Whiting Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whiting, New Jersey.
- Location
- 3000 Hilltop Road, Whiting, New Jersey 08759
- CMS Provider Number
- 315293
- Inspections on file
- 19
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Whiting Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance was transferred by a single CNA using a pull sheet, rather than the required equipment and staffing. During the transfer, the shower stretcher moved away, causing the resident to fall and sustain a left upper extremity fracture. The resident had multiple medical conditions and was fully dependent for transfers, with care plans and facility policies clearly indicating the need for two-person mechanical lift transfers. Staff interviews confirmed these requirements were standard practice.
A resident with dementia and behavioral issues was physically abused when an LPN used personal pepper spray on them during an episode of agitation, causing chemical conjunctivitis and pain. Surveillance footage showed the resident was left on the floor without medical assistance and later dragged back to their room by staff, with no care provided until emergency services arrived. Staff interviews confirmed the inappropriateness of the action, and facility policy at the time did not address weapons or pepper spray.
A cognitively impaired resident with a history of exit-seeking eloped from the facility due to inadequate supervision, lack of specific care plan interventions, and failure to follow protocols for monitoring and documentation. Staff did not notice the resident was missing until notified by an external caller, and post-incident checks of security systems were not performed. The required social services assessment was also not completed after the elopement.
The facility failed to perform quarterly smoking assessments for three residents who were active smokers, as required by their policy. One resident with moderate cognitive impairment had not been assessed for five months, another resident with intact cognition was overdue for an assessment by 63 days, and a third resident identified as an unsafe smoker had no further evaluations after the initial assessment. Conflicting information about responsibility for assessments indicated a lack of clarity within the facility.
The facility failed to ensure timely face-to-face visits by the attending physician for residents, as required by regulations. Several residents with serious conditions, such as dementia and bipolar disorder, were not seen by the physician within the mandated timeframes. Instead, APNs conducted visits and documented notes in the EMR, as confirmed by staff interviews.
The facility failed to maintain proper sanitation and food handling practices. A meat slicer was found uncovered with food debris, and pans were improperly air-dried, leading to wet nesting. In the pantry, a freezer had a thick ice buildup with debris, and staff were unaware of maintenance responsibilities.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing over residents while feeding them, contrary to the facility's policy requiring staff to sit at eye level. This was confirmed by the LNHA and DON, and observed on one unit where both an IP and a CNA did not adhere to the policy.
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. Staff were observed standing while assisting residents with meals, contrary to facility policy, and meals were served on trays, detracting from a homelike setting. The Licensed Nursing Home Administrator acknowledged these practices as inappropriate.
A resident with chronic kidney disease and hypotension did not receive Midodrine as prescribed when their systolic blood pressure (SBP) was below 100 mmHg, and received it when SBP was above 100 mmHg, contrary to physician's orders. The facility's Medication Pass policy lacked specific instructions for following hold parameters, leading to this deficiency.
A resident with a contracture in the right upper extremity was not provided with necessary assistive devices to maintain or improve range of motion. Despite recommendations for a handroll, the resident was observed without any such device, and the care plan lacked specific interventions for the contracture. Interviews with staff revealed inconsistencies in care and communication gaps regarding the resident's needs.
A resident with an indwelling urinary catheter was observed with the tubing dragging on the floor, contrary to infection control protocols. The resident, diagnosed with urinary tract infection and neuromuscular dysfunction of the bladder, had a care plan to keep the drainage bag off the floor, which was not followed. Staff interviews confirmed the tubing should not touch the ground, highlighting a deficiency in maintaining proper catheter care.
A facility failed to implement infection control measures for a resident with COPD by improperly storing a nebulizer mask. The mask was observed face down on personal belongings and undated, and later found exposed in a side table drawer. The resident had a history of COPD and was cognitively intact. The facility's policy did not address nebulizer care, and both the LPN and DON acknowledged the mask should have been bagged and labeled.
A facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. The resident, who had been receiving dialysis for five years, had missing entries for vital signs and other pertinent information on several dates. The LPN confirmed that the communication forms should be completed by the nursing staff before dialysis, but this was not consistently done. Interviews with the DON and LNHA revealed that the facility's process involved using a communication book, but the policy was not consistently followed.
A facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. The resident, admitted with palliative care, depression, and sacral wounds, was identified as being on hospice care. The LPN/Unit Manager could not provide a complete Hospice Communication Book, only showing billing and symptom management documents. The facility's policy requires documented communication with hospice providers, which was not adequately maintained.
Multiple residents with cognitive and mental health conditions were subjected to physical and verbal abuse by another resident with a history of aggression and by an LPN. Despite recommendations for one-on-one supervision and behavior tracking, the facility did not consistently implement these interventions or revise care plans in response to ongoing aggressive behaviors and medication refusals. Staff-to-resident abuse was substantiated through witness statements and incident reports, with the LPN continuing to provide care after the first incident before being suspended and terminated.
Two residents with significant behavioral and medical diagnoses were involved in separate incidents where one was involuntarily secluded in a dayroom and another threw a knife and made threats toward staff and others. In both cases, the facility did not conduct or document thorough investigations as required by its abuse prevention policy, nor did it ensure the safety of all residents and staff involved.
The facility failed to prevent and address multiple incidents of physical and verbal abuse involving residents with behavioral health needs and staff, resulting in repeated aggression, injuries, and substantiated staff-to-resident abuse. Despite recommendations for one-on-one supervision and behavioral tracking, there was inconsistent implementation and documentation of these interventions, and staff were not always aware of required protocols. The facility did not consistently notify medical providers of medication refusals or behavioral incidents, and delays in reporting and investigating abuse were noted.
A resident with Huntington's disease and asthma, who was cognitively intact, was placed in a dayroom by a CNA, who then closed and blocked the door, preventing the resident from leaving despite repeated requests. The CNA sat outside the door to monitor the resident, and the incident was confirmed by interviews and surveillance footage. This action constituted involuntary seclusion and was not in accordance with facility policies on restraints and abuse prevention.
A resident with a history of TBI and dementia fell from a geriatric chair, sustained a forehead hematoma, and subsequently declined, exhibiting decreased alertness and inability to swallow. Facility staff did not complete or document required neurological assessments or monitor for delayed complications as per policy, and the incident was not properly recorded in the medical record or fall investigation documentation.
A resident with traumatic brain injury and severe dementia experienced multiple falls, including head injuries, due to inadequate supervision and ineffective interventions. Despite repeated incidents, the care plan was not consistently updated, root causes were not always documented, and increased monitoring was not implemented as required by facility policy. Staff interviews revealed that supervision was insufficient, particularly during mealtimes when one CNA was responsible for several high-fall-risk residents.
The facility did not complete or document required annual performance evaluations for all CNAs, with personnel files missing evaluations for one or more years. Staff interviews revealed confusion about who was responsible for conducting these reviews, and neither the ADON nor HR Director could locate the necessary documentation or policy.
The facility did not report allegations of abuse and threats in a timely manner to NJDOH as required by policy and regulation. In one case, a resident with dementia and a history of inappropriate behaviors was observed touching another resident inappropriately, but the incident was not reported to NJDOH within the required timeframe. In another case, a resident with schizophrenia and anxiety disorder displayed threatening behavior, and there was no evidence this was reported. Interviews confirmed that staff were aware of reporting requirements, but these were not consistently followed.
The facility did not ensure RN coverage for at least eight consecutive hours on a specific day, as confirmed by staffing records and staff interviews. This lapse was contrary to the facility's stated policy and regulatory requirements, potentially affecting all residents.
A resident with dementia and other conditions was involved in an altercation, leading to a room change. The facility failed to notify the resident's POA about the change and did not document the notification, violating resident rights. Interviews with staff confirmed the requirement for family notification and documentation, but the facility lacked a specific policy on room changes.
A resident with dementia, depression, and anxiety experienced a fall, but the LTC facility failed to update the care plan with new interventions as required. Despite being at risk for falls, the care plan had not been revised since January, and staff interviews confirmed the oversight. Facility policy mandates updates after significant changes, but this was not followed.
Failure to Follow Transfer Protocols Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for transfers was not safely or properly transferred according to their care plan. The resident, who required a mechanical lift and two staff members for transfers, was instead moved by a single CNA using a pull sheet from the bed to a shower stretcher. During this transfer, the shower stretcher moved away from the bed, causing the resident to fall to the floor and sustain a left upper extremity humeral fracture. The incident was witnessed after a nurse heard yelling and found the resident on the floor, with the CNA present in the room. The resident involved had multiple medical diagnoses, including heart disease, end stage renal disease, diabetes, and osteoporosis, and was assessed as being completely dependent on staff for transfers. The resident's care plan specifically required the use of a mechanical lift and two-person assistance for all transfers. Documentation in the facility's records, including the Minimum Data Set and assignment sheets, confirmed these requirements. Other staff interviews confirmed that the standard procedure for mechanical lift transfers was to have two staff members present, and that this information was clearly communicated to CNAs through assignment sheets and the electronic medical record. Despite these established protocols, the CNA involved in the incident did not follow the resident's care plan and attempted the transfer alone, without the mechanical lift or a second staff member. The facility's policies also required two staff for mechanical lift transfers. The failure to adhere to these procedures directly resulted in the resident's fall and injury.
Resident Abused with Pepper Spray by LPN; Left Without Care
Penalty
Summary
A moderately cognitively impaired resident with a history of dementia, severe mood disturbances, and major depressive disorder was subjected to physical abuse by a staff member. The resident, who had a care plan addressing aggressive and combative behaviors, was observed at the nurse's station exhibiting agitation, including grabbing and throwing equipment. In response, an LPN retrieved pepper spray from her personal belongings and sprayed the resident in the face multiple times, resulting in the resident collapsing to the floor, holding their eyes, and appearing to be in pain and distress. The resident was later treated for chemical conjunctivitis and pain to the left eye at the emergency room. Surveillance footage reviewed by facility leadership and law enforcement showed that after being sprayed, the resident was left on the floor without medical assistance as staff walked away. The resident attempted to crawl to an adjacent room while disoriented, at which point a CNA and the LPN dragged the resident by their clothing back to their room and left, again without providing care. No one else entered the resident's room until police and emergency medical services arrived. Interviews with staff confirmed that the use of pepper spray was not appropriate and that staff had been educated on abuse and the prohibition of such actions after the incident. Facility policy at the time prohibited physical abuse and required that law enforcement be called if a resident became violent or uncontrollable, but there was no explicit policy regarding weapons or pepper spray. The actions and inactions of the staff directly resulted in harm to the resident and constituted a failure to protect the resident from abuse and neglect.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a history of exit-seeking behavior eloped from the facility. The resident, diagnosed with unspecified dementia, schizophrenia, and schizoaffective disorder, was independent with ambulation and had a BIMS score indicating severe cognitive impairment. The resident's care plan included interventions such as a wander guard, frequent monitoring of whereabouts, and documentation of wandering behavior, but there was no evidence of specific interventions to monitor the resident's whereabouts or to distract from wandering or exit-seeking behaviors. On the day of the incident, staff did not notice the resident was missing until notified by an external caller, and the resident was later returned by police without injury. Following the elopement, it was found that the facility did not test the wander guard system or egress doors immediately after the incident. The Director of Maintenance was not asked to check the doors or wander guard system post-incident, and only continued with routine weekly checks. Staff interviews revealed that no alarms were heard at the time of the elopement, and camera footage did not capture the resident exiting the facility. The Director of Nursing and Assistant Director of Nursing did not conduct a thorough root-cause analysis, as they did not interview all relevant staff or test the security systems after the event. Documentation of frequent monitoring and behavior logs, as required by the care plan, was not found in the resident's medical record. Additionally, the facility's elopement drill protocol required a social services assessment for emotional distress after an elopement, but this was not completed or documented for the resident. Staff were unclear about the meaning and documentation of "frequent monitoring," and there was no formal process or set time for such monitoring. The lack of specific interventions, inadequate supervision, failure to follow protocols, and insufficient documentation contributed to the resident's ability to elope undetected, resulting in a deficiency that placed the resident and others at risk.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to consistently perform quarterly smoking assessments for residents designated as active smokers, as required by their policy. This deficiency was observed in three residents. Resident #30, who has moderate cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, had not received a quarterly smoking assessment since August 2024, despite being an active smoker. The resident's care plan did not address the need for quarterly smoking assessments, and the last assessment was overdue by approximately five months. Resident #127, who has intact cognition and diagnoses including traumatic subdural hemorrhage and seizures, was observed smoking without staff supervision. The resident's smoking safety evaluation was overdue by 63 days, with the last assessment due in November 2024. The facility's corporate activity director and nursing staff provided conflicting information about who was responsible for completing smoking assessments, indicating a lack of clarity and communication within the facility. Resident #58, who is cognitively intact and has multiple diagnoses including metabolic encephalopathy and major depressive disorder, was identified as an unsafe smoker. However, no further smoking evaluations were conducted after the initial assessment in August 2024. The facility's smoking policy requires quarterly re-evaluations of a resident's ability to smoke safely, but this was not adhered to, contributing to the deficiency.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at the required intervals. Specifically, the attending physician did not see residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficiency was identified for 8 out of 35 sampled residents, including those with serious conditions such as dementia, bipolar disorder, and chronic obstructive pulmonary disease. For instance, Resident #139, admitted with dementia and anxiety disorder, was not seen by the attending physician from June 2024 to January 2025. Similarly, Resident #79, with bipolar disorder and neuropathy, had no documented visits by the attending physician since July 2024. Other residents, such as Resident #59 with bipolar disorder and non-Alzheimer's dementia, and Resident #120 with cauda equina syndrome and obstructive uropathy, also lacked timely physician visits. Interviews with facility staff, including LPNs and the Medical Director, revealed that the facility relied on Advanced Practice Nurses (APNs) to conduct visits and document notes in the Electronic Medical Record (EMR). The Medical Director confirmed that they typically see patients in the hospital and do not write physician notes, leaving this task to the APNs. The facility's policy, revised in April 2013, mandates compliance with OBRA regulations, which were not adhered to in this case.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. During an inspection, a meat slicer was found uncovered and exposed to air, with unidentified food debris and a white slimy substance present on the table behind the blade guard. The Food Service Director (FSD) confirmed that the slicer was cleaned and sanitized, but it was not covered when not in use, exposing it to potential contamination. Additionally, a stack of deep 1/4 pans was observed to be wet, indicating improper air drying before stacking, a practice known as wet nesting, which can promote bacterial growth. In the North Pantry/Nourishment room, a thick buildup of ice was observed at the bottom of the freezer, containing a white plastic spoon, pieces of napkin, aluminum foil, and Styrofoam. Bagged ice packs were stored alongside resident food, and the Licensed Practical Nurse/Unit Manager (LPN/UM) was unaware of who was responsible for the freezer's maintenance. The facility's policy on sanitization and cleanliness was reviewed, highlighting the need for proper air drying of equipment and utensils to prevent cross-contamination.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity while being assisted with meals. This deficiency was observed on one of the facility's units, where staff members were seen standing over residents while feeding them, rather than sitting at eye level as required by the facility's feeding assistance guidance. On one occasion, the Infection Preventionist was observed standing over a resident seated in a Geri chair while assisting with a meal, and admitted to the surveyor that they did not have a chair to sit on. On another occasion, a Certified Nursing Assistant (CNA) was observed standing while assisting two different residents with their meals, despite a chair being available for use. The Licensed Nursing Home Administrator and Director of Nursing confirmed during an interview that staff are supposed to sit while assisting residents with meals, aligning with the facility's policy. The facility's policy, titled 'Feeding Assistance Guidance,' explicitly states that staff should sit facing the resident at eye level. This practice was not followed, leading to the deficiency being cited under NJAC8:39-4.1(a)(12).
Deficiency in Dignity and Homelike Environment During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal assistance and did not create a homelike environment in the dining area. On multiple occasions, staff members, including the Infection Preventionist and a Certified Nursing Assistant, were observed standing while assisting residents with their meals, rather than sitting at eye level as per facility policy. This practice was noted in both the [NAME] wing and South wing, affecting residents seated in Geri chairs. Despite the availability of chairs, staff continued to stand, which was acknowledged as inappropriate by the Licensed Nursing Home Administrator during an interview. Additionally, the facility did not remove food from trays when serving meals in the dining room, which detracted from creating a homelike environment. This was observed on several occasions in the South Unit dining room, where residents were served their meals directly on trays. The Licensed Nursing Home Administrator admitted that serving meals on trays was a longstanding practice, despite it not aligning with the goal of providing a homelike dining experience. The facility's policy on feeding assistance, which advises staff to sit facing residents at eye level, was not adhered to, contributing to the deficiency.
Failure to Follow Medication Hold Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following the hold parameters for administering a blood pressure medication, Midodrine, to a resident with chronic kidney disease and hypotension. The resident, who was moderately cognitively impaired and dependent on renal dialysis, had a physician's order specifying that Midodrine should be administered when the systolic blood pressure (SBP) was less than 100 mmHg. However, the Medication Administration Records (MAR) for November and December 2024, and January 2025, revealed multiple instances where the resident's SBP was below 100 mmHg, yet Midodrine was not administered. Conversely, there were also instances where Midodrine was given when the SBP was above 100 mmHg, contrary to the physician's order. Interviews with the nursing staff, including an LPN and a Unit Manager, confirmed that the nurses did not follow the physician's hold order parameters for Midodrine on multiple occasions. The Director of Nursing acknowledged that the nurses should have adhered to the physician's orders. Additionally, the facility's Medication Pass policy did not include specific instructions for following physician's orders regarding medication hold parameters, contributing to the oversight in medication administration for the resident.
Failure to Provide Appropriate Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a contracture, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, identified as having a contracture in the right upper extremity, was observed multiple times without any assistive devices such as a splint or handroll, which are typically used to prevent further decrease in ROM. Despite the resident's family being informed that an appropriate device would be provided, no such device was observed during the surveyor's visits. The resident's medical records indicated a history of cerebral infarction and major depression, with a moderately impaired cognitive status. The care plan for the resident included monitoring for signs of immobility and providing gentle ROM exercises, but it lacked specific interventions for the contracture of the right hand. Additionally, there were no active physician orders addressing the contracture, and previous therapy recommendations for wearing a handroll were not being followed. Interviews with facility staff revealed a lack of consistent application of assistive devices and a gap in communication regarding the resident's care needs. The head therapist confirmed that the resident had not been on therapy since early 2024, and the discharge recommendations for wearing a handroll were not implemented. The Director of Nursing outlined general interventions for residents with contractures, but these were not reflected in the resident's care plan or observed in practice.
Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. During an observation, the surveyor noted that the tubing of the urinary collection bag was dragging on the ground as the resident self-ambulated in a wheelchair. The resident, who had a diagnosis of urinary tract infection, dementia, and neuromuscular dysfunction of the bladder, was cognitively intact with a BIMS score of 14/15. The resident's care plan included interventions to keep the drainage bag off the floor and covered for dignity, but these were not followed. Interviews with facility staff, including the Infection Preventionist, LPNs, and the Director of Nursing, confirmed that the urinary collection tubing should never touch the ground due to infection control concerns. The facility's Foley Catheter Care policy stated that the drainage bag must not touch the floor, but it did not explicitly mention the tubing. The deficiency was identified as a failure to adhere to infection control protocols, as the tubing was observed on the floor, posing a risk of cross-contamination and infection.
Improper Storage of Respiratory Equipment for Resident with COPD
Penalty
Summary
The facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for a resident with COPD. During an initial tour, a surveyor observed a nebulizer mask belonging to the resident placed face down inside the bedside on top of personal belongings, such as a book and a mirror, and the mask was undated. Subsequent observations revealed the nebulizer mask was consistently stored improperly, either inside a side table drawer or on top of the side table, exposed and undated. The resident, who was cognitively intact, had a history of COPD and was admitted with other diagnoses, including atrial fibrillation. The facility's documentation showed that the resident had a physician's order for Albuterol Sulfate Inhalation Nebulization Solution, which was discontinued in August 2024. Despite this, the nebulizer mask was not stored according to infection control protocols. The resident's care plan included interventions for COPD, such as the administration of bronchodilators as ordered. However, the facility's Oxygen Administration policy did not address the care or storage of nebulizers. Both the resident's LPN and the DON acknowledged that the nebulizer mask should have been bagged and labeled when not in use.
Failure to Ensure Consistent Communication with Dialysis Facility
Penalty
Summary
The facility failed to ensure consistent communication with a contracted dialysis facility for a resident requiring dialysis services. This deficiency was identified for a resident who had been receiving dialysis treatment for approximately five years due to end-stage renal disease and other related conditions. The resident attended dialysis four days a week, and the facility's policy required the use of a communication book to document vital signs and other pertinent information before the resident's departure for dialysis. Upon review, it was found that the facility did not consistently document necessary information on the dialysis communication forms. Specifically, there were missing entries for vital signs, access site status, and any problems or complaints on several dates. The Licensed Practical Nurse (LPN) responsible for the resident confirmed that the top portion of the communication form should be completed by the facility's nursing staff before the resident's dialysis treatment. However, this was not consistently done, leading to incomplete communication records. Interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) revealed that the facility's process involved using a communication book for documenting and communicating with the dialysis center. The DON acknowledged that the nursing staff was responsible for ensuring the completion of the communication forms before the resident's departure for dialysis. Despite this, the facility's policy was not consistently followed, resulting in incomplete documentation and communication with the dialysis center.
Failure to Maintain Hospice Communication Record
Penalty
Summary
The facility failed to maintain a Hospice Communication Record for a resident receiving hospice services. During an initial tour, the surveyor observed the resident in their room and identified them as receiving hospice care. The resident was admitted with diagnoses including palliative care, depression, and sacral wounds. The most recent Minimum Data Set indicated the resident was on hospice care, and their comprehensive care plan included coordination with hospice and notification of any changes in condition or medication. During an interview, the LPN/Unit Manager was unable to provide a complete Hospice Communication Book for the resident, only presenting two documents related to billing and symptom management. The facility's hospice program policy requires communication with the hospice provider to ensure resident needs are met 24/7, but the documentation was insufficient. This lack of documentation and communication with hospice providers led to the identified deficiency.
Failure to Protect Residents from Abuse by Peer and Staff
Penalty
Summary
The facility failed to protect multiple residents from physical and verbal abuse by both another resident and a staff member. One resident with a history of mental illness, aggressive behavior, and non-compliance with psychotropic medication physically assaulted two other residents on separate occasions. Despite documented recommendations for one-on-one supervision and behavior tracking, there was no evidence that these interventions were consistently implemented or that the care plan was revised in response to ongoing aggressive behaviors and repeated medication refusals. The facility did not provide documentation that the physician was notified or that behavior tracking was forwarded as recommended, and staff interviews revealed a lack of awareness regarding supervision requirements. Additionally, two residents were subjected to physical and verbal abuse by an LPN on two separate occasions. Witness statements and incident reports confirmed that the LPN pushed one resident and yelled at them, and on another occasion, used expletives and physically struck another resident's hand while attempting to take a binder away. The incidents were witnessed by other staff, and the LPN continued to provide care after the first incident before being suspended and subsequently terminated following the second incident. The facility's own investigation substantiated the staff-to-resident abuse. The residents involved had varying degrees of cognitive impairment and medical conditions, including dementia, anxiety disorder, depression, and chronic illnesses. The facility's failure to implement and maintain appropriate interventions, revise care plans, and ensure staff adherence to abuse prevention policies resulted in actual harm to the residents and placed them in situations of immediate jeopardy.
Removal Plan
- Educate the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on investigating allegations of abuse
- Review and revise policies
- Educate staff on abuse
Failure to Investigate Abuse Allegations and Threats
Penalty
Summary
The facility failed to ensure residents' safety by not conducting thorough and complete investigations into allegations of abuse and threats involving two residents. In one incident, a resident with Huntington's disease, muscle weakness, gait instability, and anxiety disorder, who was cognitively intact, reported being placed in a dayroom against their wishes during the night shift. The resident stated that a CNA, following a nurse's instructions, placed them in the dayroom with the door closed and sat outside the door, preventing the resident from leaving. The resident expressed fear and distress during the incident, and the facility's documentation confirmed that the resident was kept in the room against their wishes. However, the facility could not provide evidence of a comprehensive investigation, including interviews with all involved staff and assessment of resident safety. In a separate incident, another resident with schizophrenia and anxiety disorder was observed by an LPN throwing a knife into the hallway and making ongoing verbal and physical threats toward staff and other residents. Despite the seriousness of the behavior, the facility was unable to provide documentation that a thorough investigation was conducted to ensure the safety of other residents and staff. There was no evidence that the incident was fully investigated or that appropriate steps were taken to assess the situation and prevent further harm. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention requires protection of residents from abuse and the maintenance of a culture of compassion and caring, particularly for those with behavioral or emotional problems. In both incidents, the facility failed to implement its own policy and procedures, as there was a lack of documented evidence of complete investigations and follow-up actions to ensure resident safety following the reported events.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to ensure the safety and well-being of residents by not adequately preventing or addressing incidents of physical and verbal abuse, as well as not following its own policies regarding abuse prevention, physical restraints, and behavioral management. Multiple residents with cognitive and behavioral health diagnoses, including schizophrenia and dementia, were involved in repeated altercations and aggressive incidents. One resident with schizophrenia exhibited ongoing aggressive and violent behaviors towards both staff and other residents, including physical assaults, threats, and property damage. Despite recommendations from psychiatric consultants and outreach programs for one-on-one supervision and behavioral tracking, there was no consistent documentation that these interventions were implemented or that the physician was notified of ongoing medication refusals. The resident continued to refuse medications and engaged in multiple aggressive episodes, some resulting in injuries to other residents and staff, without evidence of timely or adequate intervention by facility leadership. In addition to resident-to-resident aggression, the report documents substantiated incidents of staff-to-resident abuse. An LPN was witnessed pushing and yelling at a resident and using inappropriate language and physical force with another resident. These incidents were observed by other staff members, and the involved LPN continued to provide care after the initial incident before being suspended and ultimately terminated. The facility's documentation revealed delays in reporting and investigating these abuse allegations, and there was a lack of immediate protective measures for the affected residents. Interviews with staff indicated that some were unaware of required supervision protocols, and there was confusion regarding the implementation and discontinuation of one-on-one supervision for residents with behavioral issues. The facility did not provide evidence that all recommended safety measures, such as consistent one-on-one supervision, behavioral tracking, and timely notification of psychiatric and medical providers, were followed. There was also a lack of documentation regarding the rationale for discontinuing supervision and the communication of behavioral incidents to appropriate authorities. The failure to implement and document these interventions contributed to repeated episodes of aggression, injury, and abuse among residents and staff, in violation of facility policies and regulatory requirements.
Involuntary Seclusion of Resident in Dayroom by CNA
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) placed a resident in the dayroom, closed and blocked the door, and sat outside to prevent the resident from leaving, despite the resident's repeated requests to exit. The resident reported feeling terrified and begged to be let out, but the CNA did not allow it. The incident was corroborated by interviews, surveillance footage, and statements from both the resident and staff, which confirmed that the resident was kept in the dayroom against their wishes. The resident involved had a diagnosis of Huntington's disease and asthma, and was assessed as having intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. The event occurred during the night shift, when the resident was found in the hallway and redirected to the dayroom by the CNA, following instructions from a nurse to keep the door closed due to fall risk concerns. The CNA remained outside the door, monitoring the resident and others in the dayroom, but did not permit the resident to leave when requested. Facility documentation, including the Reportable Event Record and investigative summaries, confirmed that the resident was involuntarily secluded in the dayroom. The facility's own policies on physical restraints and abuse prevention were not followed, as these policies prohibit involuntary seclusion and require the protection of residents' rights to freedom from such practices. The incident was reported, and the CNA involved was suspended following the event.
Failure to Assess and Monitor Resident After Fall Resulting in Hematoma
Penalty
Summary
The facility failed to assess and monitor for delayed complications after a resident fell from a geriatric chair in the day room and sustained a hematoma. The facility did not follow its own policy, which required observation for delayed complications for approximately 48 hours after a fall and documentation of findings in the medical record. There was no evidence in the resident's electronic medical record that a neurological assessment was completed or that the facility's fall assessment policy was implemented after the incident. The nursing progress notes lacked documentation of the resident's status following the fall, and the fall investigation packet did not include a neurological assessment. The resident involved had a history of traumatic brain injury, unspecified dementia with behavioral disturbances, and was severely impaired in decision making. After the fall, the resident exhibited a decline, including inability to swallow, drooling, decreased alertness, and bruising on the forehead, as observed by family members and staff. Interviews with staff and the medical director confirmed that the required assessments and monitoring were not documented or performed according to policy, and the director of nursing acknowledged the expectation for neurological assessments and documentation following such incidents.
Failure to Provide Adequate Supervision and Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident with a history of traumatic brain injury and severe dementia. The resident was dependent on staff for all activities of daily living and exhibited behavioral symptoms, including attempts to get out of bed, wheelchair, and geriatric chair. Despite multiple falls, including incidents where the resident sustained head injuries and required emergency treatment, the facility did not consistently document the root causes of the falls or update the care plan with new interventions after each event. Review of the facility's fall management policy indicated that staff were required to identify and implement interventions based on the resident's specific risks and to re-evaluate and modify interventions if falls recurred. However, after several falls, the care plan was not promptly updated with new or different interventions, and there was no evidence that increased monitoring was implemented as documented. Staff interviews revealed that supervision in the day room was insufficient, especially during mealtimes when one CNA was responsible for feeding and monitoring multiple high-fall-risk residents. Interviews with nursing staff and management confirmed that falls were discussed in meetings, but the interdisciplinary team did not consistently meet after each fall to re-evaluate interventions. The staff acknowledged that the interventions in place were not effective in preventing further falls for the resident, and there was a delay in increasing supervision or changing the approach despite repeated incidents.
Failure to Complete and Document Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct and document annual performance evaluations for all Certified Nursing Assistants (CNAs) as required. Review of personnel files for five CNAs revealed missing or outdated Performance Evaluations for Non-Exempt Employees (PENEE), with some files lacking evaluations for one or more years. Interviews with CNAs confirmed that annual reviews had not been completed in the past year or more. Additionally, the facility was unable to provide documentation or evidence of completed evaluations for the required periods. Further interviews with facility staff, including the Unit Manager, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources (HR) Director, revealed confusion regarding responsibility for completing the annual evaluations. The Unit Manager admitted to not completing the reviews in recent years and was unsure who was responsible. The DON stated that direct managers were supposed to complete the reviews, coordinated through HR, but the ADON and HR Director could not locate the necessary documentation or a performance review policy. This lack of clarity and documentation led to the identified deficiency.
Failure to Timely Report Abuse Allegations and Threats
Penalty
Summary
The facility failed to report allegations of abuse in a timely manner to the New Jersey Department of Health (NJDOH) and did not follow its own policy on abuse, neglect, exploitation, and misappropriation prevention. Specifically, an incident occurred in which one resident with dementia and a history of sexually inappropriate behaviors was observed by a CNA touching another resident, also with dementia and severely impaired cognition, inappropriately while both were fully clothed. The incident was reported to the nurse immediately, but the facility did not notify NJDOH until more than two hours after the event, which was not in accordance with federal requirements or facility policy. Documentation showed the incident occurred at 8:30 p.m. and was reported to NJDOH at 12:30 p.m. the following day. Additionally, another resident with schizophrenia and anxiety disorder was reported by an LPN to have thrown a knife into the hallway and continued to display verbal and physical threats toward staff and other residents. The facility could not provide evidence that these verbal threats were reported to NJDOH as required. Interviews with the DON confirmed that all allegations of abuse, including resident-to-resident abuse and threats, should be reported to NJDOH within two hours, but this was not consistently done. The Administrator also indicated a misunderstanding of what incidents were reportable, further contributing to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours on 08/29/23, as required by regulation. Review of the Nurse Staffing Report for that date showed no RN coverage for the required period. The Unit Secretary/Staffing Coordinator, responsible for scheduling, confirmed that RN coverage is typically arranged for eight hours daily but could not recall the reason for the lapse on the specified date. The Director of Nursing acknowledged the expectation for federal compliance. This deficiency had the potential to affect all 157 residents in the facility, as the absence of RN coverage was not in accordance with the facility's stated staffing policy and regulatory requirements.
Failure to Notify POA of Room Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) about a room change and did not document this notification in the progress notes, violating Mandatory Resident Rights. This deficiency was identified during a review of a resident who had been involved in a physical altercation with another resident, leading to a room change. The resident, who had a history of unspecified dementia, major depressive disorder, and hypertension, was assessed with a moderately impaired cognitive status. Despite the facility's protocol requiring family notification and documentation in such cases, there was no record of the POA being informed about the room change. Interviews with facility staff, including the Licensed Practical Nurse Unit Manager (LPN UM) and the Licensed Nursing Home Administrator (LNHA), confirmed that family notification should occur before a room change and be documented in the resident's progress notes. The Director of Nursing (DON) and LNHA emphasized the importance of this practice as a resident's right. However, the facility lacked a specific policy on room changes and notification, as revealed by the DON, who provided a document titled Subchapter 4: Mandatory Resident Rights, which outlines the resident's right to be notified of room changes.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement care plan interventions for a resident following a fall, as required by their policy. The resident, who was admitted with diagnoses including dementia, depression, and anxiety disorder, had a fall on September 8, 2024. Despite being identified as at risk for falls, the resident's care plan had not been updated with new interventions since January 29, 2024. This oversight was confirmed during interviews with the Licensed Practical Nurse Unit Manager (LPN UM) and the Director of Nursing (DON), who acknowledged that the care plan should have been updated within 24 to 48 hours after the incident. The facility's policy on comprehensive person-centered care plans mandates that care plans be revised when there is a significant change in a resident's condition, such as a fall. However, the care plan for the resident in question was not updated after the fall, and no new interventions were added. The DON confirmed that interventions are typically discussed during falls huddle meetings, but in this case, the care plan remained unchanged, contrary to the facility's policy and expectations.
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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