Waterfront Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Raritan, New Jersey.
- Location
- 633 State Route 28, Raritan, New Jersey 08869
- CMS Provider Number
- 315140
- Inspections on file
- 14
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Waterfront Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff did not consistently document care provided to a resident with multiple medical conditions and moderate cognitive impairment, leaving blank entries in the electronic record for several shifts. Interviews confirmed that CNAs were responsible for documentation and that management was expected to ensure completeness, in line with facility policy requiring accurate and complete records.
The facility failed to ensure food and beverages in the kitchen were properly dated and free from expired use by dates, affecting 114 residents. Observations revealed expired Russian dressing, cottage cheese, and undated nutritional shakes in the refrigerator, as well as expired and undated bread products in dry storage. The Dietary Manager confirmed these findings, acknowledging staff responsibilities for checking expiration dates and discarding expired items.
The facility failed to provide a dignified dining experience and respect resident preferences. Several residents were served meals in disposable dishware, contrary to their preferences, and one resident was left waiting for his meal while his tablemate finished eating. Another resident's table was removed without explanation, causing distress. Additionally, a resident was required to wear an identification wristband against her wishes, despite being able to express her preference not to wear it.
The facility failed to prepare menus in advance with specific vegetables, instead using 'Vegetable of the Day' for many meals, affecting residents' nutritional needs. A resident reported repetitive servings of the same vegetables, confirmed by observations. Dietary staff decided on vegetables based on availability, and the Registered Dietitian admitted the menus could not ensure nutritional adequacy without specific planning.
The facility failed to serve food at an appetizing temperature, affecting 13 residents. Residents reported meals, especially breakfast, were not hot, with complaints about cold scrambled eggs, weak coffee, and limited vegetable variety. A test tray confirmed food temperatures were below acceptable levels. The Dietary Manager was aware of these issues from previous Resident Council meetings.
The facility experienced deficiencies in meal service times, with meals served later than scheduled on multiple hallways, affecting most residents. Observations and interviews revealed consistent delays, particularly on the 400 Hallway, where residents expressed dissatisfaction with late meal delivery. The Dietary Manager and staff cited late kitchen starts and staffing issues as contributing factors.
The facility failed to provide an adequate supply of towels, impacting residents' ability to maintain a clean and comfortable environment. Residents reported a shortage of towels, with some using personal items as substitutes. Observations confirmed the lack of towels on linen carts across multiple halls, and staff interviews revealed that towels were not stocked in residents' rooms. The Director of Nursing was unsure about towel policies, and the Administrator was unaware of the issue until the survey.
A facility failed to maintain guardianship documentation for a resident unable to make healthcare decisions due to conditions like dementia and aphasia. The resident's POLST form indicated a DNR status without a guardian's signature, and the necessary guardianship papers were missing from the EMR. Staff interviews revealed that the documentation was not uploaded as required by facility policy.
A resident with intact cognition and chronic pain was verbally abused by an RN who referred to her as a 'Drug Addict' while administering medication. An LPN present confirmed the incident and later apologized to the resident. The facility's investigation led to the RN's suspension and resignation, highlighting a failure to protect the resident from verbal abuse as per facility policy.
A facility failed to update a Level One PASARR for a resident newly diagnosed with bipolar disorder, despite the resident's medical record indicating the change. The resident was initially admitted with congestive heart failure and anxiety, and the PASARR document incorrectly stated no major mental illness. The Nurse Consultant confirmed the error, highlighting the expectation for timely updates with health status changes, as per facility policy.
The facility failed to update care plans for two residents to reflect their current needs. One resident's care plan did not include physician-ordered dialysis supplies, and another resident was not included in care planning meetings despite having intact cognition. Staff interviews confirmed lapses in the care plan revision process and adherence to quarterly meeting requirements.
A resident, who was cognitively intact and expressed a preference for intellectual activities like chess and dominoes, was not provided with a meaningful activity program. The facility failed to assess the resident's activity preferences adequately, and the care plan did not reflect his interests. As a result, the resident spent most of the time in his room watching TV, leading to boredom. Staff interviews revealed a lack of awareness of the resident's interests, and the facility's policy on activities was not followed.
A facility failed to change a resident's urinary catheter monthly as ordered, leading to a deficiency. The resident, who was cognitively intact and had obstructive uropathy, had a physician's order for monthly catheter changes. However, records showed the catheter was not changed from February to May. The error was due to incorrect order entry, which omitted the order from treatment records. This oversight was confirmed by staff and contradicted the facility's catheter care policy.
A facility failed to maintain emergency dressing supplies at the bedside for a resident requiring dialysis, as per physician orders. The resident, with end-stage renal disease, was scheduled for hemodialysis thrice weekly. Despite orders to keep hemostats, gauze, and tape at the bedside, these were absent. Interviews revealed staff were unaware of this requirement, indicating a communication gap.
A resident with multiple diagnoses, including dementia and a history of falls, was using side rails without appropriate physician's orders, informed consent, or assessment. Despite the care plan indicating the use of side rails, the facility failed to follow its policy requiring a comprehensive assessment and informed consent, potentially affecting the resident's safety.
A facility failed to document a Physician's response to a Pharmacist's repeated recommendations to reduce a resident's Lexapro dose due to age-related guidelines. Despite the Pharmacist's suggestions, the resident continued on the higher dose without documented justification. Interviews revealed the Physician reviewed the recommendations but did not document the decision, contrary to facility policy.
A resident with pulmonary fibrosis and acute respiratory failure was not provided with timely changes of oxygen tubing and humidification equipment as per facility policy. Despite orders for weekly changes, records and observations showed the equipment had not been changed since admission. Interviews with nursing leadership confirmed the expectation for weekly changes, which was not met, resulting in a deficiency.
The facility failed to honor the food allergies and preferences of three residents, leading to repeated instances where they were served foods they were allergic to or disliked. Despite documented allergies and preferences, residents continued to receive inappropriate meals, indicating a lapse in following the facility's policy on accommodating dietary needs.
Failure to Consistently Document Resident Care in Accordance with Policy
Penalty
Summary
Facility staff failed to consistently document care provided to a resident in accordance with the facility's Charting and Documentation policy and accepted professional standards. Specifically, review of the Documentation Survey Report (DSR) for one resident revealed blank entries for the type of assistance provided on multiple shifts, despite the expectation that all care should be documented without omissions. The resident in question had a history of neoplasm of the prostate, anxiety disorder, and acute kidney failure, and was assessed as moderately cognitively impaired. The care plan indicated an ADL Self Care Performance Deficit, yet documentation was incomplete for several shifts. Interviews with staff, including a CNA, the Unit Manager, the Administrator, and the Interim DON, confirmed that CNAs were responsible for documenting all care in the electronic system and that nursing management was expected to ensure documentation was complete. The facility's policy, reviewed in March 2025, required that all services provided to residents be fully and accurately documented. The presence of blank entries in the DSR indicated a failure to adhere to these requirements.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility met with resident #4 to ensure all ADL care was provided as scheduled on ADL record. The nurses and nursing assistants of resident #4 were educated on the performance and documentation of Activities of Daily Living on the electronic ADL record 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. The facility recognizes that all residents have the potential to be affected by this deficient practice 3) What measures will be put into place or systematic changes to ensure that the deficient practice would not recur The facility Director of Nursing or designee will provide education to all Nurses and Nursing Assistants on completion and documenting of all resident Activities of Daily Living completed in the electronic ADL record 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic change The facility Director of Nursing or designee will audit resident electronic ADL records weekly for three months and then monthly for three months on different shifts to ensure ADLs are being completed and documented as appropriate on the ADL electronic record The Director of Nursing or designee will present the findings of the audits and review trends and needed follow up in the two facility Quarterly Quality Assurance Performance Improvement Meetings
Failure to Properly Date and Discard Expired Food in Kitchen
Penalty
Summary
The facility failed to ensure that food and beverages stored in the kitchen were properly dated and free from expired manufacturer's use by dates, potentially affecting 114 of 116 residents who consumed food prepared in the facility's kitchen. During an inspection, it was observed that an opened one-gallon container of Russian dressing and multiple containers of cottage cheese in the walk-in refrigerator had expired use by dates. Additionally, 10 cartons of nutritional shakes were found undated and thawed. The Dietary Manager (DM) confirmed these findings and acknowledged that the staff, including herself, were responsible for checking expiration dates and discarding expired items. The supplier of the nutritional shakes informed the DM that the shakes should be dated when removed from freezer storage and used within 14 days after thawing. Further observations in the kitchen's dry storage room revealed several bread products with expired use by dates and many undated packages of bread. The DM confirmed the expired and undated bread products and stated that staff were expected to date bread products upon receipt and discard those with expired dates. The facility's policy on date marking for food safety was reviewed, indicating that food should be clearly marked with the date of opening and the date by which it should be consumed or discarded, not exceeding the manufacturer's use-by date or four days, whichever is earliest. The policy also outlined responsibilities for the Head Cook and DM to check and document compliance with these requirements.
Failure to Ensure Dignified Dining and Respect Resident Preferences
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during a survey. One resident, with moderately impaired cognition, was left waiting for his meal while his tablemate had already finished eating. This resident expressed his preference to eat with his tablemates and to have his food and beverages served in non-disposable dishware, which was not honored. Another resident, who was cognitively intact, also received his meal in disposable dishware, which he did not prefer. During a resident group interview, multiple residents expressed dissatisfaction with the use of disposable silverware and cups, which were often small and inadequate for drinking. The dietary manager acknowledged the issue, citing a lack of sufficient non-disposable dishware as the reason for using disposable items. Additionally, a resident was left waiting for over 40 minutes for his meal, and his table was removed without explanation to accommodate a scheduled activity, which he found upsetting. Furthermore, the facility failed to respect a resident's right to self-determination by requiring her to wear an identification wristband against her wishes. Despite her moderate cognitive impairment, the resident was able to express her dislike for the wristband, which she felt compromised her dignity. The facility's policy required wristbands for identification purposes, but the resident's preference was not considered, even though alternative identification methods were available.
Deficiency in Menu Planning and Nutritional Adequacy
Penalty
Summary
The facility failed to ensure that menus were prepared in advance with specific vegetables, as required to meet the nutritional needs of residents. Instead, the menus frequently listed 'Vegetable of the Day' without specifying which vegetable would be served. This practice was observed in 39 out of 56 lunch and supper meals on the facility's four-week menu cycle, potentially affecting 114 of 116 residents. A resident, identified as R77, who was cognitively intact, expressed concerns about the repetitive serving of the same vegetables, such as peas and carrots, multiple times a week. Observations confirmed that the resident was served carrots as the vegetable for a meal, consistent with the 'Vegetable of the Day' listing on the menu. Interviews with dietary staff revealed that the decision on which vegetable to serve was made by the cook based on availability, rather than a pre-planned menu. The facility's Registered Dietitian acknowledged that the menus were signed and approved for nutritional adequacy, but admitted that without specific vegetables planned, it was not possible to ensure nutritional adequacy. The 'Vegetable of the Day' practice was implemented by a previous Dietary Manager, and the current system allowed for the possibility of serving the same vegetable too frequently. The facility's policies required menus to be planned in advance and reviewed for nutritional adequacy, which was not adhered to in this case.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature for 13 of 13 residents reviewed for food palatability. This issue was identified through various methods including observation, interviews, test tray reviews, and record reviews. Residents consistently reported that meals, particularly breakfast, were not served hot, and some described the food as barely edible. Specific complaints included cold scrambled eggs, weak and warm coffee, and a lack of variety in vegetables served. Several residents, including those with intact cognition and those with moderate cognitive impairments, expressed dissatisfaction with the temperature and quality of the food. For instance, one resident reported that the facility had run out of coffee and fresh fruit, requiring his wife to bring in fruit for him. Another resident mentioned that the facility frequently ran out of items like hotdog buns and coffee, leading her to purchase her own food and coffee-making equipment. Additionally, residents noted that the menu often listed "Vegetable of the Day" without specifying the actual vegetable, which was usually limited to carrots or green beans. A test tray was used to verify the residents' complaints, revealing that the food temperatures were below acceptable levels by the time they reached the residents. The scrambled eggs, oatmeal, toast, and bacon were all served at temperatures significantly lower than the acceptable standard of 135 degrees Fahrenheit. The coffee was also found to be warm and weak. The facility's Dietary Manager acknowledged awareness of these issues from previous Resident Council meetings, where residents had voiced concerns about food not being served hot. The facility's policy on food preparation emphasized the importance of serving food at safe and appetizing temperatures, which was not adhered to in this case.
Delayed Meal Service in Facility
Penalty
Summary
The facility was found to have deficiencies in meal service times, as meals were served later than scheduled to residents on four of the five facility hallways. This issue was observed to potentially affect 114 of 116 residents who consumed meals prepared in the kitchen. The Dietary Manager provided a meal service schedule, but observations revealed that meals were consistently served late, particularly on the 400 Hallway, where residents reported waiting long periods for their meals. Specific instances included a resident on the 400 Hallway who was observed waiting for lunch well past the scheduled time, expressing hunger and frustration. Other residents on the same hallway also experienced delays, with meal carts arriving significantly later than the posted times. Interviews with residents confirmed that late meal service was a frequent issue, with some residents reporting that breakfast and lunch were often served an hour or more after the scheduled times. The Dietary Manager and staff acknowledged the delays, attributing them to a late start in the kitchen's breakfast tray line and incomplete tasks from the previous evening's staff. Staffing issues were also cited as a contributing factor. Residents expressed dissatisfaction with the meal service during interviews and a Resident Group meeting, and the Director of Nursing confirmed receiving complaints about the timeliness of meal delivery.
Inadequate Supply of Towels in LTC Facility
Penalty
Summary
The facility failed to ensure an adequate supply of linens, specifically towels, for its residents, leading to a deficiency in providing a safe, clean, comfortable, and homelike environment. During a Resident Council Group interview, several residents reported issues with towel availability, with some residents resorting to using personal items like bathrobes as towels. Observations confirmed the lack of towels on linen carts across multiple halls, with some carts having no towels at all, despite the presence of numerous residents on each hall. Interviews with staff, including a CNA and the Maintenance/Housekeeping Director, revealed that towels were distributed twice daily on clean linen carts, but residents' rooms were not stocked with towels. The Director of Nursing, who was new to the position, was unsure about the policy regarding towels in residents' rooms. The facility's Administrator was unaware of the towel shortage issue until it was brought to attention during the survey. The deficiency was further highlighted by observations and resident interviews conducted by the surveyor and the Maintenance/Housekeeping Director. Many residents reported not having towels in their rooms, with some reusing towels due to the shortage. The linen carts on various halls were found to be inadequately stocked, with some having no towels at all, confirming the residents' complaints and the facility's failure to maintain an adequate supply of linens.
Failure to Maintain Guardianship Documentation for Resident
Penalty
Summary
The facility failed to ensure that guardianship documentation was in place for a resident who was not capable of making healthcare decisions. The resident, who had diagnoses including dementia, Down syndrome, and aphasia, was documented as having a legal guardian. However, the facility did not have the necessary guardianship documentation in the resident's electronic medical record (EMR). This deficiency was identified during a review of the resident's records, which included a Pennsylvania Orders for Life-Sustaining Treatment (POLST) form indicating a Do Not Resuscitate (DNR) status without a guardian's signature, and a physician's order for DNR and Do Not Intubate (DNI). Interviews with facility staff, including the Social Service Director, Admissions Coordinator, and Administrator, revealed that the guardianship papers were not uploaded into the EMR as required by the facility's policy. The Social Service Director, who had been employed for two months, confirmed the absence of the documentation. The Admissions Coordinator, who had been employed for three weeks, stated that the guardian claimed to have provided the papers to a previous social worker, but they were not found in the medical chart. The facility's policy on advance directives mandates that such documents be obtained and maintained in the resident's medical record, which was not adhered to in this case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, which was identified during a review of records and interviews. The resident, who had intact cognition and was experiencing frequent pain due to multiple health conditions, reported that a registered nurse (RN) referred to her as a 'Drug Addict' while administering her medication. This incident was corroborated by a licensed practical nurse (LPN) who was present and heard the RN make the derogatory comment. The LPN later apologized to the resident for the RN's statement. The facility's investigation confirmed the incident, and the RN involved was suspended and subsequently quit. The facility's policy on abuse, neglect, and exploitation clearly prohibits verbal abuse, which includes the use of disparaging and derogatory terms. The incident was reported timely, and an investigation was initiated, but the deficiency highlights a failure to ensure the resident was free from verbal abuse, as required by the facility's policy and regulations.
Failure to Update PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a Level One PASARR (Pre-Admission Screening and Resident Review) was revised for a resident who was newly diagnosed with a major mental illness. The resident, identified as R16, was admitted with diagnoses including congestive heart failure and anxiety. Approximately five months after admission, a diagnosis of bipolar disorder was added to the resident's medical record. Despite this significant change in the resident's mental health status, the Level One PASARR document, dated November 1, 2021, incorrectly indicated that the resident did not suffer from any major mental illness diagnoses. During an interview, the Nurse Consultant confirmed that the Level One PASARR assessment was incorrect and stated that it was expected to be updated timely with any change in a resident's health status. The facility's policy requires coordination with the PASARR program to ensure that individuals with a mental disorder receive appropriate care and services. The policy also mandates that any resident exhibiting a newly evident or possible serious mental disorder be referred promptly for a Level 2 resident review. This oversight created the potential for the resident to receive inadequate mental health services.
Failure to Revise Care Plans and Include Residents in Meetings
Penalty
Summary
The facility failed to revise the care plans for two residents, R9 and R100, to reflect their current care needs. R9, who was admitted with end-stage renal disease and required dialysis, had a physician's order for emergency dialysis dressing supplies to be maintained at the bedside. However, the care plan was not updated to include these supplies, despite the order being in place since March 2024. Interviews with facility staff, including an LPN and the MDS Coordinator, revealed that care plans are typically revised during care plan meetings, but any floor nurse could make necessary updates. The oversight was acknowledged by the staff, indicating a lapse in the care plan revision process. R100, admitted with acute respiratory failure and other conditions, had not participated in any care planning meetings since her initial care plan was implemented in December 2023. Despite having intact cognition, as indicated by a BIMS score of 15, R100 expressed a desire to be involved in care planning meetings to discuss her medications and treatments. The Social Services Director confirmed that quarterly care planning meetings were not being held as required, due to her limited availability. The facility's policy mandates quarterly reviews and revisions of care plans, which were not adhered to in this case, as confirmed by the Administrator.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful activity program for a resident, identified as R74, who was reviewed for activities among 26 sampled residents. R74, who was cognitively intact with a BIMS score of 15 out of 15, expressed a preference for intellectual activities such as chess and dominoes. However, the facility did not assess R74's activity preferences adequately, and the care plan did not reflect R74's interests. As a result, R74 was not provided with sufficient activities to prevent boredom and reported spending most of the time in his room watching TV. Observations during the survey revealed that R74 remained in his room with the TV on during multiple checks over several days. Interviews with staff, including the Activity Aide and the Activity Director, indicated that R74 did not participate in group activities and was not on a one-to-one program. The Activity Director was unaware of R74's interest in chess or dominoes and confirmed that the care plan and recreation assessment failed to identify specific activity preferences for R74. The facility's policy on activities, which mandates providing an ongoing program based on residents' comprehensive assessments and preferences, was not followed in R74's case. The policy requires that each resident's interests and needs be assessed routinely, but this was not done for R74, leading to a lack of meaningful engagement and activity options tailored to his interests.
Failure to Change Urinary Catheter Monthly as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order to change a resident's indwelling urinary catheter every month, which was identified during a review of the resident's medical records and interviews with staff. The resident, who was cognitively intact and had a diagnosis of obstructive uropathy, had a physician's order dated March 5, 2024, specifying that the catheter should be changed monthly. However, documentation revealed that the catheter was last changed on February 5, 2024, and there was no record of it being changed again until May 28, 2024. This lapse in care was confirmed by the resident, who expressed concern about the risk of developing a urinary tract infection due to the delay in catheter changes. Interviews with nursing staff and a nurse consultant revealed that the order to change the catheter monthly was incorrectly entered into the system as an order type that did not require documentation, resulting in the omission of the order from the resident's monthly treatment administration records for March, April, and May 2024. The facility's policy on catheter care, which emphasizes appropriate care and maintaining dignity and privacy for residents with indwelling catheters, was not followed in this instance, leading to the deficiency.
Failure to Maintain Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to provide emergency dressing supplies at the bedside for a resident requiring dialysis, as per physician orders. The resident, who was admitted with end-stage renal disease and diabetes mellitus type II, was scheduled to receive hemodialysis three times a week. Physician orders specified that hemostats, gauze, and tape should be kept at the resident's bedside to address potential bleeding from the dialysis port. However, an observation revealed that these supplies were not present at the bedside. Interviews conducted with the resident and staff members indicated a lack of awareness regarding the physician's orders for maintaining emergency dressing supplies at the bedside. The resident mentioned that dressing supplies were brought by the nurse during dressing changes, but none were kept at the bedside. Both the LPN and the Unit Manager confirmed their unawareness of the requirement to maintain these supplies at the resident's bedside, highlighting a communication gap in adhering to the physician's orders.
Failure to Obtain Orders and Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R105, had appropriate physician's orders, informed consent, and a proper assessment for the use of side rails. The resident was admitted with multiple diagnoses, including bilateral primary osteoarthritis of the hip, cognitive communication deficit, dementia, and a history of repeated falls. Despite these conditions, the resident's admission records and Minimum Data Set (MDS) indicated that side rails were not in use, and there were no orders for their use. However, the resident's care plan included the use of bilateral 1/4 side rails to assist with transfers and positioning in bed, without any documented assessment or informed consent. Observations confirmed the use of side rails on multiple occasions, and interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that no assessment, physician's orders, or informed consent had been obtained for the use of the side rails. The facility's policy required a comprehensive assessment and informed consent before the use of bed rails, which was not followed in this case. This oversight had the potential to affect the safety of the resident, as the necessary procedures and documentation were not in place.
Failure to Document Physician's Response to Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure a documented response to the Pharmacist's recommendations for a resident who was prescribed Lexapro, an antidepressant medication. The Pharmacist recommended a dose reduction from 20 mg to 10 mg due to the resident's age, as the maximum recommended dose for individuals over a certain age is 10 mg. Despite these recommendations being made multiple times over several months, there was no documented response from the Physician indicating whether the recommendations were reviewed or acted upon. The resident continued to receive the higher dose of Lexapro without documented justification from the Physician. Interviews with facility staff revealed that the Physician claimed to have reviewed the Pharmacist's recommendations and decided against a dose reduction because the resident was stable on the current medication. However, this decision was not documented in the resident's medical record as required by the facility's policy. The Director of Nursing and the Nurse Consultant confirmed the absence of the Physician's documented response and were unaware of the location of the forms where such documentation should have been recorded. The facility's policy mandates that the attending physician must document any action taken or rationale for no change in the resident's medical record, which was not adhered to in this case.
Infection Control Deficiency in Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper infection control for a resident receiving respiratory services. The resident, who was admitted with diagnoses including pulmonary fibrosis and acute respiratory failure with hypoxia, was ordered to receive oxygen via nasal cannula at three liters per minute. The facility's policy required that the resident's oxygen tubing, cannula, and humidifier be changed weekly on Sunday nights. However, a review of the Treatment Administration Record indicated that the resident's oxygen tubing and humidification bottle had not been changed since admission, despite the policy requirements. Observations confirmed that the resident's oxygen tubing and humidification bottle were last changed on a date that was not in compliance with the weekly change requirement. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the expectation was for the nursing staff to change the oxygen equipment weekly, which had not been adhered to in this case. The facility's Oxygen Administration Policy also emphasized the importance of changing oxygen equipment regularly to maintain sanitary conditions, which was not followed, leading to the deficiency.
Failure to Honor Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to accommodate the food allergies and preferences of three residents, leading to repeated instances where residents were served foods they were allergic to or disliked. Resident 102, who has a documented allergy to melon, was served melon on multiple occasions despite the allergy being noted on her meal tray slip. The resident had informed the facility's Registered Dietitian (RD) about this issue, yet the problem persisted, with the most recent occurrence being on 05/29/24. Resident 77, who has gastro-esophageal reflux disease, expressed that his food preferences were not honored, as he was served pancakes and mashed potatoes despite indicating his dislike for these foods on his meal tray slip. The Dietary Manager (DM) confirmed that these foods should not have been served to Resident 77, acknowledging the oversight in honoring the resident's food preferences. Similarly, Resident 81, who has type two diabetes mellitus with hyperglycemia and hemiplegia, was served pancakes and toast, which were listed as disliked foods on his meal tray slip. Despite informing staff of his preferences, Resident 81 continued to receive these foods. The DM confirmed that the resident's dislikes were noted on the meal tray slip and should have been respected. The facility's policy mandates accommodating resident allergies and preferences, which was not adhered to in these cases.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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