Stratford Manor Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Orange, New Jersey.
- Location
- 787 Northfield Ave, West Orange, New Jersey 07052
- CMS Provider Number
- 315066
- Inspections on file
- 16
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Stratford Manor Rehabilitation And Care Center during CMS and state inspections, most recent first.
Deficiencies were observed in the storage and cleanliness of food preparation areas and equipment. Specifically, soiled oven knobs and handles were noted in the food preparation area, and dented cans were found in the dry storage room still in rotation for use. The Dietary Director acknowledged the need for these areas to be cleaned and for dented cans to be removed from use.
The facility failed to ensure that primary physicians signed and dated monthly physician orders for six residents over several months, as required by facility policy. Staff interviews confirmed that physicians were expected to sign orders monthly in the EHR, but this was not consistently done.
The facility failed to follow the manufacturer's specifications for administering Alendronate Sodium (Fosamax) to a resident, resulting in the medication being given with other drugs, contrary to the required instructions. The DON acknowledged that the administration times should have been adjusted to comply with the cautionary warnings.
The facility failed to ensure that the Consultant Pharmacist identified and reported medication irregularities for three residents, including improper documentation of vital signs, lack of physician documentation for continued medication use, and improper administration of medications.
A resident with Alzheimer's and urinary retention was given tamsulosin without proper documentation of its effectiveness, indication, or benefit vs. risk statement. The medication, started during a hospital readmission, was not documented in the EMR or care plan until noted by a surveyor.
The facility failed to ensure proper storage and labeling of medications, including latanoprost eye drops and Fluticasone/salmeterol discus, and did not maintain a locked box for controlled substances. Additionally, the temperature log for the medication room's refrigerator was incomplete.
The facility failed to ensure that a resident's call light was readily accessible. The resident, with cerebrovascular disease and left-side hemiparesis, was observed twice unable to reach the call light cord, which was under their right chest. The RN confirmed the call light should be on top of the blanket and repositioned it. The facility's policy did not address the need for the call light cord to be within reach.
The facility failed to submit MDS assessments electronically within the required 14-day period for four residents. The MDS Coordinator/Registered Nurse acknowledged the late submissions, stating she was only responsible for one of the late submissions. The survey team informed the facility management of these findings.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, admitted with a myocardial infarction, did not have a care plan for their anticoagulant medication. Another resident, being treated for osteoporosis, did not have a care plan for their condition. Both deficiencies were confirmed by facility staff.
The facility failed to follow physician orders for two residents, resulting in one resident not wearing a prescribed elbow resting splint and another not having bunny booties and heel pads while in bed. Staff confusion and lack of proper documentation in the eMAR and eTAR contributed to these deficiencies.
The facility failed to administer oxygen therapy according to the physician's order, ensure nurses signed the eMAR when oxygen was administered, and properly store respiratory tubing and cannula. A resident was observed with an oxygen concentrator set incorrectly and the nasal cannula improperly stored. Medical records indicated the oxygen was to be administered at 1 LPM PRN, but the eMAR showed no documentation of administration.
The facility failed to establish appropriate infection control practices for environmental cleaning for a resident. A surveyor noticed a splash of a creamy substance on the wall near the resident's bedside table. The RN identified it as tube feeding milk and stated housekeeping would clean it. The LNHA later stated the area was already cleaned but provided no further information.
Deficiencies in Food Storage and Cleanliness Identified
Penalty
Summary
The facility was found to have deficiencies related to the storage and cleanliness of food preparation areas and equipment. Specifically, observations revealed soiled oven knobs and handles in the food preparation area, as well as dented cans in the dry storage room that were still in rotation for use. The Dietary Director acknowledged that these areas should have been cleaned and that dented cans should not be in use.
Failure to Ensure Monthly Physician Orders Signed
Penalty
Summary
The facility failed to ensure that the residents' primary physicians signed and dated monthly physician orders, which is necessary to confirm that the residents' current medical regimen was appropriate. This deficiency was observed for six residents over several months. Specifically, the medical records for Residents #12, #16, #22, #111, #13, and #62 showed that their physicians had not signed or electronically signed the monthly physician's orders for various months in 2024. The absence of these signatures was confirmed through a review of the hybrid medical records, which lacked both hand-signed and electronic signatures for the specified months. Interviews with staff, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), revealed that the primary physicians were expected to sign the orders monthly in the Electronic Health Records (EHR). However, this practice was not consistently followed. The administration acknowledged the issue when it was brought to their attention by the survey team. The facility's policy, dated December 2023, mandates that all verbal or written orders must be signed by the prescriber monthly, which was not adhered to in these cases.
Failure to Follow Manufacturer's Specifications for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of Alendronate Sodium (Fosamax) for one resident. The resident, who had an intact cognition and was diagnosed with age-related osteoporosis, received multiple medications together in the early morning, contrary to the specific instructions for Fosamax administration. The instructions required Fosamax to be taken with water at least 30 minutes before any other food, drink, or medication, and the resident's other medications were scheduled too closely to comply with these instructions. The surveyor's review of the resident's medical records and interviews with the care providers revealed that the Fosamax was administered at the same time as other medications, such as Pantoprazole and Ferrous Sulfate, which were scheduled for 6:30 AM and 6:00 AM respectively. The Licensed Practical Nurse (LPN) responsible for administering these medications confirmed that they were given together, and the Director of Nursing (DON) acknowledged that the administration times should have been adjusted to follow the cautionary warnings for Fosamax. Further investigation showed that the cautionary warning was clearly labeled on the Fosamax packaging, and the facility's policy for medication administration emphasized the importance of following manufacturer recommendations and cautionary warnings. Despite this, the facility did not ensure that the medication administration times were adjusted accordingly, leading to the deficiency. The DON admitted that the nurses should have been aware of the specific instructions and that the medication times should have been changed to comply with the manufacturer's specifications.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding several medications for three residents. For Resident #72, the CP did not identify the absence of documentation of the resident's systolic blood pressure (SBP) and heart rate (HR) in the electronic medication administration record (eMAR) for the medication Metoprolol, which was ordered to be held if SBP was less than 110 and HR was less than 60. Additionally, the CP did not identify the lack of physician documentation for the continued use of Enoxaparin, a medication for deep vein thrombosis prophylaxis, from August 2023 to April 2024. For Resident #103, the CP failed to report the off-label use of Tamsulosin (Flomax), a medication typically used to treat urinary retention in males, which was prescribed without documented indications or rationale. The resident had an indwelling urinary catheter and was scheduled for discharge, but there was no documentation supporting the use of Tamsulosin in the resident's electronic medical record (EMR) or the CP's reports. For Resident #25, the CP did not identify the improper administration of Alendronate (Fosamax), which should be given as the first medication in the morning with no other medications for at least 30 minutes. The resident's eMAR showed that Fosamax was administered at the same time as other medications, contrary to the specific instructions. Although a recommendation was made by the CP on 2/13/24, it was not acted upon, and subsequent CP reports did not repeat the recommendation. The facility's Director of Nursing (DON) acknowledged the issue but stated that the facility had not received the complete report from the CP company.
Failure to Document Unapproved Use of Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not document the effectiveness, appropriate indication, or benefit vs. risk statement for the unapproved use of tamsulosin for one resident. The resident, who had Alzheimer's disease and urinary retention with an indwelling urethral catheter, was unable to answer basic questions due to cognitive impairment. The medication tamsulosin, typically used to treat benign prostatic hyperplasia, was started during a hospital readmission and continued without proper documentation in the resident's electronic medical record (EMR) or care plan. The surveyor's review of the EMR and physician's progress notes from 1/1/24 to 4/18/24 revealed no documentation of urinary retention or the use of tamsulosin until a discharge note was made after the surveyor brought it to the facility's attention. The Director of Nursing (DON) acknowledged the oversight and stated that the medication was started at the hospital, agreeing that the physician should have documented the continued unapproved use of tamsulosin in the resident's chart.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled appropriately. This deficiency was identified in one of three medication carts and one of two medication storage rooms inspected. Specifically, a vial of latanoprost eye drops and a package of Fluticasone/salmeterol discus 500/50 were found without dates indicating when they were opened. Additionally, a package of Fluticasone/salmeterol discus 250/50 was found to have been opened for more than 30 days. The medication cart's lockable box for controlled substances was also found to be unlocked due to excess medication packages blocking it from fully closing. The temperature log for the medication room's refrigerator had blank spaces for three specific dates, indicating a failure to document temperatures as required. The surveyor discussed these concerns with the LPN assigned to the medication cart, who acknowledged the issues. The surveyor also reviewed the manufacturer package inserts for latanoprost and Fluticasone/salmeterol, which specify storage requirements that were not met. The Director of Nursing (DON) confirmed the deficiencies and stated that the medications of concern had been removed and staff had been educated. The facility's policy for medication storage was reviewed, which mandates that all controlled drugs be stored under double-lock and key, a requirement that was not adhered to in this instance.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible. This deficiency was identified for a resident with cerebrovascular disease and left-side hemiparesis, who had moderate cognitive impairment. On two separate occasions, the surveyor observed the resident in bed and unable to reach the call light cord, which was found under the resident's right chest. The resident attempted to reach the call light three times but was unsuccessful. The RN confirmed that the call light should be on top of the blanket for accessibility and repositioned it accordingly. The facility's policy on call bell audits did not specifically address the need for the call light cord to be within the resident's reach.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required 14-day period as mandated by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for four residents. Resident #2 had a Quarterly MDS with an Assessment Reference Date (ARD) of 1/15/24, which was due by 1/29/24 but was submitted on 2/9/24. Resident #5 had a Quarterly MDS with an ARD of 12/12/23, due by 12/26/23, but was submitted on 1/10/24. Resident #35 had an Entry MDS with an ARD of 10/2/23, due by 10/16/23, but was submitted on 10/17/23. Resident #225 had an Annual MDS with an ARD of 9/22/22, due by 10/6/22, but was submitted on 10/20/22. Additionally, a Discharged Return Not Anticipated (DRNA) assessment for Resident #225 with an ARD of 10/10/22 was due by 10/24/22 but was submitted on 11/7/22. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged the late submissions during an interview, stating that she started working in February 2023 and was only responsible for the late submission of Resident #5's MDS. The MDSC/RN confirmed awareness of the late submissions and stated that she follows the RAI manual. The survey team informed the Licensed Nursing Home Administrator and Director of Nursing of these findings and concerns during a meeting on 4/18/24.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to meet the medical needs of two residents. Resident #13, who was admitted with a diagnosis of Myocardial Infarction, had a physician's order for Eliquis, an anticoagulant medication. However, the care plan for this medication was not created. This was confirmed by the Licensed Practical Nurse (LPN) assigned to the resident, who acknowledged that a care plan should have been developed for the anticoagulant medication. Resident #25, who had an intact cognition as indicated by a BIMS score of 15 out of 15, was actively being treated for osteoporosis with Alendronate Sodium. Despite this, the resident's Interdisciplinary Plan of Care (IDCP) did not include a care plan for osteoporosis. The Director of Nursing (DON) confirmed that the resident should have had a care plan completed for osteoporosis. The facility's policy requires that comprehensive care plans be developed based on thorough assessments and be updated as the resident's condition changes, but this was not adhered to in these cases.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not following physician orders for two residents. Resident #5, who has cerebrovascular disease and left-side hemiparesis, was observed without the prescribed left-hand elbow resting splint on multiple occasions. The physician's order for the splint was not included in the electronic Medication Administration Record (eMAR) or electronic Treatment Administration Record (eTAR). Interviews with staff revealed confusion about who was responsible for applying the splint, and it was found that the order was not properly documented in the eTAR, leading to the splint not being applied as required. Resident #35, who has primary osteoarthritis and cellulitis of the left toe, was observed without the prescribed bunny booties and heel pads while in bed. The physician's orders for these items were also not included in the eMAR or eTAR. Staff interviews indicated that the resident did not have the required items in their room, and there was a lack of awareness among the staff about the orders. The resident was found wearing surgical shoes during therapy, which were not ordered, and the bunny booties were later found in the laundry. The facility's policy on specialty devices states that residents requiring preventative measures and positioning devices should be provided with these devices according to physician orders. However, the failure to document and follow these orders resulted in the residents not receiving the necessary care. The surveyor team discussed these findings with the Administrator and Director of Nursing, highlighting the deficiencies in maintaining professional standards of nursing practice.
Failure to Administer and Document Oxygen Therapy Correctly
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order, ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and properly store respiratory tubing and cannula. This deficiency was identified for one resident who was observed with an oxygen concentrator set at 3 liters per minute (LPM) instead of the prescribed 1 LPM. Additionally, the nasal cannula was improperly stored, wrapped around the half-side rail of the bed, and not placed in a plastic bag as required for infection control. The resident, who was admitted with diagnoses including acute on chronic diastolic heart failure, seizures, hypertension, and atrial fibrillation, was observed on multiple occasions with the oxygen concentrator set incorrectly and the nasal cannula improperly stored. The resident's medical records indicated that the oxygen was to be administered at 1 LPM as needed (PRN) for shortness of breath, but the eMAR showed no documentation that the nurses signed off on the administration of the PRN oxygen. Interviews with the nursing staff revealed a lack of adherence to the facility's policies and procedures for oxygen administration and storage. The Licensed Practical Nurse (LPN) confirmed that the oxygen concentrator was set incorrectly and that the nasal cannula should have been stored in a plastic bag. The Infection Preventionist Nurse also confirmed that the improper storage of the nasal cannula was not in line with the facility's infection control practices. Despite these observations and interviews, the eMAR remained unsigned for the dates when oxygen was administered, indicating a failure in proper documentation and adherence to physician orders.
Inadequate Infection Control Practices for Environmental Cleaning
Penalty
Summary
The facility failed to establish appropriate infection control practices for environmental cleaning for one resident. On 04/15/24 at 10:40 AM, during rounds in a resident's room, a surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The RN identified the substance as tube feeding milk and stated that housekeeping would be asked to clean it. On 04/17/24 at 1:25 PM, the surveyor team discussed the concern with the LNHA and DON, who stated that the area was already cleaned but did not provide further information.
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.
Trusted data from CMS and state health departments
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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