Canterbury At Cedar Grove: Abuse Reporting Failure - NJ
That is what inspectors found when they arrived at Canterbury at Cedar Grove in August 2025 to investigate a complaint, and what a follow-up inspection in November confirmed had gone unreported for weeks.
The resident, whose name is withheld in the inspection record, had a laceration on their left lower leg. The wound was at ankle level, the area where an ace bandage was supposed to be put on and taken off twice daily by nursing staff. According to the facility's own medication administration records, staff had signed off on completing that task on August 6, 2025, during both the day and night shifts. The Director of Nursing told the surveyor she did not think they actually did it, even though they signed it out as completed.
Nobody noticed the cut.
The certified nursing assistant who put the resident to bed that night, identified in the report as CNA #1, did not report anything to the nurse on the 3 to 11 shift. That nurse, identified as LPN #2, told the surveyor she worked that shift and did not see anything on the resident's leg. She said CNA #1 put the resident to bed and did not report anything to her, and then noted that CNA #1 did not work there anymore.
When the facility later tried to obtain a written statement from CNA #1 about what happened, it did not go smoothly. The Director of Nursing told the surveyor that CNA #1 was very upset and angry when approached by telephone, and that she did not give me a chance to obtain a written statement. The DON said CNA #1 called me a fat piece of shit, and then showed up at the facility and had to be escorted out of the building because she was beyond reproach. The DON described it as CNA #1's personality problem. She was terminated.
There was no written statement from CNA #1 in the investigation file.
A second nursing assistant, CNA #2, told the surveyor she had worked full-time at the facility for 20 years and had cared for the resident during the day shift on the date in question. She said she never saw any cuts on the resident's skin, and if she had, she would have reported any skin issues to the nurse. The first nurse interviewed, LPN #1, told the surveyor the resident had pants on.
What the inspectors were trying to understand was not just how the laceration happened, but why no one reported it to the state. Under New Jersey requirements that the facility's own written policy spells out, an injury of unknown origin must be reported to the Department of Health within two hours, by telephone, regardless of the time of day. An electronic submission follows within twenty-four hours. A summary and conclusion submission is due within five days.
None of that happened here. Not within two hours. Not within twenty-four. Not within five days.
The facility reported the laceration only after surveyors showed up in August 2025 for an onsite complaint investigation. The DON acknowledged this directly. She told the surveyor that the facility reported it after surveyor inquiry during an onsite complaint investigation from the NJDOH in August 2025, because there was a little gray area of what happened. She then said, Now I know that I should have just reported it immediately in hindsight.
The administrator's explanation for why the injury was not reported followed a different logic. He told the surveyor that because blood was found on the bolt of the wheelchair footrest and a piece of the resident's flesh was also on the equipment, it was clear cut what had happened. His position was that because the cause had been identified quickly, the reporting requirement did not apply. The injury of unknown origin rule, in his reading, only covered situations where the cause remained unknown.
The administrator also told the surveyor he was required to call in an injury of unknown origin immediately or within two hours, and that the importance of reporting was because it was a required regulation so that the NJDOH knows about it. He said this while explaining why the facility had not done it.
The resident was not able to communicate what had happened to them. The DON acknowledged this too. She told the surveyor that any injury of unknown injury should be called in to the NJDOH and the Ombudsman's Office right away, especially if the resident was not able to tell you what happened. She said this in the same interview where she confirmed the facility had not made that call.
The inspection finding was cited under F0609, which covers the obligation to report and investigate allegations of abuse, neglect, and injuries of unknown origin. The level of harm was cited as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
What the record shows is a wound severe enough to leave tissue on metal, a nursing assistant who signed documentation for care she may not have performed, an investigation that produced no written statement from the only staff member who put the resident to bed that night, and a facility that decided on its own that the injury did not need to be reported because they had figured out what caused it.
The resident whose flesh was found on the wheelchair bolt had no way to say what happened, or when, or how long it went unnoticed before anyone looked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Canterbury At Cedar Grove from 2025-11-21 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: August 5, 2026 · Our methodology
CANTERBURY AT CEDAR GROVE in CEDAR GROVE, NJ was cited for abuse-related violations during a health inspection on November 21, 2025.
The resident, whose name is withheld in the inspection record, had a laceration on their left lower leg.
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.