State appoints monitor at Elwyn
Lifts sanctions against group home company
By: Ashley Bakcerzak
and Jean Rimbach
NorthJersey.com
USA Today Network - New Jersey
..... New Jersey has taken the rare step of appointing an independent monitor to oversee one of its largest providers of group homes for adults with developmental disabilities, dropping neglect charges filed after investigating the case of a resident whew was left on the floor for nearly seven hours without assistance.
.....
The New Jersey Attorney General's Office sought no fines against Elwyn, the group home company, instead entering into a three-year consent agreement that calls for Elwyn to pay for the monitor, who will judge whether there is sufficient staff to properly care for residents at its 51 group homes.
..... The settlement agreement was recently released to NorthJersey.com . It was struck quietly in April [2026] and not publicized, a departure form the press release announcing the original charges against the company and its employees.
.....
The Department of Human Services - the sate agency hat oversees and licenses group homes - has since lifted sanctions against Elwyn, allowing it to begin accepting new residents as of August 6. [2026] The agency had taken the uncommon actions of suspending new admissions in May 2025 and placing the company under heightened supervision amid concerns abo9ut staff shortages and deaths.
..... The attorney general's Medicaid Fraud Control Unit filed criminal complaints in May 2025 against the company and six of its employees, centering around two falls caught on surveillance footage involving S.K., a woman who was at least 69 years old, at a Vineland group home run by Elwyn in April 2023.
..... Prosecutors noted that the woman had an intellectual disability, and that she wore a helmet and a gait belt and was supposed to be supervised at all times.
..... In the complaint against Elwyn, the state accused the company of neglect in "failing to put in place protocols for the safety of S.K. and failing to tend to S.K." after her falls.
..... a spokesperson for Elwyn called the criminal charges "baseless."
..... "Elwyn committed no crime in relation to the incident from 2023 and never should have been charged as an organization," said Kurt Knaus, an Elway spokesperson. "We demonstrated to the attorney general that its charges were baseless, resulting in their dismissal."
..... It is rare for New Jersey to charge a group home company. A NorthJersey.com analysis ofund only one other case since 2018, in which Middlesex County prosecutors charged Broadway Group Home LLC in 2019 with neglect and endangerment. The CEO signed a non-prosecution agreement with the county prosecutor's office in April 2020, in which it agreed to pay a $100,000 fine up front, enhance training, make police changes and pay for three years of monitoring.
..... The Attorney General's Office declined to answer why the consent agreement with Elwyn did not includes fine.
..... "The state determined that dismissal of the charges against the corporate entity was the appropriate resolution after considering all of the facts and circumstances, including Elwyn's cooperation with the investigation and its decision to enter into a consent agreement," wrote Michael Symons, press secretary for the Attorney General's Office.
Lack of transparency
..... New Jersey is historically slow to react - if at all - to problems and troubling lapses in care of adults with developmental disabilities in the 2,000 privately-run group homes and apartments around he state, NorthJersey.com found in its 2025 investigative series Hidden at Home.
..... The series found that the Department of Human Services has only once assigned a monitor to a group home provider - Bellwether Behavioral Health - and only after years of reported failings. Bellwether was later closed, losing licenses to operate its group homes.
.....
The Hidden at Home series also illuminated a glaring lack of transparency in the system: The state offers no centralized resource for parents and loved ones to learn whether a group home has faced sanctions or criminal charges.
..... Parent advocates looking for answers recently began crowd-sourcing questioned and information about Elwyn in a Facebook group with more than 8,000 followers.
Resident falls, is left for hours
..... On April 13, 2023, S.K. fell i the livering room of her Elwyn group home. She remained on the floor for three hours; two direct care workers and a manager did not make any effort to help her up or ask if she was OK, said deputy Attorney General Laura Bryant, according to court audio obtained by NorthJersey.com .
..... Two days later, S.K. entered the bathroom alone and fell again. She was left on the floor for nearly seven hours, Bryant said.
..... When one worker - not charged by the state - called a director asking for help, the director told the worker to leave her on the floor, the deputy attorney general said.
..... Another worker arrived at her shift after S.K. had been on the floor for several hours. Camera footage shows she dragged S.K. into another room, Bryant said.
.....
When S.K. crawled out, covered in fecal matter and urine because she had soiled herself, the same worker dragged S.K. back into the bathroom across the tile, showered her while she was still on the floor, and dragged her out, Bryant said.
.....
Once in the hallway, she hit S.K., according to camera footage, Bryant said.
..... The state also charged Elwyn's director of operations, alleging he failed to implement policies and procedures so S,K's fall could have been prevented.
..... S.K. has since died. Bryant said the state is not alleging that the April 2023 falls contributed to her death.
What happened to employees
..... Elwyn fired "certain employees" after investigation the falls and reported what happed to the state Department of Human Services. The state substantiated neglect and placed "several former" Elwyn employees on New Jersey's Central Registry of Offenders - a list of caregivers found to have exploited, abused nor neglected someone with intellectual or developmental disabilities.
..... Those on the registry - which is not available to the public - are banned from working with this population in state-overseen programs.
..... Human Services did not substantiate neglect by the company, the consent agreement notes.
..... The agency referred the case to the Attorney General's Office.
..... Five of the Elwyn workers were admitted to pretrial intervention, a program offered generally to first-time offenders that allows charges to be dismissed if defendants meet certain conditions and take advantage of rehabilitative services under the supervision of probation officers.
..... The sixth worker, who pleaded guilty to a third-degree charge of abandonment and neglect and a fourth-degree charge of assault, was sentence to one year of non-custodial probation and forfeited her ability to work in the public sector.
..... All six Elwyn workers cannot work as direct care workers with vulnerable populations, including individuals with intellectual disabilities, children, elderly people, or those with mental illness.
..... "The resolutions reached in these mattes reflect the state's assessment of the appropriate outcome under the facts, the applicable law, and he individualized circumstances of each defendant," wrote Symons, the Attorney General's Office spokesperson "PTI is rotted in the principles and reducing the burden on the court system."
.....
During a sentencing hearing for one of the
Elwyn workers, Superior Court Judge Cristen D'Arrigo said, "I see an institutional failure and an institutional dereliction of their obligations to the people who were placed there by the families in very vulnerable situations."
The consent agreement
..... According to the 14-page consent agreement, an independent monitor, Kim Mack Rosenberg, Esq., shall "verify, survey, inspect and improve the delivery of care and resident helaht and safety" at Elwyn;s group homes, and assess Elwyn;s compliance with the agreement twice a year. her reports will be confidential.
..... If Elwyn is in "substantial compliance" for a period of time - the length is not clearly specified in the consent agreement - the monitor ship can conclude.
.....
The terms of Rosenberg's contract and the cost Elwyn is paying are unclear; all the consent agreement says is that Elwyn "shall bear the reasonable costs of the monitor." Both Elwyn and the Attorney General's Office declined to provide NorthJersey.com with a copy of Elwyn's contract with Rosenberg.
..... Elwyn agreed to implement "and and all reasonable recommendations" made by the monitor or explain in writing why Elwyn disagreeables or is unable to put the recommendation in place.
..... "We are confident the monitor will find that we are already in compliance with many of the terms and conditions of the consent agreement," the Elwyn spokesperson said.
..... If Elwyn doesn't comply with the consent agreement, the state could seek an order imposing penalties of up to $300 per day.
..... The Department of Human Services is in the middle of crafting rules for public comment on first-ever fines against group home companies that the governor signed into law on January 18. [2026] State officials said the precess could take up to a year and companies will be retroactively fined if they broke the rules starting July 1, 2026.
..... Many of the provisions of the consent agreement with Elwyn appear already to have been required or demanded by the state Department of Human Services. among the previsions Elwyn agreed to:
* Work with an independent abuse, neglect and exploitation prevention organization. Elwyn received an accreditation from Presidium in September 2025, a process that took the company two years to complete.
* Implement a ,leadership development training program to address issues with retention and stability among front-line supervisors. Elwyn previously said it was planning to contract with Quantum Workplace.
* Complete a plan of correction submitted to Human Services in June 2025.
* Implement polices and procedures to protect residents from falls and other injuries.
..... Knaus, the Elwyn spokesperson, said the company has been making changes over the past year in coordination with the Department of Human Services that "well underway before the attorney general's charges.
..... "By strengthening hiring practices, enhancing screening process and expanding retention initiatives when have improved workforce stability across our New Jersey group homes, while reducing turnover by 19% among direct uproot professionals," Knaus said, also noting that Elwyn has "long used" cameras in its group homes.
..... "Together, these organizational improvements have produced measurable results, including a 98% reduction in staffing-related incidents, increased leadership accountability and workforce stability in the form of favorable net new hires and reduced staff vacancies," Knaus said.
State lifts Elwyn suspension
...... The Department of Human Services halted admissions to Elwyn in May 2025, writing that repeated staff shortages contributed to deaths and serious injuries to residents, and counted 525 staff shortages, 306 hospital visits, 192 neglect, allegations and 99 injuries in about the past 2 1/2 years.
..... "It is apparent to the Department that there is a direct correlation between thee staff shortages and serious injuries, neglect and deaths of individuals under your agency;s purview,: a state official told new in a letter obtained by NorthJersey.com through a public records request.
.....
"Elwyn rejects any suggestion that staffing shortages - a common problem for all providers in New Jersey - have resulted in preventable deaths for its residents," Elwyn spokespersons Taylor Allen told NorthJersey.com .
..... In a follow-up letter to the state, Elwyn conceded that the number of staff shortages is "concerning" and wrote that it found "some correlation" between "operational breakdown reports" and dates of hospitalizations, neglect allegations and injuries. But "in some cases" the two events were unrelated, taking place in different homes, the company wrote. Elwyn told the state it is focusing on seven of tis homes that it says have the worst staffing issues.
..... Elwyn was warned that the state might form a quality management team or OMT, which is the highest level of state oversight for a group home company. The team is composed of state officials who meet periodically to monitor changes and progress. Elwyn and the state participated in at least four "pre-QMT" timekeepings, according to minutes obtained by NorthJersey.com .
..... In a August 6 [2026] letter, the Department of Human Services wrote that Elwyn has "demonstrated consistent progress towards implementing its quality improvement plan" and "improved clinical services to better support individuals with complex medical needs."
..... The state conditionally lifted the admissions moratorium, writing that the agency will continue to review monthly update reports and reassess the moratorium in six months.
..... "We expect it will be fully lifted following this conditional period," the Elwyn spokesperson said.
..... Tom Hester, a spokesperson for the Department of Human Services, said, "The Health, safety, and well-being of individuals with disabilities is the department's highest priority. We expect providers to meet rigorous standards of care and accountability."
..... The state;s admissions sanction did not apply to day programs, In June, [2026] Elwyn celebrated a ribbon-cutting for a newly expanded day habitation program in Sewell.