Shore Pointe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eatontown, New Jersey.
- Location
- 139 Grant Ave, Eatontown, New Jersey 07724
- CMS Provider Number
- 315177
- Inspections on file
- 15
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Shore Pointe Care Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with a history of wandering eloped from the facility without staff knowledge. The resident was last seen by nursing staff, and a search was initiated after the resident was found missing. Despite existing policies, only wandering risk assessments were performed, and the resident was not placed on frequent monitoring. Staff were unsure how the resident exited, and there was no clear protocol for increased supervision for exit-seeking behavior, resulting in the resident being found by police in a nearby town.
A facility failed to maintain a resident's nutritional and hydration status, resulting in significant weight loss over six months. The resident's dietary preferences were not adequately addressed, and the facility relied on infrequent family visits for nutritional support. Staff did not consistently monitor or record the resident's intake of prescribed supplements, and there was a lack of suitable dietary interventions.
The facility failed to ensure menus were reviewed for nutritional adequacy, leading to discrepancies in dietary care for residents. Menus were not signed by a qualified nutrition professional, and residents received meals that did not match their preferences or physician's orders. The dietitian admitted to a lack of a formal follow-up system to ensure dietary changes were implemented.
The facility failed to ensure the Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program, as the IP was also acting in another role and spent limited time on IP duties. Despite the IP's assurance of up-to-date infection control measures, the facility did not comply with the requirement for a full-time IP dedicated solely to infection prevention and control.
The facility did not maintain clear exit discharges, as ice and snow were observed on pathways at multiple exits, including those by the employee entrance, Kitchen, and Room 105. Staff confirmed awareness of the need for snow and ice removal, affecting all 131 residents.
The facility failed to maintain its sprinkler system per NFPA 25 standards, affecting all 131 residents. Ice buildup was found on a sprinkler head in the freezer, and a missing escutcheon plate was noted in the dishwashing room. The facility lacked documentation for weekly inspections of the dry sprinkler system gauges.
The facility was found to have unsealed penetrations in smoke barriers, including gaps and overcuts in various locations such as near the Dining Room, Room 210, the Korean Office, the Break Room, and the Beauty Salon. This repeat deficiency, previously cited in a past survey, was confirmed by a facility representative who was unaware of the issue, potentially affecting all 131 residents.
The facility failed to maintain smoke barrier doors, affecting 42 residents. A door in the corridor by Room 104 did not close properly due to rubbing the floor, and a door between Rooms 210 and 211 lacked a self-closing device. Staff were unaware of these issues before the survey.
The facility failed to provide documentation of the annual tests and inspections of fire door assemblies as required by NFPA 80. During a record review, it was found that the documentation was missing from the Life Safety Code Survey Binder. Despite requests at various points, the documentation was not provided, and a staff member confirmed the inability to locate it. This deficiency had the potential to affect all 131 residents.
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99. This deficiency could potentially affect all 131 residents, as the facility has a mix of hospital-grade and non-hospital-grade receptacles in resident rooms. An interview confirmed the facility's inability to locate the missing documentation.
The facility failed to maintain its generator according to NFPA 110 standards, as it could not provide documentation of the annual fuel quality test for the diesel generator. This deficiency, confirmed during an interview, had the potential to affect all 131 residents, as the generator is crucial for emergency power.
The facility failed to maintain a sanitary environment, as observed with a resident's recliner and another's wheelchair having dried substances, and an overbed table with brownish spots. Despite a cleaning schedule, these items remained uncleaned, indicating lapses in maintaining a homelike environment.
A facility failed to report and investigate a condition involving a resident until prompted by a surveyor. CNAs noticed the condition but did not report it, assuming it was known. The facility's policies required immediate reporting of such incidents, but there was a lapse in communication. The resident's medical records showed no assessment of the condition until after the surveyor's inquiry.
A registered nurse in an LTC facility borrowed medication from another resident's supply for a resident due to unavailability in the medication cart. The nurse did not follow the protocol of contacting the pharmacy or physician for guidance. Interviews revealed a lack of clarity regarding the policy on borrowing medications, although staff were instructed not to engage in this practice.
A facility failed to maintain a medication error rate below 5%, as observed during a medication pass where a nurse administered the wrong dose of a medication to a resident. The error was identified when the nurse applied a medication patch with incorrect strength to two sites on the resident. Despite inservice training on medication administration, the facility's policy did not ensure the correct dosage was administered.
The facility failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, as observed during rounds on two units. In one case, a staff member checked a resident's condition without a gown, despite signage indicating its necessity. In another instance, a staff member performed care without a gown, later claiming she had stepped out to retrieve an item. Both residents required Enhanced Barrier Precautions due to their diagnoses, highlighting non-compliance with infection control policies.
The facility failed to notify CMS and obtain authorization for a name change from "Gateway Care Center" to "Shore Point Care Center." The surveyor observed the incorrect name on the facility's signage and business cards. Facility representatives admitted the name change was for marketing purposes and had not been reported to CMS or the New Jersey Department of Health. The facility decided to revert to the original name.
The facility failed to meet New Jersey's staffing ratios for CNAs across multiple shifts and did not enforce mask-wearing for employees with medical exemptions from the influenza vaccine. Observations and interviews revealed consistent understaffing and non-compliance with mask policies, indicating lapses in regulatory adherence.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A severely cognitively impaired resident with a history of wandering behaviors eloped from the facility without staff knowledge. The resident, diagnosed with unspecified dementia, mood disturbance, anxiety, and Alzheimer's disease, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The resident was last observed by a registered nurse at approximately 4:45 p.m., and was discovered missing by their assigned certified nurse aide at around 5:05 p.m. Despite a search initiated by staff and the activation of a Code Gray (elopement/missing person code), the resident was not found within the facility. The local police later contacted the facility, having found the resident in a nearby town approximately three miles away, and returned the resident to the facility. The facility's policy required systematic monitoring and management of residents at risk for elopement or unsafe wandering, including identification, assessment, and implementation of interventions to reduce risks. However, interviews with staff and review of facility documents revealed that only wandering risk assessments were conducted, not elopement risk assessments. The care plan for the resident included interventions for wandering and elopement risk, but staff did not place the resident on 15-minute checks, as they were not considered exit-seeking. The Director of Nursing and the Licensed Nursing Home Administrator both stated that the facility did not perform elopement risk assessments, only wandering risk assessments, and that the care plan may have mischaracterized the resident's risk. Staff statements indicated that the resident was known to wander and pace the unit, but there was no clear protocol for increased supervision or monitoring for exit-seeking behavior. The facility was unable to determine how the resident exited the building, as all doors were reported to be locked. The receptionist did not observe the resident leaving through the front entrance, and dietary and housekeeping staff did not recall seeing the resident exit. The lack of adequate supervision and failure to properly assess and monitor for elopement risk led to the resident's unsupervised departure from the facility.
Removal Plan
- All residents were visually checked to be sure they were safe and all staff facility wide were informed to check all residents to ensure safety.
- A complete head count of residents was conducted, and all other residents were accounted for.
- Audit to review the residents at risk of elopement assessments was conducted.
- Full house audit for residents at risk for elopement with review and revision of the care plans was conducted. This included implementation of interventions consistent with the residents' needs, goals and care plans to reflect current risk of elopement.
- The residents were monitored when noted in the common areas such as dayroom, dining rooms, and attending activities.
- The facility has now increased the monitoring to Q 15-minute monitoring Q shift.
- Staff were re-educated on the Elopement Policy and Procedure.
- At risk residents for elopement are identified with a discreet visual indicator listed under special instructions in the residents EMR (Electronic Medical Records).
- Elopement binders located on each unit and front entrance were reviewed and revised with the resident's profile picture in color.
- All exits, windows, and keypads were checked and functioning.
- Keypad codes were changed.
- Facility added monitoring rounds every 15 minutes for identified high-risk residents to maintain safety.
- Audit monitoring tool sheets will be completed by direct care staff and completion reviewed by the DON/Designee.
- Facility implemented a new protocol for Family/Vendors/Visitors to sign in upon entering and sign out prior to exiting the facility.
- Director of Maintenance conducted a full house audit of the keypad doors and windows noted secured, and functioning.
- The facility Director of Maintenance, Director of Housekeeping, and the Administrator will maintain the keypad codes.
- Director of Maintenance will revise the schedule for changing keypad codes, making changes more frequent to monthly to the exit doors located at the end of the units.
- Visitor Communication Signage is located at the vestibule alerting visitors and staff to monitor the surroundings prior to entering the lobby to ensure the safety of the residents.
- Facility Educator provided mandatory re-education for staff (nursing, direct care, dietary, housekeeping, maintenance, and department heads) on elopement prevention, supervision, and emergency response.
- Ongoing training will be provided with any staff on all shifts or vacations prior to the start of the next schedule shift.
- Facility Educator will continue to incorporate the Elopement prevention training into new hire orientation and annual education.
- Facility Educator provided mandatory training on the new implementation of identifying residents at risk for elopement under special instructions in the residents EMR (Electronic Medical Records).
- Facility Administrator conducted QAPI Ad Hoc (Quality Assurance and Performance Improvement) meeting with the Interdisciplinary Team to review the residents at risk for elopement care plans, interventions and elopement assessments.
- Quarterly elopement drills will be conducted to reinforce emergency response.
- Monthly review of elopement risk assessments by the interdisciplinary team will be conducted and revised as needed.
- A QAPI (Quality Assurance and Performance Improvement) has been initiated to report on the above monitoring and auditing procedures.
- Results of the audits and findings, if any, will be presented to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and revised as deemed appropriate.
- Monitoring/Auditing and reporting will continue for a minimum of three months.
Failure to Maintain Resident's Nutritional and Hydration Status
Penalty
Summary
The facility failed to maintain the nutritional and hydration status of a resident, as evidenced by the lack of appropriate interventions and monitoring. The resident experienced significant weight loss over a period of six months, which was not adequately addressed by the facility's staff. Despite the resident's preferences and dietary needs being known, the facility did not provide suitable alternatives or ensure the resident received the necessary nutrition and hydration. Observations revealed that the resident often had untouched meals and supplements, and there were instances where no lunch tray was provided. The facility relied on the resident's family to bring in preferred foods during their infrequent visits, which was not a reliable intervention. The staff failed to consistently monitor and record the resident's intake of physician-prescribed supplements, and there was no evidence of weekly monitoring of the resident's nutritional status. Interviews with staff indicated a lack of awareness and action regarding the resident's nutritional needs. The staff did not implement or document necessary interventions, such as offering suitable substitutes or adjusting the resident's diet to meet their preferences and needs. The facility's policies on weight management and nutritional procedures were not followed, leading to the resident's continued weight loss and inadequate nutritional support.
Plan Of Correction
Element 1 Resident #67's diet was liberalized to regular. [R]NJ Exec Order 26.4b1 was increased from three times a day to four times a day. The physician added an [R]NJ Ex Order 26.4(b)(1) and provided [R]NJ Ex Order 26.4(b)(1) that the resident enjoys based on their [R]EXOT preferences and enjoyment of a [R]. Element 2 [R]NJ Ex Order 26.4(b)(1) All residents have the potential to be affected by this deficiency. Element 3 The facility has hired an experienced Dietician with extensive knowledge in the management of residents with weight loss. Additionally, a Weight Loss audit is being conducted to review newly identified significant weight losses (5% weight loss in 30 days, or 10% weight loss in 180 days) in order to remain in compliance with F692. This audit began on 1/27/2025 and is reviewing all residents in the facility. The results of the audit indicated one newly identified weight loss in the month of January. Element 4 To maintain and monitor ongoing compliance, the Weight Loss audit is being conducted by the Dietician or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Menu Review and Nutritional Adequacy Deficiencies
Penalty
Summary
The facility failed to ensure that menus were reviewed and approved for nutritional adequacy in accordance with nationally accredited standards. During a kitchen tour, it was revealed that the facility followed a three-week cycle menu, but the menus provided were not signed or dated by a qualified nutrition professional to confirm their adequacy. Additionally, the facility's dietitian was unaware of who developed or reviewed the menus, indicating a lack of oversight and accountability in the menu planning process. The surveyors found discrepancies in the dietary care provided to three residents. For instance, one resident's care plan included a physician's order for a specific dietary supplement twice a day, but this was not reflected in the resident's dietary records or meal tickets. Similarly, another resident's preferences and physician's orders were not accurately documented or followed, leading to inconsistencies in the meals served. These issues were compounded by the dietitian's admission that there was no formal system to ensure that dietary recommendations and updates were implemented. Interviews with residents and staff further highlighted the deficiencies. Residents reported receiving meals that did not match their documented preferences, and the dietitian acknowledged the lack of a formal follow-up system to verify that dietary changes were executed. The facility's electronic medical record system was supposed to link with the food service software to automatically update dietary information, but manual errors and communication breakdowns persisted, resulting in unmet nutritional needs and preferences for the residents.
Plan Of Correction
Element 1 This deficiency was corrected by having the NJ Ex Order 26.4(b)(1) and NJ Ex Order 26.4 Menus reviewed and approved by a Licensed Dietitian. Additionally, a Food Preference audit was performed to ensure that all resident food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Food Preference audit was performed on 1/27/2025 to ensure all residents' food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. During the audits, seven residents expressed additional food preferences, which were immediately added to the meal ticket system. Additionally, the food preference audit will continue to ensure that the facility remains in compliance with F803. Element 4 To maintain and monitor ongoing compliance, a Food Preference audit is being conducted by the dietitian or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Inadequate Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program (IPCP) as required by regulations. The IP, who was also acting in another role, indicated that she spent only an hour to an hour and a half each day on her IP duties, with the majority of her time spent on other responsibilities. This was contrary to the requirement that facilities with 100 or more beds must hire a full-time employee in the infection prevention role with no other responsibilities. The surveyor's interviews revealed that the IP position was part-time and temporary, and there was uncertainty about whether the allocated hours were sufficient for the role. Despite the IP's assurance that infection control measures were up to date, the facility did not comply with the directive to have a full-time IP dedicated solely to infection prevention and control, as evidenced by the job description and position action form provided by the facility.
Plan Of Correction
Element 1 Upon identification of the issue regarding the employee covering Infection Prevention (IP) and Unit Manager duties, the employee's role and responsibilities were reviewed. A formal assessment was completed to ensure the employee was properly supported in these dual roles and was provided with the necessary training and resources. The facility transitioned a current staff nurse to the dedicated Unit Manager position effective 1/27/2025, and the employee covering these roles was transitioned back to their original full-time duties as the dedicated Infection Preventionist with no other responsibilities. Element 2 All residents have the potential to be affected. Element 3 The facility has established a more structured planning protocol to ensure continuity of care and leadership in all key roles, including Infection Preventionist and Unit Manager. A permanent, qualified Infection Preventionist and Unit Manager have been appointed immediately to ensure clear leadership and responsibility in these areas. Element 4 The facilities leadership (Administrator and Director of Nursing) will meet with the Infection Preventionist and Unit Manager monthly for continued support in their roles and will be reassessed to ensure they are meeting the requirements of their positions.
Failure to Maintain Clear Exit Discharges
Penalty
Summary
The facility failed to maintain means of egress free of obstructions as required by NFPA 101 Life Safety Code (2012 Edition), Section 7.1. Observations made on January 7, 2025, revealed ice and snow buildup on the pathways from the building to the public way at multiple designated exit discharges, including those located by the employee entrance and 200 Hall, the Kitchen, and Room 105. During interviews conducted at the time of the observations, the staff confirmed the findings and acknowledged awareness that the snow and ice on the sidewalks needed to be removed. This deficiency had the potential to affect all 131 residents of the facility.
Plan Of Correction
Element 1 This deficiency was corrected by shoveling the snow and salting all exit discharge pathways from the building to the public way. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Snow/Ice audit is being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K271. This audit will be completed by making rounds around the facility. Element 4 The Snow/Ice audit is being monitored by the Administrator or designee weekly for four weeks, then every other week for four weeks, and then monthly for one month. If the facility experiences any snow or icy conditions, the audit will be performed on that day, as well as the following day to ensure safe conditions. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for three months to the Quality Assurance Performance Improvement team for review and action as necessary.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, which had the potential to affect all 131 residents. During an observation, ice buildup was found on the deflector of a sprinkler head inside the walk-in freezer. The facility was aware of this issue prior to the survey. Additionally, in the dishwashing room closet, the escutcheon plate was missing from a sprinkler, a fact also known to the facility before the survey. Further review of the facility's sprinkler system records revealed a lack of documentation for weekly inspections of the gauges for the dry sprinkler system. During an interview, the facility confirmed the absence of these records and acknowledged their inability to provide documentation of the weekly inspections during the survey.
Plan Of Correction
Element 1 This deficiency was corrected by removing the ice build up on the sprinkler head deflector located inside the walk-in freezer, replacing the escutcheon plate on the sprinkler head located in the dishwashing room closet, and performed weekly inspections of the gauges for the dry sprinkler system. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Sprinkler Head audit and Dry Sprinkler System Gauge audit are being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K353. This audit is being completed by making rounds within the facility to ensure they are being completed. Element 4 The Sprinkler Head audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. The Dry Sprinkler System Gauge audit will be performed weekly on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Unsealed Smoke Barriers in Facility
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, as required by the NFPA 101 Life Safety Code (2012 Edition) Section 8.5. During observations conducted on January 7, 2025, several unsealed gaps and overcuts were identified in various locations throughout the facility. These included a two-inch unsealed overcut around conduit penetrations near the Dining Room, a similar unsealed overcut around wire penetrations by Room 210, and a six-inch unsealed gap at the top of the wall in the Korean Office. Additional unsealed gaps were found in the Break Room and near the Beauty Salon. The deficiency was confirmed during an interview with a facility representative, who acknowledged the findings and admitted that the facility was unaware of the unsealed gaps and penetrations in the smoke barriers. This issue was a repeat deficiency, having been previously cited during the Life Safety Code Survey conducted on September 29, 2023. The unsealed penetrations in the smoke barriers had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by sealing all openings within the smoke barriers including: the two inch overcut around two conduit penetrations above the ceiling located in the corridor by the dining room, the two inch overcut around the blue wire penetrations above the ceiling located in the corridor by room 210, the six inch gap at the top of the wall above the ceiling located inside the Korean Office, the two inch gap at the top of the wall above the ceiling located inside the break room, and the four inch gap in the wall above the ceiling located in the corridor by the Beauty Salon. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Smoke Barrier audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K372. This audit will be completed by making rounds within the facility to view the smoke barriers. Element 4 The Smoke Barrier audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 (Life Safety Code) 2012 Edition, Section 8.5, which had the potential to affect 42 residents. During an observation, a smoke barrier door located in the corridor by Room 104 did not close smoke tight when released from the magnetic hold open device, stopping halfway between the open and closed position. The facility staff confirmed the door was rubbing the floor and was unaware of this issue prior to the survey. Additionally, another observation revealed that a smoke door located in the bathroom between Rooms 210 and 211 lacked a self-closing device. The facility staff confirmed the absence of the self-closing device and stated they were unaware of this deficiency before the survey.
Plan Of Correction
Element 1 This deficiency was corrected by preventing the door from rubbing against the floor in the corridor near room 104, allowing the smoke barrier door to fully close and latch. Additionally, a self-closing device was installed on the bathroom door between rooms 210 and 211. Element 2 This deficiency has the potential to affect forty-two residents on the East Wing. Element 3 A Smoke Barrier Door audit is being conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K374. This audit will be completed by making rounds within the facility. Element 4 The Smoke Barrier Door audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Missing Documentation for Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual tests and inspections of the fire door assemblies as required by NFPA 80, Section 5.2. This deficiency was identified during a record review conducted on January 7, 2025, at 3:30 PM, where it was discovered that the documentation was missing from the facility's Life Safety Code Survey Binder. The surveyor requested this documentation at multiple points, including the entrance conference, during the record review, and at the exit conference, but it was not provided. During an interview at the same time, a staff member confirmed the finding and stated that the facility was unable to locate the missing documentation during the survey. This deficient practice had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by performing tests and inspections of the fire door assemblies. Element 2 All residents had the potential to be affected by this deficiency. Element 3 A Fire Door Assembly audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K761. This audit is being completed by making rounds within the facility. Element 4 The Fire Door Assembly audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Document Electrical Receptacle Testing
Penalty
Summary
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99 (2012), Section 6.3.4. This deficiency was identified during a review of the facility's Life Safety Code Survey documentation binder, where the necessary documentation was not available. The surveyor requested this documentation at multiple points, including the entrance conference, document review, and exit conference, but the facility was unable to produce it. The deficiency has the potential to affect all 131 residents in the facility, as the documentation pertains to both hospital-grade and non-hospital-grade receptacles in resident rooms. An interview with a facility representative confirmed the finding and revealed that the facility could not locate the missing documentation, indicating a lapse in maintaining required records for electrical system maintenance and testing.
Plan Of Correction
Element 1 This deficiency was corrected by conducting performance tests on the receptacles. Element 2 This deficiency has the potential to affect all residents. Element 3 A Receptacle audit was conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K914. This audit is being completed by making rounds within the facility. Element 4 The Receptacle audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), specifically Section 8.3.8. During a record review, it was discovered that the facility did not provide documentation of the annual fuel quality test for the diesel generator. This documentation was requested multiple times, including at the entrance conference, during the record review, and before the exit conference, but was not provided. An interview conducted on the same day confirmed the finding, with a staff member acknowledging the facility's inability to locate the missing documentation. This deficiency had the potential to affect all 131 residents in the facility, as the generator is a critical component of the facility's emergency power system.
Plan Of Correction
Element 1 This deficiency was corrected by performing the fuel quality test of the diesel generator. Element 2 This deficiency has the potential to affect all residents. Element 3 A Generator audit is being conducted by the Maintenance Director to ensure the facility remains in compliance with K918. This audit is being completed by reviewing the inspection book. Element 4 The Generator audit is being monitored by the Administrator or designee every three months for the next twelve months to ensure that this test is being performed annually. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for twelve months to the Quality Assurance Performance Improvement team for review and action as necessary.
Facility Fails to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations made by a surveyor. Resident #90 was observed in a recliner with dried brown substances on the sides of the chair on multiple occasions. Despite the presence of facility staff assisting the resident with lunch, the recliner remained uncleaned over several days. The resident's admission record and recent Minimum Data Set (MDS) indicated certain diagnoses, but specific details were redacted. Similarly, Resident #125 was observed in a wheelchair with dried brownish and white substances on the left wheel. The surveyor noted this during lunch assistance, and although a staff member acknowledged the issue and promised to notify housekeeping, the wheelchair remained uncleaned the following day. The resident's admission record and MDS also contained redacted information regarding diagnoses. Resident #124 was observed with an overbed table that had multiple dried brownish spots on the bottom. Despite a housekeeper's claim of a cleaning schedule, the table remained uncleaned. The facility's policy on wheelchair and recliner cleaning was reviewed, indicating a monthly cleaning schedule, but the actual practice seemed inconsistent. Interviews with staff revealed that cleaning was often adjusted based on immediate needs, but the observed deficiencies suggested lapses in maintaining a clean environment.
Plan Of Correction
1/27/25 Element 1 It is the practice of the facility to ensure that all residents reside in a safe, clean, homelike environment. The deficiency was corrected by performing a facility wide sanitization audit of all resident care areas, including overbed tables, wheelchair and Geri chairs; all areas that were identified to be dirty were immediately cleaned. Element 2 All residents are potentially affected by this deficiency. Element 3 The systemic changes that were implemented to prevent this deficiency from occurring again include: increasing sanitization rounds on resident care areas and wheelchairs as part of the facilities Guardian Angel Program. The Guardian Angel program is a comprehensive auditing tool used to identify issues throughout the facility. This program was expanded to include all resident care areas, with special attention to wheelchairs, Geri chairs, and overbed tables, in order to remain in compliance with F584. Additionally, the Housekeeping Director and Administrator make daily rounds to ensure identified issues are corrected in a timely manner. Element 4 To maintain and monitor ongoing compliance, the Guardian Angel/Homelike Environment Audit is being conducted by all Department Heads once a week for two months, then once every other week for two months, and then monthly for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Report and Investigate Resident Condition
Penalty
Summary
The facility failed to report and initiate an investigation for a specific incident involving a resident, identified as Resident #47, until prompted by a surveyor's inquiry. The deficiency was identified when the surveyor observed Resident #47 in bed and attempted to interview them, but the resident was unresponsive. Subsequent interviews with Certified Nursing Assistants (CNAs) revealed that they had noticed a condition on the resident but did not report it, assuming it was already known by the staff. Further investigation showed that the facility had not conducted a proper investigation into the incident involving Resident #47, despite having policies in place that required immediate reporting of any suspected abuse, neglect, or injuries of unknown origin. The CNAs involved had received training on these policies, but there was a lapse in communication and reporting, as they did not inform the nursing staff about the resident's condition. The Licensed Practical Nurse (LPN) and other staff members were unaware of the issue until it was brought to their attention by the surveyor. The resident's medical records and individualized plan of care indicated that they required assistance with activities of daily living and had certain medical conditions. However, there was no documentation of an assessment being completed for the resident's condition until after the surveyor's inquiry. The facility's failure to adhere to its own policies and procedures for reporting and investigating incidents led to the deficiency being cited by the surveyor.
Plan Of Correction
Element 1 Upon discovering the NJ Exec Order 26.4b1 on resident #47, immediate steps were taken to assess the injury, ensure the residents' safety, and provide appropriate care (cleaning, applying any necessary treatment). The resident was closely monitored for any further changes in condition. The Ex was promptly documented on in the resident's medical chart. On the same day, an incident report was created to ensure a complete record of the event. An in-service was completed by the Assistant Director of Nursing for all nursing staff regarding notifying the nurse immediately of any skin alterations, as well as Abuse and Neglect policy and reporting. Element 2 The standard was not met for resident #47. All residents that are at risk for skin alterations have the potential to be affected by this deficient practice. Element 3 All nursing staff were re-educated on the facility's Abuse and Neglect policies and procedures for reporting injuries and incidents. In addition, they were re-educated on the facilities abuse reporting and prevention policy. Emphasis will be placed on the importance of documenting every skin alteration. Element 4 Incident audits have been conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance and to ensure all injuries are documented and reported appropriately. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Borrowing from Another Resident's Supply
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by borrowing medication from another resident's supply. This deficiency was identified during a medication administration observation involving a registered nurse (RN#1) and Resident #122. RN#1 was observed administering medication to Resident #122 and admitted to borrowing the medication from another resident's supply because the required medication was not available in the medication cart for Resident #122. The surveyor reviewed the electronic medication administration record (EMAR) and confirmed that RN#1 had administered the borrowed medication without proper authorization. The nurse educator at the facility confirmed that nurses were not allowed to borrow medications from other residents and that the facility had a stock of over-the-counter medications available for residents with physician orders. Despite this, RN#1 did not follow the protocol of contacting the pharmacy or the physician for guidance when the medication was unavailable. Interviews with facility staff, including the nurse educator and other nursing staff, revealed a lack of clarity regarding the policy on borrowing medications. The nurse educator stated that borrowing medications could lead to medication errors and emphasized that nurses were instructed not to engage in this practice. However, there was no documented policy available at the time of the survey to reinforce this directive.
Plan Of Correction
Element 1 Upon identification of the error to resident #122 U.S. FOIA (b)(6), immediate corrective actions were implemented. The resident's condition was assessed for any adverse effects resulting from the NJ Exec Order 26.4b1 administration. The physician was notified and consulted to determine if any additional medical intervention was required. The physician initially provided a one-time order for the NJ Exec Order 26.4b1 that was applied. Additionally, the order was permanently revised to [R]. The nurse who administered the incorrect [R] was counseled and re-educated on the proper administration procedures for [R], including verifying the correct strength per the physician's order. A medication error form was completed right away, and she was successfully re-med passed by the Assistant Director of Nursing. All nurses were educated on the following: not to borrow any medications, NJ Exec Order 26.4b1 are over the counter and [R] is a prescription, and the right of medication pass (right patient, right drug, right dose, right dosage form, right route, right time). A follow-up monitoring plan was implemented to ensure the residents' comfort and safety were maintained and effective with the new order for [R]. A review of all residents receiving NJ Exec Order 26.4(b)(1) treatments, including NJ Exec Order 26.4b1, was conducted. An audit was completed ensuring all residents' [R] were in stock and had the appropriate dose in place. Element 2 All residents receiving topical analgesic treatments, including lidocaine patches, are at risk. Element 3 All nurses were educated on the proper procedure of medication administration by the Assistant Director of Nursing. RN#1 was med passed from the facility's pharmacy consultant with a 0% medication error rate on 1/24/25. A medication error form was completed right away for RN#1, and she was successfully re-med passed by the Assistant Director of Nursing. The Pharmacy consultant will continue to do their monthly unit inspections and medication passes. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance for residents who are receiving patches to ensure the right dosage was applied and available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without a medication error rate of 5% or more. During a morning medication administration observation, a surveyor observed three nurses administering medications to six residents. Out of 27 opportunities, two errors were observed, resulting in a medication administration error rate of 7.4%. The errors were identified for one resident, who was administered medications by one of the three nurses observed. The deficiency was evidenced when a Registered Nurse (RN#1) administered the wrong dose of a medication to a resident. The RN was observed applying a medication patch to two different sites on the resident, but the strength of the medication applied was not as ordered. The RN acknowledged the error after the surveyor pointed it out, and it was confirmed that the physician was contacted regarding the error. The facility's medication administration policy did not reflect procedures for ensuring the administration of the correct dosage. The surveyor's review of the resident's medical record revealed active physician orders for the medication to be applied to two different sites. The facility's staff, including the person responsible for nursing staff education, acknowledged the error and stated that the nurse should have contacted the physician if the correct medication was not available. The facility had provided inservice training on medication administration, but the error still occurred, indicating a lapse in following the correct medication pass procedures.
Plan Of Correction
Element 1 Upon identifying the error with the applied to Resident #122, immediate corrective actions were taken. The resident's condition was assessed to determine if any adverse effects occurred due to the incorrect patch. The physician was promptly notified and consulted to evaluate whether any further medical intervention was necessary. The physician initially issued a one-time order for the [R], which was applied. Following this, the order was permanently revised to the NJ Exec Order 26.4b1. The nurse who administered the incorrect patch was counseled and retrained on the proper procedures for administering lidocaine patches, including verifying the correct strength based on the physician's order. A medication error form was completed immediately, and the nurse was successfully re-med passed. Element 2 All residents receiving topical analgesic treatments, such as lidocaine patches, may be at risk. Element 3 Additionally, all nursing staff were educated on key points, including: not borrowing medications, the distinction between OTC 4% lidocaine patches and prescription 5% patches, and the rights of medication administration (right patient, right drug, right dose, right dosage form, right route, and right time) by the Assistant Director of Nursing. A follow-up monitoring plan was also implemented to ensure the residents' comfort and safety with the newly revised order for the 4% lidocaine patch. A comprehensive review of all residents receiving topical analgesic treatments, including lidocaine patches, was conducted. An audit was completed to ensure that all patches in stock were properly dosed and matched the physician's orders. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance that all medications are administered according to physician orders. All residents receiving patches will be verified to ensure the correct dosage was applied and is available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing, and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Adhere to PPE Protocols for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) as per the facility policy and acceptable standards of infection control practice. This deficiency was observed during rounds on two units, involving two unsampled residents. In the first instance, a staff member approached a resident lying in bed, donned gloves, and checked the resident's condition without wearing a gown, despite a sign indicating that both gloves and a gown were required for high-contact resident care activities. The staff member acknowledged the oversight when questioned by the surveyor. In the second instance, another staff member was observed performing care on a different resident without wearing a protective gown, although a sign indicated that a gown was required. The staff member later explained that she had stepped out of the room to retrieve an item and did not wear a gown upon returning to complete the care. The surveyor noted that there was no evidence of a discarded gown in the room's garbage can, suggesting non-compliance with the facility's policy. Both residents involved had diagnoses that necessitated the use of Enhanced Barrier Precautions, which include donning gowns and gloves during high-contact activities to prevent the transmission of multi-drug resistant organisms. The facility's policy clearly outlines the procedures for managing such infections, yet the staff failed to adhere to these guidelines, leading to the observed deficiencies.
Plan Of Correction
Element 1 Upon discovering the breach in [R], the employees involved were immediately removed from direct care duties and counseled on the proper use of personal protective equipment (PPE) required for residents on NJ Ex Order 26.4(b)(1). On 1/3/25, all staff were retrained by the Assistant Director of Nursing on the facility's protocols regarding the appropriate use of PPE, including gloves and gowns when entering rooms of residents on enhanced barrier precautions. Element 2 All residents on Enhanced Barrier Precautions have the potential to be affected. Element 3 All staff underwent immediate re-education on the facility's enhanced barrier precaution protocols, emphasizing the importance of wearing gowns and gloves when caring for residents on enhanced barrier precautions. Staff were also re-educated on how to identify which residents need these precautions; all re-education was conducted by the Assistant Director of Nursing. Element 4 Enhanced Barrier Precaution spot check audits are being conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance with PPE protocols for residents on enhanced barrier precautions. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and obtain authorization for a change in the facility's name, as required by 42 CFR 424.516. The surveyor discovered this deficiency during a review of the facility's website and physical signage, which displayed the name "Shore Point Care Center" instead of the CMS-licensed name "Gateway Care Center." This discrepancy was confirmed upon arrival at the facility, where the surveyor observed the incorrect name on the building and on business cards provided by facility representatives. During interviews, facility representatives acknowledged that the facility had been operating under the name "Shore Point Care Center" for nearly three years, and they claimed that the state licensing department was aware of this. However, the facility was unable to provide documentation showing that the New Jersey Department of Health Division of Certificate of Need & Licensing or CMS had been notified of the name change. The facility's license, issued by the New Jersey Department of Health, still listed the name as "Gateway Care Center." Further investigation revealed that the facility had not completed the necessary CMS form 855B to report the name change. The facility representatives admitted that the name change was intended for marketing purposes and had not been formally processed with the appropriate regulatory bodies. As a result, the facility decided to revert to operating under the name "Gateway Care Center" and planned to change the signage back to reflect the licensed name.
Plan Of Correction
Element 1 This deficiency was corrected by revising the name listed on facility documents back to Gateway Care Center. Element 2 All residents have the potential to be affected by this deficiency. Element 3 Facility understands that in order to operate under a different name, the Department of Health Division of Certificate of Need must be notified, and the form 855B to CMS must be completed. Element 4 To maintain and monitor ongoing compliance, the Administrator will conduct a Facility Name audit to ensure documents are listed as Gateway Care Center. The Facility Name audit will be conducted by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Staffing and Mask-Wearing Deficiencies
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficiency was observed over multiple periods, including specific weeks in October 2023, June to July 2024, and December 2024. During these times, the facility consistently had fewer Certified Nurse Aides (CNAs) than required for the day shifts, and there were also deficiencies in total staff numbers for evening and overnight shifts. Interviews with the Human Resources director and the Director of Nursing revealed attempts to meet staffing ratios through bonuses and agency staff, but these efforts were not always successful. Additionally, the facility did not ensure that employees with medical exemptions from the influenza vaccine wore surgical or procedural masks when in direct contact with patients and in common areas, as required by New Jersey law. The surveyor observed that two employees, a dietary employee and an activity employee, were not wearing masks despite having medical exemptions from the influenza vaccine. Interviews with these employees indicated a lack of awareness or enforcement of the mask-wearing requirement. The facility's policy on influenza vaccination did not address the use of masks for employees with medical exemptions. The Director of Nursing was unaware of the requirement for these employees to wear masks, which contributed to the deficiency. The facility's failure to comply with staffing ratios and mask-wearing requirements for exempt employees highlights significant lapses in adhering to state regulations designed to ensure resident safety and care quality.
Plan Of Correction
Element 1 It is the practice of the facility to ensure that the minimum direct care staff-to-shift ratios are in compliance with the mandate from the State of New Jersey. The deficiency is being corrected by offering bonuses and overtime to staff to cover openings/callouts in the schedule, offering openings/callouts to staffing agencies, utilizing job search engines (Apploi) to expand the view of job postings, and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, all staff members who are Medically Exempt from receiving the Flu Vaccine were immediately informed they must wear a surgical mask while within the facility, and given masks to wear. Element 2 All residents are affected by this deficiency. Element 3 The deficiency is being corrected by offering bonuses and overtime, utilizing staffing agencies, utilizing job search engines (Apploi), and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, a Staffing Audit is being conducted by the Staffing Coordinator to ensure the facility remains in compliance with S560. Staff were also educated that they must wear a mask while in the facility if they are Medically Exempt from receiving the Flu Vaccine; a Mask Audit is being conducted by the Infection Preventionist to ensure the facility remains in compliance. Element 4 To maintain and monitor ongoing compliance, the Staffing Audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Additionally, the Mask Audit is being monitored by the Director of Nursing or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
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.
