The Subacute At Autumn Lake Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Voorhees, New Jersey.
- Location
- 113 Route 73, Voorhees, New Jersey 08043
- CMS Provider Number
- 315513
- Inspections on file
- 29
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 19 (3 serious)
Citation history
Health deficiencies cited at The Subacute At Autumn Lake Healthcare during CMS and state inspections, most recent first.
Two residents with significant care needs had incomplete documentation in their medical records regarding toileting, bowel, and bladder care, with missing entries for multiple shifts. Additionally, after a fall incident, a resident's transfer out of the facility was not fully documented, lacking the time of transfer and details of departure. Staff interviews confirmed that CNAs were responsible for this documentation, and facility policy required complete and accurate records.
A resident with multiple medical conditions experienced ongoing nausea, decreased appetite, and diarrhea, but the facility failed to notify the physician after the resident refused STAT lab tests and did not obtain a urine specimen as ordered. The resident's critically high WBC count was not acted upon, and there was no evidence of adequate monitoring or follow-up despite worsening symptoms. Family requests for hospital transfer were denied, and communication lapses contributed to the resident's unmonitored decline and death.
A resident with advanced cancer and severe pain was admitted with physician orders for Dilaudid and acetaminophen, but staff failed to consistently administer the prescribed pain medications. Delays in obtaining prescriptions, lack of medication availability, and inadequate documentation led to the resident experiencing high pain levels without effective relief. Staff interviews revealed confusion about medication access and insufficient communication with the pharmacy and physician, resulting in significant harm to the resident.
A resident with advanced cancer and severe pain did not receive physician-ordered Dilaudid for an extended period due to failures in medication procurement, documentation, and staff communication. Despite repeated reports of high pain levels, the resident experienced delays in receiving effective pain relief, with alternative medications either not administered or proving ineffective. Staff interviews revealed confusion about procedures for accessing backup medications and escalating unresolved medication issues.
The facility failed to maintain an effective QAPI program, resulting in two residents experiencing serious harm. One resident with multiple medical conditions did not receive timely physician notification, appropriate monitoring, or follow-up after a significant change in condition and abnormal lab results. Another resident with pancreatic cancer did not receive ordered Dilaudid for pain management due to delays in pharmacy communication and lack of staff follow-up, leading to unmanaged severe pain.
An LPN was observed touching the inside of medication cups with bare fingers while administering medications to two residents, without wearing gloves. Both the LPN and facility leadership acknowledged that this practice did not meet infection control standards.
A cognitively impaired resident with dysphagia received a regular texture meal instead of a prescribed ground diet, leading to a choking incident. The CNA was unaware of the resident's dietary needs and did not verify the meal tray against the ticket information. Facility policies on therapeutic diets and care plans were not followed, resulting in the resident receiving the incorrect meal.
A resident with severe cognitive impairment and dysphagia had a family request to exclude pudding from meals, which was not honored by the facility. Despite clear signage, the resident received pudding on their meal tray. Staff interviews revealed a communication breakdown in notifying dietary staff of the family's preferences, contrary to the facility's policy on resident self-determination.
The facility failed to create comprehensive care plans for four residents, each with multiple health issues. A resident with diabetes and embolism had a care plan focusing only on pain without interventions. Another resident with cardiac arrest and diabetes had a plan addressing only nutritional status. A third resident with dementia had a plan focusing on behavior and nutrition, ignoring other needs. The fourth resident with brain hemorrhage and embolism had a plan covering only nutrition and recreation. Staff interviews revealed inconsistencies in care plan development timelines.
A facility failed to complete a comprehensive MDS assessment within the required 14 days of admission for a resident. The surveyor found the assessment overdue by five days, and the MDS coordinator confirmed it was incomplete. The Regional Director of Nursing noted the delay was due to the recent resignation of the MDS coordinator.
The facility failed to complete baseline care plans within 48 hours for two residents, one with serious health conditions and another with multiple diagnoses, including a pressure ulcer. The required sections of the care plans were incomplete, and necessary signatures were missing. Staff interviews revealed confusion about responsibilities for completing the care plans, contrary to the facility's policy.
The facility failed to ensure the Infection Preventionist attended the QAPI quarterly meeting, as required by policy. The RDON noted that no QAPI activities had been conducted since the previous year, and although training was initiated, the team was not prepared for a quarterly meeting in July. The facility's policy requires the QAA committee to meet quarterly with specific members, including the Infection Preventionist.
A resident with a history of falls was not monitored according to their care plan, resulting in them being found on the floor mat next to their bed. An LPN from an outside agency closed the resident's door instead of checking on them, despite the facility's policy for regular checks. The family, using a video monitoring device, reported the resident had been yelling prior to the fall. The facility's purposeful rounding policy was not followed, leading to the LPN's suspension.
Incomplete Documentation of Resident Care and Transfers
Penalty
Summary
The facility failed to consistently document and maintain complete medical records regarding toileting, bowel and bladder continence, and incontinent care for two residents. For one resident with diagnoses including type II diabetes, osteoarthritis, and hypertension, documentation was missing in the daily shift records and progress notes for multiple dates in February. The resident required substantial assistance with toileting, as indicated by the Minimum Data Set (MDS) and care plan, but there were gaps in the records for bladder and bowel continence and bowel movements across several shifts. Another resident, admitted with conditions such as cerebral infarction, heart failure, and mobility issues, also had incomplete documentation in October. This resident required partial assistance with toileting transfer and was fully dependent in toileting hygiene. The records lacked documentation for bladder and bowel continence and bowel movements for a specific evening shift. Additionally, after an incident where this resident was sent out of the facility for further evaluation following an allegation of a fall, the medical record did not include the time of transfer, and there was no documentation indicating when the resident left the facility, despite a note confirming the resident's return. Interviews with staff, including an LPN, Unit Manager, DON, and a CNA, confirmed that CNAs were responsible for documenting incontinent care in the electronic medical record and that documentation was important for tracking care and preventing skin issues. The DON and other staff acknowledged the presence of blanks in the documentation and emphasized that all services provided should be documented completely and accurately, as required by facility policy.
Failure to Notify Physician and Monitor Resident After Refusal of STAT Labs and Ongoing Symptoms
Penalty
Summary
The facility failed to notify the physician when a resident refused immediate (STAT) laboratory tests on two occasions, and there was no documentation in the electronic medical record (EMR) that the refusals were communicated to the provider. Additionally, the facility did not obtain a urine specimen for a urinalysis with culture and sensitivity as ordered, nor was there evidence that the physician was notified of the failure to collect the specimen. The resident, who was cognitively intact and had a history of myelodysplastic syndrome, anemia, and acute congestive heart failure, experienced ongoing symptoms including nausea without vomiting for three days, decreased appetite, and persistent diarrhea. Despite these symptoms, the facility did not adequately monitor the resident for changes in condition. Nursing notes indicated that the resident had decreased appetite and diarrhea for several days, and while Imodium was ordered for the diarrhea, there was no evidence of further assessment or monitoring after a late entry note documented the resident's ongoing symptoms. A critically high white blood cell (WBC) count of 26.4 K/CU.MM was reported, but there was no documentation that this result was acted upon or that follow-up laboratory tests were ordered as recommended by a nurse practitioner. The resident was later found unresponsive and was pronounced deceased, with the death certificate listing suspected sepsis due to diarrhea and hypokalemia as causes of death. Interviews with staff and family members revealed communication breakdowns and a lack of timely response to the resident's declining condition. Family members reported requesting hospital transfer, which was denied by staff who stated the physician did not approve it, and they were not informed of their right to call 911 themselves. The facility's own policies required timely laboratory services and provider notification, but these were not followed, contributing to the resident's unmonitored decline and subsequent death.
Removal Plan
- Educate licensed nurses on documentation and provider notification requirements when residents refuse diagnostic testing or exhibit changes in condition
- Educate licensed nurses on acute changes in condition protocol and documentation requirements
- Educate licensed nurses on honoring resident's/family rights to transfer to hospital when requested, including the obligation to inform providers and document the decision in the electronic medical record (EMR)
Failure to Provide Consistent Pain Management for Resident with Severe Pain
Penalty
Summary
A resident with a diagnosis of pancreatic adenocarcinoma and other serious medical conditions was admitted to the facility with physician orders for pain management, including Dilaudid and acetaminophen. Despite these orders, staff failed to consistently administer the prescribed pain medications as ordered. Documentation revealed that the resident experienced severe pain, with pain levels reaching up to 10 on a 0-10 scale, and there were multiple instances where pain medications were not available or not given as ordered. The resident's medication administration record showed significant delays in receiving both Dilaudid and Tramadol, and there were periods where the resident received only acetaminophen, which was documented as ineffective for their pain level. The facility's records indicated that there were issues with obtaining the necessary prescriptions from the physician and with the timely delivery of medications from the pharmacy. The pharmacy did not receive a written prescription for Dilaudid until several days after the resident's admission, resulting in the medication not being available in the facility. Staff interviews confirmed that some nurses did not have access to the Pyxis medication dispensing system due to their employment status, and there was confusion about the process for obtaining medications when they were not immediately available. Documentation also showed that alternative pain medications were not always administered promptly, and there was a lack of consistent pain assessment and follow-up after medication administration. Throughout the resident's stay, there were repeated failures to document pain levels, reasons for holding medications, and the effectiveness of pain interventions. Nursing notes and medication administration records frequently lacked explanations for missed or delayed doses, and there was insufficient communication with the physician regarding the resident's unmanaged pain. The resident continued to experience high levels of pain until pain management was eventually adjusted, but the initial failure to provide timely and appropriate pain relief resulted in significant harm and increased the likelihood of a painful death.
Removal Plan
- Educate licensed nurses on the facility's policy for Pain Management
- Educate on actions to take when physician ordered medications are unavailable for administration
- Use Pyxis for immediate availability of narcotics on admission
- Document pain scores before and after pain medication administration and document effectiveness for PRN medications used for pain
- Educate that if any resident is experiencing unmanaged pain, the nurse will call the physician for alternate orders
- Provide resident with alternate physician ordered medications to ensure relief until the prescribed narcotic is available
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A deficiency occurred when the facility failed to acquire and administer physician-ordered pain medication for a resident admitted with pancreatic adenocarcinoma and other serious conditions, including an upper gastrointestinal bleed and portal vein thrombosis. Upon admission, the resident had orders for Dilaudid and acetaminophen for pain management. Despite these orders, the facility did not ensure the timely procurement and administration of Dilaudid, resulting in the resident experiencing high levels of pain. Documentation showed that the resident repeatedly reported severe pain, with pain scores as high as 10, and that alternative pain medications were either not administered or were ineffective. The clinical record revealed significant delays in the administration of Dilaudid, with the first dose given approximately 35 hours after admission. During this period, the resident received acetaminophen and, at times, Tramadol, but these interventions provided minimal or no relief. There were also instances where pain medications were not available in the facility's Pyxis system, and staff did not consistently document pain assessments or reasons for withholding medication. Communication lapses were evident, as the pharmacy did not receive the required prescription for Dilaudid until several days after admission, and staff did not escalate the issue promptly to supervisors or the DON as required by policy. Interviews with staff indicated confusion regarding procedures for obtaining medications from the Pyxis system and the steps to take when medications were unavailable. Some staff members lacked access to the Pyxis due to their employment status, and there was inconsistency in following the facility's policy for medication procurement and escalation. The failure to provide the ordered pain medication resulted in the resident experiencing unmanaged pain for an extended period, as documented in nursing and progress notes.
Removal Plan
- Education to the licensed nursing staff on the Medication Procurement and Pharmacy Services Policies
- Education on pharmacy notification when medications are not delivered
- If ordered pain medications are unavailable, the nurse will notify the Supervisor
- If unresolved, the issue will be escalated to the DON
- If still unresolved, the Medical Director will be contacted
- Use of the Pyxis for availability of narcotics at admission
- For any resident experiencing unmanaged pain, the nurse will place a call to the physician for alternate orders
- The resident will be provided alternate physician ordered medication to ensure relief until the prescribed narcotic is available
Failure to Maintain Effective QAPI Program and Ensure Timely Pain Management
Penalty
Summary
The facility failed to maintain an ongoing, effective QAPI program that systematically identified, reported, investigated, analyzed, and prevented adverse events, as well as documented the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility did not recognize or appropriately respond to a decline in a resident's change in condition and did not consistently provide pain management or ensure that pain medication was ordered and available upon admission for another resident. These failures were identified through record review, interviews, and document review, and resulted in serious harm to two residents. One resident with myelodysplastic syndrome, anemia, and acute congestive heart failure was admitted with a high cognitive status. The facility did not notify the physician of the resident's refusal to have an immediate laboratory test, failed to obtain a urine culture and sensitivity test as ordered, did not monitor the resident after reports of ongoing nausea, decreased appetite, and diarrhea, and failed to act upon a critically high white blood cell count. Documentation and communication regarding the resident's change in condition were lacking, and there was insufficient follow-up and monitoring after significant symptoms and abnormal lab results were reported. Another resident admitted with pancreatic adenocarcinoma and other serious conditions had orders for Dilaudid for pain management, but the facility failed to consistently provide the medication as ordered. The pharmacy did not receive the written script for Dilaudid until several days after admission, resulting in the resident experiencing pain levels up to 10 out of 10. The DON was not aware of the medication's unavailability, and nursing staff did not follow up with the pharmacy when the medication was not delivered. This failure led to the resident not receiving adequate pain management during their stay.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
During medication administration, a Licensed Practical Nurse (LPN) was observed handling medication cups in a manner that did not maintain infection control standards for two residents. Specifically, the LPN was seen placing her bare index and middle fingers inside the medication cup containing medication for one resident and touching the inside of the medication cup with her index finger for another resident. In both instances, the LPN was not wearing gloves. The LPN, Infection Preventionist, and Director of Nursing all acknowledged that the nurse should not have touched the inside of the medication cup with bare hands or fingers prior to administering the medication.
Failure to Provide Correct Therapeutic Diet to Resident
Penalty
Summary
The facility failed to provide the correct therapeutic diet to a cognitively impaired resident with a known diagnosis of dysphagia, pharyngeal phase. The resident had a physician's order and plan of care for a ground diet and required feeding assistance. On the specified date, a CNA delivered a meal tray containing a regular texture meal to the resident, which included corn and tortillas that were not ground texture. The CNA confirmed that the meal tray was incorrect, and the resident's family observed the resident with food in their mouth, reporting that the resident was choking. The CNA stated that she was not aware that the resident was on an altered texture diet or that the resident required feeding assistance. The facility's policies titled Therapeutic Diet Orders and Comprehensive Care Plans were not followed, as the CNA did not verify the tray and ticket information at the resident's bedside. The CNA should have notified a nurse if the tray seemed incorrect, but this did not occur, leading to the resident receiving the wrong meal. Interviews with facility staff, including LPNs and the Food Service Director, highlighted the importance of following diet orders and care plans to ensure residents receive the care they need. The Food Service Director acknowledged that the facility did not follow its policy related to resident diet, as a resident received the wrong meal. The facility's Therapeutic Diets policy and Comprehensive Care Plans policy were reviewed, revealing that all residents should have a diet order prescribed by the attending physician and that qualified staff should be notified of their roles and responsibilities for carrying out interventions specified in the care plan.
Removal Plan
- Resident #3 was assessed for aspiration precautions.
- Resident #3's physician was notified of the incident.
- The DON (Director of Nursing) was notified of the incident.
- The CNA was in-serviced regarding verification of tray and ticket information.
- Resident care staff was in-serviced regarding meal tray accuracy.
- Kitchen staff were in-serviced regarding ensuring resident meals are of the correct texture.
- The [NAME] on shift at the time of the incident was given an Employee Corrective Action related to failure to follow the meal tracker ticket as read.
- Tray accuracy audits were performed for Resident #3's breakfast, lunch, and dinner trays. 100% accuracy was documented.
- The facility initiated weekly meal tray audits for texture meals and tray accuracy for all residents.
- A system compliance plan was developed to submit texture meals and tray accuracy results to Quality Assurance and Performance Improvement (QAPI) on an ongoing basis.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to appropriately respond to a resident family's request regarding food preferences, specifically concerning the exclusion of pudding from the resident's meals. The resident in question, who was admitted with diagnoses including dysphagia and severe cognitive impairment, had clear signage placed by the family indicating that pudding and milk should not be provided. Despite this, during a meal observation, the resident's tray included pudding, which was confirmed by the Assistant Director of Nursing (ADON) as being against the family's preferences. Interviews with facility staff, including the ADON and a Licensed Practical Nurse (LPN), revealed that there was a breakdown in communication and adherence to the resident's preferences. The ADON acknowledged that the dietary staff should have been informed of the family's request, and the LPN stated that it was the responsibility of the notified staff to ensure that all relevant personnel were aware of the resident's dietary restrictions. The facility's policy on Resident Self Determination and Participation was reviewed, which emphasized the importance of honoring resident choices and involving family input when the resident is unable to communicate preferences.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for four residents, as identified during a survey. Resident #1, who had multiple diagnoses including Type 2 diabetes mellitus and acute embolism, was observed without a comprehensive care plan addressing all identified needs. The only focus area in the care plan was pain, which lacked specific interventions, and no other areas were addressed before the resident's discharge. Resident #99, admitted with conditions such as cardiac arrest and type 2 diabetes mellitus, had a comprehensive care plan that only addressed nutritional status, despite the Minimum Data Set (MDS) indicating the need for care planning in several areas, including ADL, falls, and pressure ulcers. Similarly, Resident #6, with advanced dementia and other health issues, had a care plan that only focused on behavior symptoms and nutritional status, neglecting other identified needs like cognitive loss and urinary incontinence. Resident #96, with complex medical conditions including traumatic subarachnoid hemorrhage and pulmonary embolism, had a care plan that only addressed nutritional problems and recreational choices, leaving out other triggered areas such as cognitive loss and ADL function. Interviews with facility staff revealed inconsistencies in understanding the timeline and requirements for developing comprehensive care plans, contributing to the deficiencies observed.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of admission for a resident, as required by regulations. The deficiency was identified during a surveyor's review of the electronic medical record (EMR) for the resident, which showed that the admission assessment was still in progress and overdue by five days. The MDS coordinator confirmed during an interview that the assessment had not been completed on time, acknowledging that it should have been finalized by the specified date. The Regional Director of Nursing corroborated the surveyor's findings, noting that the assessment should have been completed earlier and attributing the delay to the recent resignation of the MDS coordinator. The facility's policy on MDS 3.0 Completion mandates that an admission assessment be completed within 14 days of admission, counting the day of admission as day one. This policy was not adhered to in the case of the resident, resulting in the identified deficiency.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for two residents, leading to a deficiency. Resident #90 was admitted with serious health conditions, including malignant neoplasm of the mandible, type 2 diabetes, protein-calorie malnutrition, and a tracheostomy. However, sections 2 and 3 of the BCP, which cover functional abilities and health conditions, were not completed within the required timeframe. Additionally, the BCP summary was incomplete, and the necessary signatures from the resident and their representative were missing, with only the Director of Rehab and Director of Social Services having signed the document. Resident #241, who was admitted with conditions such as rhabdomyolysis, sepsis, type 2 diabetes, a urinary tract infection, and a pressure ulcer, also did not have a completed BCP within 48 hours. None of the seven sections of the BCP were completed on time, although they were eventually finished on a later date. Interviews with facility staff revealed confusion about the responsibility for completing the BCP, with discrepancies between the roles of LPNs, the Unit Manager, and the Director of Nursing. The facility's policy requires the BCP to be developed within 48 hours, including essential healthcare information, but this was not adhered to in these cases.
Infection Preventionist Absence at QAPI Meeting
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist at the Quality Assurance Performance Improvement (QAPI) quarterly meeting, as required by their policy. This deficiency was identified for one of the last three quarters. During a review of the facility's QAPI documentation, it was noted that the sign-in sheet for the QAPI/QA Quarter 3 meeting lacked the signature or name of the Infection Preventionist. Additionally, the facility did not hold QAPI meetings on a quarterly basis as required, with deficiencies noted in two of the last three quarters. The Regional Director of Nursing (RDON) confirmed that upon their arrival in April, there had been no QAPI activities conducted since the previous year. The RDON initiated training and education for all department heads and staff on QAPI requirements and established a QAPI board for transparency with families. Despite these efforts, the RDON acknowledged that a quarterly meeting could have been held in July, but the team was not yet prepared. The facility's policy mandates that the QAA committee be interdisciplinary and meet at least quarterly, including specific members such as the Director of Nursing, Medical Director, and Infection Preventionist.
Failure to Monitor Fall-Risk Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a history of falls, as evidenced by an incident where the resident was found on the floor mat next to their bed. The resident, who was cognitively impaired and required extensive assistance with mobility and personal care, was supposed to be monitored hourly according to their care plan. However, a Licensed Practical Nurse (LPN) from an outside agency, who was on duty, closed the resident's door instead of checking on them, despite the resident's history of falls and the facility's policy for regular checks. The family, who had a video monitoring device in the room, reported that the resident had been yelling prior to the fall, and the nurse's action of closing the door was contrary to the facility's purposeful rounding policy. The incident was reported as a Facility Reportable Event (FRE), and it was noted that the resident was found on the floor mat by the day shift staff. The resident was assessed for injuries, and although none were found, the family requested that the resident be sent to the hospital for further evaluation. The facility's policy on purposeful rounding was not adhered to, as the resident was not checked on as frequently as required for someone with their fall risk status. The LPN involved was suspended and not allowed to work at the facility again, highlighting a failure in ensuring that staff, especially those from outside agencies, adhere to established care protocols.
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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