Plaza Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabeth, New Jersey.
- Location
- 456 Rahway Avenue, Elizabeth, New Jersey 07202
- CMS Provider Number
- 315483
- Inspections on file
- 12
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Plaza Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Laundry staff handled soiled and clean linens without appropriate PPE, such as gowns or aprons, and demonstrated confusion about proper procedures for handling isolation and regular laundry bags. Facility policies required the use of gloves and gowns when handling soiled linens, but these practices were not followed or understood by staff.
The facility did not include a plan in its emergency preparedness policy for maintaining generator power and fuel during emergencies. Staff confirmed there was no documented procedure for ensuring emergency power systems would remain operational or for supplying power if the generator failed, as required by federal regulations and referenced standards.
The facility did not meet the required CNA-to-resident staffing ratio for one day shift, providing only 10 CNAs for 87 residents when at least 11 were required. This deficiency was identified through staffing records and confirmed during an interview with the Staffing Coordinator, who stated she was aware of the staffing requirements.
The facility did not ensure that new employees, including RNs, LPNs, and CNAs, received required health examinations by a physician, APN, or PA within the mandated timeframe, as shown by missing or incomplete documentation in 6 out of 10 newly hired staff files. The DON confirmed the lack of proper records and could not provide additional information to demonstrate compliance.
The facility failed to monitor and maintain bed side rails, resulting in a loose and leaning side rail for a resident with severely impaired cognition. The Maintenance Supervisor did not conduct regular bed checks or document side rail inspections, and the facility's policy did not address the risk of entrapment.
The facility failed to update a resident's PASARR level one screening upon receipt of new serious mental health diagnoses. The resident had additional diagnoses added over time, but the PASARR screening was not resubmitted or updated, placing the resident at risk for unmet care needs and not receiving appropriate mental health support.
The facility failed to develop comprehensive care plans for three residents reviewed for side rail use and one resident reviewed for limited range of motion. The care plans did not address the use of bed rails or document refusals to wear a hand splint, despite observations and staff confirmations.
The facility failed to document attempts of alternatives before using bed rails, complete quarterly and annual side rail assessments, and obtain informed consent from residents or their representatives. This deficiency involved three residents, leading to potential risks of injury or entrapment due to improper bed rail use.
The facility failed to inform the NJDOH of an abuse allegation within the mandated two-hour period. The incident involved two residents and occurred on a specific date. The investigation was delayed, and the report was faxed to the NJDOH beyond the required timeframe. Interviews indicated that the abuse protocol was initiated late, and the Administrator was not informed until the following Monday. The facility's policy mandates immediate reporting, but this was not followed, constituting a deficiency.
Failure to Ensure Proper PPE Use in Laundry Handling
Penalty
Summary
The facility failed to ensure that laundry staff had the proper personal protective equipment (PPE) necessary to handle linens in a manner that would prevent the spread of infection. During a survey, it was observed that laundry aides were emptying dryers and handling both clean and soiled linens without the use of gowns or aprons. When questioned, one laundry aide was unaware of any PPE requirements when handling dirty linens, and no gowns or aprons were observed in the laundry area. Another staff member, who was new to laundry and housekeeping, also did not know if PPE was required and attempted to look up the information online during the survey. Further interviews revealed inconsistencies in the use of laundry bags for soiled and isolation linens. While some staff described using water-soluble bags for isolation linens, others were observed using clear plastic bags that were not biodegradable for dirty laundry. There was confusion among staff regarding which bags should be used for isolation and whether PPE was necessary when handling soiled linens. Additionally, laundry aides were seen folding clean linens in a manner that allowed the linens to touch their clothing, and no PPE aprons were available in the area. A review of the facility's policies indicated that standard precautions, including the use of gloves and gowns when handling potentially infectious materials or soiled linens, were required. The policies also specified that soiled linen should be handled with gloved hands and an apron or gown, especially for residents on transmission-based precautions. Despite these written policies, the observed practices in the laundry area did not align with the facility's infection prevention and control program requirements.
Plan Of Correction
483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Element #1. The Policy on Linen Management was updated on 6/4/2025. The laundry room personnel and the [R] were immediately in-serviced by the Infection Preventionist/Director of Nursing on the updated Linen Management Policy, especially regarding PPE and apron/gown use while handling soiled linens. Laundry personnel also received instructions on PPE supplies, gowns, and aprons. These items are readily available in the washing machine area for use by laundry personnel by the Infection Preventionist and the housekeeping director. Element #2 All residents have the potential to be affected by these deficient infection control practices. Element #3. All housekeeping and laundry personnel and the [R] were in-serviced on 6/19/2025 and educated by the Infection Preventionist on laundry and linen handling, and use of PPE/gowns/aprons. A PPE sign-off log will be present for the laundry staff to sign off daily that they are using proper PPE for infection control purposes. Element #4. For three (3) months (from 6/6/25 till 9/6/25), the Housekeeping Director and Infection Preventionist will monitor linen handling (3) times weekly for (4) weeks, then weekly for (2) months, then monthly thereafter for laundry personnel's compliance with infection prevention over the next two quarters. The Infection Preventionist and Nursing Director or designee will review the results of these audits, including any actions taken for correction. All findings to be reported and discussed by the next two QAPI meetings.
Deficiency in Emergency Generator Fuel and Power Maintenance Planning
Penalty
Summary
The facility failed to ensure that its emergency preparedness policy included a plan for maintaining generator power and fuel during an emergency. During a record review, it was found that the Emergency Preparedness Policy did not reference any procedures or strategies for keeping the emergency power systems operational in the event of a power outage or other emergency situations. This omission was specifically noted in the documentation provided by the facility. At the time of the survey, an interview with facility staff confirmed that there was no plan in place to maintain fuel sources for the emergency generator during an emergency. Additionally, there was no documented plan for supplying power to the building if the generator failed to operate during such an event. This lack of planning was acknowledged by the staff member interviewed by the surveyor. The deficiency was communicated to the facility's leadership during the Life Safety Code exit conference. The absence of a comprehensive emergency power and fuel maintenance plan was identified as a failure to meet the requirements set forth by federal regulations and referenced standards, including NFPA 99 and NFPA 110.
Plan Of Correction
Element #1 On 6/6/2025 the Administrator and the Maintenance Director went to do an audit on the facility contract and reports with our vendor Powerhouse, which services our generator. In the binder of contracts, we found the contract dated 1/1/2025, stating clearly that Powerhouse will service our facility with fuel throughout the time the generator is on during an emergency and will replace it with a rental if the current generator malfunctions (see policy attached). Element #2 All residents have the potential to be affected by this deficient practice when life safety reports and contracts are not handy and not in the right binder. Element #3 The administrator in-serviced the US FOIA (b)(6) the same day 6/6/25 about the importance of having all reports and contracts related to lift safety, to be stored in the emergency preparedness binder and to check monthly contract and report from the Vendor Powerhouse who services the generator, that they are up to date with life safety compliance. In addition, the administrator in-serviced the maintenance director on the responsibility of having a contracted vendor service the generator throughout the emergency and having a backup generator in case it malfunctions. Element #4 The Administrator will monitor the Maintenance Director for three (3) months starting 6/9/2025-9/9/2025 weekly on having all life safety reports and contracts handy and placed in the Emergency preparedness binder for all life safety compliance. All findings will be reviewed and discussed in the next Quarterly QAPI committee meeting.
Failure to Meet Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for one out of fourteen day shifts reviewed. Specifically, on one day shift, there were only 10 Certified Nurse Aides (CNAs) present for 87 residents, whereas the required minimum was 11 CNAs. This deficiency was identified through a review of the facility's "Nursing Staffing Report" for the specified weeks. During an interview, the Staffing Coordinator stated she was familiar with the CNA staffing ratios and believed the facility was able to meet them. The facility's staffing policy, reviewed in January 2025, indicated that staffing assignments were developed in accordance with resident needs and relevant regulations. However, the documentation and staffing records reviewed by the surveyor demonstrated that the facility did not meet the mandated CNA-to-resident ratio for at least one shift.
Plan Of Correction
Element #1 The staffing coordinator was in-serviced on 6/20/2025 by the Administrator and Nursing Director; education provided included the importance of meeting the minimum staffing requirements and utilizing all possible avenues to proactively increase staffing in the facility. Element #2 All residents have the potential to be affected by this deficient practice when staffing regulations are not met. Element #3 The staffing coordinator continues to utilize all possible means to increase facility staff, including offering bonuses to staff that refer to CNAs. The staffing coordinator will review the scheduled monthly staffing; any shift not adequately staffed, the staffing coordinator will reach out to our contracted staffing agencies, who assure us they will make all efforts to supply the necessary staff. In addition, the staffing coordinator can offer part-time/per-diem employment to our sister facility's CNA that may be seeking additional working hours. Staffing Coordinator, Nursing Director, and Administrator have listed job opportunities/openings on Indeed and Apploi for hiring nursing staff. Element #4 The Administrator or designee will monitor daily staffing levels with the staffing coordinator for the next 4 months (6/20/2025-10/20/2025). Weekly for the first 4 weeks and after 4 weeks, bi-weekly for 12 weeks. All findings to be reported and discussed by the next two QAPI meetings.
Failure to Ensure Timely Employee Health Examinations for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees received a required health examination by a physician, advanced practice nurse, or New Jersey licensed physician assistant within two weeks prior to employment or upon employment, or within thirty days if a registered nurse assessment was completed upon hire. During a review of 10 randomly selected newly hired employee files, it was found that 6 did not have documentation of a completed physical examination as required by regulation. Specifically, one LPN had no pre-employment health screen or documentation of a physical, and other staff had only partial or incomplete health reports. Interviews with the Director of Nursing (DON) confirmed that the facility's process was to have new hires receive a physical 1 to 2 weeks prior to starting work, typically performed by the facility's medical director. Upon review of the files, the DON acknowledged the missing or incomplete documentation and was unable to provide additional information to demonstrate compliance. The facility's policy also required a health review and physical examination for all new employees, but the records reviewed did not consistently meet these requirements.
Plan Of Correction
Element #1. On 6/5/2025 The facility Human Resource Manager (HR), Administrator and Director of Nursing began an audit on all new hire within the last (1) year to schedule date for each new hire to complete a Register Nurse (RN) assessment or physical examination. The Facility Administrator in-serviced on 6/6/2025 the director of nursing to follow the facilitys policy on completing an Registered Nurse assessment upon prior to hire date and schedule health physician exam with the facilitys medical director for all new employees in the required time frame. Element #2. All residents have the potential to be affected by this deficient practice by not completing registered nursing assessment or physician assessment within the required time frame. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting.
Failure to Monitor and Maintain Bed Side Rails
Penalty
Summary
The facility failed to have an ongoing monitoring of bed side rails as part of their routine maintenance program for one resident and 86 of 87 occupied beds reviewed for side rails. Resident 71, who had severely impaired cognition and was dependent on mobility, was observed with a loose and leaning side rail that created a hand-size gap between the mattress and the rail. The Maintenance Supervisor confirmed that bed checks were not conducted regularly, and side rail inspections were not documented. The side rail was tightened only after the issue was pointed out by the surveyor. The facility's maintenance log for January 2024 did not include entries for bed rail maintenance, and the Maintenance Supervisor admitted to not checking for gaps between the side rail and mattress. The facility's policy on the use of side rails did not address the risk of entrapment, and the Administrator could not provide a bed maintenance/inspection policy. The facility's failure to properly monitor and maintain bed side rails was evident in the condition of Resident 71's bed and the lack of documented inspections. Additionally, the facility's review of a resident roster revealed that 86 of 87 occupied beds had side rails in use, yet there was no evidence of a systematic approach to ensure their safety. The facility's policy on side rails emphasized avoiding their use as physical restraints but did not include measures to prevent entrapment. The lack of proper maintenance and monitoring of bed side rails posed a significant risk to residents' safety, as demonstrated by the observations and interviews conducted during the survey.
Failure to Update PASARR Level One Screening
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASARR) level one was updated upon receipt of new serious mental health diagnoses. Specifically, one resident, who was admitted with diagnoses of bipolar disorder and acquired absence of limb, had additional diagnoses of insomnia, bipolar disorder in partial remission, unspecified psychosis, and schizoaffective disorder depressive type added over time. However, the PASARR level one screening completed prior to admission did not identify any serious mental health diagnoses, and it was not resubmitted or updated to reflect the new diagnoses after admission. During interviews, both the Administrator and the Social Services Director acknowledged that the PASARR level one should have been resubmitted with the updated diagnoses. The facility's policy on PASARR did not address the procedure for correcting an incorrect admission screening or resubmitting the screening if a serious mental health diagnosis was received after admission. This oversight placed the resident at risk for unmet care needs and not receiving appropriate and necessary mental health support and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with goals and approaches for three residents reviewed for side rail use and one resident reviewed for limited range of motion. For Resident 32, the care plan did not address the use of bed rails despite the resident being totally dependent on staff for bed mobility and having bilateral full quarter upper rails in the up position during multiple observations. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 33, who was cognitively intact and required staff supervision for bed mobility, also had bilateral upper full quarter bed rails that were not addressed in the care plan. The resident was not advised of the risks and benefits of side rails. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 71, who had severe cognitive impairment and limited range of motion, had side rails included only as an intervention and not as a full care plan with goals and objectives. Additionally, the resident's refusal to wear a hand splint was not documented in the care plan, despite observations and staff interviews confirming the refusals. The MDS Coordinator and Director of Nursing confirmed that the refusals should have been care planned. The facility's policies on comprehensive care plans and side rail use were not followed, leading to these deficiencies.
Failure to Document Alternatives and Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that three residents (R32, R33, and R71) had documented attempts of alternatives before using bed rails, completed quarterly and annual side rail screen assessments according to facility policy, and informed consent from the resident or their representative regarding the risks and benefits of bed rail use. This deficiency was identified through observations, record reviews, interviews, and facility policy reviews. The lack of proper documentation and informed consent could potentially put residents at risk for injury or entrapment due to bed rail use. For Resident 32, the facility did not provide documentation of alternative measures utilized prior to the use of side rails. The resident had severe cognitive impairment and was observed with bed rails up on multiple occasions. The side rail assessment form dated 10/02/19 indicated the need for side rails but did not include any recent assessments or informed consent documentation. Similarly, Resident 33, who was cognitively intact, had been using bed rails for nine years without being informed of the risks and benefits. The side rail assessment form dated 08/14/15 was the only documentation provided, and no recent assessments or informed consent were available. Resident 71, who had severe cognitive impairment and physical limitations, was observed with loose and improperly installed side rails. The side rail assessment dated 07/07/22 did not include the risk of entrapment or the specific condition for side rail use. No informed consent was found in the resident's records. Despite the facility's policy requiring side rail assessments upon admission, quarterly, and annually, as well as informed consent, these procedures were not followed for the three residents reviewed, leading to the identified deficiency.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to inform the New Jersey Department of Health (NJDOH) of an abuse allegation within the mandated two-hour period. The incident involved two residents, R73 and R41, and occurred on 05/20/23. The investigation summary provided by the facility revealed that the residents were questioned on 05/22/23, and the investigation concluded on 05/23/23. The report was faxed to the NJDOH on 05/25/23, which was beyond the required reporting timeframe. Interviews with the Social Service Director (SSD) and the Licensed Practical Nurse (LPN) indicated that the abuse protocol was initiated on 05/22/23, and the Director of Nursing (DON) was informed immediately after the incident. However, the Administrator was not informed until the following Monday, and the NJDOH was not notified within the required two-hour window. The facility's policy on abuse and neglect, revised in December 2023, mandates immediate reporting of any abuse allegations to the appropriate authorities. Despite this policy, the facility did not adhere to the required reporting timeframe. The Administrator acknowledged that the NJDOH should have been informed within two hours of the accusation of physical contact between the residents. The reportable event record indicated that the alleged abuse occurred at 4:20 PM on 05/20/23, but the event was not deemed significant and was not called in immediately. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
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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