Every finding on record at Aristacare at Cedar Oaks

Based on observations, interviews, and review of facility provided documents, it was determined that the facility failed to store and prepare food in a manner which followed kitchen sanitation practices to prevent the potential development of food borne illness. This deficient practice was identified in 2 of 2 kitchens (main kitchen and ethnic specialty kitchen) reviewed, and was evidenced by the following: A.On 4/9/26 at 9:37 AM, during the initial tour of the main kitchen with the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: 1. A stacked refrigerator against the back wall. On the top shelf inside the refrigerator, the surveyor observed a dark cloth bag with a paper attached. The paper had a name and Do not touch 4/10 written on it. The FSD stated the refrigerator was used to store margarine, juice, and other small items for residents that could be grabbed by kitchen staff quickly and easily if needed. The FSD removed the cloth bag from the refrigerator and acknowledged the bag contained a staff member's food which should not have been stored in that refrigerator. 2. The walk-in freezer door did not appear to be completely closed. The FSD stated there was a problem with ice build-up. The RFSD stated he had already put in a work order for the ice build up. Inside the freezer, the following was observed:-Ice build up on the rubber floor mat, the shelves, the refrigeration unit, the freezer ceiling surface, and the food packaging boxes.The FSD removed 2 boxes from the middle shelf, which had been opened prior. The surveyor observed the inner clear plastic bags inside each box were not closed. There was frost and loose ice on the food items in both boxes. The FSD acknowledged there should not be ice build up on the boxes, and the plastic wrapping inside should have been closed. 3. In the walk-in cooler: two cardboard boxes labeled as eggs on the second shelf up from the bottom. The boxes contained several egg cartons of shelled raw eggs. The FSD acknowledged raw shelled eggs should be on the bottom shelf and moved them to the bottom shelf. 4. Dietary Aide (DA) #1 was putting racks of dishes and food service items through the dishwashing machine. The FSD stated the dishwashing machine was a low-temperature machine (used chemical sanitation with chlorine to clean dishes at lower water temperatures than high-temperature dishwashers). He stated he checked the chemical levels every morning and the person who ran the dishwashing machine checked the chemical levels every two to four hours. The RFSD added they (the kitchen staff) checked (the chemicals) before they began washing dishes from each meal. The surveyor observed the RFSD use his foot to tap a white bucket with yellow lid which was on the floor under the dishwashing area table. The RFSD stated to the surveyor the chemical sanitizer bucket for the dishwashing machine was empty. The RFSD then turned to DA #1 and stated everything washed this morning needed to be run through the machine again. The FSD replaced the empty sanitizer bucket. The RFSD stated the machine had to run a few times, then the chemical level had to be checked again, then the dishes had to go through the dishwashing machine again because they weren't sanitized. 5. On the metal shelves against the wall containing pots and pans, identified as the pot drying area. On a middle shelf, the surveyor observed ten (10) deep quarter pans lying on their sides stacked together. The FSD loosened and separated two of the pans near the middle of the stack, which revealed a brown powdery residue along the sides of the pans, The FSD wiped the residue with his finger, acknowledged that the pans were not clean, then removed the two pans to the dishwashing table. The FSD loosened and separated the rest of the pans and moved two additional pans to the dishwashing table. The FSD acknowledged the above concerns at the completion of the initial tour of the main kitchen area. On 4/10/26 at 12:15 PM, the surveyor interviewed the FSD regarding the concerns identified on the initial tour of the main kitchen. The FSD acknowledged there was a large amount of ice build up in the freezer all the time. He acknowledged the potential for contamination with ice penetration into food packaging. The FSD acknowledged the pans on the drying racks had food debris on them and should not have been on the drying racks. On 4/13/26 at 11:24 AM, during a follow up to the main kitchen, the surveyor observed DA #2 standing at a metal table in what she described as the area to get the food ready for the lunch. The surveyor observed DA #2, who was wearing gloves, take a green apple to the handwashing sink. DA #2 turned on the faucet, put the apple under running water, dried it with paper towels, then returned to the table where she wrapped the apple in plastic clear wrap, and set it in a metal pan along with other fruit. On 4/14/26 at 8:56 AM, the surveyor observed the FSD remove a box from the shelf inside of the walk-in freezer. The surveyor observed open clear plastic packaging with several whole fish exposed from head to tail, of a pink/orange color, that the FSD identified as tilapia. The fish were noted to be coated with a white frosty/ice coating and had loose pieces of ice on them. The FSD acknowledged the plastic packaging should have been closed to avoid contamination and removed the box from the freezer. B. On 4/10/26 at 11:09 AM, the surveyor observed the following in the ethnic specialty kitchen area:1.The door to the food preparation room was propped open by a wooden doorstop on the floor. 2.A tower fan was in the room. The fan was running, and the air output was facing into the food preparation area. The surveyor observed the intake vents on the back of the fan were coated with grayish brown debris. At that time, the surveyor observed three staff preparing food at the counter and stove. On 4/14/26 at 8:45 AM, the surveyor returned to the ethnic specialty kitchen area. The surveyor observed DA #3 kneeling on the floor of the food preparation room hitting a bag, which was lying on the floor, with a hammer. DA #3 lifted the bag from the floor and placed it on the counter. The surveyor observed the bag was labeled as 20 pounds of [brand redacted] whole wheat flour. DA #3 reached into the bag and removed what appeared to be large brown irregular shaped pieces of material. DA #3 stated, sugar. DA #3 led the surveyor into the ethnic specialty supply room where she presented a package of brown material to the surveyor. The label indicated the product was solid unrefined sugar. DA #3 repeated hard. On 4/14/26 at 8:50 AM, with the assistance of another surveyor who was able to interview and interpret, the surveyor interviewed DA #3. DA #3 stated the unrefined sugar was used in food preparation. She stated it was difficult to separate into smaller pieces from its original packaging, so it was placed in a large bag and placed on the floor where she hit it with a hammer to break it into smaller pieces for ease of use. DA #3 acknowledged the bag she used was not labeled as sugar. DA #3 stated she needed a large bag, and on that particular day the whole wheat flour bag was empty, so she used it. On 4/14/26 at 2:26 PM, the above concerns were presented by the surveyor during a meeting with the Chief of Clinical Operations (CCO), Regional Administrator (RA), Administrator, and Director of Nursing (DON). The surveyor reviewed the undated facility policy Dietary/Food Handling which reflected the purpose was to provide guidelines for the safe preparation, handling and storage of perishable food and proper environmental cleaning. The general guidelines contained in the policy reflected.all raw fruits must be washed thoroughly. Dishwashing units must be used as per manufacturers directions.Sanitizing may be accomplished in one of the following ways.Contact for at least one (1) minute with a chlorine solution. The surveyor reviewed the undated facility policy Food Storage which reflected that food storage areas shall be maintained in a clean, safe, and sanitary manner. The interpretation and implementation reflected.All foods stored in walk-in refrigerators and freezers will be stored on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. The surveyor reviewed the undated facility policy Refrigerators and Freezers which reflected the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. The interpretation and implementation reflected.Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. NJAC 8:39-17.2(g)

Based on observations, interviews, record review and review of pertinent facility provided documents, it was determined that the facility failed to; a.) ensure kitchen staff followed hand hygiene practices to prevent the spread of infection or food borne illness; b.) wear appropriate Personal Protective Equipment (PPE) and use appropriate hand hygiene during tracheostomy care and c.) follow appropriate hand hygiene during meal service to prevent the potential spread of infection. This deficient practice was identified in 2 of 2 kitchens observed for hand hygiene, 1 of 1 resident (#16) reviewed for tracheostomy care, and 1 of 4 dining areas reviewed for infection prevention, and was evidenced by the following: 1. On 4/9/26 at 8:52 AM, during an initial tour of the main kitchen, the surveyor observed [NAME] #1 wipe her bare hands on the sides of her pantlegs then don (put on) gloves and transport a plastic bin of food, which she identified as seasoned raw chicken, to the refrigerator. She returned, removed and disposed of her gloves, and donned new gloves. The surveyor did not observe hand hygiene was performed. On 4/10/26 at 11:09 AM, during an initial tour of the ethnic specialty kitchen, the surveyor observed Dietary Aide (DA) #1 preparing food. DA #1, with bare (ungloved) hands, lifted what appeared to be balls of a dough-like material from a bowl on the counter. She used a rolling pin to flatten and shape the material into circles, and dredged each circle in a bowl that contained a white powdery substance. She then placed each rolled out and dredged circle, one on top of the other, on a plate on the counter. The surveyor observed DA #1 complete this preparation process four (4) times with bare hands. The surveyor was unable to interview DA #2 at that time due to a language barrier. On 4/10/26 at 12:15 PM, the surveyor interviewed the FSD, who stated kitchen staff should wear gloves when handling food, even if the food is wrapped. He stated gloves should be changed after each use. On 4/13/26 at 11:30AM, in the main kitchen, the surveyor observed [NAME] #2 at the hand-washing sink, she used her right hand to expel soap from the dispenser, rubbed her hands together then rubbed her hands up and down her forearms almost to her elbows. The surveyor observed a white soapy film on [NAME] #2's hands and forearms. [NAME] #2 turned on the left and right faucet handles, with her soapy hands and ran her hands and arms up and down under the water then turned off the faucets. [NAME] #2 took paper towels, dried her hands and arms, and threw the paper towels in the trash can. [NAME] #2 took more paper towels from the dispenser, wiped them across her face, used her right hand to wipe the towels across the back of her left hand, then threw the towels in the garbage. [NAME] #2 then donned gloves and went to the cooking area. The surveyor made the FSD aware of the observation. The FSD called the employee out of the kitchen in the presence of the surveyor. The surveyor asked [NAME] #2 to verbalize the proper procedure for hand washing. [NAME] #2 stated, Wash, 20 minutes. The FSD interrupted and stated, 20 seconds. On 4/13/26 at 11:40 AM, [NAME] #2 in the presence of the surveyor and the FSD walked to the hand-washing station. [NAME] #2 turned on the faucet with her left hand while getting soap from the dispenser with her right hand, then put both hands under the running water. She used her right hand to dispense more soap and rubbed her hands together then rubbed her hands up and down her forearms almost to her elbows. The surveyor observed a white soapy residue on her hands and forearms. [NAME] #2 put her forearms and hands under the running water. The time from the second dispensing of the soap onto her hand until rinsing her arms and hands under the water was four (4) seconds. [NAME] #2 took paper towels, turned off the faucets and dried her hands and arms using the same paper towels. The surveyor interviewed the FSD who stated his observation was that [NAME] #2 performed the hand-washing procedure correctly. On 4/14/26 at 9:30 AM, during a follow up tour in the main kitchen, near the 3-bay sink (three separate sinks designated and labeled for washing, rinsing, and sanitizing food service items that are hand washed), the surveyor observed that all three sinks were filled. The surveyor observed DA #2 walk to the faucet of the 3-bay sink and turn on the faucet. With the water running into the sink identified as rinse water, the surveyor observed DA #2 put his hands under the running water, rub them back and forth, turn off the faucet, shake his hands along his sides, and exit the kitchen. The surveyor made the FSD aware of this observation. On 4/13/26 at 12:08 PM, during an interview with the Infection Preventionist (IP), the IP acknowledged it was her responsibility to complete hand-washing competency tests for all kitchen / dietary staff. The IP stated she did the competency testing yearly and more often if needed. On 4/13/26 at 1:22 PM, the IP provided the surveyor with copies of forms titled Hand Hygiene Competency Checklist. Forms were not provided for [NAME] #1 or DA #1. The surveyor reviewed the undated facility policy Dietary/Food Handling which reflected the purpose was to provide guidelines for the safe preparation, handling and storage of perishable food and proper environmental cleaning. Item 15 reflected food handlers must wash their hands.whenever reentering the kitchen.before handling any food surfaces.after handling soiled equipment or utensils.during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.after engaging in other activities that contaminate the hands. 2.) On 4/13/26 between 11:24 AM and 11:42 AM, the surveyor observed tracheostomy (a surgical procedure that creates a direct opening in the neck into the windpipe [trachea] to facilitate breathing when the airway is blocked, damaged, or requires long-term mechanical ventilation) care performed on Resident #16 by two Registered Nurses (RNs). RN #1 stated they would be the lead and RN #2 would be their assistant to ensure they maintained aseptic (sterile) technique and to help secure the ties. After verifying the resident's identity, consent was obtained and both RNs donned (put on) clean, nonsterile exam gloves to reposition Resident #16 and monitor their oxygen level prior to the procedure; the reading was at 99% (normally 92-100%). RN #1 performed hand hygiene with soap and water, donned new nonsterile exam gloves and cleaned the overbed table to use for supplies. The RN #1 disposed of the gloves and donned another set of nonsterile exam gloves then removed the resident's soiled tracheostomy site gauze then disposed of it and the gloves into the garbage. RN #1 was then observed donning the sterile procedure gloves, no hand hygiene was performed prior to donning the sterile gloves. RN #1 removed the resident's disposable inner cannula (a removable liner that fits inside the main outer tracheostomy tube. It acts as a safety device, allowing for easy cleaning or replacement to prevent mucus blockage without removing the entire tracheostomy tube) using her left hand and disposed of it. RN #1 then cleansed the site as ordered, dried it, and placed a new split gauze at the tracheostomy site. RN #1 was unable to find the new sterile inner cannula with her supplies, and asked RN #2 to get one from the supply cart on the other side of the hallway door. When RN #2 reentered the room, she donned nonsterile exam gloves without performing hand hygiene and opened the inner cannula package for RN #1; RN #1 proceeded to insert the new inner cannula and stated they would also replace the tracheostomy ties (soft foam to hold the device in place around the resident's neck). RN #1 was on the resident's left and RN #2 was on the resident's right side to facilitate a safe tracheostomy tie exchange. At that time RN #1 looked up at RN #2, then down at her scrubs; RN #1 told the surveyor that both RNs were not wearing any PPE (Personal Protective Equipment such as gowns, gloves, and masks) besides gloves, and that they should have worn a mask and gown for the procedure as well. RN #1 stated that she always wore appropriate PPE with tracheostomy care and Enhanced Barrier Precaution (EBP - an infection control strategy for nursing homes, requiring gown and glove use during high-contact resident care [e.g., dressing, bathing, transfers] to prevent Multidrug-Resistant Organism transmission) residents and simply forgot due to being nervous. Both RNs then performed hand hygiene with soap and water, donned gowns, masks, and gloves to finish the procedure by changing Resident #16's tracheostomy ties.A review of the admission Record, an admission summary, reflected that Resident #16 had diagnoses which included but were not limited to; acute and chronic respiratory failure (the lungs cannot adequately oxygenate the blood or remove carbon dioxide), tracheostomy status, gastrostomy status (a surgical opening into the stomach for long-term nutrition, medication administration), pressure ulcer of sacral region stage 4 (a severe, full-thickness wound extending to exposed muscle, tendon, or bone, often with slough [dead cells, bacteria], eschar [dead skin], and deep tissue damage), and quadriplegia (the partial or total loss of function in all four limbs and torso).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/30/26, included a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and indicated the resident was rarely understood. A review of the resident's individual comprehensive care plan (ICCP) included a focus area revised on 1/28/26, for Enhanced Barrier Precautions related to an indwelling medical device with a goal of being free from infections. Interventions included, be sure it is noted near the resident that they need EBP, make sure PPE is available and all caregivers know what they should be wearing during care, use gown and gloves during close prolonged contact with the resident. Another focus area, dated 1/26/26, reflected; [Resident #16] has a tracheostomy r/t (related to) to maintain patent airway when obstruction/aspiration (accidental breathing of food, liquid, or saliva) is a risk, with a goal; [Resident #16] will maintain adequate oxygenation. Interventions included, Ensure that trach ties are secured at all times; trach[eostomy] care Q (every) shift and PRN (as needed); and capitalized in the care plan included; Use UNIVERSAL PRECAUTIONS (refers to the practice, in medicine, of avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles) as appropriate. A focus area, revised on 3/17/26 included that [Resident #16] has an indwelling suprapubic (a thin, flexible tube surgically inserted through the lower abdomen into the bladder to drain urine, used when natural urination is impossible). The goal for the focus was, [Resident #16] will show no s/sx (signs/symptoms) of Urinary infection through the review date of 5/18/26. Interventions for the focus included, monitor output for odor, color, consistency, and amount.Document and report any signs/symptoms of infection.A review of the Order Summary Report included the following physician orders (POs):A PO, dated 2/15/26, for enhanced barrier precaution, every shift for sacral Wound/trach/g-tube.A PO, dated 2/15/26, for Tracheostomy Suction every 2 hours and PRN for excessive secretions, every 2 hours for increased secretions AND as needed.A PO, dated 2/15/26, to Change Disposable Inner Cannula Every Day and PRN, every day shift AND as needed.A PO, dated 2/15/26, for Trach care every shift and PRN.On 4/14/26 at 10:58 AM, the surveyor interviewed the Director of Nursing (DON) regarding the use of PPE during tracheostomy care. She stated that residents with EBP status require gowns, gloves, and ideally a mask for high contact care. When asked if PPE should be worn during direct resident care such as tracheostomy care, the DON stated it was her expectation that a gown, gloves, and mask would be used during tracheostomy care for any resident to prevent contamination. The DON stated that she would expect hand hygiene to be performed between clean gloves, and before donning the sterile gloves.On 4/14/26 at 2:27 PM, in the presence of the survey team and the DON, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns regarding Resident #16's tracheostomy care related to infection control practices.A review of the facility's undated Tracheostomy Care policy included.Equipment and Supplies: 1. Gloves (clean and sterile); 2. Mask and eyewear (as indicated) .General Guidelines: 1. Aseptic technique must be used: During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures.Procedure Guidelines: 3. Wash Hands, 4. Put exam gloves on both hands.8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle, 9. Wash hands.Clean the removable Inner Cannula: 1. Open tracheostomy cleaning kit, 2. Set up supplies on sterile field, 3. Maintaining sterile field pour equal parts.8. Put on sterile gloves, 9. Secure the outer neck plate with non-dominate gloved hand, 10. Unlock the inner cannula with gloved dominate hand, 11. Gently remove the inner cannula.14. Remove and discard gloves into appropriate receptacle, 15. Wash hands and put on fresh gloves.A review of the facility's undated Personal Protective Equipment – Using Gowns policy included.Objectives: 1. To prevent the spread of infections, 2. To prevent soiling of clothing with infectious material.When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident.A review of the facility's undated Personal Protective Equipment – Using Face Masks policy included.Objectives: 1. To prevent transmission of infectious agents through the air, 2. To protect the wearer from inhaling droplets (Larger respiratory particles like Flu, RSV, or rhinovirus), 3. To prevent transmission of some infections that are spread by direct contact with mucous membranes.Miscellaneous: Follow established handwashing techniques. 3.On 4/13/26 from 12:50 PM through 12:58 PM, the surveyor observed the Certified Nurse Aide (CNA) delivering the lunch trays to residents in the Cedar Unit dining room. The surveyor observed after the CNA delivered the meal trays to other residents. When he was done passing the trays, he started to feed an Unsampled Resident (UR) #1 and then was observed touching an UR #2 on the shoulder while feeding UR #1. Hand hygiene (HH) or hand washing (HW) was not performed. While feeding UR #1, the CNA left the dining room and returned with a folding chair. The surveyor observed the CNA unfolded the chair and sat behind to the right side of UR #1 and resumed feeding them without performing HH. On 4/13/26 at 1:15 PM, during an interview with the surveyor, the CNA stated we should not touch other residents while feeding them due to contamination and spread of germs. The CNA confirmed that he should have performed HH after completing meal delivery and before he started to feed UR #1. On 4/13/26 at 1:41 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated the expectation from the staff was to perform HH during delivering meal trays, before and after the staff feeds the residents. The LPN/UM stated HH was important for infection control. On 4/14/26 at 11:39 AM, the surveyor met with the DON and made her aware of the above-mentioned concerns. The DON stated the CNA should have performed HH prior to start feeding the resident, should not have been touching other residents while feeding UR #1 and HH should have performed before after the CNA returned with a folding chair to resume feeding UR #1. On 4/14/26 at 2:25 PM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, Regional LNHA and the Chief Clinical of Operations (CCO). The surveyor made the facility administration aware of the above-mentioned concerns from dining observations. A review of the facility's Infection Control Program Overview policy dated 2/25/26 revealed Under Goals.Provide a safe, sanitary, and comfortable environment. Prevent the development and transmission of communicable diseases and infections .Ensure compliance with state and federal regulations relating to infection control. A review of the facility's undated Handwashing/Hand Hygiene policy revealed it is the policy of the facility that handwashing / hand hygiene will be regarded as the single most important means of preventing the spread of infections .Appropriate handwashing / hand hygiene must be performed at the follow times .Before and after eating .Before and after all resident care activities. NJAC 8:39-19.4 (a)(m)

Based on observation, interview, and review of facility documents it was determined that the facility failed to maintain the dignity of an unsampled resident who required assistance to eat during lunch. This deficient practice was identified on 1 of 4 units (Cedar Unit) observed during lunch. This deficient practice was evidenced by the following:On 4/13/26 at 12:58 PM, the surveyor observed Certified Nursing Aide (CNA) #1 feeding an unsampled resident while standing up. At 1:01 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) instructed CNA #1 to sit down. CNA #1 left the dining room and returned with a folding chair. CNA #1 sat behind to the right side of the resident and proceeded to feed them. On 4/13/26 at 1:15 PM, the surveyor interviewed CNA #1, who stated staff were supposed to be sitting on the side of the resident or next to the resident when assisting with feeding. CNA #1 further stated you should be facing the resident so you can control and see the resident chewing their food. He further stated, if you are standing while feeding them, you cannot see their face. CNA #1 further stated I made a mistake by sitting in the back. I was standing there first. I shouldn't be standing.On 4/13/26 at 1:41 PM, the surveyor interviewed the LPN/UM about the process for feeding residents. The LPN/UM stated the staff should always be sitting and not standing for resident dignity.On 4/14/26 at 11:39 AM, the surveyor met with the Director of Nursing (DON) and made her aware of the above-mentioned concerns. The DON stated they (staff) should sit while they were feeding the residents and they know they should be sitting. The DON further stated, you cannot feed a resident without having a direct eye contact and making sure the resident was swallowing food before giving them more food. The DON acknowledged that if you are sitting behind the resident, then you would not be able to see the resident.On 4/14/26 at 2:25 PM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, Regional LNHA and the Chief Clinical of Operations. The surveyor made the facility administration aware of the above-mentioned concerns.A review of the undated facility's Resident Rights policy revealed under section Quality of Life - The facility must care for you in a manner that enhances your quality of life. Under section Accommodation of Needs - You have the right as a resident to receive services with reasonable accommodations to individual needs and preferences.A review of the undated facility's Assisting the Impaired Resident with Meals policy revealed under section Steps in the Procedure: 3. If you are going to be seated during the feeding, position a chair where it will be convenient for you and the resident. NJAC 8:39-4.1(a) 12

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident's call bell (CB; a bell used to summon staff for assistance) was readily accessible and within reach of the resident. The deficient practice was identified for one (1) of one (1) resident, Resident #184, reviewed for accommodation of needs. This deficient practice was evidenced by the following:On 4/9/26 at 11:41 AM, the surveyor observed Resident #184 resting in their bed. The surveyor greeted the resident and the resident sat up to speak with the surveyor. The surveyor observed Resident #184's CB was out of reach on the floor, which was on the left side of the nightstand. The surveyor asked the resident how they would call the staff for help, the resident stated that they would call out (shout out) for help when needed. On 4/10/26 at 12:54 PM, the surveyor observed Resident #184 sitting in their wheelchair. The surveyor observed the CB on the floor, in the same position as it was observed on the previous day. The surveyor asked the resident if they knew where their CB was and the resident stated No. Resident #184 further stated if they needed any help, they would call out for help or come out of their room to ask for help. The surveyor reviewed the electric medical record for Resident #184. A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; essential (primary) hypertension (high blood pressure that is not due to another medical condition), cerebral infarction (a type of stroke where a blockage in an artery cuts off blood and oxygen to part of the brain, causing brain cells to die), Hemiplegia (a medical condition causing paralysis [unable to move certain parts of your body] or severe weakness on one side of the body, affecting the arm, leg, and face) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, and sometimes the face) following cerebral infarction affecting right dominant (side of the body that is stronger) side.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/16/26, revealed that the resident had a Brief Interview for Mental Status score of 9 out of 15, indicating that the resident had moderately impaired cognition. Further review of the MDS revealed that Resident #184 had impairment on one side in their upper and lower extremities (the outermost parts of the human body, primarily the hands, feet, fingers, and toes) and required maximal assistance with activities of daily living (ADLs). A review of the individual comprehensive care plan (ICCP) had a focus initiated on 11/1/22 that indicated the resident had altered communication due to being usually understood/understands related to (r/t) impaired cognition secondary to diagnosis (dx) of dementia with interventions that included but were not limited to; . Call light in reach. Another focus initiated on 10/18/24 indicated the resident presents need for grab bar while in bed for assistance toward turning, positioning and transferring and assist caregivers with interventions to keep CB within reach. Further review of the ICCP revealed a focus initiated on 8/18/22 that the resident had an ADL self-care performance deficit rt right sided hemiparesis/hemiplegia following cerebral infarction and the interventions included encourage the resident to use CB to call for assistance. On 4/10/26 at 1:14 PM, the surveyor interviewed the Certified Nursing Aide (CNA) assigned to Resident #184's care. The CNA stated that she would make sure the resident's CB was in reach before she would leave resident's room. The CNA further stated it was important to keep the CB within reach for safety even if the residents were able to walk because you never know what could happen. The CNA stated Resident #184 was able to use their CB and had their call bell in reach all the time. The surveyor informed the CNA about the above-mentioned observations, the CNA stated she had not gone to resident's room earlier that day because the resident did not want staff to go in their room early.On 4/10/26 at 1:34 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #184's care. The LPN stated before leaving the resident's room, she would make sure the resident's bed was not too high and the resident had their CB with them if they needed anything and would remind the resident to use CB. The LPN further stated when the CNA's made the resident's bed and/or assisted residents back to their bed, they should place the call bell within the resident's reach. On 4/13/26 at 10:41 AM, during an interview with the surveyor, the LPN/Unit Manager (LPN/UM) stated it was important to have the call bell within reach all the time and that was the only way they (the resident) could communicate with us (the staff). The LPN/UM further stated it was important to have the CB in reach because if the resident had an emergency that's how they would call for help. The surveyor made the LPN/UM aware of the above-mentioned concerns. The LPN/UM confirmed the resident should not have to shout for help and the CB should be always within reach. On 4/14/26 at 11:39 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the CB should be in reach at all the time because if a resident needed assistance that was what they would use to call for help. The surveyor made the DON aware of the above-mentioned CB concerns for Resident #184. On 4/14/26 at 2:25 PM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, Regional LNHA and the Chief Clinical of Operations (CCO). The surveyor made the facility administration aware of the above-mentioned concerns. A review of the facility's undated Call Bells Policy revealed Policy statement: It is the policy of [Name Redacted] that all residents are to have access to call bell. Staff is expected to be as vigilant as possible in keeping the call bell within reach of the resident. Under Guidelines: 2. Be sure the call lights are plugged in and within reach at all times. 5. Ensure all call bells are within the resident's reach before leaving the room. A review of the facility provided, CNA Job Description included but was not limited to; Under section Duties and Responsibilities included Personnel Functions - Perform all assigned tasks in accordance with our established policies and procedures.Section Safety and Sanitation: Keep the nurses' call system within easy reach of the resident. A review of the facility provided, Nurse Job Description included but was not limited to; Under section Duties and Responsibilities included Administration Functions- Ensure that all nursing personnel assigned to you comply with the written policies and procedures.Section Safety and Sanitation- Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies. NJAC 8:39-27.1(a)

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete timely background checks for 4 out of 155 employees (Employee #1, #4, #12, and #14) and b.) complete timely reference checks for 3 out of 155 employees (Employee #3, #7, and #8). This deficient practice was identified for newly hired, since last survey of 11/21/2024, employee files reviewed.This deficient practice was evidenced by the following:On 4/9/26 at approximately 10:22 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 11/21/24 to the current date.a. A review of the employee personnel files revealed the following:Employee #1, a Speech Therapist with a date of hire (DOH) 7/7/25, the background check was completed 6/5/24. Employee #4, a Registered Nurse (RN) with a DOH 7/18/25, the background check was completed 7/23/25. Employee #12, a RN with a DOH 3/27/26, the background check was completed 4/1/26. Employee #14, an Occupational Therapist with a DOH 6/23/25, the background check was completed 5/10/22. b. A review of the employee personnel files revealed the following:Employee #3, a Certified Nursing Assistant (CNA) with a DOH 8/20/25, there was no evidence of reference checks prior to the start of employment.Employee #7, a RN with a DOH 3/17/25, the reference checks were completed 7/3/24. Employee #8, a Houskeeper with a DOH 3/9/26, the 2 reference check forms were not signed or dated by the facility. On 4/14/26 at 2:25 PM, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were made aware of the above concerns regarding background checks and reference checks for newly hired employees. On 4/15/26 at 10:14 AM, the Director of Human Resources stated background checks were completed immediately upon accepting the position. She further stated that reference checks are completed prior to hiring. She stated they obtained two work references either over the phone or email. She then stated that background checks and reference checks had to be completed prior to hire, especially the background check. On 4/15/26 at 11:42 AM, the survey team met with the LNHA, DON, Assistant Director of Nursing, Chief Clinical of Operations, and the Regional Director. The facility could not provide any additional information for the above concerns.A review of the facility's Employee Health Records policy, revised 5/29/2020 revealed health records will be maintained for current employees.a criminal background check is required prior to hire or as permitted by regulation. Employment is contingent upon acceptable results. Professional references must be obtained and verified.all hiring practices will comply with applicable federal, state, and DOH regulations. A review of the facility's Abuse policy dated April 9, 2024, revealed .Screening Components: it is the policy of this facility to screen employees and volunteers (as applicable per volunteer policy) prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Procedure: Employee Screening and Training. Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background.a criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation including Peak law. NJAC 8:39-9.3(b)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to address the needs of a resident with Asthma (a condition that causes your airways to swell, narrow and fill with mucus), and nebulizer treatments (a way to deliver liquid medicine directly into the lungs by turning it into a fine breathable mist). This was identified for 1 of 3 residents (Resident #69) reviewed for Respiratory Care. This deficient practice was evidenced by the following:On 04/09/2026 at 10:21 AM, the surveyor observed Resident #69's nebulizer tubing and mouthpiece (a device used to deliver medication directly into the lungs) on the table in a clear plastic bag, dated 4/8/2026.The surveyor reviewed the electronic medical records for Resident #69 which revealed the following:The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility, with diagnoses that included but were not limited to; Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), Asthma, and Hypertension (high blood pressure).A review of the resident's most comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/20/2026, included a Brief Interview for Mental Status of 13 out of 15, which indicated the resident was cognitively intact.A review of the physician order summary report as of 4/10/2026 revealed a physician's order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML inhalation orally (via nebulizer three times a day for SOB (shortness of breath)/Wheezing (shrill whistle or coarse rattle sound heard when the airway is partially blocked) ., minimum TX (treatment) 15 minutes; and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 via inhalation orally via nebulizer every 6 hours as needed for wheezing.A review of the ICCP revealed a focus of Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Fatigue initiated on 12/8/2025. Further review of the ICCP did not reveal a Focus for Asthma or nebulizer treatment.On 04/10/2026 at 12:18 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated the purpose of the CP was to know what to do for the resident which included the resident's care, ADLs, feeding, code status, medical condition, skin condition, and smoking. The surveyor asked the LPN if she would expect to see a CP for a resident with diagnoses of Asthma and nebulizer treatment, she stated, yes, it should be included in the CP. The LPN confirmed that there was no record of the resident's Asthma diagnosis or nebulizer treatment in the CP. The LPN further stated it was important for the Asthma diagnosis and the nebulizer treatment to be on the CP because it was a breathing concern.On 04/10/2026 at 12:35 PM, during a meeting with the surveyor, the Unit Manager (UM) stated the CP was the story of the resident and tells how to cater to all the resident's needs based on diagnosis, mobility, transfers, and hygiene. It involves the ADLS of the resident. The surveyor asked the UM if she would expect to see a CP for a resident with diagnoses of Asthma and she stated, Definitely, a resident with asthma should be included on the care plan to continue to monitor. The UM confirmed that there was no respiratory care including Asthma diagnosis on this resident's CP, and that there should have been one because it was one of the resident's diagnoses.On 04/14/2026 at 1:32 PM, during an interview with the surveyor, the Director of Nursing (DON) stated, the care plan depicts the care and services that the resident receives. We put pretty much every thing that pertains to the resident care and services. The DON confirmed that the diagnosis and treatment should be on the resident's care plan to show the care and treatment the resident was receiving.On 4/14/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, Regional LNHA and the Chief Clinical of Operations (CCO). The surveyor made the facility administration aware of the above-mentioned CP concern for Resident #69.A review of the undated Floor Nurse Job Description, revealed:Care Plan and Assessment Functions:Review resident care plans for appropriate resident goals, problems approaches, and revisions . A review of the Unit Manager undated Job Description, revealed:Care Plan and Assessment Functions:Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care plan to be given, goals to be accomplished, which professional service Is responsible for each element of care. A review of the facility's policy Care Plans with a date of 2/25/26, revealed:Policy Statement:An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. Policy Interpretation and Implementation:2. Each resident's comprehensive care plan has been designed to:a. Incorporate identified problem areas.b. Incorporate risk factors associated with identified problems .4. Care plans are revised as changes in the resident's condition may dictate. Care plans are reviewed at least quarterly. A review of the facility's Administering Medications through a Small Volume (Handheld) Nebulizer with a date of 2/25/26, revealed:Purpose:The purpose of this procedure is to safely administer aerosolized particles of medication into the resident's airway.Preparation:2. Review the resident's care plan . N.J.A.C 8:39-11.2 (d) (e) (1) (2) (3)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss (pressure reducing) mattress was functioning properly and accurately setup according to resident weight for a resident who was previously identified to have had an alteration in skin integrity.This deficient practice was identified for 1 of 4 residents (Resident #16) reviewed for pressure ulcers and was evidenced by the following:On 4/10/26 at 10:06 AM, the surveyor observed Resident #16 lying in bed, awake, on an air mattress. The air mattress pump was observed to be set to a weight of 380 pounds. Resident #16 was wearing a hospital gown and noted to have a tracheostomy site (a surgical hole in the neck to assist breathing). The resident was able to communicate with the surveyor using short one- or two-word answers. Resident Representative #1 was at the bedside and able to provide resident history and information to the surveyor with the resident's consent and input. Resident Representative #1 stated that they came to the facility every day to spend time with and advocate for Resident #16.On 4/10/26 at 11:50 AM, the surveyor reviewed Resident #16's electronic medical record (EMR) which reflected a resident weight of 149 pounds on 4/7/26.On 4/13/26 at 9:57 AM, the surveyor observed Resident #16 in bed, the air mattress pump set to a weight of 380 pounds. The resident was in bed wearing a hospital gown with positioning wedges on their right side to offload their sacrum (the bone located at the top, back part of the pelvis, linking the spine to the pelvis, which includes the tail bone). A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to; acute and chronic respiratory failure (the lungs cannot adequately oxygenate the blood or remove carbon dioxide), tracheostomy status, gastrostomy status (a surgical opening into the stomach for long-term nutrition, medication administration), pressure ulcer of sacral region stage 4 (a severe, full-thickness wound extending to exposed muscle, tendon, or bone, often with slough [dead cells, bacteria], eschar [dead skin], and deep tissue damage), and quadriplegia (the partial or total loss of function in all four limbs and torso).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/30/26, included a Brief Interview for Mental Status score of 0 out of 15, and indicated the resident was rarely understood. Further review of the MDS reflected that the resident was admitted to the facility with an unhealed stage 4 pressure ulcer. Additional review of the MDS, in the section Skin and Ulcer/Injury Treatments included an intervention for a pressure reducing device for the bed and for pressure ulcer/injury care.A review of the resident's individual comprehensive care plan (ICCP) included a focus area revised 3/24/26, the resident had a wound to their sacrum. Interventions included: adding the resident to wound consults and follow orders accordingly and medicating the resident prior to wound care. Another focus area dated 1/23/26, reflected that the resident had an ADL self-care performance deficit related to limited mobility. Interventions included: having 2 staff members provide care and for safe repositioning as necessary, and to provide skin care to keep clean and prevent skin breakdown. A review of the Order Summary Report included the following physician orders (PO):A PO, dated 3/30/26, for repositioning every hour and as needed. A PO, dated 4/9/26, to use 2 wedges to offload the sacrum every 2 hours, including night shift, every day for stage IV sacrum ulcer.A PO, dated 3/10/26, for wound evaluation and treat with [Company] Wound Care.A review of the Wound Care Progress Notes (WCPN) revealed that the resident was assessed weekly by a wound care specialist. A review of a WCPN, dated 4/6/26, for a follow-up evaluation reflected that the wound remained stable/unchanged from the previous evaluation.On 4/14/26 at 10:58 AM, the surveyor interviewed the Director of Nursing (DON) regarding the use of support surfaces. The DON stated that the machines at the end of some of the beds were air pumps used with specialized mattresses designed to offload pressure. The DON stated that they were used mostly for residents with wounds, but also for residents at high risk for skin breakdown related to malnutrition or other factors that might cause it. She told the surveyor that Maintenance set the bed up and nursing staff would ensure it was providing adequate relief during rounds and while providing care. When asked what the numbers on the dial indicated on the air pump, the DON responded that it was different for different companies; some had weights on the dial to be set to a specific resident weight, while others were numbered (example 1-6 given), and that each number correlated to a weight range. She stated that if an air mattress pump had weight settings on the dial, that the mattress should be set to the resident's weight to ensure proper pressure distribution. On 4/14/26 at 11:35 AM, the surveyor observed Resident #16 in bed wearing a hospital gown with Resident Representative #1 at bedside. The surveyor noted the pump on the resident's air mattress was set to 380 pounds, the resident was sleeping at that time. On 4/14/26 at 12:31 PM, the surveyor asked the Licensed Practical Nurse (LPN) caring for Resident #16 about the pump located at the foot of the resident's bed. The LPN walked the surveyor into Resident #16's room, Resident Representative #1 was at the bedside. The LPN pointed to the pump and stated that the pump was used for the resident's air mattress; that the Wound Care team would usually order them for residents with wounds or at high risk of developing them. She told the surveyor that Maintenance set them up and took care of them if they malfunctioned. When asked who checked to make sure that the mattress was functioning properly and how often; the LPN responded that the mattresses were seen every shift by nursing staff and that she would observe to see if the resident looked okay in bed and use nursing judgement if something looked wrong. The surveyor asked the LPN what the different numbers on the dial meant. The LPN stated that the numbers mean hard or soft and stated that the middle number (280) was medium. When asked to read the text under the dial, the LPN responded, it says pounds. The surveyor then asked the LPN if the number on the dial should correlate to the resident's weight; the LPN responded I'm not really sure, I wasn't trained on it. It should probably be set to the resident's weight, but it's set to 400 pounds, the dial was between 360 pounds and 400 pounds (380 pounds). The LPN stated that she would check with her supervisors and that the resident was due for a weekly weight check to record an accurate number in the EMR.On 4/14/26 at 2:27 PM, in the presence of the survey team, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns regarding Resident #16's air mattress. On 4/15/26 at 12:14 PM, the LNHA and DON acknowledged that an air mattress should be set according to a resident's weight to prevent skin breakdown and promote healing.A review of the facility's undated Support Surface Guidelines, included.any individual at risk for developing pressure ulcers should be placed on a pressure reducing device, such as foam, static air, alternating air, gel, or water mattresses when lying in bed.for residents that recline and depend on staff for repositioning, change positions at least q (every) 2 hours. If a resident has a Stage 1 or above pressure ulcer, q 2 hour turning is inadequate.monitor for other pressure ulcer risk factors and provide interventions as indicated.the following information may be recorded in the resident's EHR (electronic health record): 1. The specialty bed settings are appropriate and correspond with physician's orders, 2. The date and time when the specialty bed settings were checked.NJAC 8:39-27.1

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for oxygen therapy. This deficient practice was identified for 1 of 3 residents (Resident #101) reviewed for respiratory care.This deficient practice was evidenced by the following: On 4/9/26 at 11:25 AM, during the initial tour of the facility, the surveyor observed Resident #101 lying in their bed watching television. The surveyor observed an oxygen concentrator (device that delivers oxygen) with a nasal cannula tubing (NC - device that delivers additional oxygen through the nose) administering oxygen at 3 liters per minute (lpm). The resident stated that they always wear the nasal cannula and receive oxygen continuously. On 4/10/26 at 9:49 AM, the surveyor observed the resident in their room lying in bed awake watching television. The surveyor observed the resident receiving oxygen via nasal cannula at 3 lpm. On 4/10/26 at 12:25 PM, the surveyor observed the resident in the dining room area in their wheelchair eating lunch. The surveyor observed the resident receiving oxygen via nasal cannula from the portable oxygen tank (small and quiet devices that allow you to receive supplemental oxygen). The oxygen concentrator was set at 3 lpm at this time. On 4/13/26 at 9:35 AM, the surveyor observed Resident #101 in their bed, seated upright, eating breakfast. The resident was receiving oxygen via nasal cannula at 3 lpm. The resident stated they were doing well, and breakfast was good. The surveyor reviewed the electronic medical record (EMR) for Resident #101. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; encephalopathy (syndrome of general brain dysfunction), other nontraumatic subarachnoid hemorrhage (bleeding events in the brain's subarachnoid space), and heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/27/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. A further review of section O special treatments, procedures and programs revealed that Resident #101 received oxygen therapy while a resident. A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 9/16/25, the resident has altered respiratory status/difficulty breathing related to hypoxic hypercapnic respiratory failure (oxygen failure, categorized by a low level of oxygen in the blood) and OSA (Obstructive Sleep Apnea - serious sleep disorder where breathing repeatedly stops and starts). The ICCP interventions included; monitor for signs and symptoms of respiratory distress and report to the MD PRN (as needed).Oxygen settings at 4 L (liters) via N/C (nasal cannula) continuous. A review of the Order Summary Report included the following physician orders (PO). A PO, dated 6/6/24, O2 (oxygen) continuous at 4L (liters) via NC every shift for O2. On 4/13/26 at 1:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated she tried to go around hourly to check the resident's oxygen settings to ensure it was on the correct lpm. She further stated that Resident #101 received oxygen at 3 lpm continuously. The surveyor and LPN confirmed that the oxygen concentrator in the resident's room was set for 3 lpm. The LPN in the presence of the surveyor reviewed the physician's orders in the EMR and she confirmed that the resident's orders were for oxygen at 4 lpm continuously. On 4/13/26 at 2:03 PM, the surveyor interviewed the Unit Manager, who acknowledged that the nurse should be checking the resident's oxygen concentrator settings each shift. She further verified that Resident #101's oxygen order was for 4 lpm. She then stated that we will change his oxygen settings from 3 lpm to 4 lpm and contact the physician for clarification. On 4/14/26 at 11:06 AM, the surveyor interviewed the Director of Nursing (DON), who stated the nurse should set the oxygen concentrator at the correct lpm according to the physician's order. She then stated that each nurse assigned to the resident was supposed to make sure the oxygen concentrator setting was correct each shift. The DON in the presence of the surveyor confirmed that Resident #101 had a physician order for 4 lpm. She then stated that the importance of following the physician orders for the oxygen concentrator settings was because it was a respiratory concern for the resident. On 4/15/26 at 11:44 AM, the DON, in the presence of the Licensed Nursing Home Administrator, Assistant Director of Nursing, Regional Director, and the Chief Clinical of Operations, and the survey team, acknowledged that the resident's physician order should have been followed as ordered. A review of the facility's Oxygen Administration: policy, undated, included the purpose of this procedure is to provide guidelines for oxygen administration. Preparation: Verify that there is a provider order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Review the resident's care plan to assess for any special needs of the resident. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by performing accurate verification of a resident's name on the label of a medication (Eliquis) (a medication used to thin the blood) prior to administration. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of five (5) residents, (Resident #3) observed during the medication administration observation. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and 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 prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced as follows: On 4/13/26 at 9:00 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) administer nine (9) medications which included one (1) tablet of Eliquis 5 milligrams (MG) to Resident #3 in their room. Upon returning to the medication cart, LPN #1 reviewed with the surveyor the prescription label on the package she removed the Eliquis from for administration to Resident #3. The surveyor with the LPN #1 observed the label for the Eliquis 5 MG tablets had the name of an unsampled resident. LPN #1 stated I did not realize the resident's name was wrong. LPN #1 added that according to the electronic medication administration record (EMAR), Eliquis 5 MG was the correct medication for Resident #3. The surveyor with LPN #1 reviewed the EMAR which revealed for an administration time of 8 AM there was a physician's order (PO) with a start date of 4/3/26 for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for A-fib. LPN #1 confirmed she had removed the Eliquis 5 MG tablet for Resident #3 from another resident's labelled medication. LPN #1 then showed the surveyor Resident #3 had their own labeled Eliquis 5 MG packaged by the provider with their name on the label. LPN #1 added she should not have removed the Eliquis 5 MG tablet from another resident's supply and should have read the name on the label. LPN #1 stated that she thought the unsampled resident was discharged and that was why the medication was in the cart. The surveyor reviewed the electronic medical record for Resident #3. A review of the admission Record revealed Resident #3 was admitted with diagnoses which included but not limited to; atrial fibrillation (A-fib) (an irregular heart rhythm). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/25/26 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated the resident had intact cognition. Further review of the MDS revealed the resident spoke another language and required an interpreter. A review of the Order Summary Report (OSR) for active orders dated 4/14/26 indicated a PO with a start date of 4/3/26 for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for A-fib. A review of the unsampled resident's medications on the OSR for active orders dated 4/14/26 indicated a PO with a start date of 4/11/26 for Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet via G-tube (a medical device inserted into the stomach) two times a day for Prevent blood clot Monitor for bleeding. On 4/13/26 at 1:10 PM, the surveyor interviewed the Unit Clerk (UC #1) who stated the unsampled resident was discharged to the hospital last week and had returned and was currently residing on the unit. UC #1 added if there was a question regarding the unsampled resident then the nurse on the low side medication cart would be able to answer it. UC #1 explained there were three (3) medication carts and one (1) nurse assigned to each cart based on the resident room numbers. UC #1 added the unsampled resident had remained in the same room. On 4/13/26 at 1:42 PM, the surveyor interviewed LPN #1who stated she was assigned to the 'high side' medication cart and had been off for three (3) days and was unsure why the unsampled resident's Eliquis was in her medication cart because the unsampled resident was in a room assigned to the low side. LPN #1 added there was a previous time the unsampled resident was assigned to the high side medication cart even thought they were in a room that would have been in the low side cart, and their medications were stored in the high side cart. LPN #1 confirmed the unsampled resident was not assigned to her and the medications should not have been in her cart. LPN #1 also stated when she was assigned to the unsampled resident, their medications were removed from the low side cart and put into her high side cart. LPN #1 added moving the medications could have led to the confusion. On 4/14/2026 at 9:32 AM, the surveyor interviewed the Director of Nursing (DON) who stated there was a unit that had three (3) medication carts referred to as low, middle, and high. The DON added depending on the census of the unit the assignment of residents was divided among the three (3) nurses and consideration given to the level of care each resident needed to try to accommodate a fair division. The DON explained the nurses would switch residents or take residents from another nurses' assignment to accommodate. The DON further explained the nurses would also remove resident's medications and put them in the medication cart of the nurse who was then assigned to them as a convenience, so the nurse did not have to go between different medication carts. On 4/15/26 at 11:42 AM, the survey team met with the facility administrative team. The DON stated LPN #1 was inserviced on following the five (5) rights during a medication pass which included ensuring the medication was labelled for the right resident. The DON further stated the nurses were not to be switching medications for the residents between carts. The Licensed Nursing Home Administrator (LNHA) verified the facility policy for Administering Medications provided to the surveyor was the current policy. The surveyor reviewed the facility undated policy for Administering Medications provided by the Regional Director of Clinical Operations revealed Medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy revealed The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method of administration before giving the medication. NJAC 8:39-11.2(b), 29.2(d)

Based on observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond timely to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications (Resident #46 and #194). The deficient practice was evidenced by the following:1.On 4/9/2026 at 11:45 AM, during initial tour, the surveyor observed Resident #194 sitting in a wheelchair, in their room. The surveyor reviewed the electronic medical record (EMR) for Resident #194 A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions and could cause excessive worry), end stage renal disease (kidneys no longer function well enough to meet a body's needs) and dependence on renal dialysis (a life-sustaining treatment for kidney failure that filters waste, salt, and excess water from the blood, acting as an artificial kidney). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 3/24/26, revealed the resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15, indicating the resident was moderately cognitively impaired. Further review of the MDS revealed the resident was receiving dialysis. A review of the individual comprehensive care plan (ICCP) revealed a focus of potential for complications due to hemodialysis, revision date of 10/6/2025. A review of the pharmacy consultant recommendations (PCR) for 2/6/26 revealed the following: -Please clarify the order for bisacodyl. The order says to administer if MOM (Milk of Magnesia) is ineffective however, there is no order for MOM noted on the MAR (Medication Administration Record). Signed as completed on 4/12/26; initialed by Licensed Practical Nurse/Unit manager (LPN/UM) #1. -Please clarify lisinopril MWF (Monday, Wednesday, Friday) order. The supplementary documentation needs to be updated so that the blood pressure can be documented with each dose. Signed as completed on 4/12/26; initialed by LPN/UM #1. A review of the PCR for 3/5/26 revealed the following: -Please clarify the order for bisacodyl. The order says to administer if MOM is ineffective however, there is no order for MOM noted on the MAR. Milk of Magnesia should be avoided in residents on dialysis. Contact the physician to discontinue MOM and obtain orders for alternate therapy. Signed as completed on 4/12/26; initialed by LPN/UM #1. -Please clarify lisinopril MWF order. The supplementary documentation needs to be updated so that the blood pressure can be documented with each dose. Signed as completed on 4/12/26; initialed by LPN/UM #. A review of the February and March 2026 MARS revealed the following: -An active physician order for Lisinopril Oral tablet 20 MG (milligram) Give 1 tabled by mouth one time a day every Mon, Wed, Fri for HTN (hypertension) was signed as administered from 2/6/2026 every M, W, F at 11 am until 3/27/2026 without the supplementary documentation of the blood pressure being added to the MAR. -An active order Dulcolax Suppository 10 MG (Bisacodyl) insert 1 suppository rectally every 24 hours as needed for constipation/MOM ineffective, PRN (as needed). Further review did not reveal an order for MOM. On 4/14/2026 at 9:52 AM, the surveyor interviewed LPN/UM #1, who stated the PCR were printed by the Director of Nursing (DON) and then given to the unit managers. He said the PCRs were usually addressed within 3 to 7 days. LPN/UM #1 reviewed the PCR for Resident #194 for February and March 2026 in the presence of the surveyor. He acknowledged his signature on both forms dated 4/12/2026. He also acknowledged the same recommendations were made for both months. LPN/UM #1 reviewed the EMR, in the presence of the surveyor. He reviewed the progress notes and acknowledged the PCR were not addressed. He stated, I should have put a note in to clarify it was done. LPN/UM #1 stated the PCR were important because it is for the safety of the patients. On 4/14/2026 at 10:37 AM, the surveyor interviewed the Director of Nursing (DON) who stated the PCR reports were printed and then given to the unit managers to follow up on the recommendations. She stated every recommendation should be addressed and documentation should be done even if the physician refused or did not want to follow the PCR. The surveyor showed the DON the PCR reports for February and March for Resident # 194, she acknowledged it was late and stated that the PCR should be addressed within a week. 04/14/2026 2:25 PM, in the presence of the survey team, the surveyor made the Licensed Nursing Home Administrator, the DON, the Assistant DON, the Chief Clinical of Operations and the Regional Administrator aware of the above concerns. 2.On 4/10/2026 at 10:17 AM, Resident #46 was observed sitting in wheelchair in prayer in the Day Room. The resident was quiet, calm, and not interactive. On 4/13/2026 at 10:40 AM, the resident was observed in the Day Room during activities, the resident was sitting in wheelchair, not engaging in activities and was non-interviewable. The surveyor reviewed the EMR for Resident #46. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; acute on Chronic diastolic (Congestive) Heart Failure, Type 2 Diabetes, other specified mental disorders due to known physiological condition, and other specified depressive episodes (mood disorders characterized by significant depressive symptoms that do not fulfill the complete diagnostic criteria for any specific depressive disorder), and Hypertension (high blood pressure). A review of the admission Minimum Data Set, dated [DATE], revealed the resident had a Brief Interview for Mental Status of 13 out of 15, indicating the resident was cognitively intact. Further review revealed the resident was receiving antidepressant, anticoagulant, antibiotic, hypoglycemic, antiplatelet, and antipsychotic medications. A review of the individual comprehensive care plan revealed the focus of client was a new admission and adjusting to current placement, date initiated 3/18/2026. On 4/14/2026 at 9:00 AM, the surveyor reviewed the IMRR (Interim Medication Review) Nursing Report, an observation made by the consulting pharmacist on 3/18/2026 as high priority, revealed: Please clarify the order for diltiazem. The supplementary documentation needs to be updated so that the hold parameters (Blood Pressure) can be documented with each dose. A review of the March 2026 Medication Administration Record (MAR) revealed the following: -An active physician order for Diltiazem HCI Oral Tablet 90 MG, give 1 tablet by mouth three times a day for HTN, hold for SBP (Systolic Blood Pressure) less than 110 was signed as administered from 3/18/2026 to 3/29/26 every shift at 9:00 AM, 1:00 PM, and 5:00 PM without the supplementary documentation of the blood pressure being added to the MAR. A review of the March 2026 Medication Administration Record (MAR) revealed the above-mentioned PO had been documented as completed as of 3/18/2026 without the parameter as requested by the pharmacy consultant. On 4/15/2026 at 11:15 AM, during an interview with the surveyor, the Unit Manager (UM) stated the purpose of the pharmacy consultant was to review the purpose of the medications with regards to timing, food administration, drug interaction, if the medications are spaced out well enough, timing wise, and if they are contraindicated with other medications, and also poly pharmacy. The UM confirmed there was no supplemental documentation of the resident's BP on the MAR from 3/18/26 through 3/29/26 as the pharmacist had recommended. The UM stated there should have been a supplemental documentation with the order as soon as it was recommended, the Doctor/Nurse Practitioner should have been made aware that the medication was administered without the parameter as recommended by the pharmacist on 3/18/26. On 04/14/2026 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON), who stated the pharmacy consultant recommendations were received electronically via email, then printed and given to the managers, and they have 7 days to complete the recommendations. The DON stated the managers would speak to the Medical Doctor (MD) or Nurse Practitioner (NP) for clarification and the order would be created. The DON confirmed that the recommendation was given on 3/18/26 and it was for the resident's BP medication diltiazem, needed supplementary documentation to be done for each time it was given. The DON confirmed that on 3/18/26, the BP was not reflected on the MAR until 3/30/26 and the supplementary documentation was not added until 3/30/26, 12 days after pharmacy consultant recommendation. The DON further confirmed that the pharmacy consultant recommendation was not addressed within the required timeframe. The DON stated that the manager should have spoken to the MD/NP regarding the pharmacy consultant recommendation to ensure the recommended guidelines were followed. On 4/14/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Regional LNHA and the Chief Clinical of Operations. The surveyor made the facility administration aware of the above-mentioned concerns regarding the pharmacy consultant recommendations for Resident #46. A review of the facility's policy Pharmacy Consultant Policy and Procedure dated 2/25/2026, revealed Purpose: The purpose of this policy is to delineate the responsibilities and relationships of the consultant Pharmacist to the residents and facility staff. Policy.6. The Nurse Managers are responsible to implement the therapeutic interventions indicated in the Consultant Pharmacist report and submit the completed report to the DON within seven days of receiving them. NJAC 8:39-29.3 (1)

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to obtain consent to ensure that the residents did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #46). This deficient practice was evidenced by the following:On 04/10/2026 at 10:17 AM, Resident # 46 was observed sitting in a wheelchair in the activities, in the Day Room. The resident was quiet, calm, and not interactive.On 04/13/2026 10:40 AM, the resident was observed in the Day Room during religious activities, the resident was sitting in a wheelchair, not engaging in activities.The surveyor reviewed the electronic medical record (EMR) for Resident #46:A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; other specified mental disorders due to known physiological condition, and other specified depressive episodes (mood disorders characterized by significant depressive symptoms that do not fulfill the complete diagnostic criteria for any specific depressive disorder). A review of the admission Minimum Data Set, an assessment tool dated 3/20/26, revealed the resident had a Brief Interview for Mental Status of 13 out of 15, indicating the resident was cognitively intact. Further review revealed the resident was receiving antidepressant, anticoagulant, antibiotic, hypoglycemic, antiplatelet, and antipsychotic medications.A review of the individual comprehensive care plan revealed the focus of client was a new admission and adjusting to current placement, date initiated 3/18/2026. A review of the Order Summary Report revealed the following POs:- Aripiprazole Oral Tablet 5 MG (Abilify) Give 1 tablet by mouth in the morning for Major Depressive disorder, one time a day for depression, start 3/17/2026.-Escitalopram Oxalate Oral Tablet 10 MG (Lexapro), Give 1 tablet by mouth in the morning for Depression, start 3/17/26.A review of the March 2026 Medication Administration Record (MAR) revealed the above-mentioned POs had been documented as completed as ordered from the date of orders. A review of the progress notes for March 2026 showed no documentation that the resident or RR consented to the administration of the Psychotropic medications.On 04/13/2026 at 10:59 AM, during an interview with the surveyor, the Unit Manager (UM) stated the standard practice was when a resident came to the facility on psychiatric medications, the psychiatric Nurse Practitioner followed the resident, but before any changes were made, the Nurse Practitioner (NP) would talk to the family to get the history (Hx) as to why the resident was on the medication, and what behaviors were exhibited. On 04/14/2026 at 12:10 PM, during interview with the surveyor, the Psychiatric Advance Nurse Practitioner (APN) stated the process was when a resident was admitted she reviewed the chart and hospital records. The APN stated she saw Resident #46 once but was unable to reach the resident's representative to discuss the risk versus benefits of the medications, and the common and adverse side effects of the medications. The APN stated her colleague followed up with the resident while she was on vacation, however, she later reviewed the colleague's note and saw that the resident's representative (RR) was present during the follow up review, but there was no documentation on any additional information regarding risk versus benefits and the common and adverse side effects regarding the Lexapro 10 mg and the Abilify 5 mg. The APN stated that the colleague should have called the family or discussed with the family who was present during the visit to get the indication for the medications. The APN further stated there should have been the justification and diagnosis, and target symptoms for the medications.On 04/14/2026 at 1:49 PM, during an interview with the surveyor, the Director of Nursing (DON) stated, we do not use signed consent. The Assistant Director of Nursing who was also present, stated the process was to speak to the resident or responsible party and then document that they obtained consent and that the psych provider gets the consent. The DON stated, if it was not documented, it was not done. The DON was unable to provide a consent from the admission on the administration of Psychotropic medication.On 4/14/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administration (LNHA), DON, Regional LNHA and the Chief Clinical of Operations (CCO). The surveyor made the facility administration aware of the above-mentioned concerns for Resident #46.No additional information was provided.The surveyor reviewed the facility policy dated 2/25/26 for Psychotropic Medications provided by the Licensed Nursing Home Administrator (LNHA) revealed:PolicyTo ensure proper use, and monitoring of psychotropic medication. Procedure:3. Residents have the right to be informed of and participate in their treatment.a. Prior to initiating or increasing a psychotropic medication, the resident/RP may be informed of the benefits, risks, and alternatives for the medication.b. The resident/RP has the right to accept or decline the initiation or increase of a psychotropic medication. N.J.A.C. 8:39-27.1(a)

COMPLAINT #: NJ00183422, NJ00186468 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 08/22/25, it was determined that the facility failed to immediately implement their abuse policy to ensure residents were protected from abuse by not removing the accused staff from resident care pending full investigation of an abuse allegation. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1) and had the potential to affect all residents. According to Facility Reportable Event (FRE), at approximately 6:00 AM on 05/03/2025 Resident #6 (the roommate of Resident #1) reported to Registered Nurse #1 (RN #1) that Resident #1 moaned in pain while a Certified Nursing Assistant (CNA) was providing morning care (turning and repositioning) for the resident. The FRE included that RN #1 assessed the resident and reported the incident to the Nursing Supervisor. No further action was taken to investigate Resident #6's report as an abuse allegation. On 05/05/2025, the Unit Manager (UM) #1 and the Director of Nursing (DON) interviewed Resident #1 about a CNA being rough during care and performed a skin assessment. The resident denied being hurt at that time. No further action was taken to investigate the concern as possible abuse. On 05/13/2025, Resident #6 again reported to facility staff that on 05/02/2025 or 05/03/2025 a CNA caused Resident #1 pain while turning and positioning the resident. On 05/13/2025, an investigation which included conducting staff and resident interviews, obtaining staff statements, and suspension of the accused CNA was conducted. The facility's failure to implement their abuse policy by initiating an investigation and removing the accused CNA from resident care when staff were first alerted to the concern on 05/03/2025 allowed the alleged abuser to continue to have access to residents on 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, and 05/10/2025. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/03/2025 after Resident #6 alerted RN #1 of their concern that Resident #1 was mishandled by a CNA. The facility Administration was notified of the IJ on 08/22/2025 at 6:05 PM. The facility submitted an acceptable Removal Plan (RP) on 08/25/2025 at 4:07 P.M., indicating the actions the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: the 11-7 nursing supervisor's employment was terminated, all staff were immediately in-serviced on the facility abuse policy with a focus on implementation procedures and resident safety, the administrative team which consisted the DON, Administrator and Medical Director reviewed the facility abuse prevention policy and no change to policy required. All current residents or their designee were interviewed to ensure that they felt safe, and assessments were done on all non-verbal residents. Started 10 weekly staff interviews on the facility abuse policy and 10 weekly resident interviews about resident safety. Resident and staff interviews will be reviewed weekly with the Administrator for 3 months and will be reported monthly to the Quality Assurance Performance Committee. Implementation of the RP was verified during the continuation of the on-site survey on 08/25/2025 and determined that IJ was removed as of 08/23/2025. The evidence was as follows: This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse and was evidenced by the following:The facility policy document titled Abuse dated April 9, 2024, was reviewed. Under POLICY, page 2 of the policy revealed, It is the policy that each resident will be free from Abuse. [.] Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. [.] The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.Under C. PREVENTION page 5 of the facility policy revealed, It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without fear of reprisal or retribution. This section of the facility policy further revealed, The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. Under E. INVESTIGATION, page 7 of the facility policy revealed, It is the policy of this facility that reports of abuse' (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. This section of the policy further revealed under PROCEDURE: a. Investigation of abuse: When an incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation may include: [.] iv. Involved staff and witness statements of events [.] ix. Interview of other residents who were cared for by the accused (if applicable). Under F. PROTECTION, page 9 of the facility policy revealed, It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). This section of the facility document revealed under, PROCEDURE, Immediately upon receiving a report of alleged abuse, the Administrator and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. [.] a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected. Employees or visitor accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.Under G. REPORTING AND RESPONSE page 11 of the facility policy revealed under, PROCEDURE: INTERNAL REPORTING: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing, or designee. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to unspecified nondisplaced fracture of fifth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; unspecified nondisplaced fracture of fourth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; cognitive communication deficit (breakdown in the cognitive processes that affects how individuals think and communicate); need for assistance with personal care; abdominal aortic aneurism (enlarged area in the lower part of the body's main artery, which can be fatal if ruptured), without rupture, unspecified; and nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain). According to the Minimum Data Set (MDS), an assessment tool dated 03/27/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired. The MDS revealed that Resident #1 required assistance to roll left and right, move from sitting to laying, to move from laying to sitting, and to move from sitting to standing. The MDS also revealed that Resident #1 was occasionally incontinent of urine and was always incontinent of stool. An undated facility document, titled: Investigation Summary, regarding Resident #1 was reviewed. Under Narrative Description of Event: page 1 of the document, on 05/13/2025, Resident #6 reported that staff did not know how to care for Resident #1 and that Resident #1 was in pain. Resident #6 heard the concern but did not witness it. This section of the document further revealed that an immediate investigation was initiated, the physician was notified, the resident's sponsor and facility administration were notified. Under, Interview statements from staff who worked with the resident on 05-03-25 11pm - 7am, page 1 of the document, at approximately 6:00 A.M., RN #1 became aware that Resident #6 heard Resident #1 scream in pain during care. RN #1 assessed Resident #1 and immediately reported the concern to the Supervisor. The Supervisor then assessed Resident #1. The document revealed no further action taken by the Supervisor or other facility staff on the day that Resident #6 expressed concerns that Resident #1 was hurt by a CNA #1 that morning. According to the Investigative Summary/Conclusion: page 2 of the document, CNA #1 was suspended due to the facility's protocol pending the results of the investigation. The same section of the document on page 3 revealed that the allegations made by Resident #6 were unsubstantiated. Page 3 of the document further revealed, Due to the nature and potential risk to all resident facility staff were re-educated on abuse prevention. A facility document titled: Statement form, hand-written by CNA #1, dated 05/02/2025 was reviewed. The statement revealed that Resident #1 did not complain of pain while CNA #1 was providing care, and that the resident was left comfortably in bed. The statement revealed that as CNA #1 was leaving the resident's room, she dropped garbage on the floor which disturbed Resident #6, who then complained to CNA #1 about the noise. A telephone interview was conducted with CNA #1 on 08/22/2025 at 12:05 P.M. CNA #1 stated that she provided a written statement at the request of a Nursing Supervisor and was unsure of when she provided the statement but thought it could have been 05/02/2025. CNA #1 stated that she worked until 7:00 A.M. on the morning that Resident #6 got upset with her for making noise in their room. CNA #1 stated that she was not suspended or sent home on that day. A facility document, titled: statement form, handwritten by RN #1, dated 05/16/2025 and timed 7:00AM, was reviewed. The statement revealed that at approximately 6:00 A.M., Resident #6 reported that they heard their roommate (Resident #1) scream while a CNA was providing care. The statement further revealed that Resident #1 was assessed immediately by RN #1 and the facility Supervisor was immediately notified of the concern.The surveyor attempted to reach RN #1 for an interview without success. Review of the Progress Notes (PN) for Resident #1 revealed that on 05/05/2025 at 2:44 P.M., UM #1 interviewed Resident #1 about a recent complaint of a CNA being rough with them. The PN further revealed that Resident #1 did not recall being treated roughly and denied being hurt by anyone. An interview was conducted with UM #1 on 08/22/2025 at 1:15 P.M. UM #1 stated that the process after an allegation of rough treatment was to immediately interview the resident and their roommate, if possible; assess the resident's skin; and notify the Director of Nursing (DON) or Licensed Nursing Home Administrator (LNHA). UM #1 stated that the process included obtaining statements from staff members who cared for the affected resident. UM #1 stated that nurses, UMs, and Supervisors were responsible for obtaining statements. UM#1 stated that the process included assembling statements and skin assessments in a folder and giving it to the DON. UM #1's statement to the surveyor regarding the accused staff did not follow the facility policy reviewed under F. Protection, which stated that employees or a visitor accused of abuse will be immediately removed and will remain removed pending the results of a thorough investigation. UM #1 stated that the process included changing the assignment of the accused staff member when an accusation was made and sending the staff member home if it was determined that, something really happened. UM #1 further stated that the DON or LNHA made the decision about whether an employee should have been sent home, which is not in accordance with facility policy. During the same interview, UM #1 stated that she recalled that in May 2025, Resident #6 complained that Resident #1 was in pain during care. UM #1 stated that she was made aware of the allegation when she arrived at work at on 05/05/2025 around 7:00 A.M., and that was when she completed a skin assessment of Resident #1. UM #1 stated that she interviewed Resident #1 who denied being hurt by facility staff. UM #1 stated that she believed that the facility's DON or Assistant Director of Nursing (ADON) obtained statements about this allegation. UM #1 further stated that she was familiar with the facility's abuse policy but was not sure if the policy was followed on 05/05/2025. An interview was conducted with the DON on 08/22/2025 at 2:08 P.M. The DON stated that an allegation of rough treatment during care would have been considered an abuse allegation. The DON stated that the expectation was for staff to notify a Nurse or Supervisor immediately when there was an abuse allegation and for the DON or LNHA to be notified immediately. The expectation was for the nurse or Supervisor to assess the resident involved, and for the Supervisor to collect statements as soon as they were made aware of an accusation. The DON stated that the process when an abuse allegation was made included sending the accused staff member home pending the results of the investigation. The DON further stated that this process was important to ensure that residents were not left in the care of someone who was hurting them. During the same interview, the DON stated that she and the LNHA did the investigation of Resident #6's allegation that Resident #1 received rough treatment by a CNA. The DON stated that she was made aware of the accusation on 05/13/2025 and that is when the investigation was started. The DON stated that CNA #1's statement was obtained on 05/13/2025 and the date written on the statement (05/02/2025) refers to the date that CNA #1 started the 11:00 P.M. to 7:00 A.M. shift which was when the 05/03/2025 allegation was made. The DON stated that the statement obtained from RN #1 was dated 05/16/2025 but the statement was about the allegation made on 05/03/2025. The DON stated that it was concluded that the alleged event occurred on 05/03/2025 at approximately 5:30 A.M., RN #1 reported the allegation to the Supervisor right away. The DON further stated that the Supervisor did not report the allegation to the DON, obtain statements, or send the accused CNA home according to facility policy. A 05/05/2025 at 2:44 P.M., Progress Note by UM #1 was reviewed with the DON. The DON stated that her expectation was that she should have been notified right away of the allegation of rough treatment. A follow up interview was conducted with the DON on 08/22/2025 at 4:11 P.M. The DON stated that on 05/03/2025 the Supervisor should have notified her of the accusation made by Resident #6 and the CNA would have been suspended. The DON stated that on 05/05/2025, she (the DON) and UM #1 assessed and spoke with Resident #1 about the allegation that they were hurt by a CNA. The DON stated that no further investigation was done on 05/05/2025. The DON stated that on 05/13/2025 Resident #6 informed the facility's Assistant Administrator of the allegation of rough treatment of Resident #1, and it was on 05/13/2025 that the facility's abuse policy was fully implemented. During the same interview the DON stated that the purpose of the facility's abuse policy was to inform staff of what to do when an abuse accusation was made. The DON further stated that if the abuse policy was not followed, we put the resident in potential danger. During an interview with the LNHA on 08/22/2025 at 5:39 P.M., the LNHA stated that the expectation was that if there was an allegation of abuse the facility's abuse policy, which included starting an immediate investigation, should be implemented quickly. The LNHA stated that there was no need to follow the facility's abuse policy on 05/03/2025 and there was no need to implement the policy related to resident #6's accusation until 05/13/2025 because there were no suspicions or complaints of abuse until that date. The LNHA further stated that that facility's abuse policy is in place to safeguard the residents and because it is a regulation. NJAC 8:39-4.1(a)5

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 11/07/24 at 9:39 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and a second surveyor. The following was observed: 1. Two top reach in refrigerators that held milk. The refrigerator on the right stored four- and eight-ounce milks and the refrigerator on the left stored gallon milk. Both had gray gaskets on the doors which had a heavy buildup of a black substance on the underside of the top gaskets. The FSD stated it was mold and needed to be cleaned. 2. In the room outside the main kitchen, the surveyor observed a windowsill next to a metal rack which stored boxes of salt and pepper packets. The sill had large amount of debris, leaves and twigs. The FSD stated that when the staff opened the window debris gets in. 3. The bread rack had multiple opened bags of bagels which had a heavy build up of a green fuzzy substance. Three bags were dated 10/25/24. One bag had six bagels and the two other bags had two bagels. A fourth bag dated 10/29/24 had four bagels. The FSD stated the Assistant FSD was responsible for rotating the bread but was not working today. The surveyor observed the designated dented can area next to the bread rack. 4. In the dry storage area, there were dented cans which were in rotation for use. The surveyor observed the following dented cans: - One #10 sized cans of stewed tomatoes - One #10 sized can of sliced potatoes The FSD acknowledged that the cans were dented and should not have been in the dry storage area. 5. The double stack convection ovens had a large build up of black debris which the FSD acknowledged and stated they needed to be cleaned. 6. The two metal shelves over the range had a heavy build up of black debris on the underside of the shelves above the cooking area. The FSD acknowledged this and stated there could be cross contamination. 7. There was a slicer (not in use) which had a soiled oven mitt stored directly on the area where sliced food would be. In addition, there was a light brown debris on the blade and base. At that time, the cook stated she had not used the slicer today. A review of an undated facility policy Sanitation, included that the food service area should be maintained in a clean and sanitary manner. It also included that all kitchen areas should be kept clean and free from litter and rubbish. It further included that shelves and equipment should be kept clean and the Food Service Manager was responsible for scheduling staff for regular cleaning. A review of an undated facility policy Food Storage, included food storage areas should be maintained in a clean, safe and sanitary manner. It also included that food should be rotated as delivered and a first-in, First-out method should be used. NJAC 8:39-17.2(g)

Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 37 residents reviewed (Resident #16, Resident #34, and Resident #429). This deficient practice was evidenced by the following: 1. On 11/7/24 at 11:08 AM, the surveyor observed Resident #16 to be out of bed, in a wheelchair, and in the dayroom participating in activities. On 11/8/24 at 1:10 PM, the surveyor observed Resident #16 in a wheelchair, outside smoking with staff supervision. A smoking apron was visible on Resident #16's lap. A review of the Admission Record face sheet (an admission summary) reflected Resident #16 had diagnoses which included but not limited to: Alzheimer's disease. A review of the Admission MDS, an assessment tool dated 4/23/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition and Section J1300 was coded no for current tobacco use. On 11/13/24 at 11:00 AM, the surveyor interviewed the MDS Coordinator and asked about the current tobacco use coding, she stated oh gosh, I see it, it was not coded. It was missed. 2. On 11/7/24 at 10:40 AM, the surveyor observed Resident #34 to be out of bed, sitting in a wheelchair in the room. On 11/8/24 at 12:38 PM, the surveyor was informed by staff that Resident #34 was out to dialysis. A review of the Admission Record face sheet reflected that Resident #34 had diagnoses which included but not limited to; end stage renal disease (kidney disease), diabetes, and dependence on renal dialysis (a machine that removes waste products and excess fluid from the blood). A review of the annual MDS, dated [DATE], revealed a BIMS score of 14 out of 15, which indicated intact cognition, and Section O0110 question J1 was not coded for dialysis while a resident. A review of the individual comprehensive care plan (ICCP) included a focus area dated 3/22/18 and revised 9/11/23, that the resident had a potential for complications due to hemodialysis; a focus area dated 7/18/18 and revised on 9/11/23 regarding the resident's dialysis schedule; and a focus area dated 3/23/18 and revised 7/18/24 that the resident has end stage renal disease on hemodialysis with an increased protein need. On 11/13/24 at 11:03 AM, the surveyor interviewed the MDS Coordinator and asked about the dialysis coding, she stated, I didn't see a note at that time. 3. On 11/07/24 at 11:34 AM, the surveyor observed Resident #429 in the dayroom. A review of the Admission Record face sheet reflected that Resident #429 had diagnoses which included but not limited to; moderate dementia with behavioral disturbance. A review of the electronic medical record indicated that on 10/30/24 at 6:38 PM Resident #429 was noted cursing on and off, kicking and throwing objects. On 10/31/24 at 10:54 PM, the Resident #429 was noted to be kicking, pushing, throwing objects, and cursing on and off. A review of the Admission MDS, dated [DATE], revealed a BIMS of 0, indicating severe cognitive impairment and section E200 and E300 were coded to reflect no behavior symptoms. On 11/14/24 at 12:28 PM, the surveyor interviewed the MDS Coordinator, who indicated that the MDS assessments should be accurate. When asked about the above mentioned MDS and the coding of behaviors, she stated that she would check and get back to the surveyor. On 11/14/24 at 1:21 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team. She stated she did not code the resident's behaviors and it should have been done. A review of an undated facility policy Resident Assessment Instrument MDS included: 2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. Other assessment forms may be used in addition to gather other pertinent data. 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 8. If an error is made when completing the MDS, the error will be corrected when discovered. N.J.A.C 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure the necessary respiratory care and services were provided in a manner to prevent the spread of infection for 1 of 4 residents (Resident #4) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/7/24 at 10:57 AM, the surveyor observed Resident #4's nebulizer machine (an electric machine that converts liquid medication to a fine mist) on the dresser in their room, surrounded by personal items. The tubing attached to the nebulizer was not labeled or dated. Additionally, the nebulizer mask was not covered and was left exposed to the air. The exterior of the nebulizer machine showed yellowish stains and a brown fuzzy debris accumulation on the surface. On 11/12/24 at 12:09 PM, the surveyor observed the same nebulizer machine. The stains on the exterior of the machine and the brown fuzzy debris covering the surface remained present. The nebulizer mask was uncovered and exposed to the air. On 11/13/24 at 9:51 AM, the surveyor interviewed Resident #4 about the care and maintenance of their nebulizer equipment. The resident informed the surveyor that the staff changed the tubing on a weekly basis. However, the resident also stated that they had never seen staff clean the nebulizer machine and acknowledged that the machine was not clean. The stains on the exterior of the machine and the brown fuzzy debris on the surface were still present, and the nebulizer mask remained uncovered and exposed to air. A reviewed the Admission Record, which reflected that Resident #4 was admitted to the facility with medical diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a lung disease that makes breathing difficult), acute on chronic systolic heart failure, and cardiomyopathy (a disease of the heart muscle making it difficult to pump blood). A review of the Minimum Data Set (MDS), an assessment tool, dated 9/5/24, revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, which indicated intact cognition. A review of the physician orders for Resident #4, revealed a physicians order dated 11/8/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally three times a day for shortness of breath (SOB) for five days. On 11/13/24 at 12:51 PM, the surveyor interviewed the Unit Manager Licensed Practical Nurse (UMLPN). The UMLPN described the facility's process for changing the nebulizer tubing and masks, noting that this occured every Tuesday. The UMLPN stated the tubing and mask should be dated and placed in a bag after use, the mask should be cleaned after each use and stored in a bag. The UMLPN acknowledged that there was no established procedure for cleaning the exterior of the nebulizer machine. On 11/13/24 at 1:02 PM, the surveyor interviewed the Infection Preventionist (IP). The IP explained that the nebulizer tubing and masks were changed weekly, typically on Tuesday nights for the entire building. The mask should be dated and placed in a bag after use. She further explained the nursing staff was responsible for cleaning the nebulizer masks after each use and allowing them to air dry and ensuring that the masks were returned to the bag once cleaned. The IP further clarified that the nebulizer machines should be wiped down daily by nursing, with the final cleaning should be performed by housekeeping. During the interview, the surveyor made the IP aware of the above mentioned observations. The IP responded that this should not be like that and emphasized that the equipment should have been properly cleaned and maintained to prevent any risk of contamination. On 11/13/24 at 1:08 PM, the surveyor and the IP entered Resident #4's room to observe the nebulizer equipment. The resident was in their room at the time. The nebulizer mask was found to be bagged. Resident #4 informed the surveyor and the IP that the nurse had just been in the room about five minutes prior, changed the tubing, and placed the mask into the bag. On 11/13/24 at 1:13 PM, the surveyor and the IP went to the nurses' station, where the Unit Manger Licensed Practical Nurse (UMLPN) and the Licensed Practical Nurse (LPN), who was responsible for Resident #4's care, were present. The LPN verified that she had been in Resident #4's room and changed the tubing, and bagged the mask prior to the surveyor and the IPs observation. On 11/13/24 at 1:16 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revision date of 8/1/24. Under the Policy Interpretation and Implementation section, the policy included: Respiratory-Tubing/Equipment (nebulizer chamber) changed weekly. In between use items will be stored in a plastic bag. NJAC 8:39-27.1 (a)

Compliant #: NJ169617 Based on observation, interviews, review of the medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident received preferred and accurate meal items at lunch service and in accordance to what was indicated on the meal ticket. This deficient practice occurred for 1 of 8 residents observed during dining service (Resident #147), and was evidenced by the following: On 11/08/24 at 12:29 PM, during the lunch meal service, the surveyor observed Resident #147 sitting in a wheelchair in their room. The resident was accompanied by a family member who stated that the resident consistently received incorrect meals. The resident stated that he had ordered pork chops but was served fish instead. The resident confirmed he has previously informed the staff that he did not like fish. A review of the Admission Record (an admission summary) included that the resident was admitted with diagnoses that included but were not limited to; cerebral infarction (stroke), essential hypertension, Alzheimer's disease, unspecified dementia, psychotic disturbance, mood disturbance and anxiety. A review of the Quarterly Minimum Data Set (MDS), a tool that facilitates the management of care, dated 10/03/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15. This score indicated a moderate cognitive impairment. A review of the physician orders (PO) for Resident #147, dated 11/08/2024, revealed a PO for: No Added Salt (NAS), regular texture, thin consistency diet. A review of the nutrition care plan, dated 10/2/24, did not reflect any documented food preferences. On 11/08/24 at 12:42 PM, the surveyor observed the resident's lunch tray in the presence of Licensed Practical Nurse (LPN) #1 and the Unit Manager LPN (UMLPN) #1. The lunch tray contained a fish fillet with lemon dill sauce, rice pilaf, oriental zucchini, skim milk, and juice. A review of the meal ticket on the tray indicated the resident should have received herb breaded pork chops, rice pilaf, braised cabbage, fruited yogurt, whole milk, juice, and coffee. LPN #1 and UMLPN #1 acknowledged that the lunch tray items did not match what was indicated on the resident's meal ticket. On 11/12/24 at 10:01 AM, the surveyor interviewed the Food Service Director (FSD). The FSD stated that the kitchen ran out of pork chops, which was an alternate and popular meal choice that day. He stated that several residents had requested to change their orders from fish to pork chops and as a result, the facility ran out of pork chops. In addition, the FSD acknowledged that the facility should have notified the resident of the substitution and stated that the staff was in a rush. On 11/14/24 at 11:40 AM, the surveyor interviewed the FSD, in the presence of a second surveyor. The surveyor inquired why Resident #147 did not receive yogurt for lunch on 11/08/24. The FSD could not explain why fruit yogurt was indicated on the meal ticket but the resident did not receive it. He further stated that resident's food preferences should have been accommodated. The FSD acknowledged the importance of honoring resident's meal preferences was because it was a resident right. The FSD also stated that the Caller/Checker position at the end of the tray line was responsible to ensure meal tray accuracy and that he was ultimately responsible for the accuracy of this process. On 11/14/24 at 12:04 PM, the surveyor interviewed the Registered Dietitian (RD), in the presence of a second surveyor. The RD stated that if a resident did not receive the meal they requested or preferred consistently, this could place the resident at nutritional risk as residents are less likely to eat meals they do not want. A review of the facility-provided Week-At-A-Glance menu, which is used for residents to make their meal selections, indicated that Resident #147 had selected herb breaded pork chops, braised cabbage, rice pilaf, whole milk, juice, and coffee for their lunch meal on 11/08/2024. The meal served to the resident did not match their selection, as the tray contained fish fillet with lemon dill sauce, rice pilaf, and other items inconsistent with their choice. On 11/13/24 at 1:16 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled Resident Food Preferences, with a revision date of 8/1/24. Under the Policy Interpretation and Implementation section, the policy included: The resident's clinical record (including orders, care plans, or other appropriate locations) will document the resident's likes and dislikes, as well as any special dietary instructions or limitations, such as altered food consistency and caloric restrictions. The LNHA also provided the surveyor with a facility policy titled Meal Distribution and Tray Line Policy, with a revision date of 8/1/24. This policy included the following: Tray Assembly: Meals must be accurately assembled according to each resident's dietary plan, which includes special diets, allergies, and preferences. Each tray should be checked against the resident's meal ticket for accuracy. Quality Control: Supervisory staff will review trays for presentation and completeness before leaving the kitchen, ensuring that each resident receives their correct meal. NJAC 8:39 17.4 (a)1

Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a resident received liquids in the appropriate consistency at bedside in accordance with physician orders and b.) follow the guidance on the resident's individualized comprehensive care plan. This deficient practice was identified for 1 of 3 residents reviewed for nutrition (Resident #60). This deficient practice was evidenced by the following: On 11/13/24 at 10:40 AM, two surveyors observed Resident # 60 in bed awake and alert. The surveyors observed a 16-ounce (oz.) water cup with a straw on the bedside table which was not in the resident's reach. The resident was unable to state whether he/she had a thickened liquid diet order. A review of the Admission Record (an admission summary) reflected the resident had diagnoses that included but were not limited to: cerebral infarction (stroke), asthma and dementia. A review of a Quarterly Minimum Data Set, a tool used to facilitate the management of care, dated 10/18/24, reflected the resident had a Brief Interview of Mental Status of 12 out of 15, which indicated the resident had a moderately impaired cognition. The MDS also indicated that the resident had a diagnosis of dysphagia and was on a mechanically altered diet that required a change in texture of food or liquids such as pureed food or thickened liquids. A review of the Order Summary Report reflected the resident had a physician's order (PO) for a Honey consistency diet dated 11/6/24. A review of the comprehensive care plan reflected the resident received honey thickened liquids with a revised date of 11/9/24. A review of a Nurse Practitioner's progress note dated 11/7/24, reflected the resident had chronic oropharyngeal dysphagia (difficulty swallowing) related to advanced dementia. It also reflected the resident had a modified barium swallow (a swallowing test) on 11/6/24, which indicated the resident aspirated (inhaled) with liquids and required thickened liquids. A review of a Speech Language Pathologist (SLP) treatment progress note, dated 11/11/24, reflected the resident had a diagnosis of oropharyngeal dysphagia and required honey thick liquids. It also reflected that nursing was educated on the resident's downgrade to honey thick liquids and verbalized understanding. A review of the modified barium swallow results, dated 11/6/24, reflected a recommendation for honey thick liquids. On 11/13/24 at approximately 10:40 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) #1 in the presence of a second surveyor, who stated that the resident was on a honey thick liquid diet. In addition, she stated that she prepared thier bedside water earlier in the day. LPN #1 demonstrated how she prepared the honey thick water at the medication cart in the presence of two surveyors. She used preportioned powdered thickener in packets. In total, she mixed 16 oz. of water from a gallon jug with three thickener packets. She stated the longer it sat the thicker the fluid would become. The surveyor reviewed the packet instructions with LPN #1, which indicated two packets should have been used for every four oz. of water to achieve a honey thick liquid consistency. LPN #1 stated that she determined the appropriate consistency by visual assessment. On 11/13/24 at 10:56 AM, the surveyor interviewed the SLP, in the presence of a second surveyor. The SLP reviewed the packet instructions and verified that for every four oz. of water, two packets were required to achieve a honey thick liquid consistency. In addition, she stated that the kitchen had prethickened nectar and honey thick liquids. At that same time, LPN #1 showed the SLP and surveyors a four oz. portioned lemon-flavored nectar thick water and stated there was no prethickened honey thick water on the unit and could not state whether she contacted the kitchen for it. On 11/13/24 at 11:01 AM, the SLP and two surveyors went to the resident's room to observe the bedside water. The SLP lifted the 16 oz. clear plastic cup of water and acknowledged that it (the liquid and the powder) was separated. The bottom was cloudy, and the top was clear thin liquid. She stated, that happens a lot with the powder we use. She further stated the resident recently had a swallowing test. On 11/13/24 at 11:10 AM, the SLP mixed the contents of the cup with the straw, in the presence of two surveyors. She acknowledged that the liquid was not a honey consistency and further stated I don't think this was ever honey thick. She also acknowledged that according to the thickener packet instructions, eight packets were required to thicken 16 oz. of water to a honey thick consistency. On 11/13/24 at 11:16 AM, the surveyor interviewed the Registered Dietitian (RD) and the Regional Food Service Director (RFSD), in the presence of a second surveyor. Both stated that the kitchen had prethickened portioned honey thick juice, milk and water. The RFSD showed a full unopened case of four oz. lemon flavored honey thick water to the surveyors. On 11/13/24 at 11:31 AM, the surveyor gave the resident's 16 oz. water cup to the RFSD to assess. He stated that the fluid was not thick enough to be a nectar or honey consistency. He stated that two packets of thickener were required for every four oz. of water to achieve a honey thick liquid consistency. He further stated that the cup had too much water verse packets. At this same time, the RD also stated that the liquid was not thick, and both acknowledged the liquid was not honey thick. On 11/13/24 at 12:35 PM, the surveyor interviewed Director of Nursing (DON), in presence of the survey team. She stated that the kitchen had prethickened liquids and in the event they did not the nursing staff would have to use the powdered thickener. The DON stated that the nurses were clinically astute (able) to determine liquid consistencies visually. She stated that she would have expected the nurse to contact the kitchen for prethickened liquids if they were not available on the unit. On 11/13/24 at 12:46 PM, the surveyor provided the residents 16 oz. cup of liquid to the DON to observe. She stated, this is pretty thin, not a honey consistency. She further stated the nurse did not follow the PO. On 11/14/24 at 11:15 AM, the SLP provided an undated document to the surveyor in presence of the survey team. The document titled Liquid Consistencies indicated that the definition/description of a honey consistency were Liquids can be poured but are very slow. Liquids will require a thickening agent to reach this consistency. Food slowly drips in dollops (or blobs) off the end of a spoon. A review of the facility policy Thickened Liquids, Fluid Restrictions and NPO [nothing by mouth] dated 8/2024, included Assure that there is no water pitcher or other thinned liquids at the resident's bedside who is ordered thickened liquids . A review of the undated facility policy Care Plans, included that it reflected treatment goals and objectives. NJAC 8:39-17.4(a)(1)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain, store, and hold potentially hazardous foods in acceptable temperatures to prevent food-borne illness; b.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; c.) maintain kitchen equipment in a sanitary manner; d.) store potentially hazardous foods to prevent food-borne illness; and e.) maintain handwashing sinks to ensure appropriate infection control practices. This deficient practice was evidenced by the following: On 8/3/23 at 9:12 AM, the surveyor entered the kitchen and requested to wash their hands in the kitchen's handwashing sink. The Food Service Director (FSD) showed the surveyor the handwashing sink, and the surveyor proceeded to turn on the hot water handle, but the water came out in drops only. The surveyor then proceeded to turn on the cold water handle, and the water came out in a steady flow. The surveyor asked the FSD if there was another handwashing sink in the kitchen, and the FSD replied no. The surveyor asked how kitchen staff washed their hands without hot water, and the FSD stated that the staff could wash their hands in the bathroom and then sanitize their hands. The surveyor asked if hand sanitizer was an acceptable hand hygiene practice to use in the kitchen, and the FSD responded no. The FSD informed the surveyor that the sink was just fixed last week, so it must have just stopped working now, and that maintenance was unaware there was no hot water. On 8/3/23 at 9:20 AM, the surveyor in the presence of the FSD calibrated a thin probed digital thermometer in an ice bath to 32 degrees Fahrenheit (F). The surveyor then obtained a water temperature from the handwashing sink which was 79 F. At this time, the FSD confirmed 79 F was not an acceptable temperature for handwashing, and they would find out what the acceptable temperature was to wash hands in the kitchen. On 8/3/23 at 9:30 AM, the surveyor in the presence of the FSD toured the kitchen and observed the following: 1.) On a spice rack, one opened thirty-two ounce (32 oz) lemon juice container labeled opened 7/9/23, and use by 8/9/23. The packaging indicated refrigerate after opening. 2.) On the meal tray line steam table, an attached long white cutting board. The cutting board was deeply pitted and discolored black and brownish. The FSD confirmed the kitchen should not be using the cutting board; it could cause contamination and bacterial growth. 3.) Under the steam table, two covered white plastic bins with lids that contained serving utensils. The outside of the bins and lids were soiled with debris and stained with a brownish color dried substance. The FSD confirmed the bins should be cleaned. 4.) Behind the convection ovens and between the stove, a buildup of a black substance and loose debris on the floors, and the tiling on the wall behind was stained with brownish drip patterns. The FSD confirmed the floor and tile walls needed to be cleaned; that staff cleaned once a week. 5.) On a drying rack, two small green, one medium, one small white, and one large white cutting boards all pitted and discolored black and brownish. The large white cutting board was also melted. The FSD confirmed the cutting boards should not be in use. 6.) In the walk-in refrigerator, the surveyor observed a plastic bus bin which contained a variety of approximately 30 resident milk cartons. The surveyor felt the milk cartons that were warm to touch. Using the calibrated thermometer, the surveyor obtained the following temperatures: 8 oz fat free milk 55 F; 4 oz whole milk 50 F; and 8 oz lactose free milk 50 F. The ambient temperature of the back of the walk-in refrigerator was 40 F. At this time, the FSD stated that the milk should be at 41 F or below. 7.) In a storage area outside the main kitchen, milk reach-in refrigerator box number one that was partially ajar. The ambient temperature was 50 F. The surveyor using the calibrated thermometer obtained the following temperatures: 8 oz fat free milk 55 F; 4 oz whole milk 58 F; and 4 oz fat free milk 53 F. 8.) In a storage area outside the main kitchen, milk reach-in refrigerator box number two, the ambient temperature was 50 F. The surveyor using the calibrated thermometer obtained a temperature of an 8 oz whole milk that was 45 F. 9.) In the Indian cultural reach-in freezer chest, an accumulation of ice. The FSD confirmed it should not have ice accumulation. 10.) In the ice cream freezer chest, ice accumulation. The FSD confirmed it should not be there. 11.) In a storage area outside the main kitchen area on a storage rack, one small red, two small white, and one small blue cutting boards that were pitted and discolored. The FSD confirmed they should not be used. On 8/3/23 at 10:00 AM, the surveyor and FSD toured the Indian cultural kitchen and observed in a cabinet, a spice container labeled [NAME] soda and another spice container labeled black salt. Both containers had spoons stored directly inside. The FSD confirmed spoons and scoops should not be left inside spices. On 8/3/23 at 10:10 AM, the surveyor interviewed the Maintenance Director (MD) who stated he was now aware that the hot water for the handwashing sink was not working; someone had fixed the sink last week, and the hot water valve was shut off and not turned back on. The MD acknowledged that 79 F was not an acceptable temperature to wash your hands in the kitchen. On 8/3/23 at 11:58 AM, the surveyor re-interviewed the MD who stated the sink was still not fixed; that last week the FSD informed him in passing that the sink was dripping so one of his maintenance workers replaced the sink and had to shut off the valve. The MD stated the hot water valve was stuck in the off position, and not turned back on, so the valve needed to be replaced. The MD stated the maintenance department fixed the sink so there was no work order or invoice as to when the sink was replaced. On 8/8/23 at 1:01 PM, the MD informed the surveyor that the kitchen handwashing sink was now fixed. The MD confirmed the hot water valve was stuck in the off position, and acknowledged he would have expected staff to have informed him that there was no hot water. On 8/3/23 at 1:15 PM, the surveyor in the presence of the FSD calibrated a digital thin probed thermometer in an ice bath to 32 F. On 8/8/23 at 1:18 PM, the surveyor accompanied by the FSD went into the walk-in refrigerator and using the calibrated thermometer obtained the following resident milk carton temperatures: 8 oz fat free milk 56 F 4 oz fat free milk 54 F 8 oz fat free lactose milk 53 F 8 oz reduced fat free milk 51 F 4 oz whole milk 54 F 8 oz whole milk 54 F On 8/3/23 at 1:22 PM, the surveyor observed milk reach-in refrigerator box number one was turned off. The FSD stated that the refrigerator was not operating properly, so the kitchen transferred the milk to the walk-in refrigerator. The FSD acknowledged that the milk temperatures were still not an acceptable temperature, and stated the milk was only delivered that morning. The surveyor asked the FSD if they accepted deliveries on food and milk that were not at 41 F or below, and the FSD stated no. The surveyor then asked the FSD if the kitchen staff took temperatures of cold food and beverages when delivered, and the FSD responded no. The FSD acknowledged that the milk was above 41 F for at least four hours and needed to be discarded now. On 8/3/23 at 8:56 AM, the FSD informed the surveyor that new milk was delivered an hour ago at a receiving temperature of 35 F. On 8/3/23 at 12:57 PM, the FSD provided the surveyor with a document titled Proper Handwashing Fact Sheet, which included to wet your hands with running water as hot as you can comfortably stand (at least 100 F). The FSD confirmed the hot water should have been at least 100 F. On 8/8/23 at 11:07 AM, the surveyor informed the FSD they wanted to observe lunch meal temperatures including the tray line. The surveyor asked the FSD what the minimum temperature hot food and the maximum temperature cold food should be. The FSD stated hot food should be at 145 F (the FSD later informed 135 F) and cold food should be 41 F or below. At this time, the FSD calibrated two thin probed digital thermometers to 32 F in an ice bath. On 8/8/23 at 11:15 AM, the surveyor observed the Cook obtain the food and beverage temperatures from the lunch tray line. The following hot foods were below 135 F, and the following cold food and beverage was above 41 F: Penne Pasta 132 F Garlic Bread 124 F Yogurt 46 F Vanilla pudding 57 F; the FSD stated it was pre-portioned and placed in the refrigerator yesterday. Mandarin oranges 54 F; the FSD stated it was pre-portioned and placed in the refrigerator yesterday. Ham and cheese sandwich 53 F; the FSD stated it was made around 8:00 AM and placed in the refrigerator. The surveyor observed the reach-in tray line refrigerator the sandwich was held in was at 45 F. Orange juice 56 F Apple juice 54 F Nutritional health shake 54 F At this time, the surveyor did not observe any kitchen staff attempt to heat any food that was below 135 F or cool down any cold food or beverage that was above 41 F prior to meal service. On 8/9/23 at 11:06 AM, the FSD informed the surveyor that hot food should be maintained at 135 F or above and provided the facility's undated Food Temperature policy which indicated the same. A review of the undated facility provided Food Temperature policy included .all hot food items must be cooked to the appropriate internal temperatures, held and served at temperatures of at least 135 F. The Food Temperature policy further indicated, All cold food items must be stored and served at a temperature of 41 F or below. A review of the undated facility provided Handling Cold Foods for Trayline policy included cold food items (such as canned fruits, desserts, salads, puddings, cottage cheese, juice, milk) will be placed in the refrigerator at least three to four hours before serving. Food should be chilled to 41 F or less .at the time of service .cold food temperatures will be taken and recorded prior and halfway through service to assure foods are 41 F or below. A review of the undated facility provided General Sanitation of Kitchen policy included food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule . A review of the undated facility provided Food Storage policy included .scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers .perishable foods such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigerator temperatures should be thermostatically controlled to maintain food temperatures at or below 41 F .Time/Temperature Control for Safety [TCS] foods must be maintained at or below 41 F .refrigerated foods should be stored upon delivery . A review of the undated facility provided Receivable and Storage Policy included upon delivery, all foods will be checked to ensure packaging is intact and marked off against the packaging slip. Check for signs or thawing and refreezing on perishable food items .immediately after delivery, store all refrigerated and frozen foods first, with-in the hour. Check temperatures to ensure that all frozen foods are frozen and all refrigerated foods are 40 F or lower. NJAC 8:39-17.2(g)

Complaint NJ#: 151826 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, homelike environment. This deficient practice was identified on 4 of 4 nursing units, (Oak, Willow, Cedar, and Maple) and in 2 of 36 resident rooms, (Resident #112 & Resident #190) reviewed for residing in a clean, comfortable, homelike environment. This deficient practice was evidenced by the following: On 08/03/23 at 10:46 AM, the surveyor started the environmental tour on the [NAME] unit. Between rooms [ROOM NUMBERS], the surveyor observed a long, black in color indentation and scratch mark along the wall. There was an area to the left of the television screen on the wall where the peach-colored paint was peeling. Exposing green colored paint underneath. Green colored paint was further observed above the television. At 10:48 AM, the surveyor observed to the right of room [ROOM NUMBER] above the floorboard a hole in the wall exposing white spackle and debris. At 10:51 AM, the surveyor observed peach-colored paint chipping above the handrail between rooms [ROOM NUMBERS]. At 10:52 AM, the surveyor observed inside Resident #190's room, holes, and indentations in the baseboard. The alert and oriented resident stated that the baseboard in the room, could use some patching up. At 11:07 AM, the surveyor observed between rooms [ROOM NUMBERS], above and to the left of the computer mounted on the wall peach-colored paint peeling, exposing green paint underneath. At 11:09 AM, the surveyor observed above the medical records sign, across from room [ROOM NUMBER] paint on the wall which was peeling off. Underneath the paint exposed indentations of brown cardboard like material, surrounded by white spackle. The surveyor further observed the peach-colored paint peeling with green paint exposed underneath. At 11:13 AM, the surveyor observed underneath the supply room sign on the [NAME] unit, holes, indentations in the wall, and peeling paint. At 11:14 AM, the surveyor observed between rooms [ROOM NUMBERS] black and brown colored stains throughout the tile floor. At 11:16 AM, the surveyor observed black and brown stains on the tile floor between rooms [ROOM NUMBERS]. At 11:16 AM, the surveyor further observed outside room [ROOM NUMBER], next to the plaque presenting the room number and resident names, peach-colored paint peeling and ripping off the wall which exposed green and white paint. At 11:18 AM, the surveyor observed between rooms [ROOM NUMBERS], black and brown discoloration on the tile floor by the wall. At 11:19 AM, the surveyor observed between room [ROOM NUMBER] and 248, black, brown, and yellow discoloration on the tile floor by the wall. At 11:20 AM, the surveyor observed between rooms [ROOM NUMBERS], scuff marks and black and brown discoloration on the tile floor by the wall. At 11:22 AM, the surveyor observed between rooms [ROOM NUMBERS], black and brown discoloration on the tile floor by the wall. At that time, the surveyor further observed that the brown baseboard between rooms [ROOM NUMBERS] had scratches and indentations throughout, exposing a lighter colored wood. At 11:25 AM, the surveyor observed 21 square tables in the main open area on the [NAME] unit. 15 of the 21 square tables were observed to have a brownish colored material caked onto the bottom base of the table. There were residents seated at these tables. At 11:29 AM, the surveyor attempted to conduct an interview with the housekeeping staff member who was working on the [NAME] unit. The housekeeper was unable to conduct an interview due to English as a second language. On 08/03/23 11:37 AM, the surveyor toured Cedar unit and observed brownish colored splatter on the metal plate at the bottom of the stairwell door. At 11:38 AM, the surveyor observed between rooms [ROOM NUMBERS] scratches and indentations in the paint on the bottom portion of the wall. At that time, the surveyor further observed brownish-orange colored splatter throughout the wall. At 11:40 AM, the surveyor observed between rooms [ROOM NUMBERS] brownish-orange splatter on the bottom portion of the wall. At 11:42 AM, the surveyor observed between rooms [ROOM NUMBERS] scratches and indentations in the paint on the bottom portion of the wall. The surveyor further observed black discolorations on the beige painted wall. At 11:45 AM, on the Cedar unit the surveyor observed to the left of the plaque for room [ROOM NUMBER], brownish colored splatter on the wallpaper. At 11:46 AM, the surveyor observed on the wall in front of the door frame outside of room [ROOM NUMBER], brownish colored stains on the walls. On 08/03/23 at 12:12 PM, the surveyor began an environmental tour on the Oak unit and observed that the brown covering on the handrail between rooms [ROOM NUMBERS] was peeling at the edges on the left-hand side. At 12:20 PM, the surveyor toured the Maple unit and observed between rooms [ROOM NUMBERS] that the wall underneath the grab bar had white indentations throughout and brownish colored stains on the yellow paint. At 12:27 PM, the surveyor observed between rooms [ROOM NUMBERS], multiple scratches and indentations in the wall underneath the grab bar. The paint on the wall was yellow and the surveyor observed white and black marks where the indentations existed. At 12:29 PM, the surveyor observed between rooms [ROOM NUMBERS], multiple scratches in the wall underneath the grab bar. At that time, the surveyor further observed brown splatter on the wall. The paint on the wall was yellow in color and the surveyor observed white and black marks where the indentations existed. At 12:31 PM, the surveyor observed between rooms [ROOM NUMBERS], black colored scratch marks throughout the wall underneath the grab bar. On 08/07/23 at 10:25 AM, the surveyor entered Resident 112's room and observed a large horizontal indentation in the wall in front of the door bed. The indentation in the wall revealed black and white indentations of color that extended throughout the length of the wall. The surveyor further observed a crack, exposing a hole in the wall by the floorboard. The ceiling tile above the resident's bed toward the bathroom was observed discolored brown throughout. Behind the resident's bed, the surveyor observed paint peeling off the wall exposing white plaster. In addition, behind Resident 119's roommates' bed, there were dents in the wall which exposed white and black markings. At that time, the surveyor attempted to interview Resident #112, but the residents speech was garbled and unintelligible. On 08/08/23 at 10:35 AM, the surveyor interviewed the facility's Maintenance Director (MD) who stated that painting the facility was an ongoing process. The MD added that he started working at the facility about a year a half ago and the first thing he noticed was the building needed to be painted. The MD stated that he noticed in June 2022 that the facility needed fresh coats of paint, so he started painting the doors and door frames. The MD explained that the next step was to paint the walls throughout the facility. The MD told the surveyor that during COVID he understood that you couldn't enter the resident's rooms, but the hallways should have been done to maintain the resident's environment and the facility staff, were definitely working on it. The MD explained that they had started on the third floor and the staff was working their way down through the building. The MD further stated that the facility had a staff member working two to three times a week from 4:00 PM to 7:00 PM to paint and he did the best that he could with the staff and the resources he had. On 08/08/23 at 10:54 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that all the housekeeping staff knew they were supposed to wash the floors. The HD stated, we are so far behind in terms of cleaning the floors. The HD told the surveyor that the facility was doing their best with the staff they had. On 08/08/23 at 12:56 PM, the surveyor reviewed the above findings with the facility's Licensed Nursing Home Administrator (LNHA). The LNHA stated that a lot of the things had already been identified so the surveyor was not bringing anything knew to his attention and he was, well aware of the situation and was working on it. At that time the surveyor asked the LNHA how long ago he identified the issues? The LNHA told the surveyor that he started working at the facility January of 2022 had identified that things needed to be fixed and the facility was fixing things on an ongoing basis. A review of the facility's undated Housekeeper Job Position indicated that the purpose of the housekeepers job position was, to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or Director of Housekeeping, to assure that our facility is maintained in a clean, safe, and comfortable manner. The Housekeeper Job Description further indicated that the housekeeper was responsible for ensuring, that assigned work areas are maintained in a clean, comfortable, and attractive manner. A review of the facility's undated Director of Housekeeping Job Position indicated that the purpose of the Director of Housekeeping Job was, to plan, organize, develop, and direct the overall operation of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe. And comfortable manner. The Director of Housekeeping's Job Position further indicated that the Director of Housekeeping's was responsible for ensuring, that the facility is maintained in a clean and safe manner for resident comfort and convenience. A review of the facility's undated Maintenance Assistant Job Position indicated that the purpose of the Maintenance Assistants job position was, to maintain the grounds, facility, equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines and regulations. The Maintenance Assistant Job Position further indicated that the Maintenance Assistant was responsible for maintaining the facility in good repair, ensuring a safe, clean and orderly environment. A review of the facility's undated Maintenance Supervisor Job Position indicated, The primary purpose of your job position is to assist in supervising the day-to-day activities of the Maintenance Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Director of Maintenance, to assure that our facility is maintained in a safe and comfortable manner. NJAC 8:39-31.2 (e), 31.4(a)(f)

Complaint NJ#: 154501 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This deficient practice was identified for 5 of 39 residents, (Resident #45, #57, #58, #81, and #418) reviewed for the development and implementation of a comprehensive person-centered care plan and was evidenced by the following: 1.) On 8/2/23 at 11:08 AM, the surveyor observed Resident # 58 in bed. Resident #58 stated that they have been on peritoneal dialysis (PD) for four years and performed their PD daily. The PD supplies were observed in boxes in the resident's room. The surveyor reviewed the medical records for Resident #58. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in May of 2022 with diagnoses which included diabetes (too much sugar in the blood), end-stage renal disease (loss of kidney function), peritoneal dialysis catheter (catheter in the abdomen used to remove excess fluid, correct electrolyte problems, and remove toxins). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/25/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. A review of the Medication review order summary included a physician order dated 5/17/23, for PD total volume of 12,000 ml low calcium, 1.5% dextrose, run time of 12 hours starting on the evening shift. A review of the August 2023 Medication Administration Record (MAR) reflected the above physician order and was documented as administered by a nurse. A review of the individualized comprehensive care plan included a focused care plan for peritoneal dialysis that did not address the self-administration of the PD. On 8/8/23 at 10:10 AM, the surveyor interviewed the 3:00 PM - 11:00 PM evening shift Registered Nurse Supervisor, who stated Resident #58 did their own PD in the evening. She stated that the resident should have a care plan that indicated the resident's self-administered PD. On 8/8/23 at 10:15 AM. the surveyor interviewed the Unit Manager Registered Nurse (UM), who stated Resident #58 had a care plan for self-administration of PD. The UM reviewed the care plan in the presence of the surveyor and stated that the care plan did not address the resident's self-administered PD and the resident's care plan should have addressed that. On 8/8/23 at 12:50 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the care plan not addressing the self-administration of the PD. 43308 2.) On 08/02/23 at 10:12 AM, during the initial tour the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that Resident # 81 was currently on an antibiotic (abt). On 08/02/23 at 10:39 AM, during the initial tour Resident #81 was not in their room. At that time, the resident's roommate informed the surveyor that he/she was in the common area/dining area. On 08/02/23 at 10:43 AM, during the initial tour the surveyor observed Resident # 81 participating in a group activity in the common area/dining room. The surveyor reviewed the medical record for Resident #81. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in September of 2018 with diagnoses which included overactive bladder, major depressive disorder, and extended spectrum beta lactamase (ESBL) resistance (an enzyme found in some strains of bacteria). A review of the most recent annual MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, which indicated an intact cognition. A further review in Section N - Medications, included the resident received an abt. A review of the resident's individualized comprehensive care plan (ICCP) included a focus area initiated on 12/4/21, may present with alteration in elimination as evidence by urinary incontinence at times related to overactive bladder. Interventions included monitor and report any signs and symptoms of UTI, dysuria (difficult urination), hematuria (blood in urine), alteration in mental status, voiding (the process of removing urine from your body), and increased temperature. A further review of the ICCP did not reflect that the resident was on an abt. A review of the Order Summary Report dated active orders as of 8/4/23 included a physician's order (PO) as follows: Dated 7/20/23, with a start date of 7/21/23 and end date 10/19/23, a PO for Keflex (used to treat a wide variety of bacterial infections) oral capsule 500 milligrams (mg) Give one (1) capsule by mouth one time a day for leukocytosis (high levels of leukocytes in the urine typically indicate an infection in the urinary system) for 90 days. Dated 7/26/23, monitor Keflex every shift until 10/19/23; document infection notes [for] Keflex. A review of the July 2023 and the August 2023 Medication Administration Record (MAR) reflected the above physician's order and was documented as administered. A review of the Progress Notes from 7/21/23 to 8/4/23, reflected that the resident was on Keflex with no adverse reactions. On 08/03/23 at 09:34 AM, the surveyor observed Resident # 81 in his/her room sitting in wheelchair going through their belongings. Resident # 81 stated that everything was great, and that the care was good. Resident #81 further stated that he/she had no concerns at that time. The surveyor asked if the resident was on an antibiotic? Resident #81 replied that he/she wasn't sure because they took a lot of medications. On 08/04/23 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that any nurse could update the care plan. She stated that the importance of the care plan was it showed the interventions needed to care for the resident. She explained it was the plan of action. The LPN stated that if a resident was on an abt then it would be on the care plan and the care plan would indicate why the resident was receiving the abt and for how many days. On 08/04/23 at 12:01 PM, the surveyor interviewed the UM/LPN who stated that all the nurses were responsible for updating the care plan. She stated that the care plan was the resident's plan of care and what needed to be done to care for that individual resident. The UM/LPN stated that the care plan was important because it ensured everyone knew how to care for the resident and what their needs were. She further stated that some medications were also included especially if the resident was at risk for something and on certain medications. She explained those medications included psychotropics (any drug that affects behavior, mood, thoughts, or perception) and antibiotics. The UM/LPN stated that if the resident was on an abt, then the care plan would reflect why they were on it and how long the resident would be on it. She stated Resident # 81 was on an abt because he/she had colonized urine leukocytosis, went to the urologist and would be on the abt for 90 days. She then stated that the abt was on the resident's care plan. At that time, the surveyor asked the UM/LPN to review the care plan with the surveyor. On 08/04/23 at 12:05 PM, the surveyor and the UM/LPN reviewed the care plan in the electronic medical record (EMR) together. Upon review of the care plan the UM/LPN realized and stated, I did not update the care plan. She then stated, of course you found the one I forgot. The UM/LPN stated that the abt was under the resolved section of the care plan and confirmed it was not currently in the care plan to address that the resident was currently on the abt for 90 days. The UM/LPN acknowledged that it should have been on the care plan. After surveyor inquiry the UM/LPN stated that she was now updating the care plan to include the abt in the presence of the surveyor. On 08/04/23 at 12:14 PM, the surveyor interviewed the DON who stated that a care plan was all the details related to the specific care of the residents. The DON stated that everyone which included therapy, social services, dietary, nurses, and recreation were responsible for updating the care plan. She stated that the care plan was important because it provided specific individualized care on how to care for that resident. She further stated that they included medications such as abt on the care plan. The DON explained that the abt should be on the care plan because it shared the information with everyone and allowed staff to know how to care for that resident. When asked was Resident # 81 on an abt? The DON stated that offhand I am not sure. On 08/04/23 at 12:18 PM, the surveyor and the DON reviewed the EMR together. Upon review the DON stated that resident was on Keflex and had started it on 07/21/23. The DON then went to the care plan and stated that the abt was mentioned. The surveyor informed the DON that the original care plan did not reflect the abt and that the UM/LPN had just updated the care plan in the presence of the surveyor. At that time, the surveyor showed the DON the original care plan and the DON compared it to the care plan revised (8/4/23). The DON confirmed that the original care plan had not addressed the abt and acknowledged that it should have been on the care plan prior to surveyor inquiry. The DON explained that they did rounds daily and addressed everyone that was on an abt. On 8/7/23 at 09:05 AM, the DON provided the facility Care Plans - Comprehensive policy. At that time, the DON confirmed the policy was undated but stated that she had reviewed the policy in January of 2023. On 08/08/23 at 01:10 PM, the DON in the presence of the LNHA, the Assistant Director of Nursing (ADON), and the survey team stated that the resident's long-standing use of an abt should have been documented on the resident's care plan. 41260 3.) On 08/02/23 at 10:16 AM, the surveyor observed Resident #45 lying in bed. The resident's right hand and right knee appeared to be contracted. The surveyor reviewed Resident #45's medical record. According to the Admission Record, Resident #45 had diagnoses which included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis on one side of the body), right wrist contracture, cognitive communication deficit, and unspecified dementia. Review of the quarterly MDS dated [DATE], included the resident had a BIMS score of 5 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident had a functional limitation in range of motion (ROM) to one side of his/her upper and lower extremities. Review of the Order Summary Report included a physician's order dated 04/21/23 to, Apply knee brace to right knee at all times when in bed. Review of the Occupational Therapy (OT) Discharge Summary, dated 03/22/23, included, Instructed nursing caregivers in proper body mechanics, safe transfer techniques, safety precautions and self care/skin checks in order to facilitate improved functional abilities with 100% carryover demonstrated by primary caregivers. Review of the Physical Therapy (PT) Discharge Summary, dated 04/24/23, included discharge recommendations for a right knee brace. Review of the Care Plan included a focus of, I have an ADL [activities of daily living] self-care performance deficit r/t [related to] hemiparesis/hemiplegia secondary to cerebral infarction and DX [diagnosis] of dementia. Further review of the Care Plan did not include interventions related to the resident's right wrist contracture and right knee brace. During an interview with the surveyor on 08/07/23 at 9:59 AM, the Director of Rehab (DOR) stated Resident #45 had a history of a stroke and was previously receiving PT and OT for ROM and contracture management. The DOR further stated the resident was recommended to wear a right knee brace while in bed and for staff to perform ROM exercises to the right wrist. The DOR explained that when the resident was discharged from PT and OT services, therapy educated the nursing staff on how to perform the ROM interventions. When asked about resident care plans, the DOR stated that while residents were receiving PT and OT services, the therapy department would create care plans relevant to the resident's treatment and that care plan would remain in place after the resident was discharge from therapy if the care was still applicable. During an interview with the surveyor on 08/08/23 at 10:38 AM, Certified Nursing Assistant (CNA) stated that Resident #45 was paralyzed on the right side and had contractures to the right wrist and knee. The CNA further stated that he put the resident's right knee brace on while the resident was in bed and performed ROM exercises to the resident's right wrist to prevent stiffness in the joints. During an interview with the surveyor on 08/08/23 at 11:35 AM, the LPN stated Resident #45 had contractures to the right wrist and knee. The LPN further stated that the CNA applied the resident's knee brace and performed ROM exercises to prevent worsening of the contractures. When asked about resident care plans, the LPN stated the nurses were responsible for updating resident care plans so that it included all of the resident's needs. The LPN stated Resident #45's contractures should have been included on the care plan in order to improve the care he/she received. During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/UM stated that residents with contractures were sometimes given devices, such as splints and braces, and staff provided ROM exercises to prevent worsening of contractures. The LPN/UM further stated that when residents were discharged from therapy services, the therapy staff would educate the nursing staff on how to perform ROM exercises for the resident. When asked about resident care plans, the LPN/UM stated that the nurses were responsible for updating the care plans quarterly and as needed. The LPN/UM further stated that the care plans should include everything about the resident and that Resident #45's care plans should have included the contractures with the interventions in place. During an interview with the surveyor on 08/08/23 at 12:15 PM, the DON stated that resident contractures were identified by the therapy department and the therapy department determined if the resident needed devices, such as splints or braces, and/or ROM exercises. The DON further stated that the therapy department educated the nursing staff on the devices and ROM exercises when the resident was discharged from therapy. When asked about resident care plans, the DON stated that care plans were updated upon admission, quarterly, or when a new condition was identified. The DON further stated that Resident #45's care plan should have included the contractures along with the interventions so that all facility staff had the information to provide individualized care. Review of the facility's Range of Motion Exercises policy, undated, included, Review the resident's care plan to assess for any special needs of the resident. 4.) The surveyor observed Resident #57 lying in bed with the bed height raised to the surveyor's hip level on the following dates and times: 08/02/23 at 10:11 AM 08/03/23 at 9:18 AM 08/04/23 at 9:44 AM 08/07/23 at 9:45 AM 08/08/23 at 9:24 AM According to the Admission Record, Resident #57 had diagnoses which included, but were not limited to, muscle weakness and unspecified dementia. Review of the annual MDS dated [DATE], included the resident had a BIMS score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS included the resident's balance during transfers was, not steady, only able to stabilize with staff assistance. Review of the resident's Care Plan included a focus area initiated 10/17/22, of, I am at risk for falls related to poor balance in sitting, with an intervention of, place bed in lowest position. Review of the Progress Notes revealed a Plan of Care Note dated 07/28/22 at 2:18 PM with a focus of I am at risk for falls related to history. The documentation included, 1/7/19 lowered to floor (unwitnessed fall), and, 5/21/21 slipped to the floor. During an interview with the surveyor on 08/08/23 at 10:15 AM, the CNA stated Resident #57 did not have any fall risk interventions in place. The CNA further stated that she did not keep the resident's bed in the lowest position because she had to check the resident's brief and reposition the resident every two hours. At that time, the CNA accompanied the surveyor and entered Resident #57's room. The CNA confirmed in the presence of the surveyor that the bed was not in the lowest position. During an interview with the surveyor on 08/08/23 at 11:35 AM, the LPN stated Resident #57 did not have any fall risk interventions in place. The LPN further stated that the importance of keeping the resident bed in the lowest position was to prevent injury from falls. During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/UM stated that CNAs should adjust the height of the residents' beds depending on the residents' preferences, however the staff should not keep the residents' beds positioned high for the staff's convenience. The LPN/UM further stated that keeping the resident beds in the lowest position prevented injury from falls. During an interview with the surveyor on 08/08/23 at 12:15 PM, the DON stated individual fall risk interventions depended on the resident's care plan and that beds should be kept in the lowest position if the care plan indicated that. The DON further stated that staff should not position beds high for their own convenience and that beds are kept in the lowest position to minimize injury from falls. During a follow-up interview with the surveyor on 08/10/23 at 1:02 PM, the DON stated that staff should have been following Resident #57's care plan if it had an active intervention to keep the bed in the lowest position. 37218 5.) The surveyor reviewed the closed medical record for Resident #418. A review of the resident's Admission Record (an admission summary) reflected that the resident was admitted to the facility in March of 2022 with diagnoses that included but were not limited to benign prostatic hyperplasia with lower urinary tract symptoms (a condition in men in which the prostate gland is enlarged and not cancerous that produces symptoms that feel like a urinary tract infection), unspecified symptoms and signs involving cognitive functions and awareness, other lack of coordination, and other abnormalities of gait and mobility. A review of the resident's admission MDS dated [DATE], indicated that the resident's cognitive skills for daily decision making were moderately impaired. A further review of the resident's MDS, Section H - Bladder and Bowel reflected that the resident had an indwelling catheter (a flexible tube inserted into the bladder that drains urine). A review of Resident 418's May 2022 Order Summary Report revealed a physician's order dated 03/27/22 for foley catheter care every shift. A review of the resident's March 2022 Treatment Administration Record (TAR) reflected that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day (7:00 AM - 3:00 PM), evening (3:00 PM - 11:00 PM), and night (11:00 PM - 7:00 AM) shifts from 03/27/22 through 03/31/22. A review of the resident's April 2022 TAR indicated that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day, evening, and night shifts from 04/01/22 through 04/30/22. A review of the resident's May 2022 TAR indicated that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day, evening, and night shifts on 05/01/22. A review of the resident's comprehensive person-centered care plan in its entirety did not reveal that the resident had a care plan in place for the care of his/her foley catheter. On 08/04/23 at 12:07 PM, the surveyor interviewed the CNA who stated that if she was caring for a resident with a foley catheter, it would be her responsibility to change the indwelling urinary catheter drainage bag to a leg bag during the day. The CNA explained the process in which she would remove the indwelling urinary catheter drainage bag, empty the urine, wipe the indwelling catheter tubing with alcohol prior to placing a leg drainage bag on the resident, wash and clean the indwelling urinary catheter drainage bag, and store the indwelling catheter drainage bag in a closed system with a cap at the end of the tubing to prevent the spread of infection. The CNA further explained that the CNA caring for the resident at bedtime would remove the leg drainage bag, wipe the catheter tubing with alcohol, and place a clean drainage bag on the resident. The CNA told the surveyor that her responsibilities also included notifying the resident's nurse of the amount and urine emptied from the catheter bags during her shift. On 08/04/23 at 12:14 PM, the surveyor interviewed the resident's LPN who stated that if a resident had a foley catheter she would make sure the site was clean and dry with no redness or odor. The LPN further stated that the foley catheter bag had to be stored below the level of the bladder and the color of the urine should be, straw yellow. The LPN told the surveyor that if a resident had a foley catheter, there should definitely be a care plan because it guided the care of the resident. On 08/04/23 at 12:19 PM, the surveyor interviewed the Registered Nurse/Unit Manger (RN/UM) who stated that if the resident had a foley catheter there should be a care plan that reflected the care of the foley catheter. The RN/UM explained that upon admission, the evening supervisor and admitting nurse were responsible for creating the resident's care plan and then the unit manager of the unit was responsible for the oversite and additions of personalized care to the resident's care plan. On 08/04/23 at 12:49 PM, the surveyor interviewed the DON who stated that a resident with a foley catheter should have a care plan for the care of the foley catheter. A review of the facility's Care Plans - Comprehensive policy, undated, included the following: 3. Each resident's Comprehensive Care Plan has been designed to: . d. Reflect treatment goals and objectives in measurable outcomes . e. To attain or maintain the Resident's highest practical physical, mental psychosocial well being . g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels . h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program . 4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS) . 5. Care plans are revised as changes in the resident's condition dictate NJAC 8:39-11.2 (e) (f)

Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on interviews, review of the Medical Records (MR), and other pertinent facility documentation on [DATE], [DATE], [DATE], [DATE], and [DATE], it was determined that the facility failed to provide the services necessary to avoid physical harm. The facility failed to ensure that residents who are cognitively impaired were protected from a resident-to-resident physical abuse/altercation and recurrence, failed to initiate a care plan (CP) when behaviors started for consistent behavior monitoring, failed to provide adequate supervision and documentation to protect from physical abuse, and to follow their own policies titled: Behavior Assessment and Monitoring, RESIDENT ABUSE NEGLECT AND MISTREATMENT THE LAW, Abuse, Charting and Documentation, Care Plans-Comprehensive, and Behavioral Assessment, Intervention and Monitoring, and Acute Condition Changes - Clinical Protocol, for 4 of 11 residents (Resident #1, #2, #7, and #8) reviewed for abuse; when a.) On [DATE], Resident #2, who had impaired cognition and known history of wandering and aggressive behavior exhibited behaviors of agitation, throwing things/hitting staff with a water bottle, and threatened to kill them. Resident #2 was evaluated at the hospital on [DATE] and returned on [DATE]. On [DATE], the Valproic medication (given for Depression and Dementia with Behavioral Disturbances) was changed when Resident # 2 returned to the facility from the Acute Care Hospital (ACH). The facility did not initiate a formal behavior monitoring process, develop a CP, and/or start interventions for this aggressive behavior. Resident #2's CP and progress notes (PN) lacked documentation that the resident was being supervised or monitored to address his/her aggressive behavior displayed on [DATE]. This deficient practice resulted a resident-to-resident physical abuse/altercation when on [DATE] at 3:05 pm, a staff member witnessed Resident #1 ambulating in the hallway past Resident #2's doorway. Resident #2 was coming out of his/her room and struck Resident #1 in the head, causing Resident #1 to fall. Resident #1 was observed face down and noted with bleeding abrasions to the right eyebrow and temple. Resident #1 was hospitalized with an intracranial hemorrhage and expired on [DATE]. This resulted in an Immediate Jeopardy (IJ) which began on [DATE] and the facility was notified of the IJ on [DATE]. The facility provided an acceptable removal plan and was verified on-site on [DATE]. b.) Resident #7 and #8 who are roommates, both cognitively impaired with a known behavior of aggressiveness and outburst of agitation had a resident-to-resident abuse/physical altercation on [DATE] at 2:00 PM. Resident #7 pushed Resident #8 and Resident #8 hit Resident #7 on his/her back in return. Resident #8 was offered a room change in which the Responsible Party (RP) agreed, however, Resident #8 declined. Resident #7 was not offered a room change because he/she was not a candidate. Although the facility indicated a room change was to be actively worked on as an intervention, there was no documentation to indicate that another room change was attempted, and the residents remained roommates. Consequently, another physical altercation occurred between Resident #7 and Resident #8 on [DATE] at 11:00 AM. The incident occurred in the room and was unwitnessed. The facility's failure to provide supervision, consistently document/monitor resident behavior in the MR, and implement the plan of care posed a serious and immediate risk to the safety and well-being of all the residents in the facility. This deficient practice placed Residents #1, #2, #7, and #8 and all other residents who were at risk for a resident-to-resident physical abuse/altercation in an IJ situation for serious injuries, harm and death. This resulted in an IJ which began on [DATE] and the facility was notified of the IJ on [DATE]. The facility provided an acceptable removal plan and which was verified on-site on [DATE]. The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Nurse of Operation (CNO) were notified of the IJ and provided with the IJ template on [DATE] at 4:44 pm. The facility provided an acceptable removal plan and was verified on-site on [DATE] during the survey. On [DATE], the Surveyors conducted a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan which included; a. The Resident was no longer at the facility. All facility staff were educated on behavior care plans and behavior monitoring policy. Resident audits were initiated, reviewed and updated on all resident behavior interventions and CPs. b. Residents #7 and #8 CPs were updated on [DATE] and, as a further intervention were separated into different rooms on [DATE] post agreement of RPs. Residents #7 and Resident #8 are being monitored and the responsible parties were notified. All current resident with behaviors were audited and reviewed residents with behavior and their interventions and CPs were updated. The non-compliance remained on [DATE] for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was further evidenced by the following: Review of the REPORTABLE EVENT RECORD/REPORT (RERR), dated [DATE] at 3:05 pm, revealed a Resident-to-Resident Abuse incident involving Resident #1 and Resident #2 that was reported to the New Jersey Department of Health (NJDOH) on [DATE] at 5:00 pm. Attached with the RERR was the investigation summary report (ISR). The ISR indicated that Resident #1 was ambulating when Resident #2 came toward Resident #1 and slapped Resident #1's face, open handed, causing him/her to fall. First aid was provided to Resident #1. The Nurse practitioner (NP #1) immediately assessed Resident #1. Resident #1 was transferred to an Acute Care Hospital (ACH) via 911 and admitted with an Intracranial Hemorrhage. The ISR further indicated that Resident #2 remained aggressive, hitting, kicking staff, and was kept away from other residents. Resident #2 was transferred to the ACH via 911 at approximately 4:15 pm. On [DATE], [DATE], and [DATE], the surveyor reviewed the electronic medical record (EMR) of Resident #1 and Resident #2. 1.) According to Admission Report (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive and Dementia. The Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], indicating Resident #1's cognition was severely impaired and the resident required supervision for Activities of Daily Living (ADLs). A PN, dated [DATE] at 3:51 pm, documented by Nurse Practitioner (NP #1) indicated that she responded to a call from Maple unit. When she arrived in the unit, Resident #1 was found on the floor in a prone position, the resident woke up and began to move her/his head. She further indicated that the staff reported that Resident #1 was ambulating in the hallway when Resident #2 randomly slapped Resident #1 causing Resident #1 to fall to the floor. Resident #1 was observed to have several bleeding abrasions to the right eye, right eyebrow, temple area, and right submandibular. Staff was able to stop the bleeding and gently rolled Resident #1 to a supine position. Staff applied oxygen at 2 liters per minute (lpm), vital signs were: Pulse of 82 beats per minute (bpm), respiration of 24 bpm, blood pressure of ,d+[DATE], and oxygen saturation was 100 percent. NP #1 further indicated that Resident #1 had an altered mental status after the fall to the floor and a brief loss of consciousness. A PN, dated [DATE] at 10:25 pm, documented by Licensed Practical Nurse (LPN #5) indicated that Resident # 1 was being admitted to the hospital for an Intracranial Hemorrhage. Review of Resident #1's incident report (IR), provided by the DON on [DATE], dated [DATE] at 3:05 pm, revealed that a fall occurred in the hallway while Resident #1 was ambulating, the fall was witnessed by the Certified Nursing Assistant (CNA #1), and Resident #1 was transferred to the ACH on [DATE] at 3:45 pm. 1a.) According to AR, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder and Dementia with Agitation. The MDS dated [DATE], revealed that Resident #2 had a BIMS score of ,d+[DATE], indicating Resident #2's cognition was severely impaired and the resident required supervision for ADLs. The CP, dated [DATE], revealed that Resident #2 presented with a depressed mood related to recent admission to the facility as well as overall condition. Interventions included but not limited to: Monitor and record mood to determine if problems seem to be related to external cause. The CP further revealed that Resident #2 had potential for side effects related to psychotropic drug use of Paxil and Valproic Acid for Depression and Dementia with Behavioral Disturbances. The CP also revealed that on [DATE], Resident #2's CP was initiated for Urinary Tract Infection. Interventions were to Administer antibiotics as ordered .Educate (patient/family) on handwashing .On going communication with infection control nurse .strict handwashing . A review of the hospital record (HR), neurology progress note, dated [DATE] at 10:57 am, revealed that Resident #2 had a diagnosis of Dementia with Psychosis and Delirium. The HR indicated a resident of long-term care [gender] has a longstanding history of dementia with agitation diabetes mellitus and behavior disorder with aggressive episodes. Patient tend to become very aggressive with other residents. [Gender] refused to take medication and brought to the [to the] emergency room and admitted for further evaluation. Due to acute agitation and aggressive behavior requires one-to-one supervision for [gender] safety and medication is being adjusted .psychiatric evaluation is in progress and medication is being adjusted [gender] is started on Paxil and also continue with Namenda Aricept and Depakote .and Zyprexa and Haldol as needed for acute agitation. Patient very confused .[gender] does not follow and tend to become agitated and very uncooperative .Patient requires close observation for [gender] safety . Review of the facility PN, dated [DATE] at 9:32 pm, documented by NP #3, indicated Resident #2 was seen today for follow up on altered mental status and with associated aggressive behavior, stabilization visit. admitted to facility on [DATE], after discharge from [hospital]. Patient with multiple chronic medical conditions including dementia, who was previously at Assisted Living, presents to the ED [emergency department] due to altered mental status and aggressive behavior. Workup at the ED was negative for infection. Review of a facility PN, dated [DATE] at 7:25 pm, by the Telehealth Nurse Practitioner (TNP #1) revealed the following: Resident #2 had Change in Condition .Resident became very agitated. Throwing things at staff, danger to self and others .Onset: few minutes ago. wandering in other pt's [patient's] room, became agitated throwing things at everybody and other residents, hot drinks and can of soda, running up and down and not able to contain [Resident #2]. Nurse says sometimes agitated but 'never like this'. Nurse says [Resident #2] tried to hurt others physically .ASSESSMENT/DIAGNOSIS: Unspecified Mood Disorder .Restlessness and Agitation .and Violent behavior .General Assessment/Diagnosis Plan Notes:-stat psyc [psychiatric] eval in ER [emergency room ]; 1:1 monitoring until EMS arrives for transport . Review of a facility PN, dated [DATE] at 8:00 pm, Registered Nurse (RN #1) documented &;20pm [7:20] call from third floor for an emergency. When I arrived pt [patient] was screaming 'I'm going to kill them and theyre going to kill me. We attempted to calm pt [patient] down. Hit this writer in head with a full water bottle. All residents placed in their room with doors closed. pt [patient] attempting to get into rooms and screaming 'They're going to kill us'. Call placed to 911, telehealth made aware we were sending [gender for a psych eval at [hospital emergency room ]. [Family members] came and [family members] were placed in the day room with the doors closed. Pt [Patient] calmed down with them here. Call placed to [hospital emergency room ]. Police and ambulance transported [gender] to [hospital]. Review of the facility PN, dated [DATE] at 8:10pm, RN #1 documented All residents checked on third floor no injuries noted . Review of the facility PN, dated [DATE] at 3:17 pm, LPN #1 documented that Resident #2 was still at ACH being evaluated and was waiting to be seen by the psychiatrist. Review of the CP did not include any indication that interventions were implemented to address the aggressive behavior displayed on [DATE]. Review of the HR, psychiatry consult, dated [DATE] at 2:54 pm, revealed that Resident #2 was brought in the ED [emergency department] for aggressive and violent behaviors, [gender] has been a resident at [facility] since [DATE], reportedly [gender] has been having physical outburst, according to staffs [gender] has frequent behavioral outbursts. Review of the facility PN, dated [DATE] at 7:18 pm, LPN #2 documented that Resident #2 returned to the facility from the ACH with a diagnosis of Urinary Tract Infection (UTI). Resident #2 was seen and cleared by the ACH Psychiatrist to return to the facility. The Order Summary Report (OSR), dated [DATE], reflected that the Valproic 250 milligram (mg), give 5 milliliter (ml) was increased from every 12 hours to every 8 hours for Dementia with Behavioral Disturbance. There was no indication in the MR that behavior monitoring was initiated when the medication was changed on [DATE]. Review of the TASK form for the month of ,d+[DATE] indicated that CNAs were to monitor Resident #2's behavior every shift. The TASK form for monitoring was not signed/initialed as completed on the following dates and shifts after Resident #2 returned from the hospital: [DATE], [DATE], [DATE] during the shift of 7:00 am to 3:00 pm on, [DATE], [DATE], and [DATE] during the shift 3:00 pm to 11:00 pm, and [DATE] during 11:00 pm to 7:00 am which was not according to the Charting and Documentation policy. On [DATE] at 3:15, unit manager LPN (UM/LPN #3), who was the nurse for Resident #2 on [DATE], documented that at 2:30 pm Resident #2 was in his/her room, at 3:05 pm, another resident was walking down the hallway when Resident #2 slapped the resident causing Resident #1 fall to the ground and sustained an abrasion near the right eyebrow and temple area. On [DATE] at 4:53 pm, Nurse Practitioner (NP #1) documented Called to Maple floor stat. Patient seen on bed with ,d+[DATE] staff members monitoring and maintaining his position and location in the room after he randomly struck another resident. [Resident #2] appears agitated and restless but otherwise appears medically stable. Of note, patient just returned from the hospital on [DATE] s/p [status post] psych eval for similar aggressive behaviors. [Resident #2] was treated for UTI and completes oral ABT [antibiotic therapy] tomorrow. NP #1 further documented that her Impression/Plan: Patient with mood disorder and dementia exhibiting recurrent agitation and aggression towards staff and another resident. Day #,d+[DATE] Keflex for UTI in progress. ER [emergency room ] for psych and medical evaluation and treatment. Further review of Resident #2's medical record (MR) revealed there was no documented evidence that Resident #2's behavior was being monitored consistently after the incident on [DATE] when there was a change in condition or when the medication, Depakote was changed on [DATE]. The surveyor conducted an interview with CNA #1 on [DATE] at 9:27 am. The CNA stated that she documented the residents' behavior in the Kiosks (kiosk or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation). She stated that not all residents were being monitored, only those residents that appear in the Kiosks. She explained that a questionnaire would appear, and CNAs had to indicate if behavior occurred by answering Y for yes and N for no. She also explained that the Kiosks had to be answered and cannot be left blank to indicate that the behavior was being monitored. The surveyor conducted an interview with CNA #2 on [DATE] at 2:00 pm. The CNA stated that she documents residents' behavior in the Kiosks but not for all residents, only when being asked in the Kiosks. She explained that a questionnaire will appear, and the CNA had to indicate if behavior occurred by answering Y for yes and N for no. She stated that sometimes she documents in the Kiosks and at times she forgets or had no time to sign the Kiosks. The surveyor conducted an interview with CNA #4 on [DATE] at 10:36 am. The CNA stated that CNAs should document the care provided to the Resident to indicate that it was done. The surveyor conducted an interview with the UM/LPN #3 on [DATE] at 11:07 am. The LPN stated that CNAs should document the task provided at the end of the shift and unit managers should ensure that the CNAs document to indicate that the care was provided to the residents. However, the LPN was unable to explain why the CNAs were unable to complete their documentations. The surveyor conducted the interview with the DON on [DATE], [DATE], and [DATE]. The DON stated that Resident #2's CP was updated for UTI management on return from the hospital on [DATE]. However, the CP for Resident #2's behavior that happened on [DATE] was not created because the residents' behavior was related to the diagnosis of UTI. The DON also stated that if there was a change in medications, staff should monitor and document resident's behavior for 14 days, every shift, in the MR whether the resident's had a behavior or not. The DON was unable to provide a consistent monitoring documentation when the resident's medications were changed on [DATE]. During the tour, the surveyor conducted an interview with residents who were alert and oriented. On [DATE] at 12:59 pm Resident #5 stated that Resident #2 was a difficult resident, he/she walked around the unit and entered other resident's room, Resident #2 would lay down on other residents' beds and staff would just redirect him/her. Resident #2 hit staff and other residents for no reason including him/her. Resident #5 further stated that Resident #2 also threw a chair at one point (unable to recall time and date). Resident #5 revealed that he/she did not report the incident to the facility because the staff were aware of the resident's behavior. During an interview with the surveyor on [DATE] at 12:45 pm. Resident #6 stated that resident #2 walked around the unit, he/she would go into other residents' room and sleep on other residents' beds, he/she gets upset and hits staff and other residents when [he/she] does not get what [he/she] wants. Resident #6 stated, approximately ,d+[DATE] weeks ago between 2:30 pm to 3:30 pm, Resident #2 entered Resident #6's room, Resident #6 asked Resident #2 to leave the room, Resident #2 hit Resident #6's shoulder and walked out of the room. Resident #6 stated that he/she never reported the incident to the facility because this was a resident's normal behavior and that the staff were aware of his/her behavior. During an interview with the surveyor on [DATE] at 9:00 am, UM/LPN #3 stated that the nurses are only to document residents' behavior in the residents MR when a behavior occurred. He further stated that nurses are not required to document in the MR if the resident had no behavior. He explained that they have no documentation indicating that the residents' behaviors were being monitored every shift consistently. However, on [DATE] at 11:36 am, the LPN stated that when there is a change in condition such as a change in medication or having aggressive behaviors, the staff had to monitor the resident and document in the resident's MR. He further added that documentation is important to see if a new intervention is effective or not and to show that the intervention is being implemented and it is part of communication. UM/LPN #3 was not able to explain why Resident #2's behavior documentation was not done. During an interview with the surveyor on [DATE] at 9:15 am, UM/LPN #3 stated that the CP is a way of communication, as it summarizes the residents overall care, and should be individualized and patient centered. The CP had to be updated by the unit managers (UM), Supervisor, and DON within 48 hours for any change in condition including but not limited to, a fall, any incident, altercation, skin tear, or behavior. He further stated that it is important to update the CP to give proper care and to prevent from any recurrence. UM/LPN #3 explained that Resident #2's CP should have been updated for behaviors and medication change on return from the hospital on [DATE]. LPN was not able to provide an updated CP to address the resident behavior on [DATE]. 45621 2. During the survey on [DATE], the surveyor reviewed the facility's reportable event records for the past 3 months. The surveyor reviewed the RERR dated [DATE] involving Resident #7 and Resident #8. The RERR revealed that a resident-to-resident abuse was reported to the NJDOH on [DATE]. The attached summary indicated that on [DATE] at approximately 2:00 pm, the staff witnessed Resident #7 not allowing Resident #8 to enter their room. Resident #7 pushed Resident #8 and in return, hit Resident #7 in the back. They were separated and neither resident sustained injury. Resident #8 was offered a room change, Resident #8 declined, and the family did not like the room. It further indicated that the facility would actively work on other room options that would be appropriate. The conclusion indicated, this appears to be an isolated event. The residents have been roommates for a few months and have had no issues up until now. The room changes will be done as a precaution. On [DATE], another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8 was reported to the NJDOH. During the survey on [DATE], the surveyor reviewed the facility's RERR. Review of the RERR revealed that on [DATE] at approximately 11:00 am, staff at the nursing station heard Resident #7 yell. When staff responded, Resident #7, while exiting the room, stated that Resident #8 hit his/her hand. The incident was unwitnessed. Resident #7 was unable to provide context, and Resident #8 asked the staff to leave the room. Neither resident had injury, redness, or bruise. The interventions implemented after the incident included: Resident #8's room will be changed. Both resident's behavior will be monitored and referred for Psychiatric evaluation. It further indicated that this was the second minor incident between the resident. Both residents are ambulatory with Dementia and getting them out of each other's proximity should manage the behavior. During the tour of the unit on [DATE] at 1:20 pm, the surveyor observed Resident #7 and Resident #8 lying in bed in the same room, awake and alert. Both residents refused an interview with the surveyor. Review of MR on [DATE], [DATE], [DATE], and [DATE] revealed the following: 2a). Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The MDS dated [DATE] and [DATE] revealed a BIMS score of 7, which indicated severely impaired cognitive status, and the Resident was independent and required minimal supervision with ADLs. The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from [DATE]. The Medication Administration Record (MAR) revealed that Resident #7 received Sertraline for Depression from [DATE] to [DATE]. Additionally, the medication Depakote for Dementia with Behavioral Disturbance was started on [DATE] and the dosage was increased on [DATE] and [DATE]. Review of the PN revealed no documented evidence that the nurses consistently monitor Resident #7's behavior after the Depakote was increased on [DATE] and [DATE] when it was indicated in the facility's policy that if a resident is being treated for problematic behavior or mood, the staff will document ongoing reassessments of changes (positive or negative). Furthermore, the PN revealed documentation dated [DATE] at 2:15 pm about Resident #7 and Resident #8 physical altercation. The residents were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. The PN revealed no documented evidence that the nurses consistently monitored Resident #7's behavior after the physical altercation. The revised care plan dated [DATE] revealed that Resident #7 is possessive of his/her room and does not want people to enter. Goals and interventions included but were not limited to: Resident will not harm self or others; resident will verbalize understanding of the need to control physically aggressive behavior; when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly, if the response is aggressive, staff to walk calmly away and approach later. The care plan indicated that Resident #7, who had severely impaired cognition and a diagnosis of Dementia, would verbalize understanding of the need to control physically aggressive behavior. However, there was no indication in the CP how Resident #7 would be monitored while in the room with the roommate (Resident #8) where the physical altercations occurred. The facility's policy for behavior management indicate that interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms as well as the potential situational and environmental reasons. Additionally, the policy included that the care plan will include but was not limited to targeted and individualized interventions for the behavioral symptoms, specific, measurable goals for the targeted behavior and how the staff will monitor for effectiveness of the interventions. The PN revealed that on [DATE] at 10:55 am, the UM/LPN #3 documented that Resident #7 and Resident #8 had another physical altercation in the room and unwitnessed. During an interview with the DON on [DATE] at 12:57 pm and UM/LPN #3 on [DATE] at 2:50 pm, they both confirmed that the physical altercation took place in the residents' room, and it was unwitnessed as the residents were not monitored in the room by the nursing staff at that time. The DON further confirmed on that same date at 4:10 pm that the room change for Resident #8 was not attempted again until after the physical altercation recurred on [DATE]. She stated that the physical altercation on [DATE] was considered a minor and isolated incident and Resident #8 refused to transfer to another room. Review of the task form for the month of ,d+[DATE] indicated that CNAs were to monitor for behavior symptoms every shift which included but were not limited to yelling/screaming, kicking/hitting, pushing, and abusive language. Resident #7's task form was not signed/initialed for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE], and [DATE] to [DATE]. For the month of ,d+[DATE] for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; 11:00 pm to 7:00 am on [DATE], [DATE] to [DATE], [DATE], [DATE], and [DATE] to [DATE]. During an interview with CNA #1 on [DATE] at 11:01 am, she stated that CNAs are expected to monitor residents' behavior and document in the kiosk, ADL records task for behavior monitoring. She further said that CNAs are responsible for completing the task at the end of the shift and if incomplete or blank, it did not happen. During an interview with the DON on [DATE] at 12:57 pm, she stated that CNAs document resident's behavior in the kiosk or ADL record. She further stated that CNA observations and documentations are considered valuable they do not replace nurses observation and documentation. 2b. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia and Hypertension. The MDS dated [DATE] and [DATE] revealed a BIMS score of 3, which indicated severely impaired cognitive status, and the Resident required supervision to minimal assistance with ADLs. The nursing PN dated [DATE] at 1:04 pm indicated that Resident #8 was combative with staff and other residents. Resident wanders around the hallway and goes in and out of other residents' rooms. Redirection unsuccessful. The nursing PN dated [DATE] at 8:30 pm indicated that Resident #7 was physically and verbally abusive to staff and residents. The Resident was not easily redirected but finally agreed to go to bed. The CP initiated on [DATE] indicated that Resident #8 may present with a depressed mood related to his/her recent admission to the facility and his/her overall condition. Goals and interventions included but were not limited to: Resident #8 will have improved mood state, such as being happier, having a calmer appearance, and showing no signs and symptoms of depression, anxiety, and or sadness. Behavioral Health consults as needed. Monitor/document as needed risk for harm to self: suicidal plan, a past attempt at suicide, risky actions, intentionally or tried to harm self, sense of hopelessness, and impaired judgment or safety awareness. Monitor/record/report to MD (Medical Doctor) as needed risk for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone Review of the PN revealed documentation by the Social Worker (SW) on [DATE] at 10:32 am that Resident #8 was transferred to another room because of incompatibility with the roommate (Resident #7). The RP was made aware of the room change and staff to monitor the adjustment. However, the PN revealed no indication that the room change occurred or Resident #8 was monitored by the nurses for adjustment after the room change. Additionally, there was no documented evidence in the PN explaining what led to the room change. Further review of the PN revealed documentation dated [DATE] at 2:15 pm that Resident #7 and Resident #8 had a physical altercation. They were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. Review of the MR on [DATE] revealed no documented evidence that the nurses consistently monitored Resident #8 for safety after the physical altercation on [DATE]. In addition, there was no documented evidence that Resident #8 was offered another room change after the resident refused on [DATE] when it was indicated in the RERR summary that the facility staff would actively work on room change options. Review of the PN on [DATE] revealed documentation on [DATE] at 10:55 am about another physical altercation between Resident #7 and Resident #8. The PN indicated th [TRUNCATED]

Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on observation, interviews, medical record (MR) review, and review of other pertinent facility documentation during the on-site investigation on [DATE], [DATE], [DATE], [DATE], and [DATE], it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to follow the facility's Administrator job description and failed to ensure that policies and procedures were implemented by staff under Behavior Assessment and Monitoring, RESIDENT ABUSE NEGLECT AND MISTREATMENT THE LAW, Abuse, Charting and Documentation, Care Plans-Comprehensive, and Behavioral Assessment, Intervention and Monitoring, Accidents and Incidents, and Acute Condition Changes - Clinical Protocol. 1. On [DATE], Resident #2, who had impaired cognition and known history of wandering and aggressive behavior exhibited behaviors of agitation, throwing things/hitting staff with a water bottle, and threatened to kill them. Resident #2 was evaluated at the hospital on [DATE] and returned on [DATE]. On [DATE], the Valproic medication (given for Depression and Dementia with Behavioral Disturbances) was changed when Resident # 2 returned to the facility from the Acute Care Hospital (ACH). The LNHA unable to explain that the facility did not initiate a formal behavior monitoring process, develop a CP, and/or start interventions for this aggressive behavior. Resident #2's care plan (CP) and progress notes (PN) lacked documentation that the resident was being supervised or monitored to address his/her aggressive behavior displayed on [DATE]. This deficient practice resulted a resident-to-resident physical abuse/altercation when on [DATE] at 3:05 pm, a staff member witnessed Resident #1 ambulating in the hallway past Resident #2's doorway. Resident #2 was coming out of his/her room and struck Resident #1 in the head, causing Resident #1 to fall. Resident #1 was observed face down and noted with bleeding abrasions to the right eyebrow and temple. Resident #1 was hospitalized with an intracranial hemorrhage and expired on [DATE]. This resulted in an Immediate Jeopardy (IJ) which began [DATE]. 2.) On [DATE] at 2:00 pm, Resident #7 and #8 who are roommates, both cognitively impaired with a known behavior of aggressiveness and outburst of agitation had a witnessed resident-to-resident abuse/physical altercation. Resident #7 pushed Resident #8 and Resident #8 hit Resident #7 on his/her back. Resident #8 was offered a room change which the family agreed but Resident #8 declined. Resident #7 was not offered a room change because he/she for was not a candidate. Consequently, on [DATE] at approximately 11:00 am, another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8. When staff responded to the room, Resident #7 reported that Resident #8 hit her/his hand. The incident was unwitnessed. Resident #8 was moved to another room. This resulted in an IJ which began on [DATE] and the facility was notified of the IJ on [DATE]. The LNHA failed to ensure that adequate supervision, and consistently document/monitor resident behavior in the Medical Record (MR) in accordance with their policy and ensure that the physical altercation did not recur. Additionally, there was no indication that Resident #8's revised care plan was implemented. 3.) On [DATE] approximately 5:00 pm, Resident #7 was found in bed sleepy, drowsy when awakened, not aggressive, and unusually calm. LPN #6 found three bottles of supplements in the resident's nightstand drawer. LPN #6 placed the three supplements in her medication cart. Resident #7 was not assessed by a RN. The incident was not communicated to the oncoming nurse, nursing supervisor (NS), DON, primary physician (PP) and/or Resident's responsible party (RP). LPN #6 did not initiate an investigation. The LNHA failed to ensure that: a resident with known history of behaviors of wandering and frequently attempting to open the medication cart was monitored/supervised and failed to ensure the care plan was in place to address these behaviors, an incident or accident was reported immediately to the NS or the DON in accordance to the facility's reporting policy for incidents and accidents, a resident who was found unusually calm and drowsy when awakened was assessed by a RN and the PP was notified about the resident's change in condition, a comprehensive incident investigation was initiated to ensure that all medications were secured and locked, and the Responsible Party (RP) was notified. The LNHA's also failed to ensure that adequate supervision was provided, consistently document/monitor resident behavior in the MR, implement the plan of care, to initiate an investigation to determine how Resident #7 obtained the three bottles of unknown supplements, posed a serious and immediate risk to the safety and well-being of all the residents in the facility. This resulted in immediate jeopardy (IJ) situation which began on [DATE]. The facility was notified of the IJ on [DATE]. This deficient practice has the potential to affect all 57 residents on the memory care unit/third floor/Maple unit as evidenced by the following: The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Nurse of Operation (CNO) were notified of the IJ and provided with the IJ template on [DATE] at 4:44 pm. The facility provided an acceptable removal plan which was verified on-site on [DATE] during the survey. The facility implemented the Removal Plan which included but was not limited to; review of the policies and procedures for abuse, incidents/accidents and individualized behavior care plans, behavior monitoring for the Administrator and Administrative team. This deficient practice was identified for 4 of 11 residents (Resident #1, Resident #2, Resident #7, and Resident #8) and evidenced by the following: Ref Ftag 600 IJ Review of the REPORTABLE EVENT RECORD/REPORT (RERR), dated [DATE] at 3:05 pm, revealed a Resident-to-Resident Abuse incident involving Resident #1 and Resident #2 was reported to the New Jersey Department of Health (NJDOH) on [DATE] at 5:00 pm. Attached with the RERR was the investigation summary report (ISR). The ISR indicated that Resident #1 was ambulating when Resident #2 came toward Resident #1 and slapped Resident #1's face, open handed, causing him/her to fall. First aid was provided to Resident #1. The Nurse practitioner (NP #1) immediately assessed Resident #1. Resident #1 was transferred to an ACH via 911 and admitted with an Intracranial Hemorrhage. The ISR further indicated that Resident #2 remained aggressive, hitting, kicking staff, and was kept away from other residents. Resident #2 was transferred to the ACH via 911 at approximately 4:15 pm. 1.) According to Admission Report (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive and Dementia. The Minimum Data Set (MDS), an assessment tool dated [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], indicating Resident #1's cognition was severely impaired and the resident required supervision for Activities of Daily Living (ADLs). A PN, dated [DATE] at 3:51 pm, documented by Nurse Practitioner (NP #1) indicated that she responded to a call from Maple unit. When she arrived in the unit, Resident #1 was found on the floor in a prone position, the resident woke up and began to move her/his head. She further indicated that the staff reported that Resident #1 was ambulating in the hallway when Resident #2 randomly slapped Resident #1 causing Resident #1 to fall to the floor. Resident #1 was observed to have several bleeding abrasions to the right eye, right eyebrow, temple area, and right submandibular. Staff was able to stop the bleeding and gently rolled Resident #1 to a supine position. Staff applied oxygen at 2 liters per minute (lpm), vital signs were: Pulse of 82 beats per minute (bpm), respiration of 24 bpm, blood pressure of ,d+[DATE], and oxygen saturation was 100 percent. NP #1 further indicated that Resident #1 had an altered mental status after the fall to the floor and a brief loss of consciousness. 1a.) According to AR, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder and Dementia with Agitation. The MDS dated [DATE], revealed that Resident #2 had a BIMS score of ,d+[DATE], indicating Resident #2's cognition was severely impaired and the resident required supervision for ADLs. The CP, dated [DATE], revealed that Resident #2 presented with a depressed mood related to recent admission to the facility as well as overall condition. Interventions included but not limited to: Monitor and record mood to determine if problems seem to be related to external cause. The CP further revealed that Resident #2 had potential for side effects related to psychotropic drug use of Paxil and Valproic Acid for Depression and Dementia with Behavioral Disturbances. The CP also revealed that on [DATE], Resident #2's CP was initiated for Urinary Tract Infection. Interventions were to Administer antibiotics as ordered .Educate (patient/family) on handwashing .On going communication with infection control nurse .strict handwashing . Review of a facility PN, dated [DATE] at 7:25 pm, by the Telehealth Nurse Practitioner (TNP #1) revealed the following: Resident #2 had Change in Condition .Resident became very agitated. Throwing things at staff, danger to self and others .Onset: few minutes ago. wandering in other pt's [patient's] room, became agitated throwing things at everybody and other residents, hot drinks and can of soda, running up and down and not able to contain [Resident #2]. Nurse says sometimes agitated but 'never like this'. Nurse says [Resident #2] tried to hurt others physically .ASSESSMENT/DIAGNOSIS: Unspecified Mood Disorder .Restlessness and Agitation .and Violent behavior .General Assessment/Diagnosis Plan Notes:-stat psyc [psychiatric] eval in ER [emergency room ]; 1:1 monitoring until EMS arrives for transport . Review of a facility PN, dated [DATE] at 8:00 pm, Registered Nurse (RN #1) documented &;20pm [7:20] call from third floor for an emergency. When I arrived pt [patient] was screaming 'I'm going to kill them and theyre going to kill me. We attempted to calm pt [patient] down. Hit this writer in head with a full water bottle. All residents placed in their room with doors closed. pt [patient] attempting to get into rooms and screaming 'They're going to kill us'. Call placed to 911, telehealth made aware we were sending [gender for a psych eval at [hospital emergency room ]. [Family members] came and [family members] were placed in the day room with the doors closed. Pt [Patient] calmed down with them here. Call placed to [hospital emergency room ]. Police and ambulance transported [gender] to [hospital]. Review of the CP did not include any indication that interventions were implemented to address the aggressive behavior displayed on [DATE]. Review of the HR, psychiatry consult, dated [DATE] at 2:54 pm, revealed that Resident #2 was brought in the ED [emergency department] for aggressive and violent behaviors, [gender] has been a resident at [facility] since [DATE], reportedly [gender] has been having physical outburst, according to staffs [gender] has frequent behavioral outbursts. The Order Summary Report (OSR), dated [DATE], reflected that the Valproic 250 milligram (mg), give 5 milliliter (ml) was increased from every 12 hours to every 8 hours for Dementia with Behavioral Disturbance. There was no indication in the MR that behavior monitoring was initiated when the medication was changed on [DATE]. Review of the TASK form for the month of ,d+[DATE] indicated that CNAs were to monitor Resident #2's behavior every shift. The TASK form for monitoring was not signed/initialed as completed on the following dates and shifts after Resident #2 returned from the hospital: [DATE], [DATE], [DATE] during the shift of 7:00 am to 3:00 pm on, [DATE], [DATE], and [DATE] during the shift 3:00 pm to 11:00 pm, and [DATE] during 11:00 pm to 7:00 am which was not according to the Charting and Documentation policy. On [DATE] at 3:15, unit manager LPN (UM/LPN #3), who was the nurse for Resident #2 on [DATE], documented that at 2:30 pm Resident #2 was in his/her room, at 3:05 pm, another resident was walking down the hallway when Resident #2 slapped the resident causing Resident #1 fall to the ground and sustained an abrasion near the right eyebrow and temple area. On [DATE] at 4:53 pm, Nurse Practitioner (NP #1) documented Called to Maple floor stat. Patient seen on bed with ,d+[DATE] staff members monitoring and maintaining his position and location in the room after he randomly struck another resident. [Resident #2] appears agitated and restless but otherwise appears medically stable. Of note, patient just returned from the hospital on [DATE] s/p [status post] psych eval for similar aggressive behaviors. [Resident #2] was treated for UTI and completes oral ABT [antibiotic therapy] tomorrow. NP #1 further documented that her Impression/Plan: Patient with mood disorder and dementia exhibiting recurrent agitation and aggression towards staff and another resident. Day #,d+[DATE] Keflex for UTI in progress. ER [emergency room ] for psych and medical evaluation and treatment. Further review of Resident #2's medical record (MR) revealed there was no documented evidence that Resident #2's behavior was being monitored consistently after the incident on [DATE] when there was a change in condition or when the medication, Depakote was changed on [DATE]. During the tour, the surveyor conducted an interview with residents who were alert and oriented. On [DATE] at 12:59 pm Resident #5 stated that Resident #2 was a difficult resident, he/she walked around the unit and entered other resident's room, Resident #2 would lay down on other residents' beds and staff would just redirect him/her. Resident #2 hit staff and other residents for no reason including him/her. Resident #5 further stated that Resident #2 also threw a chair at one point (unable to recall time and date). Resident #5 revealed that he/she did not report the incident to the facility because the staff were aware of the resident's behavior. During an interview with the surveyor on [DATE] at 12:45 pm. Resident #6 stated that resident #2 walked around the unit, he/she would go into other residents' room and sleep on other residents' beds, he/she gets upset and hits staff and other residents when [he/she] does not get what [he/she] wants. Resident #6 stated, approximately ,d+[DATE] weeks ago between 2:30 pm to 3:30 pm, Resident #2 entered Resident #6's room, Resident #6 asked Resident #2 to leave the room, Resident #2 hit Resident #6's shoulder and walked out of the room. Resident #6 stated that he/she never reported the incident to the facility because this was a resident's normal behavior and that the staff were aware of his/her behavior. The surveyor conducted an interview with CNA #1 on [DATE] at 9:27 am. The CNA stated that she documented the residents' behavior in the Kiosks (kiosk or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation). She stated that not all residents were being monitored, only those residents that appear in the Kiosks. She explained that a questionnaire would appear, and CNAs had to indicate if behavior occurred by answering Y for yes and N for no. She also explained that the Kiosks had to be answered and cannot be left blank to indicate that the behavior was being monitored. The surveyor conducted an interview with CNA #2 on [DATE] at 2:00 pm. The CNA stated that she documents residents' behavior in the Kiosks but not for all residents, only when being asked in the Kiosks. She explained that a questionnaire will appear, and the CNA had to indicate if behavior occurred by answering Y for yes and N for no. She stated that sometimes she documents in the Kiosks and at times she forgets or had no time to sign the Kiosks. The surveyor conducted an interview with the UM/LPN #3 on [DATE] at 11:07 am. The LPN stated that CNAs should document the task provided at the end of the shift and unit managers should ensure that the CNAs document to indicate that the care was provided to the residents. However, the LPN was unable to explain why the CNAs were unable to complete their documentations. The surveyor conducted the interview with the DON on [DATE], [DATE], and [DATE]. The DON stated that Resident #2's CP was updated for UTI management on return from the hospital on [DATE]. However, the CP for Resident #2's behavior that happened on [DATE] was not created because the residents' behavior was related to the diagnosis of UTI. The DON also stated that if there was a change in medications, staff should monitor and document resident's behavior for 14 days, every shift, in the MR whether the resident's had a behavior or not. The DON was unable to provide a consistent monitoring documentation when the resident's medications were changed on [DATE]. During an interview with the surveyor on [DATE] at 9:00 am, UM/LPN #3 stated that the nurses are only to document residents' behavior in the residents MR when a behavior occurred. He further stated that nurses are not required to document in the MR if the resident had no behavior. He explained that they have no documentation indicating that the residents' behaviors were being monitored every shift consistently. However, on [DATE] at 11:36 am, the LPN stated that when there is a change in condition such as a change in medication or having aggressive behaviors, the staff had to monitor the resident and document in the resident's MR. He further added that documentation is important to see if a new intervention is effective or not and to show that the intervention is being implemented and it is part of communication. UM/LPN #3 was not able to explain why Resident #2's behavior documentation was not done. During an interview with the surveyor on [DATE] at 9:15 am, UM/LPN #3 stated that the CP is a way of communication, as it summarizes the residents overall care, and should be individualized and patient centered. The CP had to be updated by the unit managers (UM), Supervisor, and DON within 48 hours for any change in condition including but not limited to, a fall, any incident, altercation, skin tear, or behavior. He further stated that it is important to update the CP to give proper care and to prevent from any recurrence. UM/LPN #3 explained that Resident #2's CP should have been updated for behaviors and medication change on return from the hospital on [DATE]. LPN was not able to provide an updated CP to address the resident behavior on [DATE]. 2.) During the survey on [DATE], the surveyor reviewed the facility's reportable event records for the past 3 months. The surveyor reviewed the RERR dated [DATE] involving Resident #7 and Resident #8. The RERR revealed that a resident-to-resident abuse was reported to the NJDOH on [DATE]. The attached summary indicated that on [DATE] at approximately 2:00 pm, the staff witnessed Resident #7 not allowing Resident #8 to enter their room. Resident #7 pushed Resident #8 and in return, hit Resident #7 in the back. They were separated and neither resident sustained injury. Resident #8 was offered a room change, Resident #8 declined, and the family did not like the room. It further indicated that the facility would actively work on other room options that would be appropriate. The conclusion indicated, this appears to be an isolated event. The residents have been roommates for a few months and have had no issues up until now. The room changes will be done as a precaution. On [DATE], another resident-to-resident abuse/physical altercation involving Resident #7 and Resident #8 was reported to the NJDOH. During the survey on [DATE], the surveyor reviewed the facility's RERR. Review of the RERR revealed that on [DATE] at approximately 11:00 am, staff at the nursing station heard Resident #7 yell. When staff responded, Resident #7, while exiting the room, stated that Resident #8 hit his/her hand. The incident was unwitnessed. Resident #7 was unable to provide context, and Resident #8 asked the staff to leave the room. Neither resident had injury, redness, or bruise. The interventions implemented after the incident included: Resident #8's room will be changed. Both resident's behavior will be monitored and referred for Psychiatric evaluation. It further indicated that this was the second minor incident between the resident. Both residents are ambulatory with Dementia and getting them out of each other's proximity should manage the behavior. 2a). Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The MDS dated [DATE] and [DATE] revealed a BIMS score of 7, which indicated severely impaired cognitive status, and the Resident was independent and required minimal supervision with ADLs. The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from [DATE]. The Medication Administration Record (MAR) revealed that Resident #7 received Sertraline for Depression from [DATE] to [DATE]. Additionally, the medication Depakote for Dementia with Behavioral Disturbance was started on [DATE] and the dosage was increased on [DATE] and [DATE]. Review of the PN revealed no documented evidence that the nurses consistently monitor Resident #7's behavior after the Depakote was increased on [DATE] and [DATE] when it was indicated in the facility's policy that if a resident is being treated for problematic behavior or mood, the staff will document ongoing reassessments of changes (positive or negative). Furthermore, the PN revealed documentation dated [DATE] at 2:15 pm about Resident #7 and Resident #8 physical altercation. The residents were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. The PN revealed no documented evidence that the nurses consistently monitored Resident #7's behavior after the physical altercation. The revised care plan dated [DATE] revealed that Resident #7 is possessive of his/her room and does not want people to enter. Goals and interventions included but were not limited to: Resident will not harm self or others; resident will verbalize understanding of the need to control physically aggressive behavior; when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly, if the response is aggressive, staff to walk calmly away and approach later. The care plan indicated that Resident #7, who had severely impaired cognition and a diagnosis of Dementia, would verbalize understanding of the need to control physically aggressive behavior. However, there was no indication in the CP how Resident #7 would be monitored while in the room with the roommate (Resident #8) where the physical altercations occurred. The facility's policy for behavior management indicate that interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms as well as the potential situational and environmental reasons. Additionally, the policy included that the care plan will include but was not limited to targeted and individualized interventions for the behavioral symptoms, specific, measurable goals for the targeted behavior and how the staff will monitor for effectiveness of the interventions. The PN revealed that on [DATE] at 10:55 am, the UM/LPN #3 documented that Resident #7 and Resident #8 had another physical altercation in the room and unwitnessed. During an interview with the DON on [DATE] at 12:57 pm and UM/LPN #3 on [DATE] at 2:50 pm, they both confirmed that the physical altercation took place in the residents' room, and it was unwitnessed as the residents were not monitored in the room by the nursing staff at that time. The DON further confirmed on that same date at 4:10 pm that the room change for Resident #8 was not attempted again until after the physical altercation recurred on [DATE]. She stated that the physical altercation on [DATE] was considered a minor and isolated incident and Resident #8 refused to transfer to another room. Review of the task form for the month of ,d+[DATE] indicated that CNAs were to monitor for behavior symptoms every shift which included but were not limited to yelling/screaming, kicking/hitting, pushing, and abusive language. Resident #7's task form was not signed/initialed for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE], and [DATE] to [DATE]. For the month of ,d+[DATE] for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; 11:00 pm to 7:00 am on [DATE], [DATE] to [DATE], [DATE], [DATE], and [DATE] to [DATE]. During an interview with CNA #1 on [DATE] at 11:01 am, she stated that CNAs are expected to monitor residents' behavior and document in the kiosk, ADL records task for behavior monitoring. She further said that CNAs are responsible for completing the task at the end of the shift and if incomplete or blank, it did not happen. During an interview with the DON on [DATE] at 12:57 pm, she stated that CNAs document resident's behavior in the kiosk or ADL record. She further stated that CNA observations and documentations are considered valuable they do not replace nurses observation and documentation. 2b. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia and Hypertension. The MDS dated [DATE] and [DATE] revealed a BIMS score of 3, which indicated severely impaired cognitive status, and the Resident required supervision to minimal assistance with ADLs. The nursing PN dated [DATE] at 1:04 pm indicated that Resident #8 was combative with staff and other residents. Resident wanders around the hallway and goes in and out of other residents' rooms. Redirection unsuccessful. The nursing PN dated [DATE] at 8:30 pm indicated that Resident #7 was physically and verbally abusive to staff and residents. The Resident was not easily redirected but finally agreed to go to bed. The CP initiated on [DATE] indicated that Resident #8 may present with a depressed mood related to his/her recent admission to the facility and his/her overall condition. Goals and interventions included but were not limited to: Resident #8 will have improved mood state, such as being happier, having a calmer appearance, and showing no signs and symptoms of depression, anxiety, and or sadness. Behavioral Health consults as needed. Monitor/document as needed risk for harm to self: suicidal plan, a past attempt at suicide, risky actions, intentionally or tried to harm self, sense of hopelessness, and impaired judgment or safety awareness. Monitor/record/report to MD (Medical Doctor) as needed risk for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone Review of the PN revealed documentation by the Social Worker (SW) on [DATE] at 10:32 am that Resident #8 was transferred to another room because of incompatibility with the roommate (Resident #7). The RP was made aware of the room change and staff to monitor the adjustment. However, the PN revealed no indication that the room change occurred or Resident #8 was monitored by the nurses for adjustment after the room change. Additionally, there was no documented evidence in the PN explaining what led to the room change. Further review of the PN revealed documentation dated [DATE] at 2:15 pm that Resident #7 and Resident #8 had a physical altercation. They were separated and assessed. The event was reported to the DON, Administrator, and Assistance Administrator. On that same date at 2:53 pm, the SW notified the RP and agreed to move Resident #8 to another room. Review of the MR on [DATE] revealed no documented evidence that the nurses consistently monitored Resident #8 for safety after the physical altercation on [DATE]. In addition, there was no documented evidence that Resident #8 was offered another room change after the resident refused on [DATE] when it was indicated in the RERR summary that the facility staff would actively work on room change options. Review of the PN on [DATE] revealed documentation on [DATE] at 10:55 am about another physical altercation between Resident #7 and Resident #8. The PN indicated that Resident #7 and Resident #8 who had a physical altercation [DATE] continued to share the same room until another resident-to-resident abuse/physical altercation on [DATE]. During an interview with the SW on [DATE] at 11:30 am, she stated that Resident #8 was transferred to another room after the physical altercation on [DATE]. The resident's RP had agreed to the room change but the resident would not stay in the new room, so he/she remained in the same room with Resident #7. The SW confirmed that Resident #8 transferred again to another room after the altercation on [DATE], and Resident #8 had adjusted well to the new room. However, she could not explain why the room change was not attempted again as a precaution when it was indicated in the RERR summary on [DATE] that the facility would actively work on other room options that would be appropriate. Additionally, she could not explain what led to the room change on [DATE] but stated that Resident #7 was very territorial and due to incompatibility During an interview with the surveyor on [DATE] at 11:36 am, LPN #3, unit manager (UM) for Resident #7, could not remember a room transfer for Resident #8 on [DATE]. The revised care plan dated [DATE] for Resident #8 revealed that Resident #8 is at risk for potential negative interaction from or with a resident on the unit who has demonstrated poor impulse control. Goals and interventions included but were not limited to: Resident #8 will be free from danger and injury related to interaction with others; behavior documentation and psychiatric evaluation as needed; maintain a safe distance from the other aggressive or triggered residents; monitor Resident #8 whereabouts for safe interactions with peers. A review of the MR on [DATE] revealed no documented evidence that the nursing staff consistently monitored Resident #8 behaviors, interactions with other residents, and whereabouts as indicated in the revised care plan on [DATE]. Review of the task form for the month of ,d+[DATE] indicated that the following dates and shifts were not signed/initialed: 7:00 am to 3:00 pm [DATE] to [DATE] and [DATE] to [DATE]; 3:00 pm to 11:00 pm on [DATE] to [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], and 11:00 pm to 7:00 am on [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], and [DATE] to [DATE]. For the month of ,d+[DATE] for the following dates and shifts: 7:00 am to 3:00 pm on [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]; 3:00 pm to 11:00 pm on [DATE], [DATE], [DATE] to [DATE], [DATE] [TRUNCATED]

Complaint #: NJ00160765, NJ00160776 NJ00160791, NJ00161051 Based on interview, medical records (MR) review, and review of pertinent facility documents on 1/20/23, 1/23/23, 1/27/23, 2/2/3, and 2/7/23, it was determined that the facility failed to ensure that a.) a resident with known history of behaviors of wandering and repeatedly attempted to open the medication cart was adequately supervised and had appropriate care plan in place and b.) an incident or accident was reported immediately to the nursing supervisor (NS) or the Director of Nursing (DON) in accordance to the facility's reporting policy for incidents and accidents for 1 of 3 residents (Resident #7) reviewed for incident and accident. The deficient practice was evidenced by the following: 1.According to the Admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dementia with agitation, Major Depressive Disorder, and Anxiety Disorder. The Minimum Data Set (MDS), an assessment tool dated 10/20/22, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated a severely impaired cognitive status and the resident required minimal supervision with Activities of Daily Living (ADL). The MDS indicated that Resident #7 exhibited physical and verbal behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, yelling, cursing) 4 to 6 days during the 7 days, counting back from 10/20/22. The Physician's Order Summary Report (OSR) reflected that Resident #7 was receiving the following supplements: Multiple Vitamins-Minerals One a day and Ocuvite-Lutein, Probiotic Acidophilus Bio Beads, Potassium, Vitamin D3, Cranberry tablet, and Glucosamine. A review of the nursing progress notes (PN) revealed the following documentation: On 10/7/22 at 10:10 PM, Licensed Practical Nurse (LPN) #6 documented that Resident #7 tried opening the nurse's medication cart. On 10/15/22 at 3:32 PM, LPN #8 documented that Resident #7 was very aggressive, trying to pull medications from the medication cart several times. On 10/18/22 at 11:01 PM, LPN #5, documented despite all due medications given, the Resident kept asking for more and tried to open the medication cart. Additionally, the PN revealed the Resident attempted to open the medication cart on 10/22/22, 10/27/22, 10/31/22, and tried to enter the medication room on 10/30/22. There was no indication in the MR that the abovementioned recurring behavior of Resident #7 was addressed in the care plan. On 12/6/22 at 10:32 PM, LPN #6 documented the following in the PN: Resident #7 was in bed sleeping, drowsiness when awakened, was unusually calm. Licensed practical nurse (LPN) #6 and LPN #5 found three bottles of supplements, supplements were removed and educated the Resident who had a severe cognitive impairment not to keep medication in his/her room for safety. LPN #6 took the Resident's vital sign (VS) and recorded them in VS section of the MR. There was no documented evidence in the PN that the medication cart was locked at the time of the incident, that an investigation was initiated to ensure that all medication carts and medication room on the unit were secured and locked and determine how the unknown supplements were obtained, that an RN conducted a comprehensive assessment, that the NS or the DON was notified, that the PP or RP was notified, or the care plan was updated. Furthermore, there was no indication in the PN that the LPN provided continued observation of Resident #7 after the incident. A review of the care plan (CP) with a revision date 10/28/22 indicated the resident may do one the following, if it is not a problem for the resident, do not be concerned with: wandering .kicking and hitting med cart. Goals and interventions included but were not limited to: Resident will display positive behaviors and have decreased episodes of inappropriate behavior; Assess potential and trigger for aggression; Leave alone in a safe environment such as his/her room; Have psychiatrist/psychologist evaluate as needed and routinely. The CP did not reflect interventions of Resident #7's recurring behavior of attempting to open the medication cart or enter the medication room when it was initially documented on 10/7/22. The PN reflected that a quarterly interdisciplinary care plan meeting (IDCP) was held on 11/9/22, and it was documented that the care plans have been reviewed and are up to date. However, the behavior was not addressed in the care plan until 1/23/23. Review of the summary on the incident dated 1/24/23 with the DON's name stamp, unsigned, provided to the surveyor via email on 1/24/23 indicated the following: On 1/23/23 this writer was made aware that on 12/6/22 a nurse, LPN #6 discovered 3 bottles of supplements in a drawer of Resident #7. On 1/23/23, Resident #7's belongings were immediately checked, and no supplements of any kind were found. LPN #6 was interviewed and confirmed that she looked at the resident's drawer because the resident seemed drowsy and found the supplements, one was multivitamins with minerals and could not recall the others. Review of the resident's chart confirm that the vital signs were normal. The NS confirmed that she was not notified of the incident. The DON made the RP aware of the incident and the RP was not aware where the supplements came from. The DON asked Resident #7 who could not recall where the supplements came from. There was no documented conclusion, but it was indicated that it was unclear how the supplements arrived in Resident #7's drawer on 12/6/23. The surveyor reviewed the document Full QA Report Incident date/time: December 6, 2022, 5:00 PM forwarded by the DON post survey on 2/10/23. It was indicated on the form that LPN #6 was the assigned care giver and LPN #5 was the witness. The location of the incident was at the resident's room. There was no injury noted. Additionally, the form indicated that there was no staff interview, and the details of the incident was not documented. The form indicated that the Administrator and DON were not notified of the incident until 1/23/23. The surveyor reviewed LPN #6 signed written witness statement dated 1/23/23 forwarded by the DON post survey on 2/10/23. LPN #6 indicated that Resident #7 was sleeping around 5PM but the resident usually paces on the unit. Due to this, she awoke the resident and took his/her VS because Resident #7 was drowsy. LPN #6 indicated that she checked the resident's drawer and found supplements such as multivitamins with minerals and two others. She could not recall. She removed them and put them in the cart. The surveyor reviewed LPN #5's signed and undated written witness statement, forwarded by the DON post survey on 2/10/23. LPN #5 wrote that LPN #6 asked her to check Resident #7's room because she thinks Resident #7 took something from the med carts. LPN #5 indicated nurse searched the room and found bottles of supplements in the drawer. The Resident was awake and responsive and walking on the unit. There was documentation in the MR indicating the Resident #7 was awake and walking in the unit. The document did not indicate that an RN assessed Resident #7, that the LPNs started an incident report, and the RP and PP were notified. On 1/23/22 at 1:20 PM, Resident #7 refused an interview with the surveyor. During a telephone interview with the surveyor on 1/23/23 at 2:01 PM, LPN #6 stated that on 12/6/22, during her medication pass at approximately 5:00 PM, Resident #7 was not wandering out of the room, which she stated was unusual. Because of that, she decided to check on the resident with LPN #5. Resident #7 was found in bed sleepy, drowsy when awakened, not aggressive, and unusually calm, and for that reason, she searched the room. While searching, LPN #6 found three bottles of supplements in the resident's nightstand drawer. LPN #6 explained that she took the Resident's VS, which she stated was normal, and placed the supplements in the medication cart. She said that Resident #7 was not assessed by a RN. She further explained that she left the supplements in the medication cart for the night shift but was unable to confirm that incident was reported to the oncoming nurse. LPN #6 could not confirm if she reported the incident to the NS or the DON and could not answer when the surveyor asked why the supplements were not given to the supervisor at the time when she reported the incident. Additionally, LPN #6 stated that she could not recall the name of the supplements. LPN #6 further stated that Resident #7 had tried opening the medication cart before, but it was locked. It was confirmed during interview that she did not initiate an investigation to determined how Resident #7 obtained the medications or if all the medication carts on the unit were secured and notify the PP or RP. However, she stated that nurses are responsible for informing the PP or RP of changes in condition, incident, accident, and initiating an incident report. LPN #6 acknowledged that she should have called the PP and started an incident report. During a telephone interview with the surveyor on 1/30/23 at 1:10 PM, LPN #5 stated that she was in the room when LPN #6 found bottles of supplements or medications in the nightstand drawer. LPN #5 could not recall how many bottles or the names of the medications, was unaware where LPN #6 placed them and was unsure if LPN #6's medication cart was locked at the time of incident. She was unsure if the incident was reported to the oncoming nurse but confirmed that she did not report the incident to the NS or the DON, notify the PP or RP or initiate an investigation as she was busy with her residents. LPN #5 stated that the incident should have been reported to the NS immediately to ensure the resident's safety. During a telephone interview with the surveyor on 2/6/23 at 11:28 AM, the PP stated that she was unaware of the incident on 12/6/22 when Resident #7 was found drowsy when awakened and at the same time bottles of unknown supplements/medications were found in the resident's nightstand drawer. She explained that some residents can self-administer medications with the PP's order, but not Resident #7, due to his/her cognitive status. She further explained that she expects nurses to call her for any incident or accidents and changes in resident's condition so that she can make appropriate clinical decisions. She added that Resident #7's nurse should have notified her about the drowsiness and the medications found in the resident's room, regardless of the type of medication. During an interview with the surveyor on 1/23/23 at 2:24 PM, RN #2, NS on 12/6/22 confirmed the abovementioned incident was not reported to her. She explained that nurses are responsible for notifying the NS or DON when incidents or accidents occur, calling the PP and RP for changes in condition, and initiating an incident report or investigation and stated that LPN #6 should have immediately reported the abovementioned incident to her. During an interview with the surveyor on 1/23/23 at 11:36 AM and telephone interview on 2/10/23 at 10:24 AM, LPN #3 who was the unit manager (UM) for Resident #7, stated that he was unaware about the incident on 12/6/23 or Resident #7's abovementioned recurrent behavior. He explained that nurses are responsible for initiating or updating care plans. However, not all nurses know how to create or update CP. During an interview with the surveyor on 1/23/23 at 3:50 PM, the DON stated that nurses did not notify her or the NS about the abovementioned incident that occurred on 12/6/22. She explained that nurses are expected to report any incident/accident to the NS and initiate an incident report immediately. Also, nurses are expected to notify the RP and PP of changes in condition and when an incident or accident occurs. The DON acknowledged that LPN #6 should have immediately reported the incident to the nursing supervisor and started an incident report/investigation. During an interview with the surveyor on 1/27/23 at 1:55 PM, the Administrator stated that nursing staff must report incidents and accidents immediately to the supervisor unless it's an emergency then the DON or the Administrator must be notified immediately. The Administrator stated that he was unaware of the abovementioned incident. The surveyor asked if the incident was reported to him since the DON began the investigation on 1/23/23. The surveyor explained the details of the incident to the Administrator then he stated that he would have to look because he was not sure of the specifics. The Administrator confirmed the nurse should have followed the protocol for incident and accidents which include reporting to the NS, and notification of PP and RP. Review of an undated facility policy titled Accidents and Incidents; under Policy Interpretation and Implementation indicated 1. The Nurse Supervisor/Charge Nurse .shall promptly initiate and document investigation of the accident or incident. 2. shall be included in the report .a. the date and time .b. the nature of the injury .g. the date/time attending physician was notified as well as the time the physician responded .h. the date/time the family was notified and by whom .3. The Nurse Supervisor/Charge Nurse .shall complete a Report of Incident/Accident form and submit to the Director of Nursing Services within 24 hours . Review of the facility policy titled, Behavior Assessment and Monitoring undated, under Policy Statement indicated 1. Problematic behavior will be identified and managed appropriately .under Assessment 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including a. onset, duration, and frequency .or changes in behavior, cognition, and mood . Review of the facility policy titled, Acute Condition Changes-Clinical Protocol undated, under Assessment and Recognition indicated that nursing staff will contact the Physician .for emergencies, they will call or page the Physician and request a prompt response. Under Monitoring and Follow-Up it indicated that staff will monitor and document the resident's progress and responses to treatment . Review of the facility policy titled, Care Plans-Comprehensive undated, under Policy Statement indicated that an individualized, patient centered, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, mental, and psychological needs is developed for each resident consistent with the Resident's rights. Under Policy Interpretation and Implementation indicated 1. Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident .3. Each resident's comprehensive care plan has been designed to: a. incorporate identified problem areas .d. reflect treatment goals and objective and measurable outcomes .5. Care plans are revised as changes in the resident's condition dictate, care plans are reviewed at least quarterly . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident (Resident #169) who had a physician's order for continuous oxygen was properly identified, assessed, re-assessed, and monitored for smoking after the resident was noted to be smoking in the bathroom on three separate occasions on 4/18/21, 4/30/21 and 6/11/21. Further, the facility failed to address the smoking violations in accordance with their smoking policy and revise the resident's care plan to ensure safe smoking practices. The facility's failure to revise and implement a care plan to avoid a smoking accident while the resident had a physician's order for continuous oxygen and was found to be smoking in the bathroom on the three occasions created an unsafe environment for serious injury, combustion, and fire. This posed a serious and immediate threat to the safety and well-being of all the residents in the facility residing on 4 of 4 resident care units (Cedar, Maple, Oak, and Willow unit) which resulted in an Immediate Jeopardy (IJ) situation. The facility Administration was notified of the Immediate Jeopardy situation on 6/15/21 at 2:14 PM. The IJ began on 4/30/21 upon the second smoking violation incident and continued until 6/16/21, when the facility alleged complete implementation of the elements in their IJ Removal Plan, accepted on 6/16/21 at 4:00 PM and verified by the survey team on 6/16/21 and throughout the remainder of the Recertification Survey. The evidence was as follows: On 6/8/21, between 10:27 AM, the surveyor conducted an Entrance Conference with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator, and the Director of Nursing (DON). Included as part of the Entrance Conference, the surveyor requested a copy of a list of residents who smoked at the facility. The surveyor reviewed the list of residents identified to be smokers provided by the LNHA. The list of smokers did not include Resident #169. On 6/8/21 at 11:33 AM, during the initial tour of the facility, the surveyor observed Resident #169 in their semi-private room with no assigned roommate. The surveyor observed an oxygen concentrator (a device that supplies oxygen for supplemental use) in the room, and it was turned to the off position. The surveyor interviewed Resident #169, who stated that they used the oxygen once in a while. On 6/11/21 at 9:29 AM and 6/14/21 at 11:21 AM, the surveyor observed that Resident #169 was not using the supplemental oxygen, and the oxygen concentrator was turned to the off position. The surveyor reviewed the medical record for Resident #169. A review of the Admission Record face sheet (an admission summary) revealed that Resident #169 was admitted with diagnoses that included: shortness of breath (SOB), [CONDITION(S)] ([CONDITION(S)]) (a group of lung diseases that block airflow and make it difficult to breathe), pleural effusion (a build-up of fluid between the tissues that line the lungs and chest) and end-stage renal disease. A review of an initial Smoking Safety Screen dated 7/29/20 reflected that the resident smoked 1-2 cigarettes per day in the morning but could not light their cigarette and required supervision with smoking. The note on the smoking screen indicated that the resident had subsequently, quit smoking. A review of the admission comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/4/20 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the resident had an intact cognition with some forgetfulness. The MDS assessment further revealed that the section used to assess if the resident was a smoker reflected that they were not a current tobacco user. A review of the most recent MDS dated [DATE] reflected that the resident had BIMS score of 15 out of 15, indicating the resident had a fully intact cognition. A review of the resident's individualized comprehensive care plan initiated on 8/13/20, reflected that Resident #169 was a former smoker and not interested in smoking at this time. It further reflected that the resident had quit smoking. The goal indicated that the resident would be smoke-free through the next review date, with a single intervention to provide check-in visits to see how they were doing. The care plan further reflected that the resident was on oxygen therapy related to a respiratory illness of [CONDITION(S)] initiated 7/29/20. Interventions included to administer the oxygen at 2 liters per minute via nasal cannula. A review of the physician's order sheet (POS) reflected that the resident had a physician's order (PO) dated 8/26/20 for a nicotine patch discontinued upon hospitalization on [DATE]. The nicotine patch was re-ordered by the physician on 9/23/20 and discontinued on 9/26/20. There were no other subsequent physician orders for a nicotine patch. Further review of the POS reflected a physician order dated 2/16/21 to administer two liters of supplemental oxygen continuously every shift via the nares using a nasal cannula for shortness of breath (SOB). The surveyor reviewed the electronic Progress Notes (ePN) for April, May, and June 2021, which reflected that the resident had three incidents of smoking in the bathroom. The Behavior Notes written within the ePN reflected the following: An ePN dated 4/18/2021 at 2:53 PM included that the Resident was smoking in the bathroom. The Licensed Practical Nurse (LPN) documented that she asked the resident why they were smoking in the bathroom, but the resident denied doing it. No other details were documented in the ePN regarding the smoking paraphernalia, notification to the physician or chain of command, and the resident's use of oxygen during the alleged incident. A review of the electronic Medication Administration Record (eMAR) for April 2021 reflected the PO dated 2/16/21 to continuously administer supplemental oxygen at 2 liters per minute. The eMAR was signed to reflect that the resident received the supplemental oxygen continuously via nasal cannula every shift on 4/18/21. A review of the comprehensive individualized care plan initiated 8/13/20 reflected that the care plan for smoking was not updated after the alleged smoking violation incident on 4/18/21 until nine days later on 4/27/21, which indicated to educate resident as needed on the dangers of smoking while being on O2 [oxygen]. There was no documented evidence in the medical record that reflected that the resident received the education on the dangers of smoking while being on oxygen and how they responded to the education since the first alleged incident on 4/18/21. The surveyor reviewed the second smoking violation incident documented in the ePN dated 4/30/21 at 2:21 PM. The note indicated that the same LPN wrote the following Behavior Note: Resident was smoking in the room, oxygen in use, resident denied, social worker, informed. There was no subsequent re-assessment for smoking for Resident #169 after the first smoking violation. A review of the ePN dated 4/30/21 at 3:08 PM, reflected that the Social Worker (SW) wrote that two social workers performed a room search and confiscated a full pack of cigarettes and matches. The Behavior Note indicated that the resident denied smoking in the room and stated they go outside to smoke. The SW continued, Writer re-educated the resident on the smoking policy, and at this time, there is no smoking. The SW concluded the note by documenting that the resident was aware of all the above. A review of the eMAR for April 2021 reflected the PO dated 2/16/21 to continuously administer supplemental oxygen at 2 liters per minute. The eMAR was signed to reflect that the resident received the supplemental oxygen continuously via nasal cannula every shift on 4/30/21. A review of the comprehensive individualized care plan initiated on 8/13/20 reflected that the care plan for smoking was not updated after the alleged smoking violation incident on 4/30/21 until nearly a month later on 5/26/21, which indicated a new intervention to offer the resident a Nicotine patch. The eMAR for April 2021 and May 2021 was signed every shift that the resident continued on supplemental oxygen continuously on 4/30/21. There was no documented evidence that the resident had a physician's order or received a Nicotine Patch. A review of a Care Plan Meeting Note within the ePN dated 5/26/21 and authored by the Activities Director (AD) reflected that the Resident was unable to attend care planning meeting as [Resident #169] was in the shower. The AD also documented in this progress note that, Resident is a smoker, has not smoked the last few months d/t [due to] Covid -19 restrictions and guidelines. The resident had one violation of smoking in [their] room and was educated. Resident is non-compliant with medical advice. The surveyor reviewed that a third smoking violation incident occurred on 6/11/2021 when an SW wrote a Behavior Note in the ePN timed at 4:09 PM for Resident #169. The note reflected: Writer received a call smoke smelled coming from room. Myself and Admin [Administrator] conducted a room search with resident present. The SW quoted the resident, who stated, I just lit it in the bathroom and put it out in the toilet. The Behavior Note concluded that the resident handed over a lighter willingly. No other smoking materials found after search completed. The eMAR for April, May, and June 2021 was signed every shift that the resident continued to receive supplemental oxygen at 2 liters per minute via nasal cannula continuously in accordance with the physician's order, including on the date of the third smoking violation on 6/11/21. A review of an ePN Behavior Note dated 6/11/2021 at 4:51 PM reflected that the Director of Nursing (DON) documented that Daily room checks will be done over the weekend to ensure no smoking paraphernalia is found. A review of the comprehensive individualized care plan initiated on 8/13/20 reflected that the care plan for smoking was not updated until 6/14/21, after the alleged smoking violation on 6/11/21. The surveyor continued to conduct interviews with facility staff. The following was revealed: On 6/14/21 at 1:49 PM, two surveyors interviewed the SW regarding her responsibility with residents who smoke. The SW stated that her only involvement regarding residents who smoke was to provide smoking counseling and conduct a room search. The SW added that she would offer counseling regarding issues with smoking and reiterate to the resident the facility's rules and smoking requirements. The surveyor inquired if incident reports or any type of investigation were conducted for any smoking violations. She replied that the incident report would be filled out if needed if there was a smoking violation. She stated that she completed incident reports within the electronic medical record, specifically in the electronic Progress Note section. The SW said that the ePN would get attached to a 24-hour report (a shift-to-shift nursing report to communicate incidents or changes in resident condition). The SW continued that nursing staff would then know by reading the 24-hour report that they would have to go by the resident's room to make sure they didn't smell anything unusual like smoke. She stated that they would conduct a room search if necessary. The SW added that the smoking privileges would be taken away for 24 hours after the first offense. After the second offense, they would lose their privileges for a few days. The SW further stated that the consequences were spelled out in the smoking policy, which was given to all residents who smoke. She then stated, We all know what the rules are. She explained that the Recreation Department was in charge of the smoking program. The SW explained that the Activities Director (AD) distributed the list of smokers to all the nursing units. Resident #169 was taken off the list because he/she was on continuous oxygen. The SW clarified that as of recently, the resident no longer needed continuous oxygen, and therefore they were allowed to smoke. She stated that the resident's name was subsequently put back on the facility list of residents who smoke. On 6/14/21 at 2:11 PM, the surveyor interviewed the AD, who indicated that Resident #169 was not on the smoking list because they weren't cleared to smoke until today (upon surveyor inquiry). She stated that they just reached out to the Attending Physician to add Resident #169 to the smoking list because they were cleared to smoke. When asked if there had been any violations during smoking, the AD was unaware whether-or-not Resident #169 had violated any smoking rules. The AD stated that nursing did an initial smoking screen upon admission and that the resident would need a further smoking assessment before being placed on the smoking program. She further stated that Physical Therapist would complete a safety screen for residents who qualified and wanted to smoke. She stated that she also did an initial assessment that was activity-based. The AD added that residents would sign their names in a book outside when smoking in addition to signing a smoking contract. The AD stated that Resident #169 was not in the smoking program because he/she did not qualify. She explained that the resident kept saying that they did not smoke, and so he/she was not on the smoking list. The AD stated that Resident #169 always stated to her that he/she previously quit but had now just re-started smoking. When asked about smoking violations and consequences, the AD explained that the first violation would result in resident education and warning. She stated that if the resident was not on the smoking list and had a smoking violation anyway, the resident could still get consequences if necessary. The AD continued that for the second violation, the resident would lose privileges for one day, and for the third violation, privileges would be lost for three days. The AD concluded that Resident #169 now has a smoking contract. She stated that the resident was not smoking in April 2021 and had just started [smoking] today, on 6/14/21. On 6/15/21 at 9:02 AM, a second surveyor observed five residents with the Recreation Aide (RA) outside on the patio area where smoking was permitted. The surveyor interviewed the RA, who stated that he had a binder with smoking instructions for each resident, and each resident signed a Smoking Sign Off Sheet when taking a cigarette for the date and time. The RA added that smoking times were only at 9:00 AM and 1:00 PM because several activity programs were being done in the afternoon. The surveyor interviewed a resident (Resident #109) who was present smoking and stated that there had been additional smoking times in the past, but now the times were only 9:00 AM and 1:00 PM daily. On 6/15/21 at 9:30 AM, the surveyor conducted a second interview with the AD, who stated that she thought that the facility had stopped the smoking program in November or December 2020. She said that if staff smelled smoke in a resident room in a location not approved for smoking, they would contact the SW, who would counsel the resident and conduct a room search. When asked if she had any smoking violations on Resident #169, the AD just stated that the social worker would do a room search and an investigation. The AD did not answer the question regarding if Resident #169 had any smoking violations. The AD provided a copy of the facility's undated Smoking Policy which included the following: Due to the safety-related to non-compliance with the smoking policy, the following consequences will be enforced. Violations will include but are not limited to: Smoking in areas not designated for smoking, maintaining supplies/lighting materials that should be locked up, and/or smoking without supervision when assessment indicates otherwise. 1st violation-resident will be educated and given a warning. 2nd violation-resident will lose smoking privileges for one day. 3rd violation-resident will lose smoking privileges for three days. 4th violation-resident will lose smoking privileges for seven days. 5th violation-resident will lose smoking privileges in this facility. 6th violation-resident will have possible discharge from the facility. The surveyor reviewed that the Smoking Policy was signed by Resident #169 on 6/14/21. There was no documentation provided that revealed that Resident #169 signed a Smoking Policy or other smoking contract prior to 6/14/21. On 6/15/21 at 10:11 AM, two surveyors interviewed the DON and the LNHA. The DON explained that a smoking assessment was performed and documented on the Nursing Admission Summary. She stated that if the resident answered yes that they were a smoker, the facility would initiate screening, and a smoking assessment would be done, and the AD would further complete the smoking assessment. The DON also stated that the Therapy department would be incorporated into the assessment to determine if the resident could safely hold a cigarette. At that time, the LNHA stated, There was a period of time that we weren't allowing smoking due to the COVID-19 pandemic and the risk for the spread of infection, and instead were offering Nicotine patches. The LNHA elaborated that some residents had a desire to quit smoking. When asked specifically about Resident #169, the DON stated that he/she wasn't medically cleared to smoke. She continued that the resident denied smoking on the Nurse's Assessment. The DON then referenced the incident that occurred on 6/11/21: The incident last Friday. I physically smelled the cigarette. [Resident #169] lit it quickly and threw it away . This is why we're trying to get to the bottom of this. The LNHA concluded that they spoke to the nurse who wrote the note on 4/30/2021 and that the nurse did not see the resident smoking that day. He stated that his understanding was that cigarettes were only found and confiscated. The LNHA said, I was not aware that [Resident #169] was smoking in the room. We're trying to find out now. He then stated that as far as physically seeing the resident smoking .No one saw. On 6/15/21 at 10:30 AM, the DON presented the facility's investigations for Resident #169 since 4/1/21; The surveyor had requested these files on 6/14/2021. There was no investigation or report related to the Behavior Note dated 4/18/21 regarding the resident smoking in the bathroom. One new Interdisciplinary Care Plan Intervention was added on 4/27/21 to Educate resident as needed on the dangers of smoking while being on O2. This intervention was added nine days after the actual, alleged incident. The folder provided regarding the 4/30/21 incident contained two papers: one was a copy of the Behavior Note from the medical record written by the SW on that date. The other was an Employee Concern Report completed by the Assistant Administrator and signed by the LNHA on 4/30/21. The Detail of Concern was that cigarettes were found in Resident #169's room. Findings and Disposition: Removed smoking materials and complete room check done. Follow Up/If Applicable: Resident verbally educated that residents cannot have smoking materials in room as per our smoking policy. There were no other details provided within the investigation. There were no written statements from the LPN who discovered the resident smoking in the room while supplemental oxygen was in use or statements from any potential witnesses, including the resident. There was no investigation regarding where the resident may have obtained the smoking materials. The only intervention added to the resident's Care Plan was to Offer Nicotine Patch. This intervention was not initiated until 5/26/21, 26 days after the incident occurred. The only evidence in the medical record that the nicotine patch was offered to Resident #169 was dated ten months prior, on 8/25/20. The Care Plan Meeting Note dated 5/26/21 authored by the AD did not address that the resident was offered or refused a Nicotine Patch. It reflected that the resident was a smoker and has not smoked the last few months d/t [due to] Covid -19 restrictions and guidelines. The investigation of the third smoking violation incident on 6/11/21, which occurred within the dates of the Recertification Survey, included statements from witnesses including the DON, LNHA, SW, and AD. The resident's Interdisciplinary Plan of Care was revised regarding smoking on 6/14/21. There was a signed daily check of the resident's room for lighters, dated 6/12/21, 6/13/21, and 6/14/21. There was a smoking policy signed by the resident, dated 6/14/21. The Smoking Violation Review, dated 6/11/21, revealed that the facility considered this incident as the resident's Level 1: First Offense, requiring a Warning with education. There was no documentation that a first or second offense was issued for either the 4/18/21 or 4/30/21 incidents. On 6/15/21 at 11:10 AM, the surveyor attempted to conduct a phone interview with the LPN who wrote the Behavior Notes regarding Resident #169 smoking in the bathroom on 4/18/21 and 4/30/21. A message was left on the LPN's phone to contact the surveyor at the facility, but the LPN did not respond. On 6/15/21 at 11:15 AM, the LNHA presented a timeline regarding Resident #169, which included the following information: 7/29/2020: Smoking - Safety Screen completed. Resident quit smoking. 7/30/2020: Nurse Practitioner (NP) Progress Note: History of smoking not current [sic] smoking due to medical condition. 8/13/2020: Resident told recreation that [he/she] had quit smoking and donated [his/her] cigarettes . to another resident. 8/25/2020: Resident went outside during smoke times to smoke a cigarette. Recreation staff spoke with resident about smoking. Clinically smoking is not recommended. Resident agreed to nicotine patch. 8/27/2020: NP Note: Discussed smoking cessation program. 10/8/2020: NP Note: No current smoking. 11/15/2020: Covid outbreak-Smoking put on hold. 2/26/2021: Reviewed smoking changes due to Covid- Resident states [he/she] does not have cigarettes and does not ask for any. 4/18/2021: Resident found smoking in the bathroom. Resident denied. 4/30/2021: Resident found smoking in room -social worker informed. 4/30/2021: Social worker performed room search and confiscated full pack of cigarettes and matches. [Resident #169] denied smoking in the room and states [he/she] goes outside when [he/she] wants to smoke. Resident was re-educated on policy. 5/25/2021: Resident Council - Discussed re-implementing smoking. 5/26/2021: Recreation note summarizing smoking violation. 6/11/2021: Smelled smoke from room. Room search completed. Resident educated. Daily checks put into place for residents [sic] room for smoking paraphernalia. 6/14/2021: Restarted smoking and Smoking -Safety Screen updated. On 6/15/21 at 1:00 PM, the LNHA provided a written statement regarding a phone interview with the LPN who wrote the Behavior Notes for Resident #169. The statement revealed the following conversation that the LNHA had with the LPN: In the 4/18/21 Behavior Note statement, the LPN stated that she had smelled a strong air freshener smell and possibly smoke when in the resident's room. She asked the resident if they were smoking. Resident #169 denied smoking at the time. The statement did not indicate that a chain of command at the facility was made aware of the incident. In the statement for the 4/30/21 Behavior Note, the LPN stated that she smelled smoke from the resident's room. She found the resident in the bathroom, where she believed Resident #169 might have been smoking. The resident denied smoking. The oxygen concentrator was on in the room away from the bathroom. The Supervisor and Social Services were made aware. On 6/15/21 at 1:01 PM, the surveyor interviewed the Registered Nurse (RN), who stated that Resident #169 used supplemental oxygen when in the facility's lobby. She noted that the resident sometimes used the oxygen concentrator when in their room. On 6/15/21 at 1:10 PM, the surveyor interviewed Resident #169, who was observed smoking in the courtyard. The resident was not receiving supplemental oxygen at that time. The resident stated that he/she was offered a nicotine patch in the past and that he/she refused it, because it didn't work. The facility was notified of the Immediate Jeopardy (IJ) situation on 6/15/21 at 2:14 PM. The facility's LNHA and DON were informed that the facility's failure to ensure Resident #169, who had a physician's order for continuous oxygen, was properly identified, assessed, re-assessed, and monitored for smoking after the resident was allegedly noted to be smoking in the bathroom on three separate occasions on 4/18/21, 4/30/21 and 6/11/21. Further, the failure to address each of the smoking violations in accordance with their smoking policy, and revise the resident's care plan in a timely manner to ensure safe smoking practices, posed a serious and immediate threat to the safety and wellbeing of all the residents in the facility. The Removal Plan was accepted on 6/16/21 at 4:00 PM. The immediacy was removed on 6/16/21 based on the accepted implemented elements of the Removal Plan verified by the survey team on 6/16/21. The plan included the following: Removal Plan and Completion Date 6/16/21 On 6/11/21, members of the Interdisciplinary Team met with Resident #169 to review the smoking violation and conduct a room search. With the resident's permission, measures were initiated on 6/11/21 and documented on a log sheet. The Unit Manager/Nursing Supervisor was charged with overseeing the log for compliance. During the public health emergency, the smoking program was put on hold. Residents were offered smoking cessation alternatives. Smoking was reinitiated on 6/14/21. The nursing department increased random room checks to three times per day on 6/15/21 for the resident. In-service was initiated for all front desk receptionists regarding checking packages delivered to Resident #169. A new smoking evaluation was conducted, revealing that Resident #169 was safe to smoke with supervision. Smoking times were increased from twice daily to four times a day. The [CONDITION(S)] center and ambulance transport company were notified that they should not provide smoking materials to Resident #169 or any of the residents from the facility. Staff were interviewed regarding the resident's smoking events since April 2021. Resident #169 was made aware that he/she would be searched upon return from all medical appointments. The resident was re-educated regarding the dangers of smoking with or near oxygen. All oxygen supplies were removed from the resident's room and chair, as the physician's order for the supplemental oxygen was changed from continuous to as needed. The facility held a smoking program meeting on 6/15/21 with all residents who smoked. The facility revised the smoking evaluation and completed a new smoking evaluation on each resident that currently smokes or who formerly smoked within the past six months. An individualized care plan was completed for these residents. The facility revised the smoking policy to include updates on violations. Education was initiated with the direct care staff of Resident #169 to include expectations of random room checks related to smoking materials/violation of the smoking policy. The survey team verified the Removal Plan from 6/16/21 to 6/21/21 during the remainder of this Recertification Survey. The surveyors continued to interview facility staff and review pertinent facility documents regarding the three smoking violations. The following was revealed: On 6/16/21 at 11:59 AM, the surveyor interviewed the LPN who wrote the Behavior Notes on 4/18/21 and 4/30/21. The LPN stated that regarding the [second] smoking incident that occurred on 4/30/21, she had walked into the resident's room and asked if he/she was okay. The resident was in the bathroom, and as soon as they came out, the LPN stated that she could smell smoke. Even though she could smell the smoke, she asked the resident, and Resident #169 denied that he/she was smoking. The O2 concentrator was on in [his/her] room. I went to the desk to report it. Staff came upstairs right away and searched [Resident #169] room and found cigarettes and a lighter. The surveyor reviewed the Statement Forms provided by the LNHA regarding Resident #169 in response to the surveyor's inquiry. There were two forms signed on 6/15/21 completed by a Certified Nursing Aide (CNA #1). CNA #1 wrote on one form that on 4/18/21, she smelled a special spray in the resident's bathroom, and she notified the nurse. The second Statement Form reflected that CNA #1 witnessed Resident #169 with a cigarette and called the nurse on 4/30/21. The surveyor reviewed the eMARs for Resident #169 for April, May, and June 2021. The eMARs indicated that O2 was administered to Resident #169 continuously on every shift from 4/1/21 until the evening shift of 6/14/21, with the exception of 4/24/21 during the day shift, which documented that the resident refused the continuous oxygen that shift. The three smoking violations and subsequent investigative reports provided to the surveyor did not include an examination of the eMAR and a determination if Resident #169 may have been using continuous oxygen on 4/18/21, 4/30/21, and 6/11/21, when the eMAR had been signed to reflect the resident was receiving the oxygen continuously every shift on those dates. On 6/16/21 at 12:02 PM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the current June 2021 eMAR regarding nurses' signatures for the physician's order for oxygen. The LPN/UM stated that the nurses were recording O2 saturations (O2 Sats) (a measure of the oxygen levels carried in the resident's blood) on the eMAR. Further review of the eMAR had indicated that the O2 Sats corresponded with the physician's order for O2 at 2 liters via N/C (nasal cannula) Continuous every shift for SOB. The LPN/UM added that he thought the nurses were signing for the O2 Sats and that they were not signing that they had administered O2 continuously to Resident #169. On 6/16/21 at 12:03 PM, the surveyor interviewed LPN #1, whose signature appeared numerous times on the eMAR. LPN #1 stated that she had documented the O2 saturation levels on the dates indicated on the eMAR. LPN #1 added that she did not think that she was signing for continuous O2 administration for Resident #169. On 6/16/21 at 1:13 PM, the surveyor interviewed the DON regarding the resident's eMAR. She stated that her understanding of the nurses signing and checking the eMAR for an order on the left-hand side stating O2 at 2 liters via N/C Continuous every shift for SOB meant that the O2 was administered as ordered. The surveyor reviewed the Facility assessment dated [DATE]. This document included that Services and Care [are] Offered Based on our Resident's Needs. Within this section of the Assessment, the document reflected that the facility would Provide person-centered/directed care, including Identify hazards and risks for residents. A review of the undated Smoking Policy provided upon the Entrance Conference on 6/8/21 included that the facility shall establish and maintain safe smoking practices. Supervised smokers will smoke only during the following scheduled times: 9:00 AM - 9:15 AM; 1:00 PM-1:15 PM. There is No Smoking after 1:15 PM until 9 AM. Smoking is only permitted in the area that is designated as a smoking section.Smoking restrictions shall be strictly enforced in all nonsmoking areas .[The Facility] may check periodically to [TRUNCATED]