Sinai Post-acute Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, New Jersey.
- Location
- 65 Jay Street, Newark, New Jersey 07103
- CMS Provider Number
- 315236
- Inspections on file
- 21
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sinai Post-acute Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident dependent on staff for colostomy management did not receive consistent ostomy care when the colostomy drainage bag was not emptied during the overnight shift, resulting in the bag bursting and soiling the resident and bed. The oversight was acknowledged by the responsible nurse, who stated she forgot to check on the resident due to being busy.
A resident with a history of mood and anxiety disorders witnessed the death of another resident and subsequently experienced increased anxiety, depression, and substance use. Despite these changes, the care plan was not updated to include emotional support services, and the social worker did not escalate the resident's refusal to discuss the incident to the DON or administrator.
A resident with a history of substance abuse was found unresponsive after reportedly using illicit drugs with others in a peer's room. An LPN administered Narcan and performed CPR, but the resident died. Despite existing care plans and facility policies for monitoring and searching high-risk residents, staff did not conduct or document a thorough investigation following the incident, and key staff were not promptly interviewed.
A resident with severe cognitive impairment and multiple fractures was found to have a lidocaine patch applied to the right thigh instead of the right hip as ordered for pain management. An LPN confirmed the incorrect placement during a survey, and the DON acknowledged that the physician's order was not followed, as required by facility policy.
A resident with a history of mental health and substance use disorders did not receive necessary behavioral health care after witnessing the death of another resident following illicit drug use. The resident reported increased anxiety and depression, and although a social worker made one attempt to speak with the resident, there was no further follow-up or documentation. Facility staff did not provide or document psychosocial support, and relevant policies did not address procedures for such incidents.
A resident with a history of substance abuse and other medical conditions experienced two overdose incidents requiring Narcan. Despite these events, the care plan was not updated to reflect the changes in the resident's condition. Interviews with staff confirmed the oversight, which was contrary to the facility's policy requiring timely care plan updates.
The facility failed to follow physician orders and its Medication Administration Policy for two residents. One resident did not receive prescribed wound care on multiple occasions, and another did not receive a scheduled methadone dose. Documentation and PCP notification were lacking, as confirmed by staff interviews and policy review.
The LNHA failed to implement policies for resident rights and prevent seclusion, affecting 11 Justice Involved Residents (JIRs) who were secluded and restrained by law enforcement. These residents were not allowed to participate in group activities or community dining and were kept in their rooms with metal ankle cuffs, without physician orders. Staff confirmed that these actions were due to instructions from the Bureau of Prisons, despite being against federal regulations.
The facility failed to ensure the rights of 11 Justice Involved Residents, who were secluded in their rooms, guarded by law enforcement, and not allowed to participate in group activities or community dining. They were served meals on disposable trays and some were observed with ankle restraints. Interviews revealed restrictions on communication and movement, violating their rights to autonomy and dignity.
The facility failed to treat 11 Justice Involved Residents with dignity and respect, as they were physically restrained with metal ankle cuffs and secluded from participating in group activities, community dining, and intermingling with other residents. These residents were also restricted from communicating with visitors and leaving their rooms at will. The facility did not have physician orders for the use of restraints, and the residents' care plans did not address the use of restraints or the need for constant supervision by detention guards.
The facility failed to support the self-determination of 11 Justice Involved Residents (JIRs) by restricting their ability to make choices about their care, participate in activities, and interact with the community. The JIRs were confined to their rooms, only allowed to leave for showers, and not assessed for activities. Despite being alert and oriented, no individualized care plans were created for them, and they did not sign the facility Admission Agreement.
The facility failed to prevent the involuntary seclusion of 11 Justice Involved Residents, who were confined to their rooms and guarded by law enforcement officers. These residents were not allowed to participate in community activities or receive visitors without approval, and they wore ankle restraints. The facility did not implement care plans addressing the use of restraints or the supervision required by law enforcement officers, and there were no physician orders or consents for the restraints used.
The facility failed to ensure that 11 Justice Involved Residents were free from physical restraints, as they were shackled to their beds with metal chains and guarded by law enforcement. The use of restraints was not documented in care plans, and no consent was obtained. Facility staff were instructed not to mix JIRs with other residents, and the JIRs were isolated, unable to participate in activities or interact with others. The facility's actions resulted in an Immediate Jeopardy situation.
The facility failed to provide meaningful group and individualized activity programs for 11 Justice Involved Residents (JIRs), who were restricted to their rooms and not allowed to participate in group activities. Despite being alert and oriented, these residents did not have individualized care plans for activities, and the comprehensive Minimum Data Set (MDS) was not completed. Staff interviews revealed that the Director of Recreation was instructed not to interact with the JIRs, and the facility's policy on activity programs was not followed.
Failure to Provide Consistent Ostomy Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for colostomy management did not receive consistent ostomy care. The resident, admitted with diagnoses including colon cancer and a colostomy, was documented as requiring staff assistance for ostomy management according to the Minimum Data Set (MDS). The resident's care plan instructed nursing staff to keep the skin around the stoma clean and dry. However, during a review, it was found that the colostomy drainage bag had not been emptied during the overnight shift by the nurse on duty. On the following morning, a CNA discovered the resident with a full colostomy drainage bag that had burst, resulting in stool on the resident and the bed. The CNA alerted the nurse, who assessed the resident and found no skin excoriation. The nurse then cleaned the resident and notified the responsible party. When questioned, the overnight nurse admitted to forgetting to check on the resident due to being busy. The facility's policy emphasizes maintaining cleanliness and skin integrity for residents with ostomies, which was not followed in this instance.
Failure to Update Care Plan for Emotional Support After Resident Witnessed Death
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing emotional support services for a resident who witnessed the death of another resident. The resident, who had a history of mood disorder, opioid abuse, and anxiety disorder, reported increased anxiety and depression following the incident and stated that no one had spoken to them regarding the death. The resident also disclosed using cocaine after the event, which was brought into the facility by an outside individual. Despite these developments, the resident's individualized comprehensive care plan did not include interventions or support for emotional needs related to witnessing the death. Interviews revealed that the social worker attempted to speak with the resident about the incident, but the resident refused the conversation. The social worker did not report this refusal to the DON or the administrator, and the care plan was not updated to reflect the resident's changed emotional status. The DON confirmed that emotional support services should have been included in the care plan after the resident witnessed the death, in accordance with the facility's policy requiring ongoing assessment and revision of care plans as residents' conditions change.
Failure to Supervise and Investigate After Resident Drug Overdose and Death
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment for a resident with a known history of substance abuse, resulting in an unexpected death. The resident, who had diagnoses including major depressive disorder, opioid abuse, and cocaine abuse, was found unresponsive in another resident's room after reportedly smoking crack and cocaine with two other residents. An LPN responded to the emergency, administered Narcan twice, and performed CPR, but the resident did not recover. The care plan for this resident included interventions such as random room searches, toxicology screenings, and monitoring for signs of drug use and overdose, but these measures did not prevent the incident. Following the event, interviews revealed that staff were aware of the resident's high-risk status and the facility had policies in place for drug screening and searches, especially for residents returning from authorized out-on-pass visits. Despite these policies, the facility did not conduct or document a thorough investigation immediately after the incident where Narcan was administered. The DON stated that an investigation was not warranted at the time, and key staff involved in the incident were not interviewed promptly. Additionally, the facility's policy required that all incidents and accidents be documented and investigated as soon as they were reported, but this was not followed in this case. The lack of timely and comprehensive investigation, as well as insufficient supervision and monitoring of residents with known substance abuse histories, contributed to the deficient practice identified by the surveyors.
Failure to Follow Physician's Order for Pain Management Patch Placement
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow a physician's order regarding pain management for a resident with significant medical needs. The resident, who had been admitted with a displaced intertrochanteric fracture of the right femur and an unspecified fracture of the sacrum, also had severe cognitive impairment and required staff assistance for activities of daily living. The physician's order specified that a lidocaine patch was to be applied topically to the resident's right hip in the morning for pain management and removed per schedule. During a surveyor's observation, it was found that the lidocaine patch had been applied to the resident's right thigh instead of the right hip as ordered. The LPN confirmed the incorrect placement when asked to review the order in the presence of the Unit Manager and surveyor. The facility's medication administration policy required medications to be administered according to prescribed orders, including verifying the correct method and site of administration. The Director of Nursing confirmed that the LPN should have followed the physician's order for the correct application site.
Failure to Provide Behavioral Health Care After Traumatic Incident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident after the resident witnessed the death of another resident in their shared room, following an incident involving illicit drug use. The resident who witnessed the event had a documented history of major depressive disorder, unspecified mood disorder, opioid and alcohol abuse, substance-induced mood disorder, schizoaffective disorder, and anxiety disorder. The resident was on a methadone program and had interventions in place for substance abuse, including opportunities to vent feelings and random toxicology screenings. After the incident, the resident reported increased anxiety and depression and stated that no one from the facility spoke to them regarding the death. The social worker made one attempt to speak with the resident, who refused to discuss the incident, but did not make further attempts or document the refusal. The Director of Nursing was unaware of the social worker's visit and stated that the incident should have been discussed in an interdisciplinary care plan meeting and documented. The Licensed Nursing Home Administrator also indicated that the social worker should have documented the interaction in the progress notes. A review of the resident's medical record showed that the physician and psychiatric nurse practitioner saw the resident after the incident, but there was no documentation of psychosocial support being provided. The facility's policies did not include procedures related to psychosocial support following such incidents, and the social worker's job description required working directly with residents experiencing emotional difficulties. The lack of follow-up and documentation resulted in the failure to provide necessary behavioral health care and services to the resident.
Failure to Update Care Plan After Resident Overdoses
Penalty
Summary
The facility failed to review and revise the care plan in a timely manner for a resident who was admitted with diagnoses including a displaced oblique fracture of the right fibula, muscle wasting and atrophy, opioid dependence, and cocaine abuse. The resident was cognitively intact and required partial/moderate assistance with activities of daily living. On two separate occasions, the resident was found unresponsive due to suspected overdoses, requiring the administration of Narcan. Despite these significant incidents, the care plan, which initially identified the resident's risk for falls and history of poly-substance abuse, was not updated to reflect these changes in the resident's condition. Interviews with facility staff, including the Unit Manager and the Director of Nursing, confirmed that the care plan was not updated following the incidents on 7/1/24 and 7/7/24. The facility's policy requires care plans to be updated within 24 to 48 hours when there is a change in condition, but this was not adhered to in this case. The failure to update the care plan was acknowledged by the staff, indicating a lapse in following the established procedures for care plan revisions.
Failure to Follow Medication Administration Policy
Penalty
Summary
The facility failed to adhere to physician orders and its own Medication Administration Policy for two residents, leading to deficiencies in medication administration. Resident #3, who was admitted with surgical aftercare needs, had a physician order to apply Silvadene cream to incision sites daily. However, the Medication Administration Record (MAR) for July 2024 showed no documentation of treatment on three specific dates, and there was no evidence that the Primary Care Physician (PCP) was notified of these omissions. This lack of documentation and communication indicates a failure to follow the prescribed treatment plan and facility policy. Similarly, Resident #4, who was on a methadone program for opioid dependence, had a physician order for a daily dose of Methadone Oral Solution. The MAR for July 2024 revealed that the medication was not documented as administered on one date, and there was no record of PCP notification. Interviews with the Unit Manager and Director of Nursing confirmed that nurses were expected to document medication administration and notify the PCP if medications were not given. The facility's Medication Administration Policy also required documentation of medication administration and reasons for any omissions, which was not followed in these cases.
Failure to Implement Resident Rights and Prevent Seclusion
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of policies and procedures for resident rights and self-determination, as well as policies to prevent physical restraints and seclusion. This failure affected 11 Justice Involved Residents (JIRs) who were admitted to the facility. These residents were not provided with the autonomy to participate in group activities, community dining, or to leave their rooms at will. They were also not afforded the opportunity to sign Admission Agreements upon admission. The Immediate Jeopardy (IJ) situation began when the first JIR was admitted and secluded by law enforcement officers. The IJ was identified when all 11 JIRs were observed being secluded in their rooms, guarded by law enforcement officers, and restricted from participating in normal resident activities. The facility's policies, which were supposed to ensure residents' rights to dignity, respect, and freedom from restraints, were not followed. The JIRs were kept in their rooms, guarded, and restrained with metal ankle cuffs, which were not ordered by a physician. Interviews with facility staff revealed that the facility's corporate offices instructed the administration not to mix JIRs with other residents and to keep them roomed together. The Director of Nursing and other staff members confirmed that the JIRs were being treated differently due to instructions from the Bureau of Prisons, which imposed restrictions on the JIRs. The LNHA acknowledged that these practices were against federal regulations but felt constrained by the Department of Justice's authority. The Medical Director was unaware of the restraints and seclusion, as he had not written any orders for such measures.
Violation of Resident Rights for Justice Involved Residents
Penalty
Summary
The facility failed to ensure that 11 Justice Involved Residents (JIR) were afforded their rights to autonomy and dignity. These residents were secluded in their rooms, guarded by law enforcement officers, and not permitted to participate in group activities or community dining. They were also restricted from communicating freely with visitors and other residents, and were not allowed to leave their rooms at will. This situation was identified as an Immediate Jeopardy (IJ) to the health and safety of the residents. The report highlights that the JIRs were subjected to conditions that violated their rights as nursing home residents. They were served meals in their rooms on disposable trays and utensils, unlike other residents who used regular dishware. Some residents were observed with ankle restraints connected to their beds, further indicating a lack of freedom and dignity. Interviews with residents revealed that they were only allowed to leave their rooms for showers, which were supervised by prison guards, and they could only have private phone conversations with their lawyers. The facility's policies on dining environment and activity programs were not adhered to for the JIRs. The policies emphasized promoting a positive dining experience and encouraging maximum individual participation in activities, which were not provided to the JIRs. The Director of Social Work acknowledged that the seclusion of JIRs was against federal regulations, as it constituted a form of resident seclusion. The lack of care plans for supervision of Activities of Daily Living (ADL) care, restraints, activities, or seclusion further demonstrated the facility's failure to protect and promote the rights of these residents.
Violation of Resident Rights for Justice Involved Residents
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified and respectful manner, specifically concerning 11 Justice Involved Residents (JIR). These residents were physically restrained with metal ankle cuffs and secluded from participating in group activities, community dining, and intermingling with other residents. They were also restricted from communicating with visitors and leaving their rooms at will. This situation was identified as an Immediate Jeopardy (IJ) to the health and safety of the JIR residents and all other residents in the facility. The deficiency began when the first JIR was admitted to the facility and was secluded to the room by law enforcement officers. The surveyors observed that the JIRs were being guarded by law enforcement officers and were not permitted to participate in normal activities or leave their rooms unless escorted for showering. The facility's policies on resident rights, which include the right to be free from physical restraints and to have autonomy and choice, were not adhered to for these residents. Interviews with facility staff, including the Director of Nursing, Licensed Practical Nurses, and the Licensed Nursing Home Administrator, revealed that the facility was aware of the restrictions imposed on the JIRs by the Bureau of Prisons. However, the facility did not have physician orders for the use of restraints, and the residents' care plans did not address the use of restraints or the need for constant supervision by detention guards. The facility's administration acknowledged that the treatment of JIRs was not in line with federal regulations for long-term care facilities.
Facility Fails to Support Self-Determination of Justice Involved Residents
Penalty
Summary
The facility failed to promote and facilitate the self-determination of 11 Justice Involved Residents (JIRs), denying them the right to make choices regarding their life and care, participate in activities, and interact with the community. The Director of Nursing (DON) stated that the facility's Corporate Office instructed the administration to shackle the JIRs, have them guarded by law enforcement officers, and prevent them from interacting with other residents. This directive led to the JIRs being confined to their rooms, only allowed to leave for showers twice a week, and not being assessed for or allowed to participate in any activities. The Director of Recreation confirmed that no activity assessments were completed for the JIRs, as they were informed by the Interdisciplinary Team and the Licensed Nursing Home Administrator (LNHA) that the JIRs would not attend any activities. Interviews with the Unit Manager and Resident #4 revealed that the JIRs were restricted to their rooms, with limited privacy for phone calls, and were not allowed to mingle with other residents. Attempts by surveyors to interview other JIRs were denied by law enforcement officers. Medical records showed that the JIRs had various diagnoses, including osteomyelitis, multiple sclerosis, polyneuropathy, and dementia, among others. Despite being alert and oriented, with some able to make their own decisions, no individualized care plans were initiated to address their choices regarding significant aspects of their lives. Additionally, the JIRs did not sign the facility Admission Agreement, and their comprehensive Minimum Data Sets (MDS) were unavailable for review.
Involuntary Seclusion of Justice Involved Residents
Penalty
Summary
The facility failed to ensure that 11 Justice Involved Residents (JIRs) were free from involuntary seclusion, which is a violation of federal regulations. These residents were secluded from having autonomy and making choices about their daily lives and care, similar to other nursing home residents. The seclusion was enforced by law enforcement officers from the Bureau of Prisons, who guarded the residents and restricted their movement and interactions with others. The residents were confined to their rooms, wore metal ankle cuffs, and were not allowed to participate in community activities or receive visitors without approval from the U.S. Marshals. The facility's administration, including the Director of Nursing and the Licensed Nursing Home Administrator, were aware of the situation but stated that the restrictions were imposed by the Bureau of Prisons, not the facility itself. Despite this, the facility did not implement care plans addressing the use of restraints or the supervision required by law enforcement officers. The residents' care plans did not document the restrictions on their activities of daily living, community interactions, or dining arrangements. Additionally, there were no physician orders or consents for the use of restraints, and the facility's policy on resident rights was not upheld. Observations by surveyors confirmed that the JIRs were confined to their rooms, guarded by law enforcement, and wore ankle restraints. Interviews with facility staff revealed that the JIRs were not allowed to leave their rooms except for showers, and they were served meals on disposable trays in their rooms. The facility's Director of Recreation and Director of Social Work were instructed not to interact with the JIRs or include them in activities, further isolating these residents from the rest of the facility's community.
Justice Involved Residents Restrained with Shackles
Penalty
Summary
The facility failed to ensure that 11 Justice Involved Residents (JIRs) were free from physical restraints, as required by federal regulations. These residents were restrained with ankle shackles attached to their beds with metal chains, guarded by law enforcement officers. The use of restraints was not documented in the residents' care plans, and no consent for the use of physical restraints was obtained from the residents or their representatives. The facility's policy on physical restraints was not followed, as restraints were used without a physician's order or a pre-restraining assessment. The Director of Nursing (DON) and other facility staff were instructed by the facility's Corporate Offices not to mix JIRs with other residents and to room them together. The JIRs were not allowed to attend facility activities, intermingle with other residents, or leave their rooms except for showers. The facility's Licensed Nursing Home Administrator (LNHA) acknowledged that the restrictions were imposed by the Bureau of Prisons, not the facility, but admitted that the JIRs were treated differently than other residents. Interviews with facility staff, including the Director of Recreation and the Director of Social Work, revealed that the JIRs were isolated and not allowed to participate in activities or interact with other residents. The Medical Director was unaware of the restraints and did not write orders for them. The facility's actions resulted in an Immediate Jeopardy situation, as the JIRs were not treated with dignity and respect, and their rights were violated.
Failure to Provide Meaningful Activities for Justice Involved Residents
Penalty
Summary
The facility failed to provide meaningful group and individualized activity programs that reflected the residents' preferences, specifically for 11 Justice Involved Residents (JIRs). These residents were admitted with various diagnoses, including osteomyelitis, multiple sclerosis, polyneuropathy, and dementia, among others. Despite being alert and oriented, the residents did not have individualized care plans (CPs) implemented for activities or seclusion, and the comprehensive Minimum Data Set (MDS) was still in progress and not completed. Interviews with the residents and staff revealed that the JIRs were restricted to their rooms and not allowed to participate in group activities, except for leaving their rooms for showers. The Director of Recreation (DOR) stated that she was instructed by the Licensed Nursing Home Administrator (LNHA) not to interact with the JIRs or complete an activities assessment upon their admission. Instead, the JIRs were provided with a basket of puzzles and cards, but were not allowed to attend any activities outside their rooms. Further interviews with the Unit Manager and Licensed Practical Nurse (LPN) confirmed that the JIRs remained in their rooms at all times and did not participate in group activities. The facility's policy on activity programs, which was revised in February 2024, stated that activities should encourage maximum individual participation and be geared to the individual resident's needs. However, this policy was not followed for the JIRs, as evidenced by the lack of recreation screens, notes, or care plans for the residents, despite physician orders for recreation as tolerated.
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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