St Mary's Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherry Hill, New Jersey.
- Location
- 220 St Mary's Drive, Cherry Hill, New Jersey 08003
- CMS Provider Number
- 315060
- Inspections on file
- 17
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Mary's Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
Two residents with complex medical needs did not receive prescribed medications and nutritional treatments as ordered, and providers were not notified in a timely manner. Documentation in the MAR showed missed and refused doses, but there was no evidence in progress notes that providers were informed, as required by facility policy. Staff interviews confirmed that provider notification and documentation were expected but not completed.
The facility failed to accommodate dietary preferences for several residents, as evidenced by missing or incorrect food items on meal trays. A resident on a specific diet did not receive their ordered items, and another resident reported not receiving requested beverages. The Dietary Department's policy was not followed, leading to unmet resident preferences and inadequate communication among staff.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by surveyors. Issues included expired hot dog rolls and cucumber salad, unlabeled pizza dough, and open containers of food thickener and flour. Additionally, an unlabeled plate of food and outdated blueberries were found in unit pantry refrigerators. These practices were not in compliance with the facility's food storage and dietary policies.
The facility's Arbitration Agreement failed to inform residents or their representatives of their right not to sign as a condition of admission or continued care. The agreement also lacked language allowing communication with officials, as confirmed by the LNHA and Admissions Director.
The facility did not properly test and maintain battery-operated smoke detectors in resident rooms, as required by NFPA 101. Documentation lacked details such as make, model, and battery type, and only included monthly checkmarks. The manufacturer's manual required weekly testing, which was not documented. This affected all 114 smoke detectors, potentially impacting all residents.
The facility failed to conduct fire drills with varying activation types and times as required by NFPA 101: 2012 Edition. The fire drill reports lacked specificity regarding the method of alarm transmission, and six out of twelve drills were conducted on a Saturday without varying times for the first shift. This deficiency had the potential to affect all residents.
The facility's emergency generator annunciator panel was found to be malfunctioning, as the test lamp button did not work and no alarm condition lights functioned, despite the generator running. This issue was identified during an observation and had the potential to affect all residents.
The facility failed to keep an exit stairway free of storage, as required by NFPA 101. During an observation, two chairs were found obstructing the path of egress in the physical therapy stairway, potentially affecting 50 residents. A U.S. FOIA representative confirmed that nothing should be stored in stairway exits.
The facility failed to ensure that an electrical outlet next to a water source in the Physical Therapy room was equipped with GFCI protection, as required by NFPA 70 and NFPA 99. This deficiency, observed during an inspection, had the potential to affect ten residents.
The facility failed to maintain a clean and safe environment, as observed by a surveyor. Linen was found unfolded and piled on a linen cart handle, and soiled utility rooms had overflowing linens and untied trash bags on the floor. The Infection Preventionist and LNHA acknowledged the issues, with the LNHA noting that soiled utility rooms are checked twice during the day shift, but additional checks were requested.
A resident with a history of falls and severe cognitive impairment experienced multiple falls without thorough investigation or documentation. Incident reports lacked witness statements, vital signs, and clarity on whether falls were witnessed. Staff interviews confirmed inconsistencies in following facility policy, and the Director of Nursing acknowledged the deficiencies.
A facility staff member failed to wear a gown during high-contact activities for a resident under Enhanced Barrier Precautions, despite the requirement outlined in the resident's care plan and facility policy. The CNA was observed providing incontinence care with only gloves and a mask, which was confirmed by the UM/LPN, Infection Preventionist, and DON. The facility's policy mandates gown and glove use during such activities to prevent the spread of MDROs.
The facility failed to maintain the required minimum CNA-to-resident ratios as mandated by New Jersey law. Multiple instances of insufficient staffing were identified across several weeks in 2023 and 2024, with the facility consistently falling short of the required number of CNAs during the day shift. Despite the facility's policy to provide sufficient staffing, the documented levels did not meet the state-mandated ratios, as confirmed by interviews with the Staffing Coordinator and the DON.
Failure to Notify Providers of Unadministered and Refused Medications
Penalty
Summary
The facility failed to notify providers in a timely manner when prescribed treatments and medications were not administered as ordered for two residents. For one resident with severe cognitive impairment and multiple complex diagnoses, including epilepsy and cancer, there were several missed doses of phenobarbital documented in the Medication Administration Record (MAR) over multiple dates. The MAR indicated missed doses using a chart code, and progress notes showed that the medication was on order and not yet delivered. However, there was no documentation that the provider was notified of these missed doses until several weeks later, and for some missed doses, no provider notification was documented at all. For another resident with moderate cognitive impairment and multiple medical and psychiatric conditions, including anorexia nervosa, malnutrition, and gastrointestinal disorders, there were missed and refused doses of intravenous nutritional support (Clinimix and Clinolipid) documented in the MAR. The chart codes indicated both unadministered and refused doses, but there was no documentation in the progress notes that a provider was notified of these events. Interviews with staff, including a unit manager and the Director of Nursing (DON), confirmed that provider notification and documentation were expected but not completed or recorded in these cases. Facility policy required that the attending physician or nurse practitioner be notified of changes in condition or when medical intervention was warranted, and that such notifications be documented in the medical record. The DON and other staff acknowledged that the medical record should reflect all care provided, including provider notifications, and that the lack of documentation was not consistent with facility policy. Interviews with providers did not confirm that they had been notified of the missed or refused medications, further supporting the finding that timely provider notification and documentation did not occur.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate resident preferences with specific food items as documented on meal tickets for four out of six sampled residents. Resident #2, who was cognitively intact and on a specific diet due to medical conditions, reported not receiving their food preferences. The Dietician confirmed that Resident #2's lunch tray did not contain the ordered items and communicated this issue to relevant staff. However, the Food Service Director acknowledged that the resident's request for sugar packets was not fully met, and there was no documentation of staff education to prevent recurrence. Resident #1 also reported not receiving requested items like coffee with creamer and sugar, and tea during meals, which was a common complaint in Resident Council Meetings. The Licensed Nursing Home Administrator was aware of a tray being delivered to the wrong room, indicating a lapse in communication and coordination among staff. Additionally, Resident #5 did not receive the ordered two juices and garlic spinach, as confirmed by the Unit Manager and the Certified Nursing Assistant, who admitted to being sidetracked and not fulfilling the resident's request. The Dietary Department's policy required that meal trays be provided as ordered, with routine checks by the Food Services Manager or supervisor. However, the facility's failure to adhere to these policies resulted in residents not receiving their dietary preferences, as evidenced by the surveyor's observations and interviews with staff and residents. The deficiency highlights a lack of effective communication and documentation within the dietary department, impacting the residents' rights to receive meals according to their preferences.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the kitchen's walk-in refrigerator, 15 bags of hot dog rolls were found with a received by date of 11/11/24, and an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. Both items were acknowledged by the Dietary Director (DD) and were discarded. Additionally, in the walk-in freezer, an opened clear plastic bag with pizza dough was found without a label or date, which the DD also discarded. In the prep area, large containers of food thickener and flour were left open and exposed to air, which the DD subsequently closed. Further observations included an unlabeled, covered plate with fish, pork, and fries in a unit pantry refrigerator, which was removed by a Nurse Manager. Another observation in a different pantry refrigerator revealed a plastic container of fresh blueberries dated 11/23/2024, with some appearing dry. The Nurse Manager was unaware of the expiration date for fresh fruit and removed the blueberries. The facility's policies on food storage, freezer management, and dietary practices were reviewed, indicating that the observed practices were not in compliance with the established guidelines.
Plan Of Correction
Plan of Correction F812 Level F Completion Date: 1/15/2025 Corrective Action: Items that were outdated (hotdog rolls and cucumber salad were discarded). Pizza dough was discarded. Open containers in work area were closed. Personal resident food in pantry (blueberries) were discarded. ID Other Residents: Residents who require nutrition from the Dietary Department or who have personal food brought into the facility. Systemic Change: In-service Labeling, Dating and Discarding Food to the Dietary Department by the Dietary Director completed by 1/15/2025. In-service Resident Food Brought into the Facility to Dietary and Nursing Department by the Dietary Director completed by 1/15/2025. Daily rounds will be completed by the dietary staff in the kitchen and pantry to monitor for outdated items and dispose of them per policy. Monitoring: Audit - Labeling and Dating of Items will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by the Dietary Director. Audit Nursing Pantry Refrigerator will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in Arbitration Agreement Language
Penalty
Summary
The facility failed to include explicit language in their Arbitration Agreement to inform residents or their representatives of their right not to sign the agreement as a condition of admission or continued care. This deficiency was identified through a review of the facility's admission packet, which included an Arbitration Agreement titled 'Voluntary, Binding Arbitration.' The agreement did not contain any language explicitly stating that signing was not a requirement for admission or continued care. Additionally, the agreement lacked language allowing residents or others to communicate with federal, state, or local officials, including representatives of the Office of the State Long Term Care Ombudsman. During interviews, the Licensed Nursing Home Administrator (LNHA) and the Admissions Director confirmed the absence of such language in the arbitration agreement. The LNHA acknowledged that the agreement did not explicitly state that signing was not a condition for admission or continued care. Furthermore, the LNHA confirmed that the agreement did not allow for communication with federal, state, or local officials, although an Ombudsman notification form was included in the admission agreement. This oversight has the potential to affect all residents who signed the binding arbitration clause.
Plan Of Correction
1/15/25 Plan of Correction F847 Level F Completion Date: 1/15/2025 Corrective Action: Admissions Agreement changed to reflect appropriate language in regards to Voluntary Binding Arbitration. Admissions Agreement now will state THIS AGREEMENT IS OPTIONAL FOR RESIDENTS AND FACILITY. ADMISSION TO THE FACILITY IS NOT CONDITIONAL UPON A RESIDENT'S WILLINGNESS TO ENTER INTO THIS AGREEMENT. Appropriate officials and departments for the New Jersey Department of Health and Human Services Division of Aging and Long-Term Care Ombudsman contact information added to Admissions Agreement. Added information will be available to those individuals who have previously signed admissions agreements prior to the above changes being made. ID Other Residents: Any resident or Responsible Party who sign an Admission Agreement. Systemic Change: In-service Updated Admissions Agreement to the Admissions Department by the LNHA completed by 1/15/2025. Monitoring: Audit - Admissions Agreement will be completed on the following schedule: (4) weekly x 2 weeks then (4) monthly x 2 months then (4) quarterly x 1 quarter by the Admissions Coordinator. Results of the audits will be brought to QA/QAPI on a quarterly basis x 3 quarters.
Failure to Maintain Smoke Detectors
Penalty
Summary
The facility failed to ensure proper testing and maintenance of battery-operated smoke detectors in resident rooms, as required by the NFPA 101 Life Safety Code: 2012 Edition. This deficiency was identified during an interview and documentation review, which revealed that the facility's preventative maintenance logs lacked detailed information about the smoke detectors, such as make, model, installation date, and battery type. The logs only contained a checkmark for each room every month, without any further details. Additionally, the manufacturer's user manual indicated that the smoke detectors should be tested at least once a week, a requirement that was not reflected in the facility's documentation. This oversight affected all 114 documented battery-operated smoke detectors in the facility, potentially impacting all residents. The findings were communicated to the U.S. FOIA (b)(6) during the Life Safety Code exit conference.
Plan Of Correction
Plan of Correction K0347 Level F Completion Date: 1/15/2025 Corrective Action: 10 year maintenance free battery operated smoke detectors were tested in all resident rooms on 12/12/24 and operational as designed. ID Other Residents: Any resident within the facility Systemic Change: In-service Monitoring Smoke Detectors to the Maintenance Department by the Maintenance Director completed on 12/20/24. Smoke Detectors will be tested monthly and a log maintained by the Maintenance Department. Monitoring: Audit - Smoke Detectors will be completed on the following schedule: (10) quarterly x 3 quarter by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Inadequate Fire Drill Procedures
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Sections 19.7.1.4 through 19.7.1.7. This deficiency was identified during a document review and interview on December 3, 2024, in the presence of the U.S. FOIA (b)(6). The review revealed that the facility's fire drill reports did not specify the method used for the simulation of alarm transmission signals. Additionally, six out of twelve drills were conducted on a Saturday, and the times for the first shift drills were not varied, which is a requirement for ensuring staff preparedness under different conditions. The lack of specificity in the fire drill reports and the failure to vary drill times and activation types had the potential to affect all residents in the facility. The findings were verified by the [R] at the time of the record review, and the U.S. FOIA (b)(6) confirmed the inadequacies in the documentation and execution of the fire drills. These issues were discussed at the Life Safety Code exit conference on December 4, 2024.
Plan Of Correction
Plan of Correction K0712 Level F Completion Date: 1/15/2025 Corrective Action: - Additional 12/24 Fire Drill will be performed during the day shift and not on a weekend. - Additional 12/24 Fire Drill will reflect type of signal. ID Other Residents: - All residents within the facility have the potential to be affected. Systemic Change: - In-service Fire Drill Testing, Scheduling, Monitoring to the Maintenance Department by the Maintenance Director on 2/2/24. - Fire Drills will be performed during the evening and night shifts and not on the weekend to ensure fire drill training is completed on all shifts. - Supervision log will be utilized to ensure fire drills are completed timely, note signal type and vary for the appropriate shift and time. Monitoring: - Audit - Fire Drill will be completed on the following schedule: (3) quarterly x 3 quarters by the Maintenance Director/Designee. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Emergency Generator Annunciator Panel Malfunction
Penalty
Summary
The facility failed to ensure that the emergency generator annunciator was fully functional and operating in normal mode, as required by NFPA 99: 2012 Edition, Section 6.4.1.1.17 and 6.4.1.1.17.5. During an observation at 11:32 AM, it was noted that the generator annunciator panel's test lamp button did not work when activated. Although the generator produced a green light on the annunciator panel indicating it was running, no other alarm condition lights functioned at the time of observation. This deficiency was identified for the only generator annunciator panel in the facility and had the potential to affect all residents. The findings were communicated to the relevant personnel at the Life Safety Code exit conference.
Plan Of Correction
K0916 Level F Completion Date: 1/15/2025 Corrective Action: The generator was inspected and found to be functioning as designed and a new annunciator control board ordered for Generator Annunciator Panel. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Annunciator Panel Monitoring and Resident Safety to the Maintenance Department by the Maintenance Director completed by 12/20/2024. Monitoring: Audit - Annunciator Panel will be completed on the following schedule: every quarter x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Obstruction in Exit Stairway
Penalty
Summary
The facility failed to maintain one of its six exit stairways free of storage, as required by NFPA 101: 2012 Edition, Sections 19.2.2.3, 19.2.2.4, and 7.2. During an observation conducted on December 4, 2024, in the presence of a U.S. FOIA representative, it was noted that two chairs were obstructing the path of egress in the physical therapy stairway. One chair was located on the middle landing, and another was on the lower level of the exit/egress stairs leading to the public way. This deficiency had the potential to affect 50 residents. In an interview at the time of the observation, the U.S. FOIA representative acknowledged that nothing should be stored in the stairway exits at any time. The findings were communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
1/15/25 Plan of Correction K0225 Level E Completion Date: 1/15/2025 Corrective Action: - 2 chairs removed from therapy stairwell. - Other stairwells were checked and no obstruction noted. ID Other Residents: - Any resident within the facility have the potential to be affected. Systemic Change: - In-service Stairwells Free of Obstruction to the Maintenance and Therapy Departments by the Maintenance Director completed on 12/20/24. Monitoring: - Audit - Obstruction in Stairwell will be completed on the following schedule: (4) quarterly x 3 quarter by the Maintenance Director. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Equip Electrical Outlet with GFCI Protection
Penalty
Summary
The facility failed to ensure that one of ten electrical outlets located next to a water source was equipped with Ground-Fault Circuit Interrupter (GFCI) protection, as required by NFPA 70 and NFPA 99. This deficiency was observed on December 4, 2024, during an inspection in the Physical Therapy room. At 11:50 AM, it was noted that a device was plugged into a standard duplex wall outlet instead of the required GFCI outlet for wet locations. This oversight had the potential to affect ten residents. The finding was confirmed by the U.S. FOIA (b)(6) at the time of observation and was communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
Plan of Correction K0912 Level F Completion Date: 1/15/2025 Corrective Action: Existing outlet was removed and replaced with GFCI outlet. Facility wide inspection has been completed for GFCI outlets. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Testing and Inspection of GFCI Outlets to the Maintenance Department by the Maintenance Director on 12/20/2024. Facility wide inspection of installed GFCI. Monitoring: Audit - GFCI Outlet will be completed on the following schedule: (4) quarterly x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by observations made by a surveyor. On December 3, 2024, in the St. [NAME] hallway, linen including towels and blankets were found unfolded and piled onto the outside handle of the linen cart. Additionally, in the St. [NAME] Soiled Utility room, linens were observed overflowing and not bagged from the receptacle, with two trash bags placed on top of the trash receptacle. In the St. Mary's soiled utility room, linens in untied trash bags were left on the floor. During an interview on December 4, 2024, the Infection Preventionist acknowledged that soiled utility rooms should not be piled up and confirmed that she ensures nothing is on the floor. On December 5, 2024, the Licensed Nursing Home Administrator (LNHA) stated that soiled utility rooms are checked twice during the day shift, but additional checks by housekeeping were requested. The LNHA confirmed that trash bags should be in receptacles and not on the floor.
Plan Of Correction
Plan of Correction F584 Level D Completion Date: 1/15/2025 Corrective Action: Linen found outside of the linen cart was placed in soiled laundry. Linens in the Soiled Utility Room were tied, taken off the floor and placed in the receptacle. Soiled linen was removed from Soiled Utility Room. ID Other Residents: Any resident within the facility Systemic Change: In-service Proper Storage of Linens will be given to the Nursing Department and Laundry by Nurse Educator completed by 1/15/2025. In-service Proper Disposal of Soiled Linens will be given to the Nursing Staff and Laundry by Nurse Educator completed by 1/15/2025. Soiled linens will be collected by laundry service 3 xs daily on the morning shift and 2 xs daily on the evening shift. Additional laundry disposal bins will be purchased to handle the amount of soiled linen that is created. Monitoring: Audit - Clean and Soiled Linen will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xos 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Audit Soiled Utility Room Linen Disposal will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xos 3 quarters.
Inadequate Fall Investigation and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and conduct thorough investigations for a resident who experienced repeated falls. The surveyor reviewed incident reports for falls that occurred on three separate occasions. The reports lacked essential details such as statements from witnesses, vital signs, and whether the falls were witnessed or unwitnessed. The facility's policy required these elements to be included in the incident reports, but they were missing in the cases reviewed. The resident involved had a history of repeated falls and was admitted with diagnoses including cardiomegaly and hypomagnesemia. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). Despite these conditions, the incident reports did not include comprehensive assessments or documentation of the resident's condition following the falls, such as vital signs or any potential injuries. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the documentation process. Staff confirmed that statements from witnesses and detailed assessments were not consistently obtained or recorded. The Director of Nursing acknowledged the deficiencies in the incident reports and confirmed that the facility's policy was not followed, as the reports lacked signatures, titles, and complete information about the incidents.
Plan Of Correction
Plan of Correction F610 Level D Completion Date: 1/15/2025 Corrective Action: Resident #347 incident report dated 26 was reviewed and reinvestigated by Nursing Administration. Statements were obtained by nursing staff involved in care of resident during incident. Post incident follow up was rewritten. ID Other Residents: Any resident within the facility who has an incident that requires an investigation. Systemic Change: In-service How to Complete a Thorough Investigation to the Nursing Department by Nursing Administration by 1/15/2025. In-service What to Include in an Incident Report: to the Nursing Department by Nursing Administration by 1/15/2025. Statements will be obtained for all unwitnessed incidents by those individuals who interacted with resident within the timeframe of the incident. Monitoring: Audit - Incident Reports and Investigations will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration by 1/15/2025. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to appropriate infection control practices by not wearing a gown during high-contact activities in a resident's room who was under Enhanced Barrier Precautions. This deficiency was identified for a resident reviewed for respiratory care. The resident's electronic medical record indicated an order for Enhanced Barrier Precautions every shift for catheter/wound care, requiring staff to wear a gown and gloves during high-contact activities such as dressing, bathing, transfers, linen changes, providing hygiene, brief changes, toileting assistance, indwelling medical device care, and wound care. During an observation, a Certified Nurse Aide (CNA) was seen providing incontinence care to the resident without wearing a gown, despite wearing gloves and a mask. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the CNA's failure to wear a gown during the care. The Infection Preventionist and the Director of Nursing (DON) both confirmed that staff are expected to wear a gown and gloves when providing incontinence care to residents under Enhanced Barrier Precautions. The facility's policy on Enhanced Barrier Precautions, dated March 2024, also outlined the requirement for gown and glove use during high-contact resident care activities to reduce the transmission of multiple-drug resistant organisms.
Plan Of Correction
Plan of Correction F880 Level E Completion Date: 1/15/2025 Corrective Action: 1:1 in-service provided to CNA #1 regarding appropriate PPE when providing care to a resident on Enhanced Barrier Precautions. ID Other Residents: Any resident within the facility who requires care. Systemic Change: In-service Enhanced Barrier Precautions and Proper PPE will be given facility to the Nursing Department by Infection Preventionist will be completed by 1/15/2025. Personal Protective Equipment (PPE) will be made available in clean work rooms as well as in each resident room who is identified on Enhanced Barrier Precautions (EBP). Monitoring: Audit - PPE for Enhanced Barrier Precautions will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the facility's Nurse Staffing Report (AAS-11) and interviews with facility staff. The report highlighted multiple instances where the facility did not meet the staffing requirements for Certified Nurse Aides (CNAs) during the day shift across several weeks in 2023 and 2024. For example, during the week of October 29, 2023, to November 4, 2023, the facility was deficient in CNA staffing on four out of seven day shifts, with the number of CNAs ranging from 13 to 21, while at least 25 were required for the number of residents present. Further deficiencies were noted in subsequent periods, including April 28, 2024, to May 11, 2024, where the facility was deficient on 11 out of 14 day shifts. The number of CNAs ranged from 16 to 21, while at least 25 were required for the resident count. Similar patterns of insufficient staffing were observed in August and November 2024, with the facility consistently failing to meet the mandated staffing ratios. These deficiencies were confirmed through interviews with the Staffing Coordinator and the Director of Nursing, both of whom claimed that the facility met the staffing requirements despite evidence to the contrary. The facility's policy titled "Staffing," revised in March 2020, stated that the facility would provide sufficient numbers of staff with the necessary skills and competency to care for all residents. However, the documented staffing levels did not align with this policy, as the facility repeatedly failed to meet the minimum staffing requirements based on the residents' needs and the state-mandated ratios. This discrepancy between policy and practice contributed to the identified deficiency in staffing levels.
Plan Of Correction
Plan of Correction S560 Completion Date: 1/15/2025 Corrective Action: - No residents were identified - Staffing levels were reviewed for all deficient dates listed - Additional staff were recruited to meet the minimum staffing standards moving forward ID Other Residents: - Potential to affect all residents residing within the facility Systemic Change: - Bonuses are offered for double shifts, extra shifts, and weekends - Perfect attendance bonuses are offered on a weekly basis - In-service Lateness and Attendance Policy - Usage of Staffing Agencies to supplement staffing needs - Offering of Certified Nursing Assistant Courses within the facility - Referral Program promoted for staff - Sign on bonuses to assist with staff recruitment - Employee Appreciation parties - In-service State Mandated Staffing Levels: to the Nursing Department by Nursing Administration by 1/15/2025 - Additional shifts will be made available to meet staffing levels for Certified Nursing Assistants - Licensed staff will supplement Certified Nursing Assistant positions if the need arises that staffing levels go below the state required minimum Monitoring: - Nursing Administration will conduct weekly CNA staffing schedule audits - Nursing Administration will report findings to the Administrator - Results of the audits will be brought to QA/QAPI on a quarter basis for 3 quarters.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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