Wynwood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cinnaminson, New Jersey.
- Location
- 1700 Wynwood Drive, Cinnaminson, New Jersey 08077
- CMS Provider Number
- 315047
- Inspections on file
- 16
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Wynwood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident's shower documentation was inconsistent between the MAR and the POC system, with nurses and CNAs recording different information about when showers were given or refused. Staff interviews confirmed that both groups are responsible for ensuring accurate documentation, and facility policy requires records to be complete and accurate. This resulted in a failure to maintain accurate and complete medical records.
The facility failed to ensure safe smoking practices for residents, leading to inadequate supervision and improper handling of smoking materials. Residents were found with lighters, lighting each other's cigarettes, and resting lit cigarettes on smoking aprons, causing burn marks. Staff did not enforce the smoking policy, resulting in a deficiency identified by surveyors.
A facility failed to protect residents from abuse and did not adequately supervise a cognitively impaired resident with a history of wandering. This resident entered other residents' rooms, leading to physical altercations and inappropriate sexual behavior. Despite awareness of these issues, the facility did not implement effective interventions, resulting in an Immediate Jeopardy situation.
The facility failed to thoroughly investigate injuries and abuse allegations for three residents. One resident with cognitive impairment had an infected wound that worsened, leading to hospitalization and amputation, without proper documentation or physician communication. Another resident's sexual abuse allegation was delayed in investigation, lacking documentation and immediate reporting. A third resident's hip fracture was not thoroughly investigated, with missing documentation and insufficient staff interviews. The facility did not adhere to its policies on unexplained injuries and abuse reporting.
A resident with moderate cognitive impairment and total dependence on staff developed a stage IV pressure injury due to the facility's failure to implement and document necessary interventions. Despite being at risk, the resident's wound progressed to necrotic exposed bone, leading to a hospital transfer and right above-the-knee amputation. The facility did not adequately monitor or report the wound's condition, contributing to the resident's severe health decline.
The facility failed to provide timely incontinence and nail care for residents, as observed by surveyors. A resident reported staff refusal to assist with incontinence care, while another had untrimmed, dirty nails. Several residents were found soaked in urine, and a CNA confirmed that staff shortages led to residents being left soiled. Double incontinence briefs were used improperly, and residents reported being left soiled for extended periods. The facility's policy on daily living activities was not followed.
The facility failed to provide adequate staffing, resulting in residents being left soiled and without proper nail care. Staff shortages led to neglect in incontinence care, with residents found in unsanitary conditions. Additionally, the facility did not ensure staff competency in handling allegations of sexual abuse, as a resident's report of inappropriate touching was not properly documented or addressed.
The facility failed to provide adequate supervision and care for residents, leading to incidents of injury, inappropriate behavior, and insufficient incontinence care. A resident with wandering behaviors was not properly monitored, resulting in injury and inappropriate contact with another resident. The facility also failed to investigate adverse events thoroughly, such as a severe wound requiring amputation and a fracture. Inadequate staffing led to poor incontinence care, and the QAPI program did not address significant concerns, contributing to the facility's deficiencies.
The facility failed to implement effective QAPI systems, leading to deficiencies in managing a wandering resident who committed sexual abuse, inadequate supervision of smoking residents, and neglect in providing incontinence care. Additionally, adverse events like fractures were not properly documented or reviewed.
The facility failed to provide proper pharmaceutical services, as observed during a survey. Issues included an undated and unlabeled prescription medication in a medication room, expired supplies, and undated blood glucose test strip bottles on medication carts. Additionally, discrepancies were found in the administration log for Zolpidem 5mg, which was removed without a physician's order for a resident. The facility's policy on reporting and resolving discrepancies was not followed, raising concerns about accountability and reconciliation of controlled substances.
A resident with a history of confusion and exit-seeking behavior managed to break a window latch and exit the facility, despite having a wanderguard in place. The incident was witnessed by staff and reported internally but was not reported to the DOH as required. The Maintenance Director confirmed the resident exerted enough force to dislodge the window brackets. The LNHA considered the incident an anomaly and did not report it.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day period for a resident who elected hospice services. The resident, diagnosed with cancer and hypertension, began hospice care, but the SCSA was completed 20 days late, as confirmed by the MDS Coordinator.
A resident with hemiplegia reported that their resting hand splint had not been applied for months, despite a physician's order. Observations confirmed the splint was not in use, and staff inaccurately documented its application. The care plan and facility policy on range of motion were not followed, as the splint was found unused in the resident's dresser.
A resident receiving tube feeding expressed a desire for oral feeding, having passed a feeding test. However, the facility failed to document or follow up on this request, maintaining an NPO status without consulting the physician or reviewing swallowing studies. The RD confirmed the resident's history of aspiration and increased tube feeding for wound healing but did not document discussions with the interdisciplinary team or follow up on the resident's preferences, leading to a deficiency.
A resident with congestive heart failure and dementia was prescribed Seroquel for a mood disorder, despite no marked behaviors or appropriate indications for the drug. The facility failed to attempt a gradual dose reduction (GDR) annually, as required by policy, citing contraindications without clear evidence. The care plan was outdated, and staff interviews revealed reliance on psychiatric evaluations that did not document previous GDR attempts.
An LPN in a facility failed to perform hand hygiene during medication administration, risking infection spread. The LPN did not wash hands after removing PPE and before handling medications, despite facility protocols requiring hand hygiene. The facility's Infection Preventionist and policy emphasized the importance of hand hygiene, which was not followed, leading to a deficiency.
Inaccurate and Incomplete Shower Documentation for Resident
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for one resident regarding documentation of activities of daily living (ADL) care, specifically showers. A review of the medication administration record (MAR) for the resident showed that nurses documented showers on multiple dates throughout the month. However, a review of the Certified Nursing Assistants' (CNA) documentation in the point of care (POC) system indicated discrepancies, including a recorded refusal on one date and showers given on two other dates, with the remaining dates marked as not applicable. Interviews with facility staff, including the unit manager, assistant director of nursing (ADON), a CNA, and an LPN, confirmed that both nurses and CNAs are responsible for documenting showers and that the POC and MAR documentation should match. The facility's policy requires that documentation in the medical record be objective, complete, and accurate. The inconsistency between the MAR and POC documentation for the resident's showers demonstrated a failure to maintain accurate and complete records in accordance with accepted professional standards.
Inadequate Supervision and Unsafe Smoking Practices
Penalty
Summary
The facility failed to ensure a consistent and safe smoking process for 17 residents identified as smokers. This deficiency was observed through inadequate supervision and monitoring of residents who required assistance while smoking. Specifically, residents were found to be in possession of lighting materials, which they used to light other residents' cigarettes, contrary to the facility's smoking policy. Additionally, residents were observed resting lit cigarettes on their smoking aprons, causing burn marks, and disposing of cigarette ashes improperly. Resident #29, who had contractures and required close supervision while smoking, was observed without adequate supervision. The resident's cigarette was lit by another resident, and the resident was seen resting the lit cigarette on a charred smoking apron. The staff failed to intervene appropriately, and the ashes from the smoking apron were improperly disposed of over the patio and into the bushes. This lack of supervision and improper handling of smoking materials posed a risk of serious injury to the residents. The facility's smoking policy was not effectively communicated or enforced among staff and residents. Staff members, including the Activity Director and CNAs, were observed allowing residents to retain lighters and light each other's cigarettes. The facility's failure to adhere to its own smoking policy and ensure proper supervision and safety measures for residents who smoke led to the identification of this deficiency by the surveyors.
Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse and did not ensure adequate supervision for a severely cognitively impaired resident with a history of wandering. This resident, identified as Resident #84, had been documented as wandering into other residents' rooms since February, leading to incidents of physical altercations and inappropriate sexual behavior. On one occasion, Resident #84 was shoved by another resident, resulting in a fall and a skin tear. Additionally, Resident #84 was reported to have inappropriately touched another resident, Resident #94, in a sexual manner, which was not adequately addressed by the facility. The facility's inaction in addressing Resident #84's wandering behavior and inappropriate conduct was evident in the lack of timely interventions and documentation. Despite multiple reports and observations of Resident #84's behavior, including urinating in inappropriate places and entering other residents' rooms, the facility did not implement effective measures to prevent these incidents. The care plan for Resident #84 included interventions such as applying a wander guard and redirecting the resident, but these were not effectively executed, leading to repeated incidents. Interviews with staff and residents revealed that the facility was aware of Resident #84's behavior but failed to take appropriate action. The Director of Nursing and other staff members were not fully informed or did not act on the reports of abuse and wandering. The facility's investigation into the incidents was incomplete, lacking statements from key witnesses and failing to address the full extent of the reported abuse. This lack of action and oversight resulted in an Immediate Jeopardy situation, placing all residents at risk of harm.
Removal Plan
- Resident #84 was placed on a one to one and Resident #84 was discharged from the facility.
- The facility identified that all residents have the potential to be affected. All alert and oriented residents were interviewed by the Social Worker and all remaining cognitively impaired residents had full body skin checks completed to rule out abuse that could have occurred by a resident wandering into their rooms.
- The Director of Nursing and designee began in-servicing all facility staff in every department on the Abuse-Neglect-Exploitation Policy, implementing effective interventions to prevent all residents from abuse and neglect, implementing effective interventions to prevent residents who wander from entering other residents' rooms, protecting residents who wander from being abused, and implementing effective interventions after a resident abuse allegation. This in-servicing will continue until all staff that work in the center are in-serviced. Staff will be in-serviced prior to starting their assignment.
- The LNHA or Director of Nursing will conduct audits on all residents with wandering behaviors by direct observation, resident interviews, and staff interviews to ensure that residents who have the potential to wander into other residents' rooms have effective interventions in place to prevent them from wandering into other residents' rooms and that abuse has not occurred. These audits will be weekly for four weeks, then bi-weekly x four weeks, and then monthly x one month. The Nursing Home Administrator or Director of Nursing will interview five alert and oriented residents regarding abuse. These audits will be weekly for four weeks, then bi-weekly x four weeks, and then monthly x one month. Findings of all audits will be reviewed by the Quality Assurance Committee at the monthly QAPI meetings x three months.
Deficiencies in Investigation of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into injuries of unknown origin and allegations of abuse, leading to deficiencies in care for three residents. One resident, who had moderate cognitive impairment and was dependent on staff for all activities of daily living, was found with an infected wound that required hospitalization and was later diagnosed with osteomyelitis. Despite the worsening condition of the wound, there was no documentation of wound assessments or communication with the physician. The resident was later found with exposed bone and fractures, necessitating hospitalization and eventual amputation. The facility did not document or investigate the wound's progression adequately, and the Director of Nursing (DON) was unable to provide additional information or documentation. Another resident reported an allegation of sexual abuse to an LPN, but the facility delayed the investigation until several days later. The incident was not documented in the resident's medical record, and the investigation lacked a statement from the LPN who initially heard the allegation. The DON and the Social Worker were not fully aware of the details of the allegation, and the investigation did not include all necessary documentation or interviews with involved parties. The facility's policy on abuse reporting was not followed, as the allegation was not reported immediately to the appropriate authorities. A third resident, who had a history of being combative with care, reported new onset pain in the right hip/leg and was later diagnosed with a fracture. The facility's investigation into the injury was incomplete, with missing dates and insufficient documentation of staff interviews. The DON confirmed that the investigation did not go back 72 hours as required, and there was no evidence of a thorough investigation to rule out abuse or neglect. The facility's policy on unexplained injuries was not adhered to, as the investigation lacked critical information and documentation.
Failure to Prevent and Manage Pressure Ulcer Leads to Amputation
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development and worsening of a stage IV pressure injury for a resident. The resident, who had moderate cognitive impairment and was totally dependent on staff for all activities of daily living, was admitted with several diagnoses, including dementia and failure to thrive. Despite being identified as at risk for pressure injuries, the facility did not adequately monitor or document the resident's wound condition, leading to a severe deterioration of the wound. The resident initially had a skin tear on the left lower leg, which was documented but not properly managed, resulting in the wound progressing to necrotic exposed bone. The facility's records showed that skin checks and wound care were supposedly completed, but there was a lack of narrative documentation regarding the wound's condition. The wound was not reported as infected until a nurse practitioner identified it during wound rounds, and the facility failed to notify the physician or wound care team of the infection. The resident was eventually transferred to the hospital, where the wound was diagnosed as infected with osteomyelitis, leading to a right above-the-knee amputation. The facility's failure to document and report changes in the wound condition, as well as to follow their own policy on unexplained injuries, contributed to the resident's severe health decline. The Director of Nursing and Licensed Nursing Home Administrator were unable to provide additional information or rationale for the lack of documentation and intervention.
Inadequate Incontinence and Nail Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide routine and appropriate incontinence and nail care for dependent residents, as evidenced by multiple observations and interviews. A surveyor noted a strong odor of feces in a resident's room, and the resident reported that staff refused to assist with incontinence care. Another resident was observed with long, jagged fingernails coated with a black substance, despite their care plan indicating regular nail maintenance. During an incontinence care tour, several residents were found soaked in urine, and a CNA confirmed that residents were often left soiled due to staff shortages. Further investigation revealed that residents were sometimes left in double incontinence briefs, which were not changed in a timely manner. One resident was found covered in feces and urine, wearing two saturated briefs, and the CNA admitted that this was not the first occurrence. The facility had previously provided education against using double briefs, but staff shortages during certain shifts led to this practice. Interviews with CNAs confirmed that the facility was understaffed, with only two CNAs caring for 45 residents during the night shift, contributing to inadequate care. Additional interviews with residents and their representatives highlighted ongoing issues with incontinence care. One resident reported being left soiled for hours and stated that incontinence care was not provided during the night shift. Another resident's representative mentioned that the resident was left in a chair for an extended period without being changed. The facility's policy on Activities of Daily Living was reviewed, which stated that residents should receive necessary services to maintain hygiene, but the facility failed to adhere to this policy.
Inadequate Staffing and Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient and competent staff to meet the needs of residents, resulting in inadequate incontinence care and nail care. Several residents were found soiled with urine and feces, indicating a lack of timely care. For instance, one resident was observed covered with feces and urine, with saturated double incontinent briefs, bed protector, and sheets. The CNA admitted that due to staff shortages, residents were often left soiled. Another resident reported being left soiled from one night until the next evening, and despite notifying the DON and Administrator, the issue persisted. Additionally, the facility failed to provide proper nail care for a resident who was dependent on staff for ADLs. The resident was observed with overgrown, jagged fingernails with black substances underneath, indicating neglect in personal hygiene care. This further highlights the facility's inability to meet the basic care needs of its residents due to insufficient staffing. The facility also failed to ensure staff competency in handling and documenting allegations of sexual abuse. A resident reported an incident of inappropriate touching by another resident, which was not properly documented or addressed by the LPN. The resident's roommate corroborated the account, stating that the perpetrator had been wandering into their room for months, and despite reporting this to staff, no action was taken. This lack of response and documentation of serious allegations further underscores the facility's deficiencies in staff training and resident safety protocols.
Deficiencies in Resident Supervision and Care
Penalty
Summary
The administrator of the facility failed to ensure effective supervision and care for residents, leading to several deficiencies. A resident with known wandering behaviors was not adequately supervised, resulting in an incident where the resident was injured after being shoved by another resident. Additionally, this resident was involved in an inappropriate sexual incident with another resident, which was not promptly investigated, creating an Immediate Jeopardy situation. The facility also failed to thoroughly investigate adverse events, such as a resident developing a severe wound that progressed to exposed bone and required amputation, and another resident experiencing a fracture that was not promptly addressed. The facility did not maintain adequate documentation and communication regarding wound care, leading to a resident's wound worsening significantly without proper intervention. There was also a failure to report an elopement incident to the Department of Health, as required. Staffing levels were insufficient to meet the needs of residents, resulting in inadequate incontinence care for multiple residents, with some residents being left soiled for extended periods. This lack of care was exacerbated by the practice of double briefing residents, which was against facility policy. The Quality Assurance and Performance Improvement (QAPI) program was not effectively implemented, as it failed to identify and address significant concerns such as resident safety, supervision, and care deficiencies. The program did not include a review of significant or reportable events, and issues such as wandering, incontinence care, and smoking safety were not brought to the QAPI committee's attention. The administrator's lack of awareness and action regarding these issues contributed to the facility's failure to provide adequate care and supervision for its residents.
Deficiencies in Resident Care and Safety Protocols
Penalty
Summary
The facility failed to implement effective systems and procedures for feedback to identify areas for Quality Assurance and Performance Improvement (QAPI). This deficiency was evident in several areas, including the management of a resident known to wander, who had a history of being injured by another resident and subsequently sexually abused another resident. Despite repeated reports from the affected resident and their roommate, the facility did not take adequate measures to address the wandering behavior, leading to a serious incident of sexual abuse. Additionally, the facility did not ensure proper supervision and safety measures for residents who smoked. Observations revealed that residents were lighting each other's cigarettes and handling lighting materials unsupervised, which posed a significant safety risk. Staff were also observed disposing of cigarette waste inappropriately, further indicating a lack of effective supervision and safety protocols for smoking residents. The facility also failed to provide appropriate incontinence and daily living care for several residents. Surveyors noted strong odors of feces and urine in resident rooms, indicating neglect in incontinence care. Residents reported that staff refused to assist with their care needs, and observations confirmed that residents were left soiled due to staffing shortages. Furthermore, the facility did not adequately document or investigate adverse events, such as fractures requiring hospitalization, which were not reviewed or addressed in the QAPI meetings.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as observed during a survey. In one of the medication rooms, an undated and unlabeled prescription medication, Lidocaine Prilocaine 2.5%/2.5% Cream, was found among over-the-counter medications. The Licensed Practical Nurse (LPN) acknowledged that prescription medications should be labeled, even if intended for backup use, and took steps to remove the item and inform the Unit Manager (UM). Additionally, expired supplies, including syringes and needles, were found in the medication room, which the LPN also removed and reported to the UM. Further deficiencies were noted in the medication carts. In the North wing, an opened blood glucose test strip bottle was found without a date, which is necessary to track its six-month usability period. The LPN responsible for the cart admitted to opening the bottle the previous night but forgetting to date it. Another LPN on the same wing also found an undated test strip bottle and confirmed it should have been dated. Both LPNs took action to discard the undated bottles and inform their UM. A significant issue was identified with the electronic back-up machine (EBM) for controlled substances. The surveyor found discrepancies in the administration log for Zolpidem 5mg, which was removed without a corresponding physician's order for Resident #27. The Director of Nursing (DON) acknowledged the discrepancy and noted that it was not identified until the surveyor's inspection, despite the presence of a UM or Supervisor over the weekend. The facility's policy requires immediate reporting and resolution of such discrepancies, but this was not adhered to, leading to concerns about accountability and reconciliation of controlled substances.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who was confused, wandered, and was identified as being exit-seeking. The resident, who had a history of alcohol dependence with withdrawal delirium, difficulty walking, and schizoaffective disorder, managed to break a latch on a window and exited the building. This incident was witnessed by a nurse and a certified nurse aide, who followed the resident outside and brought them back inside. Despite the incident being reported internally to the Director of Nursing (DON) and the Administrator, it was not reported to the Department of Health (DOH) as required. The resident had been assessed for confusion, wandering, and exit-seeking behaviors, and a wanderguard was in place to prevent elopement. However, the wanderguard did not prevent the resident from exiting through the window. The Maintenance Director later confirmed that the resident had exerted enough force to pull the screws out of the window brackets, allowing the window to open fully. The Licensed Nursing Home Administrator (LNHA) stated that they did not believe the incident met the reportable requirement, considering it an anomaly.
Failure to Timely Complete SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who elected hospice benefits, as required by the Center for Medicare/Medicaid Services (CMS) guidelines. The deficiency was identified for a resident with diagnoses including cancer and hypertension, who began receiving hospice services on March 26, 2024. According to the CMS Resident Assessment Instrument (RAI) 3.0 Manual, an SCSA must be performed within 14 days of a resident's election of hospice services to ensure a coordinated plan of care between the hospice and the nursing home. In this case, the Assessment Reference Date (ARD) for the SCSA was set for April 6, 2024, but the assessment was not completed until April 29, 2024, which was 20 days late. The MDS Coordinator, who confirmed the timeline, acknowledged that the SCSA should have been completed within the 14-day window following the hospice election. This oversight resulted in a failure to adhere to the required timeline for conducting the SCSA, as outlined by CMS regulations.
Failure to Apply Resting Hand Splint as Ordered
Penalty
Summary
The facility failed to follow a physician's order for the application of a resting hand splint to the right hand of a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, reported concerns about the lack of physical therapy and assistance with range of motion (ROM) exercises to prevent further contractures in the right hand. Despite the physician's order dated January 24, 2024, for the application of the resting hand splint in the morning and removal at night, the resident informed the surveyor that the splint had not been applied for months. Observations by the surveyor confirmed that the splint was not in use, and the Treatment Administration Record (TAR) was inaccurately initialed by staff, indicating the splint had been applied when it had not. The resident's care plan, which included the use of the resting hand splint as an intervention, was not adhered to, and there was no documentation in the progress notes from May to July 2024 indicating any refusal by the resident to wear the splint. The facility's policy on range of motion, which requires interventions to maintain and improve ROM, was not followed. The surveyor's review of the resident's electronic medical record and discussions with the resident revealed a lack of compliance with the prescribed care, as the splint was found in the resident's dresser, unused, during the surveyor's visit.
Failure to Address Resident's Nutritional Preferences and Follow-Up
Penalty
Summary
The facility failed to ensure comprehensive follow-up on a resident's nutritional goals and preferences, particularly for a resident receiving nutrition via a tube. The deficiency was identified during a surveyor's interview with the resident, who expressed a desire to receive food orally, stating that they had passed a feeding test conducted by the Veteran's Administration. Despite this, the resident's care plan continued to list them as NPO (nothing by mouth), and there was no documented evidence of follow-up on the resident's request for pleasure feeding. The Registered Dietitian (RD) at the facility confirmed that the resident had a history of aspiration and was agreeable to an increase in tube feeding to aid wound healing. However, the RD did not communicate with the physician regarding the resident's request for oral feeding, nor was there documentation of discussions with the interdisciplinary team about the resident's previous pleasure feedings. Additionally, the RD did not review any available swallowing studies, which were recommended by the Veteran's Administration but had not been scheduled. The facility's Nutritional Management Policy requires that nutritional recommendations be made based on the resident's preferences and clinical condition, followed up with the physician for orders. However, the facility was unable to provide documented evidence of follow-up on the resident's wishes or the scheduling of a swallowing study. This lack of documentation and follow-up led to the deficiency noted in the survey report.
Failure to Attempt Gradual Dose Reduction of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) of an antipsychotic medication, Seroquel (quetiapine), was attempted annually for a resident with congestive heart failure and dementia. The resident, who had no marked behaviors or history of schizophrenia or bipolar disorder, was receiving Seroquel for a mood disorder, which is not a manufacturer's indication for the drug. Despite the absence of behaviors warranting the medication, the facility did not attempt a GDR, citing contraindications without clear evidence of necessity. The resident's care plan, last updated in 2022, included interventions for anxiety, depression, and mood disorder, with a note that the family was not interested in a dose reduction. However, the care plan was not revised to reflect any changes or considerations for a GDR. The facility's policy required an annual GDR unless clinically contraindicated, but this was not adhered to, as the resident continued to receive the medication without a documented attempt at dose reduction. Interviews with facility staff, including the Certified Consultant Pharmacist (CCP) and the Advanced Practice Nurse-Certified (APN-C), revealed a reliance on psychiatric evaluations that deemed a GDR contraindicated. However, these evaluations did not provide specific dates or evidence of previous GDR attempts. The facility's failure to attempt a GDR and the lack of clear documentation and rationale for continued use of Seroquel without marked behaviors or appropriate indications contributed to the identified deficiency.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to minimize the potential spread of infection during medication administration, as observed by a surveyor. On the morning of June 28, 2024, a Licensed Practical Nurse (LPN) was observed preparing medications for a resident on the North Wing. The LPN donned gloves and a PPE gown before entering the resident's room to check blood sugar levels. After exiting the room, the LPN removed the gloves and gown but did not perform hand hygiene before retrieving a syringe and administering insulin to the resident. This lack of hand hygiene was repeated when the LPN prepared and administered medication to another resident, failing to wash hands after removing soiled PPE and before handling medications. The LPN was observed not performing hand hygiene at several critical points during the medication pass, including after removing PPE and before handling medications and the computer keyboard. The LPN admitted to the surveyor that she thought hand hygiene was only necessary when moving from one resident to another, acknowledging the risk of infection spread due to her actions. The Unit Manager and Director of Nursing confirmed that staff were required to perform hand hygiene before and after medication administration, and the facility's policy emphasized the importance of hand hygiene in preventing infection spread. The facility's Infection Preventionist reiterated the expectation for nursing staff to use Alcohol-Based Hand Rub (ABHR) between residents and to wash hands before donning and after doffing gloves. The facility's hand hygiene policy, last revised in May 2024, clearly stated that gloves do not replace hand hygiene and emphasized the need for proper hand hygiene procedures to prevent infection spread. The surveyor's observations and interviews with staff highlighted a failure to adhere to these protocols, resulting in a deficiency in infection prevention and control.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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