Every finding on record at Abingdon Care & Rehabilitation Center

Complaints: 2706516, 2743086 Based on interview and review of facility documentation, it was determined that the facility failed to employ a full-time Social Worker (SW) from August 2024 until 02/12/2026. This deficient practice had the potential to affect all residents and was evidenced by the following:On 02/11/2026 at 10:05 AM, a survey entrance conference was conducted with the Licensed Nursing Home Administrator (LNHA) who stated that the facility did not have a full-time Social Worker (SW) and the facility's part-time SW left approximately two weeks prior. On 02/12/2026 at 9:34 AM, an interview was conducted with the Human Resources Director (HRD) who stated the facility had no full-time SW for the last five months. The HRD stated after the full-time SW left, a part-time or per diem (as needed) SW worked up to 30 hours per week but they left two weeks ago. On 02/12/2026 at 12:17 PM, an interview was conducted with the LNHA. The LNHA reviewed a Director of Social Work job posting dated 08/16/2024 with the Surveyor and stated that it was around that time that the facility lost their full-time SW. The LNHA further stated that the facility should have a full-time SW to meet the residents' needs. Review of facility provided timecards for SW revealed that they worked as follows:For the 11/16/20205 - 11/29/2025 pay period: 8.42 hoursFor the 11/30/2025 - 12/13/20205 pay period: 7.00 hoursFor the 12/14/2025- 12/27/2025 pay period: 7.83 hoursFor the 12/28/2025 - 01/10/2026 pay period: 8.92 hoursFor the 01/11/1016 - 01/24/2026 pay period: 4.25 hours. The facility was on record as being licensed for 180 beds. The CMS guidelines implemented 11/28/17, included but were not limited to a qualified SW full-time for a facility with over 120 beds. A review of the facility's Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. N.J.A.C. 8:39-39.3(a); 39.2

Complaints: 2706516, 2743086 Based on interviews, review of the medical records, and review of other pertinent facility documentation on 02/11/2026 and 02/12/2026, it was determined that the facility failed to provide for the medically related social service needs for residents who required assistance with obtaining needed services from outside entities; or who should have received emotional support after an allegation of staff to resident abuse. This deficient practice was identified for 3 of 3 residents (Resident #3, Resident #4, and Resident #5) reviewed and was evidenced by the following:A review of the Resident Council Minutes dated 11/26/20205 revealed that residents inquired about when the facility would have a Social Worker (SW). A review of the Resident Council Minutes dated 12/31/2025 revealed that SW #1 was in the facility a few days a week and that that the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) could help out if residents needed anything. 1. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; muscle weakness; need for assistance with personal care; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/2025, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident had moderately impaired cognition. Further review of the MDS revealed that Resident #3 was dependent on a helper to move from sitting to standing, and to move from a chair to bed. The Progress Notes (PNs) for Resident #3 were reviewed. A PN dated 11/17/2025 at 10:59 AM, revealed that Resident #3 complained of back pain and asked to be returned to bed by facility staff. Review of an untitled and undated facility document revealed that an insurance case worker reported that Certified Nursing Assistant (CNA) #1 was rough with Resident #3 during the transfer to bed. The facility document revealed that CNA #1 was immediately suspended pending an investigation, and the resident was evaluated by Pain Management. The Interventions, section of the document did not reveal that a member of the Social Services (SS) Department monitored the resident's status in response to the incident and investigation. 2. Review of a facility Grievance Report, with a filed date of 01/27/2026 revealed that Resident #5 wanted assistance with community housing. The document further revealed that the Regional Admissions Director met with the resident and provided information on how to get a phone and contact information for community housing programs. According to the AR, Resident #5 was admitted to the facility with diagnoses including but not limited to: Type 1 diabetes mellitus with proliferative diabetic retinopathy (advanced damage to blood vessels in the eye) without macular edema, unspecified eye; muscle weakness (generalized); unsteadiness on feet; need for assistance with personal care; type 1 diabetes with diabetic neuropathy (nerve damage leading to pain and numbness); acquired absence of left leg below knee (amputation). A review of the Quarterly MDS dated [DATE] revealed that Resident #5 had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #5 wanted to talk to someone about leaving the facility and living and receiving services in the community. The PNs for Resident #5 were reviewed and revealed the following Social Services notes: A PN dated 09/22/2025 at 10:25 AM, revealed that the resident was admitted and had no physician or pharmacy in the community. A PN dated 10/06/2025 at 2:18 PM, revealed that the resident was presented with a mail-in ballot. A PN dated 01/10/2026 at 10:38 PM, written by the LNHA revealed that the LNHA spoke to a family member of Resident #5 who stated that they would take care of transferring Resident #5 and were waiting to hear from other facilities. No additional SS related PNs were provided. An interview was conducted with Resident #5 on 02/12/2026 at 10:05 AM. Resident #5 stated that they had been requesting assistance from a SW to get a phone and housing since September 2025. Resident #5 stated that they met briefly with a SW from Corporate (CSW) who provided incorrect contact information for community resources. The resident stated that the CSW also provided forms, but the resident was unable to complete the forms due to their neuropathy. The resident stated that they were not comfortable having other facility staff help fill out the forms with their personal information. The resident further stated, I need help and I am not getting it. 3. On 02/12/2026 at 10:35 AM, the surveyor observed Resident #4 in their room with a family member (FM) packing their belongings. Resident #4 and their FM confirmed that the resident had been discharged . An interview was conducted with Resident #4 and their FM on 02/12/2026 at 10:35 AM. Resident #4 stated that the facility's discharge process was tough and that they could not speak to the proper people for arranging their discharge. The resident's family member stated that there had not been a meeting with family or any discussion with a SW about the resident's discharge. The resident's family member further stated that they and another family member had to do most of the arrangements needed for Resident #4's discharge. According to the AR, Resident #4 was admitted to the facility with diagnoses including but not limited to: myelofibrosis (blood cancer characterized by scarring in the bone marrow); chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe); muscle weakness (generalized); difficulty walking not elsewhere classified; bone marrow transplant status; and need for assistance with personal care. A review of the Quarterly MDS dated [DATE] revealed that Resident #4 had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #4's goal was to be discharged to the community; and that active discharge planning was occurring for the resident to return to the community.No SS PNs related the resident's discharge or discharge planning were provided. Entrance conference was conducted with the LNHA on 02/11/2026 at 10:05 AM. The LNHA informed the surveyor that the facility did not currently have a SW, and that the part time SW had left approximately two weeks prior. A follow up interview was conducted with the LNHA on 02/12/2026 12:17 PM. The LNHA stated that the facility should have a full time SW to meet the residents' needs, and that a SW should be part of the interdisciplinary team and care planning for the residents. The LNHA confirmed that Resident #3 was not seen by SS after the abuse allegation involving them. The LNHA stated that Unit Manager #1 assisted with connecting Resident #4 with community resources for discharge. The LNHA stated that a SW would normally assist residents with these issues. The LNHA stated that he spoke with Resident #5's family about finding other living arrangements for the resident. The LNHA stated that a SW would normally assist residents with these issues. Review of the undated facility policy titled, ABUSE PREVENTION PROGRAM revealed under, POLICY INTERPRETATION AND IMPLEMENTATION, that when information concerning a report of abuse was received, the LNHA or their designee will request that a representative from the SS department monitors the resident's psychosocial status in response to the incident and investigation. A review of the facility's undated Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Under, Duties and Responsibilities, the job description revealed . Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. [.] Assure that social service progress notes are informative and descriptive of the services provided and the resident's response to the service. [.] Participate in regularly scheduled reviews of resident discharge plans. NJAC 8:39-39.4(b)(f)(h)

Complaint #: 2723631 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 02/11/2026, it was determined that the facility failed to update the care plan (CP) with clear focus, goals, and interventions for a resident (Resident #3) involved in a staff to resident abuse allegation. This deficient practice was identified for 1 of 4 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; muscle weakness; need for assistance with personal care; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/2025, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident had moderately impaired cognition. Further review of the MDS revealed that Resident #3 was dependent on a helper to move from sitting to standing, and to move from a chair to bed. The Progress Notes (PNs) for Resident #3 were reviewed. A PN dated 11/17/2025 at 10:59 AM, revealed that Resident #3 complained of back pain and asked to be returned to bed by facility staff. The PN revealed that facility staff returned the resident to their bed. Review of an untitled and undated facility document revealed that an insurance case worker reported that Certified Nursing Assistant (CNA) #1 was rough with Resident #3 during the transfer to bed and the resident was saying, ow, while the transfer was taking place. The facility document revealed that CNA #1 was immediately suspended pending an investigation. The document further revealed that the allegation of rough handling was unsubstantiated. A review of Resident #3's CP revealed a focus of Documented Resident/Representative Concerns Documented Resident/ Rep. Concerns the focus was initiated on 11/17/2025. Interventions/Tasks related to this focus included that the nurse would identify area of concern; Nurse would notify appropriate department leaders of concerns per facility protocol; and that the nurse would notify Social Services of the concern and the possible need for a care conference. An interview was conducted with Unit Manager #1 on 02/11/2026 at 12:30 PM. UM #1 stated that after an abuse allegation the CP of the resident involved should be updated so staff could know that allegations were made and know what to do. UM #1 stated that typically he or the Director of Nursing were responsible for updating resident CPs. On 02/11/2026 at 3:18 PM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that the 11/17/2025 update to Resident #3's CP did not meet her expectations for a CP update after a resident was involved in a staff to resident abuse allegation. The RDON stated that the CP update was not acceptable because the issue being addressed was not clear. Review of the facility's undated policy titled Care Plans revealed under POLICY STATEMENT, An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under POLICY INTERPRETATION AND IMPLEMENTATION, 4. Care plans are revised as changes in the resident's condition may dictate. NJAC 8:39-11.2 (e)(2)

Complaint #NJ184191/394091Based on, interviews, and record review, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 7 residents (Resident #5).This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem.According to the facility admission Record, Resident #5 was admitted to the facility with diagnoses which included: atherosclerosis of native arteries of other extremities with ulceration ( a condition where plaque buildup in the natural arteries of the limbs narrows the blood vessels, reducing blood flow and causing skin or tissue ulcerations due to a lack of oxygen and nutrients), muscle weakness, and type 2 diabetes mellitus (chronic condition where the body resists insulin or doesn't produce enough, leading to high blood sugar levels ) without complications.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 09/11/25, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated an intact cognition.On 09/26/25 at 09:10 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that his medication process consisted of verifying that he had the correct resident, then checking the order, and then signing out his medications for residents one by one. When questioned regarding if medications should be left at bedside, the LPN stated that it was a no-no to leave medications at bedside because the nurses would not know if the resident took their medications. The LPN further stated that nurses should stay with residents until the nurse could make sure the residents have taken their medications.On 09/26/25 at 10:43 A.M., the surveyor interviewed the Unit Manager (UM) who stated that she expected her staff to go into a resident's room, introduce themselves, verify they have the correct resident, and to check the medication orders. The UM further stated that she expected her nursing staff to inform and educate the residents on the medications being administered and that the nurse administering the medication should stay with the resident to make sure they swallow their medication. The UM also stated that meds should never be left at bedside, under no circumstances.On 09/26/25 at 11:44 A.M., the surveyor interviewed the Director or Nursing (DON) and Licensed Nursing Home Administrator (LNHA) together and they confirmed that LPN #2 left Resident #5's mediation at bedside on 09/14/25.On 09/26/25 at 12:04 P.M., the surveyor interviewed LPN #2 who was the LPN who had left medications at bedside via phone call. LPN #2 stated she left medications at bedside on 09/14/25 while she was looking for Resident #5's eyedrops. She stated that the Assistant Director of Nursing (ADON) notified her that she had left medications unattended at bedside and educated her that medications should never be left at bedside.A review of the facility's policy titled Administering Medications, revealed under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed.NJAC 8:39-29.2(d)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the four week cycle menus for nutritional adequacy in accordance with nationally accredited standards and the facility provided Diet Manual, b.) residents consistently received the standard serving of the main entree/protein (16 out of 56 lunch and dinner meals were inadequate) or an alternate item (2 out of 9 were inadequate) for high biological value protein (proteins of high biological value, also known as complete proteins, are those that contain all the essential amino acids in the appropriate proportions that the body needs to carry out its functions optimally), c.) alternate menu items were available as posted, and d.) that a resident (Resident #54) consistently received breakfast meat daily as requested as well as receive a nutritionally equivalent protein food as a menu substitute from the facility Always Available List (a list of foods available for lunch and dinner besides the menu choice for that day). This deficient practice was also identified by 7 out of 7 residents that attended the Resident Council Meeting on 4/15/25. The deficient practice was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted an initial kitchen tour with the Food Service Director (FSD). The surveyor observed an empty metal rack to the right of the kitchen entrance which the FSD identified as a bread rack. The surveyor observed a few cardboard boxes with bread. The FSD stated it was delivered that morning and that they received bread deliveries every three days. He further stated, we have to stay in budget. Towards the end of this tour, the FSD stated that they followed a four-week cycle menu, and they were currently on cycle 4. He provided the surveyor with a copy of these menus on 4/14/25 at 11:36 AM. There was one meal option offered for lunch and dinner. At that same time, the FSD provided an Always Available Items (only for lunch and dinner) list which included Chicken, Hamburger, Hot Dog, Tuna Sandwich, Ham and Cheese Sandwich, Turkey and Cheese Sandwich, Peanut Butter and Jelly Sandwich, Egg Salad Sandwich, Fruit Cup, Fresh Fruit (Apple, Orange, Banana), Garden Salad, Tuna Platter, and Grilled Cheese. On 4/14/25 at 10:20 AM, the surveyor conducted an entrance conference with the Director of Nursing (DON) and the Corporate Clinical Officer (CCO). They stated the facility census was 99 residents. On 4/14/25 at 11:39 AM, the surveyor interviewed Resident #54. The resident stated that they were unable to choose their meals and if they called for something else, the kitchen staff would tell them that one hot dog was available. On 4/15/25 at 10:17 AM, the surveyor conducted a group meeting with seven residents. 7 out of 7 residents had the following concerns; there were limited food choices, the quality of the food was poor, always available items were not consistently available, sandwiches were available if there was bread, the kitchen never have buns for hamburgers or hot dogs, they can't order something if it's not on the menu, the fish patty had very little fish, the chicken patty was all breading, the burgers tasted like they had fillers and were not real meat, and when spaghetti and meatballs were served they received three meatballs which was not enough and did not taste like real beef. On 4/16/25 at 9:13 AM, the surveyor interviewed Resident #54, who stated they had spoken to the Registered Dietitian (RD) to request a serving of a breakfast meat each morning. The resident stated they did not always receive breakfast meats daily. On 4/16/25 at 12:14 PM, the surveyor interviewed Resident #54 who stated there was only one menu choice and even if you requested an alternate item, it was not always available. On 4/16/25 at 12:36 PM, the surveyor observed Resident #54 in their room who stated they received chili but did not want that and the nurse ordered hotdogs as a substitute. On 4/16/25 at1:01 PM, the surveyor observed one hotdog in a bun brought up by kitchen staff on a plate for Resident #54. On 4/22/25 at 1:15 PM, the surveyor observed a food service staff member deliver two hot dogs on bread (not hotdog buns) to a resident on the Noble unit. On 4/22/25 at 10:24 AM, the surveyor interviewed the FSD who stated he did not have a diet manual, and that the RD may have one. He stated that he thought his Regional FSD and the Regional RD developed and reviewed the menus, but he could not really speak the process. On 4/22/25 at 5:17 PM, the CCO stated that the menus were developed as a team and the Regional RD approved the menus for adequacy. At this same time the FSD entered the conference room and provided the surveyor with the last three months' worth of food purchase invoices. On 4/22/25 at 1:01 PM, the surveyor conducted an additional kitchen tour in the presence of a second surveyor. The FSD acknowledged that the facility did not provide residents with a selective menu. He stated the facility made macaroni and cheese from scratch, and they used 2-5 pound (lb.) bags of cheddar cheese to prepare the cheese sauce. He stated that when they served manicotti on the menu, they provided two per serving and they provided four to five ravioli per serving when on the menu. The FSD also acknowledged that on Tuesday mornings they may not have breakfast meats available for resident who requested it daily. He stated that they are light on meat at times because meat deliveries were on Tuesdays. During this kitchen tour the surveyors reviewed some items on the Always Available list as well as other menu items for nutritional adequacy. There was a box of frozen hamburgers and a box of frozen manicotti (60 per box) that did not have nutritional information nor ingredients listed on the box. There were [name redacted] hotdogs and the nutritional information on the package indicated one hotdog provided 6 gms of protein. The FSD stated that if a resident wanted hotdogs to replace a meal, they would have provided two. He acknowledged 6 gms of protein would not have been adequate and that a minimum of 3 ounces (oz.) of protein should be provided at the lunch and dinner meals. He further acknowledged that 3 oz. of protein was equivalent to 21 gms. The FSD also acknowledged that food items that provided less than that would not be an adequate serving of protein as a main meal or alternate/substitute. There was a plastic 5 lb. sleeve of sliced cheese which had the nutritional information on the package and indicated two slices of cheese provided 4 gms of protein. The FSD stated that when the kitchen prepared cheese sandwiches or grilled cheese, two slices of cheese were used. There were frozen chicken patties and the nutritional information on the box indicated that one patty provided 11 gms of protein. The FSD stated that one patty was served per meal and acknowledged that was an inadequate amount of protein. A few other menu items in question regarding protein content per serving were the breaded fish, meatballs, manicotti and ravioli, which were not available for review. The surveyor requested the FSD for the nutritional information. The surveyor observed that the bread rack did not have hot dog or hamburger buns. The FSD acknowledged the same and stated he would give a slice of bread instead and that a delivery would arrive tomorrow. On 4/22/25 at 2:40 PM, the surveyor interviewed the RD. She stated that the menus were developed by the Regional FSD and that she and the FSD also reviewed them and collectively they approved the menus for nutritional adequacy. She stated she would provide the surveyor with the Diet Manual for review. She stated that she was aware there were no selective menus and that residents could choose from the Always Available list. The RD stated she was unaware of concerns about always available items not being available as well as bread and buns. She could not speak to who ensured food products were nutritionally adequate. She acknowledged that 3 oz. or 21 gms of protein should be provided for lunch and dinner. She acknowledged that one hotdog which provided 6 gms of protein was not an adequate substitution. On 4/22/25 at 2:35 PM, the FSD provided the surveyor with copies of the nutritional information for the frozen manicotti, breaded fish and ravioli. On 4/22/25 at 5:30 PM, the CCO provided the surveyor with a copy of an undated [name redacted] Dietary Manual and a [name redacted] Cycle Menu Recipe Book. On 4/23/25 at 10:47 PM, the surveyor interviewed the FSD in the presence of the Regional FSD. The FSD stated that when they make pizza for the residents, they used nine-inch round pie crusts and 12-13 lbs. of mozzarella cheese. He acknowledged that if a resident ordered a substitute it was required to be nutritionally equivalent and that some prepared products that were used did not meet protein requirements. He also acknowledged that recipes provided to the surveyor, as an example Breaded Baked Fish, was for a scratch recipe (which was not used) and only had instructions for a one serving recipe and indicated that the fish ingredient would be a four oz. portion of cod fillet (which would have provided 28 gms of protein). On 4/23/25 at 1:04 PM, the Regional FSD provided the surveyor with a copy of cycle 1 and 2 of the menus signed and undated by the facility RD. On 4/23/25 at 1:21 PM, the surveyor interviewed the RD and Regional FSD in the presence of the survey team. The RD stated, she signed cycle 1 and 2 within the last week (but could not speak to date) and that her signature attested to the fact that cycle 1 and 2 were nutritionally adequate. Both stated that they were still working on cycle 3 and 4. The RD stated she could not attest to whether or not they were nutritionally adequate. They acknowledged that a 3 oz. portion of protein equaled 21 gms of protein. They acknowledged the surveyor had previously discussed examples of menu items did not meet nutritional requirements for protein. The RD stated the menus were nutritionally adequate for protein. The Always Available list provided hotdog and grilled cheese; already established to have inadequate protein per serving during survey which yielded 6 and 4 gms of protein, respectively. During interviews with the FSD, he stated that he used 10 lbs. of cheddar cheese to make macaroni and cheese for the building (99 residents/census). That would yield approximately 12 gms of protein per person. He also stated that when cheese pizza was prepared, he used 12-13 lbs. of mozzarella cheese for the building. If 13 lbs. were used, that would yield approximately 15 gms of protein per person. A review of the food purchase invoices the FSD provided reflected that on 3/20/25, the facility received 3 cases of frozen manicotti. There were 60 manicotti per case which yielded 180 pieces. That would provide 1.8 manicotti per person. The nutritional information provided to the surveyor indicated that 1 manicotti provided 7 gms of protein. Therefore approximately 2 manicotti provided 14 gms of protein per person. A review of a food purchase invoice dated 3/27/25, reflected the facility received 3 cases of frozen medium cheese ravioli. The invoice indicated the brand [redacted] and that there were 200 ravioli per case. The FSD provided the surveyor with nutritional information for a different brand [name reacted] and there were 100 ravioli per case and were Jumbo verse the invoice Med (medium). Investigation for the brand [name redacted] ravioli indicated on the invoice, would have provided 9.1 gms of protein per 1 cup portion of those ravioli, which was the portion size indicated on the cycle menus. A review of the food purchase invoice dated 4/1/25, reflected the facility received 3 cases of 1 oz meatballs from brand [name redacted]. Investigation for the brand [name redacted] meatballs revealed 12 gms of protein would have been provided if 3 meatballs were served, which was the portion size indicated on the cycle menus as well as verbalized by residents in the Resident Council Meeting. A review of the nutritional information for the Breaded Fish provided by the FSD, indicated a 4 oz. portion (1 piece) provided 14 gms of protein. A review of the facility's Week-At-A-Glance [name redacted] Spring/Summer 2025 four-week cycle menus reflected the following items served 16 meals out of 56 provided an inadequate amount of protein: Week 1 Monday Lunch Cheese Pizza (15 gms) Dinner Breaded Baked Fish (14 gms) Tuesday Dinner Chicken Patty on a Bun (11 gms) Thursday Dinner Manicotti (14 gms) Friday Dinner 1 All Beef Hot Dog on a Bun (6 gms) Week 2 Wednesday Lunch Baked Macaroni and Cheese (12 gms) Thursday Dinner Manicotti (14 gms) Week 3 Sunday Dinner Cheese Ravioli (9.1 gms) Monday Lunch Breaded Baked Fish (14 gms) Dinner Macaroni and Cheese (12 gms) Friday Dinner Cheese Ravioli (9.1 gms) Week 4 Sunday Dinner Spaghetti with Meatballs (12 gms) Monday Lunch Breaded Baked Fish (14 gms) Dinner Cheese Pizza (15 gms) Wednesday Lunch 1 All Beef Hot Dog on a Bun (6 gms) Friday Lunch Cheese Pizza (15 gms) A review of the Dietary Manual [name redacted] provided by the facility, included the Regular diet portion sizes for protein at lunch and dinner should be 3 oz. In addition, the section titled Quality of Life reflected, The obligation of Nutrition Professionals is to ensure and enhance the quality of life for each resident in the nursing facility by providing appropriate nutrition care and by recognizing and honoring the individuality of each person. The section titled Resident Rights and Responsibilities included the following rights: To make choices about where, when and what to eat. To be served attractive, well-seasoned food in portions acceptable. To be offered substitutes of similar nutritive value when food served is refused. NJAC 8:39-17.1 (b), 17.4 (a) (1) (3) (c) (e)

Based on interviews, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 7 alert and oriented residents (Resident's #4, #22, #53, #58, #70, and #81) during the resident council meeting and was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). At the end of the initial tour, the surveyor requested a copy of residents who received labeled snacks, as well as a list of snacks that were sent to the units in the evening to be distributed after dinner. The FSD stated, we really don't send HS (evening) snacks, there was no list. He further stated, we send labeled snacks and if another resident wanted something before the kitchen closed, we would provide it; and if a resident wanted something later there was a key at the front desk, and a supervisor could get a snack. On 4/15/25 at 9:00 AM, the surveyor reviewed an undated Mealtime and Delivery Schedule, which the facility provided to the survey team. There was more than a 14-hour span between dinner and breakfast service. On 4/15/25 at 10:17 AM, the surveyor conducted a resident council meeting with 7 residents invited by the President of Resident Council. 6 of 7 residents had a Brief Interview for Mental Status of 15 out of 15, which indicated their cognition was intact. On 4/15/25 at 10:57 AM, 7 of 7 residents stated that labeled HS snacks were put on the nursing station or in the pantry after dinner. They stated that Certified Nurse's Aides (CNA) were supposed to give out labeled snacks, which was done inconsistently. They agreed that when the snacks were left on the nurse's station, other residents would take the snacks. They agreed that there were no extra items delivered or available to provide to residents without a labeled snack. On 4/22/25 at 9:36 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 on the [NAME] Unit. They both stated that there was no accountability system in place to account for the provision of HS snacks to residents in the electronic medical record (EMR) or on paper. On 4/22/25 at 9:50 AM, the surveyor interviewed RN #2, who was the Unit Manager for both the [NAME] and Noble Units. She stated that some residents received labeled snacks, however there was no accountability system to record the provision of HS snacks to residents. She stated residents should be provided HS snacks and if they refused, it should be documented. On 4/22/25 at 10:24 AM, the surveyor interviewed the FSD. He stated that there should be no more than a 10-12-hour span between dinner and breakfast service. He could not speak to further requirements if the span of time was greater. On 4/22/25 at 12:43 PM, the Corporate Clinical Officer, stated in presence of survey team, that the facility would be installing kiosks (an electronic accountability system which would provide CNAs the ability to record the provision of HS snacks to residents) for CNAs. At that time, she could not speak to whether or not there was an accountability system on paper. On 4/22/25 at 2:40 PM, the surveyor interviewed the Registered Dietitian (RD). She stated that if there was more than a 14-hour span between dinner and breakfast service, the residents should be provided with a nutritious snack like a half of a sandwich. The RD stated there should be accountability; however, she stated there was no accountability in the EMR and she did not think there was accountability on a paper system. A review of the minutes from Resident Council Meetings dated 1/30/25, 2/26/25 and 3/27/25, all included [name redacted], and other residents reported CNAs do not distribute the snacks when the kitchen brings up the snacks. The facility was unable to provide policy's related to mealtimes and HS snacks. NJAC 8:39-17.2 (f) )(1) (i) (ii)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor toured the kitchen with the Food Service Director (FSD). The following was observed: 1. Inside the ice machine there was a reddish like substance on the bottom of the white baffle (a flow-directing panel that restrained ice), as well as both sides of the interior walls of the ice machine near screws. The FSD took a clean towel and wiped both areas. The discoloration was removable and the FSD acknowledged that it needed to be cleaned. 2. There was a two door reach in refrigerator in which the FSD stated was for the cooks. The surveyor observed built up debris on the inside and gasket of the left door as well as the bottom of the unit. The FSD acknowledged the debris and stated, It's Monday. 3. There was a large exhaust fan near two prep sinks, which had a heavy buildup a fuzzy grey/brown debris. The FSD acknowledged the debris and stated that maintenance needed to clean it. 4. There were two prep sinks which had a broken handle plastic spatula on the bottom of the right sink. The top of the spatula was discolored and disfigured. The FSD acknowledged it was broken and the front was melted and should not be used. In addition, there was a soiled rag with debris draped over the divider between the two sinks. The FSD acknowledged it was soiled and should not have been there. 5. There was a metal covering to a grease trap on the floor, which had a heavy buildup of a black sticky-like substance, which the FSD acknowledged. 6. There were two green, one blue and one yellow cutting boards observed on a clean dry equipment rack which had gouging. The FSD acknowledged the same and stated they should be changed since gouging was where bacteria can collect and could cause cross contamination. 7. The bottom of the spice rack had built up debris. The FSD stated the rack was old and would, take a long time to clean. 8. There was a soiled mop head on the floor near the right side of a griddle. The FSD stated the griddle leaked grease and they keep the mop head there, so we don't fall or slip. 9. There was a plastic scoop stored inside the flour bin, the handle was in direct contact with the flour. The FSD stated it should not be stored inside the bin. 10. The base of the can opener had a buildup of a black sticky substance. The FSD acknowledged the buildup and stated, it needed to be cleaned. 11. Three wells of a four well steam table, had a heavy buildup of brown debris on the bottom. On top of each the four wells were stainless steel folding covers which had a reddish/brown built up substance. The FSD stated they were old, and that it would take a long time to clean. 12. In the first walk-in refrigerator, the surveyor observed a case of raw eggs stored above a case of liquid pasteurized eggs. The FSD stated that the raw eggs were pasteurized yet was unable to show where that was indicated on the case. 13. In the second walk-in refrigerator, the surveyor observed 3 metal shelves that had a buildup of black debris. The FSD wiped the shelving with a clean wet pink and wipe cloth towel. The debris was removable and the FSD acknowledged it needed to be cleaned. 14. The towel dispenser above the hand washing sink was broken and empty. The towel ring was exposed and placed on the metal post of the spice rack for use, opposite the hand washing sink. On 4/22/25 at 2:02 PM, the FSD provided the surveyor with vendor invoices from January 2025 to present. Invoices from [name redacted] indicated, MEDIUM EGGS GRADE A were delivered. There was no indication that they were pasteurized. A review of an undated facility policy Ice Machines and Ice Storage Chests, reflected that ice machines will be used and maintained to ensure a safe and sanitary supply of ice. It also included that ice could become contaminated by unsanitary manipulation by employees, water-borne microorganisms, colonization by microorganisms, and improper storage or handling of ice. A review of an undated facility policy Sanitation, reflected the food service area will be maintained in a clean and sanitary manner. It also reflected all kitchen areas should be kept clean, including shelves, counters, utensils and equipment. This included maintaining food service items in good repair so as not to affect their use and proper cleaning. Additionally, it reflected that ice that is used in connection with food and drink should be handled in a sanitary manner. A review of an undated facility policy Food Storage, reflected that food storage areas should be maintained in a clean, safe, and sanitary manner; and that food service staff should maintain clean food storage areas at all times. NJAC 8:39-17.2(g)

REPEAT DEFICIENCY Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to have a system in place to ensure that facility garbage receptacles were covered, and all garbage was contained and removed timely to prevent a buildup of refuse, and that the receptacles including a trash compactor and the surrounding areas were maintained in a clean manner to prevent the accumulation of debris. The deficient practice was evidenced as follows: On 4/14/25 at 9:00 AM, the survey team arrived at the facility. From the parking lot, the surveyor was able to view the dumpster area, in the presence of the survey team. There were two oversized uncovered dumpsters overflowing with waste/debris and had black garbage bags around and between the two dumpsters, as well as debris on the ground. Up against the building loading dock there was a compacter, and an uncovered cardboard dumpster overflowing with cardboard. On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During this tour, the surveyor and FSD went outside the building and onto the loading dock to view the receptacle area for refuse. The cardboard container was uncovered and overflowing. The FSD stated it did not need to be covered. The compacter had a buildup of discolored liquid underneath. The FSD stated the compacter was picked up once every week or week and a half. There were two oversized dumpsters overflowing with debris to the right of this area along a back fence. There was debris on the ground around the three dumpsters as well as the compacter. The FSD acknowledged there was debris on the ground and could not speak to who was responsible to ensure the area was clean, maintained and free of debris on the ground. On 4/22/25 at 2:26 PM, the surveyor interviewed the Director of Environmental Services (DES). He stated he was ultimately responsible to ensure the dumpster area was clean and maintained. He stated he had porters that clean that area however, the observation was made early Monday, and he was unable to get that done. The DES further stated the cardboard dumpster was picked up once a week and when the compacter was picked up, staff would clean underneath. He stated, [name redacted] company was used for removal of the cardboard dumpster and compacter; however, he was unable to speak to the responsibility for the two other oversized dumpsters. On 4/22/25 at 5:29 PM, the surveyor reviewed the above concern with the Administrative team (Licensed Nursing Home Administrator, Director of Nursing and the Chief Clinical Officer), in the presence of the survey team. On 4/23/25 at 11:30 AM, the survey team met with the Administrative team for responses or additional information. Nothing further was provided. A review of an undated facility policy Maintenance Service, reflected that maintenance service would be provided to all areas of the building and grounds, which included the parking lot. NJAC 8:39-31.4(b)

Repeat Deficiency Based on observation and interview it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (Noble and [NAME]) and was evidenced by the following: 1. On 04/14/25 at 10:27 AM, during initial tour of the Noble unit, the surveyor noted dark scuff marks in the hallway outside room [ROOM NUMBER]. Inside room [ROOM NUMBER], the surveyor observed the heater unit with a dark brown/reddish substance noted on the fins of the heater and brownish/blackish marks on the body of the heater unit. At 10:40 AM, the surveyor noted multiple cracked floor tiles in room [ROOM NUMBER]. At 10:49 AM, the surveyor observed the heater in room [ROOM NUMBER] with brown/black substances in fins of unit and on body of heater unit. The closet doors were noted to be off the track and bottom dresser drawer front was broken and askew. Also, in this room the surveyor noted a missing section of floor tile and cracks in the tile were noted under the bed. On 4/16/25 at 10:34 AM, the surveyor reviewed the work order report dated 4/15/25. Heaters in rooms [ROOM NUMBERS], cracked tiles in room [ROOM NUMBER], and cracked/missing tile in room [ROOM NUMBER] were not found on list. On 4/16/25 at 12:41 PM, the surveyor interviewed the Director of Maintenance/Housekeeping/Laundry (DMHL). When asked about the floors on the Noble unit, specifically the scuff marks by room [ROOM NUMBER], the DMHL stated the floors are mopped daily and the scuff marks don't come up with mopping. He stated those marks were from bed swaps. When the surveyor asked about the heaters in rooms [ROOM NUMBERS], the DMHL stated they (heater units) all need to be painted. The DMHL further stated regarding the heater units, This is certainly not ok, they're on the list. When the surveyor asked about the closet doors and drawer front in room [ROOM NUMBER], he stated they are currently addressing the closet doors. The DMHL further explained that the closet doors are about forty years old and have exceeded their life expectancy. He went on to explain that the closest doors aren't an easy thing to fix, it's an involved process. When the surveyor asked about the missing tile on floor in room [ROOM NUMBER] and cracked tiles in room [ROOM NUMBER], he stated it's on the list. The surveyor mentioned that these items were not on the list he provided to the team, he stated he has other lists, in addition to the one provided to surveyors the day before. He then showed the surveyor his phone with a long list between himself and his assistant. The DMHL further explained that he stars the priorities and can move the items around as needed. He further explained that he just discovered a cache of tiles that matched the ones on the floors and that the work just needs to be scheduled to be done. On 4/17/25 at 11:25 AM, the surveyor observed the drawer front and closet doors were repaired. The scuff marks in Noble hallway outside room [ROOM NUMBER] are no longer present and area of lighter colored floor noted in that area. 40042 2. On 4/14/25 at 11:50 AM, the surveyor observed fluid leaking from the ceiling tiles in the hallway that leads to the main dining room on the first floor, in the presence of the Food Service Director (FSD). The FSD acknowledged the leak and stated the Noble unit was above this area and he thought there were leaking sinks on the unit. He further stated the new maintenance director was aware. On 4/15/25 at 10:00 AM, the surveyor observed the back wall inside the elevator. To the right of a frame there was a large circle-like area that had multiple layers of peeled paint. In addition, the interior wooden guard rails around the perimeter of the elevator were scratched and gouged. On 4/17/25 at 12:22 PM, the DMHL acknowledge the new pictures in the elevator were covering the peeled paint and stated, I have to do what I have to do. 41858 3. On 4/14/25 at 11:52 AM, during the initial tour of the [NAME] unit, the surveyor noted room [ROOM NUMBER] had missing floor tile under the sink and brown discolored ceiling tiles with a vent, that had a buildup of black debris, at the nurse's station. On 4/15/25 at 11:58 AM, the surveyor observe the corner end of the hand rail, between the [NAME] Nurse's station and the pantry, was missing and the corner piece of the lower portion of the column at the nurse's station was pulled away from the column and there was exposed white spackle and debris. On 4/15/25 at 12:00 PM, the surveyor interviewed the DMHL, who stated he did environment tours daily. He explained he does a visual inspection of each unit every day. He stated he looks up and down the walls of the units and stands in the doorway of every room looking for something out of place. He stated staff can enter maintenance requests directly into the maintenance computer system. At that time, the DMHL toured the [NAME] unit with the surveyor. He observed the missing floor tiles in room [ROOM NUMBER] and stated the tiles are [AGE] years old and I can't find matching tiles. He acknowledged the brown discolored ceiling tiles and the black debris on the vent at the nurse's station. He stated, there was a terrible leak here about 2 weeks ago and I did not replace tiles. He stated, the vent was not clean but they should be done quarterly when we do the filters. On 4/15/25 at 12:22 PM, the DMHL toured the Noble unit with the surveyor. He acknowledged the missing end cap of the hand rail at the nurse's station and stated they are [AGE] year old railings and it's difficult to find replacement pieces. He acknowledged the corner of the column at the nurse's station and stated, it's on my list. On 4/17/25 at 12:22 PM, the surveyor interviewed the Certified Nursing Aid (CNA #1), who stated he would try to fix things himself and if he couldn't fix it, he would call maintenance. On 4/17/25 at 12:28 PM, the surveyor interviewed CNA #2, who stated if she identified something was in disrepair, she would report it to the nurse or the supervisor. On 4/17/25 at 12:32 PM, the surveyor interviewed the Licensed Practical Nurse (LNP #1), who stated if something needed to be repaired she would enter it directly into the maintenance computer system and if maintenance didn't respond within 30 minutes, she would call them because they usually fixed things right away. 34033 4. On 4/15/25 at 8:00 AM, during the morning medication administration observation, the surveyor observed a brown stain on two (2) of the ceiling tiles that were to the right of the door when entering inside room [ROOM NUMBER]. The brown stains covered a majority of the tiles. On 4/15/25 at 8:06 AM, during the morning medication administration observation, the surveyor observed, a brown stain on one (1) ceiling tile above the doorway inside room [ROOM NUMBER]. The brown stain covered the majority of the tile. On 4/16/25 at 12:25 PM, the surveyor observed again, the same brown stained ceiling tiles, as described above, in room [ROOM NUMBER] and 233. On 4/17/25 at 12:22 PM, the DMHL acknowledged the brown stained ceiling tiles in room [ROOM NUMBER] and 233 and stated, I will add them to my list. On 4/22/25 at 4:26 PM the Licensed Nursing Home Administrator (LNHA), Corporate Clinical Officer (CCO), and Director of Nursing were notified of the above concerns. The LNHA stated the facility had a system of non-clinical rounds by the department heads and the DMHL does his own rounds as well. The CCO stated they (the management company) buys buildings that need to be spruced up and then manage or buy them and fix them up, but it takes time, not everything can be done at once. N.J.A.C. 8:39-31.4 (a) (c) (f)

Based on observation, interview, record review, and facility documentation it was determined that the facility failed to: a.) maintain receipt, accountability, reconciliation, secure storage and removal from active inventory of controlled drugs, (Lorazepam (Ativan) (benzodiazepine Schedule IV), Fentanyl Patches (opioid Schedule II), Methadone(opioid Schedule II), Hydrocodone/Acetaminophen (opioid/analgesic Schedule II), and Morphine Sulfate (opioid Schedule II), for three (3) residents, (unsampled Residents #201, #203, #204) that were discharged [DATE], 5/7/24 and 9/6/24 respectively, until surveyor inquiry, stored in one (1) of two (2) medication rooms, b.) maintain accurate accountability, reconciliation and removal from active inventory upon discontinuation for controlled drugs, (Diazepam gel (benzodiazepine Schedule IV) and Nayzilam (Diazepam nasal spray), stored in the medication cart, for one (1) of four (4) medication carts from 2/2/25 and 3/3/23 respectively, until surveyor inquiry for one (1) resident (unsampled Resident #202) and c.) accurately document the disposition of a controlled drug (Buprenorphine (opioid Schedule III) patch) stored in one (1) of four (4) medication carts for one (1) resident, (unsampled Resident #34). The deficient practices were evidenced by the following: 1. On 4/17/25 at 10:45 AM, the surveyor with a Licensed Practical Nurse (LPN #1) inspected the medications stored in the locked refrigerator on the Noble unit. At that time, the surveyor with LPN #1 observed a 30 milliliter (ML) opened bottle of Lorazepam (Ativan) solution 2 milligram (MG)/per ML labeled for Resident #201. The bottle had no date when opened and had approximately 20 ML remaining. On 4/17/25 at 10:47 AM, LPN #1 could not speak to the Ativan bottle for Resident #201 and referred to the Unit Manager/Registered Nurse (UM/RN). UM/RN stated that Resident #201 no longer resided in the facility and that the Ativan bottle should have been dated when opened and discarded 90 days after opening or when Resident #201 was discharged . At that time, UM/RN was unable to provide the Individual Patient Controlled Substance Administration Record (IPCSAR) for Resident #201 that corresponded with the Ativan bottle. The UM/RN acknowledged that without an IPSCAR, the Ativan was not being counted during the shift-to-shift count of controlled medications. On 4/17/25 at 11:05 AM, during further inspection of the medication room on the Noble unit, the surveyor, with UM/RN, observed in an unlocked cabinet, a clear plastic bag that contained the following controlled drugs labeled for Resident #204: three (3) unopened boxes of Fentanyl 50 microgram (MCG) patches (5 patches per box), one (1) opened box labeled Fentanyl 50 MCG patches contained three (3) patches (1 patch was 50 MCG and 2 patches were 100 MCG), two (2) unopened boxes of Fentanyl 100 MCG patches (5 patches per box), a bottle of 21 Hydromorphone 2 MG tablets, a bottle of 58 Hydromorphone 4 MG tablets, a bottle of two (2) Hydrocodone/Acetaminophen 5-325 MG tablets, a 20 ML bottle of Morphine Sulfate solution 100 MG/5 ML with approximately 19 ML remaining and 15 unopened and sealed bottles each with 6 ML of Methadone liquid 10 MG/ML. In addition, in the clear plastic bag, labeled for Resident #203: a bottle of five (5) Alprazolam 0.5 MG tablets. At that time, the UM/RN stated that she had been the UM for approximately three (3) weeks and was unaware of the clear plastic bag with controlled drugs kept in the unlocked cabinet in the medication room. The UM/RN stated that all the controlled drugs should have been returned to the provider pharmacy or destroyed and that it was ridiculous. On 4/17/25 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated she was DON for the past month and had not had any reports of discrepancies regarding controlled drugs. The DON also stated all the above controlled drugs in the bag should have been destroyed by the previous DON with another nurse. The DON acknowledged controlled drugs were not to be stored in the medication room in an unlocked cabinet and required double locked storage. The DON was unable to provide an IPCSAR for Resident #203 and #204 corresponding to each controlled drug in the bag and stated she would have to check. The DON acknowledged the controlled drugs in the bag were not being accounted for during the shift-to-shift count of controlled medications. The DON stated she was unaware of the controlled drugs in the cabinet and would have to begin an investigation. On 4/17/25 at 1:25 PM, the surveyor interviewed LPN #2 who had completed the admission records for Resident #204. LPN #2 looked at the controlled drugs labeled for Resident #204 in the bag and stated that she could not remember the resident coming to the facility with the medications in the bag. On 4/17/25 at 1:45 PM, the surveyor interviewed the DON who provided the surveyor with an IPCSAR labeled for Ativan 2 MG/ML for Resident #201. The surveyor with the DON reviewed the IPCSAR which revealed that 30 ML of Ativan was received on 6/26/24 and a declining inventory was documented from 6/26/24 until 7/3/24. The remaining balance was 20.5 ML of Ativan on 7/3/24. Further review of the IPCSAR, revealed the date of disposition was 10/4/24 and signed by the former DON and former ADON. The DON verified the IPCSAR inaccurately documented the Ativan remaining amount of 20.5 ML was destroyed on 10/4/24. A review of the Admission Record (AR) for Resident #201 revealed that the resident had expired at the facility on 7/3/24. The DON was unable to provide documentation or an IPCSAR that would indicate receipt, accountability and reconciliation of the above listed controlled drugs that were contained in the clear plastic bag. A review of the AR for Resident #204 revealed that the resident had expired at the facility on 9/6/24. A review of the AR for Resident #203 revealed that the resident was discharged from the facility on 5/7/24. On 4/17/25 at 2:06 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Corporate Clinical Officer (CCO) and DON. The CCO stated the UM/RN was new to the facility and would not have knowledge of the controlled drugs found in the medication room. The CCO acknowledged that the medication room should have been checked for proper storage. The DON stated that a unit inspection was performed monthly by the Consultant Pharmacist (CP) and reviewed those reports. The DON acknowledged that controlled drugs should not have been stored in the medication room in an unlocked cabinet and accurate records were supposed to be maintained. A review of CP Unit Inspection reports from May 2024 to March 2025 had not identified the above findings. On 4/22/25 at 8:49 AM, the surveyor interviewed the CP via telephone. The CP stated that she was not the CP who had completed the unit inspection reports but was able to speak to any questions. The CP explained that medication room cabinets and medication refrigerators were checked as part of the unit inspection and any concerns identified would be listed on the reports. In addition, the CP stated controlled drug accountability and reconciliation was spot checked once a month, meaning on the day of the inspection at that moment the controlled drugs were reviewed. The CP added that she may not have the knowledge of residents who had been discharged but if the medication was expired would bring that to the attention of nursing right away. The CP could not speak to what happens after bringing expired medications or medications that needed to be disposed of to nursing. The CP also added that the current DON was more receptive to the reports than the previous DON. On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, Assistant Administrator (AA) and DON. The DON stated the controlled drugs for Resident #204 that were in the bag were brought in the facility by the family and there was a nursing progress note indicating that the family was called to pick up the controlled drugs after Resident #204 expired. The DON also stated that usually medications from home would not be accepted and was unable to verify when the controlled drugs were accepted in September 2024. The DON acknowledged there was no system of receipt, accountability and reconciliation that had being done. The DON could not speak to why the Ativan bottle for Resident #201 was not removed from active inventory when there was no corresponding IPSCAR on the unit and the opened bottle had no open date and was expired. The DON also could not speak to why there were no records for the bottle of five (5) Alprazolam 0.5 MG tablets for Resident #203. CCO added that the nurses were inserviced by the DON and the controlled drugs that needed to be destroyed were documented. A review of the facility undated policy titled Storage of Medications provided by the CCO/RN reflected Controlled Substances will be stored in a separate container under double lock. A review of the facility policy titled Controlled Substances updated 8/22/24 provided by CCO reflected the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. In addition, Controlled substances will be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, will count the controlled substances together. Both individuals will sign the designated narcotic record for the pharmacy records. Also, Accurate accountability of the inventory of all controlled substances is maintained. Nursing staff will count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty will complete the count together. They must document and report any discrepancies to the Director of Nursing Services. Further review reflected, When a resident or patient is transferred or discharged , controlled substances may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies. A review of the manufacturer specifications for Lorazepam (Ativan) Intensol Oral Concentrate 2 MG/ML reflected that the Ativan solution be stored in the refrigerator and Discard opened bottle after 90 days. 2. On 4/17/25 at 11:33 AM, the surveyor with LPN #1 inspected the controlled drugs on the medication cart for Resident #202, which revealed an IPCSAR labeled for Resident #202 for Nayzilam spray 5 MG, two (2) solutions and indicated that the remaining balance was one (1). LPN #1 was unable to show the surveyor the remaining one (1) Nayzilam spray. LPN #1 thought there was only one (1) sent by the provider pharmacy. LPN #1 verified that her signature was on the IPCSAR as receiving the drug but had not signed the date received or amount received but the provider pharmacy label indicated two (2) solutions, the number two (2) was circled and there was a Nurse Administering signature for the number (2) indicating removal of one (1) and remaining balance of one (1). LPN #1 stated that she had not reported any discrepancies regarding controlled drugs for the medication cart. LPN #1 verified that she had signed the Resident Controlled Substance Accountability Log for the Incoming Nurse for 4/17/25 for the 7 AM to 3 PM shift with another nurse who signed the Outgoing Nurse and neither had a discrepancy. Further review of controlled drugs for Resident #202 revealed two (2) IPCSAR for Diazepam gel 20 MG as indicated: -IPCSAR #1 with a prescription (RX) number ending in 244 dated as received 8/19/24 with an amount received of two (2) indicated that the remaining balance was one (1). The surveyor with LPN #1 observed two (2) Diazepam gel 20 MG rectal dispensers labeled for Resident #202 with corresponding RX number ending in 244. - IPCSAR #2 with RX number ending in 149 dated as received 10/5/24 with an amount received of two (2) indicated that the remaining balance was (2). The surveyor with LPN #1 observed one (1) Diazepam gel 20 MG rectal dispenser labeled for Resident #202 with corresponding RX number ending in 149. In addition, there was a partially torn paper wrapped around the dispenser titled Return (discontinued crossed out) Medication Form dated 10/15/24. LPN #1 stated she was not sure why the form was there but thought the medication was to be returned to the provider pharmacy. At that time, LPN #1 verified IPCSAR#1 and IPCSAR#2 were not accurately corresponding to the remaining balances. LPN #1 also verified that the nurses should be corresponding the RX numbers of the controlled drug to the IPCSAR. On 4/17/25 at 11:35 AM, the surveyor interviewed the DON who stated she was the DON for the past month and had not had any reports of discrepancies regarding controlled drugs. On 4/17/25 at 11:42 AM, the surveyor interviewed the DON and UM/RN regarding the IPSCAR labeled for Resident #202 for Nayzilam spray with a remaining balance of one (1). The DON stated Resident #202 was admitted to the hospital last night and would have to look for the Nayzilam spray if two sprays were received. DON acknowledged that the Diazepam gel IPCSAR #1 and IPCSAR #2 were inaccurate and that the nurses were to check the corresponding RX numbers. The DON was unable to speak to the paper tilted Return Medication Form. The DON added that controlled drugs were not returned to the pharmacy. On 4/17/25 at 2:06 PM, survey team met with LNHA, CCO and DON. DON acknowledged that the IPCSAR for Nayzilam spray should be completed for received date and amount received. The CCO stated that they were reviewing the shift to shift Resident Controlled Substance Accountability Log that the nurses signed when counting controlled drugs and had identified that the form was not being completed properly and needed to be changed. On 4/22/25 at 8:49 AM, the surveyor interviewed the CP via telephone. CP stated that she was not the CP who had completed the unit inspection reports but was able to speak to any questions. The CP explained that medication room cabinets and medication refrigerators were checked as part of the unit inspection and any concerns identified would be listed on the reports. In addition, the CP stated controlled drug accountability, and reconciliation was spot checked once a month, meaning on the day of the inspection at that moment the controlled drugs were reviewed. The CP added that she may not have the knowledge of residents who had been discharged but if the medication was expired would bring that to the attention of nursing right away. The CP could not speak to what happens after bringing expired medications or medications that needed to be disposed of to nursing. The CP also added that the current DON was more receptive to the reports than the previous DON. The CP also stated that the RX number for the IPSCAR must match the controlled drug count for accuracy. A review of CP Unit Inspections from May 2024 to March 2025 had not identified the above findings. On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, AA and DON. CCO stated that Nayzilam spray for Resident #202 was not found because the night nurse had discarded the Nayzilam spray without documentation and was unsure what had happened. CCO added that the nurse was written up. CCO acknowledged that destruction of controlled drugs was to be documented on the IPCSAR. CCO stated Diazepam gel should not have had a form for return because controlled drugs were not returned to the pharmacy. CCO added that the nurses were inserviced by the DON and the controlled drugs that needed to be destroyed were documented. A review of the physician's orders for Resident #202 revealed that Nayzilam was discontinued on 3/3/23. On 4/22/25 at 11:52 AM, the surveyor interviewed a Pharmacist (RP) representative from the provider pharmacy via telephone. The RP stated that Nayzilam spray was dispensed for Resident #202 on 12/6/22 in a box containing two (2) sprays. The RP was unable to identify an expiration date on the nasal sprays dispensed at that time. On 4/22/25 at 1:19 PM, the surveyor interviewed LPN #3 who stated that she had worked last week 11 PM to 7 AM and on the morning of 4/15/25 she was cleaning out the medication cart for any expired medications. LPN #3 added that when she counted the controlled drug inventory with LPN #1 she had noticed that the Nayzilam spray was expired and remembered removing the spray and carrying other expired medications with her to go to the computer to reorder the Nayzilam spray where she realized there was no current physician's order. LPN #3 then stated that she thinks she accidentally discarded the Nayzilam spray with the other medications that she had removed from the medication cart. I made a stupid mistake. On 4/22/25 at 4:27 PM, the survey team met with LNHA, CCO, AA and DON. The CCO stated Resident #202 was in the hospital currently and the Diazepam gels were destroyed and documented. The CCO added that she would check regarding the physician's order dating for the Diazepam gel. A review of the physician's orders for Resident #202 revealed Diazepam gel was discontinued 2/2/25. A review of the IPCSAR #1 and IPCSAR #2 labeled for Resident #202 for the Diazepam gels provided by the DON indicated that the DON and UM/RN had destroyed the Diazepam gel dispensers on 4/17/25. On 4/23/25 at 11:14 AM, the survey team met with LNHA, CCO, AA and DON. CCO stated with UM/RN in place now, if a resident was discharged all medications would be removed. The DON added that it was the responsibility of the nurses to remove from active inventory any medications for discharged residents or for any discontinued physician's orders. A review of the facility policy titled Controlled Substances updated 8/22/24 provided by CCO reflected the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. In addition, Controlled substances will be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, will count the controlled substances together. Both individuals will sign the designated narcotic record for the pharmacy records. Also, Accurate accountability of the inventory of all controlled substances is maintained. Nursing staff will count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty will complete the count together. They must document and report any discrepancies to the Director of Nursing Services. Further review reflected, When a resident or patient is transferred or discharged , controlled substances may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies. 3. On 4/17/25 at 11:24 AM, the surveyor with LPN #2 inspected the controlled drugs in the medication cart for Resident #34 which revealed a Controlled Substance Administration Record for Patches (CSARP) labeled for Buprenorphine (Butrans) Patch 10 MCG/hour dated as received 4/15/25 with the amount received as three (3) patches. Further review, revealed that at 10:41 AM on 4/17/25 LPN #2 signed on line three (3) indicating the patch was removed from inventory and applied. In addition, on the same date and time the patch the LPN #2 signed for was removed and wasted. LPN #2 stated she had first removed an old Butrans patch from last week and put the new patch on Resident #34. LPN #2 added she had just started the new CSARP and showed the surveyor the remaining balance of (2) patches in the medication cart. The surveyor, with LPN #2, reviewed the current physician's order which indicated a start date of 3/20/25 for Butrans Transdermal Patch Weekly 10 MCG/HR (Buprenorphine) Apply 1 patch transdermally one time a day every Thu (Thursday) for pain management. LPN #3 acknowledged the patch she had applied today, 4/17/25, would be removed and wasted next Thursday. LPN #2 acknowledged that the documentation on CSARP indicated the same patch she applied had been removed and discarded today. LPN #2 stated she would have to review with DON. In addition, LPN #2 stated she had wasted the old patch that she removed from the resident and showed LPN #1, but that LPN #1 had not signed the CSARP yet. LPN #2 acknowledged that when the patch was wasted both signatures were needed. On 4/17/25 at 11:42 AM, the surveyor interviewed the DON and UM/RN regarding the CSARP labeled for Resident #34 for Butrans patch. The DON stated there should be two nurses' signature for the wastage of the controlled drug. DON acknowledged that the CSARP had not reflected the application and removal properly and would have to look into it. On 4/17/25 at 2:06 PM, the survey team met with LNHA, CCO and DON. The DON stated that she would have to review and /or change the process of the controlled drug patch wastage signatures. On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, AA and DON. The CCO stated LPN #2 had signed for the removal of the Butrans patch but had not wasted the patch and was holding the patch in a cup in the medication cart until LPN #1 was available to destroy the patch. The CCO added the regulation, and our policy requires signing at the time of destruction. The CCO was unable to speak to the interview with the surveyor and LPN #2 at the medication cart. The CCO stated LPN #2 was on vacation now. The CCO also stated the corresponding IPSCAR for the old Butrans patch that was removed by LPN #2 was not in the controlled drug binder at the time LPN #2 removed the patch to waste. The CCO added that the nurses were inserviced by the DON. On 4/22/25 at 10:41 AM, the CCO stated that the policy for documenting the destruction of a controlled drug patch was reflected in the policy titled Controlled Substances updated 8/22/24 7. When a resident refuses a non-unit dose medication or it is not given, or receives partial tablets or single dose ampules, or it is not given, the medication shall be destroyed with two witnesses and may not be returned to the container. NJAC 8:39- 29.4(g), 29.4(i), 29.4(k), 29.7(c)

Based on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 12/7/24 to 4/16/25. This deficient practice was evidenced by the following: On 4/15/25 at10:17 AM, the surveyor met with seven residents for a resident council meeting. During that meetin, 6 out of the 7 alert and oriented residents voiced concerns that the facility did not have a full-time social worker. The residents explained for the last 2 or 3 months there was a social worker that worked only Saturdays/Sundays for about 5 hours. On 4/15/25 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated there was a new social worker starting this week. He confirmed the current social worker (SW#2) usually comes in a few hours on Saturday's and Sundays. He verified the last SW's (SW#1) last day was 12/6/24. A review of the facility provided time clock punches for SW #2 revealed SW #2 worked as follows: -12/7/24 to 12/29/24 a total of: 31.5 hours -1/8/25 to 1/25/25 a total of: 22.58 hours -2/1/25 to 2/15/25 a total of: 23.41 hours -3/1/25 to 3/29/25 a total of: 37.61 hours -4/5/25 to 4/12/25 a total of:10.68 hours On 4/16/25 at 1:35 PM, the surveyor interviewed SW#2 via telephone. SW #2 stated that he had a full-time position at another facility and had been helping by working on Saturdays for five (5) hours since the middle of January. SW #2 stated that his responsibilities on Saturday were to complete any needed social histories, social determinants of health, Minimum Data Set (an assessment tool used to facilitate the management of care for a resident) requirements and/or obtain signed pertinent paperwork for identified residents. SW #2 added that his responsibilities were based on a list or print out of identified residents he received. In addition, he stated that he would try to spend time with any resident that wished to speak with him. SW #2 also stated, I do what I can in 5 hours. He added that when residents spoke with him and had a concern that he was unable to follow up with, he would refer the resident's concern to a full-time administrative staff that could handle what the resident needed. SW #2 explained for example that if a resident wished to be discharged or transferred then he would let the Admissions staff member know because they worked Monday through Friday and would be able to handle those type of requests. On 4/22/25 at 11:46 AM, the surveyor interviewed the Admission Director (AD), who stated her role was to bring the residents in, and the SW brings them out. She stated if a resident wanted to transfer to another facility the resident or family would let her know what facility and she would facilitate the transfer. The AD explained that the rehabilitation department would set up durable medical equipment if a resident needed to be discharged home and nursing would do the actual discharge paperwork. On 4/22/25 at 4:28 PM, during a meeting with the survey team, the Corporate Clinical Officer, the Director of Nursing, the LNHA, and the Assistant Administrator were made aware of the above concerns. The facility was on record as being licensed for 180 beds. The CMS guidelines implemented 11/28/17, included but were not limited to a qualified SW full-time for a facility with over 120 beds. A review of the facility's Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. N.J.A.C. 8:39-9.3(a); 39.2; 39.4(i)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was evidenced by the following: On 4/14/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or at either nursing unit. The receptionist was present at the front desk. On 4/15/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or on the Noble nursing unit. The receptionist was present at the front desk. On 04/16/25 at 9:44 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/15/25 for the 7-3 shift. On 4/16/25 at 11:16 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/16/25 for the 7-3 shift. On 04/17/25 at 9:24 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/17/25 for the 7-3 shift. On 4/22/25 at 9:32 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/22/25 for the 7-3 shift. On 4/15/25 at 11:00 AM, the surveyor interviewed the staffing coordinator (SC), who stated staffing was usually posted at the front desk. She further stated I am responsible, I have been gone for 2 weeks. I just got back yesterday. Nobody posted the staffing while I was gone. The staffing was not posted yesterday or today, until I got it here. I just now printed it. I usually wait until after morning meeting to post it so it's accurate. I give it to the lady at the front desk but doesn't look like she did it. On 4/22/25 at 4:26 PM, the survey team met with the Director of Nursing (DON), who stated she was not sure who was responsible to post the nursing staffing report when the SC was away. She further stated maybe the receptionist was responsible. On 4/23/25 at 11:10 AM, the survey team met with the DON, who stated the staffing report was not posted on Monday (4/14/24). A review of undated facility provided policy Staffing Policy Statement included: Our facility provides adequate staffing to meet needed care and services for our resident population. Policy 5. Staffing will be posted in a visible location. NJAC 8:39-41.2 (a)

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for two out of four Quality Assurance and Performance Improvement (QAPI) meetings reviewed and was evidenced by the following: 04/23/25 11:33 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated QAPI meetings were held at least quarterly and as needed, he added we also meet monthly. He stated the required members were the administrator (LNHA), the director of nursing (DON), the medical director and other staff were required to attend the meetings at least quarterly. The LNHA stated also will be including a certified nursing assistant in the meetings. At that time, the LNHA reviewed the facility provided QAPI sign in sheets, he removed the sign in sheets for the quarterly QAPI meetings. A review of the Quarterly QAPI Meeting Attendance sign in sheets revealed meeting were conducted on 4/17/2024, 7/17/2024, 10/16/24 and 1/15/2025. The surveyor asked the LNHA to identify the IP on the sign in sheets. After reviewing the sheets, he was unable to identify the IP was present at the 4/17/2024, 10/16/24 and 1/15/2025 meetings. During the same interview, the LNHA stated he was not aware the IP was required to be in attendance. At 12:32 PM, the LNHA provided evidence that the IP was off on 1/15/2025 but was able to provide evidence that infection control was reviewed with the committee. At that time, the surveyor requested evidence of infection control review for the 4/17/204 and 10/16/24 QAPI meetings. No additional information was provided. A review of the facility's policy Quality Assurance and Performance Improvement Plan revealed III. Guidelines for Governance and Leadership .b. i. The QAPI committee provides the organization structure for QAPI. This group includes administrator, DON, medical direction and/or designee, at least three other members of the facility's staff and the infection control and prevention officer .ii. Currently QAPI committee maintains record of attendance and minutes with supporting documentation. NJAC 8:39-33.1(b)

Repeat Deficiency Based on observation, record review, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not placing a resident with open wounds on Enhanced Barrier Precautions (EBP- a gown and gloves be worn when performing high contact care), for one of two residents (Resident #45) reviewed for pressure ulcers. The deficient practice was evidenced by the following: On 4/16/25 at 9:33 AM, during a wound treatment observation, the surveyor observed the Certified Nurse Aide (CNA) holding Resident #45 on their right side with their sacral and right heel wound exposed. The CNA was wearing gloves. The surveyor then observed the Licensed Practical Nurse (LPN) cleanse the sacral wound and apply the treatment and dressing. The LPN was wearing gloves. After performing hand hygiene, the LPN donned (put on) gloves and the LPN cleansed the right heel wound and applied the treatment. The surveyor had not observed EBP signage at the resident's doorway or in the room. The surveyor reviewed the electronic medical record (EMR) for Resident #45. A review of the Order Summary Report revealed a physician orders (PO) dated 4/14/25 for Zinc Oxide External Paste 20%. Apply to buttocks . and Medihoney Wound/Burn Dressing External Gel Apply to right heel . A review of the Admission Record, (an admission summary), reflected diagnoses that included but not limited to; Dementia (brain disorder), hypertension (elevated blood pressure) and diabetes (elevated blood sugar). The Individual Comprehensive Care Plan (ICCP) included a focus area of potential impairment to skin integrity. Interventions included medihoney to left heel after cleansing and zinc oxide to buttocks. On 4/16/25 at 9:48 AM, the surveyor interviewed the LPN. The LPN stated that Resident #45 should not be on EBP because there was no discharge from the wounds. She further stated that EBP was important if fluid was involved. On 4/16/2025 at 10:10 AM, the surveyor interviewed the CNA. The CNA stated that she should not have worn a gown when caring for Resident #45. She further added that she knew who was on isolation from report and signage on the door. On 4/16/2025 at 12:11 PM, the surveyor interviewed the Unit Manager Registered Nurse (UM/RN). She acknowledged that Resident #45 should have been on EBP because they had a wound. On 4/22/25 at 10:10 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse, who stated that if a resident had a wound, EBP were needed. A review of facility policy PPE for MDRO Updated December 15, 2024 revealed: Enhanced Barrier Precautions Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug-resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: . Wound care: any skin opening requiring a dressing. N.J.A.C. 8:39-19.4 (a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the kitchen was free of pests. The deficient practiced was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During this tour, he stated that he used a [name redacted] electronic communication system as well as verbal communication with the Director of Environmental Services (DES) when there was a maintenance concern in the kitchen. The surveyor observed an open drain on the floor next to a grease trap. The surveyor observed many flies in this area, coming from the drain, in the air and on the wall. The FSD acknowledged this and stated they were drain flies, and that the grease trap needed to be cleaned. In addition, the FSD stated the exterminator treated the area and that it did not help since there was an open drain. On 4/22/25 at 1:01 PM, the surveyor conducted a second kitchen tour with an additional surveyor and the FSD. The FSD provided a pest control logbook to the surveyor for review. The form indicated the last visit from the exterminating company was on 4/1/25; however, there was no indication of what or where treatment was performed in the kitchen. The FSD stated that the exterminator conducted weekly visits every Tuesday. During this tour, both surveyors observed the same type of flies on the wall just outside the dish machine room. On 4/22/25 at 2:26 PM, the surveyor interviewed the DES. He stated that the pest control company came in weekly and there was a logbook for the kitchen. He stated that he was unaware there were drain flies in the kitchen. On 4/22/25 at 3:36 PM, the DES provided the surveyor invoices from the exterminating company from 2/18/25 through 4/8/25 which revealed kitchen pests had not been addressed. In addition, there was an invoice dated 4/15/25, which indicated No service was performed due to state conducting survey. On 4/22/25 at 3:51 PM, the surveyor interviewed the Regional Property Manager, who was unaware of a fly issue in the kitchen. On 4/22/25 at 5:29 PM, the surveyor reviewed the above concern with the administrative team (Licensed Nursing Home Administrator, Director of Nursing and the Chief Clinical Officer), in the presence of the survey team. On 4/23/25 at 11:26 AM, the LNHA stated that the exterminator treated for flies in the kitchen about a month and a half ago but nothing specific to flies were recorded on paperwork. A review of the facility Work Orders between the kitchen and maintenance department from 3/18/24 through 3/31/25, did not address flies. A review of an undated facility policy Pest Control, reflected the facility would maintain an effective pest control program. It also reflected the facility maintained an on-going pest control program to ensure the building was kept free of insects. A review of an undated policy Sanitation, reflected kitchen areas would be kept clean and protected from flies and other insects. N.J.A.C. S 8:39-31.5

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a) a resident assessment was completed to rule out injury, and the physician was immediately notified when staff witnessed a resident who banged finger hard on a door frame and yelled ouch. This resulted in a delay in treatment for one and a half hours, and the resident experienced pain and was subsequently diagnosed with a fracture of the third finger left hand, and b) appropriate incontinence care and related services were provided for two residents dependent on staff for care. The deficient practice was identified for 1 of 2 residents reviewed (Resident #52) for accidents and 2 of 6 residents who were dependent on care and reviewed for provision of incontince care (Resident #13 who did not have a sacral pressure ulcer prior to not being providedd with incontinence care for 15 hours which then resulted in a facility acquired pressure ulcer, and Resident #14 who had not been provided with incontinence care for over 12 hours and was left saturated with urine and embedded feces and had a Stage IV Pressure Ulcer. and Resident #14) and was evidenced by the following: a.) On 10/18/23 at 9:46 AM, the surveyor observed Resident #52 in his/her room. The resident looked at the surveyor but did not speak to the surveyor. The resident had one shoe on and was wearing a non-skin sock on the other foot. On 10/19/23 at 11:07 AM, the surveyor observed Resident #52 wearing non-skid socks and ambulating around the nurse's station with staff holding his/her arm for assistance. Resident #52 was easily redirected. On 10/20/23 at 7:54 AM, the surveyor observed the resident in a wheelchair in front of the nurse's station. A review of the EMR revealed that Resident #52 had diagnoses which included but were not limited to; other symptoms and signs involving the musculoskeletal system, history of falling, vascular dementia, and muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool used to facilitate a resident's treatment, dated 07/01/23, included but was not limited to; was rarely or never understood so a Brief Interview for Mental Status (BIMS) could not be conducted, severely impaired cognition, continuous behaviors of inattention and disorganized thinking, wandering daily, required limited assistance of at least one staff member when ambulating in the hallway, and as having had a fall with injury since admission or readmission. A review of the Order Summary Report included a physician's order dated 02/02/23, for Tylenol (used for pain) 325 milligrams (mg) give two tablets by mouth every 6 hours as needed for pain. An order dated 08/20/23, to refer the resident to a hand surgeon for a fracture of the third finger left hand. A review of the August 2023, Medication Administration Record (MAR) included but was not limited to; the Tylenol 325 mg order to administer two tablets every 6 hours for pain. There was no documentation on 08/20/23, that Tylenol had been administered for pain. A review of the person-centered comprehensive Care Plan (CP) included but was not limited to; a focus area of being at risk for falls with actual falls on 08/31/23 and 09/23/23. Interventions included but were not limited to; ensure the resident is wearing appropriate footwear, review information on past falls and attempt to determine cause of falls .pain management. A focus area of having a potential for pain. Interventions included but were not limited to; monitoring/record pain characteristics, monitor/record/report any s/sx (signs and symptoms) of non-verbal pain (grunting, moaning, yelling out). On 10/26/23 at 12:00 PM, during an interview with Surveyor #1, the Licensed Practical Nurse (LPN) #1 stated he was familiar with Resident #52 and remembered the incident on 8/20/23. LPN #1 stated he saw the resident getting up and hit his/her left hand pretty hard on the door frame. LPN #1 stated he had not documented what happened in the electronic medical record (EMR), and stated I went to get [him/her] and I assisted [him/her] to the a chair and stated Resident #52 yelled ouch when the resident hit [his/her] hand on the door frame. LPN #1 stated, I sat him/her back in his/her chair and took his/her vital signs. LPN #1 then stated, It was an hour and a half later that the resident's finger was discolored and the resident was in pain. When the surveyor inquired if an assessment was immediately conducted upon observing the resident hit [his/her] hand or any care that had been provided to Resident #52, the LPN stated, I don't have the documentation of assessing the resident's hand. LPN #1 stated he only placed Resident #52 in a chair. LPN #1 confirmed that he had not contacted the physician at the time the resident hit [his/her] hand and stated he should have maybe done something. When inquired to LPN #1 what should be done when a resident has a potential injury, the LPN stated further the process would have been to assess the resident, call the nursing supervisor or Director of Nursing (DON), call the physician, and notify the family. LPN #1 stated that an assessment should have been completed and documented, and confirmed it had not been completed. A review of the Progress Notes (PN) revealed documentation by the LPN #1 dated 08/20/23 at 9:50 AM, revealed Resident c/o [complaint of] pain about middle finger of left arm, noted discolored, cold to touch, painful at touch. Vitals stable, called placed to md [medical doctor], new order for x ray of the middle finger of the left hand for c/o pain and discoloration. On 10/26/23 at 12:30 PM, the Medical Director (MD) during a telephone interview with the surveyors, stated that she was Resident #52's physician. The MD stated she was aware Resident #52 had falls but could not remember everything about the 08/20/23 incident. The MD stated her expectations would be that if a resident fell , the staff should tend to the resident, call the physician, and describe the injury so she would know the course of action. The MD further stated that if a staff member witnessed the resident hit their hand, she would expect a call immediately. She accessed her EMR and informed the surveyors that she was informed the finger was fractured on 08/23/23, three days ago and the staff was not sure how the injury occurred. On 10/27/23 at 10:46 AM, the above concern was addressed with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations, and the Regional Clinical Nurse (RCN). On 10/31/23 at 8:21 AM, during an interview with the surveyor, LPN #2 stated if she witnessed a resident fall into something or injury themselves, she would assess their whole body, write an incident report, but give first aid immediately in case the resident had pain and next call the doctor. On 10/31/23 at 8:22 AM, LPN #3 stated if she witnessed a resident injury themselves, she would immediately assess the resident and provide first aid and inform the doctor. She stated she would provide first aid definitely right away to protect the resident. On 10/31/23 at 10:24 AM, the Regional Clinical Nurse (RCN) stated LPN #1 should have called the doctor, used ice and pain management immediately given the resident yelled ouch. She stated the expectation would have been to assess for pain and administer the already ordered Tylenol for pain. The facility had no additional documentation or policies to provide. 27193 b. 1.) On 10/18/23 at 10:35 AM, Surveyor #2 toured the Noble Unit (High side), and observed Resident #13 in bed. Their eyes were open and the resident was able to communicate with the surveyor. A care tour was completed with the Certified Nursing Assistant (CNA) assigned to the unit and revealed the following: Resident #13 was unshaven, the skin on the face was covered with flakes. The lower extremities extended to the toes had areas that were covered with callus type skin areas with dry skin flakes which were noted on the bed also. The adult incontinent brief that the resident was wearing, was secured properly and was not soiled. The skin on the back and buttocks was intact and there were no open areas. No redness was noted. There was no documentation that Resident #13 had been non-compliant with care. An interview with the CNA revealed that the resident required extensive assistance of two staff for bed mobility and transfer. The CNA added that the resident remained in bed and would refuse to get out of the bed. When the surveyor inquired about the dryness noted on the face and the lower extremities, the CNA stated, There is a skin remedy that could be applied. On 10/19/23 at 8:45 AM, Surveyor #2 observed the resident in bed. The resident was unshaven and the skin was dry. An interview with the Registered Nurse Unit Manager (RN/UM) revealed that the podiatrist visited the resident on 10/18/23, and there were no new orders. On 10/20/23 at 7:45 AM, Surveyor #2 observed the resident in bed, their eyes were closed, and the side-rails were elevated. The surveyor returned during lunch and observed the resident was in bed, unshaven, and large number of flakes and dry calluses were noted on the bed. On 10/23/23 at 9:00 AM, Surveyor #2 returned to the unit and observed Resident #13 in bed. A CNA was at the bedside assisting Resident #13 with the breakfast meal. The resident was unshaven, and their face was covered with white flakes. The surveyor asked the resident if he/she would consider getting out of the bed today. The resident replied, Not really. I am itchy. I would like to get washed. On 10/23/23 at 9:30 AM, after breakfast Surveyor #2 asked two CNAs to assist with a care tour. The surveyor observed that Resident #13 was wearing two incontinent briefs which were both saturated with urine. The gown that the resident was wearing was brown and stained. The pulled sheet was also brown and stained. Resident #13 was noted with scratch marks and redness to the sacrum and buttock areas. The Registered Nurse Unit Manager (RN/UM) was not available on the Noble Unit. The surveyor summoned another surveyor to the room along with the Director of Nursing (DON). On 10/23/23 at 9:52 AM, the DON in the presence of Surveyor #2 verified that incontinence care had not been provided on the prior shift. (11:00 PM-07:00 AM shift). Surveyor #2 left the room and reviewed the 11:00 PM-7:00 AM staffing. The Census was 52, and only 1 CNA had been assigned to care for 52 residents. On 10/26/23 at 11:00 AM, Surveyor #2 conducted a telephone interview with the CNA who worked the prior 3:00 PM-11:00 PM shift. The CNA revealed that she provided care to Resident #13 on 10/22/23 at 6:30 PM and applied two adult incontinent briefs on the resident. The CNA stated that at 6:30 PM, she had to change the sheets including the gown, as Resident #13 was saturated with urine. The CNA confirmed that she applied two adult incontinent briefs prior to finishing her shift. She informed the surveyor that she clocked out at 7:00 PM. On 10/26/23 at 12:53 PM, Surveyor #2 conducted a telephone interview with the 3:00 PM -11:00 PM Registered Nurse (RN) who worked on the Noble Unit. The RN stated that two CNAs left at 7:00 PM, and the other CNA on the unit did not ask for assistance with care. He stated that staffing was lacking but he would assist if requested. He could not elaborate on whether incontinence care had been provided. On 10/27/23 at 9:25 AM, Surveyor #2 checked Resident #13 again and observed the sacral redness was still present. A small open area to the left buttock was observed and there was no documentation regarding the newly open area which was not measured or provided a treatment. On 10/27/23 at 9:32 AM, Surveyor #2 asked the RN/UM to measure the affected area. The sacrum measured: 9 centimeter (cm) x 8.5 cm. The left buttock measured 6.5 cm x 1.5 cm. On 10/27/23 at 9:49 AM, Surveyor #2 conducted an interview with the RN/UM regarding the process to ensure that the residents were being cared for. The RN/UM stated that in the morning, she would get a verbal report from the 11:00 PM-7:00 AM shift and would follow up on anything important. She stated she would assign nurses and gave report to CNAs. The CNAs should check the residents as soon as they received their report. Residents' dependent on staff for care should be checked at minimum every two hours and as needed. The RN/UM further stated that she was not aware that some of the residents did not receive care during the 11:00 PM-7:00 AM shift. In the morning during report, she was informed that adequate staffing was an issue, and the night nurse did not elaborate further. She went on to state, if she was made aware of residents not having received care, she would have asked the CNAs to check and change the residents that were not changed during the prior shift immediately. On 10/27/23 at 7:50 AM, Surveyor #2 conducted a face-to-face interview with the Licensed Practical Nurse (LPN) who worked the 11:00 PM-7:00 AM shift on 10/22/23. The LPN informed the surveyor that staffing had been an issue at the facility for the last 5 years. The LPN made it clear that on 10/22/23 during the night, they provided safety and answered call lights. When inquired regarding if she aided the CNAs to change and turn some of the residents, she stated, No, I was busy also. We provided safety that is all we could do. When asked if the administrative staff was aware of the staffing issue, she stated, yes. On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the CNA who cared for the resident during the 11:00 PM -7:00 AM shift on 10/22/23. The CNA confirmed that he did not provide incontinence care to the resident during the shift (8 hours). The CNA told the surveyor he was overwhelmed and could not get to the resident. He stated that for that shift he provided care for 30 residents. The CNA stated he provided safety and ensured the call lights were being answered. On 10/27/23 at 10:55 AM, the DON revealed she was not aware that the facility had one CNA working for the 11:00 PM- 7:00 AM shift. She further stated, if she had been made aware, she would have call to get more staff. She added that she was not aware that incontinence care had not been provided. Her expectations were that all residents looked cleaned and received the care they deserve. A statement from the LPN assigned to the 7:00 AM-3:00 PM shift indicated that she was informed by the CNA that Resident #13 was heavily saturated with urine and had 2 adult briefs on. She informed the DON and applied periguard cream to the skin. She rechecked the resident in the afternoon after care was provided and there was no skin breakdown observed. On 10/27/23 Surveyor #2 reviewed Resident #13's EMR. The admission Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, Parkinsonism, unspecified, contracture left elbow, psoriasis and unspecified Dementia. Review of R 13's most recent annual MDS with an Assessment Reference Date (ARD) of 07/18/23, reflected that Resident #13 had moderate cognitive impairment. Resident #13 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section V. Care Area Assessment (CAA) Summary, Section V 02000. CAA and Care Plan (CP) decision, documented cognitive loss, urinary incontinence, Activities of daily living, nutritional status, pressure ulcer, psychosocial well-being, and psychotropic drug use were triggered and identified to develop a care plan. Record Review (RR) of Resident #13 revealed that R #13 did not have a pressure sore. Section M which addressed skin condition, coded Resident #13 to be at risk. Surveyor #2 reviewed Resident #13's Care Plan (CP), last reviewed/revised on 07/17/23. The CP had a focus area for impaired skin integrity related to healing Stage 4 Sacrum, incontinence and impaired mobility and chronic circulatory insufficiencies. The goal was for Resident #13 to develop no new areas of skin breakdown. The interventions included, keep skin clean and dry. Apply lotion on dry skin. Turn and reposition at frequent intervals while in bed. The care plan did not reflect that Resident #13 had a pressure injury to the sacrum extended to the buttocks areas. A review of an interdisciplinary (IDCP) meeting conducted by the facility on 10/24/23, timed 15:44 (3:44) PM, reflected the following: IDCP met to review Quarterly plan of care. Resident had not had a significant change(s) in condition. Resident is compliant with care and takes his/her meds. Skin is intact at present . Despite the observed skin injury verified by the facility staff on 10/23/23, there was no documentation that the physician or the Resident Representative (RR) was informed of the issue with incontinence care resulting in skin injury. The care plan was not revised. On 10/31/23 at 9:30 AM, the RN/UM informed Surveyor #2 that the resident was seen by the wound team and provided the following progress notes dated 10/30/23 timed 13:06 (1:06) PM. Resident was seen on wound round. Left buttocks redness resolved. Right buttock redness measuring 9 centimeter (cm) x 6.5 cm. Skin is intact. Treatment, Antifungal cream. Sacrococcyx MASD (Moisture Associated Skin Damage) measuring 0.3 cm x 0.5 cm x 0.1 cm. 100% epithelization tissue present. Scant serous drainage present. Treatment with Silvadene twice daily. b. 2.) On 10/23/23 at 11:00, Surveyor #2 entered Resident #14's room with two CNAs for a care tour. The surveyor observed that Resident #14 was not provided with incontinence care. Large amount of secretions was noted on the sheet. Strong feces odor was noted in the room. During the care tour at 11:15 AM, the surveyor along with facility's staff observed Resident #14's sacrum and bottom which were covered with feces. Resident #14 had a stage 4 pressure ulcer that was covered with feces. The gauze covering the dressing was noted in the incontinent brief covered with feces exposing the open areas of skin that were also covered with feces. On 10/23/23 at 12:30 PM, Surveyor #2 interviewed the CNA assigned to Resident #14. The CNA confirmed that she had not checked or changed the resident prior to go on break at 11:00 AM. On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the 11:00 PM-7:00 AM CNA. The CNA informed the surveyor that he checked the resident possibly at 6:00 AM and the resident was not soiled. When inquired about who assisted him with the resident, he stated, I did it alone. (Resident #14 required extensive assist of two persons for bed mobility. The surveyor then asked the CNA what he observed on the resident backside area, he stated there was nothing in place. Resident #14 had a wound and a protective dressing was to be in place but was missing per the CNA. On 10/27/23 the 11:00 PM- 7:00 AM CNA provided the following statement, I was the only CNA on the unit last night. I did rounds, offered water to the residents but did not provide incontinent care. I was alone and it was difficult. I did not ask for assistance from the nurse. It just escaped my mind. I must be honest, I made rounds, offered water but I did not change or check the residents. A telephone statement from the LPN dated 10/25/23, indicated the following: I was the only nurse and he was the only CNA. I helped the CNA with residents that he could not change alone. I have one CNA who could not do the entire floor. The LPN stated that at 6:00 AM, she observed that Resident #14 was in bed, appeared to be comfortable and he/she was covered. I did not noticed any odor during my rounds. The surveyor reviewed Resident #14's clinical record. The admission Face Sheet reflected that Resident #14 was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, heart failure, right and left hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen. The Quarterly Minimum Data set (MDS) an assessment tool used by the facility to prioritize care dated 09/08/23, revealed that the resident was non verbal and totally dependent on staff for all Activities of Daily Living (ADLs). All needs must be anticipated. Resident #14 required two persons physical assist for bed mobility and toilet use. Resident #14's Comprehensive Care Plan dated 02/07/18, with a revision date of 03/09/21, reflected a focus for ADL Self Care Performance Deficit and is totally dependent on staff for all ADLS related to impaired mobility and cognition. The goal was for staff to anticipate and meets all Resident #14's needs with Target date of 09/21/2023. The interventions included: for personal hygiene: Resident #14 required total assistance with personal hygiene. Resident #14 also had a focus for impairment to skin integrity on sacrum related to stage 4, incontinence, immobility. The goal was for the wound to show sign and symptoms of healing through the review date of 09/21/23. Interventions included: Daily skin checks with care initiated 02/07/18. Follow facility protocols for treatment of injury. Identify causative factors and eliminate/resolve where possible. keep skin clean and dry revision date 02/07/18. Air mattress to relieve pressure to pressure points. (02/07/18). Turn and reposition every 2 hours. Weekly skin assessments by licensed nurse with a revision date of 02/07/18. On 10/20/23 at 11:15 AM, Surveyor #2 conducted a face to face interview with Resident #14's Representative (RR). The RR revealed concerns with the care delivery. The RR stated that the facility did not have enough staff to care for the residents. The RR went on to state that during visits, the RR would observe the resident soiled and laying in bed with a soiled brief for long periods of time and could not find any available staff to change the resident. The RR stated this had been discussed with the RN/UM and the prior Director of Nursing. On 10/23/23 at 11:00 AM, Surveyor #2 conducted a care tour with two CNAs assigned to Noble Unit (high side). On 10/23/23 at 11:15 AM, in the presence of the LPN assigned to the unit and two CNAs, Surveyor #2 observed that Resident #14 was heavily soiled with feces. The adult brief and the pads were covered with feces. The CNA assigned to the resident was on break and could not be interviewed. On 10/23/23 at 12:30 PM, the surveyor interviewed the CNA assigned to the 7:00 AM- 3:00 PM. The CNA revealed that she reported to work at 6:50 AM, and had not yet checked the resident during the shift. Statements from the CNA who worked the 11:00 PM-7:00 AM shift indicated that incontinence care was not provided during the prior shift because he was the only CNA. Resident #14 was totally dependent on staff for care. Resident #14 was not provided incontinence care for over 12 hours. During wound care on 10/23/23 at 11:30 AM, a new open area of skin was noted on the right buttock which was not measured by the nurse. The nurse dressed the wound with Periguard and secured the wound with the adult brief. A review of the indication for Periguard (skin barrier) indicated the following: Do not use on open and punctured wound. The LPN did not have an order to apply Periguard to the open wound. On 10/23/23 at 12:40 PM, during an interview with the Director of Nursing, she stated that the nurse should have applied a wet to dry saline dressing until she got an order from the physician. Review of the skin evaluation dated 10/23/23, provided by the facility, revealed that the resident had a stage 4 pressure ulcer to the sacral area. The pressure injury to the left buttock was identified on 10/23/23, during care and wound treatment. Review of the Physician Order Sheet (POS) dated 10/01/23, reflected an order to cleanse the sacral wound with saline and pat dry. Apply Calcium Arginate Silver to wound, cover with gauze and dry dressing daily. Silvadene 1% (Silver Sulfadiazine) was to be applied to the right buttock. There was no order to apply Periguard to the left and right buttocks. A Progress Notes dated 10/23/23 timed 6:20 PM, revealed the following: Left buttock MASD measuring 9.0 centimeter (cm) 4 cm x 0.1 cm. Right buttock MASD superior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Right buttock inferior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Treatment ordered with Silvadene. The facility provided, Skin Evaluation dated 10/23/23, indicated that a new issue was identified: Noted with stage 4 sacrum, MASD to left buttock and reopening of MASD to right buttock. A review of the Comprehensive Care Plan did not include documentation of the skin injury identified on 10/23/23. The rationale for not revising the care plan after the pressure injury was identified was not provided. The above concerns were discussed with the administrative staff during the survey and again on 10/30/23, during the pre-exit conference. The DON added that she started the investigation and would provide the investigation on 10/31/23. The DON provided the investigation on 10/31/23. All staff involved with Resident #13's and #14 care on 10/22/23 and 10/23/23, were interviewed. The 3:00 PM-11:00 PM shift confirmed she provided care to Resident #13 at 6:30 PM, and applied 2 adult briefs on the resident. The 11:00 PM-7:00 AM CNA provided a statement which reflected that he did not provide incontinence care to the residents. Resident #13 and #14 did not receive care according to their plan of care. The resident (#13)was last changed at 6:30 PM on 10/22/23. On 10/31/23 at 11:30 AM, in the presence of the survey team, the DON acknowledged that based on the investigation and her observation specifically for Resident #13, incontinence care was not provided. The DON further stated that all residents dependent on staff for care should have been checked and changed every 2 hours and as needed. A review of the facility provided, Abuse, Neglect and Explotation, policy revised 09/2022, included but was not limited to; Policy: to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Neglect is defined as the failure of the facility to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the facility provided, Abuse, Neglect and Mistreatment of the Elderly Policy, undated, included but was not limited to; B. Prevention: 4. adequate staffing levels are maintained at all times so that the needs of residents are met. D. Identification: 2. examples of neglect may include: a. pressure sores, b. poor personal hygiene, e. dirty, soiled bed, fecal or urine odor. A review of the facility provided, Certified Nurse Aide position summary, undated, included but was not limited to; Responsibilities: handles and attends to residents in a manner conductive to their safety and comfort; bathes the resident cleans and cuts fingernails and gives shampoos; and reports changes in resident's condition to the charge nurse or supervisor. A review of the facility provided, Licensed Practical Nurse position summary, undated, included but was not limited to; Responsibilities: takes an active role in direct resident assessment and care; assesses each resident daily and implements a change in the course of action as needed; maintains accurate resident care records and documents pertinent data; ensure that residents receive the highest quality of service .promoting dignity and respect; A review of the facility provided, Registered Nurse, position summary, undated, included but was not limited to; takes an active role in direct resident assessment and care; must have the ability to recognize and identify symptoms and to make decisions quickly in emergencies; assess each resident daily and implements a change in the course of action as needed; ensures that residents and families receive the highest quality of service .promoting dignity and respect. A review of the facility provided, Director of Nursing Services, position summary, undated, included but was not limited to; monitors nursing care to assure that all residents are treated fairly, with kindness, dignity and respect; completes daily rounds on the unit to observe residents and determine if nursing needs are being met; reviews nursing progress notes to ensure they are informative and descriptive of the nursing care provided; and provides direction to the nursing staff. NJAC 8:39-27.1 (a), 27.2 (c)(d)(g)(h)(j)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure the surety bond contained sufficient funds to protect the residents' trust funds. This deficient practice had the potential to affect all residents who resided in the facility that had Personal Needs Account (PNA) funds and was evidenced by the following: On 10/19/23 a 12:45 PM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a three-page document labeled Checking Account Statement, Statement Type: Bank, Trust Account [number redacted]. The document was dated 07/25/23 through 10/18/23. The document revealed a beginning balance $144,211.45, on 07/25/23, and a balance of $129,340.81 on 10/18/23. Additionally, the surveyor was provided with a 2-page Checking Account Statement dated 07/20/23 through 10/18/23 which was labeled as Petty Cash Account [number redacted]. On 10/19/23 1:10 PM, the LNHA provided a copy of the Surety Bond. The document revealed a Renewal Verification/Continuation Certificate for an anniversary premium Period dated 4/1/23 - 4/1/24 in the amount of $85,000. The surveyor observed that the Surety Bond did not cover the balance of the funds in the account labeled Trust Account by more than a $44,000 deficit as of the 10/18/23 balance. On 10/19/23 at 1:26 PM, the surveyor interviewed the LNHA regarding the purpose of the PNA. The LNHA stated the PNA was to ensure that any resident money for resident's that had over $50.00 was held in an interest-bearing account. The LNHA stated the resident would have access to their money 7 days a week and 365 days per year and and the person who handled the PNA would be able to explain things further. On 10/19/23 at 1:44 PM, the surveyor interviewed the Revenue Cycle Manager (RCM) in the presence of the LNHA. The RCM stated she was the person responsible for the centralized oversight of the business office functions for the facility which included the PNA funds. The RCM stated that the resident's PNA was kept the in an interest-bearing account. The surveyor asked the RCM about the purpose of the surety bond. The RCM stated it was an insurance policy because the money in the account does not belong to us. She stated that each facility had a surety bond, and the bond should cover what is in the trust, normally we don't have that much money in the account. The RCM stated that from 2020 through 2021 each resident received 3,000 from the Covid money and maybe there had been money left in the account. On 10/26/23 at 1:52 PM, the surveyor interviewed the RCM in the presence of the LNHA. The RCM stated to the surveyor that there was an oversight, and the facility surety bond did not cover the full amount of funds as documented in the resident PNA account statement. The RCM confirmed that facility had not been aware of the surety bond was not meeting the total amount of the PNA funds held by the facility until brought to the facility's attention during the survey. NJAC 8:39-9.5(c)(3)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents dependent on staff assistance for care, by failing to provide: a) nail care, b) assistance with dressing, c) personal hygiene care, and d) provide incontinence care, including prior to delivering a meal tray. This deficient practice was identified for 5 of 21 residents reviewed for ADLs (Resident #7, #13, #14, #41, and #73) on 2 of 2 resident care units (Noble and [NAME]). This deficient practice was evidenced by the following: a. On 10/18/23 at 9:40 AM, Surveyor #1 toured the [NAME] unit and observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. Resident #7's right hand ring finger had a long fingernail that was curled over and inward and in direct contact with the resident's fingertip. On 10/19/23 at 10:42 AM, Surveyor #1 observed Resident #7 lying in bed with his/her fingernails visibly soiled, long, and jagged. Resident #7's right hand ring finger's fingernail was curled over and inward and in direct contact with the resident's fingertip. A review of the medical record revealed Resident #7 had diagnoses that included but were not limited to; dementia, hypertension (elevated blood pressure), chronic kidney disease, and palliative care. A review of the quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated 09/22/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) documented as not conducted resident is rarely/never understood. Section G Functional Status documented that Resident #7 required extensive assistance with one-person physical assist for personal hygiene. Section E Behavior indicated that the resident did not exhibit rejection of care. A review of the person-centered comprehensive Care Plan (CP) included but was not limited to; a focus area revised 07/18/19, ADL (activities related to personal care, including bathing, dressing, getting in and out of bed, using the toilet and eating) self-care performance deficit with interventions that included to encourage the resident to participate; and a focus area revised 07/14/22 impairment to skin integrity related to fragile skin Interventions included avoid scratching and keep fingernails short; a focus are revised 06/20/23 hospice services and interventions that included to adjust provision of ADLs to compensate for the resident's changing abilities and to work cooperatively with the hospice team. A review of the My Daily Rhythm of Life form dated 10/23, included but was not limited to; I trust that you will assist me with all my needs (getting dressed, fixing my hair, shaving, cutting my nails) to get ready for the day or night. On 10/19/23 at 11:21 AM, a Certified Nursing Assistant (CNA) #1 stated he was not Resident #7's care giver. He further stated that the hospice aide comes in the mornings to care for the resident. On 10/19/23 at 11:35 AM, Surveyor #1 observed the Licensed Practical Nurse (LPN) #1 in Resident #7's room. The LPN was encouraging the resident who was feeding themselves lunch. LPN #1 exited the room. On 10/19/23 at 12:17 PM, LPN #1 stated that she was not familiar with the resident as she usually worked on the other unit. On 10/19/23 at 12:20 PM, CNA #2 stated she was familiar with Resident #7. She stated that the resident was total care, could move around in their bed, was somewhat alert, and that hospice usually came in the morning. CNA #2 entered Resident #7's room with the surveyor. When asked about the resident's nail care, CNA #2 stated, they need to be cut. She stated that hospice would clean the resident up in the morning. CNA #2 further stated that if hospice did not provide care, the facility staff would be responsible for Resident #7's care. On 10/19/23 at 12:22 PM, LPN #1 entered Resident #7's room with the surveyor. When asked about the resident's nail care, LPN #1 stated, The nails need to be cut. I don't do that. When asked where the documentation of nail care would be, LPN #1 stated there was a book on the unit. LPN #1 showed Surveyor #1 the CNA book for resident care but was unable to locate any documentation for Resident #7. On 10/19/23 at 12:30 PM, the Director of Nursing (DON) stated that the hospice staff was not the only staff responsible for the resident's care. She stated that nail care should be completed at least once per week and as needed. She further stated that filing the fingernails may need to be done by a nurse. The DON was in Resident #7's room with the surveyor. The DON stated the resident's fingernails were too long and should not look like that. The DON further stated that the reason would be for personal hygiene, skin integrity, and dignity. When asked about the documentation of fingernail care, the DON stated she had only been at the facility a few weeks and was not sure where the documentation would be located. On 10/20/23 at 8:13 AM, the hospice aide stated that Resident #7 was total care which consisted of changing him/her but that he/she could feed him/herself. The hospice aide further acknowledged that Resident #7's fingernails needed to be trimmed but that she did not complete nail care for the resident. On 10/23/23 at 8:44 AM, Surveyor #1 observed Resident #7 lying in bed. Resident #7 held both hands out, motioned with one hand that he/she was scratching the other arm and was simultaneously shaking his/her head to indicate no. When asked if he/she enjoyed his/her nails shorter and clean, the resident shook his/her head to indicate yes. On 10/31/23 at 10:00 AM, upon interview, the DON stated that there was no documentation in the Progress Notes or in the Resident #7s Care Plan (CP) that the resident was resistant to nail care. She further stated that moving forward the facility would make multiple attempts to provide nail care, document any refusal, and update the CP as needed. The DON stated that the reason for keeping residents nails shorter and clean was for infection control purposes. 27193 b. On 10/18/23 at 10:05 AM, the surveyor observed incontinence care provided to Resident #13, who was in bed, the head of the bed was elevated, and the resident was able to answer questions. The surveyor observed the resident was unshaven and the facial area was covered with flakes. The CNA informed the surveyor that Resident #13 required total care for all ADLs, including to be fed all meals and the surveyor observed that there were no sacral wounds observed on the resident or reddened areas at that time. The surveyor observed while the lower extremities were exposed, and large number of dry callus type skin were observed on the bed. On 10/19/23 at 8:30 AM, the surveyor observed Resident #13 in bed. The head of the bed was elevated. The resident was still unshaven, and the dry flakes were still observed. On 10/20/23 at 10:30 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that he/she had received care this morning. On 10/20/23 at 10:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #13 on her assignment. The CNA revealed that she had been on vacation for two weeks, she reported to work this morning and observed some changes regarding Resident #13's care. On 10/23/23 at 9:00 AM, the surveyor observed Resident #13 in bed. Upon inquiry, the resident stated that he/she had not received morning care yet. On 10/23/23 at 9:20 AM, the resident informed the surveyor that he/she was itchy and would like to be washed. The surveyor alerted two CNAs of the request and the surveyor then observed the care provided to the resident. The surveyor along with the CNAs, who changed the resident had observed that Resident #13 was wearing two incontinent briefs, and both were saturated with urine and bulging from the back. The gown including the pulled sheet were also saturated and yellow stained. Resident #13 could not elaborate if he/she was cared for on the prior shift. On the same day, at 9:52 AM, another surveyor entered the room with the Director of Nursing (DON). At the surveyor's request, the resident's incontinent brief was checked by staff. The resident was observed to be saturated with urine. Also observed were some scratch marks on the back and redness to the buttock area which was not observed on 10/18/23 during the surveyor's observations. The DON was asked about her expectations for incontinence care and the DON replied, better then what I just observed. The surveyor attempted to interview the resident a short while later, but he/she could not elaborate on any care received on 10/22/23 during the 11:00 PM-7:00 AM shift. On 10/26/23 at 11:55 AM, the surveyor interviewed the DON regarding the observation of Resident #13 wearing two incontinence briefs. The DON stated Resident #13 should not have had two incontinence briefs on. The DON stated the facility's protocol was to provide incontinence care every two hours and as needed. The DON further stated that she would address the above concerns. On 10/26/23 at 12:30 PM, the surveyor interviewed the CNA who cared for Resident #13 on 10/23/23. The CNA stated that she reported to work on 10/23/23 at 6:50 AM. The CNA stated she had to care for another resident that was saturated with urine at that time. The CNA stated, It was so bad, I had to call the clinical director to verify that care was not provided on the prior shift. On 10/26/23 at 12:45 PM, the surveyor reviewed Resident #13's electronic medical record (EMR). Resident #13's Admission Record (AR) revealed, Resident #13 was admitted to the facility with diagnoses which included but were not limited to: Quadriplegia, Parkinsonism, unspecified, contracture left elbow, psoriasis and unspecified Dementia. The Annual Minimum Data Set (MDS) assessment tool used by the facility to prioritize care, dated 07/18/23, revealed that Resident #13 was moderately cognitively impaired. Resident #13 received a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #13 was totally dependent on staff for care. Review of the Care Plan for Resident #13 initiated on 02/08/18, included a Focus for ADL Self Care Performance Deficit related to: quadraparesis, limited physical mobility. The goal was for Resident #13 to maintain current level of function in bed mobility, transfers, eating , dressing, toilet use and personal hygiene through the review date. The interventions were to assist with feeding for all meals. Encourage to get out of bed. Resident #13 required the total assistance of one care partner for help with turning and repositioning while resting in bed. The care plan did not specify when staff were to provide care to the resident and the frequency for staff to turn, change and reposition the resident. c. On 10/23/23 at 11:00 AM, the surveyor observed Resident # 14 in bed. The surveyor left the room to review the assignment sheet. The staff informed the surveyor that the assigned CNA was on break. The surveyor asked the Licensed Practical Nurse (LPN) and 2 random CNAs to assist with a care tour observation. The CNAs repositioned the resident to the left side. The surveyor observed that the resident's mid-back and buttocks were covered with feces. Feces were expelling from both side of the adult brief. Resident #14's sacral wound was covered with embedded feces. The staff informed the surveyor that morning care had not yet been provided. The resident was nonverbal and could not be interviewed. On 10/23/23 at 12:30 PM, an interview with the LPN assigned to the Noble Unit, revealed that staff should have checked the resident at the start of shift to ensure that the resident was not soiled. The surveyor then reviewed Resident #14's EMR which revealed the following: Resident #14 was admitted to the facility with diagnoses which included but were limited to: Quadriplegia, heart failure, right and left-hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen. The Quarterly Minimum Data set (MDS) an assessment tool used by the facility to prioritize care dated 09/08/23, revealed that the resident was nonverbal and totally dependent on staff for all Activities of Daily Living (ADLs). All needs must be anticipated. Resident #14 required two persons physical assist for bed mobility and toilet use. Resident #14's Comprehensive Care Plan dated 02/07/18 with a revision date of 03/09/21 reflected a focus for ADL Self Care Performance Deficit and is totally dependent on staff for all ADLS related to impaired mobility and cognition. The MDS also reflected that Resident #14 had a Texas (Condom Type) Catheter in place and was always incontinent of stool. The goal was for staff to anticipate and meet all Resident #14's needs with Target date of 09/21/2023. The interventions included: for personal hygiene: Resident #14 required total assistance with personal hygiene. According to the MDS) dated [DATE], Resident #14 had a BIMS score of 00 out of 15 which was indicative of severe cognitive impairment. On 10/23/23 at 12:30 PM, the surveyor interviewed the assigned CNA who stated that she did not check the resident that morning and she was not aware that the resident was not changed during the prior shift. On 10/23/23 at 12:45 PM, the surveyor interviewed the RN/UM who stated that the facility's protocol was for all CNAs to check and provide incontinence care to their residents right after morning report. The UM further stated that she was not aware that some of the residents were not provided with incontinence care during the prior shift. d. On 10/18/23 at 10:45 AM, the surveyor observed Resident #41 sitting in bed. The resident was wearing a brightly colored gown on and informed the surveyor that they were at the facility for rehabilitation. On 10/19/23 at 12:55 PM, the surveyor observed Resident #41 in bed the same gown and the Resident stated that they had lunch already. The surveyor reviewed Resident #41's EMR which revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; adult failure to thrive, difficulty in walking, need for assistance with personal care and unspecified severe protein-calorie malnutrition. On 10/20/23 at 10:29 AM, the surveyor returned to the unit and observed the resident in bed and was wearing the same gown. On 10/20/23 at 10:35 AM the surveyor interviewed the Unit Manager (UM) who revealed that she was not aware that the resident had not been changed. The surveyor escorted the UM to Resident #41's room where the resident confirmed to the UM that they had not been changed and agreed to have their clothing changed. On 10/23/23 at 9:42 AM, the surveyor observed Resident #41 in bed, their feet appeared dry and scaly with large amount of dry callus type skin on the bed. The surveyor escorted the DON to the room where we all observed the same. The surveyor asked the DON how the facility would address dry/scaly skin. The DON showed to the surveyor the cream at the Resident's bedside. On 10/23/23 10:43 AM, the surveyor again visited the resident after AM care was provided. The resident stated, They put some cream on my legs today, it feels like a smoothing feeling, they had not done it for a while. On 10/23/23 the surveyor reviewed Resident #41's EMR which revealed: Resident #41 had a care plan initiated on 08/23/23 and last revised 08/24/23 for Self-Care Performance Deficit related to reconditioning. The goal was for resident #41 to improve current level of function in ADL tasks through the review date (09/06/23). The interventions were for Resident #41 to participate in Physical and Occupational Therapy to promote strengthening. Encourage to participate to the fullest extent possible with each interaction. Resident #41 also had a care plan for impaired skin integrity related to physical mobility, anticoagulant use, dry skin to bilateral lower extremities, cellulitis to bilateral lower extremities. The goal was for Resident #41 to be free from skin injury. The interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep skin clean and dry. Use lotion on dry skin. (The care plan was not being followed). On 10/24/23 at 10:01 AM, the surveyor asked the UM who is directing the resident care to ensure it is happening. The UM stated, myself and the DON. The surveyor then interviewed the UM regarding her responsibilities. The UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignment, and make rounds. The surveyor then asked the UM if she made rounds this morning to ensure the residents had received care. The UM replied, No e. On 10/26/23 at 9:04 AM, the surveyor smelled a strong urine odor that permeated the hallway and detected a stronger odor while approaching Resident #73's room. The surveyor asked a CNA to assist the surveyor with a care observation. The CNA identified the urine odor as coming from Resident #73's room. The surveyor then entered Resident #73's room and observed the resident seating in the wheelchair eating breakfast. The top sheet was visibly soiled with dried feces. The resident's incontinent brief along with the pants were noted to be on the floor and were saturated with urine. The padding to protect the bed was observed on the floor saturated with urine. When inquired if the resident was assisted with incontinence care prior to breakfast, the CNA stated that the resident was not on her assignment. The surveyor then exited the room to review the daily assignment and identified the CNA assigned to the resident that day. The surveyor escorted the UM to the room where we all observed Resident #73 eating breakfast in the same manner and the UM stated that should not happened. The UM proceeded to remove the soiled/ saturated clothing from the floor and then stripped the resident's bed. On 10/26/23 at 9:30 AM, the surveyor interviewed the CNA assigned to Resident #73 who stated that she did not serve breakfast to the resident. On 10/26/23 at 10:00 AM the surveyor went to the kitchen and inquired regarding tray delivery in the morning. The kitchen aid provided the signed log that the breakfast trays was delivered on the Noble Unit (high side at 8:32 AM. On 10/26/31 at 11:15 AM, the UM informed the surveyor that the activity staff delivered the tray to Resident #73. On 10/26/23 at 12:30 PM, an interview with the activity staff revealed that she did not observe the soiled clothing on the floor. She stated that the resident was in bed, she did not realize that the sheet was soiled with feces. She did not comment on the urine odor that permeated in the hallway and became stronger while approaching Resident #73's room. On 10/31/23 at 9:00 AM, during an interview with the UM, she stated that staff were to complete resident rounds, and check the resident for incontinence care prior to serving breakfast. On 10/26/23 the surveyor reviewed Resident #73's EMR which revealed: Resident #73 was admitted to the facility with diagnoses which included but were not limited to: major depressive disorder, mild intellectual disability, and alcohol dependence. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #73 had a BIMS score of 15 out of 15 which was indicative of intact cognition. However, Resident #73 had intellectual disability and was unable to communicate their needs. When asked how he/she felt regarding eating breakfast without being changed, he/she just waived their hands and did not offer any comment. The MDS also indicated that Resident #73 required limited assistance for Activities of Daily Living (ADL) and was occasionally incontinent of urine. An additional interview with the CNA revealed that the resident did not use the bathroom during the night. The CNA added that the resident would be soaked with urine most of the time. She could not provide the rationale for not checking the resident for incontinence prior to breakfast. Review of the Care Plan for Resident #73 initiated on 09/26/22 and last revised 09/26/22, revealed a focus for ADL self-care performance deficit related to limited physical mobility. The goal was for Resident #73 to maintain current level of function in ADL tasks through the review date 08/23/23. The interventions included: Encourage to participate to the fullest extent possible with each interaction. Resident to use bell to call for assistance. The care plan did not provide specifics to the direct care staff regarding the resident care. The above concerns with incontinence care and hygiene were discussed during the survey and again on 10/27/23 again on. The DON indicated that the staff were in -serviced. The surveyor then asked the facility what had been done to improve the care, if any investigations were done regarding residents not being changed and turned and wound not being cared for after incontinence care was provided. The DON indicated she would continue to address the above concerns. A review of the facility provided, ADL Care policy, revised 10/2023, included but was not limited to; Policy: to provide ADL care to residents requiring such assistance to ensure all ADL needs are met on a daily basis. Guidelines: 3. The level of assistance needed for any ADL activity will be included on the resident's plan of care. 5. The CP will include approaches to address distress triggers or behaviors and to facilitate completion of ADL tasks. 6. A variety of approaches will be utilized in assisting the dementia unit residents with ADLs. NJAC 8:39-27.2 (g)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were competent and appropriate care was provided for the hemodialysis (the filtration of waste when the kidneys are no longer able to do so) access sites, and staff were trained to differentiate between an AV (Arteriovenous) Fistula (an abnormal connection between an artery and a vein), and a Permacath (tunneled hemodialysis catheter) a flexible tube used for dialysis treatment, and b.) ensure that staff were trained to properly assess, and document care of the hemodialysis access sites which includes the auscultation/palpation of the AV fistula for Bruit (an abnormal sound generated by turbulent arterial blood flow) and Thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 1of 4 residents (Resident #90) reviewed for hemodialysis treatment and was evidenced by the following: On 10/19/23 at 10:55 AM, the surveyor observed Resident #90 laying in bed awake, watching television with snacks on his/her bedside table. Resident #90 stated that he/she had been going to hemodialysis for a while. The resident stated that he/she used to have a catheter in his/her chest, while pointing to his/her right side of chest and neck area, but now had a fistula in his/her right arm, pointing to his/her right upper arm. The surveyor did not observe any catheter or permacath in resident's right chest wall. The surveyor observed 2 bulging sites on the resident's right upper arm. There were no dressings on the 2 sites and some bruising was noted. Resident #90 stated it hurts to get the needles put in. The resident added that he/she goes to hemodialysis every Monday, Wednesday and Friday and takes a communication binder to his/her treatments, which the facility staff kept at the nurse's desk. A review of the Admission Record reflected that Resident #90 was admitted to the facility with diagnoses which included, but were not limited to, acute ischemic heart disease (sudden reduction or blockage of blood flow to the heart), end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs.) A review of the Quarterly Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 08/18/2023, revealed that Resident #90 received a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. Section O of the MDS titled Special Treatments, Procedures, and Programs revealed that the resident received dialysis outside the facility. A review of Resident #90's physician's orders dated 06/08/2023 indicated: Monitor AV shunt to right upper chest wall for signs and symptoms of infection and bleeding every shift for monitoring. A review of Resident #90's Dialysis Communication Records in the resident's dialysis communication binder dated 10/02/2023 to 10/18/2023 revealed on each record documentation: Pre-dialysis (sending facility nurse) Graft Site: intact. The pre-dialysis documentation did not indicate type of access, location of access and what kind of access assessment was performed by the nurse. Post-dialysis (Receiving Facility nurse) Graft Site: intact. The post-dialysis documentation did not indicate type of access, location of access, and what kind of access assessment was performed by the nurse. A review of Resident #90's Medication Administration Record (MAR) dated 10/01/2023-10/31/2023 indicated: Monitor AV shunt to right upper chest wall for signs and symptoms of infection and bleeding every shift for monitoring. Surveyor observed check marks for each shift from 10/01/2023 to 10/23/2023 indicating documentation that nurses administered or signed off for monitoring of the resident's access. During an interview with the surveyor on 10/19/23 at 11:27 AM, the assigned Licensed Practical Nurse (LPN) for Resident #90 stated that the resident had a fistula in his/her chest, while pointing at his arm, and that the thrill and bruit must be checked, while pointing at his chest, before and after the resident's dialysis treatment and then documented. During an interview with the surveyor on 10/19/23 at 11:41 AM, another LPN on the same unit stated that the protocol for dialysis residents was to monitor their dialysis site for thrill and bruit. The LPN demonstrated on her arm with 2 fingers how to feel the bruit, and added that if it was in the neck, she would check for swelling or bleeding and can change the dressing if needed. The LPN stated that the facility educated the staff regarding monitoring and notifying the doctor or the dialysis center of any problems or issues. During an interview with the surveyor on 10/19/23 at 11:42 AM, the Registered Nurse/Unit Manager (RN UM) stated that her expectations of the staff for hemodialysis residents was to take vital signs, assess and monitor the access site, and check the fistula in the arm for thrill and bruit, while pointing to her chest. The RN UM stated that there should be a physician order to listen and check the thrill and bruit of a fistula. The RN UM revealed that the staff were educated on how to care for hemodialysis residents and how to monitor and check for the thrill and bruit of a fistula. During an interview with the surveyor on 10/19/2023 at 12:03 PM, an LPN from another unit stated that the process for a dialysis resident was to check the vital signs and monitor the site. The LPN added that should also check the thrill and bruit of the fistula. The surveyor asked if the nurse used a stethoscope to check for thrill and bruit of a fistula? The LPN responded, No. The LPN demonstrated by placing her 2 fingers on her upper arm and stated to feel for the pulsating fistula. She also stated that if a resident had a catheter in the neck that staff do not touch the catheter and to only check for bleeding or swelling at the site and that the dressing is okay. A review of Resident #90's care plan indicated a focus that Resident #90 needed hemodialysis related to renal failure. -New AV fistula created 06/06/2023, -Right Chest Permacath with an initiation date of 02/11/2023 and a Revision date of 06/08/2023. The care plan did not clearly indicate the resident's type of access and location of the access. Interventions included but not limited to check and change dressing at access site per MD's (medical doctor's) order and document. The interventions did not include checking of thrill and bruit of the fistula as stated by the nursing staff interviewed by the surveyor. A review of the Facility Assessment, with an effective date of 11/2017, indicated that residents requiring hemodialysis are treated at the dialysis center in the community. Care and treatment for these residents is a joint effort of the facility and the dialysis center staff. The facility assessment would include staff competencies that are necessary to provide the level and types of care needed for the resident population. A review of the facility's Dialysis Policy ,with a revision date of 03/2023, indicated that the nurse will ensure the type and location of the dialysis access device in the resident's medical record. In addition, monitoring for patency of the dialysis access will be documented in the resident's medical record. A review of the Nursing Services and Sufficient Staff policy ,with a revised date of 09/2022, revealed that the facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessment and described in the plan of care. On 10/19/2023 at 12:59 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) orientation packets or any documentation of competencies, education, or training for their staff nurses regarding care of residents who received dialysis . During an interview with the surveyor on 10/23/2023 at 10:47 AM, the DON stated that her expectations of the nursing staff in caring for residents that receive dialysis was to check the resident's vital signs, follow the physician's orders for medications, and to know what medications to hold prior to going to hemodialysis. The DON added to also monitor the resident's diet, to check the access and monitor for any signs of infection, bleeding, or swelling. The DON stated the nurses should document in the communication binder that accompanied the resident to the dialysis facility and communicate any changes with the resident to the hemodialysis center. The DON stated that when the resident returned from their hemodialysis treatment, the nurses should check the resident's vital signs, check the access, and note any changes in the communication binder from the dialysis center. She revealed that the nurses would check the thrill and bruit of the access site. The DON stated if the resident had a permacath, the permacath would have a dressing and the nurses should only check the site for swelling or bleeding and not do anything else with the access. The surveyor asked if the nurses were trained in the checking of the thrill and bruit of a fistula? The DON stated that she would expect the nurses to already know how to do that. The DON revealed that she was not sure if there was any facility education regarding residents who received hemodialysis that was provided to the nursing staff. The DON stated that there should be a physician order for checking the thrill and bruit of an AV fistula and that should also be included in the resident's care plan. The surveyor requested from the DON for any documented education or training for their nursing staff regarding hemodialysis. During an interview with the surveyor on 10/23/2023 at 10:51 PM, the LNHA stated that her expectations of the nursing staff in caring for residents receiving dialysis was to document in the dialysis communication binder the resident's vital signs, checking of the access site, weights, dietary changes and any unusual occurrences. She stated that the nurses should also check the thrill, bruit and for any bruising or signs of infection of the access site. The LNHA added that if the resident had a permacath, the nurses should check for signs of infection or swelling at the site. The LNHA stated the permacath dressings were changed at the dialysis center, and the facility nurses did not change the dressings or do anything else with the permacath. The LNHA confirmed that there should be a physician's order to check the thrill and bruit of a fistula and should also be documented on the resident care plan. The surveyor, again, requested from the LNHA any staff education, training, or competencies related to dialysis. On 10/23/2023 at 12:01 PM, the surveyor observed Resident #90 in bed awake with oxygen on at 2-liter nasal cannula and watching television. The resident stated that he/she just returned from hemodialysis. The surveyor observed residents right upper arm AV fistula sites with no dressings on the sites. Resident #90 stated that he/she removed the dressings because they were itchy. The resident stated, they are always itchy when I come back so I remove them. The resident revealed that his/her access had not been assessed yet today since returned from dialysis. On 10/23/2023 at 12:27 PM, the surveyor reviewed Resident #90's communication binder and observed that the post-dialysis (receiving nurse section) was not completed. The surveyor asked the assigned LPN what time Resident #90 returned from his/her dialysis treatment? The LPN stated that she wasn't sure if the resident had returned back from dialysis yet, they may still be working with him/her. The surveyor informed the LPN that the resident had returned back from dialysis and was in his/her room. On 10/23/23 at 1:57 PM, the surveyor observed Resident #90's assigned LPN perform an assessment of the resident's right upper arm (RUA) AV fistula. The LPN sanitized a stethoscope and then applied gloves. The LPN did not perform hand hygiene before applying the gloves to her hands. The LPN explained to the resident that she will be checking his/her access. The LPN had resident extend his/her right arm and stated to the surveyor, You take 2 fingers to feel the bruit. The LPN applied 2 fingers on the antecubital (crook of the elbow) area of the resident's right arm and the LPN stated that she could feel the area pulsating. The LPN then placed the stethoscope to the resident's antecubital area and stated to the surveyor that she could hear the thrill. The LPN then removed and discarded her gloves, closed the resident's overhead light and thanked the resident. The LPN did not perform hand hygiene after removing her gloves or sanitize the stethoscope after performing an assessment of the resident's access site. In addition, the LPN failed to place her fingers just above the access sites to feel for the thrill (the vibration caused by the blood flowing throught the fistula), and did not place the stethoscope near the fistula incisison sites to listen for the bruit (a whooshing sound generated by blood flow). On 10/23/2023 in the presence of the survey team, the DON stated that there was no specific time requirement for the pressure dressing to be removed from the AV fistula. The DON added that when a resident returned from dialysis and there was no bleeding at the access site, the nurses could remove the dressing. During an interview with the surveyor on 10/25/2023 at 9:40 AM, the charge nurse at Resident #90's dialysis center stated that she was familiar with Resident #90. The charge nurse stated she would expect the facility nurses to visually check a fistula access post hemodialysis which included to check the fistula for bleeding, check the thrill and bruit, and remove the dressing the following day; in 24 hours. The charge nurse added that if there was no thrill and bruit and/or the nurses have difficulty assessing the thrill and bruit of a fistula access, the nurses can call the center and the center can help with the access and/or set-up for the resident to be seen by the access center if needed. For a Permacath, the facility nurses should not touch the access and do not change the dressing and to monitor the access site for bleeding, swelling or pain and notify the center. If a resident was pulling at a permacath or pulled out a permacath even slightly, notify the center and the resident would need to be sent out for an X-ray to check for placement or for a catheter exchange. The surveyor asked the charge nurse if the facility should notify the center if Resident #90 removed the dressings from his/her AV fistula sites due to itching when he/she returned to facility after her dialysis treatment? The charge nurse stated that the nurses should notify the dialysis center because the dressings should not be removed for 24 hours, and the center could possibly change the tape on the dressings to hypoallergenic tape. The charge nurse added that the nurses should not apply any creams or lotions to the access sites due to the possibility of infection to the sites. The charge nurse stated that she would expect the communication form to be accurate and complete and the nurses should immediately assess the dialysis resident upon return to the facility from their dialysis treatments. On 10/26/2023 at 09:37 AM, the facility was unable to provide any documented proof for nurse competencies, signed in-services, education, or any training regarding the care of dialysis residents. During a phone interview with the surveyor and in the presence of the survey team on 10/26/2023 at 12:48 PM, the Medical Director (MD) stated that she was familiar with Resident #90 and would expect the nurses to know how to care for any resident's access, either a permacath or a fistula, and to keep the access clean and monitor for infection. On 10/27/2023 at 10:47 AM, in the presence of the survey team, the LNHA stated that it was important for the nurses to know about the access sites for hemodialysis and perform hand hygiene when checking the access sites to prevent infection of the access site. The Infection Preventionist (IP) stated that it was important for the nurses to know what body part to assess, check the vital signs, and make sure no bleeding at the site. The IP revealed that the facility would need to educate the nursing staff regarding assessment of a permacath and a fistula. On 10/31/2023 at 10:52 AM, and in the presence of the survey team, the IP confirmed that the nursing staff should have identified Resident #90's hemodialysis access in the physician orders and it should have been discovered and/or corrected on the 24-hour chart check. The IP informed the survey team that, since surveyor brought to the facility's attention, in- service education was done regarding care of the residents receiving dialysis treatment and identification and care of access sites. NJAC 8:39-27.1(a)

Complaint # NJ 00162113 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to (a) provide assistance dressing, provide personal hygiene and incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs), b) provide nail care for a resident who was dependent on staff for ADLs, and c) respond to call lights in a timely manner. This deficient practice was identified for 5 of 21 residents (Resident #13, #14, #41, #73 and #7 ) on 2 of 2 nursing units. This deficient practice was evidenced by the following: Refer to 684G and 677F. Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. On 10/18/23 at 9:24 AM, Surveyor #1 interviewed the Registered Nurse Unit Manager (RN UM) of the Noble Unit who stated that the unit's census was 51 and staffing today was 2 Licensed Practical Nurses (LPN)s and 5 Certified Nursing Assistants (CNA)s. During the initial tour of the [NAME] Unit on 10/18/23 at 9:51 AM, the surveyor interviewed an LPN who stated that they are usually short staffed, not only on the weekends but during the week too. During an interview with the surveyor on 10/18/23 at 10:32 AM , the CNA stated that she has worked at the facility for [AGE] years. The CNA stated that staffing was an issue. She further stated that on that day she had 10 residents and 5 of those residents were total assists (needed total assistance with all activities of daily living). We usually have a lot more residents, sometimes there are only two CNAs on the unit and sometimes there are 3 or 4 CNAs on the day shift. During an interview with the surveyor on 10/18/23 at 10:35 AM, the CNA on the Noble Unit stated that she had 10 residents for day shift. The CNA further stated that sometimes there are only 2 CNAs on the unit. A review of the staffing sheet provided by the facility for the 11 PM-7 AM shift on Sunday 10/22/23 on the Noble Unit revealed one Registered Nurse (RN), one LPN and one CNA were scheduled to provide care for all residents on the unit. a).A review of the medical record revealed Resident #13 had a diagnosis, including but not limited to: Quadriplegia, Parkinsonism, and unspecified Dementia, had moderately impaired cognition, and required total dependence on staff for all ADLs. On 10/23/23 at 9:30 AM, Surveyor #1 asked two CNAs to assist with a care tour and observed Resident #13 wore 2 briefs which were saturated with urine. The gown including the pulled sheet were brown stained. Resident #13 could not elaborate if he/she was cared for on the prior shift. At 09:52 AM, another surveyor entered the room with the Director of Nursing (DON). At the surveyor's request, the resident's incontinent brief was checked by staff. The resident was observed to be saturated with urine. Also noted were some scratch marks on the back and redness to the buttock area which were not observed on 10/18/23 during the observed incontinence tour. When asked about her expectations, the DON replied, better then what I just observed. The DON verified that the incontinence care had not been provided on the prior shift (11:00 PM-7:00 AM). On 10/26/23 at 11:55 AM, Surveyor #1 interviewed the DON who stated that Resident #13 should not have had two incontinence briefs on. The facility's protocol was to provide incontinence care every 2 hours and as needed. On 10/26/23 at 11:00 AM, the surveyor completed a telephone interview with the CNA who provided care to Resident #13 on 10/22/23 3:00 PM-11:00 PM shift. The CNA stated that she had applied 2 adult incontinent briefs on Resident #13. The CNA confirmed that she had provided incontinence care to Resident #13 at 6:30 PM on 10/22/23 which included changing the resident and their sheets due to being saturated with urine. The CNA stated she clocked out at 7 PM. On 10/26/23 at 12:53 PM, the surveyor conducted a telephone interview with the Registered Nurse (RN) who worked the 3:00 PM-11:00 PM shift on 10/22/23 who confirmed that that 2 CNAs had left at 7 PM on that shift and the other CNA on the unit did not ask for assistance with care. On 10/26/23 at 12:30 PM, Surveyor #1 interviewed the CNA who cared for Resident #13 who stated that she reported to work on 10/23/23 at 6:50 AM and had to care for another resident that was saturated with urine. The CNA stated, It was so bad, I had to call the clinical director to verify that care was not provided on the prior shift. On 10/27/23 at 7:50 AM, the surveyor interviewed the LPN who had worked the 11:00 PM -7:00 AM shift on 10/22/23 who stated that she did not assist the CNAs to change and turn some residents. The LPN stated No I was busy also. We provided safety that is all we could do. On 10/27/23 at 8:40 AM, the surveyor interviewed the CNA who cared for Resident #13 during the 11:00 PM-7:00 AM shift on 10/22/23 who stated that he did not provide incontinence care to the residents during the 8 hr. shift. The CNA stated that he provided care for 30 residents that night and he was overwhelmed and could not get to the resident. b) A review of the medical record revealed Resident #14 had a diagnosis, including but not limited to :Quadriplegia, heart failure, right and left hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen, had sever cognitive impairment, was nonverbal and required total assistance for all ADL care. . On 10/23/23 at 11:00 AM, Surveyor #1 observed Resident # 14 in bed and was informed that the CNA assigned to this resident was on break. The surveyor asked the LPN and 2 random CNAs to assist with a care tour. The CNAs repositioned Resident #14 to the left side. The surveyor observed that the resident's mid-back and buttocks were covered with feces. Feces were expelling from both side of the adult brief. Resident #14's sacral wound was covered with feces. The staff informed the surveyor that morning care had not been provided yet. On 10/23/23 at 12:30 PM, Surveyor #1 interviewed the LPN assigned to the Noble Unit who stated that staff should have checked the resident at start of shift to ensure that the resident was not soiled. Surveyor #1 interviewed the assigned CNA who stated that she did not check the resident this morning. She was not aware that the resident was not changed during the prior shift. On 10/23/23 at 12:45 PM, Surveyor #1 interviewed the RN/UM who stated that the facility's protocol was for all CNAs to check and change their residents right after morning report and that she was not aware that some of the residents were not provided with incontinence care during the prior shift. On 10/27/23 at 8:40 AM, Surveyor #1 conducted a telephone interview with the 11:00 PM-7:00 AM CNA. The CNA informed the surveyor that he checked the resident possibly at 6:00 AM and the resident was not soiled. When inquired about who assisted him with the resident, he stated,' I did it alone.( Resident #14 required extensive assist of two persons for bed mobility.) c)A review of the medical record revealed Resident #41 was admitted to the facility with diagnoses which included but were not limited to; Adult failure to thrive, difficulty in walking, need for assistance with personal care and unspecified severe protein-calorie malnutrition. On 10/18/23 10:45 AM, Surveyor #1 observed Resident #41 sitting in bed dressed in a colorful gown. The resident informed the surveyor that she was here for rehabilitation. On 10/19/23 at 12:55 PM, Surveyor #1 observed Resident #41 in bed with same clothing as day prior. Resident stated that she had lunch already. On 10/20/23 at 10:29 AM, Surveyor #1 returned to the unit and observed Resident #41 in bed with the same clothing as days prior. On 10/20/23 at 10:35 AM, Surveyor #1 interviewed the Registered Nurse Unit Manger (RN UM) who stated that she was not aware that the resident had not been changed. The surveyor escorted the RN UM to the Resident #41's room where the resident confirmed she had not been changed and agreed to have her clothing change. On 10/23/23 at 09:42 AM, Surveyor #1 observed Resident#41 in bed, their feet were dry and scaly with large amount of dry callus type skin on the bed. The surveyor escorted the DON to the room where we all observed the same. The surveyor asked the DON if they have any skin remedy for the resident skin. She stated yes and showed to the surveyor the cream at the bedside. 10/23/23 10:43 AM, Surveyor #1 revisited the resident after AM care was provided. The resident stated, They put some cream on my legs today, it feels like a smoothing feeling, they had not done it for a while. The resident observed with the same colorful gown noted on in bed this morning. 10/24/23 10:01 AM, Surveyor #1 asked the RN UM who was directing the care, she stated, Myself and the DON. The RN UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignments, and make rounds. The surveyor then asked the RN UM if she made rounds this morning. The RN UM replied, No. d)A review of the medical record revealed Resident #73 was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, mild intellectual disability, and alcohol dependence, was cognitively intact but unable to communicate his/her needs, required limited assistance for ADLs and occasionally incontinent of urine. On 10/26/23 at 9:04 AM, Surveyor #1 smelled a strong urine odor permeated the hallway and was stronger while approaching Resident #73's room. The surveyor asked a random CNA to assist with a care tour and when they entered Resident #73's room, they observed the resident seating in the wheelchair eating breakfast. The top sheet was visibly soiled with dry feces. Resident #73's adult brief along with the pants were noted on the floor saturated with urine. The padding to protect the bed were noted on the floor saturated with urine. When inquired if the resident was assisted with incontinence care prior to breakfast, the CNA stated that the resident was not on her assignment. The surveyor left the room to review the daily assignment and identified the CNA assigned to the resident that day. The surveyor escorted the RN UM along with the assigned CNA to the room where we all observed Resident #14 eating breakfast in an unsanitary environment. The RN UM stated that should not have happened and proceeded to remove the soiled clothing from the floor and removed the linens from the bed. On 10/26/31 at 11:15 AM, the RN UM informed the surveyor that the activity staff delivered the breakfast tray to Resident #73. On 10/26/23 at 12:30 PM, Surveyor #1 interviewed the activity staff who delivered the breakfast tray who stated that she did not observe the soiled clothing on the floor. She stated that the resident was in bed, and she did not realize that the sheet was soiled with feces. Resident #73 was not checked for incontinence care prior to receiving the breakfast tray. Staff reported to work at 7:00 AM and had not checked the resident until the surveyor brought the issue to their attention. On 10/27/23 at 10:44 AM, Surveyor #1 interviewed the RN UM who stated that the CNAs were to check the residents and provide care prior to breakfast. On 10/27/23 at 11:15 AM, Surveyor #1 interviewed the CNA and inquired about the soiled clothing observed on the floor the morning of 10/26/23. The CNA stated, I did not check the resident, nor provided care yet. The CNA further stated that the resident would be combative with care. There was no documentation in the clinical record regarding rejection of care. 2.) A review of the medical record revealed Resident #7 had diagnoses that included but were not limited to; dementia, hypertension (elevated blood pressure), chronic kidney disease, and palliative care, resident is rarely/never understood and required extensive assistance with one-person physical assist for personal hygiene. On 10/18/23 at 9:40 AM, Surveyor #2 observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. Resident #7's right hand ring finger had a long fingernail that was curled over and inward and in direct contact with the resident's fingertip. On 10/19/23 at 10:42 AM, Surveyor #2 observed Resident #7 lying in bed with his/her fingernails visibly soiled, long, and jagged. Resident #7's right hand ring finger's fingernail was curled over and inward and in direct contact with the resident's fingertip. On 10/19/23 at 11:21 AM, Surveyor #2 interviewed the CNA who stated that he was not Resident #7's care giver. He further stated that the hospice aide comes in the mornings to care for the resident. On 10/19/23 at 11:35 AM, Surveyor #2 observed an LPN in Resident #7's room and was encouraging the resident who was feeding themselves lunch then the LPN exited the room. On 10/19/23 at 12:17 PM, the surveyor interviewed LPN #1 who stated that she was not familiar with the resident as she usually worked on the other unit. On 10/19/23 at 12:20 PM, CNA #2 stated she was familiar with Resident #7. She stated that the resident was total care, could move around in their bed, was somewhat alert, and that hospice usually came in the morning. CNA #2 and the surveyor entered Resident t# 7's room and when asked about the resident's nail care, CNA #2 stated, they need to be cut. She stated that hospice would clean the resident up in the morning. CNA #2 further stated that if hospice did not provide care, the facility staff would be responsible for Resident #7's care. On 10/19/23 at 12:22 PM, LPN #1 and the surveyor entered Resident#7's room and when asked about the resident's nail care, LPN #1 stated, The nails need to be cut. I don't do that. When asked where the documentation of nail care would be, LPN #1 stated there was a book on the unit. LPN #1 showed Surveyor #1 the CNA book for resident care but was unable to locate any documentation for Resident #7. On 10/19/23 at 12:30 PM, the DON stated that the hospice staff was not the only staff responsible for the resident's care. She stated that nail care should be done at least once a week and as needed. The DON was in Resident #7's room with the surveyor. The DON stated the resident's fingernails were too long and should not look like that. On 10/20/23 at 8:13 AM, the surveyor interviewed the hospice aide who acknowledged that Resident #7's fingernails needed to be trimmed but that she did not do that for the resident. On 10/31/23 at 10:00 AM, the DON stated that there was no documentation in the Progress Notes or in the CP that the resident was resistant to nail care. 3. On 10/19/23 at 10:59 AM, Surveyor #3 observed the call light illuminated outside room [ROOM NUMBER] and room [ROOM NUMBER] which were located at the end of the hallway. At 11:05 AM, the surveyor observed room [ROOM NUMBER]'s call light was turned off, but the surveyor did not observe any staff had entered the room. (Total 6 minutes the call light was on). At 11:06 AM, the surveyor observed a housekeeper enter room [ROOM NUMBER] to answer the call bell and the call light was turned off (total 7 minutes the call light was not answered). During an interview with the surveyor on 10/19/23 at 11:21 AM, the LPN stated that staffing today consisted of 2 LPNs and 3 CNA's (census 51). During an interview with Surveyor #3 on 10/19/23 at 11:24 AM, the unit secretary (US) stated that the resident call system console was located at the nurse's station behind a computer monitor. The US stated that the call light could be turned off from the nurse's station[at the resident call system console] but you needed to go see what the resident needed before you turned off the call light. On 10/19/23 at 11:40 AM, Surveyor #3 observed the call light illuminated outside room [ROOM NUMBER]. At 11:50 AM, room [ROOM NUMBER]'s call light still illuminated in the hallway. Surveyor #3 observed an LPN at the medication cart with another surveyor but no other personnel in the hallway. The surveyor observed the resident call system console was not emitting a visual red light or an audible sound from the console. At 11:51 AM, Surveyor #3 observed the RN UM sitting at the nurse's station next to the resident call system console . The surveyor asked the RN UM if there were any call lights activated and she looked at the resident call system console and noted there were no red lights emitting from the monitor and stated no. The RN UM stated that when a resident pressed the call bell, a light will go on outside the resident's room, there would be a ringing sound and a red light will light on the resident call system console. On 10/19/23 at 11:57 AM, Surveyor #3 observed room [ROOM NUMBER] call light was still illuminated outside the resident's room. The LPN stated she was looking for the CNA who was assigned to room [ROOM NUMBER]. At that time there were 2 other CNAs in the hallway by the nurse's station, but the call light was not answered. At 12:00 PM, the LPN who was assigned to room [ROOM NUMBER] answered the call light.( call light was unanswered for 20 minutes) On 10/19/23 at 12:02 PM, the surveyor informed the RN UM that room [ROOM NUMBER]'s call light was not answered for 20 minutes. The RN UM stated that anyone can answer a call light, such as CNA's, housekeepers, nurses, then they would get the appropriate person to assist the resident. The RN UM stated that an appropriate response time for a call light to be answered would be 2-3 minutes. On 10/24/23 at 10:30 AM, Surveyor #3 interviewed the DON who stated that she would expect the staff to respond to a call light as soon as the call light was on and that the response time would be about 5 minutes. The DON stated that anyone could answer a call light. A review of the facility's policy titled Nursing Services and Sufficient Staff, reviewed 09/22, revealed that the facility will supply services by sufficient numbers of each of the following personnel types on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans, a. except when waived, licensed nurses: and b. other nursing personnel; including but not limited to nurse aides. A review of the facility's policy titled Call lights: Accessibility and Timely Response, reviewed 09/22, revealed that all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. NJAC 8:39- 4.1(a)11; 27.1(a)

Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirement which affected all residents safety in the facility. The Administrator failed to a.)ensure the implementation of mitigation strategies to prevent the transmission of COVID-19 by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI) for the virus and b.) perform timely testing of residents who were exposed to the virus. This placed 99 of 124 residents on the second floor at risk for infection during a survey on 11/19/20. Additionally, during a removal plan survey on 11/25/20, the facility failed to ensure that a housekeeper was wearing proper personal protective equipment (PPE) when inside a PUI room. This deficient practice was evidenced by the following; Refer to F880L as it pertains to the facility's failure to ensure the implementation of Infection Control Practices and Precautions during an identified COVID-19 outbreak. During the survey conducted on 11/19/20, the surveyors identified and observed deficient practices for Infection Control regarding identification of individuals who were not identified as Persons Under Investigation (PUI), and timely resident testing for COVID-19. These deficient practices were identified on 2 of 3 well units. The facility submitted a removal plan by e-mail which after 3 revisions was reviewed and accepted on 11/24/20 at the Department of Health (DOH). On 11/25/20, the surveyors conducted an onsite visit to verify the removal plan. During verification of the removal plan, the surveyor observed a deficient practice for infection control on the PUI unit. The facility was found to be not in compliance. This deficient practice was evidenced as follows; A review of the Administrator's job description provided by the facility revealed the following; Position Summary- The Administrator is responsible for planning and is accountable for all activities and department of the facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents; Responsibilities/Accountabilities- Implements the facility objectives as determined and directed for the governing body; Interprets personnel practices within policy guidelines and recommends change as necessary; Concerns him/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. Also, ensures that the facility adheres to the legal,safety, health, fire and sanitization codes by being familiar with his/her role in carrying out the facility's fire safety, and disaster plans and by being familiar with current material safety data sheets; Oversees and guides department managers in the development and use of department policies and procedure; Ensures the residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's needs and rights. Job skills- must have a working knowledge of all government regulations impacting on nursing facility; On 11/19/20 at 4:25 PM, the facility's Administrator was notified that an Immediate Jeopardy (IJ) situation was identified related to the facility not identifying residents as PUI after exposure from a certified nurses aide (CNA) and a housekeeper who tested positive for COVID-19. Additionally, the facility did not conduct resident testing timely after the exposure. On 11/24/20, the facility's removal plan was accepted. According to the removal plan, residents on the Noble Unit who were identified in coming to close contact with the CNA were cohorted and placed on transmission based precautions, and all the residents residing on the [NAME] unit where the housekeeper worked, were also cohorted and placed on transmission based precautions. All licensed staff were re-inserviced on PUI isolation, COVID testing and investigation of an outbreak. During verification of the removal plan on 11/25/20, the surveyor observed Housekeeper #2 inside a PUI room where two residents were residing. The housekeeper was observed wearing a gown and a surgical face mask just below the housekeeper's nose. The housekeeper was not wearing a N95 mask or a face shield which was required for the PUI unit. The facility was found to be not in compliance. During an interview with Surveyor #1 on 11/19/20 at 10:22 AM, the RN/ IP explained that the facility utilized three cohort groups. Green, a well unit; Yellow, a PUI unit; and Red a COVID unit. The IP/RN stated that the PUI unit was utilized for new resident admissions/residents with signs and symptoms of COVID-19. The RN/IP stated that the facility was in an outbreak status due to two confirmed positive residents and two confirmed staff on the second floor well units, She further stated she was waiting for guidance from the Local Health Department (LHD). The RN/IP stated that the COVID-19 positive residents and staff were retested right away and the second test results were COVID-19 negative. The surveyor asked what precautions were in place for the staff and residents on the second floor. The RN/IP stated that there were no different precautions in place except to monitor the residents for signs and symptoms of COVID-19 three times a day. The RN/IP stated that the staff and residents were to continue to wear surgical masks and the exposed residents could leave the room because they weren't showing any signs or symptoms of COVID-19. The RN/IP stated that she, the DON, and Administration reviewed the Outbreak Response Plan and follow Local, State and CDC guidelines. On 11/19/20 At 11:21 AM, Surveyor #1 reviewed the facility's COVID-19 Outbreak Response Management and Response policy with the RN/IP. The policy included under infection prevention and control to implement standard and transmission based precautions including use of a N95 respirator or higher (or facemask if unavailable), gown, gloves, and eye protection for new and re-admissions, confirmed and suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive HCP [Health Care Provider]. At that time, the surveyor asked the RN/IP if that is what was put into place and the RN/ IP stated that TBP were not put into place for the residents when the two staff members were identified as positive. During an interview with the surveyors on 11/19/20 at 12:42 PM, the DON stated that the exposed residents should have been quarantined, and full PPE should have been used. The DON stated, We missed it because we were happy when we saw negative results. The DON stated staff were retested on [DATE] and the residents were not COVID-19 tested because they were not in an outbreak anymore. She further stated she was waiting on guidance from the LHD and NJDOH. The DON stated that the residents were last tested on [DATE] and were scheduled be tested again on 11/20/20 (11 days later). During a follow up interview with the surveyors on 11/19/20 at 1:15 PM, the RN/IP confirmed that the last resident COVID-19 testing date was on 11/9/20 and that the residents should have been retested right away, and placed on precautions because everyone could be positive. The RN/IP stated that she and the DON read the Outbreak Response Management incorrectly. The IJ was identified on 11/19/20 and the Administrator, Assistant Administrator and DON were notified of the IJ at 4:25 PM. A removal plan was accepted on 11/24/20 which included that residents who were identified in coming into close contact with the CNA were cohorted into one area and placed on TBP. The residents who were on the unit where the housekeeper worked were also cohorted and placed on TBP. All licensed staff were re-inserviced on PUI isolation, COVID testing and investigation of an outbreak. On 11/25/20, a removal plan survey was conducted. During the entrance conference on 11/25/20 at 9:50 AM, the Administrator was informed that the purpose of the visit was to ensure implementation of the removal plan and the surveyors requested documentation related to the removal plan. The Administrator stated that the DON and RN/IP would be the contacts for the status of the residents, and the inservice education. On 11/25/20 at 10:39 AM, the surveyors met with the RN/IP in the conference room. She stated that the facility had an additional CNA and resident test positive for COVID-19. She stated that all residents on the second floor, Noble and [NAME], were on a 14-day quarantine. She stated the required PPE for those units was for staff to wear a face shield and a surgical mask. The use of the N95 mask was only needed on the COVID positive Unit. The RN/IP stated some staff could not tolerate wearing the N95, and could wear a double surgical mask. At that time, Surveyor #1 reviewed the facility's COVID Outbreak Response Management to the RN/IP that indicated a N95 was to be worn for a confirmed or suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive HCP. The RN/IP responded that she did not tell staff to wear a N95 in the PUI unit. The RN/IP left the conference, returned and stated that she made a mistake and that all staff received a N95 and was wearing them on the units. On 11/25/20 Surveyor #2 toured the second floor Noble and [NAME] Units. During the tour on the Noble Unit at 10:55 AM, the surveyor noted that 8 rooms were identified as PUI, and on the [NAME] Unit at 11:15 AM, 15 rooms were identified as PUI. The rest of the rooms on the unit were identified as well resident rooms. Staff were observed wearing N95 masks and a face shield. On 11/25/20 at 11:20 AM, on the low side of the [NAME] Unit, Surveyor #2 entered a closed double door with signage that indicated contact and droplet precautions. The surveyor observed a housekeeping cart parked outside of Resident #16 and #17's room. The surveyor observed Housekeeper #2 inside the resident's room. Housekeeper #2 left the room and stood at her cart wearing a gown and surgical mask. The surgical mask was even with the tip of her nose and not fully covering her nose. She stated that she could wear that PPE on the low side because the residents on that side were not sick. She stated she was given an N95 and a face shield, but they were in her locker. She stated she wore an N95 mask and a face shield when she worked downstairs because those residents are sick, and the residents up here were not sick. She stated she was in serviced on hand washing and PPE. She stated that it was ok to wear just a surgical mask. She stated that she had to clean the rooms on the other side of the closed doors first then she had to clean the low side of [NAME] afterwards. The housekeeper then went across the hall to her locker and came back with a face shield to use and continued to wear the surgical mask. During an interview with the surveyors on 11/25/20 at 11:40 AM and 12:04 PM, the DON stated that the second floor contained 2 PUI units. On Noble, there were 16 residents who had contact with CNA #1 who were in PUI unit, and on [NAME], there were 24 residents who were in the PUI unit. The DON stated 6 of the residents on [NAME] were PUI due to Housekeeper #1's exposure and 18 residents were in the unit due to a second CNA that was positive for COVID-19 on 11/19/20. The DON confirmed that the entire second floor was not on PUI as the RN/IP had previously stated. The DON also acknowledged that the removal plan stated that all residents in the [NAME] Unit were on TBP. The DON stated that after she did contact tracing, Housekeeper #1 only had contact with 6 residents. The DON added that all staff were to wear N95 mask and a face shield on any unit in the facility and were in serviced by the RN/IP, with follow up by the department heads of each department. During an interview with the surveyors on 11/25/20 at 12:30 PM, the Director of Housekeeping stated he had last in-serviced the housekeeping staff for infection control on 11/11/20 and 11/12/20. He stated when staff enter the PUI units, they are expected to gown up use face shield, N95, gown and gloves. He stated the housekeeper had to get an N95 and shield from him before entering the closed-door unit. He stated that Housekeeper #2 usually followed protocol and does not know why today would be any different. The Director of Housekeeping stated that there were no new in-services from when the surveyors were in the facility on 11/19/20. During an interview with the surveyors on 11/25/20 at 1:25 PM the DON stated everyone in the entire building must wear an N95 and face shield. The DON stated this was verbally in serviced and put into place after the surveyors had left the faciity on [DATE] and also because the facility had another Covid-19 positive staff member and resident. The DON stated that the RN/IP initially inserviced all staff, and then the individual department heads inservice their staff. On 11/25/20 at 1:56 PM, the surveyors met with the Administrator and the DON. The Administrator, who was formally the assistant administrator, stated he was assigned as Administrator on 11/20/20 and that he, the prior administrator and the DON developed the removal plan. He stated all staff in the facility were inserviced on the use of PPE, N95, face shield and cohorting of residents, and that all staff were given an N95 in a paper bag. The surveyors informed the Administrator and DON of the survey findings and informed the Administrator that due to the evidence, the immediacy had not been removed and that the residents and staff remained in an immediate jeopardy situation. Review of a facility policy titled, COVID-19 Outbreak Management and Response revised 8/2020, revealed that the facility shall take all reasonable and necessary measures to respond to outbreaks of COVID-19 with in the facility to stop transmission of pathogens and prevent additional infections. Any suspect or confirmed outbreak shall be reported to the LHD and/or state health department as per the reporting requirements for communicable diseases and work-related conditions. Implement standard and transmission-based precautions including use of a N95 respirator or higher, gown, gloves, and eye protection for new and re-admissions, confirmed or suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive health care personnel. (HCP). The facility shall test all previously negative patients/residents weekly until no new facility onset cases of COVID-19 are identified among patients/residents and positive cases in staff and at least 14 days have elapsed since the most recent positive results and during this 14 day period at least two weekly tests have been conducted with all individuals having tested negative. Review of a facility policy titled, Infection Prevention and Control Program Policy revised 11/2019, revealed that it was the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Review of a facility policy titled, COVID-19 Surveillance revised 3/9/20, included that the facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. The Infection Preventionist will monitor the status of the COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. Review of the NJDOH's Considerations for Cohorting COVID-19 Patients in Post Acute Care facilities, dated 10/22/20, which was utilized in the facility and provided to the surveyors, revealed Cohort 2, was a COVID-19 negative exposed cohort. This consisted of symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure regardless of test results. Patients/residents who test negative for COVID-19 could be incubating and later test positive. Review of facility policy titled, COVID-19 Testing Policy revised on 5/20/20, revealed that the facility shall take all responsible and necessary measures to conduct all testing of all patients and staff in efforts to stop transmission of pathogens and prevent additional infections associated with the novel coronavirus. A unit-by-unit testing approach should be used. Patients/residents and staff must remain cohorted to their designated unit. The maximum time elapsed between testing each unit should be days, not weeks. Patients/resident and staff who tested at baseline shall be retested every 3-7 days. NJAC 8:39-27.1 (a)

Based on observation, interview, medical record review and other facility documentation, it was determined that the facility failed to a.) implement mitigation strategies to prevent the transmission of COVID-19 by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI) for the virus and b.) perform timely testing of residents who were exposed to the virus. This placed 99 of 124 residents on the second floor at risk for infection during a survey on 11/19/20. On 11/24/2020 the facility submitted a removal plan for F 880 by e-mail to The New Jersey Department of Health (NJDOH). On 11/25/20 during an onsite removal plan verification survey, the facility was found to be out of compliance. The surveyor observed a housekeeper in a PUI room in which two residents were residing. The housekeeper was wearing a gown, and a surgical mask worn just below her nose. The housekeeping was not wearing a N95 mask or face shield which was required to be worn. This deficient practice was identified on 2 of 3 non Covid (well) units during a focused infection control survey on 11/19/20, and 1 of 3 PUI units during a removal plan verification survey on 11/25/20. On 11/12/20 and 11/13/20, the facility became aware that two staff members, a Certified Nurses Aides (CNA) #1 and a Housekeeper, were confirmed positive of COVID-19 in the facility. CNA #1 who worked on the Noble Unit and cared for a total of 14 residents was confirmed positive on 11/12/20. Resident #1 who was on CNA #1's assignment, tested positive on 11/11/20 and was moved to the COVID Unit. The Housekeeper worked on the [NAME] Unit, and was confirmed positive on 11/12/20. Resident #2 who resided on the [NAME] Unit tested positive on 11/13/20 and was moved to the COVID unit. Both units were on the second floor and were both identified as well non exposed units. The facility failed to identify the residents residing on both units exposed to COVID-19 as persons under investigation (PUI) in an effort to mitigate the spread of the virus. During the survey conducted on 11/19/20, the surveyors observed staff on the second floor Noble and [NAME] units wearing either a surgical or N95 mask as the only personal protective equipment (PPE). The residents on units were not identified as being exposed nor placed on transmission based precautions (TBP). In addition, the exposed residents were last tested on [DATE]. After surveyor inquiry, the surveyors were told the residents were not scheduled to be retested until 11/20/20 (11 days later). The facility's failure to identify residents on the second floor Noble and [NAME] Units as exposed to COVID-19 and implement strategies to prevent the spread COVID-19, posed a serious and immediate threat to the safety and well being of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 11/12/20 when the facility was notified of the confirmed positive staff member. The facility Administration was notified of the IJ on 11/19/20 at 4:25 PM. During a removal plan verification survey on 11/25/20, it was determined that the facility failed to ensure their removal plan was implemented and the non compliance continued. The evidence was as follows: 1. On 11/19/20 at 9:45 AM, the surveyors met with the Assistant Administrator, Director of Nursing (DON) and the Registered Nurse/Infection Preventionist (RN/IP) in the conference room. The DON stated that the facility had just completed their outbreak on 11/10/20. The DON stated that the first floor consisted of a well unit, a PUI unit and a COVID unit. The second floor consisted of two well units, Noble and [NAME]. The RN/ IP stated that a surgical mask was the minimum requirement for staff to wear on the well units. The DON stated that there were two residents (Resident #1 resided on the Noble Unit) and Resident #2 (resided on the [NAME] Unit), who were confirmed positive on 11/11/20. On 11/13/20 they were transferred to the COVID unit. The DON also stated that there were two staff members who tested positive, a CNA on the Noble Unit and a Housekeeper on the [NAME] Unit, and were currently quarantined at home. The DON stated that a retest was done for the COVID-19 positive staff and residents. In addition, Resident #1, CNA #1, the Housekeeper were COVID-19 negative on retest. The DON added that the Local Health Department (LHD) was notified and all residents who resided in the facility were to be tested on [DATE] (11 days later). During an interview with Surveyor #1 on 11/19/20 at 10:22 AM, the RN/ IP explained that the facility utilized three cohort groups. Green, a well unit; Yellow, a PUI unit; and Red a COVID unit. The IP/RN stated that the PUI unit was utilized for new resident admissions/residents with signs and symptoms of COVID-19. The RN/IP stated that the facility was in an outbreak status due to two confirmed positive residents and two confirmed staff on the second floor well units, She further stated she was waiting for guidance from the LHD. The RN/IP stated that the COVID-19 positive residents and staff were retested right away and the second test results were COVID-19 negative. The surveyor asked what precautions were in place for the staff and residents on the second floor. The RN/IP stated that there were no different precautions in place except to monitor the residents for signs and symptoms of COVID-19 three times a day. The RN/IP stated that the staff and residents were to continue to wear surgical masks and the exposed residents could leave the room because they weren't showing any signs or symptoms of COVID-19. The RN/IP stated that she, the DON, and Administration reviewed the Outbreak Response Plan and follow Local, State and CDC guidelines. Review of the PCR lab results (PCR test for the qualitative detection of nucleic acid from [CONDITION(S)]-CoV-2/COVID-19) revealed the following: -Resident #1's swab specimen was collected on 11/9/20, received on 11/10/20 and was reported as positive detected for [CONDITION(S)]-Cov-2 on 11/11/20; a second swab specimen was collected on 11/11/20, received on 11/12/20 and reported [CONDITION(S)]-Cov-2 as negative not detected on 11/13/20; -Resident #2's swab specimen was collected on 11/10/20, received on 11/11/20, and reported as positive detected for [CONDITION(S)]-Cov-2 on 11/13/20; -CNA#1's and the Housekeeper's swab specimen was collected on 11/10/20, received on 11/11/20, and reported as detected for [CONDITION(S)]-Cov-2 on 11/12/20. A second swab specimen for CNA #1 was collected on 11/12/20, received on 11/13/20 and reported [CONDITION(S)]-Cov-2 as negative not detected on 11/14/20. A second swab specimen for the Housekeeper was collected on 11/13/20, received on 11/14/20 and reported [CONDITION(S)]-Cov-2 as not negative not detected on 11/15/20. Review of the facility's line listing included the following: -Resident #1 was placed on TBP on 11/11/20; -Resident #2 was placed on TBP on 11/13/20; -CNA #1 was placed on TBP on 11/12/20; -the Housekeeper was placed on TBP on 11/13/20. Review of the facility's Resident List Report indicated that there were a total of 51 residents residing on the Noble Unit and a total of 48 residents residing on the [NAME] Unit. On 11/19/20 at 9:55 AM, Surveyor #2 toured the second floor Noble and [NAME] Units and confirmed by observation that the residents residing on the units were not identified as PUI and not placed on TBP. At 11:21 AM, Surveyor #1 reviewed the facility's COVID-19 Outbreak Response Management and Response policy with the RN/IP. The policy included under infection prevention and control to implement standard and transmission based precautions including use of a N95 respirator or higher (or facemask if unavailable), gown, gloves, and eye protection for new and re-admissions, confirmed and suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive HCP [Health Care Provider]. At that time, the surveyor asked the RN/IP if that is what was put into place and the RN/ IP stated that TBP were not put into place for the residents when the two staff members were identified as positive. At 11:36 AM, the RN/IP accompanied Surveyor #1 to the 2nd floor Noble Unit. The surveyor observed residents in the hallways and in their rooms with doors open. There was no PPE set up noted on the unit. Staff were observed wearing a surgical mask and a licensed practical nurse (LPN) was observed wearing only an N95 mask. Some residents were observed wearing surgical masks, and three residents were observed in the hallway wearing no mask. At that time, the surveyor interviewed the LPN Unit Manager (LPN UM) of the Noble Unit who stated that residents on the unit were not exposed to COVID-19 and were monitored for signs and symptoms of COVID-19. The surveyor asked what precautions were in place when a staff member is confirmed positive, and the LPN UM stated that nothing was done differently and wasn't sure why. The surveyor asked LPN/UM for the residents who were on CNA #1's assignment. Review of the list of residents provided by the LPN/UM revealed that CNA #1 was assigned to 14 residents, one of which was Resident #1. During an interview with the surveyors on 11/19/20 at 12:30 PM, the RN/IP stated the facility had concluded their outbreak on 11/10/20, and the following day (11/11/2020) had a confirmed positive result (Resident #1). The IP/RN stated the DON was communicating with the LHD and the New Jersey Department of Health (NJDOH). She stated she was waiting for guidance because CNA #1, the Housekeeper and Resident #1 had retested with a COVID-19 negative result. The surveyors requested communication emails to the NJDOH and the LHD. Review of the email from the NJDOH to the facility dated 11/10/20 at 4:46 pm indicated that the outbreak from the facility from 4/9/20 -9/11/20 was concluded and that the facility no longer needed to submit line lists to the LHD, however if a new or suspected case for a staff or resident was identified, the facility was to contact the LHD by phone. In addition, the email indicated that the facility should continue to follow NJDOH guidance for infection prevention and comply with all applicable regulatory requirements set forth by NJDOH, Centers for Medicare and Medicaid Services (CMS), or other regulatory agencies. The email provided Internet links to the guidance. Review of the emails sent to the NJDOH dated 11/11/2020 at 4:46 PM from the DON revealed that an asymptomatic resident with no known exposure at the facility had a positive result and after a stat [MEDICATION(S)] test ([MEDICATION(S)] tests are immunoassays that detect the presence of a specific [CONDITION(S)] [MEDICATION(S)], which implies current [CONDITION(S)] infection) was done, the resident's results were COVID-19 negative. A response from the NJDOH on 11/12/20 at 10:14 AM asked the DON if the tests were a PCR and if the same specimen was used to conduct the [MEDICATION(S)] test. A second email sent to the NJDOH and LHD dated 11/12/20 at 10:59 AM from the DON revealed that Resident #1's positive result was a PCR test received on 11/11/20, and the [MEDICATION(S)] test conducted on 11/11/20 was negative. The facility submitted another PCR test on 11/11/20. There were no further emails provided after the email from the NJDOH until 11/16/20. Review of an email from the LHD sent to the NJDOH and copied to the DON dated 11/16/20 at 12:42 PM, revealed that the facility had a positive staff member and a positive resident who were retested negative and the DON wanted to know if the staff and resident were considered COVID cases. The LHD stated that the NJDOH would have to review the test results. The email did not include the second staff member or Resident #2's positive result. During an interview with the surveyors on 11/19/20 at 12:42 PM, the DON stated that the exposed residents should have been quarantined, and full PPE should have been used. The DON stated, We missed it because we were happy when we saw negative results. The DON stated staff were retested on [DATE] and the residents were not COVID-19 tested because they were not in an outbreak anymore. She further stated she was waiting on guidance from the LHD and NJDOH. The DON stated that the residents were last tested on [DATE] and were scheduled be tested again on 11/20/20 (11 days later). During a follow up interview with the surveyors on 11/19/20 at 1:15 PM, the RN/IP confirmed that the last resident COVID-19 testing date was on 11/9/20 and that the residents should have been retested right away, and placed on precautions because everyone could be positive. The RN/IP stated that she and the DON read the Outbreak Response Management incorrectly. The IJ was identified on 11/19/20 and the Administrator, Assistant Administrator and DON were notified of the IJ at 4:25 PM. A removal plan was accepted on 11/24/20 which included that residents who were identified in coming into close contact with the CNA were cohorted into one area and placed on TBP. The residents who were on the unit where the housekeeper worked were also cohorted and placed on TBP. All licensed staff were re-inserviced on PUI isolation, COVID testing and investigation of an outbreak. 2. On 11/25/20, the surveyors conducted a removal plan verification survey. During the entrance conference on 11/25/20 at 9:50 AM, the Administrator was informed that the purpose of the visit was to ensure implementation of the removal plan and the surveyors requested documentation related to the removal plan. The Administrator stated that the DON and RN/IP would be the contacts for the status of the residents, and the in services. On 11/25/20 at 10:39 AM, the surveyors met with the RN/IP in the conference room. She stated that the facility had an additional CNA and resident test positive for COVID-19. She stated that all residents on the second floor, Noble and [NAME], were on a 14-day quarantine. She stated the required PPE for those units was for staff to wear a face shield and a surgical mask. The use of the N95 mask was only needed on the COVID positive Unit. The RN/IP stated some staff could not tolerate wearing the N95, and could wear a double surgical mask. At that time, Surveyor #1 reviewed the facility's COVID Outbreak Response Management to the RN/IP that indicated a N95 was to be worn for a confirmed or suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive HCP. The RN/IP responded that she did not tell staff to wear a N95 in the PUI unit. The RN/IP left the conference, returned and stated that she made a mistake and that all staff received a N95 and was wearing them on the units. On 11/25/20, Surveyor #2 toured the second floor Noble and [NAME] Units. During the tour on the Noble Unit at 10:55 AM, the surveyor noted that 8 rooms were identified as PUI, and on the [NAME] Unit at 11:15 AM, 15 rooms were identified as PUI. The rest of the rooms on the unit were identified as well resident rooms. Staff were observed wearing N95 and a face shield. On 11/25/20 at 11:20 AM, on the low side of the [NAME] Unit, Surveyor #2 entered a closed double door with signage that indicated contact and droplet precautions. The surveyor observed a housekeeping cart parked outside of Resident #16 and #17's room. The surveyor observed Housekeeper #2 inside the resident's room. Housekeeper #2 left the room and stood at her cart wearing a gown and surgical mask. The surgical mask was even with the tip of her nose and not fully covering her nose. She stated that she could wear that PPE on the low side because the residents on that side were not sick. She stated she was given an N95 and a face shield, but they were in her locker. She stated she wore an N95 mask and a face shield when she worked downstairs because those residents are sick, and the residents up here were not sick. She stated she was in serviced on hand washing and PPE. She stated that it was ok to wear just a surgical mask. She stated that she had to clean the rooms on the other side of the closed doors first then she had to clean the low side of [NAME] afterwards. The housekeeper then went across the hall to her locker and came back with a face shield to use and continued to wear the surgical mask. During an interview with the surveyors on 11/25/20 at 11:40 AM and 12:04 PM, the DON stated that the second floor contained 2 PUI units. On Noble, there were 16 residents who had contact with CNA #1 who were in PUI unit, and on [NAME], there were 24 residents who were in the PUI unit. The DON stated 6 of the residents on [NAME] were PUI due to Housekeeper #1's exposure and 18 residents were in the unit due to a second CNA that was positive for COVID-19 on 11/19/20. The DON confirmed that the entire second floor was not on PUI as the RN/IP had previously stated. The DON also acknowledged that the removal plan stated that all residents in the [NAME] Unit were on TBP. The DON stated that after she did contact tracing, Housekeeper #1 only had contact with 6 residents. The DON added that all staff were to wear N95 and a face shield on any unit in the facility and were in serviced by the RN/IP, with follow up by the department heads of each department. During an interview with the surveyors on 11/25/20 at 12:30 PM, the Director of Housekeeping stated he had last in serviced the housekeeping staff for infection control on 11/11/20 and 11/12/20. He stated when staff enter the PUI units, they are expected to gown up use face shield, N95, gown and gloves. He stated the housekeeper had to get an N95 and shield from him before entering the closed-door unit. He stated that Housekeeper #2 usually followed protocol and does not know why today would be any different. The Director of Housekeeping stated that there were no new in services from when the surveyors were in the facility on 11/19/20. During a follow up interview with Surveyor #2 on 11/25/20 at 1:05 PM, the RN/IP stated when staff work on the green zone everyone had to wear a surgical mask but it would be up to the staff if they wanted to wear an N95. When the staff worked on the yellow zone/PUI unit and the red zone/Covid-19 positive unit the staff were required to wear an N95. Review of an Inservice titled Infection Control (Covid-19) Out Break Management dated 11/19/20, by the RN/IP revealed all staff who enter the room on any resident with suspected or confirmed COVID-19 should adhere to Standard precautions and use a face mask (did not specify which type), gown, gloves and eye protection as PPE. Further review revealed prior to entering double doors from the PUI to COVID-19 area, staff should wear their N95 and full PPE as provided by the facility and observed all the guidance by OSHA, CDC and facility protocol. The inservice revealed the housekeeper #2 had signed the attendance sheet. Review of an an additional inservice given by the RN/IP labeled Infection Control : PUI Management dated 11/19/20 revealed all patients on PUI status required staff to wear PPE: gowns, gloves, eye protection and N-95 masks. Proper donning and doffing of PPE must be done prior to entering the room. The inservice revealed the housekeeper #2 had signed the attendance sheet. During an interview with the surveyors on 11/25/20 at 1:25 PM, the DON stated everyone in the entire building must wear an N95 and face shield. The DON stated this was verbally in serviced and put into place after the surveyors had left the faciity on [DATE] and also because the facility had another Covid-19 positive staff member and resident. The DON stated that the RN/IP initially inserviced all staff, and then the individual department heads inservice their staff. The surveyors reviewed the in-services that had conflicting information regarding mask usage with the DON. The DON stated that both in-services should state N95 mask was to be worn. On 11/25/20 at 1:56 PM, the surveyors met with the Administrator and the DON. The Administrator, who was formally the assistant administrator stated he was assigned as Administrator on 11/20/20 and that he, the prior administrator and the DON developed the removal plan. He stated all staff were inserviced on the use of PPE, N95, face shield and cohorting of residents, and that all staff were given an N95 in a paper bag. The surveyors informed the Administrator and DON of the survey findings and informed the Administrator that due to the evidence, the immediacy had not been removed and that the residents and staff remained in an immediate jeopardy situation. Review of a facility policy titled, COVID-19 Outbreak Management and Response revised 8/2020, revealed that the facility shall take all reasonable and necessary measures to respond to outbreaks of COVID-19 with in the facility to stop transmission of pathogens and prevent additional infections. Any suspect or confirmed outbreak shall be reported to the LHD and/or state health department as per the reporting requirements for communicable diseases and work-related conditions. Implement standard and transmission-based precautions including use of a N95 respirator or higher, gown, gloves, and eye protection for new and re-admissions, confirmed or suspected COVID-19 case(s), and any patient/resident cared for by a confirmed or suspected COVID-19 positive health care personnel. (HCP). The facility shall test all previously negative patients/residents weekly until no new facility onset cases of COVID-19 are identified among patients/residents and positive cases in staff and at least 14 days have elapsed since the most recent positive results and during this 14 day period at least two weekly tests have been conducted with all individuals having tested negative. Review of a facility policy titled, Infection Prevention and Control Program Policy revised 11/2019, revealed that it was the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. Review of a facility policy titled, COVID-19 Surveillance revised 3/9/20, included that the facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. The Infection Preventionist will monitor the status of the COVID-19 outbreak through the CDC website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. Review of the NJDOH's Considerations for Cohorting COVID-19 Patients in Post Acute Care facilities, dated 10/22/20, which was utilized in the facility and provided to the surveyors, revealed Cohort 2, was a COVID-19 negative exposed cohort. This consisted of symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure regardless of test results. Patients/residents who test negative for COVID-19 could be incubating and later test positive. Review of facility policy titled, COVID-19 Testing Policy revised on 5/20/20, revealed that the facility shall take all responsible and necessary measures to conduct all testing of all patients and staff in efforts to stop transmission of pathogens and prevent additional infections associated with the novel coronavirus. A unit-by-unit testing approach should be used. Patients/residents and staff must remain cohorted to their designated unit. The maximum time elapsed between testing each unit should be days, not weeks. Patients/resident and staff who tested at baseline shall be retested every 3-7 days. Review of the Job Description for the housekeeper/room attendant, dated March 2016, under the heading of Essential Functions revealed housekeepers follow all safety procedures, infection control policies and universal precaution to ensure the health and welfare of residents, staff and visitors. Further review revealed under the heading of Knowledge, skills and abilities the housekeeper must be able to understand and follow basic infection control procedures. NJAC 8:39-19.4 (a)(b)(c)(d)

Complaint # NJ Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to protect 1 of 11 sampled residents (Resident #3) from verbal and mental abuse. On 4/19/2015, at 8 a.m., Certified Nurses Aide (CNA) #1 and Unit Licensed Practical Nurse (LPN) #1 observed that Resident #3's sitter from Resident #3's prior residence, who was providing one to one (1:1) supervision was not watching the resident. At 10 a.m., Certified Nurses Aide (CNA #1) reported to LPN #1 that Resident #3's sitter wouldn't notify CNA #1 that the resident needed assistance to the bathroom, allowing the resident to be incontinent and the resident was not wearing a helmet. At 12:15 p.m. CNA #1 reported to LPN #1 that the sitter was rude, spoke to the resident badly and was not watching her while the sitter was on the phone. At 1:30 p.m., LPN #1 heard screams coming from Resident #3's room, entered the room and saw Resident #3 in bed, on both knees pleading, crying and shouting for the sitter to give her back her helmet. The sitter stated she took it away because Resident #3 won't shut up. Although LPN #1 instructed the sitter to leave Resident #3's door open, the sitter continually closed the door and was heard by LPN #1 telling Resident #3 to tell the staff you want the door closed and I (sitter) won't take the helmet. At approximately 2 p.m., LPN #1 notified the Registered Nurse Supervisor (RN #1) of the incident. The sitter explained to RN #1 that she takes off the helmet to redirect the resident when she is having behavioral problems and gives it back when she calms down. RN #1 also asked the sitter to keep the resident's door open but the sitter closed the door as soon as staff leaves the room. The sitter was allowed by facility staff to continue to stay with Resident #3 until the end of her shift, 4:00 p.m. on 4/19/2015. The Immediate Jeopardy, which began on 4/19/2015 when facility staff witnessed and/or were informed of the verbal and mental abuse and failed to remove the sitter from supervision of Resident #1 was identified and relayed to the Administrator and Director of Nursing (DON) on day three (3) of survey, 5/19/2016 at 10:00 a.m. The Past Non Compliance IJ was corrected on 5/21/2015 when facility wide abuse inservices were completed. The deficient practice is evidenced by the following; 1. Review of the facility's titled; Policy Abuse, Neglect & Mistreatment of [REDACTED]. No one may subject residents to abuse including, but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. Observances, complaints or evidence of alleged abuse, neglect and/or mistreatment are thoroughly investigated and reported to the appropriate parties. This is a ZERO TOLERANCE policy and will be strictly enforced. Any staff member must report to his/her immediate Supervisor, Department Head or the Administrator if they suspect that there has been abuse, neglect or mistreatment toward any resident. Care planning and behavior monitoring will be done for residents identified with needs and behaviors which might lead to conflict or neglect. The Nurse Manager/Supervisor will conduct the initial investigation. He/She: Obtains written statements of the staff assigned to the Resident for the shift during which allegation is noted, and 24 hours prior, if indicated. Interviews witnesses, if any. Reviews the Resident's record. Reports incident to the Director of Nursing and/or Administrator. In the event of the abuse investigation, residents will be protected from harm by the following measures. The employee accused of participating in the alleged abuse will be suspended pending investigation .If the alleged abuse involves a visitor or family member, the facility is obligated to protect the resident during the investigation. According to the facility Admission Record, Resident #3 was admitted to the facility in 4/2015. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 4/29/2015, indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment, and required assistance with Activities of Daily Living (ADLs), was continent of bowel and had occasional bladder incontinence. A Care Plan (CP), initiated 4/17/2015, included impaired thought process and communication problem related to (r/t) Mental Impairment and was at high risk for falls r/t Mental Impairment and Hypertension. Interventions included but were not limited to; needs assistance with decision making, Resident #3 has a sitter, with her around the clock, enjoys passing the time for several hours conversing with the sitter, engage in simple structured activities that avoid overly demanding tasks, keep routine consistent, needs an appropriate adaptive equipment or devices as needed for continued appropriateness, ensure/provide a safe environment: call light in reach, avoid isolation, monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Additionally, the CP included a focus on Resident #3's deficit for ADLs self care performance r/t impaired cognitive function secondary to mental impairment. An intervention, initiated 4/21/2015, 2 days after the 4/19/2015 incident, included to wear helmet at all times in order to promote safety for [MEDICAL CONDITION] precautions. A Facility Reportable Event Record (AAS-45), faxed by the facility to the New Jersey Department of Health (NJDOH) on 4/21/2015, revealed that on 4/19/2015, a sitter, provided by Resident #3's prior residence was possibly verbally abusive to the resident. The facility requested that the resident's prior residence Supervisor investigate the issue on their end and not to allow the sitter to return to the facility. The AAS-45 included statements from the 7 a.m.-3 p.m. shift RN #1, Assistant Director of Nursing (ADON) and 7 am-3 p.m. LPN #1. Review of a summary and conclusion signed by the Director of Nursing (DON), at that time, was provided to the surveyor on the second day of survey, 5/12/2015. The summary included that on 4/19/2015, the day shift RN #1 called the DON and reported that LPN #1 felt the sitter was taunting Resident #3 by taking off the resident's helmet and refusing to give it back to her. The DON requested statements be completed and left in her mailbox. On 4/21/2015, the DON reported the incident to the NJ DOH and also called the Assistant Director of Resident #3's prior residence, who assured the DON the sitter would not be sent back to the facility. The conclusion indicated that the DON reported the incident to the NJDOH and Resident #3's prior residence staff would take over the investigation. Review of a Nursing Health Status Note (NN), dated 4/19/2015 at 4:42 p.m., by LPN #1 revealed that at 8 a.m. upon entering room resident (#3) was noted in bed alert and verbal, sitter was laying in the adjacent bed not watching resident (#3) but on cellphone (cell phone), due meds (medications) given and sitter made aware that the bed was clean and made in anticipation of incoming residents .sitter proceeded to ignore my (LPN #1) instructions. CNA (#1) entered the room and asked the sitter if she is going to leave the resident like she did for an extended period yesterday, she needs to let the staff know that she is not going to be in the room as she does not want the resident to fall. Sitter then stated you do expect that I have to eat don't you. I went to get food. CNA #1 then explained to the sitter that the resident cannot be alone and if she was leaving the room, to notify CNA #1 so she could watch her so the resident did not fall. The NN further revealed that at 10 a.m., CNA #1 reported that she had been trying to do morning care on Resident #3 and each time the CNA entered the room, Resident #3's helmet was off and the sitter does not want to put it on, that she (sitter) won't call for assistance when resident (#3) wants to go to the bathroom and is allowing resident (#3) to go on herself and she is not wearing a diaper, I (LPN #1) went and spoke with resident (#3) who continues to say she is OK. heard commotions coming from RM (room), went (when) I (LPN #1) entered, sitter verbalized,: do you have anything to knock her (Resident #3) out, she is getting on my nerves, shout (shut) her up, I (LPN #1) explained that I (LPN #1) found no reason to give her any meds (medications) at this time, her (Resident #3) speaking does not warrant me (LPN #1) giving her medication, maybe she wants someone to talk to .sitter then rolled her eyes. At 12:15 p.m., CNA (#1) again complained that the sitter was rude and speaks to the resident badly, that she (sitter) is not watching her (Resident #3), .only talking on phone .I (LPN #1) again went into room but when resident (#3) was questioned she stated she was OK. The NN further revealed that at 1:30 p.m., LPN #1 heard screams coming from Resident #3's room. I (LPN #1) immediately ran to room and saw resident (#3) on both knees in bed crying and shouting for the sitter to give her back her helmet, I (LPN #1) asked the sitter why was the helmet not on, she stated 'took it away because she won't shout (shut) up, she has gotten on my nerves', meanwhile resident is crying and pleading with sitter to get the helmet back, I (LPN #1) cautioned the sitter that speaking to her (Resident #3) in that manner and withholding her belongings is abuse and will not be condoned in this facility (.) (It) was at this time, (the) sitter stated 'she has behavior problems lady, this is want (what) we do went (when) she acts up at the (prior residence), we take the helmet, she (sitter) then turned to the resident and with a commanding voice shouted, 'when you shoot (shut) up you will get it back.' I (LPN #1) then turned to resident (#3) and asked if she could calm down, resident (#3) immediately became quiet, at which time I (LPN #1) told the sitter,: know (now) she is quiet please give she (her) back her helmet, sitter then stated, I will give it back when I fell (feel) like it (,) matter of fact I am not even going to argue with you just shout (shut) up (,) this is how we handle then (them). I (LPN #1) then walked over to the bed took the helmet up and handed it to the resident, sitter then started laughing as if to taunt and stated 'make no sense I am only going to take it back when you leave the room anyways', I (LPN #1) warned her that from now on the door will remain open, I most (must) be able to see resident (#3) from the hallway, that I (LPN #1) have had enough of her attitude, she is abusing the resident and it will not continues (continue), I (LPN #1) am calling the supervisor, Sitter stated I don't care . I (LPN #1) opened the door a total of 4 times and each time I (LPN #1) left the room the sitter would slam it, I (LPN #1) left the room to page supervisor (RN #1), upon entering the room the door was closed, I (LPN #1) could hear the sitter cohousing (coercing) resident (#3), just say you want you (your) door closed, just tell then (them) you want to keep the door close and I won't take the helmet, when I (LPN #1) entered the room, resident shouted; I (Resident #3) want my door close, sitter started laughing and then responded, you heard her, she wants the door close, I (sitter) know my rights, we (Resident #3 and sitter) need our privacy, she (Resident #3) wants her door to be closed. Shortly thereafter supervisor (RN #1) entered room and spoke with sitter. Review of a typed statement, dated 4/19/2015, signed by LPN #1, reiterated the 4/19/2015 NN at 4:42 p.m. The surveyor was unable to interview LPN #1. Review of a statement, dated 4/19/2015 by RN Supervisor #1 revealed that she was called by the Unit RN #1 at 2 p.m. who reported that the sitter takes off the resident's helmet and refuses to give it to her. I (RN #1) spoke to the sitter .who claims that she takes off the pt's (patient's) helmet to redirect her when she is having behavioral problems; she gives it to her when she calms down. I (RN #1) also asked her to keep room door open at all times so that staff can see the patient. She also closes the door as soon as staff leave the room. Review of a statement, dated 4/20/2015, signed by the current DON, formally the ADON on 4/19/2015, included that she spoke with Resident #3 on 4/20/2015 but the resident did not answer questions related to (r/t) 4/19/2015. The statement also revealed that the ADON called Resident #3's prior residence on 4/20/2015, requested that the sitter involved not be sent back to the facility. The prior residence's Supervisor requested that the nurse's statement be faxed to her and she would follow up including notifying Resident #3's responsible party. Review of a written statement, dated 5/13/2015, signed by Resident 3's assigned CNA #1 which revealed that on 4/19/2015, CNA #1 worked with Resident #3. CNA #1 found Resident #3 several times by herself when she was supposed to have a 1:1 (sitter) with her. When I (CNA #1) finally saw the 1:1 (sitter), I (CNA #1) asked her when she leaves, to let me know so there won't be any incidents. She (sitter) replied she has to eat .I (CNA #1) asked her (sitter) to leave the door open so I (CNA #1) can check on (Resident #3) when passing by. She (sitter) replied she didn't have to keep the door open and every time I (CNA #1) open (opened the) door she (sitter) immediately close (closed) it .She (sitter) was verbally abusive to (Resident #3) threatening to remove her helmet if she (Resident #3) didn't do what's asked of her . During an interview with the surveyor on 5/12/2015 at 3:15 p.m., CNA #1 confirmed her statement and added that at one time during the weekend, 4/18-4/19/2015 she stayed with the resident because the sitter was not with the resident. Additionally, CNA #1 added that she observed the sitter yelling at Resident #3 because she was wet and should have told (the sitter) that she (Resident #3) had to go to the bathroom. CNA #1 stated she remembered the sitter got mad and left and CNA #1 stayed in Resident #3's room until the end of her shift, 3:00 p.m. Review of a Facility Incident/Accident Report (IR), dated 4/19/2015 and signed by LPN #1, revealed the incident occurred on 4/19/2015 at 1:30 p.m. LPN #1 documented that the sitter assigned to resident (#3) was noted removing helmet provided for safety measures as a form of punishment and refused to give back even after resident was quiet stating this is what they do when in (Resident #3's prior residence). The IR indicated a physician was made aware. During a telephone interview with the surveyor on 5/13/2016 at approximately 3 p.m., the former facility DON, at the time of the incident, confirmed she received a telephone call at approximately 2-3:00 p.m. on 4/19/2015 from RN #1 and was told that the sitter was withholding Resident #3's helmet from the resident, not leaving the door to Resident #3's room open and arguing with the nurses. The former facility DON stated; It was a vague report and she instructed RN #1 to obtain statements and leave them in her mailbox. The DON added that Resident #3 had an intellectual disability and the sitter was provided by the Resident's prior residence and there for constant 24 hour 1:1 supervision due to impulsive behavior. Additionally, the former DON added that it was not until the next day, 4/20/2015 after reviewing the investigation that she realized the incident was as severe as it was and if she had known we would have taken steps to remove the sitter at that time. She confirmed that the sitter worked the full shift until 4 p.m. on 4/19/2015. The former DON also stated that LPN #1 should have reported all of the incidents r/t care immediately. The former DON stated she was unable to remember if she had conducted abuse inservices after the incident but stated that the facility is consistently inservicing staff on abuse. The former DON confirmed that she was not aware of any information sent by Resident #3's prior residence r/t the sitter. The DON stated; They were employees of the (former residence) and trained by them. The DON additionally stated that the ADON on 4/19/2015, now the current facility DON, reviewed the statements the next day on 4/20/2015, conducted an investigation and after reviewing the statements, both the ADON and the former DON felt that the incident needed to be reported to the NJDOH. The surveyor asked the DON if she spoke with LPN #1 and RN #1 regarding the facility policy on abuse and removal of the alleged abuser during an abuse allegation. The former DON stated that she did not remember conducting abuse inservices with any of the staff but inservices on abuse were ongoing. On 5/12/2015, the surveyor requested any personnel information, including orientation and inservicing and any Criminal Background Checks r/t the sitter, however, the facility was unable to provide any information. The current DON added that after Resident #3's discharge, 5/8/2015, there had been no further sitters at the facility. During an interview with the surveyor on 5/12/2016 at 2:50 p.m., RN #1 confirmed she was the day shift weekend Nursing Supervisor working on 4/19/2015 and had received a call from LPN #1 at approximately 2 p.m. r/t the sitter taking away Resident #3's helmet, the resident screaming and the resident's door being closed. RN #1 confirmed her 4/19/2015 written statement and stated she asked Resident #3 if she was ok and RN #1 stated the resident was calm. She (Resident #3) did not want the sitter to leave and said she loves her. The surveyor asked RN #1 why she called and notified the DON of the incident and RN #1 stated because LPN #1 thought that taking the helmet from the resident was abuse. RN #1 stated she wanted to make sure the resident was safe at all times so she called Resident #3's prior residence and left a message that the incident needed to be addressed and not to send the sitter back to the facility and then notified the DON. RN #1 stated she was instructed by the former DON to complete the IR, obtain statements and submit them to the DON. RN #1 stated that she did not remove the sitter from the resident's room and as far as she was aware the sitter continued to work to the end of her shift. Additionally, RN #1 stated the resident's door remained open after she spoke with the sitter and staff made frequent checks. RN #1 stated the staff should have reported all of the incidents that occurred that day, earlier and it was not until 3 p.m. that she was made fully aware of them. RN #1 stated the former DON did inform her that the sitter should have been removed from Resident #3 immediately after the allegation of abuse but RN #1 did not remember when that occurred. During an interview with the surveyor on 5/19/2016 at 9:30 a.m., the current DON confirmed that she was the ADON at the time of the incident and when she was notified of the incident on 4/20/2015 she interviewed the staff involved and asked them why the sitter was not removed from the facility. The current DON confirmed that staff should have removed the sitter from the resident. In addition, the DON stated that all visitors to the facility, including the sitters, are supposed to sign in and out of the facility at the front desk on the Visitor Sign In Sheet. Review of the 4/19/2015 Visitor Sign In Sheet revealed no indication that the sitter signed in or out of the facility on that date. The Immediate Jeopardy, past non compliance, which began on 4/19/2015 was corrected based on an acceptable plan of correction accepted on 5/19/2016 at 2:30 p.m., implemented on 5/21/2015 as follows; 1. The Sitter was not allowed to return back to the facility on [DATE] and Resident #3's prior residence was notified of the incident on 4/20/15. 2. The facility staff that were involved were in-serviced via telephone on the Policy & Procedures on Abuse, Neglect & Mistreatment of [REDACTED]. 3. Following the event, the Nursing staff identified Residents using Sitters and there were no other Residents utilizing Sitters. 4. Residents using Sitters will be affected by the same deficient practice. 5. All staff were in-serviced regarding Sitter policy, Abuse, Neglect & Mistreatment of [REDACTED]. 6. The Unit Nurses and CNA's spot checked the Sitter and Resident #3 every 1 hour and PRN, while rendering care to ensure that there were no potential acts of Abuse, Neglect and Mistreatment of [REDACTED]. This was initiated on 4/19/15 and ended on 5/8/15 when Resident #3 was discharged . 7. There were no other reports of any other Sitters for any other Resident other than the affected Resident. There were no negative findings reported. NJAC 8:39:27.1 (a). 8:39:4.1 (a) 5.

Complaint # NJ CROSS REFERENCE F223 Based on interviews and review of the medical record (MR) and other facility documentation, it was determined that the facility failed to report, investigate and remove a resident's sitter timely, in accordance with facility policy on abuse, when an allegation of abuse was reported by staff for 1 of 11 sampled Residents (Resident #3). On 4/19/2015, at 8 a.m., Certified Nurses Aide (CNA) #1 and Unit Licensed Practical Nurse (LPN) #1 observed that Resident #3's sitter from Resident #3's prior residence, who was providing one to one (1:1) supervision was not watching the resident. At 10 a.m., Certified Nurses Aide (CNA #1) reported to LPN #1 that Resident #3's sitter wouldn't notify CNA #1 that the resident needed assistance to the bathroom, allowing the resident to be incontinent and the resident was not wearing a helmet. At 12:15 p.m. CNA #1 reported to LPN #1 that the sitter was rude, spoke to the resident badly and was not watching her while the sitter was on the phone. At 1:30 p.m., LPN #1 heard screams coming from Resident #3's room, entered the room and saw Resident #3 in bed, on both knees pleading, crying and shouting for the sitter to give her back her helmet. The sitter stated she took it away because Resident #3 won't shut up. Although LPN #1 instructed the sitter to leave Resident #3's door open, the sitter continually closed the door and was heard by LPN #1 telling Resident #3 to tell the staff you want the door closed and I (sitter) won't take the helmet. At approximately 2 p.m., LPN #1 notified the Registered Nurse Supervisor (RN #1) of the incident. The sitter explained to RN #1 that she takes off the helmet to redirect the resident when she is having behavioral problems and gives it back when she calms down. RN #1 also asked the sitter to keep the resident's door open but the sitter closed the door as soon as staff leaves the room. The sitter was allowed by facility staff to continue to stay with Resident #3 until the end of her shift, 4:00 p.m. on 4/19/2015. The facility failed to implement their own policy titled; Policy Abuse, Neglect & Mistreatment of [REDACTED]. The sitter was allowed by facility staff to continue to stay with Resident #3 until the end of her shift, 4:00 p.m. on 4/19/2015. The Immediate Jeopardy, which began on 4/19/2015 when the facility staff witnessed and/or were informed of the verbal and mental abuse and failed to remove the sitter from supervision of Resident #1 was identified and relayed to the Administrator and Director of Nursing (DON) on day three (3) of survey, 5/19/2016 at 10:00 a.m. The IJ was corrected on 5/19/2016 when facility Quality Assurance was initiated. This deficient practice is evidenced by the following; 1. See Example #1. The immediate jeopardy, to resident's health and safety which occurred on 4/19/2015 was corrected and lifted on 5/19/2016 at 2:30 p.m., based on an acceptable plan of correction as evidenced by the following; 1. The assigned staff that were involved with Resident #3 were in-serviced via telephone on the Policy and Procedures on Abuse, Neglect & Mistreatment of [REDACTED]. 2. All Residents have the potential to be affected by the deficient practice. 3. Facility wide in-servicing of all staff regarding strict enforcement of the Policy and Procedure on Abuse, Neglect and Mistreatment of [REDACTED]. 4. Unit Managers started to conduct random interviews of at least 2 staff per shift on the process for prevention, identification, investigation, & reporting of abuse, neglect, mistreatment, & misappropriation of property. Interviews will be done monthly for 3 months and results reported quarterly in QAPI meetings. Completion Date: 5/19/16 and on-going NJAC 8:39-27.1(a) 8:39-27.1 (b)

Complaint # NJ 514 A. Based on observation and interview it was determined that the facility failed to handle potentially hazardous foods in a manner that would prevent food-borne illness. This deficient practice could potentially affect all residents who would consume food prepared in the facility's kitchen. The immediate jeopardy for substandard food-handling practice was identified on 12/1/11 at 4:00 p.m. and the Administrator and the Director of Nursing were notified. The immediate jeopardy was corrected on 12/1/11 at 7:30 p.m. after the facility submitted and implemented an acceptable plan of correction, but noncompliance remained at the lower level scope and severity level of F. The deficient practice was evidenced by the following sequence of events which occurred in the kitchen on 12/1/11: A-1. At 10:37 a.m., a maintenance employee showed the state surveyor the soldering work he had done in an effort to repair the rusty, corroded sections of the 3 compartment pot- washing sink. The maintenance man did not complete the repair work on the sink and left the kitchen before the next observation. At 11:40 a.m., the Vice President of Operations for Pinnacle Food Services (V.P. of Operations) stated that they had stopped using the pot washing sink on 11/29/11. A-2. At 12:09 p.m., 2 surveyors observed the cook preparing to make sandwiches for residents. The cook began by rinsing a knife under running water in the 3 compartment sink that was under repair. The sink had not been cleaned or sanitized. It was in a state of complete disrepair and there was evidence of blackened debris covering the inside surface of all 3 compartments in addition to the rust and corrosion that was initially observed. A-3. At 12:12 p.m., in the presence of 2 surveyors, the cook proceeded to remove the cellophane wrapper from a head of lettuce. She then lifted the soiled trash can lid and disposed of the wrapper. Without washing her hands or changing into clean gloves, the cook handled the raw lettuce. The cook took the head of lettuce into the soiled dishroom, where pots were being washed. The room was laden with dirty pots and the dump sink, itself, was filled with waste that had been rinsed off dishes and pots. The cook grabbed the spray hose and rinsed the lettuce under the nozzle over the dirty sink. The surveyor stopped her before she used the raw produce for sandwiches and the lettuce was discarded immediately. A-4. At 12:15 p.m., the V.P.of Operations was told about the incidents where the cook washed lettuce in the dishroom and cleaned the knife in the pot-washer's sink. He stated, in the presence of 2 surveyors and the Pinnacle Regional Food Service Manager, that the Food Service Worker had been washing vegetables in the dishroom since Wednesday (11/30/11), but that they were told to only use that sink before the staff began washing pots and dishes. Throughout the 7 survey days, the dishroom was never observed to be clean. According to the staff, it was the only area that could be used to clean and sanitize pots and pans as well as dishes, therefore, it was nearly always in operation. A-5. On 12/1/11 at 10:45 a.m., the surveyor observed the following: a. The sink adjacent to the coffee urn was half- filled with a black liquid that would not drain. b. The prep sink by the stove was not being used by the staff because it would not drain. c. The prep sink by the juice dispenser could not be used because it was not draining properly. d. Only one out of five sinks in the kitchen were functional and that was the hand-washing sink. which was not appropriate for food preparation. The Immediate Jeopardy was corrected on 12/1/11 at 7:30 p.m. when the facility presented an acceptable plan of correction which included that: 1. A satellite kitchen was opened in the dining room to prepare the evening meal on 12/1/11 and breakfast on 12/2/11. Main kitchen was closed due to drainage issues. 2. An in-service on proper food safety precautions was conducted for food service personnel. 3. Emergency menu consisting of cold food items, approved by Registered Dietitian to ensure nutritive value will be implemented. 4. All items procured that require washing and slicing such as produce will be purchased from an approved vendor precut. 5. Paper products will be used during the the process. 6. Mobile kitchen on-site will be cleaned with bleach and water, along with being power washed. Then it will be re-inspected by local health department for use to produce resident meals. 7. Monitoring of these activities provided by FSD, the 2 Pinnacle Regional Managers, the Pinnacle Director of Purchasing, and the Pinnacle Director of Clinical Services. The noncompliance remained at the lower scope and severity level of F based on the evidence in Part B. B. Based on observation and interview it was determined that the facility failed to handle potentially hazardous foods in a safe, consistent manner. This was cited on the survey of 1/11/2011 and was included in their Plan of Correction. This continuing deficient practice was evidenced by the following: B-1. On 11/29/11, during the initial tour of the kitchen, from 9:50 a.m. to 11:00 a.m., the surveyor observed the following in the facility kitchen in the presence of the FSD and the V.P. of Operations: a.) In the walk-in refrigerator, 2 large logs of unlabeled, undated, thawed ground beef were in a large pan with 2 bags of chopped meat which were dated "11/26". The FSD stated that 11/26 was the "pull date" for the meat and added that she "guessed" that all the meat in that pan was pulled on the same day. b.) In the produce walk-in refrigerator, there were 2 cups (4 oz.each) labeled with "H" only and no date. The FSD and V.P. of Operations stated that the "H" stood for either honey-thickened liquids or health shake. Another cup was labled "L.T." with no date. Neither Pinnacle employee knew what was contained in that cup. c.) In the same refrigerator, on the bottom shelf, there was a large metal bowl of a thick, liquid substance. There was no label or date on the plastic wrap that covered the bowl. The FSD stated that it was "Bisquick." d.) In the produce walk-in box, there were 7 one- pound tubes of non-dairy whipped cream. None of the tubes were dated and no one on the kitchen staff could identify when the product was placed in the refrigerator. B-2. On 11/29/11 at 12:00 noon in the Warren Day Room, the surveyor observed during meal service, in the presence of the of the FSD the following: a.) The 4 wells in the steam table contained water from a previous meal. Small amounts of food debris were observed in the cloudy water where fresh pans of food were inserted for lunch that day. The FSD stated, "I'll be honest, it was not cleaned today." In addition, the glass sneeze guard and the bottom shelf of the portable steam table were also soiled with dried liquid and food splatters. b.) At 12:15 p.m., the FSD dropped her thermometer on the floor, picked it up and then proceeded to serve food without first changing gloves or washing her hands. B-3. On 12/1/11 at 10:37 a.m. a food service worker, who was assisting the cook, opened a cardboard carton of frozen meat patties. He handled one of the patties without first washing his hands or changing his gloves. The meat pattie was discarded. B-4. On 12/1/11 at 10:45 during meal preparation, the surveyor observed 2 ceiling tiles that were pushed aside directly above the aisle between the cook's preparation table and the cooking equipment. This situation potentially exposed the food being prepared to contaminants from the area above the ceiling tiles. NJAC 8:39-17.2 (g)

A. Based on observation, interview and record review, it was determined that the facility failed to monitor smoking materials. This deficient practice was identified for 1 of 8 (Resident #4) smokers reviewed for smoking safety and resulted in an immediate jeopardy situation. The resident had a history of [REDACTED]. The resident was able to self- propel throughout the facility with the smoking materials, unsupervised. This placed the resident, other residents, and the facility at risk. The immediate jeopardy was identified on 12/1/11 at 4:50 p.m. and the Administrator and the Director of Nursing were notified. The immediate jeopardy was removed on this date at 7:30 p.m., but non compliance remained at a lower scope and severity level of E. This deficient practice was evidenced by the following: A-1. On 11/30/11 the surveyor reviewed the medical record on 12/1/11 at 9:15 a.m. on the long term care Noble Unit on the second floor. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) cognitive assessment dated on 1/23/11 documented that Resident #4 had disorganized thinking, with recall cueing required. The surveyor reviewed the interdisciplinary progress notes (IDC) of 7/26/11 which stated that the resident was a strong-willed person and non-compliant with following the smoking policy. The IDC notes dated 8/12/2011 indicated the resident had taken a bottle of alcohol located at his lunch table and poured it into his milk. Documentation on 8/17/11 noted that he informed a social worker he wanted to use another resident's cell phone to call a friend "so he could come here and shoot the place up." On 10/9/11 from 12:15 p.m. to 12:45 p.m., staff documented that Resident #4 became upset with a social service staff member and stated he was being discriminated against when told to come indoors to eat lunch and put out his cigarette. On 12/2/11, Social Service documentation noted he was angry and agitated and yelling about being singled out regarding the smoking policy. The resident "pointed his finger at the Administrator, called him "boy" and he said "now I will make you a girl." The resident then stated "If you want to single me out, I will single you out." The resident was followed by the facility psychiatrist for the [DIAGNOSES REDACTED]. The psychiatric consultation report dated 12/3/11 stated "lately his paranoia getting worse. He is talking about FBI "don't call Police, call FBI." He acts out verbally due to paranoia." The psychiatrist also indicated that the resident's affect was "angry." On 12/1/11 at 9:30 a.m., the surveyor interviewed Resident #4 in the activity room on the Noble Unit. The resident identified himself to the surveyor as a smoker. He stated he refused to sign the facility smoking policy contract dated 8/16/11. The resident and the surveyor then went in the resident's room where he opened the nightstand drawer next to the bedside. The drawer contained the cigarette lighter and loose papers. The resident removed the lighter and lit it. The resident commented that the facility's (previous) Administrator knew he had the lighter in his possession. He stated he was allowed to hold his own cigarettes's and lighter without supervision . The surveyor interviewed the Unit Manager (UM) at 12 Noon. The UM identified Resident #4 as an individual with an argumentive personalty pattern, with no specific triggers to set him off. The surveyor interviewed the Director of Social Workers (DSW) at 12:17 p.m. and reviewed the smoking contract that indicated Resident #4's refusal to follow the smoking rules. The smoking policy contract (#7) indicated that "Smoking Material such as lighters, matches and cigarette's cartons must be labeled with resident's names and kept at the nurses station based on nursing assessment." The smoking policy also indicated that failure to follow the policy "will result in loss of some or all of my smoking privileges and non compliance with said policy may result in further disciplinary actions as determined by the Interdisciplinary Care Plan ( IDCP) team including a recommendation for discharge." The DSW stated that in the past, if a resident was alert and oriented they could hold their own cigarettes and lighter and the nurse determined if the resident could hold them. At 12:40 p.m., the surveyor interviewed the UM regarding smoking assessments. The UM stated Resident #4 hands did not shake and he could hold his own cigarettes and lighter which he kept in his drawer by the bedside. The surveyor asked the UM where the smoking materials for Resident #4 were located. The UM stated they were not in his room because he (Resident #4) had them on him. The surveyor and the UM went into the resident's room .The surveyor questioned how the UM would know if other lighters were in the room, and how many lighters did the resident have and how many lighters were in the building. The UM was unable to answer the questions. The surveyor reviewed the medical record on 12/1/11 at 10:30 a.m. The quarterly smoking assessment of 11/8/10 noted that the resident dropped ashes on himself "sometimes" and placed cigarettes in his pocket. A smoking assessment dated [DATE] also stated that the resident "sometimes" dropped ashes on himself. The assessment form quoted the resident's: "I ain't going to wear no apron just to smoke." The current assessment dated 12/1/11 documented the resident as not being receptive to wearing an apron. The Immediate Jeopardy was removed on 12/1/11 at 7:30 p.m. when the facility provided an acceptable plan of correction (POC) which included the following: - The resident's cigarettes's and lighter were removed from his possession and given to his primary nurse. - The resident would be monitored and supervised for smoking during the facility's smoking hours of 8 a.m. to 8 p.m. - All residents that wanted to smoke would be re-assessed for safety and awareness and residents would have their smoking materials labeled and kept at the nurses station in a secured box from 8 p.m. to 8 a.m. In the morning an assigned staff member would retrieve these materials and keep them in their possession. Staff members would have the resident sign out when taking a smoking break in order to monitor the resident's smoking materials. - Inservices for facility staff regarding the policy and its implementation were begun on 12/2/11 and were to continue on the next three shifts. B. This noncompliance remained at the lower scope and severity level of E. Based on observation, interview and review of the medical record, the facility failed to monitor smoking safety for 1 of 8 residents , Resident #3, reviewed for smoking safety and was evidenced by the following: B-1. The surveyor reviewed the medical record of Resident # 3 on 11/30/2011 at 9:30 a.m. on the Heritage Nursing unit. During review of the medical record, the surveyor observed that Resident #3 had [DIAGNOSES REDACTED]. (COPD) and had a physician order [REDACTED]. The interdisciplinary progress notes dated 5/27/11 indicated that the Social Worker and the previous Administrator spoke to the resident about the risks of smoking while using oxygen. According to the MDS 3.0 dated 9/1/11, the resident was alert and oriented. The surveyor interviewed the Charge Nurse (CN) on 11/30/11 at 10:30 a.m. The CN stated that the resident was found in the patio area during the 3 -11 p.m. shift smoking with the oxygen canister on the wheelchair. The CN stated the resident currently self -propelled in the wheel chair with the attached portable oxygen bottle at 2 liters running continuously and would take his lighter and cigarettes, (which were kept at the nursing station), then would switch into a wheel chair without an oxygen canister in the activity room. The resident would then go to the patio to smoke unsupervised. During an interview on 11/30/11 at 12:30 p.m., Resident #3 stated that he does keep his cigarettes and lighter at the nurses station. The resident stated he picked up his cigarettes and lighter and with the portable oxygen running at 2 liters per minute via nasal cannula he self propelled to the activity room to switch to the wheel chair with no oxygen tank. The resident stated that he was supposed to go through the main dining room when the activity room was being used. "Nobody watches me out in the patio area." The surveyor reviewed the resident's current smoking assessment. Even though the resident had been found smoking with the oxygen canister on the wheelchair in May 2011, there was no updated smoking assessment completed indicating that the resident was assessed as being able to smoke unsupervised. C. Based on random interviews conducted with facility staff members regarding the implementation of the new smoking policy and procedures that resulted from the Immediate Jeopardy on 12/1/11, it was determined that all staff were not inserviced as identified in the plan of correction and was evidenced by the following: C-1. On 12/6/11 between 4:30 p.m. and 5:15 p.m., the surveyors interviewed two Housekeepers , a contracted Physical Therapy Assistant, and an Activity Assistant on Noble Unit all who stated they were not in-serviced on the any recent smoking policy changes by the facility. The 3-11 p.m. LPN on Warren Unit could not recall being recently inserviced on a new policies procedures for smoking after being questioned by the surveyor for over 10 minutes. On the Heritage Unit, one housekeeper said he hadn't been in-serviced in years and one LPN on the same unit stated that the cigarette lighters had to be at the nurses station or medication cart and did not know about any sign- in or sign- out sheets required for the residents to sign when smoking. D. Based on observation, interviews and review of facility documentation, the facility failed to secure a storage area which contained hazardous materials and was evidenced by the following: D-1. At 2 p.m. on 12/1/11, the surveyor observed a storage room in a hallway leading to the main dining room, the door was held open with plastic material wrapped around a metal shelf attached to the doorknob. The surveyor entered the room and saw a cabinet containing 10 used red "Sharps" containers that were filled with syringes and 2 used red "Sharps" containers partially filled in an unsecured brown cabinet. A cart against the wall next to the cabinet was holding 3 half- filled red "Sharps" containers. A locked cart had one red filled "Sharps" container. The metal shelf contained multiple cardboard boxes filled with old clothes and labeled with names. In the center of the storage room there were several dirty and dusty wheelchairs,commodes, and tables. At 2:25 p.m., the Administrator stated to the surveyor in the presence of the Maintenance Director that a non- employee was replacing ceiling tiles and was supposed to lock the door. The non- employee stated he thought he locked the door. The Director of Nursing stated the cabinet was supposed to be locked. NJAC 8:39- 27.1 (a)