Complete Care At Voorhees, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Voorhees, New Jersey.
- Location
- 3001 Evesham Road, Voorhees, New Jersey 08043
- CMS Provider Number
- 315219
- Inspections on file
- 22
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Complete Care At Voorhees, Llc during CMS and state inspections, most recent first.
A resident with acute kidney failure, diabetes, and a UTI had a urine culture collected, and the abnormal result was reported to the facility but not promptly communicated to a practitioner. Facility staff, including the UM/LPN and DON, stated that nurses are expected to notify providers as soon as abnormal lab results are received and that clinicians, although able to access labs in the electronic record, rely on nursing notification. The resident’s abnormal urine culture was not acted upon until several days later, when an NP reviewed the result, noted a severe UTI, and ordered antibiotics, and the NP confirmed this delay in notification and treatment was contrary to expectations and represented a delay in care.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Surveyors found that multiple residents did not receive their medications within the required time frame, and there was a lack of documentation explaining late or missed doses or notification to the PCP. Medications for conditions such as infection, pain, hypertension, and glaucoma were affected, and staff interviews confirmed inconsistent adherence to the facility's medication administration policy.
The facility was found deficient in handling potentially hazardous foods and maintaining sanitation. Observations included improper hand hygiene, lack of temperature logs, and soiled kitchen equipment. A dietary aide wore an inadequate beard guard, and opened food items were not dated. The District Food Service Manager failed to follow proper handwashing procedures, and a resident's cup was improperly stored in the freezer, raising infection control concerns.
The facility failed to provide a dignified dining experience for residents, as observed in one unit where meal trays were not delivered simultaneously to roommates. During a resident council meeting, residents expressed concerns about the timing of meal deliveries. A surveyor observed delays and missing items in meal trays, which were confirmed by a CNA. The LNHA acknowledged the issue, highlighting a discrepancy between observed practices and facility policies on resident dignity and meal distribution.
The facility failed to maintain a safe and sanitary environment, with issues including low air temperatures and unclean bathrooms. A resident reported feces left uncleaned for hours, while another had a discolored toilet seat not promptly replaced. The facility's cleaning policy was not adequately followed, leading to these deficiencies.
The facility failed to administer medications within the scheduled time for two residents, leading to a deficiency in professional standards. One resident had multiple medications administered late over several months, and another resident was found with pain patches applied without a physician's order. The facility's policies require medications to be administered within a specific timeframe and only upon a signed order, which was not adhered to in these cases.
A facility failed to provide adequate foot care for a resident with diabetes, gait abnormalities, and Alzheimer's. Despite a care plan requiring daily foot inspections, the resident's feet were observed to be dry with untrimmed toenails. The Podiatrist had not seen the resident since May 2024 due to combative behavior, and the facility was unaware of the resident's do-not-return status. The RDON confirmed that CNAs were responsible for daily foot care, but the facility's policies were not followed, resulting in the deficiency.
A resident with end-stage renal disease did not receive their noon dose of Midodrine on dialysis days due to the facility's failure to adjust medication times. The resident experienced low blood pressure and dizziness during dialysis. Staff interviews revealed a lack of communication and coordination, and the facility's policies prohibited sending medications with residents to dialysis.
The facility failed to serve food at appetizing and palatable temperatures, as observed during a survey. Residents reported meals being cold and unappetizing. Observations showed food temperatures below required levels, with puree green beans at 116°F and puree meatballs at 112°F. Cold items like puree apple sauce were above 40°F. Breakfast sampling revealed unseasoned scrambled eggs and an unidentifiable brown puree. Facility policies on food temperature were not followed.
A facility failed to provide adequate nail care and implement a care plan for a resident with impaired cognition and physical limitations. The resident was observed with medium-length fingernails containing residue, despite requiring assistance with personal hygiene. The care plan included keeping nails short to prevent skin impairment, but this was not followed. Staff interviews confirmed the responsibility for nail care was not met, contrary to facility policies on maintaining personal hygiene.
The facility failed to honor resident dietary preferences, resulting in multiple instances where residents did not receive the correct items on their meal trays. A resident with a swallowing disorder was served bread against their dietary restrictions, and another resident did not receive condiments as indicated on their meal ticket. The facility's policy requires meal accuracy, but this was not consistently followed, leading to dissatisfaction among residents.
Failure to Promptly Notify Practitioner of Abnormal Urine Culture Result
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of an abnormal urine culture result and to follow its own lab notification policy for one resident. The resident was admitted with diagnoses including acute kidney failure, diabetes, and a urinary tract infection, and had a BIMS score of 6/15, indicating severely impaired cognition. A urine culture collected on 11/12/2025 was reported to the facility on 11/14/2025 at 1:49 PM as abnormal. However, progress notes show that antibiotic therapy was not ordered until 11/18/2025, when a nurse practitioner reviewed the urine culture results and initiated treatment. Interviews with the UM/LPN, DON, Regional Nurse, and the nurse practitioner established that facility expectations and policy required nurses to promptly notify the practitioner of abnormal lab results once received. The UM/LPN stated that a four-day delay in notifying the provider of an abnormal lab result would be considered a delay in care and acknowledged that policy was not followed for this resident. The DON and Regional Nurse confirmed that although clinicians can access lab results in the electronic system, nurses are expected to alert them when abnormal results are received, and that lack of notification and documentation means the policy was not followed. The nurse practitioner caring for the resident stated that the provider should have been notified on the date the abnormal result was reported and confirmed that the delay constituted a delay in care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Administer and Document Medications According to Policy
Penalty
Summary
Surveyors identified that the facility failed to administer medications in accordance with accepted nursing standards and the facility's own medication administration policy for four out of seven sampled residents. For one resident with multiple chronic conditions, a one-time dose of Fosfomycin Tromethamine for a urinary tract infection was ordered but not documented as administered, and there was no evidence that the primary care physician (PCP) was notified of the missed dose or any refusal. Additionally, there was no documentation in the progress notes regarding the missed administration or any resulting harm. For three other residents, multiple scheduled medications were not administered within the required time frame of one hour before or after the scheduled dose, as stipulated by facility policy. The medications included treatments for constipation, infection, pain, hypertension, cough, and glaucoma. The medication administration records (MAR) and audit reports showed repeated late administrations, sometimes by several hours, with no documentation explaining the delays or indicating that the PCP was notified. Progress notes for these residents also lacked any mention of the late administrations or communication with the PCP, and there was no documented evidence of harm resulting from the delays. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires medications to be administered within a one-hour window of the scheduled time and that any late or missed doses should be documented, with the PCP notified as appropriate. However, the DON was unable to confirm whether the missed dose for the resident with the UTI was given, and staff interviews revealed inconsistent documentation practices. The facility's policy on medication administration, dated September 2024, was reviewed and confirmed the one-hour administration window requirement.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. During an inspection, it was observed that the handwashing sink at the kitchen entrance lacked a trash can, and the nearest trash can was covered with a lid without a foot pedal. The ovens in the kitchen were heavily soiled, and the Food Service Director (FSD) could not provide documentation of recent cleaning. Additionally, a dietary aide was improperly wearing a beard guard, leaving facial hair exposed, which was corrected after being pointed out by the FSD. In the nursing unit pantries, several issues were identified. In the 100 Unit Pantry, there was no temperature log for the refrigerator and freezer, and an opened carton of thickened water was not dated. The freezer lacked a thermometer, and a container of ice cream was hard to the touch. In the 200 Unit Pantry, the refrigerator temperature was outside the acceptable range, and an opened carton of orange juice was not dated. A clear plastic cup with ice, belonging to a resident, was found in the freezer, which was identified as an infection control issue. Further observations in the kitchen revealed improper hand hygiene practices by the District Food Service Manager (DFSM), who washed his hands for only eleven seconds outside the stream of running water and failed to perform hand hygiene after removing gloves. Interviews with the Infection Preventionist and the Director of Nursing highlighted the importance of proper handwashing techniques and the need for facial hair to be properly restrained. The facility's policies on staff attire, food preparation, and hand hygiene were reviewed, indicating requirements for proper sanitation and food safety practices.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure that residents' dining experiences were conducted in a manner that promoted dignity and respect. This deficiency was observed in one of the five units, specifically the 100 unit. During a resident council meeting, four residents expressed that their meal trays were not served simultaneously with their roommates. On a separate occasion, a surveyor observed that several residents, including a resident and their roommate, did not receive their breakfast trays at the same time. The delay in meal delivery was confirmed by a Certified Nursing Assistant (CNA), who had to call the kitchen for missing trays. Additionally, one resident received a tray missing an item listed on the meal ticket, and the CNA did not provide the tray to the resident until the missing item was addressed. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue, stating that the expectation was for meal trays to be delivered without missing items and for residents in the same room to receive their meals simultaneously. The facility's policies on promoting resident dignity and meal distribution emphasize the importance of timely and accurate meal delivery. However, the observed practices did not align with these policies, leading to a failure in maintaining the residents' right to a dignified dining experience.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by several observations and interviews. During a tour of the 500 Unit, the hallway was found to be chilly with an air temperature of 65 degrees, which is below the comfortable range of 71 to 81 degrees. The Director of Maintenance confirmed the low temperature, and the Licensed Nursing Home Administrator was unaware of the required temperature range. Additionally, air temperature logs from various units showed consistent temperatures below the recommended range. Resident #126 expressed concerns about the cleanliness of their bathroom, noting that feces were left on the toilet and floor by a roommate and were not cleaned by housekeeping until hours later. The resident's cognition was intact, as indicated by a BIMS score of 15 out of 15. Similarly, Resident #106's bathroom was observed with a black substance and yellow stains, and the resident was unsure when it was last cleaned. The resident had moderate cognitive impairment and was continent of bowel and bladder. Housekeeping staff were expected to clean rooms three times during their shift, but there was no staff from 10:00 PM to 7:00 AM, leading to delays in addressing cleanliness issues. Resident #107 reported a discolored toilet seat, which was not replaced despite previous discussions with the LNHA and DM. The resident's cognition was fully intact, with a BIMS score of 15 out of 15. A housekeeper confirmed that the yellow substance on the toilet was urine, not staining, and cleaned it promptly. The DM acknowledged the need to replace the toilet seat but had not documented the task. The facility's Routine Cleaning and Disinfection policy emphasized the importance of maintaining a sanitary environment to prevent infections, but the observed deficiencies indicated a failure to adhere to this policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered within the physician's order scheduled time for two residents, leading to a deficiency in professional standards of practice. Resident #86 had multiple medications scheduled for specific times, but the Medication Administration Audit Report revealed that medications were administered late a total of 47 times in June, 58 times in July, and 34 times in August. The facility's staff, including the LPN/UM and LPN, acknowledged that medications should be administered within a one-hour window before or after the scheduled time, and failure to do so constitutes a medication error. However, the Progress Notes did not indicate that the physician was notified of these late administrations. In another instance, Resident #160 was observed with undated and unidentified pain patches on both knees, which were not supported by a physician's order. The resident, who had a history of chronic pain related to arthritis, reported increased pain, but the facility's records did not show any physician's order for the patches prior to the surveyor's inquiry. The LPN/UM confirmed that the patches should not have been applied without a physician's order, and the facility's Medication Administration policy requires medications to be administered only upon a signed order from an authorized prescriber. The facility's policies on Medication Administration and Medication Errors emphasize the importance of adhering to the six rights of medication administration and ensuring medications are administered according to physician's orders and professional standards. The failure to administer medications within the prescribed timeframe and the application of pain patches without a physician's order highlight deficiencies in the facility's adherence to these standards, as evidenced by the surveyor's observations and interviews with the facility's nursing staff.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident with diabetes mellitus, abnormalities of gait and mobility, and Alzheimer's disease. The resident's comprehensive care plan included daily foot inspections and care, but observations revealed that the resident's feet were dry and the toenails needed trimming. The Licensed Practical Nurse (LPN) and the Hospice Aide (HA) were unsure of when the resident's toenails were last trimmed by the Podiatrist, and the HA admitted to not performing foot care on the day of the surveyor's observation. The resident's representative also noted that the resident's feet were often dry and flaky, requiring her to request foot care from the staff. The facility's Regional Director of Nursing (RDON) confirmed that the resident had not been seen by the Podiatrist since May 2024 due to the resident's combative behavior, and the facility was unaware that the resident was on a do-not-return list. The RDON acknowledged that the Certified Nursing Assistants (CNAs) were responsible for daily foot care and should report any concerns to the nurse. The facility's policies on Activities of Daily Living and Skin Integrity - Foot Care were not followed, as the resident's feet were not properly cared for, leading to the deficiency.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to adjust medication administration times for a resident requiring dialysis, leading to a deficiency. The resident, who had diagnoses including end-stage renal disease and chronic kidney disease, was observed to have missed a scheduled dose of Midodrine, a medication for low blood pressure, on dialysis days. The medication was supposed to be administered three times a day, including at noon, but was not sent with the resident to dialysis, resulting in the resident experiencing low blood pressure and dizziness during dialysis. The resident's comprehensive care plan did not include interventions to adjust medication times around dialysis schedules. The facility's staff, including LPNs and the Regional Director of Nursing, acknowledged that medications should not be scheduled during dialysis times and that the physician should have been contacted to adjust the medication schedule. However, the medication was not adjusted, and the facility's policy prohibited sending medications with residents to dialysis. Interviews with staff revealed a lack of communication and coordination regarding medication administration for dialysis patients. The facility's policies required timely communication with the dialysis facility about medication administration, but this was not effectively implemented. The Licensed Nursing Home Administrator and other regional staff were made aware of the issue, highlighting a gap in adherence to the facility's medication administration and hemodialysis policies.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at appetizing and palatable temperatures, as evidenced by observations and resident feedback. During a Resident Council meeting, four residents reported that their meals were served cold and were not appetizing or recognizable. Subsequent observations by the surveyor revealed that while food temperatures on the steam table were initially above 135°F, the temperatures of the food served to residents were significantly lower. For instance, puree green beans were at 116°F, and puree meatballs were at 112°F, both below the required 135°F. Additionally, cold items like puree apple sauce and mandarin oranges were not served at the appropriate temperature, being above the required 40°F. Further issues were noted during a breakfast test tray sampling, where the scrambled eggs with red and green peppers lacked seasoning and taste, and a brown pureed substance was unidentifiable with a pasty texture. The facility's policies on meal distribution and food preparation, which emphasize maintaining proper food temperatures, were not adhered to. The Licensed Nursing Home Administrator expressed surprise at the residents' concerns, indicating a lack of awareness of the ongoing issues with food temperature and palatability.
Failure to Provide Nail Care and Implement Care Plan
Penalty
Summary
The facility failed to provide adequate nail care to a resident who required assistance with activities of daily living, as well as failed to implement the comprehensive care plan. During an incontinence tour, a surveyor observed a resident with multiple blister-like areas on their lower legs and medium-length fingernails containing reddish-brown residue and thick brown matter. The resident had a history of hemiplegia and hemiparesis following a stroke, chronic kidney disease, and depression, and was assessed to have severely impaired cognition. The resident required moderate assistance with personal hygiene and substantial assistance with other activities of daily living. The resident's comprehensive care plan included interventions to prevent skin impairment, such as keeping fingernails short and assisting with general hygiene. However, the resident's fingernails were not trimmed or cleaned as required, and the care plan was not followed. Interviews with facility staff, including an LPN and the Regional Director of Nursing, confirmed that the CNAs were responsible for maintaining the resident's nail hygiene, but this was not done. The facility's policies on activities of daily living and comprehensive care plans emphasized the need for providing necessary services to maintain personal hygiene, which was not adhered to in this case.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that resident dietary preferences were accurately identified and implemented for several residents. During a resident council meeting, multiple residents reported that condiments and food preferences were not consistently honored on their meal trays. Additionally, when residents requested substitute food items, they experienced delays or did not receive them at all. Specific instances included a resident receiving bread despite a dietary restriction against it, and another resident not receiving margarine, salt, and pepper as indicated on their meal ticket. In one case, a resident with a swallowing disorder and a need for a mechanically altered diet was served a biscuit, contrary to their dietary restrictions. The resident's family had previously reported similar issues, and the facility's Director of Social Services confirmed the discrepancy. The Registered Dietician expressed concern about the risk of aspiration if the resident consumed bread products. Another resident did not receive a ham and cheese sandwich with the specified lettuce and tomato, highlighting a recurring issue of missing items from meal trays. The facility's Meal Distribution policy requires nursing staff to verify meal accuracy and ensure timely delivery, but this was not consistently followed. The Licensed Nursing Home Administrator acknowledged the importance of adhering to meal tickets, diet orders, and resident preferences, emphasizing that it is the residents' right. Despite these expectations, the facility's failure to comply with dietary preferences and orders was evident in multiple instances, as observed by the surveyor.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
