Complete Care At Wayne Hills Rehab & Resp Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, New Jersey.
- Location
- 130 Terhune Drive, Wayne, New Jersey 07470
- CMS Provider Number
- 315110
- Inspections on file
- 19
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Wayne Hills Rehab & Resp Center during CMS and state inspections, most recent first.
A resident with functional quadriplegia, moderate cognitive impairment, and documented need for 2-person assist with repositioning experienced a fall from bed during care when only one CNA was turning the resident, resulting in the resident’s legs falling off the bed. The care plan identified fall risk but did not specify the resident’s risk level or required number of staff for repositioning, and there was no documentation of interventions implemented after the fall. In the days following, staff later observed bruising, pain behaviors, and swelling, but there was no evidence of ongoing monitoring for pain or injury or documentation of the origin of a right-hand bruise and swelling; hospital imaging ultimately showed bilateral femur fractures and a suspected finger fracture, which the facility’s investigation linked back to the earlier fall.
A resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment developed swelling and bruising of the right hand that was added to the care plan but not reported to the NJDOH as an injury of unknown origin. A facility reportable event submitted days later did not address this hand injury, and the DON confirmed there was no documentation showing it had been reported, despite a facility abuse/neglect policy requiring timely reporting of all alleged violations to state authorities.
The facility failed to conduct thorough, separate investigations into two incidents involving a resident with muscle weakness, functional quadriplegia, and moderate cognitive impairment. During incontinent care, the resident’s legs slid off the bed while the upper body remained on the bed, and later the resident developed right hand swelling and bruising that was added to the care plan. Despite facility policy requiring prompt reporting and same-day, signed witness statements with an investigation initiated by the nursing supervisor, the DON acknowledged that no separate investigation was completed for the first incident and no investigation was conducted to determine how or when the right hand injury occurred.
A resident with severe cognitive impairment and total dependence on staff for eating did not receive the necessary assistance with breakfast, as evidenced by an untouched meal tray at the bedside. Staff failed to provide the required support despite the resident's documented needs and care plan interventions.
Two residents with significant cognitive and physical impairments did not consistently receive or have documented wound care as ordered by their physicians, as shown by multiple blank entries in the Treatment Administration Records for various wound treatments and assessments. The DON confirmed that nursing staff were responsible for implementing and documenting these orders, but the facility's own documentation policy was not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severely impaired cognition and a history of false accusations reported sexual abuse while hospitalized. The facility's DON and LNHA failed to report the allegation to the NJDOH, as required by state and federal regulations, because the report was not made directly to them and the resident was not in the facility at the time. This oversight violated the facility's policy on reporting and investigating abuse allegations.
A resident with severely impaired cognition reported an alleged sexual abuse incident to a hospital social worker, which was not investigated by the LTC facility staff. The DON and LNHA were informed of the allegation during a morning meeting but did not report it to the appropriate agencies, as required by the facility's policy. The social worker also did not investigate, assuming it was the responsibility of the DON and Administrator.
The facility failed to ensure that primary physicians signed monthly orders and wrote progress notes every other month for 10 residents over six months. Despite frequent visits by the physician and NP, records showed inconsistent signage and note-taking. Facility policies did not ensure compliance with regulations for physician visits every 60 days.
The facility failed to submit MDS assessments within the required timeframe for a resident, with delays noted in both Quarterly and Significant Change MDS submissions. A resident, who was cognitively intact and had a history of urinary tract infections, was involved. The Regional MDS Coordinator was consulted but did not provide further information.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care management. One resident's bowel continence was incorrectly coded, and pain presence and fall history were not assessed. Another resident's bowel continence was initially not rated, and CNA documentation was inconsistent. These issues were identified through interviews and record reviews, revealing gaps in assessment and documentation processes.
A facility failed to accurately document a resident's bowel elimination status, despite the resident reporting regular bowel movements. Staff interviews revealed inconsistencies in documentation, with the CNA and RN/UM stating the resident had regular movements, while the MDSC/RN noted the resident was documented as always incontinent. The facility's policy emphasized the need for accurate records to ensure effective communication among the care team.
A resident with severe cognitive impairment and acute respiratory failure was observed receiving oxygen therapy incorrectly, as the nasal cannula was not positioned in the nostrils but on the cheek. The oxygen tubing lacked markings to indicate when it was applied, contrary to facility protocol. The Registered Nurse Unit Manager confirmed the oversight and adjusted the cannula, acknowledging the need for proper dating and regular changing of the equipment.
Failure to Implement Fall-Prevention Interventions and Post-Fall Assessment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement adequate fall-prevention interventions and to thoroughly assess and monitor a resident after a fall and subsequent signs of injury. The resident was admitted with multiple significant diagnoses, including acute respiratory failure, muscle weakness, schizoaffective disorder, seizures, and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A comprehensive nursing assessment documented that the resident’s mobility was very limited, that they were unable to make frequent or significant changes independently, and that they were dependent on others for ADLs. Progress notes prior to the incident documented that the resident required total care with two-person assist for repositioning, but the baseline care plan, while identifying a fall risk focus area, did not specify the resident’s fall risk level or the number of staff required to assist with repositioning in bed. On the date of the fall, the Facility Reportable Event (FRE) stated that while a CNA was providing care, the resident was squirming and holding the side rail while being turned in bed, and the resident’s lower legs fell off the bed while the torso remained on the bed. The CNA and an RN then repositioned the resident back to bed and assessed the resident. However, there was no documented evidence that the facility implemented any interventions following this fall to address the resident’s fall risk or to protect the resident from further injury. An employee statement from the CNA did not indicate that two staff assisted with repositioning during the care at the time of the incident, and in a subsequent interview, the RN confirmed that she did not assist the CNA with repositioning, only assessing the resident afterward and noting no pain. The RN did not provide information regarding follow-up interventions or the required level of care for the resident. In the days following the fall, the facility failed to adequately assess and monitor the resident for pain and injury. The FRE documented that an LPN later noticed bruising on the resident’s bilateral lower extremities, and other staff statements described the resident exhibiting signs of pain, flinching during assessment, and having bruising on both thighs and the lower back. The resident was then sent to the hospital, where imaging revealed acute fractures of the distal shafts of both femurs and a suspicious subtle fracture at the base of the proximal phalanx of the right third finger, associated with pain and bruising. The facility’s FRE did not address the right-hand swelling and bruise, and there was no documentation regarding the origin of the right-hand injury. The facility’s investigational summary concluded that the bilateral femur fractures identified later were the result of the earlier fall, but there was no evidence that the facility monitored the resident for pain and injury after the fall or implemented interventions on the date of the fall to prevent further injury, despite a policy stating that appropriate and immediate interventions and root cause analysis would be conducted for incidents and accidents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) after swelling and bruising were identified on a resident’s right hand. The resident had diagnoses including muscle weakness and functional quadriplegia and a Brief Interview for Mental Status (BIMS) score of 9/15, indicating moderate cognitive impairment. On 12/01/25, the resident’s care plan documented a focus area of swelling and bruising to the right hand, but there was no corresponding report of this injury to NJDOH as required for suspected abuse, neglect, or injury of unknown origin. A review of the facility’s Reportable Event submitted to NJDOH on 12/05/25 showed that it did not address the bruise and swelling on the resident’s right hand. During an interview on 1/29/26, the DON stated that the facility could not provide any documented evidence that the swelling and bruise identified on 12/01/25 had been reported to NJDOH. This failure occurred despite the facility’s Abuse, Neglect and Exploitation policy, revised 9/01/25, which required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified time frames, depending on whether abuse or serious bodily injury was involved.
Failure to Conduct Separate and Thorough Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving one resident. The resident was admitted with diagnoses including muscle weakness and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A progress note dated 11/27/25 documented that during incontinent care, while the resident was being turned in bed, both lower extremities slid off the bed and touched the floor while the upper body remained on the side of the bed. A statement from the RN involved indicated the resident was not injured and did not exhibit signs of pain after this fall. The unit manager LPN stated that the facility’s process requires the assigned nurse to report incidents to the nursing supervisor, who is then expected to obtain, on the day of the incident, signed and dated witness statements from all staff involved and to start the investigation. The resident’s care plan included a focus area for right hand swelling and bruising, initiated on 12/01/25. However, the DON reported that there was no separate investigation conducted for the 11/27/25 incident apart from an investigation related to a later incident on 12/03/25. The DON also confirmed that the swelling and bruise identified on the resident’s right hand on 12/01/25 did not have a separate investigation to determine how or when the injury occurred. As a result, the facility did not follow its stated process for timely and complete incident investigation and failed to investigate the origin of the resident’s right hand injury, leading to the cited deficiency under NJAC 8:39-4(f).
Failure to Provide Required Assistance with Meals for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs), including eating, did not receive the necessary assistance with breakfast. The resident had diagnoses of functional quadriplegia, dementia, and severe protein calorie malnutrition, and was assessed as having severely impaired cognition with a BIMS score of 3 out of 15. The resident's care plan specified total dependence on two staff members for eating. Despite these documented needs, the resident's breakfast tray was found untouched at the bedside, indicating that staff did not provide the required assistance. Interviews revealed that the resident's representative observed the untouched breakfast tray and reported it to the Director of Social Services, who confirmed the tray had not been touched and that the resident required staff assistance to eat. The Director of Nursing stated that residents needing meal assistance were identified on the CNA assignment sheet and that CNAs, nursing staff, and the DON were responsible for providing this assistance. However, in this instance, the necessary support was not provided, resulting in the resident not receiving help with their meal as required by their care plan.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that two residents received wound care as ordered by their physicians, as evidenced by multiple missed or undocumented wound treatments. For the first resident, who was admitted with significant medical conditions including anoxic brain damage, severe contractures, impaired mobility, and incontinence, the care plan identified actual skin breakdown and multiple wounds, including pressure ulcers and arterial injuries. Review of the Treatment Administration Records (TARs) for September, October, and November revealed numerous blank entries where wound care orders were not documented as completed, including treatments for pressure ulcers, arterial ulcers, and skin tears, as well as required weekly skin assessments and offloading interventions. These omissions were confirmed through record review and interviews with the Director of Nursing (DON), who stated that facility nurses were responsible for implementing and documenting wound care orders received from an external wound care company. The second resident, admitted with diagnoses such as functional quadriplegia, dementia, and severe protein-calorie malnutrition, also had a care plan indicating actual skin breakdown, including multiple pressure ulcers and a trauma wound. Review of this resident's November TAR showed blank entries for several physician-ordered wound treatments, including the application of betadine, medihoney, and Triad Hydrophilic wound dressings to various wounds. These treatments were not documented as completed on the specified dates, and the DON confirmed that nursing staff were responsible for carrying out and documenting these orders. The facility's policy on documentation requires licensed staff and interdisciplinary team members to document all assessments, observations, and services provided in the resident's medical record. Despite this policy, the records for both residents showed repeated failures to document or complete ordered wound care treatments, as evidenced by the blank spaces in the TARs and confirmed by staff interviews.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to report an allegation of sexual abuse made by a resident to the New Jersey Department of Health as required. This deficiency was identified for one resident who had a history of false accusations towards staff and utilized nonverbal communication due to severely impaired cognition. The resident was admitted to the hospital with tracheostomy malfunction and respiratory distress, and during this time, the hospital social worker reported the alleged sexual abuse to the facility's Admissions Director via text. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of the allegation during a morning meeting but did not report it to the appropriate authorities. The DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. Both the DON and LNHA acknowledged their failure to report the allegation as per state and federal regulations and did not follow the facility's policy for reporting and investigating abuse allegations.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility staff failed to investigate an alleged incident of sexual abuse reported by a resident to the New Jersey Department of Health. This deficiency was identified for one resident who had a history of false accusations and severely impaired cognition, as indicated by a BIMS score of 0 out of 15. The resident was admitted to the hospital with a tracheostomy malfunction and respiratory distress. During a morning meeting, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed by the Admissions Director about a text from a hospital social worker stating that the resident reported being sexually assaulted at the facility. However, the DON did not address the allegation because the social worker had not contacted her directly, and the resident was not in the facility at the time of the alleged incident. The facility's policy requires all allegations of abuse to be reported immediately to the Administrator and appropriate agencies, but this was not followed. The DON and LNHA acknowledged their failure to report the allegation within the required timeframe and did not adhere to the facility's policy for reporting and investigating abuse allegations. The social worker, who heard about the allegation during the morning meeting, did not investigate it, believing it was the responsibility of the Administrator and DON. The facility's policy outlines the need for immediate reporting and investigation of all allegations, but these procedures were not followed in this case.
Deficiency in Physician Order Signage and Progress Notes
Penalty
Summary
The facility failed to ensure that the primary physicians of residents signed and dated monthly physician orders and wrote progress notes every other month, alternating with the nurse practitioner. This deficiency was observed in 10 out of 20 residents reviewed over a six-month period. For several residents, the physician only electronically signed the monthly orders for March 2024, with no other orders signed in the previous months. Additionally, there were no monthly progress notes written by the physician during this period. The surveyor's review of the hybrid medical records revealed that the primary physicians did not consistently sign monthly orders or write progress notes for the residents. Interviews with facility staff indicated that the physician and nurse practitioner were present at the facility multiple times a week. However, the facility's policies and procedures for physician orders and visits, which were provided to the survey team, did not ensure compliance with state and federal regulations requiring physician visits at least every 60 days.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required timeframe for at least one resident. Specifically, the Quarterly Minimum Data Set (QMDS) for a resident was due to be transmitted to the Centers for Medicare and Medicaid Services (CMS) by April 4, 2024, but was not submitted until April 26, 2024. Additionally, a Significant Change MDS (SCMDS) for another resident was due by October 12, 2023, but was not submitted until October 21, 2023. These delays in submission were identified during a surveyor's review of the facility's records. The surveyor observed a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident's electronic medical record showed a history of urinary tract infections. The Regional MDS Coordinator was consulted regarding the late submissions but did not provide further information. The deficiency was noted as a failure to adhere to the timelines set forth by the CMS Resident Assessment Instrument (RAI) Manual, which requires assessments to be transmitted within 14 days of completion.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the management of their care. For Resident #63, the MDS was incorrectly coded as 'not rated' for bowel continence, despite the resident being incontinent and dependent on staff for care. The MDS Coordinator/Registered Nurse (MDSC/RN) acknowledged the error, noting that the MDS was modified to reflect the resident's incontinence. Additionally, the MDS failed to assess pain presence and fall history, despite documentation indicating no pain and no falls during the relevant period. The MDSC/RN admitted that the assessments were not addressed correctly, highlighting a lack of proper interviews and assessments. For Resident #85, the MDS initially failed to rate bowel continence, which was later corrected to indicate the resident was always incontinent. The resident's care plan confirmed total dependence on staff for incontinence care. However, the CNA documentation for a specific period was either blank or incorrectly coded, failing to reflect the resident's bowel movements accurately. Nursing progress notes did indicate incontinence, but the inconsistency in documentation contributed to the deficiency. These deficiencies were identified through interviews and record reviews conducted by surveyors. The MDSC/RN and other staff members were interviewed, revealing gaps in the assessment and documentation processes. The facility's failure to accurately code and assess the MDS for these residents resulted in a lack of proper care management, as evidenced by the discrepancies in the residents' records and the staff's acknowledgment of the errors.
Inaccurate Documentation of Bowel Elimination Status
Penalty
Summary
The facility failed to maintain the nursing professional standard of clinical practices by not accurately documenting the bowel elimination status of a resident who was reviewed for urinary catheter use. The resident, who was admitted with diagnoses including urinary tract infections, was observed to be cognitively intact and reported having a bowel movement at least once daily without issues. However, the facility's documentation, including the CNA Documentation Survey Report and Progress Notes, did not reflect the resident's bowel elimination status accurately during a specified period in March 2024. Interviews with facility staff, including a CNA, RN/UM, MDSC/RN, and DCS, revealed inconsistencies in the documentation and understanding of the resident's bowel movement schedule. The CNA and RN/UM indicated that the resident had regular bowel movements and would call for assistance when needed. However, the MDSC/RN noted that the resident was documented as always incontinent of bowel elimination, and the DCS highlighted the importance of accurate documentation. The facility's policy on Charting and Documentation emphasized the need for accurate records to facilitate communication among the interdisciplinary team.
Improper Oxygen Administration for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as observed by a surveyor. During an interview with the resident, it was noted that the nasal cannula, intended to deliver oxygen, was not positioned correctly in the resident's nostrils but was instead located on the cheek. Additionally, the oxygen supply tubing lacked any markings indicating when it was applied, which is against the facility's protocol. The resident, who was admitted with acute respiratory failure with hypoxia and essential hypertension, was assessed to have severe cognitive impairment, scoring 7 out of 15 on the Brief Interview for Mental Status (BIMS). Further observations confirmed the nasal cannula was still misplaced, and the Registered Nurse Unit Manager (RNUM) had to adjust it. The RNUM acknowledged the oversight and mentioned that oxygen tubing should be dated and changed weekly or sooner if needed. The facility's policy on oxygen administration specifies that the nasal cannula should be placed approximately one-half inch into the resident's nose. The deficiency was discussed with the facility's administrative team, including the Regional Clinical Registered Nurse, Regional Administrator, Director of Nursing, and Administrator.
Latest citations in New Jersey
A resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment was discharged home despite prior documentation that their house had no utilities, was in disarray, and had insect infestation. The IDT discussed the need to repair a burst water pipe and relied on the resident’s assurance that repairs would occur, but did not verify that plumbing, heat, or utilities were restored before discharge. Discharge instructions referenced HHA and APS involvement and anticipated HVAC repairs, yet were unsigned, and the HHA later confirmed it had declined the referral and notified the facility. The resident ultimately left via cab without signing the discharge summary, and there was no documented APS referral or confirmation of home safety. After discharge, PD and a social worker found the resident in a home without running water or heat, with limited electricity and expired food, and observed the resident could only descend stairs by scooting on their buttocks, leading to the determination that the facility failed to ensure a safe discharge destination in accordance with its own policy.
A resident with severe cognitive impairment, schizophrenia, and identified elopement and fall risks exited through a window and was later found on the ground outside with suspected serious injuries, including a possibly fractured leg. Staff documented the unwitnessed fall, transfer to the hospital, and EMS concern for internal injuries after a fall from an estimated 17–18 feet. Despite facility policies requiring reporting of falls, elopements, and potential neglect to appropriate agencies within specified timeframes, the fall with suspected major injury and the elopement were not reported to the state health department because the administrator stated they lacked hospital injury details and did not consider the event an elopement since the resident remained on facility grounds.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A resident with severe cognitive impairment and psychiatric diagnoses, previously assessed as an elopement risk and care‑planned with a Safety Band (SB) on the wheelchair and monitoring of whereabouts, was observed by an LPN in the lobby near the front entrance without the LPN approaching, re‑checking the SB, or notifying other staff before leaving at the end of the shift. The receptionist, trained on the elopement book and SB system, reported not seeing the resident in the lobby and not hearing any SB alarm. During subsequent rounds, staff discovered the resident missing, and the resident was later found off premises by police; hospital staff reported that no SB was on the wheelchair. Facility records and interviews showed that, despite policies requiring SB use, front‑desk identification of elopement‑risk residents, and alarm activation when an SB wearer approached exits, the resident was able to leave the building without staff knowledge, leading surveyors to cite an F689 Immediate Jeopardy deficiency for failure to maintain a safe environment and adequate supervision to prevent elopement.
The facility failed to provide and document routine bathing in accordance with ADL care plans and resident preferences for several cognitively intact and impaired residents with conditions including dementia, schizophrenia, depression, diabetes, heart failure, and spastic hemiplegic cerebral palsy. One resident who required staff assistance for bathing had only a single documented refusal and no other bathing entries over a month. Another resident requiring assistance had no bathing documented over the same period and no refusals recorded. A third resident had only one bath documented in 30 days, and a fourth had no bathing care plan and no documented baths or refusals. In a group interview, three residents reported they never received more than one bath per week, preferred twice‑weekly baths, and described long intervals without bathing, with one stating they believed they smelled and another reporting a family member had to take them home to bathe. Facility leadership confirmed they could not locate documentation showing consistent bathing according to resident preferences.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
The facility failed to maintain complete and accurate medical records when two residents who required assistance with toileting and were incontinent had multiple missing entries in their Documentation Survey Reports for bowel/bladder elimination, toilet transfers, and toilet hygiene over several days and shifts, despite staff stating that incontinent rounds and EMR documentation should occur routinely with no blanks. In addition, a cognitively intact resident with chronic kidney disease and depression requested a specific roommate and staff reported holding meetings and developing an alternate plan, but there was no documentation in the EMR or grievance file of the roommate request, the meetings, or the resident’s agreement, contrary to facility policies on ADL documentation and room-change requests.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Ensure Safe Discharge Home for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge home for a resident with schizophrenia, muscle wasting, difficulty walking, and moderate cognitive impairment (BIMS 11/15). The resident had been admitted from an inpatient psychiatric facility after being found by neighbors living in deplorable conditions at home, including a burst water pipe causing water to leak from the house, utilities turned off, the house in complete disarray, and insect infestation. Hospital psychological and social services documentation noted the resident was disheveled, malodorous, had not showered in five years due to fear of slipping, had poor functional status, and had no insight into their condition or deterioration. The facility’s own Social Services Assessment reiterated that the resident’s home had no electricity or water and was in deplorable condition prior to admission. During the stay, the resident’s care plan documented a goal to return to the community and interventions to evaluate and discuss prognosis for independent or assisted living, including identifying and addressing limitations, risks, and needs for maximum independence. The Social Services Director (SSD) and Administrator discussed with the resident the need to fix the broken water pipe before discharge and delayed discharge for the resident to arrange repair. The DON reported receiving a call from the local police department (PD) stating the building was no longer red taped and that the resident could go home anytime if the water pipe was fixed, but this conversation was not documented in the electronic medical record. The SSD stated that the resident was adamant the house was safe to return to and that she arranged home health care and transportation for discharge, relying on the resident’s report that repairs would occur on the day of discharge. The facility did not verify that the water pipe or utilities had actually been repaired or that the home environment was safe before discharge. On the day of discharge, the discharge instructions indicated the resident was to go home via ambulette, that a home health agency (HHA) and Adult Protective Services (APS) would be called for home care, and that an HVAC company would be on-site for repairs the next day per the resident. The discharge instructions were not signed by a nurse or the resident. A progress note documented that the resident left the facility via cab, left before signing the discharge summary, and that attempts to contact the resident afterward were unsuccessful. The HHA later confirmed that it had declined the referral and had notified the facility by email, meaning no home health services were in place. APS confirmed that the conversation with the SSD was not a formal referral and that there was no open APS case or follow-up visit. After discharge, the local PD and a social worker hired by the PD found the resident at home with no running water, no working heat, limited electricity, expired food, and unable to walk down the stairs except by scooting on their buttocks. The PD subsequently contacted the facility questioning why the resident had been discharged home under those conditions. The facility’s own policy required that discharge destinations meet health and safety needs, that unsafe settings be treated similarly to refusal of care with documentation of options offered, and that AMA and APS referral procedures be followed when appropriate; these requirements were not met in this case, leading to the cited deficiency for failure to ensure a safe discharge.
Failure to Report Fall With Injury and Elopement to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health (NJDOH) a fall with injury and an elopement involving a cognitively impaired resident. The resident had diagnoses including follicular lymphoma, schizophrenia, and auditory hallucinations, and a Brief Interview for Mental Status (BIMS) assessment showed severely impaired cognition. An Elopement/Wandering Risk Assessment identified the resident as an elopement risk, and the care plan documented wandering, elopement risk related to impaired safety awareness, and risk for falls due to deconditioning and gait and balance problems, with interventions such as structured activities, walking inside and outside, use of an elopement alarm, and education on safety and what to do if a fall occurred. On the date of the incident, a progress note by the DON documented that the resident had a fall and was transferred to the hospital. A Resident Accident/Incident Report recorded that nursing staff could not find the resident in the room or dayroom, then observed the resident’s window screen removed and the window open, and found the resident outside on the ground. The fall was documented as unwitnessed, the extent of injuries was unknown at that time, and the resident was transferred to the hospital. A township police department Investigation Report indicated EMS suspected internal injuries and requested helicopter transport due to suspected serious injuries, and documented that the height from the resident’s window to the ground was between 17 and 18 feet. In an interview, an RN stated that during rounds with the ADON, the resident was not seen, and after searching other rooms, the ADON called out to call 911; the RN then saw the open window and the resident on the ground outside, noting one leg appeared shorter than the other, which she stated could indicate a broken leg. The LNHA acknowledged that falls with major injuries should be reported to NJDOH but stated the fall was not reported because the facility was unable to obtain information from the hospital on the extent of the injuries. The LNHA also stated the exit through the window was not reported as an elopement because the resident did not leave facility grounds. Facility policies on falls, elopement and wandering, incidents and accidents, and compliance with reporting allegations of abuse/neglect/exploitation required reporting of falls, elopements, and incidents that may constitute neglect to appropriate agencies within prescribed timeframes, including immediate notification to appropriate agencies no later than two hours after discovery or forming suspicion, but the fall with suspected serious injury and the elopement event were not reported to NJDOH as required.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Elopement of High‑Risk Resident Due to Inadequate Supervision and Safety Band Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent the elopement of a resident who had been identified as an elopement risk. The resident had diagnoses including paranoid schizophrenia, schizoaffective disorder, and anxiety disorder, and a recent MDS showed a severely impaired cognitive status with a BIMs score of 7/15. An elopement assessment documented that the resident became impatient when waiting to be picked up, self‑propelled toward doors, and had exit‑seeking behavior at times. On the day prior to the incident, nursing documentation noted restlessness, poor impulse control, impatience, and self‑propelling toward the door while expressing a desire to go out front, leading to placement of a Safety Band (SB) on the back of the wheelchair and a care plan focus identifying the resident as an elopement risk with interventions including SB use and monitoring of whereabouts. On the day of the elopement, an LPN assigned to the resident on the 7 AM–3 PM shift documented on the Treatment Administration Record that the SB on the back of the wheelchair had been checked for placement. The LPN later stated in interview that she was aware of the resident’s elopement risk and that interventions included monitoring and redirecting the resident when exit‑seeking behaviors were observed. At approximately 3 PM, the LPN observed the resident seated in a wheelchair in the main lobby near the front door but did not approach the resident, did not verify the presence of the SB on the wheelchair at that time, and did not notify other staff that the resident was in the lobby near the front entrance. The LPN then left the facility at the end of her shift. The receptionist on duty, who had been trained on the Elopement Book and SB system and was responsible for observing for wandering residents near exits, reported that she did not see the resident in the lobby at that time and did not hear the SB alarm. According to the facility’s own incident documentation, the resident was last seen by staff in the first‑floor lobby at approximately 3 PM. During rounds at approximately 3:15 PM, staff on the 3–11 shift discovered that the resident was not in the room and initiated a search. The DON and local police were notified at about 3:20 PM. Police later located the resident in the neighborhood near the facility and transported the resident to the hospital for evaluation. Information obtained by the LPN unit manager from hospital staff indicated that the SB was not on the resident’s wheelchair when the resident arrived at the hospital. Facility leadership concluded, based on staff reports and the absence of the SB on the wheelchair at the hospital, that the SB must have been removed prior to the resident exiting the facility. The SB alarm system itself was reported by maintenance to be functioning properly based on testing before and after the incident. These actions and inactions resulted in the resident leaving the facility without staff knowledge, constituting a failure to implement interventions to maintain a safe environment with adequate supervision to prevent elopement. The facility’s policies on resident elopement and SB use required that residents at risk for elopement be identified, care plans updated after elopement attempts, and interventions implemented by the interdisciplinary team. The SB policy specified that SB placement would aid in elopement prevention, that names and photos of all residents at risk for elopement would be kept in a log at the front desk, and that an alarm would activate if a resident wearing an SB attempted to leave through monitored exits. Despite these policies, the resident, who had been assessed and care‑planned as an elopement risk and ordered to have an SB on the wheelchair with checks each shift, was able to be in the lobby near the front door without effective staff intervention or alarm activation, and subsequently left the facility undetected until discovered missing during shift rounds. The surveyors determined that this failure placed the resident and all residents at risk and constituted an Immediate Jeopardy situation under F689. The facility’s failure to provide a safe environment and adequate supervision to prevent the resident from leaving the facility without staff knowledge placed this resident as well as all residents at risk for elopement, at risk of likelihood of serious harm, injury, impairment, or death.
Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Multiple Medication Administration Errors for a G-Tube Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors during medication administration. The resident had multiple diagnoses, including history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting the right dominant side, and was severely cognitively impaired with a BIMS score of 1 out of 15. Active physician orders included thiamine, lactulose, chewable aspirin, Miralax, Duoneb, budesonide, a scopolamine patch, and Glucerna 1.5 via g-tube, as well as nebulized medications. The MAR/TAR for the review period indicated the resident received medications as ordered. During an observed medication pass, the LPN administered aspirin even though the expiration date on the medication label was smeared and not visible. The LPN did not administer lactulose or thiamine after determining these medications were not available in the medication cart and did not obtain them before completing the pass. The LPN stated an intention to assess the resident’s bowel status before giving Miralax but did not perform the assessment and did not administer the Miralax. The LPN also administered the inhaled steroid budesonide before the bronchodilator Duoneb, contrary to the sequence later confirmed by nursing leadership. Additional errors occurred with the resident’s enteral feeding and scopolamine patch. The LPN administered only 330 ml of Glucerna 1.5 instead of the 360 ml ordered via g-tube, while believing the order was for 330 ml. The LPN was unable to locate documentation on the MAR for the scopolamine patch, removed the patch from behind the resident’s left ear without verifying the physician’s order, and did not replace it, even though the patch had been applied the previous day and was ordered to remain in place for 72 hours. Facility policies required medications to be administered safely and in accordance with orders, including verification of the right medication, dose, time, route, and expiration date, and required enteral feeding orders to specify the product and volume for each bolus, which were not followed in this instance. The facility’s failure to ensure the resident received medications as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Failure to Maintain Complete Toileting and Room-Change Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with professional standards, specifically related to documentation of toileting, bowel and bladder elimination, and response to a roommate request. For one resident with osteoarthritis, morbid obesity, and rhabdomyolysis, who had intact cognition and required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel and bladder, the Documentation Survey Report v2 (DSR) for April showed multiple missing entries. There was no documentation of bowel and bladder elimination, toilet transfer, or toilet hygiene on several identified dates and shifts, despite the resident’s care plan indicating the need for extensive assistance and the use of a mechanical lift for transfers. Another resident, with heart failure, rheumatoid arthritis, and cachexia, also cognitively intact and requiring partial/moderate assistance with toileting hygiene and transfers, and documented as occasionally incontinent of bowel and frequently incontinent of bladder, had extensive gaps in the DSR for April. There was no evidence of documentation for bowel and bladder elimination, toilet transfer, or toilet hygiene across multiple consecutive days and shifts. Staff interviews confirmed that CNAs were responsible for providing and documenting incontinent care in the electronic medical record, that incontinent rounds were to be completed every two hours to prevent skin breakdown, and that all care provided should be documented with no blanks. The Regional Nurse Consultant and Licensed Nursing Home Administrator acknowledged that there should not be blanks on the DSR and that unit managers were responsible for ensuring CNA documentation, but could not explain the missing entries. The deficiency also includes the lack of documentation regarding a resident’s request for a specific roommate. A cognitively intact resident with chronic kidney disease and depressive disorder had a care plan noting a special relationship with another resident, initiated in early February, and expressed a desire to have that resident as a roommate. The resident reported having told staff about wanting this roommate but still not being placed together. The Unit Manager stated that room change requests were referred to the social worker and that this had been done, and the Director of Social Work and the Administrator both described meetings and an interdisciplinary team discussion in which an alternate plan was developed and agreed upon by the resident. However, there was no documentation in the electronic medical record of the roommate request, the meetings, or the resident’s agreement with the plan, and no grievance was on file, despite facility policies requiring documentation of ADL care in real time and social work involvement in room change requests.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
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