The incident at Total Rehab Moorestown exposed confusion among staff and management about basic safety protocols during bathing assistance. State inspectors found that while some staff understood residents should never be left unattended during showers, the facility's Director of Nursing contradicted this guidance.
The resident required "cueing and guiding" assistance during bathing according to their care plan. Instead, Certified Nursing Assistant #1 stepped out of the bathroom while the resident sat on the shower chair, leaving them completely unattended.
When the aide returned with the towel, they found the resident sliding off the chair. The aide tried to reach them in time but failed to prevent the fall.
CNA #2 told inspectors during a January 20th interview that staff were supposed to bring everything needed into the bathroom before beginning any bathing task. "CNAs were not supposed to leave residents alone in the shower or on the toilet," the aide stated clearly.
The Unit Manager agreed with this assessment during questioning on January 2nd. The manager said staff should bring all necessary supplies into the bathroom before starting to bathe any resident. If they forgot something, they should use the call bell to request assistance from other staff members.
"If residents were left alone in the shower they could have fallen," the Unit Manager told inspectors. The manager specifically stated that CNA #1 stepping out while the resident sat on the shower chair "could have led to the resident's fall."
But the Director of Nursing gave inspectors conflicting guidance about the same safety protocols.
During an initial interview, the Director of Nursing said the resident should have received "cueing and guiding" assistance throughout the bathing process, as specified in their care plan. This level of assistance requires continuous staff presence and verbal direction.
However, during a follow-up interview three hours later, the same Director of Nursing reversed course entirely. She told inspectors she "considered it acceptable for CNA #1 to leave Resident #2 on the shower chair to step out of the bathroom to get a towel."
The Director of Nursing could not explain why she was contradicting the resident's documented care requirements. Inspectors noted she failed to clarify the difference between the assistance level indicated on the resident's comprehensive assessment versus what was written in their care plan.
Facility policy explicitly requires staff to develop comprehensive, person-centered care plans that meet each resident's needs as identified during assessment. The care plans must describe "the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being."
The facility's incident and accident policy, reviewed in January 2025, defines any unusual event that may or may not result in injury as requiring investigation. The policy states that accident investigations help evaluate the care provided to residents, assist in preventing future incidents, and assess whether proper interventions were implemented.
Despite these written policies, the facility's top nursing administrator publicly endorsed practices that directly violated both the resident's individualized care plan and basic safety protocols understood by frontline staff.
Inspectors were unable to reach CNA #1 for a telephone interview to get their account of why they left the resident unattended during such a vulnerable moment.
The incident illustrates how management confusion about safety standards can undermine even basic resident protections. While nursing assistants on the floor understood that leaving residents alone during bathing created fall risks, the Director of Nursing's contradictory guidance sent mixed messages about acceptable care practices.
The resident's fall occurred because an aide prioritized retrieving a towel over maintaining continuous supervision of someone who needed hands-on guidance throughout bathing. The few seconds it took to step out of the bathroom proved sufficient for the resident to lose stability and slide from the chair to the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Total Rehab Moorestown from 2026-01-02 including all violations, facility responses, and corrective action plans.