Embassy of Newark violated fall prevention protocols for two of five residents reviewed during the inspection, affecting patients with serious mobility issues and cognitive impairment.
Resident #1 had clear medical orders dating back to February requiring his bed to remain in the lowest position when occupied. The patient suffers from peripheral vascular disease, blood clots in his legs, and unsteadiness on his feet. He depends entirely on staff for moving in bed and cannot walk.
Despite these vulnerabilities, inspectors found his bed elevated during every observation over nine days in August. They checked on August 11 at 9:30 a.m., August 14 at 11:00 a.m. and 2:30 p.m., August 19 at 3:00 p.m., and August 20 at 10:40 a.m.
Each time, the bed was not in the lowest position.
Licensed Practical Nurse #403 confirmed during an August 18 interview that the resident had an active order for the bed to be lowered when occupied. At that moment, inspectors observed, the bed was elevated.
The patient's care plan specifically identified him as high-risk for falls due to medication effects, decreased mobility, inability to walk, and obesity. The plan required staff to ensure his call light stayed within reach, keep his bed lowered when occupied, and follow facility fall protocols.
His cognitive abilities remained sharp. An assessment scored him 14 out of 15 on a mental status exam, indicating intact decision-making capacity.
The second case involved a patient with severe cognitive impairment and physical disabilities. Resident #43 scored just 9 out of 15 on the same mental assessment, indicating severely impaired cognition for daily decisions.
This patient had suffered a pathological fracture of his left femur, lived with vascular dementia, experienced muscle weakness, and had difficulty walking. His medical history included a stroke that caused paralysis on his left side.
His care plan identified multiple fall risk factors: the stroke with left-side paralysis, psychotropic medications, cognitive impairment, and vitamin D deficiency. The plan specifically required staff to place reminder signs in his room telling him to call for assistance before getting up.
No such signs existed.
Inspectors checked his room twice — on August 12 at 3:10 p.m. and August 20 at 9:40 a.m. Both times, they found no posted reminders about calling for help.
Registered Nurse #999 confirmed during an August 20 interview that no sign was posted in the resident's room, despite the care plan requirement and fall prevention orders.
The facility's own policy, revised in March 2021, requires staff to implement individualized fall prevention plans that address each resident's specific risk factors. The policy mandates a "resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of a fall."
Both violations occurred at a 105-bed facility where staff had clear written instructions about preventing falls for vulnerable residents. The inspection followed a complaint filed with state regulators.
Embassy of Newark's failures affected residents with markedly different needs but equally serious vulnerabilities. One patient retained full mental capacity but faced severe physical limitations requiring careful bed positioning. The other struggled with dementia and stroke-related paralysis but needed constant reminders about safety protocols.
The missed interventions represent basic safety measures that require no special equipment or training — simply following existing medical orders and posting reminder signs as care plans specify.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to residents. The investigation stemmed from complaint number 2582471 filed with state health officials.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Embassy of Newark from 2025-08-21 including all violations, facility responses, and corrective action plans.