South Jersey Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeton, New Jersey.
- Location
- 99 Manheim Avenue, Bridgeton, New Jersey 08302
- CMS Provider Number
- 315061
- Inspections on file
- 19
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at South Jersey Extended Care during CMS and state inspections, most recent first.
The facility failed to have a Surety Bond in place to protect resident personal needs account funds, affecting all residents with such funds. The LNHA initially provided a Commercial Crime Policy that did not cover resident funds, and a Surety Bond was only obtained after surveyor inquiry. The LNHA could not provide a prior bond or explain its absence before the surveyor's request.
The facility failed to maintain adequate RN staffing, with the DON serving as the only RN on duty on multiple occasions when the resident census exceeded 60. This occurred due to a staffing shortage after a weekend supervisor quit, leading to non-compliance with the facility's policy requiring RN services for at least 8 consecutive hours per day.
The facility failed to provide regular in-service education to CNAs based on job performance appraisals, with deficiencies identified for three CNAs. Performance appraisals showed a need for immediate improvement, but comments and goals were left blank, and no follow-up education was documented. The DON confirmed the lack of a policy on appraisals, leaving it to their discretion.
A survey revealed deficiencies in food handling and sanitation practices at a facility. A Dietary Aid was observed without a beard guard, and several food items, including hot dog buns, sandwiches, and iced tea, were improperly labeled or stored. A dented can of diced potatoes was also found in storage. These actions violated the facility's policies on food safety and sanitation.
Surveyors found a deficiency in the facility's management of resident smoking activities when a resident was observed smoking independently outside designated areas. The resident had signed a waiver releasing the facility from responsibility, but there was no specific policy supporting this practice. The care plan did not address the resident's ability to hold smoking materials, and the LNHA was unaware of a policy for residents holding lighters and smoking outside designated areas.
The facility failed to accurately report RN hours in their PBJ submission to CMS for a specific quarter. The report incorrectly showed 'No RN Hours' on several dates, despite the current DON and the President of Clinical Services working as RNs on some of those days. This was confirmed during an interview with the current DON, who assumed her role in April 2024.
A resident's bathroom toilet remained non-functional for four days, filled with debris and lacking water. Despite awareness of the issue, the facility failed to log the repair need, and staff did not report the recurring problem of the resident flushing inappropriate items. Interviews with a CNA, LPN, Unit Manager, and Maintenance Director highlighted communication lapses and a lack of follow-through in addressing the issue.
A resident's room was found infested with black flies, and the resident was addressed in an undignified manner by staff. The resident's urinary catheter was improperly placed on the bed, and the room had a noticeable urine odor. Despite the presence of flies, staff failed to maintain cleanliness, and an LPN used derogatory language towards the resident, violating the facility's dignity policy.
A resident's preferences for daily routine and personal belongings were not accommodated by the facility. Despite being cognitively intact, the resident's care plan lacked specific details about their preferences, and efforts to retrieve personal belongings from a previous facility were inadequate. The social worker's attempts to contact the previous facility were unsuccessful, and alternative communication methods were not pursued. The resident expressed dissatisfaction with their situation, including a preference for wearing personal clothing.
The facility failed to enforce its smoking policy, allowing two residents to hold their own cigarettes and lighters, contrary to the policy requiring smoking materials to be kept at the nurse's station. One resident was observed smoking outside the designated area, and staff interviews revealed inconsistencies in policy enforcement. The deficiency highlighted a lack of adherence to safety protocols intended to protect residents.
A resident with respiratory failure was not receiving continuous oxygen as ordered, with the nasal cannula improperly stored and exposed. The facility's staff, including the DON and an LPN, acknowledged the oversight, which was contrary to the facility's oxygen administration policy.
Surveyors observed that the facility failed to maintain a clean and sanitary environment in resident rooms and common areas. In the Sub-Acute smoking courtyard, cigarette butts and empty packages were improperly discarded despite posted signs. A resident's room had a stained privacy curtain, soiled walls, a broken window blind, and flies, which the resident confirmed. These issues were reported to the LNHA, DON, and Interim Infection Preventionist nurse.
A facility failed to conduct a PASARR Level II assessment for a resident newly diagnosed with a mental illness. Despite a new diagnosis of depression and psychotic disorder, the facility did not initiate the required assessment. The Director of Social Services confirmed that a new psychiatric diagnosis should have triggered a Level II PASARR, but this was not done, contrary to the facility's policy.
A resident in an LTC facility did not receive timely incontinence care, leading to a deficiency. The resident, who was alert and cognitively intact, reported not receiving care since 3:00 AM, despite being soiled. The CNA assigned to the resident had not yet provided care by 9:24 AM, and the resident was found wearing two saturated briefs, contrary to facility protocol. The facility's policy required incontinence care every two hours, but the care plan did not specify frequency, resulting in the deficiency.
A facility failed to resolve conflicting physician orders for a resident's emergency treatment. The resident's records showed both a full code order and a DNR/DNI order, confirmed by the LPN Unit Manager and other staff. The facility's policy requires regular review of code status, which was not followed, leading to unresolved conflicting orders.
A facility failed to notify a physician of an abnormal HbA1C lab result for a resident with uncontrolled blood glucose, leading to a deficiency. Despite the result being highlighted in the electronic medical record, there was no documentation of physician notification. The resident had been hospitalized with multiple diagnoses, including acute kidney injury and dehydration. The DON stated that a nurse practitioner visited twice weekly, but the LPN confirmed the lack of notification. The Medical Director expected same-day notification of abnormal results.
A facility failed to obtain a Physician's Order for an orthotic device for a resident with multiple sclerosis and hemiplegia. The resident was observed with an orthotic near their right elbow, but no order was found in the records. Interviews with staff confirmed the absence of the required order, which was against the facility's policy requiring physician orders for such equipment.
A resident with complex medical conditions was discharged from an LTC facility without a comprehensive care plan or physician's order, despite needing assistance with daily activities. The discharge process lacked input from the interdisciplinary team and ignored family concerns about the resident's ability to care for themselves. The facility's discharge policy was not followed, and the discharge was reportedly driven by insurance coverage expiration.
The facility failed to maintain an operable resident call system, with multiple instances of malfunctioning call lights and delayed repairs, especially over weekends. A resident reported delayed staff response times, and the Maintenance Director acknowledged the issues but could not provide complete logs or confirm interim measures. The Director of Nursing lacked call bell audits, and the Administrator could not provide documentation of actions taken during the reported period.
A facility failed to properly don PPE and store respiratory equipment, leading to potential contamination. A resident's oxygen equipment was left exposed, and staff did not secure PPE gowns, causing them to drag on the floor. Despite previous training, staff did not follow proper procedures, as observed by surveyors.
Failure to Ensure Surety Bond for Resident Funds
Penalty
Summary
The facility failed to ensure a Surety Bond was in place to protect the personal needs account funds of residents. This deficiency affected all residents with personal needs funds held by the facility. The issue was identified when a surveyor requested a Surety Bond from the Licensed Nursing Home Administrator (LNHA) on two occasions, but the LNHA initially provided a Commercial Crime Policy that did not specify coverage for resident funds. A Surety Bond effective the same day was later provided, raising questions about its timing and the absence of a prior bond. Further investigation revealed that the facility's policy required proof of a Surety Bond or an acceptable alternative, such as a crime policy, which must designate an obligee and be managed by a third party. The LNHA was unable to provide a prior Surety Bond or explain why it was not in place before the surveyor's inquiry. The facility had no additional information to offer during the exit conference, and the LNHA could not address the actions of the previous owners regarding the bond.
Inadequate RN Staffing and DON Role Misuse
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This deficiency was identified during a review of the Nurse Staffing Reports and Payroll Based Journal (PBJ) Reports, which revealed that the DON worked as the only Registered Nurse (RN) on several days when the resident census exceeded 60. Specifically, on multiple occasions in May and June 2024, the facility had only one RN on duty during the day shift, despite having a census ranging from 90 to 100 residents. The Human Resource Director confirmed that the DON covered these shifts due to a staffing shortage after a weekend supervisor quit. Further investigation into the PBJ Report for the fiscal year quarter 2, 2024, showed that the facility triggered for no RN hours on several dates, with the previous DON working as the only RN on days when the census was over 60. The facility's policy requires the utilization of RN services for at least 8 consecutive hours per day, 7 days per week, which was not adhered to. Interviews with the DON and the Vice President of Clinical Services (VPCS) revealed a lack of clarity and planning regarding RN coverage, contributing to the deficiency.
Deficiency in CNA In-Service Education and Performance Appraisals
Penalty
Summary
The facility failed to provide regular in-service education to Certified Nurse Aides (CNAs) based on their job performance appraisals. This deficiency was identified for three out of ten CNAs reviewed. The performance appraisals for these CNAs revealed scores indicating a need for immediate improvement in areas such as Adaptability, Leadership, and Dependability. However, the comments and goal sections of these appraisals were left blank, and there was no documentation of any follow-up education or training provided to address these deficiencies. The Director of Nursing (DON) acknowledged that the appraisals were incomplete and confirmed that there was no formal training on how to complete them. Interviews with the DON and the Vice President of Clinical Services (VPCS) revealed that the facility lacked a policy on employee job performance appraisals, leaving it to the discretion of the DON. The facility's assessment indicated that training and education should be provided whenever an area of concern is identified, but this was not followed. The DON's job description included responsibilities for evaluating work performance and implementing discipline, but these duties were not adequately fulfilled, as evidenced by the lack of documented follow-up on the CNAs' performance issues.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food handling and sanitation practices during a survey conducted on June 13, 2024. A Dietary Aid was observed preparing food without wearing a beard guard, which is against the facility's policy requiring all kitchen staff to wear proper attire to prevent food contamination. Additionally, an opened package of hot dog buns was found without an opened date and use by date, contrary to the facility's policy that mandates dating of opened food items. A can of diced potatoes with a dent on the seam was also found in the dry storage area, which should not have been used according to the facility's food purchasing policy. Further observations revealed multiple instances of improperly labeled food items in the walk-in refrigerator. Ten prepared salami sandwiches, fifteen dessert cups of diced pineapple, three pitchers of iced tea, a plate of leftover cheese ravioli, and leftover sautéed spinach were all found without proper labeling of preparation and use by dates. The facility's policy requires all time and temperature control for safety foods to be labeled, covered, and dated when stored. These deficiencies indicate a failure to adhere to the facility's food safety and sanitation policies, potentially compromising food safety.
Deficiency in Smoking Policy Management
Penalty
Summary
The deficiency in the facility was identified when surveyors observed a resident, identified as Resident #25, walking alone around the building's perimeter and smoking a cigarette. The resident was found to have signed a waiver releasing the facility from responsibility for any injuries sustained while outside the building. This waiver was created by the Director of Nursing (DON) and the previous administrator, allowing certain residents to come and go freely, despite the facility's policy against residents holding their own smoking materials and lighters. The waiver was not supported by a specific policy, and the facility's smoking policy did not account for residents smoking outside designated areas. The resident's medical records indicated a history of encephalopathy, major depressive disorder, and hemiplegia, but also showed that the resident was cognitively intact with a perfect score on the Brief Interview for Mental Status. The care plan for the resident included a focus on smoking, stating that the resident was an independent smoker who did not require direct supervision. However, the care plan did not address the resident's ability to hold smoking materials and lighters or the implications of smoking around the building. The facility's smoking assessment confirmed the resident's capability to handle smoking materials independently, but there was no care plan related to the waiver or the resident's independent smoking activities. The Licensed Nursing Home Administrator (LNHA) was interviewed and acknowledged his responsibility for ensuring compliance with facility policies, including the smoking policy. However, he was unaware of a specific policy regarding residents holding lighters and smoking outside designated areas. The LNHA admitted that a handful of residents were allowed to smoke independently outside, but there was no formal policy or procedure to manage this practice. The lack of a clear policy and the use of an informal waiver system led to a deficiency in the facility's management of resident smoking activities, potentially affecting the safety of all residents.
Inaccurate RN Hours Reporting in PBJ
Penalty
Summary
The facility failed to submit accurate Registered Nurse (RN) hours in their Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 2, covering January 1 to March 31, 2024. Specifically, the report inaccurately reflected 'No RN Hours' on several dates, including January 27, January 28, February 24, February 25, March 10, March 23, and March 24. Upon review, it was found that on January 27 and 28, the facility's current Director of Nursing (DON), who was not yet promoted to the DON role, worked as an RN. Additionally, on March 23 and 24, the President of Clinical Services served as the RN. This discrepancy was confirmed during an interview with the current DON, who stated she assumed her role in April 2024. The facility's policy mandates the submission of timely and accurate staffing data through the CMS PBJ system, which was not adhered to in this instance.
Failure to Maintain Sanitary and Functional Toilet
Penalty
Summary
The facility failed to maintain a sanitary and functional toilet in a resident's bathroom for four days. On multiple occasions, the surveyor observed the toilet in the resident's room filled with brown debris and paper products, with no water present in the bowl. The resident confirmed that the toilet had been non-functional for several days, and the facility was aware of the issue. Despite this, the toilet was not listed for repair in the maintenance log, and no work order was generated until a separate issue with a paper towel dispenser was addressed. Interviews with facility staff, including a CNA, LPN, Unit Manager, and Maintenance Director, revealed a lack of communication and follow-through regarding the toilet's condition. The CNA and LPN acknowledged the recurring issue of the resident flushing inappropriate items, such as paper towels, leading to frequent clogs. However, neither reported the recent clogging incident. The Unit Manager confirmed that all repair needs should generate a work order, but this was not done for the toilet. The Maintenance Director admitted that a toilet should not remain clogged for four days, recognizing it as an inconvenience and unhealthy for the resident.
Insect Infestation and Dignity Violation
Penalty
Summary
The facility failed to maintain a resident's room and environment free of insects and did not address the resident in a dignified manner. This deficiency was observed in the case of Resident #55, who was found in a room with a noticeable urine odor and black flies present. The resident's urinary catheter was lying on the bed, and the resident confirmed awareness of the flies. During multiple observations, surveyors noted the presence of flies on the bedspread, remote, and meal tray lid. The Licensed Practical Nurse Unit Manager acknowledged the uncleanliness and presence of flies but claimed not to have seen them before. Additionally, the staff's interaction with Resident #55 was undignified. An LPN referred to the resident in a derogatory manner, calling the resident a "dirty old [gender redacted]" and described the resident as noncompliant. This behavior was witnessed by surveyors and confirmed by the Director of Nursing, who acknowledged it as a dignity issue. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by the disrespectful language used by the LPN and the failure to maintain a clean and dignified environment for the resident.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the preferences of a resident, identified as Resident #12, regarding their daily routine and personal belongings. During an initial tour, the resident expressed a desire to get out of bed at a specific time, which was not honored by the facility. The resident was observed in a hospital gown and expressed distress over not being able to contact their family and retrieve personal belongings from a previous facility. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not specify their preference for getting out of bed, and their personal needs were not adequately addressed. The facility's social worker attempted to contact the previous facility to retrieve the resident's belongings but was unsuccessful and did not pursue alternative communication methods, such as sending a letter. The social worker also failed to escalate the issue to the facility's administrator for further guidance. The resident continued to express dissatisfaction with their situation, including a preference for wearing personal clothing rather than a hospital gown. The facility did not provide documentation of efforts to address the resident's concerns until prompted by the survey team, indicating a lack of proactive measures to ensure the resident's rights and preferences were respected.
Failure to Enforce Smoking Policy for Resident Safety
Penalty
Summary
The facility failed to adhere to its smoking policy, resulting in a deficiency related to the safety of residents who smoked and held their own cigarettes and lighters. This issue was identified for two residents. Resident #22, who had intact cognition and was admitted with diagnoses including respiratory failure and alcohol abuse, was observed holding their own cigarettes and lighter in their room. Despite the facility's smoking policy requiring all smoking paraphernalia to be kept at the nurse's station, the resident stated that the facility was aware of their possession of these items. Interviews with staff, including the Smoking Aide, Licensed Nursing Home Administrator (LNHA), Social Worker (SW), and Licensed Practical Nurse (LPN) Unit Manager, revealed inconsistencies in the enforcement of the smoking policy, with some staff incorrectly believing that alert residents could hold their own smoking materials. Resident #25 was observed smoking outside the designated smoking area, walking around the building with a personal lighter. The resident's care plan indicated they were an independent smoker who did not require direct supervision, but it did not specify that they could hold their own smoking materials. The resident confirmed they smoked a pack of cigarettes a day and kept a personal lighter. The facility's smoking policy, which was confirmed by the LNHA, stated that residents were only permitted to smoke in designated areas and that all smoking products should be lit by a smoking monitor or designated staff member. The deficiency was further highlighted by the lack of adherence to the facility's smoking policy, which was intended to ensure the safety of residents. The policy required a smoking monitor to observe all smokers and prohibited residents from holding their own lighters. However, both residents were found to be in possession of lighters, and staff interviews revealed a lack of consistent understanding and enforcement of the policy. This failure to follow the established smoking policy posed a potential safety hazard for the residents involved.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for continuous oxygen administration for a resident, leading to a deficiency. The surveyor observed that the resident, who was diagnosed with conditions including diffuse traumatic brain injury, dementia, and respiratory failure, was not receiving the prescribed oxygen therapy. On two separate occasions, the resident was found without the nasal cannula in place, and the oxygen equipment was improperly stored, with the nasal cannula exposed to the environment. The resident's medical records indicated a requirement for continuous oxygen at 2 liters per minute, which was not being followed. The Director of Nursing and the Licensed Practical Nurse Unit Manager acknowledged the oversight when it was brought to their attention. The facility's oxygen administration policy, which was last revised in 2010, was not being followed, as evidenced by the lack of proper oxygen delivery and equipment handling. The deficiency was identified during a survey, and the facility's existing policy was the only guideline available at the time of the incident.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms and common areas, as observed by surveyors. In the Sub-Acute smoking courtyard, cigarette butts were scattered throughout the lawn area surrounding the gazebo, on top of a garbage can, and partially filled an open bucket on the ground, which also contained empty cigarette packages. Despite signs instructing proper cigarette disposal, these items were improperly discarded. In a resident's room, the surveyor noted several deficiencies, including a stained privacy curtain, soiled walls, a broken window blind, and the presence of flies. The resident confirmed the presence of flies in the room. These observations were reported to the LNHA, Director of Nursing, and Interim Infection Preventionist nurse.
Failure to Conduct PASARR Level II Assessment for New Psychiatric Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) Level II assessment for a resident who was newly diagnosed with a mental illness. This deficiency was identified during a survey when it was found that a resident, who had previously been assessed with a negative Level I PASARR indicating no mental illness, was later diagnosed with depression and a psychotic disorder. Despite this new diagnosis, the facility did not initiate a Level II PASARR assessment as required. The Director of Social Services, who started working at the facility in February 2024, acknowledged during an interview that a new psychiatric diagnosis should have prompted an interdisciplinary conference and a request for a Level II PASARR. However, no such assessment was completed for the resident following the diagnosis of psychosis in December 2023. The facility's policy, implemented in January 2024, mandates that any resident with a newly evident serious mental disorder should be referred for a Level II review, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence and personal hygiene care for a resident, leading to a deficiency in activities of daily living. The resident, who was alert and cognitively intact, reported that incontinence care was not provided in a timely manner. The resident was last assisted with incontinence care at 3:00 AM and had not received care by 9:24 AM, despite being soiled and requesting to be changed. Upon observation, the resident was found wearing two saturated incontinent briefs, which was against the facility's protocol. The Certified Nursing Aide (CNA) assigned to the resident confirmed that she had not yet provided incontinence care to the resident and had a total of 10 residents on her assignment, seven of whom required total assistance. The CNA stated that she would complete her first round of care by 11:00 AM. The Unit Manager and the surveyor observed the resident with double briefs, which was not the facility's practice, and the issue had been addressed earlier in the year with staff in-service training. The facility's protocol required incontinence care every two hours and as needed, but the care plan for the resident did not specify the frequency for incontinence care. The resident's care plan included a focus on maintaining dignity by being clean, dry, odor-free, and well-groomed. The facility's policy emphasized providing necessary services to maintain good nutrition, grooming, and personal hygiene for residents unable to carry out activities of daily living. Despite these protocols, the resident did not receive timely care, resulting in the deficiency.
Conflicting Code Status Orders for a Resident
Penalty
Summary
The facility failed to identify and resolve conflicting physician orders regarding emergency treatment for a resident. The resident's electronic medical record contained a full code order with a start date of May 2, 2024, and a DNR/DNI order with a start date of January 29, 2024. Additionally, the resident's POLST dated October 3, 2022, indicated a do not attempt resuscitation and do not intubate order. This discrepancy in the resident's code status was confirmed during an interview with the LPN Unit Manager, who acknowledged the conflict and stated that the order should not indicate a full code. Further interviews with the Director of Nursing, Licensed Nursing Home Administrator, and Interim Infection Control Preventionist confirmed that the resident should not have both full code and DNR/DNI status. The facility's policy on POLST/Advanced Directive, dated November 13, 2023, requires a review of code status on a quarterly basis or upon significant change with the resident or healthcare representative. This policy was not adhered to, resulting in the conflicting orders remaining unresolved in the resident's medical record.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure a system was in place to review and notify physicians of laboratory values, resulting in a deficiency for one resident. The resident, who was observed in bed and responding to questions, had been discharged to the hospital with diagnoses including acute kidney injury, altered mental status, dehydration, hypernatremia, Diabetes Type 2, and a urinary tract infection. A Nutrition Note indicated the resident was on a no concentrated sweets puree diet, with varying intake and an uncontrolled blood glucose level, as evidenced by an HbA1C of 11.8%. This laboratory result was highlighted as abnormal in the electronic medical record. Despite the abnormal HbA1C result, there was no documentation indicating that the physician was notified. The Director of Nursing stated that a nurse practitioner visited the facility twice weekly to complete progress notes. However, during an interview, the Licensed Practical Nurse Unit Manager confirmed that there was no record of the physician being informed of the abnormal lab result. The Medical Director stated that he should be notified of abnormal laboratory values on the same day they are received, which did not occur in this instance.
Failure to Obtain Physician's Order for Orthotic Device
Penalty
Summary
The facility failed to obtain a Physician's Order for an orthotic device for a resident who was reviewed for positioning and mobility. The resident, who was admitted with diagnoses including multiple sclerosis, cerebral infarction, and hemiplegia, was observed with an orthotic device near their right elbow. Despite the occupational therapy discharge summary recommending a right elbow extension orthotic, the Order Summary Report did not include an order for this device. Interviews with the President of Clinical Services and a Licensed Practical Nurse confirmed that there should have been a physician's order for the orthotic device. The facility's policy on Range of Motion, Splinting, and Bracing, which requires a physician's order for such equipment, was not followed. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with their own policies and state regulations.
Inadequate Discharge Planning for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to adequately plan and execute the discharge of a resident, identified as Resident #194, who had multiple complex medical conditions including hypertension, pulmonary emboli, deep vein thrombosis, pneumomediastinum, multiple hemorrhagic strokes, and a history of intravenous drug use. The resident was discharged without a comprehensive care plan addressing their discharge needs, despite requiring assistance with activities of daily living such as bed mobility, transfer, and toileting. The discharge planning process was incomplete, lacking a physician's order and failing to incorporate input from the interdisciplinary team or the resident's family, who had expressed concerns about the resident's ability to care for themselves independently. Interviews with facility staff revealed significant lapses in the discharge process. The Licensed Practical Nurse Unit Manager acknowledged that discharge planning should begin upon admission and involve all care team members, but this was not done for Resident #194. The nurse responsible for completing the discharge paperwork was unfamiliar with the resident's care and was only present for one day, leading to incomplete documentation. Additionally, the Director of Nursing admitted that the discharge summary was incomplete and that there was little she could do as she was not the physician. The facility's policy on discharge planning, which requires an interdisciplinary approach and input from all relevant parties, was not followed. The policy mandates that discharge plans be initiated within seven days of admission and that a physician's order is necessary for discharge, neither of which were adhered to in this case. The resident's representative reported that the discharge was prompted by the expiration of health insurance coverage, despite the resident's ongoing need for assistance, highlighting a failure to prioritize the resident's care needs over administrative concerns.
Deficient Call System Maintenance and Response Delays
Penalty
Summary
The facility failed to maintain an operable resident call system, as evidenced by multiple instances of malfunctioning call lights across different units. During a survey, a resident reported that while the call light was functional, staff response times were delayed, sometimes taking up to 30 minutes. Maintenance logs revealed numerous entries indicating broken or non-functional call lights on two of the four units, with repairs often delayed, especially over weekends when no maintenance service was available. The Maintenance Director acknowledged these issues but could not provide logs for the unit where the complaint originated, nor could he confirm if alternative measures were implemented during the downtime. The surveyor's investigation highlighted a significant delay in addressing a call light issue on Unit AB, which took seven days to repair. The Maintenance Director admitted that the system was defective and could not be repaired immediately, but he was unable to provide details on interim measures or whether the Department of Health was notified. The Director of Nursing was unable to provide any call bell audits, indicating a lack of proactive monitoring of the call system's functionality. The facility's policies on maintenance inspections and call light accessibility were reviewed, revealing that routine inspections and immediate corrective actions were required but not consistently implemented. The Administrator, who was not employed during the period of the reported issues, stated that the protocol for a defective call light system involved notifying the state and providing residents with alternative alert methods, but no documentation was available to confirm these actions were taken. The facility's inability to provide comprehensive documentation on how the call light issues were addressed further underscores the deficiency.
Improper PPE Use and Oxygen Equipment Storage
Penalty
Summary
The facility failed to appropriately don Personal Protective Equipment (PPE) and store respiratory equipment to prevent contamination and exposure to the environment. On June 13, 2024, a surveyor observed a staff member assisting Resident #42, who was wearing a nasal cannula attached to a portable oxygen tank set at 2 liters per minute. The following day, the surveyor noted that the resident's portable oxygen tank was left on the back of a recliner chair in the hallway, with the nasal cannula tubing exposed to the environment and not in a protective covering. Additionally, the resident was found in bed without the oxygen tubing in a protective covering, and it was in direct contact with a mechanical lift pad. The Director of Nursing (DON) and a Licensed Practical Nurse Unit Manager (LPN UM) acknowledged the resident was not receiving continuous oxygen as ordered. The LPN UM donned a PPE gown but failed to secure the tie around her waist, resulting in the gown dragging on the floor while she attended to the resident. Similarly, two Certified Nursing Assistants (CNAs) arrived to assist the resident and also failed to properly secure their PPE gowns, which were observed falling down and dragging on the floor during their tasks. The facility's policies on oxygen administration and PPE use were reviewed, revealing that the oxygen administration policy did not include guidelines for storing oxygen delivery equipment. The PPE policy outlined the proper procedure for donning gowns, which was not followed by the staff. Despite previous in-service training on PPE, staff members failed to adhere to the correct procedures, leading to potential contamination risks.
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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