Citations in New Jersey
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Jersey.
Statistics for New Jersey (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Jersey
A resident was physically restrained overnight when a staff member placed a bedside tray table and wheelchair against the bed, restricting movement. This action was not supported by medical necessity or the resident's care plan, and staff interviews confirmed the use of restraint for convenience, in violation of federal regulations and facility policy.
A resident with multiple chronic conditions did not receive a physician-ordered dose of Xarelto for atrial fibrillation because the medication was unavailable, and staff were unable to borrow it from other units. There was no documentation that the physician was notified of the missed dose, and pharmacy records showed a delay in resupply. Facility policy requires nurses to follow physician orders, but this was not followed in this instance.
The facility did not have an RN present for at least eight consecutive hours on one day, as required. An RN was scheduled but called out, and although the agency was contacted, an LPN was sent instead. The absence of an RN was not discovered until the next shift, resulting in a lapse in required RN coverage for resident care and assessments.
A resident's medical record was found to be incomplete when the facility could not provide the full Controlled Drug Administration Record (CDAR)/Declining Sheet for a prescribed medication, despite repeated requests and searches by the DON. Only a partial record was available, resulting in a deficiency for failure to maintain complete and accurate documentation as required.
The facility did not meet required CNA-to-resident staffing ratios on multiple day shifts over several weeks, with staffing levels consistently below state-mandated minimums for the number of residents present. This deficiency was identified through interviews and review of facility records, and had the potential to affect all residents.
The facility did not consistently meet New Jersey's required CNA-to-resident ratios on numerous day and some overnight shifts, as confirmed by staffing records and staff interviews. Despite awareness of the mandated ratios and a policy reflecting these standards, the facility's staffing levels repeatedly fell short of requirements during several reviewed periods.
The facility did not provide the minimum required nursing staffing hours on two days, with actual hours falling short of the calculated requirement based on resident count and acuity, despite having a contingency staffing plan in place.
A staff member failed to immediately report witnessing two residents with cognitive impairments engaged in sexual activity, instead completing her task and taking a lunch break before informing a co-worker. This delay was contrary to facility policy, and staff interviews revealed confusion about the residents' capacity to consent. The incident was not promptly addressed, and the safety of the involved residents and others was not immediately ensured.
A staff member observed two residents engaged in an incident but failed to immediately report it, instead completing her task and taking a lunch break before notifying a co-worker. The delay in reporting was confirmed through interviews, and the residents involved had cognitive and behavioral histories relevant to the event. Facility administration did not ensure staff followed established protocols for immediate reporting and intervention.
The facility was unable to provide its QAPI plan and meeting minutes when requested by surveyors, as the responsible staff member could not access or print the documents due to lack of internet access. This resulted in a failure to demonstrate evidence of an ongoing QAPI program as required by regulations.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
Surveyors identified a deficiency related to the improper use of physical restraints for one resident. During the overnight shift, a staff member placed a bedside tray table and wheelchair against the resident's bed, which restricted the resident's ability to move freely. This action was captured on video and reported by the resident's family, who alleged that the resident was restrained during the night. The staff member involved was suspended pending investigation, and the assigned LPN did not respond to facility inquiries regarding the incident. The resident involved had a documented medical history that included multiple diagnoses and was assessed using the Minimum Data Set (MDS), which indicated cognitive status and care needs. The resident's care plan included interventions requested by the family, but there was no documentation or evidence that the use of physical restraints was required to treat the resident's medical symptoms. The facility's policy on a restraint-free environment defines physical restraints as any device or equipment that the resident cannot remove easily and prohibits their use for discipline or convenience. Interviews with staff confirmed that the tray table and wheelchair were intentionally positioned to restrict the resident's movement, and staff acknowledged that this constituted a restraint. The facility failed to ensure that the resident was free from physical restraints imposed for purposes of discipline or convenience, as required by federal regulations. The deficiency was substantiated by direct observation, interviews, and review of facility documentation.
Plan Of Correction
F-604 Right to be Free from Physical Restraints Element 1: Resident number 2 was immediately assessed by Licensed Nurse with [R]. Resident was also assessed by Nurse Practitioner or [R] with [R]. Involved [R] was immediately suspended pending investigation on [R]. The [R] received a one-on-one re-education from the Director of Nursing and licensed nurse educator on Residents' rights, identifying and reporting [R] prevention and reporting or [R]. The involved [R] was reported to the Board of Nursing on 06/09/2025 and blocked from returning to the facility. A FRIDAY form was completed and submitted to the Department of Health for the [R] on 6/9/2025. The [R] returned to work on [R]. A repeat in-service education was provided by the Director of Nursing on Residents' rights, identifying and reporting [R] prevention and reporting. The [R] is placed on a 30-day Performance Improvement probationary period and will be monitored and reviewed by the Director of Nursing/designee. Element 2: Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this cited practice. Element 3: Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On NJ Executive Order 26.451, and ongoing, ALL staff were re-educated by the Director of Nursing and licensed nurse staff educator on Federal regulations on restraint use and prohibition under F604. Abuse prevention, reporting, and intervention. Steps to protect residents when restraint use is observed, or abuse is suspected. ALL staff signed attendance sheets and demonstrated understanding through return demonstrations, written quizzes, or verbal validation. This in-service education and competencies will be given during orientation for newly hired staff, annually, and as deemed necessary by the nurse educator. Element 4: Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing/Designee will do weekly random audits of 15 residents for 4 weeks covering all shifts to ensure that residents are free from physical restraint, then monthly for 3 months. Negative findings will be addressed immediately through one-on-one re-in-service education, progressive disciplinary measures as appropriate by the Director of Nursing and/or nursing supervisors. The results of all audits will be submitted to the Quality Assessment and Assurance (QAA) committee, who meets quarterly for review and will determine the necessity of future audits and recommendations. Completion date: 07/09/2025.
Failure to Provide Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic kidney disease, aneurysm of artery of lower extremity, and peripheral vascular disease did not receive a physician-ordered medication, Xarelto 20mg, for atrial fibrillation. The resident was cognitively intact, as indicated by a BIMS score of 15/15. On the specified date, the medication was not administered during the 3:00 p.m. to 11:00 p.m. shift, as shown by a blank entry on the Medication Administration Report. The Director of Nursing confirmed that if a medication is not available, nurses are expected to check backup supplies and contact the pharmacy, and if a dose is missed, the physician should be notified. The Infection Preventionist nurse stated that attempts to borrow the medication from other units were unsuccessful. There was no documentation in the resident's progress notes that the physician was notified of the missed dose. Pharmacy records indicated that a resupply request for the medication was made the following day, and the medication was received from the contracted pharmacy over the next two days. Facility policy requires nurses to follow physician orders and recommendations. The failure to ensure the medication was available and administered as ordered, and the lack of physician notification regarding the missed dose, led to the cited deficiency.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least eight consecutive hours on one of the days reviewed. Specifically, review of the facility's Nurse Staffing Reports showed that there was no RN coverage for any shift on a particular day. During interviews, facility staff confirmed that an RN was scheduled but called out, and although the agency was contacted to provide a replacement, a Licensed Practical Nurse (LPN) was sent instead. The error was not identified until the next shift, resulting in a full day without RN coverage. The facility's policy requires sufficient staffing, including RNs, to provide nursing care in accordance with resident care plans. However, on the day in question, the absence of an RN meant that there was no RN available to assist with assessments and overall care of the residents, as confirmed by staff interviews. The deficiency was identified through document review and staff interviews, with staff acknowledging the oversight and the failure to ensure RN coverage as required by federal regulations.
Plan Of Correction
1. The facility failed to ensure there was a Registered Nurse working for at least 8 consecutive hours on 1 of 21 days reviewed. 2. All residents have the potential to be affected by this practice. 3. The Facility continues to actively fill all open Registered Nurse positions to comply with Federal Nursing Regulation to have 8 consecutive hours a day, 7 days a week. Staff requirements and facility policy were reviewed with Human Resources and the Staffing Coordinator, who were able to reiterate minimum staffing requirements. The facility will take the following measures to ensure this deficient practice does not occur. The facility will focus on recruitment and retention strategies as follows: identify vacant Registered Nurse positions daily and attempt to fill positions with current Registered Nurses staff or agency; work diligently with the Administrator, Director of Nursing, and Corporate Recruiter to advertise, recruit, and hire sufficient Registered Nurse staff. 4. The Staffing Coordinator will review schedules daily to ensure that at least 8 RN hours are scheduled and will review with the Director of Nursing. The Administrator or designee will audit the schedules weekly for 4 weeks and monthly for 2 months to ensure there is an RN scheduled for 8 consecutive hours 7 days a week. Results and audits will be reviewed at the monthly Quality Assurance Meeting for 3 consecutive meetings. Based upon the results of these audits, a decision will be made regarding the need to continue submission and reporting.
Incomplete Medical Record for Controlled Drug Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of four sampled residents. Specifically, the surveyor requested the complete Controlled Drug Administration Record (CDAR)/Declining Sheet for a resident's medication, but the facility was unable to provide the entire documentation. The only available record was a single sheet with a specific date issued, and despite further requests and searches by the Director of Nursing, the full CDAR/Declining Sheet could not be located. An email response confirmed that the document was still missing at the time of the survey. This deficiency was identified through observations, interviews, and review of medical records and facility documentation. The resident involved had multiple diagnoses and was receiving medication as ordered, but the lack of a complete CDAR/Declining Sheet meant that the facility did not have a full record of the administration of a controlled drug as required by federal and state regulations.
Plan Of Correction
1. Resident #2 was discharged from the facility. 2. All residents who have orders for medications that require a Controlled Drug Administration Record/Declining Sheet have the ability to be affected by this practice. 3. The Medical Record staff was re-educated on the procedure for maintaining accurate, complete, readily accessible, and systematically organized records by the Director of Nursing or designee. The Drug Administration Record Declining sheet will be reviewed for accuracy and placed in residents' charts. 4. The Director of Nursing/Designee will audit the Controlled Drug Administration Record/Declining Sheet on each cart weekly x 4 and monthly x 2. The results of the audit will be reviewed at the Monthly Quality Assurance Meeting for three months. Continuation of the audits, reporting, and frequency after three months will be determined by the QA Committee.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.
Plan Of Correction
1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.
Failure to Maintain Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through observation, interviews, and review of facility documentation, and was evidenced by multiple instances where the number of Certified Nurse Aides (CNAs) scheduled for the day shift was below the minimum required for the census. The deficiency was found on 43 of 49 day shifts and 4 of 49 overnight shifts reviewed across several complaint periods, with specific examples provided for each period showing the number of CNAs present versus the number required by law. Interviews with the Staffing Coordinator, DON, and LNHA confirmed their awareness of the state-mandated ratios (1:8 for day shift, 1:10 for evening, and 1:14 for night), but also revealed that the facility did not always meet these requirements. The Staffing Coordinator stated that when there was a shortfall, other staff members who were also CNAs, such as the Staffing Coordinator, Unit Clerks, or Recruiter, would provide resident care. Despite these efforts, the documented staffing levels on numerous shifts did not meet the minimum ratios. A review of the facility's own Nursing Staffing Policy, revised in January 2025, reiterated the commitment to adhere to state staffing standards and outlined the required CNA ratios. However, the documented staffing schedules for multiple weeks showed consistent shortfalls in CNA coverage, particularly on the day shift, and occasional deficiencies in total staff on overnight shifts. No specific residents or patient conditions were mentioned in relation to the deficiency.
Plan Of Correction
I. Corrective Action Accomplished for Resident(s) Affected: Director of Nursing/Designee meets daily and before weekends with a staffing coordinator to review staff sufficiency to ensure minimum staffing hours requirement is met along with extra hours needed to meet special services need of our residents as required at N.J.A.C 8:39-25.1. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADONs and Nursing Supervisor. II. Residents identified having the potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing Assistant (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking, and trending. The Administrator will report the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 6/22/25
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for 2 out of 14 days during the review period. Specifically, on two separate days, the actual nursing staffing hours fell short of the required minimum hours calculated based on the total number of residents and the acuity of care needed, including services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, respirator use, and advanced neuromuscular/orthopedic care. On one day, there was a deficit of 48.5 hours, and on another, a deficit of 15.75 hours compared to the required staffing levels. The deficiency was identified through a review of the Nursing Staffing Reports for the two weeks prior to the survey, which was conducted in response to specific complaints. The facility's contingency staffing plan, dated 8/1/24, was also reviewed and included provisions to ensure sufficient qualified staff to meet residents' needs based on assessments and care plans. However, despite this plan, the facility did not provide the minimum required nursing hours on the identified days.
Plan Of Correction
I. Corrective Action accomplished for Resident(s) affected: Director of Nursing/Designee meets daily and before weekends with a staffing coordinator to review staff sufficiency to ensure the minimum staffing hours requirement is met along with the extra hours needed to meet the special services needs of our residents as required at N.J.A.C 8:39-25.1. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADONs and Nursing Supervisor. II. Residents identified having the potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking, and trending. The Administrator will report on the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 6/22/25
Failure to Immediately Report and Respond to Resident-to-Resident Sexual Incident
Penalty
Summary
A deficiency occurred when a staff member failed to immediately report an observed incident involving two residents engaged in sexual activity. The staff member entered the room, witnessed the event, completed her task of collecting hangers, and then left the room without reporting the incident. She subsequently went on her lunch break for approximately 30 minutes before informing a co-worker, who then reported the incident to the appropriate supervisory staff. This delay in reporting was contrary to the facility's policy, which requires prompt reporting of any witnessed abuse or neglect to the charge nurse. Both residents involved had documented cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores. The medical records and care plans showed that one resident had a history of seeking sexual intimacy and related behaviors, while the other also had cognitive limitations. The staff and supervisory interviews revealed uncertainty among staff regarding the residents' capacity to consent to sexual activity, especially given their BIMS scores. Despite the facility's policy allowing sexual intimacy between consenting adults deemed capable by MDS guidelines, staff were unclear about the application of these guidelines in this situation. The failure to immediately report the incident and ensure the safety of both residents, as well as all other residents in the facility, constituted a breach of the facility's abuse/neglect policy. The delay in reporting and lack of immediate intervention placed all residents at risk, as the staff did not promptly assess or secure the safety of those involved or others who might be affected. The deficiency was identified through interviews, medical record reviews, and examination of facility documentation, confirming that the required procedures were not followed.
Plan Of Correction
F 600 Tag F0600 438.12 Free from Abuse, Neglect and Exploitation 1. Corrective Action – On [R] Resident#1 and Resident #2 were [R] and placed on [R] by nursing. – On [R] Resident #1 and Resident #2 were transferred to the local hospital for evaluation. – On [R] the incident was reported to local [R]. – On [R] upon return from the hospital, Resident #1 and Resident #2 were placed on [R]. – On [R] the US FOIA (b)(6) received education from the HR Director on [R] and [R] and timely reporting. – Or [R] the US FOIA (b)(6) received a final discipline from HR Director for lack of timely reporting of the event to the appropriate staff. – On NJ Exec Order 26, the facility orientation for new employees was revised by the HR Director to include education on and NJ Exec Order 26.4 NJ Exec Order 26.4b1 and timely reporting. – Or NJ Exec Order 26.4D, the employee annual orientation requirements have been revised by the HR Director to include sexual abuse, timely reporting, and resident's ability to consent to sexual activity. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: – All residents have potential to be affected by the deficient practice. 3. Measures Put in Place: – The DON/designee will conduct facility education for all staff and assess all staff competency related to abuse and neglect, timely reporting, and facility sexual intimacy policy monthly for 6 months. – The HR and/or designee will randomly audit monthly, for 6 months, 10 employees' comprehension of facility abuse and neglect policy and timely reporting. 4. How Will These Actions Be Measured: – The results of the monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated facility staff on the facility's policy on NJ Exec Order 26.4b1
- Educated staff on the ability for residents to consent to NJ Exec Order 26.4b1 with each other
- Educated staff to report any incidents between residents and ensure the NJ Exec Order 2 residents were safe
- Conducted audits to monitor compliance with education
- Conducted staff assessment and testing to ensure staff had a true understanding of education
Failure to Ensure Timely Reporting and Implementation of Policies Following Resident Incident
Penalty
Summary
A deficiency occurred when facility staff failed to implement policies and procedures regarding an incident between two residents. A staff member entered the room of two residents, observed one resident engaged in an act with the other, and then proceeded to finish her task of collecting hangers before leaving the room. Instead of immediately reporting the incident to a supervisor or nurse as required, the staff member went on her lunch break for approximately 30 minutes. Upon returning from lunch, she reported the incident to a co-worker, who then reported it to the appropriate personnel. The delay in reporting was confirmed during interviews, with the staff member admitting she was aware of the need to report immediately but did not do so out of fear and uncertainty about her supervisor's availability. The residents involved had relevant medical histories and cognitive assessments documented in their records. One resident had a BIMS score indicating impaired cognitive function, and the other also had a care plan noting a history of certain behaviors and interventions. The facility's investigation and interviews with staff revealed that both residents were questioned about the incident, with one denying and the other confirming what was observed. Staff interviews further indicated confusion and inconsistency regarding the residents' capacity to consent to the observed actions, particularly in relation to their BIMS scores. The facility's administration was found to have failed in ensuring that staff followed established protocols for reporting and responding to such incidents. The administrator and department heads were not immediately aware of the delay in reporting, and the staff member's written statement did not accurately reflect the sequence of events. The deficiency was identified as placing all residents at risk due to the failure to ensure prompt reporting and intervention, as required by facility policy and regulatory standards.
Plan Of Correction
F835 Administration 1. Corrective Action: - Effective May 13, 2025, the Administrator of record is no longer employed at the facility. The new Administrator of record began on NJ Ex Order 26.4(b)(1). - On May 15, 2025, the corporate Administrator oriented the new Administrator of record to her job description, previous and current plans of corrections, and statement of deficiencies. 2. Identification of other areas having the potential to be affected due to the nature of this deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put in Place: - The corporate Administrator and/or designees will meet weekly with the new Administrator of record for 4 weeks and then monthly for 6 months to assure that processes and procedures are compliant with company policy. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission of reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated the Administrator on their job description.
- Educated the department heads on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.
- Educated the governing body on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.
Failure to Provide QAPI Documentation During Survey
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its Quality Assurance and Performance Improvement (QAPI) program as required by federal and state regulations. During a survey, the surveyor requested the facility's QAPI plan and the most recent meeting minutes. The staff member responsible for these documents stated she was unable to retrieve or print them due to a lack of internet access, as the documents were stored on her computer and not otherwise accessible. Further interviews confirmed that the QAPI plan and meeting minutes were not readily available to the surveyors upon request. The staff member acknowledged that the QAPI documentation should have been accessible but was not, citing technical limitations as the reason. The facility's own policy requires that minutes of all meetings be recorded and documentation maintained according to internal policy, but this was not achieved at the time of the survey. No information was provided in the report regarding specific residents or their medical conditions in relation to this deficiency. The deficiency was identified solely based on the facility's inability to provide required QAPI documentation and evidence of an ongoing QAPI program during the survey process.
Plan Of Correction
F865 QAPI 1. Corrective Action: On 4/23/25 upon identification, the Administrator printed a copy of QAPI meeting minutes, performance improvement plans, data tracking logs, and related documentation, sent the information to the DOH and placed the printed items in a QAPI binder entitled QAPI 2025. 2. Identification of other residents or areas having the potential to be affected due to the nature of this deficiency: All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: Monthly audits X6 months will be conducted by the Administrator or their designee to ensure the QAPI binder is current and complete. 4. How Will These Actions Be Measured: The results of the monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held June 6, 2025. S 000
Some of the Latest Corrective Actions taken by Facilities in New Jersey
- Re-educated all staff on the abuse policy regarding when and to whom to report abuse allegations (J - F0610 - NJ)
- Re-educated the LNHA on the abuse and investigation sections of the abuse policy (J - F0610 - NJ)
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to maintain hot water temperatures at a safe level on one of its nursing units, specifically the C-Wing, resulting in water temperatures ranging from 137.1°F to 138.4°F in resident rooms and the shower room. These temperatures were significantly above the safe range of 95°F to 110°F, as acknowledged by both the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD). The C-Wing unit, which included cognitively impaired residents, was serviced by a separate boiler that lacked a temperature gauge and was found set to high. Multiple staff, including the RLNHA, confirmed the excessive temperatures and agreed that such conditions could cause burns. Residents on the C-Wing reported that the hot water was so hot it could be used to make tea or instant noodle soup, indicating prolonged exposure to unsafe water temperatures. One resident with fully intact cognition and another with moderately impaired cognition both confirmed the water had been excessively hot for some time. The surveyors directly measured the high temperatures in the presence of facility staff, who acknowledged the findings. Despite daily water temperature checks being claimed by the MD, the temperature logs for C-Wing were incomplete and did not show any recent entries, nor did they specify the locations where temperatures were taken. The facility did not have a written water temperature policy and relied on regulatory standards. The lack of documentation and monitoring, combined with the absence of a temperature gauge on the C-Wing boiler, contributed to the failure to detect and address the hazardous water temperatures. The issue was identified during a survey following a recent fire that had affected utilities, but the facility's staff denied any prior issues with high water temperatures. The deficiency was found to have placed residents, including those with cognitive impairments, at risk of serious injury from scalding.
Removal Plan
- The Maintenance Director lowered the hot water temperature on the boiler.
- Water temperatures were obtained throughout every residents' room in the facility.
- The facility initiated water temperatures to be taken every two hours for three days.
- All residents on C-Wing were assessed for skin damage.
- The facility conducted a resident council meeting to discuss safe water temperatures with the residents.
- The Director of Nursing/designee initiated a house-wide staff in-service on safe water temperatures, the process of taking water temperatures, and any staff not in-serviced would be prior to their next shift.
Failure to Thoroughly Investigate Abuse Allegation and Notify Authorities
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving a Certified Nursing Assistant (CNA) and a resident. After being notified by Ombudsman representatives that a CNA was attempting to get a resident out of bed while the resident was screaming, the Licensed Nursing Home Administrator (LNHA) suspended the CNA and conducted an investigation. However, the LNHA did not interview other residents who had received care from the CNA, as required by the facility's abuse investigation policy. The LNHA also did not notify local police of the abuse allegation, believing police notification was only necessary for serious injuries or elopements. The resident involved had a history of dementia, depression, and required moderate assistance with activities of daily living. During the incident, the resident reported pain and bruising to the left arm, which was confirmed by a Registered Nurse's assessment. Another resident later reported to the surveyor that the same CNA had previously humiliated and mistreated them, but had only reported this to the Ombudsman and not to facility staff. The LNHA confirmed that she did not follow up with other residents or obtain statements from them regarding the CNA's conduct, nor did she ask the Ombudsman for the identities of residents who had complaints. The facility's failure to follow its own abuse investigation policy, specifically the requirement to interview other residents cared for by the accused staff member, resulted in the CNA returning to work after the initial allegation. This allowed the CNA to continue providing care until further complaints were brought to the LNHA's attention by the Ombudsman, at which point the CNA was terminated. The lack of a thorough investigation and failure to notify authorities constituted a deficiency in the facility's response to alleged abuse.
Removal Plan
- CNA #1 was terminated from the facility
- The LNHA conducted an investigation into abuse allegations involving CNA #1, which included resident interviews
- All facility staff were re-educated on the facility's abuse policy regarding when to report abuse allegations and to whom
- The facility's owner re-educated the LNHA on the abuse and investigation sections of the abuse policy
- The Director of Nursing (DON) conducted audits to see if any residents had experienced any form of abuse
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