision and did not communicate effectively about monitoring responsibilities. The resident was able to leave the unit by accessing an elevator without a security code and exited the building undetected during a period of increased activity at the main entrance. The resident was later found outside the facility and returned without injury.
The facility failed to complete DEA 222 forms accurately for controlled medications, missing details on the number and date of receipt. The DON was unaware of the requirement to fill in Part 5, and the MD only signed the forms without verifying medication receipt. The CEO/CP confirmed the nursing department's responsibility for documentation, but the Consultant Pharmacist had not checked the forms as required.
The facility failed to follow physician's orders and nursing standards during medication administration for two residents. An LPN did not remove a Lidocaine patch as ordered, due to a transcription error, and another LPN administered blood pressure medications without rechecking a low diastolic reading or consulting a physician. Both actions were against the facility's medication administration policy.
An LPN failed to follow proper infection control practices during medication administration, including inadequate hand hygiene and not cleaning a blood pressure cuff between residents. The LPN did not sanitize her hands after turning off a faucet with bare hands and prepared medications for a resident on Enhanced Barrier Precautions without performing hand hygiene. The facility's policies on hand hygiene and equipment cleaning were not adhered to, leading to potential infection control issues.
The facility failed to properly store Alcohol Based Hand Rub (ABHR) dispensers, exceeding the five-gallon limit in a single smoke compartment. Observations in Atrium Building #1 revealed 61 cases of ABHR, totaling approximately 96 gallons, stored in Resident room #308. The dispensers contained 80% ethyl alcohol and were not stored according to safety standards, as noted during a Life Safety survey.
The facility did not maintain the required minimum direct care staff to resident ratio as mandated by New Jersey law. During a recertification survey, it was found that the facility was short of CNAs on six out of fourteen day shifts, with the number of CNAs ranging from 10 to 15, while at least 16 were required. Interviews with the Staffing Coordinator and DON confirmed awareness of the staffing requirements, yet the facility's policy was not followed.
The facility did not meet the mandatory nurse staffing requirements for one day, providing 360 actual staffing hours instead of the required 379.25 hours. The DON acknowledged occasional low staffing days but was unsure of the reasons. The facility's staffing policy emphasized adjusting staffing based on resident acuity and care needs.
The facility did not send their Emergency Preparedness Plan (EPP) to the Camden County and Local Office Emergency Management officials for review, as required. This deficiency was identified during a review of the EPP book, which showed no evidence of submission from January 2023 to December 2024. The Administrator could not provide documentation of the EPP being sent, affecting all 132 residents.
The facility failed to maintain proper food safety and sanitation standards, as observed by surveyors. Issues included exposed food in storage areas, a dirty ice machine, improper chemical storage, and inadequate dishwashing sanitization due to a lack of chemical sanitizer. The facility's cleaning schedules did not address necessary maintenance tasks, contributing to these deficiencies.
The facility failed to maintain a clean and safe environment, with surveyors observing unlined trash receptacles, improper disposal of soiled items, and unswept floors. Maintenance issues included stained ceiling tiles, missing drawers, holes in walls, and broken blinds. Staff interviews revealed a lack of timely reporting and repair, with the Executive Director acknowledging the need for increased maintenance rounds.
Two residents with ventilator dependence were admitted to the facility, but their care plans failed to document essential needs such as tracheostomy, ventilator use, and oxygen requirements. The care plans were not completed within the required timeframe, and staff interviews revealed inconsistencies in care plan responsibilities.
A resident with severe cognitive impairment and multiple medical conditions was moved to a private room with a non-functional bathroom, compromising their dignity and safety. The bathroom was bolted shut due to water damage, and repairs were delayed. Staff interviews revealed the resident had to use alternative bathrooms, and the move was attributed to an error by a former Unit Manager. Facility policies on maintaining a safe environment were not followed, as evidenced by incomplete repairs and inappropriate room transfer.
A resident with a fracture was not scheduled for a follow-up with an orthopedic surgeon, and the prescribed splint was not consistently used. The resident, who was cognitively impaired, returned from the hospital with instructions for non-weight bearing and splint use, but the facility failed to ensure compliance. The BOM and LNHA acknowledged the facility's responsibility to cover the appointment costs, but the follow-up was not pursued, and documentation of splint use was inconsistent.
A resident with a urinary catheter was observed with their drainage bag improperly managed, being in contact with the floor and not secured to the bed frame, contrary to physician orders and care plan instructions. Interviews with facility staff confirmed the risk of infection from such practices, and the facility's policy emphasized the importance of keeping catheter equipment off the floor.
Two residents in a LTC facility did not receive proper respiratory care. One resident with severe respiratory conditions was found without oxygen delivery due to an empty tank and non-functioning concentrator, with outdated tubing and an unreachable call bell. Another resident with a tracheostomy had undated respiratory equipment and lacked a physician's order for oxygen flow rate. Staff interviews confirmed these deficiencies, highlighting a failure to follow the facility's oxygen administration policy.
The facility failed to ensure proper accountability of narcotic shift count logs, as observed by a surveyor. On two medication carts, missing nursing signatures and pre-signed sections were found in the narcotic logbooks. LPNs confirmed these discrepancies, acknowledging that logs should not have pre-signed sections and that all counts should be documented at the time they are completed. The ADON confirmed that the facility's policy requires incoming and outgoing nurses to count narcotics together and sign the logs to confirm the count.
A surveyor found deficiencies in medication storage and labeling at a facility, including undated and unlabeled fluticasone nasal spray bottles and a tuberculin PPD vial. Staff confirmed that opened medications should be dated and labeled with resident information, as per facility policy.
The facility failed to adhere to infection control standards in respiratory care for two residents. A resident's suction catheter was improperly stored, uncovered in a drawer, contrary to facility policy. Another resident received tracheostomy care without proper hand hygiene between glove changes, as the respiratory therapist followed an outdated policy. The Infection Preventionist confirmed these practices did not comply with current facility policies.
A resident was not offered the pneumococcal vaccination upon admission due to confusion over consent responsibilities and lack of a Unit Manager. The resident's immunization status was not updated in the EHR, and the facility's policy requiring vaccination assessment within five days was not followed.
The facility failed to notify CMS and apply for a name change to include Doing Business As (DBA) in accordance with 42 CFR 424.516. The facility's documentation inconsistently used the names The Grove Center for Rehabilitation and Healthcare and The Grove at Cherry Hill, while the official license listed Silver Healthcare Center. The Executive Director admitted they had not completed the necessary CMS 855 B form, leading to the deficiency finding.
Failure to Maintain Continuous 1:1 Supervision for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate monitoring and supervision to prevent a fall for a resident who was assessed as high risk for falls and placed on one-to-one supervision. The resident had multiple diagnoses including rib fractures, head laceration, prior unspecified fall, muscle weakness, lack of coordination, and unspecified dementia with moderate cognitive impairment (BIMS 12/15). The resident used a wheelchair, had impaired upper extremity range of motion, and was dependent on staff for transfers. Prior to the cited event, the resident had a history of falls, including an unwitnessed fall where the resident reported bumping their head and another unwitnessed fall in the bathroom resulting in a head hematoma and laceration, after which the resident’s fall risk score increased and one-to-one supervision was initiated. On the date of the incident, the resident was on one-to-one monitoring during the 3:00 PM–11:00 PM shift. The CNA assigned as the one-to-one monitor stated that she was responsible for remaining with the resident at all times unless relieved, consistent with facility expectations. Near the end of her shift, this CNA reported informing an LPN that the resident required one-to-one monitoring and stated that the LPN then asked another CNA to watch the resident, although she could not identify that CNA. The unit manager and DON both stated that a resident on one-to-one supervision should always have a staff member with them and that supervision should not be discontinued until another staff member confirms taking responsibility, as required by the facility’s continuous 1:1 supervision policy. Around the time of shift change, documentation and staff statements showed a gap in clearly assigned supervision. The RN’s incident report and handwritten statement indicated that the resident’s one-to-one monitor had left and that the RN was unsure when the one-to-one and the resident separated or whether the resident had been placed in the care of the LPN. The LPN’s written statement indicated that no one spoke with him about the resident’s care and he denied assuming responsibility or witnessing the fall. Another CNA reported clocking in shortly after 11:00 PM, seeing the resident in a wheelchair across from the nurse’s station, and then observing the resident stand and walk, with the wheelchair spinning and the resident striking their face and arm before the CNA could reach them; this CNA did not state that she had been assigned as the one-to-one monitor. The resident sustained a skin tear to the arm and later was noted to have a forehead bruise and new-onset aphasia, and was subsequently admitted to the hospital with a subdural hematoma. The DON acknowledged that assignment sheets did not identify who was assigned as the resident’s one-to-one monitor for the 11:00 PM–7:00 AM shift, demonstrating that the facility did not ensure continuous, clearly assigned one-to-one supervision as required by its policy.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Lapses in Environmental Controls
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors and prior elopement attempts was not adequately supervised, resulting in the resident eloping from the facility. The resident was on a 15-minute monitoring schedule, and staff last observed the resident pacing in the hallway before the incident. The assigned CNA was providing care to another resident and did not inform the nurse that she would be unavailable to monitor the resident at risk for elopement. The nurse was also engaged in medication pass and was not aware that the CNA was occupied, leading to a lapse in supervision. During this period, the resident was able to leave the unit, likely by following a visitor into an elevator that did not require a keypad code for operation at the time. The facility's protocol did not require a code to use the elevator, allowing residents or others to access the first floor without restriction. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving, possibly due to increased activity and the presence of a transport company at the entrance. The resident exited the building without being detected and was later found in a nearby strip mall parking lot. Facility documentation and staff interviews confirmed that the resident was identified as an elopement risk, with care plans and progress notes indicating the need for close observation and safety precautions. Despite these documented risks and interventions, the lack of communication between staff and insufficient environmental controls contributed to the resident's unsupervised exit from the facility.
Removal Plan
- Resident #2 had head-to-toe assessment, placed on one-to-one monitoring for observation and emotional support.
- If elevator #1 is required, the visitor, vendor and/or transportation staff will be escorted by a staff member on and off elevator #1 until elevator access could be restricted.
- Restricted access to elevator #1 by installing keypad inside elevator and designating only receptionists, designees who cover receptionists, and leadership staff have the code, resulting in the elevator being inoperable to all other staff, visitors and residents.
- All codes changed and will be changed monthly, or as needed.
- All exit doors checked by maintenance for proper functioning and locking mechanism.
- Facility reviewed and updated elopement binders on each unit and by the receptionist area.
- Facility audited EMRs for presence of resident's profile pictures.
- Facility audited new admissions for presence of the elopement risk evaluation and corresponding care plan (if applicable).
- Facility conducted additional elopement drills on day, evening, and night shifts.
- Additional security measures added to include keypads inside and outside of the elevator, restricting access to elevator operation.
- Court-1 (first floor) outside Elevator #1 keypad code needed to access elevator by designated staff only.
- Elevator #1 keypad inside elevator code needed to operate first floor button (#1) to activate elevator to access first floor when on Court-2 (second floor).
- Code only given to receptionist, and designees who cover receptionists, and leadership staff.
- Receptionist and designees who cover the desk educated not to give out keypad codes.
- Added alarms to all court building stairwell exit/egress.
- Larger sign at the entrance to the elevator, redirecting visitors to the other elevator.
- Receptionist and designees who cover receptionists educated to wait to release the main entrance doors until anyone attempting to exit is identified as staff, visitors, vendors and authorized resident only.
- Elopement policy reviewed.
- ADON or designee, initiated re-education of staff members on the elopement policy and procedure.
- ADON or designee, initiated education to changes to the elevator #1 access with keypads restricting operation.
- Agency, PRN, and employees on PTO will be educated prior to their next scheduled working shift/day.
- The DON or designee audited current residents for elopement risk and implemented immediate interventions if a high elopement risk score is triggered.
- The DON or designee audited new admissions for elopement risk and implement immediate interventions if a high elopement risk score is triggered weekly.
- The DON or designee evaluated elopement risk for residents who present with new wandering/exit seeking behaviors as soon as the behavior is identified and weekly.
- The DON or designee conducted weekly observations of staff/visitors/vendors safety practices when entering and exiting secured units.
- Findings from audits and observations will be reported to the monthly QAPI Committee.
Incomplete DEA 222 Forms for Controlled Medications
Penalty
Summary
The facility failed to ensure that all DEA 222 forms were completed with sufficient detail for accurate accountability and reconciliation of controlled medications. This deficiency was identified in six out of six DEA 222 forms reviewed in the backup controlled medication storage area. The forms, dated between August and December, were missing the number of controlled medications received and the date they were received, as required in Part 5 of the form. The Director of Nursing (DON) was unaware of the requirement to fill in Part 5, as she had not read the instructions on the form and was following previous instructions given to her. Interviews with the facility's pharmacy provider and the Medical Director (MD) revealed that the process required the purchaser, or nursing home, to complete Part 5 of the DEA 222 forms. The Pharmacist and the Chief Executive Officer/Consultant Pharmacist (CEO/CP) confirmed that the nursing department was responsible for documenting the quantity and date of receipt of controlled medications. The MD stated that he only signed the forms and was not involved in the receipt of medications. The CEO/CP noted that the Consultant Pharmacist, who checked the forms quarterly, had not verified the completion of Part 5, which was a mandatory requirement according to Board of Pharmacy regulations.
Plan Of Correction
1. No resident had a negative outcome due to the deficient practice of incomplete 222 forms section 5. On 12/20/2024, US FOIA (b)(6) received 1:1 education by the Regional Director of Nursing on the importance of completing section 5 of the 222 form and attaching the packing slip when medication is received. 2. All residents on narcotic medication have the potential to be affected by the deficient practice. Section 5 of the 222 forms were reviewed to ensure completion. 3. On 12/20/2024, the Regional Director of Nursing educated the US FOIA (b)(6) on the importance of completing section 5 of the 222 forms. In addition, a new process was implemented where the pharmacy consultant will audit 222 forms on a monthly basis. 4. The Director of Nursing will audit 222 forms weekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reported to the QAPI Committee monthly for 3 months.
Failure to Follow Physician's Orders and Nursing Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order and professional standards of nursing practice during medication administration for two residents. In the first instance, an LPN was observed administering a Lidocaine 4% Patch to a resident's left knee without removing the previous patch as per the physician's order. The order specified that the patch should be removed at bedtime, but it was left on overnight due to a transcription error in the electronic health record, which scheduled the removal for the following morning instead of at night. This error was not caught by the pharmacy review or the 24-hour chart check, leading to the patch being left on longer than its effective period. In the second instance, another LPN administered blood pressure medications to a resident without rechecking a low diastolic blood pressure reading or notifying the physician. The resident's blood pressure was recorded as 108/40, which is below the recommended threshold, yet the LPN proceeded with administering amlodipine and Torsemide without confirming the accuracy of the reading or consulting the physician for guidance. The resident had a history of hypertension related to chronic kidney disease, and the care plan included monitoring for side effects and obtaining blood pressure readings under consistent conditions. The facility's policy on administering medications requires that medications be given safely and timely, as prescribed, and that any concerns about dosages or potential adverse consequences be discussed with the attending physician. In both cases, the nurses failed to follow these protocols, leading to the administration of medications without proper adherence to the physician's orders or verification of vital signs, which could potentially impact the residents' health.
Plan Of Correction
1. A. Resident #34 had [R] as a result of the deficient practice of nurses not following physician's order to remove [R] after the ordered duration (12-hour after placement). The [R] was removed and [R] assessed with no [R] noted and replaced with the ordered [R]. The order was clarified and updated to reflect correct removal time. B. Resident #49 had [R] as a result of the deficient practice of not retaking a [R] after initially getting a [R] and administering the medication without consulting the physician regarding the concern. Resident's doctor was notified and assessed Resident #49 and there were no new recommendations. 2. A. All residents with lidocaine patch orders have the potential to be affected by this deficient practice of nurses not following physician's order to remove lidocaine patch after the ordered duration (12-hour after placement). B. All residents with blood pressure medications could be affected by the deficient practice of not retaking a blood pressure after initially getting a low diastolic blood pressure and administering the medication without consulting the physician regarding the concern. 3. A. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#1 who was responsible for resident #34's EXEC order 26,451 in question on transcription policy and removal of as ordered. Additionally, all nurses received education by the Assistant Director of Nurses on the policy and procedure for following physician orders for including removal and transcription. An audit was conducted for NJ Exec Order 26.4b1 orders to ensure proper order transcription. No further issues identified. B. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#2 who was responsible for resident #49's medication administration on holding medication and seeking physician consultation when vital signs results show NJ Exec Order 26.4b1. Additionally, all nurses received education by the Assistant Director of Nurses on the policy to hold medication and seek physician consultation when vital signs results show NJ Exec Order 26.4b1. 4. The Director of Nurses, Assistant Director of Nurses, and Unit managers will audit new orders for lidocaine patches weekly for 4 weeks and monthly for 2 months to ensure all resident lidocaine orders are transcribed properly and followed. The Director of Nurses, Assistant Director of Nurses, and Unit Managers will audit med pass weekly for 4 weeks and monthly for two months to ensure any concerning vital sign results are communicated to the Physician for consultation prior to administration of medication. The results of these audits will be reported to the QAPI committee monthly for 3 months.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during a medication administration observation. On December 17, 2024, an LPN was observed preparing medications for a resident without following appropriate hand hygiene protocols. After taking the resident's blood pressure, the LPN washed her hands for 15 seconds but found no paper towels available to dry them. She turned off the faucet with her bare hands and used a tissue to dry her hands without sanitizing them afterward. Later, the LPN prepared medications for another resident on Enhanced Barrier Precautions without performing hand hygiene and entered the resident's room without cleaning the blood pressure cuff. The LPN admitted to the surveyor that she should have used hand sanitizer after touching the faucet and acknowledged the risk of spreading germs by not cleaning the blood pressure cuff between residents. The LPN/Unit Manager and the LPN/Infection Preventionist confirmed that the LPN should have washed her hands after touching the faucet and cleaned the blood pressure machine between residents. The Director of Nursing also stated that the failure to clean the blood pressure cuff could pose an infection control issue. The facility's policies on hand hygiene and cleaning of reusable equipment were not followed, contributing to the identified deficiencies.
Plan Of Correction
1. Resident #33 and resident #49 had [R] as a result of the deficient practice of: a. LPN #1 who failed to properly perform hand hygiene after removing gloves. b. LPN #1 who failed to clean a NEXO cuff between residents. On 12/17/2024, Assistant Director of Nursing completed 1:1 education with LPN #1 on hand hygiene and disinfecting NJ Exec Order 26.4b1 cuff between residents. 2. All residents have the potential to be affected by these deficient practices. 3. On 12/17/2024, Infection Preventionist completed one on one education with LPN #1 on hand hygiene and proper infection prevention when donning and doffing Personal Protective Equipment (PPE) and disinfecting equipment between residents. Competency on hand hygiene was completed with nurse with satisfactory return demonstration. Additionally, education was initiated for all nurses on Hand Hygiene and proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. Rounds and observations were completed to ensure staff were using proper hand hygiene when donning and doffing PPE and proper disinfecting of BP cuffs between residents. 4. Infection Preventionist will complete rounds weekly for 12 weeks to ensure all staff perform hand hygiene on proper infection prevention when donning and doffing PPE and disinfecting equipment between residents. The results of these audits will be reported to the QAPI committee monthly for 3 months.
Improper Storage of ABHR Exceeding Allowable Limits
Penalty
Summary
The facility failed to ensure proper storage of Alcohol Based Hand Rub (ABHR) dispensers, exceeding the allowable limit of five gallons in a single smoke compartment. This deficiency was observed in one of the three buildings, specifically in the Atrium Building #1, Resident room #308. During the survey, it was noted that there were 61 cases, each containing six one-liter containers of ABHR, amounting to approximately 96 gallons. The label on each dispenser indicated that the active ingredient was 80% ethyl alcohol, and it included warnings about flammability and the need to keep the product away from fire or flame. The survey conducted on December 17, 2024, revealed that the facility did not comply with the requirements for storing ABHR, as outlined in the NFPA 101 and related regulations. The dispensers were not stored in a proper location, which is a violation of the safety standards. This issue was brought to the attention of the facility's representatives during the Life Safety survey exit on December 18, 2024.
Plan Of Correction
1. No residents experienced negative outcomes as a result of the deficient practice of excess storage of alcohol-based hand rub sanitizer within a single smoke compartment. On 12/18/2024, the excess supply was immediately discarded appropriately. 2. All residents have the potential to be affected by this deficient practice. Additional supply closets were audited and no issues were found. 3. On 12/18/2024, Maintenance and Housekeeping staff were educated by the regional Plant Operations Director on proper storage of Alcohol-based hand rub sanitizer. 4. Maintenance Director/Designee will audit single smoke compartments for alcohol-based hand rub sanitizer storage monthly for x3 months. Any concerning findings will be corrected immediately. The results of these audits will be reported to the monthly Quality Assurance Performance Improvement committee.
Failure to Meet Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratio as mandated by the State of New Jersey. This deficiency was identified during a recertification survey, which revealed that for two weeks prior to the survey, the facility did not meet the staffing requirements on six out of fourteen day shifts. Specifically, the facility was short of Certified Nurse Aides (CNAs) on multiple days, with the number of CNAs ranging from 10 to 15, whereas at least 16 CNAs were required for the number of residents present. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that they were aware of the New Jersey minimum staffing requirements, which stipulate one CNA for every eight residents during the day shift. Despite this knowledge, the facility's staffing policy, revised in June 2024, which stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, was not adhered to, resulting in the deficiency.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 4. Recruitment bonus and sign-on bonuses offered. 5. Competitive wage analysis. 6. Hired Elite Recruiting to support increased recruiting of nurses and aides. 7. Weekend warrior program started. 8. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined by New Jersey regulations for one day during the period from December 1, 2024, to December 14, 2024. Specifically, on December 1, 2024, the facility provided 360 actual staffing hours, which was 19.25 hours less than the required 379.25 staffing hours. This deficiency was identified through a review of the Nurse Staffing Reports for the specified weeks. During an interview on December 20, 2024, the Director of Nursing (DON) acknowledged that the facility's staffing was based on New Jersey's minimum requirements and the residents' acuity levels. The DON admitted that there were occasional days with low staffing but was unsure of the reasons behind these occurrences. The facility's staffing policy, revised in June 2024, stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, ensuring sufficient personnel to provide high-quality care. However, the facility did not meet these requirements on the specified date.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 5. Recruitment bonus and sign-on bonuses offered. 6. Competitive wage analysis. 7. Hired Elite Recruiting to support increased recruiting of nurses and aides. 8. Weekend warrior program started. 4. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.
Failure to Submit Emergency Preparedness Plan for Review
Penalty
Summary
The facility failed to send a copy of their Emergency Preparedness Plan (EPP) to the Camden County Office Emergency Management (CCOEM) and Local Office Emergency Management (LOEM) officials for review, as required by NJAC 8:39-31.6(h). This deficiency was identified during a review of the EPP book on December 18, 2024, at approximately 8:45 AM, which revealed no evidence of the EPP being sent to the relevant emergency management offices. During an interview, the Administrator was unable to provide evidence of the EPP being sent from January 1, 2023, through December 16, 2024. The deficiency was communicated to the Administrator and Maintenance Director during the Life Safety survey exit on December 18, 2024, at approximately 1:34 PM. This oversight had the potential to affect all 132 residents of the facility.
Plan Of Correction
1. No residents were affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. On 12/18/2024, an email request was sent to the County Office of Emergency Management to schedule a review of the facility's Emergency Management Plan. 2. All residents could be affected by deficient practice of failing to send a copy of the facility Emergency Preparedness Plan to the County Office of Emergency Management. 3. On 12/18/2024, a 1:1 education was completed by the Regional Plant Operations Manager with the US FOIA (b)(6) on the requirement to request an annual review of the facility's Emergency Preparedness Plan. 4. To monitor and maintain ongoing compliance, the Administrator and Regional Director of Plant Operations will review the facility's Emergency Preparedness Plan annually and ensure the Director of Maintenance requests review by the County Office of Emergency Management. The review and request to the County Office of Emergency Management will be presented to the Quality Assurance and Performance Improvement team annually to ensure compliance is maintained.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation, leading to several deficiencies observed by the surveyor. In the kitchen's dry storage area, an opened bag of rainbow pasta was found with a hole, exposing it to contamination. Similarly, in the walk-in freezer, opened boxes of frozen pancakes and French toast slices were improperly stored on milk crates, leaving them exposed. The walk-in refrigerator had an excessive amount of dust-like debris on the fan guard, which had not been cleaned despite a verbal request to maintenance. Additionally, opened boxes of frozen breaded chicken patties were found exposed in the freezer. In the Court 2 pantry, the ice machine was found to have a brown/green/black substance on the drip ledge, indicating it was dirty and needed cleaning. The maintenance department was responsible for cleaning the ice machine, but it was not scheduled for cleaning until the following month. In the Court 1 pantry, an opened bottle of Refresher Antibac Foam was stored alongside food items, which is against facility policy. A take-out container with dried food debris was also found in the same cabinet. The dishwashing process was compromised as the facility ran out of chemical sanitizer for the low-temperature dish machine. The dietary aide confirmed that dishes were being washed without sanitizer, and the interim Food Service Director was aware of the issue. The facility's policy requires a chlorine level of 50 ppm for sanitization, but the test strip indicated 0 ppm. The Regional Director later obtained liquid bleach to rectify the situation. Additionally, a quarter pan of grape jelly was found partially covered in the reach-in refrigerator, exposing it to contamination. The facility's cleaning schedules and checklists failed to address the cleaning of the fan in the walk-in refrigerator/freezer.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations across different units. On Court 1, surveyors noted that trash receptacles in residents' rooms lacked bag liners, and trash, including soiled wound care pads and incontinence briefs, was improperly disposed of. Residents reported that staff did not regularly sweep the floors, leading to food debris accumulation. Interviews with the Housekeeping Director and the Licensed Nursing Home Administrator confirmed that trash receptacles should have liners and that soiled items should not be placed in room trash cans. In addition to cleanliness issues, the facility also exhibited significant maintenance deficiencies. Surveyors observed stained ceiling tiles, missing drawers, holes in walls, and broken window blinds in various rooms. Maintenance staff acknowledged awareness of some issues but had not addressed them due to workload constraints. The Maintenance Director admitted that certain repairs, such as fixing the roof leak and replacing broken blinds, were pending despite being marked as high priority in the work orders. Further observations revealed deteriorated windowsills with exposed rusted metal and rotted wood, as well as broken wall panels and mold-like substances on windows. These conditions posed potential safety hazards to residents. Interviews with staff, including CNAs and the Maintenance Director, highlighted a lack of timely reporting and repair of these issues. The Executive Director acknowledged the environmental damage and stated efforts were being made to increase maintenance rounds and address the deficiencies.
Failure to Develop Comprehensive Care Plans for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to develop comprehensive, resident-centered care plans for two residents, both of whom were dependent on ventilators. Resident #28 was admitted with acute respiratory failure and dependence on a respirator. Despite having a tracheostomy and requiring continuous oxygen, suctioning, and trach care, the care plan did not document these needs. The care plan was not completed within the required 24 hours of admission, as confirmed by the Unit Manager/LPN, who acknowledged that the ventilator care plan was only initiated days after admission. Similarly, Resident #116, admitted with acute and chronic respiratory failure and ventilator dependence, had a care plan that failed to document the use of a tracheostomy, ventilator, and oxygen. The care plan only mentioned respiratory impairment without specifying the resident's ventilator use. The Unit Manager/LPN confirmed the absence of a specific ventilator care plan, indicating a lack of comprehensive documentation for the resident's needs. Interviews with facility staff, including the Assistant Director of Nursing, revealed inconsistencies in the understanding and execution of care plan responsibilities. The ADON stated that baseline care plans should be completed on the day of admission, but there was uncertainty about the timeline for completing comprehensive care plans. The facility's policy mandates timely, person-centered care plans, but this was not adhered to, resulting in repeated deficiencies noted in the survey.
Resident Moved to Room with Non-Functional Bathroom
Penalty
Summary
The facility failed to promote resident dignity and ensure a safe, clean, and comfortable environment when a resident was transferred into a private room without a functional bathroom or accessible handwashing sink. The deficiency was identified in one of the facility's units, affecting one resident who was observed for accommodation of needs. The resident's room had a bathroom that was bolted shut due to water damage, rendering it unsafe for use. Maintenance staff confirmed that the bathroom was closed off after the sheet rock buckled, and repairs had not yet begun due to pending materials. The resident involved had a medical history that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, chronic diastolic heart failure, and aphasia. The resident was also noted to have severe cognitive impairment and was always incontinent of bowel and bladder. Despite these conditions, the resident was moved to a room with a non-functional bathroom, which was an error attributed to a former Unit Manager. Staff interviews revealed that the resident was using a bathroom in the hallway or the tub room bathroom instead. The facility's policies on Environment of Care and Resident Rights emphasize maintaining a safe and operable environment and ensuring residents have a safe, clean, and homelike environment. However, the facility failed to adhere to these policies, as evidenced by the lack of timely repairs and the inappropriate room transfer. The Licensed Nursing Home Administrator acknowledged the error and the need for a working bathroom for the resident's privacy and dignity. Maintenance records showed high-priority work orders for the room's repairs, but there was no documented evidence of completed repairs.
Failure to Follow Physician's Orders for Resident with Fracture
Penalty
Summary
The facility failed to follow physician's orders for a resident who was readmitted with a closed fracture of the fourth metacarpal bone. The resident was supposed to have a follow-up appointment with an orthopedic surgeon and was required to wear a prescribed splint. However, the resident was observed without the splint, and there was no record of the follow-up appointment being scheduled. The resident, who was severely cognitively impaired, was readmitted with a diagnosis of unspecified fracture and dementia, and the care plan included non-weight bearing instructions and a follow-up with orthopedics. The Licensed Practical Nurse/Unit Manager (LPN/UM) and Certified Nursing Assistant (CNA) confirmed that the resident did not have the splint on, and there was no documentation of an orthopedic follow-up. The Business Office Manager (BOM) and Licensed Nursing Home Administrator (LNHA) acknowledged that the facility was responsible for ensuring the resident attended the follow-up appointment, even if the resident's Medicaid was pending. The BOM had informed the former Unit Manager that the facility should cover the cost of the appointment, but the follow-up was not pursued. The Director of Rehabilitation and Occupational Therapist noted that the resident had removed the splint, and the order for the splint was not discontinued despite the resident's non-compliance. The facility's policy required documentation of splint use and removal for skin assessment, which was not consistently done. The Director of Nursing stated that nursing should document splint use every shift, but this was not adhered to, contributing to the deficiency.
Improper Management of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as evidenced by multiple observations of improper catheter drainage bag management. During an initial tour, a surveyor observed the resident's catheter drainage bag in contact with the floor, which was not secured to the bed frame as required. On a subsequent observation, the drainage bag was found outside of its privacy bag, exposing its contents, and the privacy bag was not positioned correctly. These observations were contrary to the physician's order and the resident's care plan, which specified that the drainage bag should be kept below the bladder and off the floor, and that a dignity bag should be used when the resident is out of bed or in a low bed. Interviews with the facility's Infection Preventionist and Director of Nursing confirmed that the catheter drainage bag should not be in contact with the floor due to the risk of infection. The facility's policy on urinary catheters, dated April 2024, explicitly stated that catheter tubing, bags, or spigots should not touch the floor, highlighting the increased risk of infection for residents with urinary catheters. Despite these guidelines, the facility did not adhere to the established standards of practice, resulting in a deficiency in the care provided to the resident.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide continuous oxygen to an oxygen-dependent resident in accordance with physician's orders, as observed during a survey. Resident #37, who was diagnosed with acute respiratory failure with hypoxia, COPD, chronic diastolic heart failure, and aphasia, was found without oxygen delivery while seated in a wheelchair. The resident's oxygen tank was empty, and the oxygen concentrator was not in use, with tubing dated from two weeks prior. The resident's call bell was also out of reach, preventing them from seeking assistance. Staff interviews revealed that the CNA was not aware of the resident's oxygen needs and had not checked the resident's room. The CNA attempted to switch the resident to an oxygen concentrator, which was not functioning properly, and informed the nurse. The LPN confirmed the oxygen tank was empty and the concentrator was not set correctly. The LPN also noted that the oxygen tubing was outdated and the call bell was misplaced, which could have posed a risk to the resident. In another instance, Resident #33, who had a tracheostomy and required oxygen therapy, was found with undated respiratory equipment and tubing that had not been changed in over a month. The facility lacked a physician's order for the oxygen flow rate, and the equipment was not maintained according to professional standards. The Infection Control Preventionist Nurse and Unit Manager acknowledged these deficiencies, indicating a failure to adhere to the facility's oxygen administration policy.
Narcotic Shift Count Log Discrepancies
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs in accordance with its policy, as observed during a survey. On two separate medication carts, the surveyor found missing nursing signatures and pre-signed sections in the narcotic logbooks. Specifically, on the Pavilion nursing unit's medication cart, there were missing signatures for certain shifts and pre-signed entries for others. Similarly, on the Vent nursing unit's medication cart, there were missing signatures for specific shifts. Licensed Practical Nurses (LPNs) confirmed these discrepancies, acknowledging that the logs should not have pre-signed sections and that all counts should be documented at the time they are completed. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires incoming and outgoing nurses to count narcotics together and sign the logs to confirm the count. The facility's Controlled Substances policy, reviewed in January 2024, mandates that controlled medications be counted at the end of each shift, with any discrepancies reported to the Director of Nursing Services. The surveyor's findings indicate a failure to adhere to this policy, as evidenced by the missing and pre-signed entries in the narcotic logbooks.
Improper Storage and Labeling of Multidose Medications
Penalty
Summary
The facility failed to properly store and label opened multidose medications, as observed by a surveyor. During an inspection of the Vent nursing unit's medication cart, three opened fluticasone propionate nasal spray bottles were found without the date of opening or resident identifying information. An LPN present during the observation confirmed that the facility's protocol requires nurses to date the medication container and label it with the resident's name to ensure proper identification and prevent mix-ups. Additionally, in the Court 1 nursing unit's medication storage room, an opened and undated vial of tuberculin purified protein derivative (PPD) was found in the medication refrigerator. The Unit Manager/LPN acknowledged that the vial should have been dated with the opened date on the vial itself, as it is used for multiple residents. The Assistant Director of Nursing reiterated the expectation that opened multidose medication containers should be dated, emphasizing that some medications have a shorter expiration date once opened. The facility's policy mandates that improperly labeled drugs be returned to the pharmacy for proper labeling before storage.
Infection Control Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to adhere to accepted standards of infection control practices in the storage of respiratory tubing and hand hygiene during respiratory care treatment. For Resident #33, the surveyor observed a suction catheter (Yankauer) improperly stored in a bedside drawer, uncovered and touching other items, over multiple days. The resident, who had a tracheostomy and required oxygen and suctioning, was at risk due to this improper storage. Interviews with the Infection Preventionist and the Respiratory Therapist confirmed that the storage did not comply with the facility's policy, which required the catheter to be stored in a plastic sleeve and bag after use. For Resident #42, the surveyor observed a respiratory therapist performing tracheostomy care without proper hand hygiene between glove changes. The resident, who was cognitively intact and dependent on a ventilator, required tracheostomy care every shift. The respiratory therapist failed to use alcohol-based hand rub after removing gloves and before donning new ones, contrary to the facility's hand hygiene policy. The Infection Preventionist confirmed that hand hygiene should be performed between glove changes and noted that the respiratory therapist was following an outdated policy. The facility's policies on suctioning and hand hygiene were not followed, leading to deficiencies in infection control practices. The Infection Preventionist acknowledged the improper storage of equipment and the outdated policy used by the respiratory therapist. The facility's hand hygiene policy required the use of alcohol-based hand rub after contact with inanimate objects and after removing gloves, which was not adhered to during the observed tracheostomy care.
Failure to Administer Pneumococcal Vaccine Upon Admission
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission, specifically for one resident who was reviewed for immunization administration. This deficiency was identified during a survey when a resident was observed with stitches and was unable to recall how the injury occurred. The resident's admission record indicated diagnoses including Alzheimer's Disease and a history of COVID-19, with no known allergies. The resident's immunization status in the Electronic Health Record (EHR) showed an undated entry for Pneumovax 20, indicating a requirement for the immunization. However, the resident's Annual Minimum Data Set (MDS) assessment revealed that the pneumonia vaccine was not up to date due to an unspecified medical contraindication. Interviews with facility staff, including an LPN and the Infection Preventionist (IP), revealed confusion and lack of clarity regarding the responsibility for obtaining consent for the vaccination. The LPN was unsure who was responsible for obtaining consent, while the IP stated that the resident should have been offered the vaccination upon admission, with consent required from a family member due to the resident's cognitive impairment. The IP acknowledged that there was no Unit Manager assigned to the nursing unit, which may have contributed to the oversight. The facility's policy required assessments of pneumococcal vaccination status within five working days of admission, but this was not adhered to in this case, leading to the delay in vaccination administration for the resident.
Failure to Notify CMS of Name Change
Penalty
Summary
The facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and apply for a change in name to include Doing Business As (DBA) in accordance with 42 CFR 424.516. This deficiency was identified through interviews and a review of facility documentation. The facility's admission and arbitration agreements listed the name as The Grove Center for Rehabilitation and Healthcare, while business cards and other documents referred to it as The Grove at Cherry Hill. However, the facility's license, issued by the New Jersey Department of Health, listed the name as Silver Healthcare Center. During an interview, the Licensed Nursing Home Administrator (LNHA) and the Executive Director (ED) acknowledged that they had not applied for a CMS 855/chow (Change of Ownership) form and were using The Grove name for marketing purposes. The Executive Director stated that the facility was operating under a DBA, allowing them to use both names, but admitted that they had not completed the necessary CMS 855 B form. The surveyor pointed out the inconsistency in the facility's documentation, which included the use of The Grove name in admission agreements and arbitration agreements. The ED acknowledged that changing the documentation would be easy but had not yet taken steps to align the facility's official name with its marketing and operational practices. This failure to comply with federal regulations regarding name changes and enrollment status updates led to the deficiency finding.
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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