Canterbury At Cedar Grove
CANTERBURY AT CEDAR GROVE in CEDAR GROVE, NJ — inspection on November 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
nurse. LPN #1 further stated that the resident had pants on. On 11/12/25 at 1:30 PM, the surveyor interviewed CNA #2 who worked full-time at the facility for 20 years and had reportedly cared for the resident during the day shift. CNA #2 stated that she never saw any cuts on the resident's skin, and if she did she would report any skin issues to the nurse. On 11/12/25 at 1:49 PM, the surveyor interviewed LPN #2 who stated that she worked on the 3-11 shift on the day that the laceration occurred, and she did not see anything on the resident's leg. LPN #2 stated that CNA #1 put the resident to bed and did not report anything to me. LPN #2 further stated that CNA #1 did not work here anymore. On 11/12/25 at 2:20 PM, the surveyor interviewed the DON and asked the DON if the ace wraps were donned (put on) and doffed (removed) as indicated on the MAR on 8/6/25 during both the day night shifts, why had staff not noticed the laceration on the resident's left lower extremity timely.
The DON stated that if the ace wraps were on, the cut was at the level of the resident's ankle.
The DON further stated, I do not think that they did it (donned and doffed the ace wrap) even though they signed it out as completed. At that time, the DON stated that there was no written statement from CNA #1 because she was very upset and angry when approached via telephone about the resident's injury and she did not give me a chance to obtain a written statement.
The DON stated CNA #1, called me a fat piece of shit, and then she showed up here and had to be escorted out of the building because she was beyond reproach.
The DON stated that it was CNA #1's personality problem, and she was terminated. At that time, the DON stated, unfortunately, the resident cut their leg, and no one noticed.
The DON further stated that any injury of unknown injury should be called in to the NJDOH and Ombudsman's Office right away especially if the resident was not able to tell you what happened.
The DON stated that we did not call the laceration in because it only took one to two hours to determine that the injury occurred on the wheelchair.
The DON stated that we 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.
The DON further stated, Now I know that I should have just reported it immediately in hindsight.
On 11/13/25 at 10:31 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that when an injury of unknown injury occurred we first need to rule out abuse.
The LNHA stated that he was required to call the injury of unknown injury in immediately or within two hours, and then the electronic submission must be sent within twenty-four hours and followed up with a summary and conclusion submission within five days.
The LNHA stated that the importance of reporting was because it was a required regulation, so that the NJDOH knows about it. At that time, the LNHA stated that the reason why the resident's laceration was not called in was because there was blood found on the bolt of the resident's wheelchair footrest and a piece of the resident's flesh was also on the equipment, and it was clear cut what had happened.
The LNHA stated that he was aware of CNA #1's reaction when she was questioned about the incident, and he believed that CNA #1 felt accused when we requested a statement.A review of the facility's Abuse, Neglect and Mistreatment of Residents policy, reviewed 9/2025, included:.The Administrator and Director of Nursing will be made aware of all such incidents occurring in Facility and will review completed reports. If any accident is of a serious nature, medically or suspected abuse, neglect, telephone within 2 (two) hours regardless of the time of day.
The Administrator/designee will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstance of the incident.The Administrator/Designee will notify the Department of Health within two (2) hours.NJAC 8:39-9.4 (e) 4
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