The Center For Rehab & Nursing Washington Township
Inspection history, citations, penalties and survey trends for this long-term care facility in Sewell, New Jersey.
- Location
- 535 Egg Harbor Road, Sewell, New Jersey 08080
- CMS Provider Number
- 315231
- Inspections on file
- 17
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Center For Rehab & Nursing Washington Township during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of depression, anxiety, and severe cognitive impairment told a CNA that a night-shift CNA had punched them in the ribs. The CNA reported the allegation only to an LPN, who allegedly said he did not want to get involved, and the CNA did not escalate the report further, leaving the allegation undocumented in the record. When later interviewed, the resident stated they had received a couple of punches from a staff member and that the CNA knew who it was. Other staff described the resident as confused but not prone to false accusations. Facility leadership stated that all abuse allegations must be immediately reported up the chain of command for investigation and that accused staff should be removed from duty, but they were unaware of this allegation until informed by surveyors, indicating the facility’s abuse reporting policy was not followed.
A resident with a sacral wound did not receive timely wound care due to a failure to transcribe a verbal order into the facility's system. The wound worsened, leading to hospital admission for debridement. Interviews confirmed that facility procedures for wound care orders were not followed, contributing to the deficiency.
The facility failed to provide a homelike environment by not ensuring adequate access to clean linens for residents. A surveyor observed a shortage of washcloths and towels in the 500 Unit, affecting 30 residents. Staff interviews revealed that linens were delivered late, and there were frequent complaints about the lack of linens. The DON and LNHA acknowledged the issue, with the DON attributing it to improperly labeled bins leading to discarded linens.
A facility failed to update a resident's care plan after a new wound was identified. The resident, admitted with conditions like anemia and muscle weakness, developed a skin tear in the sacral area. Although documented in progress notes, the care plan was not revised to include interventions for the wound. Interviews revealed a lack of understanding and adherence to the facility's policy on care plan updates.
A facility failed to secure a treatment cart and properly label a wound dressing during care for a resident. An RN left the treatment cart unlocked and unattended while performing wound care, and applied a dressing without initialing, dating, or timing it. Interviews confirmed the importance of these actions for safety and compliance with facility policies.
The facility was found deficient in food safety and storage practices, with observations of undated and expired food items, and incomplete temperature logs in the kitchen. The Dietary Director acknowledged the issues, which included expired bread and undated juice containers, contrary to the facility's food service policy.
A facility staff member failed to follow infection control practices by returning an opened pack of unused 4x4 gauze to the treatment cart after wound care, instead of discarding it. This was observed by a surveyor and confirmed by the RN involved, as well as the Infection Preventionist and DON, who reiterated the importance of discarding unused supplies to prevent cross-contamination.
The facility's wireless call bell system failed to alert staff effectively, leading to delayed responses to residents' needs. A resident with a fracture and other conditions reported a 50-minute delay in response, while another with COPD and anemia experienced similar issues. Staff interviews revealed that the system did not ring to work areas, requiring visual monitoring in hallways. The DON and LNHA confirmed the lack of a centralized alert system.
A facility failed to provide adequate nursing staff, resulting in delayed incontinence care for a resident. The resident was found with a saturated brief, and the CNA responsible had an excessive workload, including 13 residents needing significant assistance. Staffing records showed consistent deficiencies in meeting mandated ratios, impacting care quality. The DON acknowledged the shortfall, and the facility's staffing policy aimed to meet required ratios but fell short.
The facility failed to maintain safe food handling and sanitation practices, as observed in the kitchen and five pantries. Open food items were found in the walk-in freezer, and several pantries had issues such as missing thermometers, debris, and unlabeled resident food. Staff interviews revealed miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas.
The facility failed to maintain a sanitary environment by not properly disposing of garbage in the dumpster area. Observations revealed debris and trash bags on the ground, contrary to the facility's policy. The FSD, FM, and LNHA acknowledged the issue, emphasizing the responsibility of maintenance, housekeeping, and dietary staff to keep the area clean to prevent pest infestations.
The facility failed to provide a dignified dining experience in one dining area, where two residents seated at the same table were not served their meals simultaneously. This led to one resident taking food from another's plate. The Registered Dietician and DON confirmed that meals should be served at the same time to maintain dignity, as per facility policies.
A facility failed to document a resident's life-sustaining treatment preference on the physician's orders. The resident, admitted with multiple diagnoses and an intact cognitive status, had no documented code status in their medical record. Interviews with staff revealed that the code status should have been determined upon admission, as per facility policy, but this process was not followed.
A facility failed to report an allegation of staff-to-resident abuse to the NJDOH and the Office of the Ombudsman in a timely manner. A resident with dementia and other conditions was allegedly emotionally abused by a CNA, as reported by the resident's family. The DON and staff did not follow proper reporting procedures, resulting in incomplete documentation and incorrect faxing of the report. The facility's policy requires immediate reporting of abuse allegations, which was not adhered to in this case.
A facility failed to conduct a thorough investigation into an alleged staff-to-resident abuse incident. A resident's family reported emotional abuse by a CNA, but the facility's investigation lacked comprehensive interviews and documentation, including missing statements from the involved CNA and the resident's roommate. The facility's policy requires thorough investigations, which was not adhered to in this case.
A facility failed to update a resident's care plan after the resident developed contractures. Despite therapy recommendations for daily range of motion (ROM) exercises, the resident's care plan did not reflect these needs. Interviews with staff revealed that the resident's contractures were not included in the care plan, and there were no physician orders or CNA instructions for ROM exercises. The Director of Nursing confirmed that the care plan should have been revised to include these details.
A resident with severe cognitive impairment and physical limitations did not receive proper nail care, resulting in a long, jagged fingernail on a contracted hand. Despite the care plan's directives and facility policy, staff were unclear about their responsibilities, leading to a lapse in care. Interviews revealed inconsistencies in understanding who was responsible for nail care, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses was not provided with meaningful activities reflecting their preferences. Despite a care plan indicating a preference for group activities, there was no documentation of participation or refusal in the past six months. On the survey day, the resident was found in bed during a scheduled activity, and the activity staff did not conduct the planned event. Staff interviews revealed a lack of coordination and documentation regarding the resident's activity participation.
A resident with multiple health issues, including a risk for skin integrity alteration, was found with an undocumented bandage on their forearm. The facility failed to notify the physician, obtain a treatment order, and document the injury, contrary to their policies. Staff interviews confirmed the lack of documentation and investigation.
A resident with severe cognitive impairment and a history of falls was observed without required floor mats on multiple occasions, despite physician orders and care plan interventions. Staff interviews confirmed the expectation for floor mats to be in place, but the facility lacked a policy and did not document the order in the treatment administration record.
A resident requiring CPAP therapy upon admission did not receive it until several days later due to communication failures and procedural oversights. The CPAP equipment was improperly stored, and the therapy was not included in the resident's care plan, contrary to facility policies.
The facility did not ensure the daily Nursing Home Resident Care Staffing Report was posted in an accessible location for residents and the public. The report was only available at the receptionist's desk in the front lobby, requiring a pass code for access to nursing units. The Director of Nursing and Licensed Nursing Home Administrator were unaware of the requirement for the report to be accessible without request, and the Staffing Coordinator confirmed limited posting locations. The facility's staffing policy lacked details on the required daily posting.
A resident with pressure ulcers received wound care from an LPN who failed to follow proper hand hygiene protocols. The LPN did not consistently wash hands or use ABHR between glove changes, washing hands for only eight seconds instead of the required twenty. This deficiency was confirmed through interviews with the LPN, Infection Preventionist, and DON, highlighting a significant infection control concern.
Failure to Report and Act on Resident’s Allegation of Staff Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. The resident had multiple diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and cognitive impairment, with a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan included interventions related to cognitive loss, the right to be free from abuse, and approaches for resistive or noncompliant behavior. Progress notes from 1/20/26 through 2/3/26 contained no documentation of any abuse allegation. During an interview, a CNA reported that approximately a week prior, the resident told her that a night-shift CNA had punched the resident in the ribs. The CNA stated she immediately informed an LPN, who allegedly responded that he did not want to get involved, and the CNA did not report the allegation to anyone else. The CNA believed the alleged perpetrator was another CNA who worked overnight and had previously received a written warning related to resident care. When interviewed, the resident initially had difficulty recalling the incident but then stated they had received a couple of punches from a staff member and indicated that the CNA probably knew who the perpetrator was. Other staff described the resident as confused but not known to make false accusations. Facility leadership, including the DON and LNHA, stated that staff were required to immediately report any abuse allegations to a supervisor so an investigation could be initiated and that staff accused of abuse should be suspended to protect residents. They reported being unaware of the allegation until informed by the surveyor and confirmed that the CNA should have reported the allegation beyond the LPN. Review of the facility’s Abuse Prevention Program policy showed requirements to protect residents from abuse, train staff on identification and reporting of abuse, and identify, assess, investigate, and report all possible incidents of abuse, which were not followed when the initial allegation from the resident was not promptly and fully reported or acted upon.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to obtain a Physician's Order for a wound care recommendation, which resulted in the worsening of a pressure ulcer for a resident. The resident, who was cognitively intact and admitted with conditions including anemia, depression, and muscle weakness, developed a skin alteration in the sacral region. Despite a verbal order for wound care being received by an LPN, it was not transcribed into the facility's electronic system, Point Click Care (PCC), as required by the facility's policy. Consequently, there was no documented wound care order in place from the time the skin alteration was identified until the wound worsened. The resident's sacral wound was initially identified on 01/23/2025, and a wound consult on 01/28/2025 noted the wound's size and condition. However, the wound care recommendations were not implemented, and the wound progressed in size by 02/04/2025. The resident complained of pain in the sacral area, and although the dressing was changed, there was no evidence of consistent wound care being provided. It was not until 02/05/2025 that a formal wound care order was documented, but by then, the resident required hospital admission for wound debridement. Interviews with the LPN, DON, and the resident's Physician confirmed that the facility's procedures for wound care orders were not followed. The LPN admitted to not entering the verbal order into PCC, and the DON acknowledged that the absence of a treatment order could lead to the worsening of the wound. The Physician emphasized the importance of immediate implementation of wound care orders to prevent deterioration. The facility's policies on wound care and documentation were not adhered to, contributing to the deficiency.
Facility Fails to Provide Adequate Linens for Resident Care
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not providing adequate access to clean linens. During a tour of the 500 Unit, the surveyor observed a significant shortage of washcloths and towels in the linen rooms, with only a few washcloths available for 30 residents. Interviews with staff, including a housekeeper and a CNA, revealed that linens were delivered late, and there were frequent complaints from residents about the lack of linens. The CNA reported having to cut bath blankets to provide care due to the shortage of washcloths and towels. The Director of Nursing acknowledged the issue, attributing it to improperly labeled bins in the soiled linen room, which led to staff discarding linens. The Housekeeping Director also recognized that the PAR levels for linens were low and needed adjustment. The Licensed Nursing Home Administrator was aware of the linen shortage and had ordered more linens, but the problem persisted, as evidenced by the surveyor's observations and staff interviews. The deficiency was further corroborated by Resident Council Meeting Minutes, which documented ongoing resident complaints about the lack of linens.
Failure to Update Care Plan for Resident's New Wound
Penalty
Summary
The facility failed to update and revise a resident's care plan for a newly identified wound. Resident #4, who was admitted with diagnoses including anemia, depression, and muscle weakness, was found to have a skin tear in the sacral area on 01/23/2025. Despite the wound being documented in the progress notes and wound care recommendations being provided, the care plan was not updated to reflect this new condition. The care plan initially noted the resident was at risk for skin integrity issues due to fragile skin and immobility, but it did not include interventions for the actual wound. During interviews, the Resource Nurse/Registered Nurse was unable to explain the importance of the care plan or who was responsible for updating it. The Director of Nursing confirmed that the care plan should have been updated with the new wound information and that the interdisciplinary team is responsible for such updates. The facility's policy requires care plans to be revised as new information about residents becomes available, but this was not followed in the case of Resident #4.
Failure to Secure Treatment Cart and Properly Label Wound Dressing
Penalty
Summary
The facility failed to ensure that the treatment cart was secured during a wound care observation and did not adhere to professional standards of clinical practice by not initialing, dating, and timing a dressing before applying it to a resident. During the observation, a Registered Nurse (RN) parked the treatment cart outside the resident's room, performed hand hygiene, donned clean gloves, and gathered supplies before entering the room to perform wound care. The treatment cart was left unlocked and unattended, out of the RN's line of sight, while the RN was in the resident's room. No residents were observed in the hallway near the treatment cart at that time. After completing the wound care, the RN applied a clean dressing to the resident's wound without initialing, dating, or timing it. Interviews with the RN, Resource Nurse, and Director of Nursing (DON) confirmed the importance of locking treatment carts to prevent residents from accessing potentially harmful items and the necessity of initialing, dating, and timing dressings to inform staff of the last dressing change. The facility's policies on Storage of Medications and Wound Care were not followed, as they require compartments containing drugs and biologicals to be locked when not in use and dressings to be initialed, dated, and timed before application. These deficiencies were identified for one resident observed for wound care.
Deficiency in Food Safety and Storage Practices
Penalty
Summary
The facility failed to ensure proper food safety and storage practices, as evidenced by several observations during a survey. The surveyor, along with the Dietary Director (DD), noted that food items in the kitchen were not properly dated, and some were past their use-by dates. Specifically, an unopened loaf of rye bread and an opened gluten-free bread were found with expired use-by dates, and a bag of English muffins lacked any labeling or expiration date. Additionally, the temperature log for the walk-in refrigerator was incomplete, with a missing entry for the PM temperature on a specific date. Further inspection of the walk-in refrigerator revealed undated opened juice containers, including a pitcher of orange juice and two bottles of cranberry juice. The DD acknowledged that all food and juice items should have been dated upon opening and agreed that expired items should have been discarded. The facility's food service policy mandates that food be clearly marked with the date it should be consumed or discarded, and the DD's job description includes monitoring food preparation and storage to ensure compliance with health and sanitation regulations.
Infection Control Breach During Wound Care
Penalty
Summary
The facility staff failed to maintain appropriate infection control practices during a wound care observation. Specifically, a Registered Nurse (RN) completed a wound care treatment and improperly returned an opened pack of unused 4x4 gauze to the treatment cart instead of discarding it. This action was observed by a surveyor and confirmed during an interview with the RN, who acknowledged that the opened gauze should have been discarded to prevent cross-contamination. Further interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the facility's policy requires unused treatment supplies to be discarded after use. Both the IP and DON emphasized the importance of not returning opened supplies to the treatment cart to prevent the potential spread of infection. The facility's policy, revised in January 2025, outlines the need for an Infection Control Program to prevent disease transmission, which was not adhered to in this instance.
Deficient Call Bell System Delays Resident Assistance
Penalty
Summary
The facility failed to ensure that their wireless call bell system effectively communicated calls directly to the staff, resulting in delayed responses to residents' needs. Resident #1, who was admitted with a fracture, sarcoidosis, and hypertension, reported that it took staff 50 minutes to respond to their call light. The surveyor confirmed this delay by observing the call bell light still on without an audible sound after 14 minutes. Resident #1 mentioned that this was a recurring issue and had been reported to the nurse. Resident #3, with chronic obstructive pulmonary disease, anemia, and hyperlipidemia, also experienced delays in call light responses. The resident stated that staff sometimes never responded to the call light, and this issue was reported to the charge nurse. Similarly, Resident #7, who had diabetes, morbid obesity, and a history of falls, reported that staff took more than ten minutes to respond to call bells, particularly during the evening shift. Interviews with staff, including CNAs, LPNs, and RNs, revealed that the call bell system did not ring to staff work areas, and staff had to visually monitor the lights in the hallways. The system's design required staff to be present in the hallways to notice the call lights, as there was no centralized alert system. The Director of Nursing and the Licensed Nursing Home Administrator confirmed the lack of a centralized call bell system, and the facility's policy emphasized the need for prompt responses to call bells.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by the inability to provide timely incontinence care to a resident. On a specific day, a resident was observed lying in bed with a saturated incontinence brief that had leaked onto the cloth underpad. The resident's family member noted that the resident was usually washed, dressed, and in their wheelchair by that time. The assigned LPN and CNAs confirmed the saturated condition of the brief. The CNA responsible for the resident explained that she had to prioritize getting rehabilitation residents ready for therapy, which delayed her usual morning routine with the resident. The staffing issues were further highlighted by the CNA's workload, which included 13 residents, many of whom required total assistance with activities of daily living (ADLs) and feeding. The facility's staffing records revealed consistent deficiencies in CNA staffing over several weeks, failing to meet the New Jersey mandated staffing ratios. The Director of Nursing acknowledged the staffing shortfall and confirmed that the CNA should not have been assigned 13 residents, as it exceeded the mandated ratio of one CNA for every eight residents on the day shift. The facility's staffing policy, revised in December 2023, outlined the requirement to meet federal, state, and local staffing requirements, including specific staff-to-resident ratios. Despite efforts to manage staffing levels based on census and resident care needs, the facility consistently fell short of the required staffing ratios, impacting the quality of care provided to residents. The surveyor's interviews with the staffing coordinator and DON revealed attempts to address staffing challenges, but the facility continued to experience deficiencies in meeting the mandated staffing levels.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by the surveyor in the kitchen and five pantries designated for resident food. In the walk-in freezer, a box of French toast and a box of veggie burgers were found open to the air, which the Food Service Director acknowledged should have been closed and wrapped. Additionally, the 200-unit pantry's freezer lacked a thermometer and had dark dust-like debris, while the 100-unit pantry's freezer also had debris and the microwave contained dried food particles. The 300-unit pantry's freezer was missing a thermometer, had ice buildup, and contained an unlabeled pint of ice cream with ice buildup on the container. Further observations revealed that the 400-unit locked pantry had a stainless-steel sink with dried food particles and dust-like debris, and the water machine outside had white debris on the grate. The 500-unit locked pantry had food particles outside the microwave and liquid on the refrigerator's bottom tray. Interviews with staff, including the Housekeeping Supervisor and Food Service Director, indicated miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas, including the stainless sinks, refrigerators, and freezers. The facility's policy required all foods in refrigerators or freezers to be covered, labeled, and dated, and for refrigerators to have working thermometers, but no policy was provided for cleaning the pantry area.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly disposing of garbage and refuse in the dumpster area. During an initial kitchen tour, the surveyor observed debris, trash, and leaves around the enclosed dumpster area, which included four blue dumpsters and one black dumpster for used oil. Five black trash bags were found lying directly on the ground next to the first dumpster, and one black trash bag was lying next to the third dumpster. The trash company driver stated that he had moved the bags to access the dumpster, and the Food Service Director (FSD) acknowledged that there should be no debris or trash bags outside the dumpster area. The FSD indicated that maintenance, housekeeping, and dietary staff were responsible for cleaning the area to prevent pest or rodent infestations. Further interviews revealed that both maintenance and dietary staff were responsible for keeping the dumpster area clean, as confirmed by the Facility Manager (FM). The Licensed Nursing Home Administrator (LNHA), along with the Director of Nursing (DON) and the survey team, also stated that leaving trash bags on the ground was unacceptable. The facility's policy on garbage disposal, reviewed and revised in March 2024, mandates that containers and dumpsters be kept covered when not being loaded and that the surrounding area be kept clean to minimize debris accumulation and insect or rodent attraction. The policy also specifies that garbage should not accumulate or be left outside the dumpster.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents, as observed in one of the six dining areas, specifically the activities room. During the observation, two residents were seated at the same table, but only one had received their lunch tray. The delay in serving the second resident led to the resident taking food from the other resident's plate. This incident was witnessed by a surveyor and involved intervention by an LPN. The Registered Dietician and the Director of Nursing both acknowledged that residents seated at the same table should be served simultaneously to maintain dignity and respect. The facility's policies on Dining Room Services and Resident Rights emphasize treating residents with dignity and respect during mealtimes. However, the failure to serve meals simultaneously resulted in a breach of these policies. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that the resident who was not served on time usually ate in the main dining room, but due to its unavailability, was rerouted to the activities room, leading to the oversight. This deficiency was identified as a failure to honor the residents' rights to a dignified existence and self-determination.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document a resident's life-sustaining treatment preference on the physician's orders, which was identified during a survey. The deficiency was noted for a resident who was admitted with multiple diagnoses, including heart failure and chronic kidney disease. Despite having an intact cognitive status, as indicated by a BIMS score of 13 out of 15, there was no documented evidence of the resident's code status in their medical record. This oversight was confirmed by a Registered Nurse (RN) who acknowledged the absence of the code status in the electronic medical record and expressed uncertainty about how it was missed. Interviews with facility staff, including the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), revealed that the resident's code status should have been determined upon admission as part of the facility's admission process. The facility's policy required the Social Services Director or designee to inquire about any written advance directives prior to or upon admission. However, the process was not followed, resulting in the lack of a documented code status for the resident. The DON explained that if a Provider Orders for Life-Sustaining Treatment (POLST) form was not available upon admission, it should be confirmed during a care conference with the Interdisciplinary Team (IDT), and a physician order should be written accordingly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman in a timely manner, as required by state and federal regulations and the facility's own policy. This deficiency was identified during a review of a case involving a resident with multiple diagnoses, including dementia and major depressive disorder, who was alleged to have experienced emotional abuse by a Certified Nursing Assistant (CNA). The incident was reported by the resident's family member, who claimed that the CNA was rude and asked them to leave the room during care, leading to the CNA walking out when the family refused. The Director of Nursing (DON) and other staff members failed to follow proper procedures for reporting the incident. The Reportable Event Record/Report (RER/R) was not completed correctly, as it lacked the date and time the incident was reported to the NJDOH. Additionally, the RER/R was faxed to an incorrect number, and there was no evidence that the NJDOH received the report. The facility also did not provide documentation that the Office of the Ombudsman was notified of the incident. The DON admitted to human error in the reporting process and was unsure of the specific time frame required for reporting such incidents. The facility's policy mandates that all allegations of abuse must be reported immediately, or within two hours if the incident involves abuse, and within 24 hours if it does not involve abuse or serious bodily injury. The policy also requires that the findings of abuse investigations be reported to the appropriate agencies. However, the facility failed to adhere to these requirements, as evidenced by the lack of timely notification to the NJDOH and the Office of the Ombudsman, and the absence of a completed investigation report submitted within the required time frame.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of staff-to-resident abuse, as required by their policy. The incident involved a resident with intact cognition, who was reported by their family to have experienced emotional abuse by a CNA. The family alleged that the CNA was rude and did not provide timely care, which left the resident tearful. Despite the family’s report, the facility did not document a comprehensive investigation, including interviews with all potential witnesses such as the resident's roommate. The facility's documentation was incomplete, as evidenced by the absence of a statement from the CNA involved, despite it being referenced in the investigation report. The Director of Nursing (DON) acknowledged the missing statement and attempted to rectify this by contacting the CNA after the event. However, the investigation did not include interviews with the resident, the resident's roommate, or other staff members who might have witnessed the incident, which was contrary to the facility's policy. The facility's policy mandates a thorough investigation of abuse allegations, including interviews with all relevant parties and documentation of findings. However, the investigation into this incident was insufficient, as it lacked comprehensive interviews and documentation. The failure to adhere to the policy resulted in an incomplete understanding of the events and potentially compromised the resident's right to be free from abuse and neglect.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan after the resident developed contractures. The deficiency was identified during a survey when a resident was observed with a contracted left hand. The resident's medical record indicated diagnoses of unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. The Minimum Data Set (MDS) assessment revealed impaired range of motion (ROM) in both upper and lower extremities, but the resident's Individualized Comprehensive Care Plan (ICCP) did not reflect these impairments or include interventions to address or prevent further reduction in ROM. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Rehab (DOR), revealed that the resident had been seen by Occupational Therapy (OT) and Physical Therapy (PT) earlier in the year. The therapies had provided education to staff on the importance of ROM exercises, and recommendations were made for daily ROM exercises to be incorporated into the resident's care. However, the ICCP was not updated to include these recommendations, and there were no physician orders or CNA instructions for ROM exercises in the resident's records. Further interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that contractures should be included in the resident's care plan to ensure proper care. The DON acknowledged that the ICCP should have been revised to include the resident's contractures and therapy recommendations. The facility's policies on ROM exercises and comprehensive care plans emphasized the need for ongoing assessments and updates to care plans as residents' conditions change, which was not adhered to in this case.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was unable to perform activities of daily living (ADL) due to severe cognitive impairment and physical limitations. The resident, diagnosed with unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was observed with a contracted left hand and a long, jagged fingernail on the left middle finger. The resident's care plan included interventions for nail care, specifying that nails should be checked and trimmed on bath days and as necessary. However, there was no documentation of the resident refusing nail care, and the facility staff were unclear about their responsibilities regarding nail care. Interviews with facility staff revealed inconsistencies in understanding who was responsible for nail care. A CNA stated that activities staff were responsible, while the Activities Director indicated that their staff only painted nails and did not trim them. The DON confirmed that CNAs were responsible for filing nails and should notify a nurse if a resident refused care. Despite these protocols, the resident's left-hand fingernails remained untrimmed, indicating a lapse in care. The facility's policy on nail care emphasized the importance of regular cleaning and trimming to prevent injury, yet this was not adhered to, as evidenced by the resident's condition.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities that reflected the preferences of a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was dependent on staff for all activities of daily living. The resident's care plan indicated a preference for group activities, yet there was no documentation of the resident's participation or refusal of activities in the past six months. On the day of the survey, the resident was observed lying in bed during a scheduled activity time, and the activity staff did not show up to conduct the planned activity. The Activities Director admitted to not being present for the activity and acknowledged that the resident would benefit from attending activities for social stimulation. Despite the resident expressing a desire to attend an activity when asked, there was no prior documentation of refusals or attempts to engage the resident in activities. Interviews with staff revealed a lack of coordination and communication regarding the resident's participation in activities. CNAs and LPNs were unclear about their responsibilities in encouraging and documenting the resident's involvement in activities. The facility's policy emphasized the importance of tailoring activities to residents' interests and maintaining records of participation, but these practices were not followed, leading to the deficiency.
Failure to Document and Report Resident's Skin Injury
Penalty
Summary
The facility failed to notify the physician of an injury sustained by a resident, obtain a physician's order for a wound treatment, and document a skin assessment in accordance with the facility policy and professional standards of nursing practice. This deficiency was identified for a resident who was observed with a bandage on their right lower forearm, which was not dated, and a dried red substance on their pillow. The resident reported that the bandage was applied by an unknown staff member after they scratched themselves. The resident's medical record review revealed multiple diagnoses, including repeated falls, multiple fractures, cancer, chronic obstructive pulmonary disease, and a pressure ulcer. The resident's comprehensive care plan indicated a risk for skin integrity alteration due to impaired mobility, with interventions including weekly body audits and reporting changes to the medical doctor. However, there was no documented evidence of the resident's forearm skin alteration in the progress notes or skin assessments. Interviews with facility staff, including a CNA, RN, and the DON, confirmed that the bandage was not documented, and no wound investigation or treatment order was obtained. The facility's policies on accidents, incidents, and documentation require prompt investigation, documentation, and communication of changes in a resident's condition, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that floor mats were in place for a resident who was at risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed on multiple occasions without floor mats on either side of the bed, despite having physician orders and care plan interventions for floor mats to be placed on both sides of the bed. The resident had a history of rolling out of bed and sustaining a head injury, which was documented in the progress notes and incident report. Interviews with facility staff, including a hospice aide, certified nursing assistant, licensed practical nurses, and the director of nursing, confirmed that floor mats should have been in place while the resident was in bed to prevent injury from falls. The facility was unable to provide a policy related to the use of floor mats, and the treatment administration record for the relevant month did not include the physician order for the floor mat, indicating a lapse in following the prescribed care plan and physician orders.
Failure to Provide and Manage CPAP Therapy for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required a CPAP machine upon admission. The resident, who had a history of obstructive sleep apnea among other medical conditions, did not receive CPAP therapy until several days after admission, despite the need being documented in the Admission Notification form and physician's progress notes. The delay in providing the CPAP was due to a breakdown in communication and procedure, as the Admission Notification form did not reach the admitting nurse, and the discharge summary did not include the CPAP requirement. Additionally, the facility did not store the CPAP equipment according to professional standards. The CPAP mask was observed on multiple occasions to be improperly stored, either uncovered on the nightstand or hanging and touching the floor. This improper storage was confirmed by nursing staff, who acknowledged that the mask should be cleaned and stored in a bag when not in use. Furthermore, the resident's comprehensive care plan did not include the CPAP therapy, which is a critical component of the resident's care needs. The omission was confirmed by the nursing staff and the Director of Nursing, who stated that the CPAP should have been included in the care plan to ensure all staff were aware of the resident's needs. The facility's policies on Durable Medical Equipment and comprehensive care planning were not adhered to in this case.
Failure to Post Daily Staffing Report Accessibly
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in a location that was readily accessible to both residents and the general public. This deficiency was observed across all five nursing units. On a specific date, the surveyor noted that the staffing report was only posted on the receptionist's desk in the front main lobby, which required a pass code to access the nursing units. During a subsequent inquiry, the Director of Nursing stated that the report was posted at both facility entrances, but the Licensed Nursing Home Administrator was unaware of the requirement for the report to be accessible without request. The Staffing Coordinator confirmed that the report was only posted in the front and rehab lobbies, not on the nursing units. Additionally, the facility's staffing policy, reviewed in December 2023, did not include details about the required daily posting of the staffing report.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during a wound treatment for a resident. The resident, who had a history of osteomyelitis, diabetes mellitus with chronic kidney disease, muscle weakness, and pressure ulcers, was observed receiving wound care from an LPN. The LPN did not consistently perform hand hygiene between glove changes, which is a critical step in preventing infection. Specifically, the LPN did not wash hands or use alcohol-based hand rub (ABHR) after doffing gloves and before donning new ones, which is against the facility's hand hygiene policy. The resident's medical record indicated the presence of a Stage 4 pressure ulcer on the sacral region and a Stage 2 pressure ulcer, both of which required specific wound care treatments as per physician orders. During the wound care observation, the LPN was seen preparing and applying treatments such as Medihoney and Santyl without following proper hand hygiene protocols. The LPN washed hands for only eight seconds on two occasions, which is below the required minimum of twenty seconds as per the facility's policy. Interviews with the LPN, the Infection Preventionist, and the Director of Nursing confirmed the deficiency in hand hygiene practices. The facility's policy mandates hand washing for at least twenty seconds, especially after removing gloves and before handling clean or soiled dressings. The failure to adhere to these protocols was identified as a significant infection control concern, as it could lead to cross-contamination and compromise resident safety.
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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