Daughters of Israel: Accident Hazard Violations - NJ
The November incident at Daughters of Israel Pleasant Valley Home violated the resident's care plan, which had mandated two-person transfers for nearly 10 months. The nursing assistant later admitted she never checked the care requirements before attempting the solo transfer.
Resident #3 ended up on the bathroom floor, on their knees and crying, complaining of right knee pain after the failed transfer attempt. A nurse responding to the scene found the resident in distress and immediately notified all responsible parties.
The facility's nurse practitioner ordered an X-ray of the injured knee and requested rehabilitation department screening for occupational and physical therapy treatment. Despite these precautions, the resident's condition deteriorated enough to warrant emergency department transport.
Hospital testing revealed no fractures, but doctors discovered a urinary tract infection requiring antibiotic treatment. The resident was readmitted to the nursing home on medication.
The nursing assistant's explanation exposed a fundamental breakdown in care coordination. During a telephone interview with state inspectors on November 10, CNA #3 stated "she was not aware that the resident required two staff members for transfers and that she should have checked the resident's plan of care before transferring them."
Records showed the two-person transfer requirement had been in effect since January 18, 2024 — nearly 10 months before the bathroom incident. The resident care coordinator confirmed this requirement remained active through the date of the fall.
The facility's Director of Nursing acknowledged the violation during interviews with the state survey team, confirming that CNA #3 should have followed the resident's care plan mandating two-person transfers.
Daughters of Israel's own policies demanded thorough investigation of such incidents. The facility's accident and incident report policy, reviewed in July 2025, required staff to "interview any witnesses to the event to determine what occurred" and obtain "written, signed statement indicating any knowledge or information they have pertaining to the incident."
The fall policy contained identical language, mandating complete documentation and investigation of all falls "whether or not injury occurs." Both policies required witnesses to provide written statements submitted to supervisors after entry into electronic medical records.
Yet the facility's care planning policy, revised in January 2025, contained "no information about CP update and revision," according to the inspection report. This gap may have contributed to the nursing assistant's claimed ignorance of transfer requirements that had been in place for months.
The incident highlights broader concerns about communication between care planning and direct care staff. Despite having detailed policies for incident investigation, the facility failed to ensure frontline workers understood basic safety requirements for vulnerable residents.
Federal inspectors found the violation caused "minimal harm or potential for actual harm" affecting "some" residents. The classification suggests systemic issues beyond this single incident, though the facility provided no additional information to inspectors about corrective measures.
The resident's hospital stay and antibiotic treatment represented the most serious consequences. While X-rays ruled out fractures, the trauma of falling in a bathroom while needing assistance, combined with the discovery of an untreated urinary tract infection, illustrated the cascading effects of improper care.
The nursing assistant's admission that she "should have checked the resident's plan of care" came only after the resident had already suffered injury and hospitalization. For a resident requiring two-person assistance since January, the solo transfer attempt represented a nearly year-long failure of care coordination.
The bathroom floor became the scene where policy met reality, with Resident #3 on their knees, crying, paying the physical price for a system that couldn't ensure its own safety requirements reached the staff members who mattered most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Daughters of Israel Pleasant Valley Home from 2025-11-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DAUGHTERS OF ISRAEL PLEASANT VALLEY HOME in WEST ORANGE, NJ was cited for violations during a health inspection on November 10, 2025.
The nursing assistant later admitted she never checked the care requirements before attempting the solo transfer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.