Willow Springs Rehabilitation And Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Brick, New Jersey.
- Location
- 1049 Burnt Tavern Road, Brick, New Jersey 08724
- CMS Provider Number
- 315213
- Inspections on file
- 21
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Willow Springs Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
A facility failed to administer medications according to standards when an LPN allegedly left Tramadol at a resident's bedside. The resident, who was cognitively intact and had multiple health issues, requested a CNA to hand them the medication after a shower. The facility's investigation concluded the LPN left the medication, although the LPN did not recall doing so. The facility's policy was not followed, as medications should not be left unattended at a resident's bedside.
The facility failed to meet the required CNA staffing ratios for 13 out of 14-day shifts, as mandated by New Jersey law. During the review period, the number of CNAs consistently fell short of the required number needed to care for the residents, indicating a systemic issue in maintaining staffing levels.
A resident with severe cognitive impairment experienced an unwitnessed fall, resulting in a delayed assessment and a right hip fracture. The LPN failed to follow protocol by not notifying an RN or documenting the incident. Additionally, another resident was found with a Wander Bracelet without a physician order or care plan documentation, contrary to facility policy. Interviews confirmed lapses in protocol adherence.
The facility consistently failed to maintain adequate CNA staffing levels, as required by New Jersey Department of Health guidelines, across several months. Interviews revealed that staff often had to manage more residents than recommended, and the facility struggled to meet staffing ratios, particularly during weekends. Despite efforts by the DON and other staff to address call-outs, the facility frequently fell short of the required staffing levels.
A facility failed to administer medications and enteral feedings within the required time frame for a resident with dysphagia and other conditions. The resident's treatments, including Apixaban and Metoprolol, were frequently delayed beyond the facility's policy of one-hour administration window. Staff interviews revealed a lack of adherence to procedures, and the Director of Nursing could not explain the delays, indicating oversight and documentation issues.
A facility failed to maintain and label respiratory equipment for a resident with respiratory failure and asthma. Observations revealed unlabeled and undated oxygen tubing and storage bags, despite physician orders and facility protocols requiring weekly changes and proper labeling. Interviews with staff confirmed the protocol, but it was not followed.
A resident receiving Seroquel for behavioral disturbances related to dementia was not monitored for target behaviors or side effects, contrary to facility policy. Despite the resident's severely impaired cognition and history of care rejection, there were no documented orders for such monitoring until prompted by a surveyor. The nursing staff and administration acknowledged the oversight, which led to the deficiency.
A resident's privacy was compromised during an incontinence care check when an LPN/UM failed to pull the privacy curtain. The resident, diagnosed with Diabetes, Depression, and Unspecified Epilepsy, was observed in bed with the head elevated. The LPN/UM could not explain why the privacy curtain was not used, leading to a deficiency in maintaining personal privacy.
The facility failed to maintain a clean and homelike environment on the Applewood Unit, with persistent strong odors of urine and feces noted by surveyors. Despite housekeeping efforts, the odors were attributed to dirty linens, which were picked up every 2 to 3 hours. Staff interviews confirmed the issue, and the facility's cleaning policy was reviewed.
A resident with severe cognitive impairment was mistakenly given an antibiotic not prescribed to them, due to a failure in following medication administration protocols. The facility's policy requires verification of the resident's identity and medication checks, but these were not adhered to, resulting in the error.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to acceptable standards of nursing practice for one resident. The incident involved a Licensed Practical Nurse (LPN) allegedly leaving medications at the bedside of a resident who was cognitively intact and had multiple diagnoses, including cellulitis, hypertension, heart failure, depression, and acute kidney failure. The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The medication in question was Tramadol, prescribed as needed for pain. On the day of the incident, a Certified Nursing Assistant (CNA) informed the resident that their medication was on the bedside table after the resident returned from a shower. The resident requested the CNA to hand them the medication, which the CNA did. The facility's investigation concluded that the LPN left the medication at the bedside, although the LPN did not recall doing so. The Assistant Director of Nursing (ADON) confirmed that the expectation was for nurses to ensure residents took their medications before leaving the room, as leaving medications unattended could pose a risk. Interviews with the Assistant Director of Nursing, the LPN, and the Director of Nursing (DON) revealed that the facility's policy was not followed, as medications should not be left unattended at a resident's bedside. The DON stated that the investigation could not confirm what medication was left at the bedside, and the resident was transferred to the hospital shortly after the incident. The facility's policy required that medications be administered in accordance with prescriber's orders and that nurses should return to administer medications if a resident is not available during the initial medication pass.
Plan Of Correction
All residents had potential to be affected. 1. Resident #1 no longer resides at the facility. The DON re-educated LPN #1 on 11.25.24 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. No further variances were noted. CNA#1 on 11.25.24 was educated to immediately notify the supervisor if medications are noted at the bedside. 2. Rounds were made on current residents on 12.3.24 by the DON with no medications noted at resident beside. On-going rounds continued. 3. Licensed Nurses were re-educated on 11.25.2024 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. Facility staff were educated on 11.25.2024 on notifying the nursing supervisor immediately if medications are noted at bedside. 4. The Director of Nurses/designee will conduct 3 rounds on each floor weekly to validate no medications are left at the bedside. Variances will be addressed. In addition, 3 medication pass competencies will be completed to validate that the medication administration process is in compliance with professional standards. These audits will be conducted weekly x 4 weeks, then monthly x 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates a minimum of one Certified Nurse Aide (CNA) for every eight residents during the day shift. This deficiency was identified during a review of staffing records for the period from November 24, 2024, to December 7, 2024. During this time, the facility was consistently understaffed on 13 out of 14-day shifts, with the number of CNAs falling short of the required number needed to adequately care for the residents. For instance, on November 24, 2024, the facility had 14 CNAs for 143 residents, whereas at least 18 CNAs were required. Similar deficiencies were noted on other days, such as November 25, 2024, with 13 CNAs for 143 residents, and December 2, 2024, with 12 CNAs for 134 residents. This pattern of insufficient staffing was observed throughout the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels, which had the potential to affect all residents in the facility.
Plan Of Correction
No residents were identified. Residents of the facility have the potential to be affected. The Director of Nursing, Staffing Coordinator, and Administrator will meet daily during the week to review recruitment efforts, staffing for the next day, and staffing for the upcoming week. The facility has developed a Culture Committee focused on recruitment and retention of staff along with customer service and the employee experience. The facility has implemented the Care Champion Program to mentor new employees, which has been proven to raise retention rates. The facility participates in an interdisciplinary Quality Care Resource call to review open positions, recruitment tactics, and changes to improve outcomes. The facility has implemented a multifaceted approach for recruitment and retention of employees, including job fairs, flexible scheduling, increased utilization of PRN staff, implementation of OnShift, multimedia advertisements, partnership with schools, sign-on bonuses, referral bonuses, pick-up shift bonuses, a boomerang campaign to rehire staff that have resigned, rate adjustments, benefit adjustments, contract staff utilization, and text message campaigns. An ongoing staffing analysis is reviewed by shift to determine the amount of direct care staff and licensed nursing staff required by regulatory requirements to meet the care needs of the residents based on the daily census. This analysis is used to ensure additional staff are scheduled to cover call outs. Vacancy and retention rates are analyzed weekly by the DON and Staffing Coordinator to identify additional hiring to ensure care needs and regulatory requirements are met. The staffing schedule was reviewed by the DON, DON consultant, Administrator, and the Staffing Coordinator to identify by shift the required number of direct care and licensed nursing staff based on current and projected census. Innovative scheduling is being used to ensure adequate licensed nursing staff meet the regulatory requirements and resident care needs based on acuities. The facility has agreements with CNA programs/schools to utilize the facility as a clinical site for their students. A QAPI root cause analysis was conducted, including direct care and licensed nurses from all shifts, to identify internal and external barriers to attract new staff. Assignments were reviewed to assure residents with high acuities are equally distributed on direct care staff assignments. Performance evaluations are completed, and targeted education is provided to staff to ensure they feel competent in their role to enhance job satisfaction. Job applications are readily available at the reception desk to ensure individuals looking for a job can be provided with an application immediately, and an interview can be coordinated that same day to expedite hiring. The administrator/designee will review the minutes from the resident council to determine whether any concerns regarding care and services are identified monthly for two months and then quarterly. The results of Resident Council minutes, as well as recruitment data, will be reviewed by the Administrator or designee at the quarterly QAPI meeting. These audits will be conducted weekly for 4 weeks, then monthly for 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.
Deficiencies in Fall Assessment and Elopement Prevention
Penalty
Summary
The facility failed to assess a resident in a timely manner after an unwitnessed fall, which resulted in a significant injury. Resident #534, who had severe cognitive impairment and was independent with walking, fell in front of the nursing station. The fall was reported by a CNA to an LPN, who did not follow the facility's policy for unwitnessed falls. The LPN failed to notify an RN supervisor for a full assessment, did not document the incident, and did not inform the resident's family or primary medical doctor. As a result, the resident was not properly assessed until the following day, when severe pain and a right hip fracture were identified, leading to hospitalization. Additionally, the facility did not ensure proper documentation and physician orders for the use of a safety device intended to prevent elopement. Resident #107, who had severe cognitive impairment and was at risk for elopement, was observed with a Wander Bracelet. However, there was no physician order or care plan documentation for the device. The facility's policy required a physician order and care plan update when a Wander Bracelet was recommended, but this was not followed. Interviews with facility staff revealed a lack of adherence to established protocols for both fall assessment and elopement prevention. The DON confirmed that the LPN should have notified an RN for assessment and reported the fall immediately. Similarly, the absence of a physician order and care plan for the Wander Bracelet was acknowledged by the LPN/UM, who indicated the need to address the oversight.
Consistent Understaffing in Nursing Facility
Penalty
Summary
The facility failed to maintain sufficient nursing staff on a 24-hour basis to meet the needs of its residents, as evidenced by multiple instances of understaffing across several months. The Nurse Staffing Reports revealed consistent deficiencies in the number of Certified Nursing Assistants (CNAs) available during day shifts, with the facility often falling short of the required staffing ratios as per New Jersey Department of Health guidelines. For example, on numerous occasions, the facility had significantly fewer CNAs than the required number, impacting the care provided to residents. Interviews with staff and residents highlighted the impact of this understaffing. A resident mentioned that the facility seemed short-staffed on weekends, while a CNA reported having a heavy workload, often caring for more residents than the recommended ratio. The Director of Human Resources acknowledged the challenge of meeting staffing requirements, especially when faced with call-outs, and admitted that the facility did not always meet the staffing ratio requirements. The Director of Nursing (DON) confirmed the staffing patterns and ratios used by the facility, which were intended to align with state guidelines. However, the DON also noted that despite efforts to meet these requirements, the facility struggled to maintain adequate staffing levels, particularly during weekends. The DON and other staff members, including the Assistant Director of Nursing and Unit Managers, were expected to assist when necessary, but the facility still faced challenges in maintaining the required staffing levels consistently.
Failure to Administer Medications and Enteral Feedings Timely
Penalty
Summary
The facility failed to ensure that medications, treatments, and enteral feedings were administered within the required time frame, consistent with professional standards and facility policy. This deficiency was identified for one resident who required enteral feeding and various medications administered via a PEG tube. The resident's medical history included conditions such as retention of urine, symbolic dysfunctions, and dysphagia, necessitating careful and timely administration of prescribed treatments and feedings. The Medication Administration Audit Report revealed multiple instances where medications and enteral feedings were administered two or more hours late. Specific medications such as Apixaban, Metoprolol, and Phos-NaK, among others, were frequently delayed. The facility's policy required medications to be administered within one hour of the prescribed time, yet this was not adhered to, and there was no documentation in the progress notes to explain the delays or notify the physician and family. Interviews with facility staff, including LPNs and the Director of Nursing, highlighted a lack of adherence to the facility's policies and procedures. Staff acknowledged the importance of timely administration but failed to provide reasons for the delays. The Director of Nursing was unable to explain why the medications and feedings were documented as late, indicating a gap in oversight and documentation practices. The facility's policies on enteral nutrition and medication administration emphasized the need for timely and accurate administration, which was not followed in this case.
Failure to Maintain and Label Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary care and maintenance of respiratory equipment for a resident with respiratory needs. During multiple observations over several days, the surveyor noted that the oxygen tubing and the storage bag for a resident were not labeled or dated as required. The resident had been admitted with diagnoses including respiratory failure with hypoxia and asthma, and there was a physician's order for continuous oxygen administration at 2 liters per minute via nasal cannula. The order also specified that the oxygen tubing, humidifier, and filter should be changed weekly and labeled accordingly. Interviews with facility staff, including an LPN, the Infection Preventionist, and the Director of Nursing, confirmed that the facility's protocol required weekly changes of respiratory equipment on the Friday night shift, with documentation in the electronic record and proper labeling. However, the observations indicated that these procedures were not followed, as the equipment was neither labeled nor dated. The facility's policy on oxygen administration, revised in 2010, also emphasized the need to verify physician orders and follow protocol for oxygen administration, which was not adhered to in this case.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that specific target behaviors were monitored prior to the administration of an anti-psychotic medication for a resident who had been receiving Seroquel since May 2024. The resident, who was admitted with diagnoses including heart failure, chronic kidney disease, restlessness, agitation, and dementia, had a severely impaired cognition score and exhibited behaviors of care rejection. Despite these conditions, there was no documented order to monitor the behaviors associated with the use of Seroquel or the potential side effects of the medication. Observations and interviews revealed that the nursing staff, including LPNs and the Unit Manager, were not documenting the presence or absence of behaviors or side effects related to the use of Seroquel. The staff acknowledged that there should have been orders for monitoring these aspects, but they were not in place until the surveyor's inquiry prompted a new order. The facility's policy required monitoring for target behaviors and side effects, but this was not adhered to in the case of the resident. The Assistant Director of Nursing confirmed that monitoring should have been in place from the initiation of the Seroquel order to ensure the resident was not taking medications unnecessarily or experiencing unnecessary side effects. The Director of Nursing also acknowledged the lack of orders for behavior and side effect monitoring, which was contrary to the facility's policy and regulatory requirements. This oversight led to the deficiency identified by the surveyors.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during an incontinence care check. This deficiency was identified during a surveyor's observation of a Licensed Practical Nurse/Unit Manager (LPN/UM) who did not pull the privacy curtain while attending to a resident. The resident, who was in bed with the head elevated at 45 degrees, was admitted with diagnoses including Diabetes, Depression, and Unspecified Epilepsy. During an interview, the LPN/UM was unable to provide a reason for not pulling the privacy curtain, which compromised the resident's privacy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the Applewood Unit, as evidenced by persistent strong odors of urine and feces. During a survey conducted on two separate days, the surveyor noted a strong urine odor upon entering the unit, despite the presence of housekeeping staff actively cleaning. On one occasion, a strong feces odor was also detected, although no dirty linens were observed on the cart, and incontinence care was not being provided at that time. Interviews with staff revealed that the Licensed Practical Nurse/Unit Manager (LPN/UM) acknowledged the presence of the urine odor and attributed it to dirty linens, which were reportedly picked up by laundry every 2 to 3 hours. The LPN/UM stated that the unit was cleaned in the morning, with floors and rooms cleaned twice per shift. The Housekeeping Director (HD) confirmed that rooms were cleaned twice a day and that Certified Nursing Assistants (CNAs) were responsible for changing linens. The HD was made aware of the odor issue by a nurse. The facility's policy on cleaning schedules was reviewed, indicating that cleaning schedules are developed to maintain a safe, clean, and comfortable environment.
Medication Error Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident #19. The resident, who was severely cognitively impaired with a BIMS score of 0/15, was mistakenly administered an antibiotic that was not prescribed to them. This error occurred during a medication pass on the Applewood Unit, as documented in an incident report dated November 1, 2022. The resident's medical history included major depressive disorder, constipation, unspecified dementia, abnormal gait, and dysphagia, and they had no known allergies. The error was acknowledged by the staff member involved, who stated that they administered the wrong medication and were subsequently educated on the seven rights of medication administration. The facility's policy, revised in April 2019, emphasizes the importance of verifying the resident's identity and checking the medication label three times to ensure the correct administration. Despite these guidelines, the error occurred, and the surveyor was unable to interview the nurse responsible for the mistake. The Regional Director of Specialty Program highlighted the expectation for nurses to follow physician orders and regulations during medication administration.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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