Every finding on record at Aristacare at Cherry Hill

COMPLAINT #2801510Based on interviews, review of medical records and other pertinent facility documentation on 6/4/26 and 6/5/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice, when staff failed to consistently document that wound care was provided on the Treatment Administration Record (TAR). This deficient practice was identified for 2 of 3 residents reviewed for wound care (Resident #3 & Resident #6) and was evidenced by the following:a). A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: paraplegia, injury of the thoracic spinal cord at the T7-T10 level, and chronic pain syndrome. Review of Resident #3's care plan (CP) indicated that Resident #3 had a focus related to the resident having skin impairment. Interventions for this focus area included to provide treatments per facility protocol. A review of Resident #3's Treatment Administration Record (TAR) for March 2026 revealed two treatments as follows:- Change wound dressing to left ischium [left hip area] . every Mon, Wed, Fri, for wound care- Cleanse left ischial wound. every day shift for wound care.Blank boxes (indicating the wound treatment as not done) for the above treatments on 3/2/26 and 3/26/26. A review of Resident #3' progress notes (PN), did not include documentation that the above treatments were provided. b). A review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to: frostbite with tissue necrosis of the left and right foot, acquired absence of the left and right foot, and unspecified disorder of muscle. Review of Resident #6's care plan (CP) indicated that Resident #3 had a focus related to the resident having skin impairment. Interventions for this focus included that treatments were to be provided per facility protocol. A review of Resident #6's Treatment Administration Record (TAR) for May 2026 revealed two treatments as follows:-Betadine Solution was to be applied to the left heel for wound care on the evening shift. Area was to be cleansed and gauze was to be applied.-Betadine Solution was to be applied to the right heel for wound care on the evening shift. Area was to be cleansed and gauze was to be applied.Blank boxes noted, (indicating wound care not provided) as ordered for the above treatments on 5/18/26 and 5/21/26.A review of Resident #6' progress notes (PN), did not include documentation that the above treatments were provided. An interview was conducted on 6/4/26 at 3:36 PM with the Licensed Practical Nurse (LPN #1) who stated that documentation was important to show that care was provided. LPN #1 recalled being assigned to Resident #3. She stated that Resident #3 was always compliant with care during her assignments and that she must have forgotten to document that treatment was provided. She further stated that she was familiar with Resident #6 also and that she must have either forgotten to document that the wound treatments was provided, or she forgot to document that the resident refused. A joint interview was conducted on 6/4/26 at 4:19 PM with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). During the interview the DON stated that after staff completed wound treatments, she expected that nurse document that that care was provided in the resident's electronic medical record. She further stated that documentation confirmed that care was provided. No additional documentation was provided related to the above treatments. A review of the facility's undated Charting and Documentation policy revealed that services provided to residents would be documented. The policy further described the minimum care-specific details that would be included when documenting treatments including, but not limited to, the name of the person providing the treatment along with the date and time it was provided. N.J.A.C. 8:39-27.1(a)

CFR9s): 483.70(h)(1)S483.70(h) Medical records.S483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 1/16/26, it was determined the facility failed to ensure Medication Administration Record (MAR) documentation was accurate as evidenced by a.) the Licensed Practical Nurse #1 (LPN) not obtaining and transcribing an order for a resident who required medication administration to correct low blood sugar and b.) the Director of Nursing (DON) completing medication administration entries on behalf of LPN#1. This resulted in inaccurate medical records and failure to identify potential medication errors, this deficient practice was identified for 1 of 4 residents reviewed for resident records (Resident #2), and was evidenced by the following:On 1/16/26 the surveyor Resident #2's December 2025 Medication Administration Record (MAR) and Order Summary Report (OSR) and did not find orders for glucagon that were given to Resident #2 by the LPN three times during 12/20/25 and 12/21/25 for Resident #2's hypoglycemic events.On 1/16/26 at 12:59 PM, the surveyor interviewed the DON regarding Resident #2's December 2025 MAR and questioned why the DON's signature was reflected on the MAR instead of the LPN. The DON stated she had spoken to the LPN #1 and that LPN #1 had informed her that Resident #2 had refused the insulin and since the LPN #1 was remote, she filled in the MAR for the LPN #1.According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: infective myositis (a rare inflammation of skeletal muscles caused by germs like bacteria, viruses, fungi, or parasites), sepsis (a life-threatening medical emergency where the body's extreme, overactive response to an infection triggers a chain reaction, causing the immune system to attack its own tissues and organs, leading to damage, failure, and potentially death if not treated immediately), and Type 2 Diabetes Mellitus with Hyperglycemia ( the most common form of diabetes, where the body either doesn't make enough insulin or doesn't use it effectively, leading to persistently high blood sugar levels).A review of the Minimum Data Set (MDS), an assessment tool dated 08/07/25, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated Resident #2's cognition was cognitively intact.On 1/16/26 at 11:10 AM, the surveyor attempted to interview LPN#1 by phone and LPN#1 did not return the surveyor's phone call.On 1/16/26 at 12:13 PM, the surveyor interviewed LPN#2 regarding residents who are diabetic. LPN #2 told the surveyor that she follows physician orders for her residents who are diabetic regarding checking resident sugars, administering insulin, and parameters. She further stated she follows physician orders for all her medication administrations for residents.On 1/16/26 at 12:59 PM, the surveyor interviewed the DON regarding Resident #2's December 2025 MAR, OSR, and glucagon administrations by LPN#1. The DON stated that LPN #1 gave Resident #2 glucagon without a provider order as Resident #2's blood sugar was an emergent situation. She stated that ideally, LPN #1 should have reached out to the provider after Resident #2 was stable and the order for glucagon should have been transcribed and admitted that this was not done by LPN #1. When questioned why LPN #1 should have reached out to the provider for the order transcription the DON stated, signing out the order is a reflection that an intervention was implemented, utilized and that it was effective for patient safety.During this same interview, the DON stated that she had spoken to LPN#1 who reported that Resident #2 had refused their insulin on 12/16/25 and 12/17/25. When the surveyor questioned why the DON's electronic signature was on Resident #2's MAR instead of LPN#1's for those dates, the DON stated she filled it in for LPN #1 to reflect his statements as he is remote and does not have access to the MAR.On 1/16/25 at 2:02 PM, the surveyor had requested the DON to ask LPN#1 if he would return the surveyor's phone call for the investigation and the DON informed the surveyor that LPN#1 respectfully was declining to return the surveyor's call.A review of the facility's policy titled Physicians' Medication Orders that did not have a date on it, included the following information under Policy Statement: Medications shall be administered only upon the written order of a person duty licensed and authorized to prescribe such medications in this state. Under, Policy Interpretation and Implementation: 4. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order. PCC will record date and time.A review of the facility's policy titled Charting and Documentation that did not have a date on it, included the following information under Policy Statement: all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Under, Policy Interpretation and Implementation: 2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, Certified nursing assistant, etc.,) in accordance with state law and facility policy.NJAC 8:39-35.2

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner, and b) maintain the garbage dumpster area in a clean, safe manner, and free from pests as evidenced by the following:On 8/21/25 at 10:36 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following:1. The can-opener blade had a metal chip on the right side and brown sticky food debris on the blade and screw connection. The FSD acknowledged it had not been changed since she started working at the facility. The FSD acknowledged that the can-opener was not cleaned according to facility policy. The FSD was unable to produce a maintenance log to indicate when the blade should be replaced.2. The can-opener holder attached to the counter had a blue insert which was covered with brown sticky debris. A cleaning log for the can-opener could not be provided. The FSD acknowledged that it was not cleaned according to facility policy.3. The garbage dumpster and surrounding area had loose debris on the ground, and the dumpster lids were left open. The FSD acknowledged it and stated that it should be cleaned and closed according to facility policy.On 8/25/25 at 1:57PM The surveyor interviewed the FSD, who stated, the can-opener should have been cleaned, and the blades should be checked and changed when needed. She further stated, the dumpster lids should have been closed, fallen debris should have been picked up, and the surrounding area should have been cleaned to prevent the attraction of flies, rodents or other vermin. The FSD acknowledged the surveyors concerns and agreed that it was not done according to the facility policy.On 8/27/2025 at 10:12 AM, the surveyor met with Licensed Nursing Home Administrator (LNHA) and Chief Operating Officer (COO). The LNHA acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment and dumpster area. The LNHA stated that the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury. The LNHA stated this ensures the safety of our resident and staff.A review of the facility's undated, Food Preparation Area policy, .[Facility name redacted] will maintain a clean, sanitary, and safe food preparation area.all machines and equipment that require cleaning shall be cleaned after use.A review of the facility's undated, Sanitation policy, .the food service area shall be maintained in a clean and sanitary manner.keep food service areas, equipment, and utensils clean, sanitary, and well maintained.repair or discard damaged items that affect cleanliness or safety.Food Service Manager to schedule cleaning and oversee staff maintenance of cleanliness and equipment.A review of the facility's undated, Food-Related Garbage and Rubbish Disposal policy,.food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters.garbage and rubbish containing such wastes will be stored in a manner that is inaccessible to vermin.outside dumpsters provided by garbage pickup services may be kept closed and free of surrounding litter.NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a) follow appropriate infection control protocol for hand hygiene during the medication pass observation b) ensure that essential personal protective equipment (PPE, equipment worn to prevent the spread of infection) was readily available for all staff and visitors: This deficient practice was identified for 1 of 2 nurses on 1 of 2 nursing units (Second Floor) during the medication pass observation and for 3 of 3 nursing units observed for adherence to infection control practices. This deficient practice was evidenced by the following:1) On 8/22/25 at 8:21 AM, the surveyor met with Licensed Practical Nurse (LPN) #4 at the medication cart to observe the medication pass. LPN #4 stated that she needed to clean the electronic blood pressure machine prior to use. LPN #4 then proceeded to donn (put on) gloves before she used a disinfectant wipe to clean the attached blood pressure cuff and pulse oximeter probe (a device placed on the finger to obtain the amount of oxygen in the blood). LPN #4 then doffed (removed) her gloves and discarded them and then failed to perform hand hygiene before she proceeded to donn a disposable face mask. LPN #4 then proceeded to push the rolling automated blood pressure machine into Resident # 49's room. LPN #4 then placed the blood pressure cuff on the resident's right arm and then placed the pulse oximetry probe (a device placed on the finger to measure the blood oxygen level) on the resident's left index finger and obtained the resident's vital signs (blood pressure, heart rate, and pulse oximetry reading). On 8/22/25 at 8:27 AM, the surveyor observed LPN #4 as she returned to the medication cart and donned a pair of gloves before she cleaned the blood pressure machine, blood pressure cuff, and pulse oximetry probe with a disinfectant wipe. LPN #4 then proceeded to doff her gloves and failed to perform hand hygiene before she accessed the computer and picked up the water pitcher and poured water into a disposable cup intended for the resident. LPN #4 then prepared Resident #49's medications for administration. Immediately after, LPN #4 entered Resident #49's room and handed the resident their oral medications that were stored in a plastic medication cup and then handed the resident a cup of water to take their medications with. On 8/22/25 at 8:34 AM, LPN #4 returned to the medication cart and used alcohol-based hand rub (ABHR) to clean her hands after she medicated Resident #49. On 8/22/25 at 8:48 AM, LPN #4 entered the room of Resident #116 and placed a blood pressure cuff on the resident's right arm and a pulse oximetry probe on the resident's left index finger. At that time, LPN #4 donned gloves and requested assistance of another staff member to pull the resident up in the bed in preparation for medication administration. On 8/22/25 at 8:55 AM, LPN #4 doffed her gloves and failed to perform hand hygiene after before she began to prepare medications for Resident #116. LPN #4 stated that that she ordered Keppra (anti-seizure medication) 500 MG (milligrams) half tablets (250 MG) yesterday, but the order was not yet received. LPN #4 then stated, I can just break it in half and then proceeded to use her bare hands to split the Keppra 500 MG scored (marked) tablet in half. LPN #4 then proceeded to crush the resident's medications with a pull crusher before she placed the crushed medication in apple sauce and administered the medication to the resident with a plastic spoon. On 8/22/25 at 9:01 AM, LPN #4 entered the pantry and proceeded to wash her hands for twenty seconds. When finished, she dried her hands on a paper towel, and she then used the same paper towel that she dried her hands off with to turn off the faucet. On 8/22/25 at 9:03 AM, LPN #4 donned gloves and proceeded to clean the blood pressure machine, cuff, and pulse oximetry probe with a disinfectant wipe. At that time, Resident #19 approached the medication cart in a wheelchair and asked LPN #4 for their medications. Without first doffing her gloves and performing hand hygiene, LPN #4 then proceeded to place a blood pressure cuff on Resident #19's left lower arm with her gloved hands that she had previously worn to clean the blood pressure machine. On 8/22/25 at 9:07 AM, LPN #4 then cleaned the blood pressure cuff and machine after use with a disinfectant wipe. On 8/22/25 at 9:08 AM, LPN #4 doffed her gloves and accessed the computer without first performing hand hygiene. LPN #4 then opened the top drawer of the medication cart and removed a multidose bottle of aspirin without first performing hand hygiene. On 8/22/25 at 12:54 PM, in a later interview with LPN #4, LPN #4 stated that hand hygiene should have occurred before she donned her gloves and after she doffed her gloves. LPN #4 stated that she should have sanitized her hands prior to medication administration for infection control purposes. LPN #4 stated that she should have cleaned her hands after she obtained Resident #116's vital signs and pulled the resident up in bed. LPN #4 further stated that she should have then washed her hands before she touched a medication with her bare hands for infection control purposes. LPN #4 stated that it was an infection control issue if soiled gloves were worn to clean the blood pressure machine and then proceeded to obtain Resident #19's vital signs. LPN #4 further stated that she should have performed hand hygiene before she then proceeded to prepare medications for Resident #19 for infection control purposes. On 8/22/25 at 1:12 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that it was an infection control issue if gloves were worn to clean the blood pressure machine, hand hygiene was not performed after the gloves were doffed. The LPN/UM #1 stated that hand hygiene should have been performed prior to medication administration. The LPN/UM #1 stated that you had to remove your gloves after the blood pressure machine was cleaned and then cleaned your hands before you obtained the resident's vital signs for infection control purposes. The LPN/UM #4 stated that the nurse should not have broken the scored medication with her bare hands because that was an infection control issue. On 8/22/25 at 2:05 PM, the surveyor interviewed the Director of Nursing (DON) #1 who stated that it was not appropriate to break a scored medication with your bare hands for infection control purposes. The DON #1 stated that LPN #4 should have used hand sanitizer or washed her hands after she cleaned the blood pressure machine and before she medicated the resident for infection control and to prevent the spread of germs. The DON #1 stated that LPN #4 should have doffed her gloves and washed her hands before she obtained the resident's vital signs. At that time, DON #1 stated that after you washed and dried your hands and disposed of the paper towel, you should get a dry paper towel to turn off the faucet. The DON #1 further stated that the same paper towel that was used to dry your hands should not have been used to turn off the faucet for infection control purposes. On 8/26/25 at 1:23 PM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA) was made aware of all infection control concerns that were observed during the medication pass observation. 2) On 08/21/2025 at 11:18 AM, a surveyor observed a resident room with a blue bird sign on the name plate. The surveyor asked Licensed Practical Nurse (LPN) #1 what the sign meant, she replied they indicated Enhanced Barrier Precautions (EBP) residents required the use of gloves and gowns to be worn for when a resident had a wound, or indwelling urinary catheter, etc. When asked where Personal protective equipment (PPE) was kept, LPN #1 stated that gloves were in the room, and gowns and masks were kept in a yellow cart at the end of the hallway. The surveyor observed the cart and noted that there were no gowns inside. On 8/22/25 at 12:34 PM, the surveyor observed the first-floor PPE (personal protective equipment, clothing or equipment worn to protect one from infection or harm) cart in the hallway and it was out of protective gowns. On 08/25/2025 at 10:08 AM, the surveyor observed the second floor yellow PPE cart in the hallway. It was stocked with gloves and masks, but no protective gowns were observed. The surveyor interviewed LPN #2 who stated all the PPE was kept in the yellow PPE carts, and there was one per unit. When asked about the lack of gowns in the PPE cart, LPN #2 stated that the cart must be out of stock, and that more gowns were stored downstairs. LPN #2 further stated that she would let someone know. On 8/26/25 at 10:36 AM, the surveyor observed the first floor yellow PPE cart in the hallway. It was stocked with gloves and masks, but no gowns were present. On 8/26/25 at 11:43 AM, the surveyor observed the second floor yellow PPE cart in the hallway. It was stocked with gloves, masks, and three isolation gowns were present. At that time the surveyor asked LPN/Unit Manager (LPN/UM) #1 how staff was made aware that caring for a resident would require PPE; she stated the rooms were marked with a blue bird sign, and the isolation status was listed in the resident's chart. When asked if all PPE was stored in the yellow carts, LPN/UM #1 stated that all PPE for the unit was kept in the cart; and if the cart ran out of a particular PPE item, she would call down to request more from central supply. On 8/26/25 at 12:28 PM, the surveyor, in the presence of another surveyor and the Chief Operation Officer (COO) observed the first-floor isolation cart with no isolation gowns available. The COO confirmed that gowns were not present in the cart and he walked the surveyors to the central supply room where they confirmed that the facility was out of gowns and had placed an order the day before on 8/25/25 and was expecting a delivery by 8/27/25. When asked about the importance of having isolation gowns and other PPE readily available for staff and visitors; the COO stated the use of PPE was important to prevent the spread of infection, house wide, and that the Infection Preventionist usually kept Periodic Automatic Replacement (PAR) levels, but they were on vacation. On 8/26/25 at 1:19 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) was made aware of all infection control concerns related to Personal Protective Equipment. A review of the facility's undated Handwashing/Hand Hygiene policy, Included: It is the policy of this facility that handwashing/hand hygiene be regarded as the single most important means of preventing the spread of infections. .Appropriate handwashing/hand hygiene must be performed at the follow [sic.] times:.Before preparing medication pass,.before and after all resident care activities. A review of the facility's Enhanced Barrier Precautions policy undated, included, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/Showering, Transferring, Providing hygiene, changing linens, device care or use, wound care, changing briefs or assisting with toileting.make PPE, including gowns and gloves, available immediately outside of the resident room. NJAC 8:39-19.4;19.8

Based on interview and document review, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA): a.) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) and b.) funds and final accounting of those funds were conveyed within 30 days of the resident's discharge to the proper jurisdiction.This deficient practice was identified for 3 of 3 residents (Resident #50, #55 and #143) reviewed for PNA and was evidenced by: A review of the facility's Trial Balance revealed 3 (three) residents had balances that ranged from $1,901.47 to $6,917.52.On 8/25/2025 at 1:59 PM, the surveyor interviewed the Business Office Manager (BOM) who stated a written notification should be sent out when the resident's balance reached $1800.00 for the monies to be spent down. She stated the residents could not have more than $2,000 in their account. The BOM stated if the resident was over the limit they would not be eligible for recertification for Medicaid eligibility because they were over resourced. At that time, the BOM stated that Resident #50 Trial Balance was $2,112, and the resident's representative payee should have been notified. The BOM then stated she did not know if the representative was notified because she did not manage the accounts.The BOM stated Resident #55 was at $1,901.47 and there was no way to know if the notices were sent out. The BOM stated Resident #143's Trial Balance reflected a balance of $6,917.52, and the monies for room and board were not applied. The BOM stated that the resident was discharged on 7/9/24, and the balance that remained in the account should have been sent to the resident directly if he/she requested it or sent back to social security. The BOM stated the monies should have been returned in 30 days, but that preceded her employment. The BOM acknowledged and confirmed that the residents should have been notified of the need to spend down their monies at the $1,800 balance mark. The BOM further stated that the monies should have been returned within 30 days of the resident being discharged . On 8/26/25 at 2:35 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of 8/21/25. On 8/27/25 at 10:03 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) #2 confirmed the notifications were not sent. He acknowledged the written notification letter should have been set out to the resident reaching the maximum amount and the monies should have been sent back within 30 days of the resident being discharged . A review of the facility's Resident Funds policy undated, included, to provide clear accountability for each resident's funds held by the facility.upon DC [discharge] the facility will convey in 30 days the resident's funds and a final accounting of those funds to the resident NJAC 8:39-9.5

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a) administer medications in a timely manner in accordance with the facility policy and professional standards of nursing practice b) ensure accountability of the narcotic shift count logs, c) accurately account for the administration of controlled medications d) follow a physicians order (PO) for both the application and the removal of a Lidocaine Pain Patch (transdermal pain reliever). This deficient practice was identified on one (1) of three (3) medication carts (Second floor, Low Cart), and the Automated Medication System (AMS) (an automated system, including robotic and intelligent dispensing cabinets to store and manage medications and supplies) in the First Floor Medication Room that was inspected during the medication storage observation. And for 2 of 4 residents (Resident #22 and #116) on 2 of 3 nursing units (First Floor and Second Floor) reviewed during the medication administration observation d) for 1 of 4 residents (Resident # 18) observed for medication administration timeliness. This deficient practice was evidenced by the following:1) On 8/21/25 at 10:45 AM, during the initial tour of the facility, the surveyor observed Resident #22 lying in their bed awake. The resident stated they had a concern with their medications being administered late. On 8/22/25 at 11:05 AM, the surveyor reviewed the medical record for Resident #22. A review of the admission Record, an admission summary, reflected that the resident was admitted to the facility with diagnoses that included but not limited to; generalized anxiety disorder (feeling extremely worried or nervous), hypothyroidism (thyroid gland does not make enough thyroid hormone), and asthma (airways become inflamed). A review of the most recent comprehensive MDS(Minimum Data Set), an assessment tool dated 7/20/25, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicated an intact cognition. The surveyor reviewed the Physician's Order Summary Report (OSR), dated as of 8/26/25, which revealed the active orders for Resident #22 which included the following Physician's Orders (PO): A PO, dated 5/23/22, for Baclofen (used to treat spasms) Tablet 10 milligram (MG) give one tablet by mouth three times a day for musculoskeletal. A PO, dated 2/14/24, for Colace capsule 100 MG (Docusate Sodium) Give 1 (one) tablet by mouth two times a day for constipation. A PO, dated 7/30/25, for Colchicine Tablet 0.6 MG Give 1 (one) tablet by mouth one time a day for gout flares (form of arthritis that causes severe pain). A PO, dated 5/20/22, for Cranberry-Vitamin C capsule 450-125 MG Give 1 (one) capsule by mouth two times a day for supplement. A PO, dated 2/24/25, for Cyanocobalamin tablet 500 microgram (MCG) Give 1 (one) tablet by mouth one time a day for for supplement B12. A PO, dated 5/1/25, for Guaifenesin Oral Tablet 200 MG (Guaifenesin) give 1 (one) tablet by mouth every eight hours as needed for cough. A PO, dated 8/12/25, for Hydroxyzine HCL tablet 25 MG Give 1 (one) tablet by mouth three times a day for itching. A PO, dated 12/4/24, for Levothyroxine Sodium Oral Tablet 25 MCG Give 1 (one) tablet by mouth one time a day for hypothyroidism (abnormal thyroid gland function that affects metabolism). A PO, dated 11/2/24, for Lipitor Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 (one) by mouth at bedtime for prophylaxis. A PO, dated 5/30/24, for Metformin HCL ER Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCL) Give 1 (one) tablet by mouth in the evening for diabetes mellitus(DM), diabetes, a chronic metabolic disease characterized by high blood sugar (glucose levels). A PO, dated 8/28/24, for Metformin HCL Oral Tablet 500 MG (Metformin HCL) Give 0.5 tablet by mouth one time a day for DM half tablet for DM 1/2 tab=250 MG. A PO, dated 2/20/25, for Metoprolol Tartrate Tablet 25 MG Give 1 (one) tablet by mouth every 12 hours for HTN (hypertension, high blood pressure) Hold for HR (heart rate) less than 60; SBP (systolic blood pressure, the top value in a blood pressure reading) less than 110. A PO, dated 6/15/22, for Mobic Tablet 15 MG Give 1 (one) tablet by mouth one time a day related to for idiopathic gout (unknown cause of elevated uric acid levels). A PO, dated 9/12/24, for Multivital M Tablet (Multiple Vitamins-Minerals) Give 1 (one) tablet by mouth in the evening for supplement (Must be separate from Synthroid). A PO, dated 2/20/25, for Norvasc Oral Tablet 10 MG (Amiodipine Besylate) Give 1 (one) tablet by mouth in the morning related to Essential (Primary) Hypertension (elevated blood pressure). Hold for SBP less than 110. A PO, dated 5/19/22, for Potassium Chloride Crys ER Tablet Extended Release 20 MEQ Give 2 (two) tablets by mouth one time a day for supplement. A PO, dated 8/8/25, for Prednisone tablet 5 MG Give 3 (three) tablets by mouth one time a day for inflammation. Admin (administer) meds with food or meals. A PO, dated 6/6/25, for Tylenol Extra Strength Oral Tablet 500 M (Acetaminophen) Give 2 (two) tablets by mouth two times a day for joint pain/headache. A PO, dated 2/24/25, for Victoza Subcutaneous (under the skin) Solution Pen-Injector 18 MG/3 ml (milliliters) subcutaneously one time a day for DM, CV (cardiovascular) and Renal (kidney) risk reduction, obesity. A PO, dated 5/15/25, for Vitamin D3 Tablet 2,000 Unit (Cholecalciferol) Give 1 (one) tablet by mouth in the morning for supplement. A PO, dated 8/11/25, for Zyloprim Tablet 100 MG (Allopurinol) Give 3 (three) tablets by mouth one time a day for Gout. A review of Resident #22's August 2025 Medication Administration Record (MAR) revealed that it appeared that all the resident's medications were given as scheduled at 0800 (8:00 AM), 0900 (9:00AM), 1300 (1:00 PM), 1700 (5:00 PM), 1800 (6:00PM), and 2100 (9:00 PM). On 8/22/25, the surveyor requested to view Resident #22's Medication Admin Audit Report (MAAR, a document that detailed the exact time of medication administration not detailed on the MAR) for August 2025. A review of the MAAR revealed that on the day shift from 8/1/25 to 8/22/25 there were 255 medications administered late out of 420 opportunities. A further review of the MAAR revealed that on the evening shift from 8/1/25 to 8/21/25 there were 127 medications administered late out of 189 opportunities. A review of Resident #22's Progress Notes failed to contain documented evidence that the resident's physician was notified that the resident received their scheduled medications beyond the scheduled administration time. There was also no documented rationale within the resident's electronic health record (EHR) to explain why the medication was not administered timely as required. On 8/25/25 at 1:10 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated that medications should be administered one hour before or one hour after the prescribed time. LPN #1 further stated that medication administration documentation is completed in the EHR after the resident took the medication. LPN #1 further stated that if a medication is administered late, she would notify the primary provider. On 8/26/25 at 12:35 PM, the surveyor interviewed the Director of Nursing (DON) #2, who stated that medications should be administered as close to the ordered time. DON #2 stated that the nurses have one hour before or an hour after the scheduled administration time. The DON #2 stated that nursing should notify the provider if a medication was not administered on time. The DON #2 confirmed with the surveyor that there were multiple medications administered late in the month of August 2025. The DON #2 further stated that the medications should have not been administered late. On 8/27/25 at 10:03 AM, the DON #2, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that medications should be administered within one hour of their prescribed time. 2) On 8/26/2025 at 12:17 PM, the surveyor, accompanied by the Licensed Practical Nurse (LPN) #3, reviewed the second floor, Low Cart narcotic logbook. On the Record of Narcotic, Barbituate (sedative and sleep inducing drug) Use Drug Count (RNBDC) log (a log that shows accountability for narcotics and barbituates for each shift) for August 2025, the nurse's signatures were missing as follows: The outgoing nurse on 8/21/2025 for the 7:00 AM to 3:00 PM (day) shift. The outgoing nurse on 8/25/2025 for the 7:00 AM to 3:00 PM shift. The incoming and outgoing nurse on 8/25/2025 for the 3:00 PM to 11:00 PM (evening) shift. The incoming nurse on 8/26/2025 for the 7:00 AM to 3:00 PM shift. At that time, LPN #3 stated that today (8/26/2025 ), she conducted a shift-to-shift narcotic count with the outgoing nurse but did not sign the incoming 7:00 AM signature slot on the RNBDC. A further review of the narcotic logbook revealed that the resident-specific declining inventory logs had discrepancies as follows: Resident #6 should have had 13 tablets of oxycodone IR (immediate release) 5 (mg) milligram (a controlled medication used to treat pain), but only 12 tablets were on hand. Resident #11 should have had 25 tablets of oxycodone IR 5 mg, but only 24 tablets were on hand. Resident #32 should have had 14 tablets of oxycontin ER (extended release) 10 mg (used to treat moderate to severe pain), but only 13 tablets were on hand. Resident #37 should have had 18 tablets of lyrica 200 mg (used to treat neuropathic pain) , but only 17 tablets were on hand. Resident #75 should have had 42 tablets of tramadol 50 mg (used to treat pain), but only 41 tablets were on hand. Resident #76 should have had 11 tablets of oxycontin ER, but only 10 tablets were on hand. Resident #89 should have had 14 tablets of tramadol 50 mg, but only 13 were on hand. Resident #145 should have had eight tablets of oxycodone IR 30 mg, but only seven tablets were on hand. The same resident should have had 9 bottles of methadone 210 mg (used to treat opioid use disorder), but only 8 bottles were on hand. At that time, LPN #3 stated that she administered all the above medications during the morning medication pass. She further noted that the narcotics should have been signed out on the declining inventory sheet once it was removed from the bingo card and administered. A review of the Medication Administration Record (MAR) for the residents above and their corresponding medications also indicated that the medicines were administered that morning. On 8/26/2025 at 12:53 PM, the surveyor and Licensed Practical Nurse/Unit Manager (LPN/UM) #1 reviewed the Low Cart RNBDC log and the resident-specific narcotic declining inventory log. LPN/UM #1 confirmed the above findings. At that time, the LPN/UM stated that after the incoming nurse gets the shift-to-shift resident report, they are supposed to conduct the narcotic count with the outgoing nurse, then both nurses should sign in their respective slots. She further stated that the nurse should sign the resident-specific declining inventory log after removing and administering the medication. On 8/26/2025 at 1:16 PM, the surveyor, accompanied by LPN/UM #1 and #2 entered the first floor medication storage room to conduct a narcotic count of the AMS. Upon review of the narcotic logbook for the AMS, there was no shift-to-shift narcotic accountability log for August 2025. At that time, LPN/UM #1 and #2 both confirmed the above finding. On 8/26/2025 at 2:03 PM, the surveyor interviewed the Director of Nursing (DON) #2 who stated that the narcotic count should take place each shift between the oncoming and outgoing nurses and each nurse should sign the shift-to-shift log for accountability. The DON #2 also stated that today (8/26/2025) was her second day at the facility as the DON #2 and that she did not have access to the AMS. The DON also stated that LPN/UM #1 and #2 were the only two nurses with access to the AMS. She further stated that she was unaware of how often the narcotics in the AMS should be counted. She also noted that she does not believe a process was in place. On 8/27/ 2025, at 9:07 AM, the surveyor conducted a follow-up interview with LPN/UM #2, who stated that prior to today (8/27/2025), she had no involvement in the AMS narcotic count, as her assigned unit was the farthest away from it. On 8/27/2025 at 9:12 AM, the surveyor conducted a follow-up interview with LPN/UM #1, who stated that before yesterday (8/26/2025), she was not counting the narcotics in the AMS, and was unsure how often they should have been counted. She further noted that when the previous DON was employed at the facility, she would count the AMS narcotics with her once in a while. 3) On 8/22/25 at 8:44 AM, during the medication pass observation the surveyor observed Licensed Practical Nurse (LPN) #4 as she reviewed the medication orders, and prepared and administered four oral medications to Resident #116. LPN #4 sought the assistance of a second staff member to pull the resident up in the bed into an upright position prior to medication administration. On 8/22/25 at 10:52 AM, the surveyor completed a medication reconciliation (a process of comparing a patient's medication orders to all medication orders on record) which revealed that Resident #116 had a physician's order dated 4/20/25, for Lidocaine Pain Relief 4 (four) % Patch (a topical anesthetic applied to skin to relive pain by blocking nerve signals). Apply to back topically one time a day related to muscle wasting and atrophy (to shrink) and remove per schedule. A review of the Electronic Medication Administration Record (EMAR) revealed that the medication order was not signed out at 9:00 AM, to indicate the administration status of the medication and the entry was left blank without a signature status. Further review of the EMAR revealed that the Lidocaine Pain Relief 4 (four) % Patch was scheduled for removal at 9:00 PM. On 8/22/25 at 12:54 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 and asked why a Lidocaine Pain Relief 4 (four) % Patch was not offered to the resident during the medication pass observation. LPN #4 stated that the resident did not have their Lidocaine Patch on, but they should. LPN #4 stated that she normally administered all medications first, and then went back and administered treatments, even though a Lidocaine Patch was technically a medication. LPN #4 stated that the medication was not time released, and the next shift would pull it off the resident at 9 (nine) PM. LPN #4 further stated that she would have put it on the resident around 10:30 AM, but she had gotten behind in her work. On 8/22/25 at 1:07 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that nursing had one hour before and one hour after a scheduled medication time to administer a Lidocaine Pain Patch. The LPN/UM #1 stated that the Lidocaine Pain Patch should have been offered to the resident at the scheduled time, otherwise, it was considered a medication error because the nurse neglected to give the resident their Lidocaine Patch that was ordered for pain relief. On 8/22/25 at 2:01 PM, the surveyor interviewed the Director of Nursing (DON) #1 who stated that a Lidocaine Pain Patch should be offered to a resident if ordered for pain management. The DON #1 stated that if it were not administered as ordered, it could hinder the resident's movement and productivity and could also affect the resident emotionally if their pain was not relieved. The DON #1 further stated that the medication should have been administered as scheduled an hour before or an hour after the scheduled time in accordance with the facility policy. The DON #1 further stated that the nurse was required to offer the medication to the resident. The DON#1 stated that the order should have been signed out as administered or not administered to reflect the administration status of the medication. The DON #1 stated that the nurse was not in compliance with the medication pass if the Lidocaine Patch that was scheduled for 9:00 AM, was still not offered by lunch time as the medication was time sensitive. On 8/25/25 at 12:03 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that if a Lidocaine Patch were not offered, it would be considered a missed item, and it was considered a medication error. The CP stated that the medication was scheduled, because the medication was to be removed in 12 hours. The CP stated that the resident could have pain, and it was a quality-of-life issue if the lidocaine patch were not applied timely. The CP further stated that the Lidocaine Patch was a transdermal patch and was absorbed through the skin at a certain rate and was to be removed within 12 hours of scheduled application at 9:00 PM. On 8/26/25 at 1:26 PM, in the presence of the survey team the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the concern related to the failure of LPN #4 to offer Resident #116 a physician prescribed Lidocaine Pain Patch at 9:00 AM and document the outcome during the medication pass observation. 4) On 8/22/25 at 8:11 AM, the surveyor observed Licensed Practical Nurse (LPN #3) prepare medications for Resident #18, which included two 4 % pain patches to be applied to the left knee and to the right knee. The surveyor observed LPN #3 remove the pain patches form the package and initialed and dated both patches. LPN #3 then removed the pain patches from Resident #18's right and left knees prior to applying the pain patches to the resident's right and left knee. On 8/22/25 at 11:09 AM, the surveyor interviewed LPN #3 who confirmed that, during the medication observation, she had removed pain patches form Resident #18's knees prior to applying the new pain patches. LPN #3 checked the physician orders in the medication administration record (MAR) and stated that the pain patches from both knees were scheduled to be removed at 9:00 PM and confirmed the MAR indicated that the pain patches were signed out as removed on 8/21/25 at 9:00 PM. The surveyor reviewed the medical record for Resident #18. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, muscle weakness, rheumatoid arthritis (causes pain, swelling, and irritation in the joints), and chronic pain syndrome. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated7/20/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. The MDS further revealed that the resident received pain medication and had frequent pain at a moderate pain level. A review of the individual comprehensive care plan (ICCP), dated 1/12/2022, included a focus that the resident had pain to bilateral (both) knees. Interventions included: Administer analgesia (pain medication) as ordered. A review of the Order Summary Report (OSR), with an order range of 8/1/25-8/31/25, included the following physician orders (PO): A PO, dated 8/5/25, for Lidocaine Pain relief external Patch 4% (Lidocaine) apply to Left knees topically one time a day for pain and remove per schedule. A PO, dated 8/5/25, Lidocaine Pain relief external Patch 4% (Lidocaine) apply to Right knees topically one time a day for pain and remove per schedule. A review of the August 2025 Medication Administration Record (MAR) included the above PO with administration times as follows: Lidocaine Pain relief external Patch 4% (Lidocaine) apply to Left knee was scheduled to be applied at 9:00 AM and to be removed at 9:00 PM. Lidocaine Pain relief external Patch 4% (Lidocaine) apply to Right knees was scheduled to be applied at 9:00 AM and to be removed at 9:00 PM. A review of the August MAR revealed that the pain patches to both knees were signed out as removed on 8/21/25 at 9:00 PM. On 8/25/25 at 11:30 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that evening shift should have removed the pain patches at 9: 00 PM. Pian patches should only be placed on the resident for 12 hours and after 12 hours the pain medication was not effective. On 8/26/25 at 11:33 AM, the surveyor interviewed the Director of Nursing (DON #2) who stated the pain patches should have been removed after 12 hours and as scheduled at 9:00 PM. DON #2 further stated that after 12 hours the pain patches lose their efficacy (effectiveness). A review of the facility's Administering mediations policy, undated, included medications shall be administered in a safe and timely manner, and as prescribed.medications must be administered in accordance with the orders, including any required time frame.medications may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall click N on the eMAR and then document as prompted by the [name redacted] computer software.the date and time the medication was administered is time stamped within the system. A review of the facility's AUTOMATED MEDICATION SYSTEM (or BACK-UP SUPPLY), revised 2014 revealed, Controlled substances must be checked and documented by a licensed professional every 24 hours. A review of the facility's Controlled Substances undated policy revealed, [Facility Name redacted] shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.7. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They document and report any discrepancies to the Director of Nursing Services. 8. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility [sic.] parties, and shall give the Administrator a written report of such findings. A review of the facility's undated Administering Medications policy, included: Medications shall be administered in a safe and timely manner, and as prescribed. .Medications must be administered in accordance with the orders, including any required time frame. .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall click N on the EMAR (Electronic Medication Administration Record) and then document as prompted. A review of the facility's Administering Medications policy, undated, revealed that medications must be administered in accordance with the orders, including any required time frame. NJAC 8:39-29.7(c); 29.2(d); 29.3(a)5

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner for 3 of 3 nursing units (100 unit, 200 unit, and 300 unit) observed for environment.This deficient practice was evidenced by the following: 1) On 8/21/25 at 11:18 AM, during the initial tour of the first-floor unit, the surveyor observed an unsampled resident in room130-D lying in bed with his/her eyes closed. The surveyor observed brown liquid on the floor at the base of the tube feeding pole next to the head of the bed. There was a black fly observed on the linens on bed 130-D. At that time, the surveyor observed the linens on the unoccupied bed in room [ROOM NUMBER]-C had a brown stain in the middle of the bed and had three (3) three black flies on the linens and one (1) black fly on the air mattress pump. The surveyor also observed a white plastic laundry basket next to bed 130-C that had a brown substance smeared inside of the basket. On 8/25/25 at 9:04 AM, the surveyor observed two (2) black flies on the resident's linens in room [ROOM NUMBER]-D and two (2) black flies on the linens of bed 130-C. On 08/25/25 at 9:31 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #2 who also acknowledged the presence of black flies on bed 130-C. CNA #2 stated that there had been flies on resident's beds before, but they are mostly residents who were incontinent. On 8/25/25 at 9:07 AM, the surveyor observed a floor mat next to the bed in room [ROOM NUMBER]-A with white crumbs noted on the mat. On 8/26/25 at 9:16 AM, the surveyor interviewed the housekeeper (HK) #1 who stated that she was the housekeeper for H1, which included the rooms, the unit kitchen and the bathroom. HK #1 stated that each room was cleaned daily, and the rooms were only deep cleaned when a resident was discharged . HK #1 further stated that she had not seen any flies in the residents' rooms. On 8/2625 at 9:27 AM, the surveyor interviewed the housekeeping director (HD) who stated that that the housekeepers clean each room daily. He stated that there was a schedule for daily cleaning. The HD further stated that the previous director of housekeeping did not have a schedule for rooms to be deep cleaned and the rooms were only deep cleaned after a resident was discharged . The surveyor showed the HD the pictures from room [ROOM NUMBER] which included the flies, linens and brown liquid on the floor. The HD stated that he had room [ROOM NUMBER] on the list to be deep cleaned. The HD stated that it was important that residents' rooms were kept in a clean and sanitary condition because they lived at the facility, and it was their right. On 8/26/25 at 10:23 AM, the surveyor interviewed the Director of Maintenance (DOM) who stated that no one had alerted him about the black flies in room [ROOM NUMBER]. The DOM stated If I was notified of the black flies, I would have called an exterminator. On 8/26/25 at 12:05 PM, the surveyor interviewed with Licensed Nursing Home administrator (LNHA) who stated the resident's rooms were cleaned every day. The housekeepers have a schedule they used when cleaning the nursing units. The LNHA stated there was a schedule for rooms to be deep cleaned and he would provide the schedule. The LNHA stated that it was important that residents' rooms were kept clean and sanitary because the residents should have a homelike environment. The LNHA stated that If the staff saw flies in a resident's room, the staff should put it in the electronic maintenance log or verbally inform the maintenance department. The LNHA stated We were aware that room [ROOM NUMBER] had been a problem, so we put that room on a every two-weeks deep cleaning schedule. On 08/27/2025 at 9:36 AM, the LNHA stated that the previous housekeeping director had a deep clean schedule that each room was deep cleaned every 60-90 days. The LNHA provided a calendar schedule for August 2025 that included room [ROOM NUMBER] was to be deep cleaned on 8/27/25, but he was unable to provide any documentation when room [ROOM NUMBER] was last deep cleaned. The LNHA also proved a copy of the pest log which revealed there were no reports of black flies in resident's rooms until 8/26/25, after surveyor inquiry. The surveyor showed the LNHA pictures of the black flies, laundry basket, linens, brown liquid on the floor in room [ROOM NUMBER] and the picture of the floor mat in room [ROOM NUMBER]. On 8/26/25 at1:21 PM, the surveyor notified the LNHA and the DON of the concern with the environment in room [ROOM NUMBER] and room [ROOM NUMBER]. On 8/27/25 at 10:02 AM, in the presence of the survey team and DON, the LNHA stated that room [ROOM NUMBER] should have been on a more frequent deep cleaning schedule and will now be on every two-week deep cleaning schedule. 2) On 8/21/2025 at 10:47AM, in the presence of the Director of Maintenance (DOM) and the Assistant Maintenance Technician (AMT), the Life Safety Code surveyor (LSC) observed rotted, crumbling sheetrock (dry wall) behind the loose cove base (a trip piece used to transition between a wall and the floor) in room [ROOM NUMBER]. At 10:50 AM, the LSC surveyor observed a shared hall bathroom, across from the nursing station on 200 hall, with the door wide open, feces smeared across the toilet seat, and what appeared to be a used adult brief was opened and laid on the upright toilet seat, and an overflowing trash can. At 11:00 AM, the LSC surveyor observed bags and boxes piled on the tile floor of the resident shower room. When interviewed, the DOM and AMT confirmed the observations. On 8/21/2025 at 1:37 PM, in the presence of the AMT, the LSC observed environmental concerns in room [ROOM NUMBER] while conducting a Life Safety tour of the room. The LSC surveyor noted five flies on the toilet seat in the bathroom and flies were seen flying within the bathroom as well. When the LSC surveyor approached bed B, a resident pointed out what appeared to be drain flies hovering over the bed. Across from this bed was a laundry basket that was smeared with what appeared to be feces with flies on it. The room was generally dirty with an unpleasant odor. In an interview with an unsampled resident of the room, it was stated that the bed assigned had not been slept in since arriving at the facility because of the flies surrounding it. The AMT confirmed the observations. 3) On 8/22/25 at 1:27 PM, Surveyor #2 entered room [ROOM NUMBER] with Resident #9's permission and noted that all of the vents from the PTAC Unit (Packaged Terminal Air Conditioner, a heating and air conditioner unit) had been removed from the top of the unit which left the internal components exposed and there was a moderate amount of dried food that had fallen inside of the unit. The resident also had a portable air conditioning unit at the bedside that was reportedly in use. When interviewed at that time, the resident stated, They will get around to it eventually. On 8/25/2025 at 2:44 PM, the surveyor entered room [ROOM NUMBER] accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who viewed the PTAC unit and stated, Who took this apart? LPN/UM #1 stated that the PTAC Unit was nonfunctional. She stated the unit would have to cleaned out and she assumed that maintenance was trying to fix it. On 8/25/2025 2:46 PM The surveyor accompanied by LPN/UM #1 entered the bathroom in room [ROOM NUMBER] and noted a strong, foul odor in the bathroom and the flooring had marked stickiness and the baseboards and miter joints (the way the baseboards are joined in the corner) had a thick buildup of a gray dried matter. The LPN/UM #1 stated that she thought that the base boards needed to be cleaned with bleach, but the floors were mopped by housekeeping. On 8/25/2025 at 2:47 PM, The Director of Maintenance (DOM) entered the room and stated that somebody removed all these vent covers, and he proceeded to place the vent covers back into the PTAC Unit. The MD stated that the facility did monthly cleaning and vacuumed the dust out. The MD stated that we probably did not see the food in there. On 8/26/2025 at 10:36 AM, the surveyor interviewed Housekeeper (HK) #1 who stated that she mopped the bathroom floors daily and used a chemical cleaner and a brush for the corners. HK #1 stated that she was not assigned to room [ROOM NUMBER]. On 8/26/2025 at 10:59 AM, the surveyor interviewed the Housekeeping Director (HD) in room [ROOM NUMBER]. The HD stated that since there was a blue cleaning solution that remained inside the toilet bowl, there should be no smell. The HD stated the moldings should be cleaned with a brush. The MD stated, The floor was dirty if it was sticky. The HD stated this floor needed to be restriped because wax was laid over dirt. Blue cleaning agent was in toilet and was left to sit. The HD stated, The smell of urine was overpowering the cleaner and that should not be. The HD stated that he did rounds daily and saw this during his first week on the job. The HD stated that he had not spoken to his lead cleaner who was assigned to the room about it, and he was disappointed that she did not bring it to his attention. The HD stated that carbolization (a terminal room cleaning) was done upon resident discharge. He stated the facility did not have a carbolization schedule in place prior. On 8/26/2025 at 11:10 AM, the surveyor interviewed HK #2 in the presence of the HD, and she stated that she already cleaned room [ROOM NUMBER] today. HK #2 stated that she cleaned the bathroom and wiped down the toilet. HK #2 stated it was hard to get behind the toilet which was heavily soiled with a black substance. HK #2 stated the floor techs cleaned the moldings and jams. At that time, the HD stated that wax was placed over dirt and the floor was not cleaned or rinsed first before wax was applied. The HD stated the condition of the bathroom could be better because this was their home. On 8/26/2025 at 11:18 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the bathroom should be cleaned every day. The LNHA stated that he would not expect for the floor to be sticky after it were cleaned. The LNHA further stated it was not a proper home like environment. 4) On 8/26/2025 at 11:00 AM, the surveyor toured the resident lounge area with the Licensed Practical Nurse/Unit Manager (LPN/UM) #2. The surveyor observed debris lodged in the refrigerator door seal gasket, no freezer thermometer, non-working refrigerator thermometer, no temperature log for refrigerator, and no temperature log for freezer. The freezer door contained opened package of sausages which was labeled with a name and room number, but was not dated or sealed. The top shelf of the refrigerator had one clear plastic contained filled with food and the lid was labeled but was not dated. On 8/26/2025 at 11:15 AM, the surveyor interviewed LPN/UM #2, who acknowledged that the resident refrigerator was not clean and the food contents were not labeled or dated. There was no temperature log for the freezer or refrigerator. The LPN/UM #2 was unable to provide the temperatures to the surveyor because neither the freezer nor the refrigerator had a portable thermometer. On 8/26/2025 at 11:30 AM, the surveyor interviewed the Resident Housekeeper (RH) who was newly assigned to this area and was unaware of the need to clean the refrigerator in the Chapel Unit area. On 8/26/2025 at 11:45 AM, the surveyor toured the First Floor Unit Pantry with the Housekeeping Director (HD) and observed debris in the freezer door seal gasket, debris in the lower cabinet under the sink, debris on lower cabinet door, a missing drawer from the lower cabinets, and cabinet space under the sink had a warped, broken, cracked floor and wall. The HD acknowledged that the pantry was not cleaned. On 8/26/2025 at 11:50 AM, the surveyor interviewed Resident Housekeeper #2 (RH) #2 who stated the First Floor Unit pantry was cleaned every Monday. On 8/26/2025 at 11:55 AM, the surveyor interviewed the HD who acknowledged the findings on both units and agreed that it was not cleaned or maintained according to the facility policy. On 8/26/2025 at 12:05 PM, the surveyor interviewed the Maintenance Director (MD) who was made aware of the missing lower base cabinet drawer located in the First Floor Unit Pantry. He stated, he had not received an electronic work order but would go and assess and fix the pantry. On 8/27/2025 at 10:12 AM, the surveyor met with Licensed Nursing Home Administrator (LNHA) and Chief Operating Officer (COO), who reviewed pictures presented by the surveyor and acknowledged the surveyor findings. The LNHA stated that it was his expectation that all personnel including housekeeping and maintenance, should enter any issues into the electronic maintenance system for repairs timely. A review of the facility's undated Homelike Environment Policy, included: Residents are provided with a safe, clean, comfortable and homelike environment . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment; . .Clean bed and bath linens that are in good condition; Pleasant, neutral scents . A review of the facility's undated Foods Brought by Family/Visitors, policy, included.Liberalized diets will be permitted as much as possible. Staff must be aware of, and approve, food(s) brought to a resident by family/visitors .Perishable foods must be discarded after an appropriate time (specific to food and temperature). Food kept in the refrigerator for a resident must be labeled with the resident's name and the date. A review of the facility's undated Refrigerators and Freezers policy, included.the facility will ensure safe refrigerator and freezer maintenance, temperatures, sanitation, and will observe food expiration guidelines.Acceptable temperatures shall be 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers.Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.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 8:39-27.1(a);31.4(a)

Intake ID: 393868Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of misappropriation of property to the New Jersey Department of Health (NJDOH) immediately, within two hours, or within 24 hours of the allegation if no harm occurred and submitted the outcome of the investigation within five working days in accordance with state and federal requirements. This deficient practice was identified for 1 of 5 residents (Resident #33) reviewed for abuse and was evidenced by the following:On 8/25/2025 at 12:23 PM, the surveyor reviewed the closed medical record of Resident #33. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included: fusion of spine, lumbar (five vertebra in the low back) region, pathological (caused by disease or illness) dislocation of right knee, not elsewhere classified, heart failure, not elsewhere classified, other bipolar disorder (a mental disorder characterized by periods of elevation and depression), and other specified anxiety disorders. A review of the resident's most current comprehensive Minimum Data Set (MDS), an assessment tool, included the resident had a Brief Interview for Mental Status Score of 15 out of 15, which indicated that the resident was cognitively intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/11/2025, included the resident reported that he/she was missing money implicating staff took it. Interventions included: .Provide a lock box for valuables . A review of the progress notes failed to include any documentation that pertained to the resident's allegation of misappropriation of property that reportedly occurred on 6/12/2025. On 8/25/25 at 4:43 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with an Incident Report dated 6/12/25 at 2:00 PM. A review of the Incident Report detailed that on 6/12/25, the resident reported that he/she had money missing and that the Certified Nursing Assistant (CNA) #4 took it. The resident did not see her take the money, but she was acting funny. Further review of the Incident Report revealed that the resident was provided with education to use the lock box in their room for which the resident had a key, the resident's family was notified, the CNA was removed from the schedule, statements were gathered, the Care Plan was updated, and the Ombudsman was notified on 6/14/25 at 6:59 AM. A review of an undated Investigational Summary and Conclusion revealed that on 6/12/25 at 2:00 PM, the resident reported that they had an undisclosed amount of money missing and that CNA #4 took it. The resident was unable to provide any time frames when interviewed. Action: .An investigation was immediately initiated. The Facility administrator, MD (Medical Director), DOH (Department of Health), Ombudsman, and family contact for the resident was notified of the incident.CNA #4 was sent home and suspended pending investigation. The Social Worker interviewed eight cognitively intact residents who all denied any abuse, neglect, or intentional mishandling of any kind. The investigation failed to include a statement that was written by CNA #4. A review of the Conclusion revealed that after a thorough investigation was conducted by the facility and based on statements gathered, we concluded that we are unable to substantiate the allegations of an attempt of misappropriation of resident funds. When interviewed, Resident #33 was unable to provide dates or time frames, and after further questioning, stated that they were just upset at the aide, and she was acting funny. He/She had no further concerns about money being taken. At this time, there are no substantiated findings of abuse, neglect or misconduct by CNA #4. On 8/26/2025 at 9:04 AM, the surveyor interviewed the LNHA who stated that the resident admitted that the accusation was retaliatory in response to an event that occurred in the smoking yard prior. The LNHA stated that the CNA no longer worked at the facility, and that she only worked one more shift after the accusation was made and then she resigned. The Director of Nursing (DON) #1 who completed the investigation terminated employment with the facility on 8/22/25 and was unavailable for an interview. The LNHA stated that he was involved with the investigation and could answer any related questions. At that time, the surveyor requested proof that the summary, conclusion and all supporting documentation was sent to the DOH within the required time frame for reporting. On 8/26/2025 at 11:30 AM, in a later interview with the LNHA, he stated that he was unsure if the summary and conclusion were sent out to the DOH. The LNHA stated that CNA #4 was called, was suspended and taken off the schedule. The LNHA further stated that CNA #4 returned to work on 8/16/25, after the investigation was complete.The LNHA further stated that an allegation of abuse, with no harm was required to be phoned into the facility within 24 hours. He stated that then we have five days to submit the completed investigation. The LNHA stated that we do not necessarily document these incidents in the progress notes as we document in the incident report, and do not put allegations in a nursing note. On 8/27/25 at 10:03 AM, the surveyor interviewed the LNHA in the presence of the survey team who stated that DON #1 was required to report any allegation of abuse immediately or not greater than two hours. The LNHA stated that he also found emails from the DOH requesting outstanding information with mention of a site visit if the information was not presented from facility when requested. The LNHA acknowledged that the investigation and related summary and conclusion was not reported within the required time frames in accordance with state and federal requirements. A review of the facility's undated Abuse Prevention Program included: .When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the Administrator/Designee will notify the following persons or agencies of the incident:New Jersey Dept. of Health & Senior Services.Ombudsman (residents over age of 60) .The policy failed to include the required timeframes for reporting any allegations of abuse.NJAC 8:39-9.4(e) (2)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's a.) anti-anxiety medication and, b.) history of diabetes mellitus.This deficient practice was identified for 1 of 5 residents (Resident #5) reviewed for unnecessary medications and evidenced by the following:On 8/22/25 at 9:00 AM, the surveyor observed Resident #5 with his /her eyes closed sitting in a reclining chair in the day room. The surveyor reviewed the medical record for Resident #5.A review of the admission Record, (an admission summary), revealed the resident had diagnoses which included, but were not limited to, dementia, and encephalopathy (a medical condition that affects brain function, leading to changes in mental state, behavior, and cognitive abilities) and Type 2 diabetes mellitus.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/8/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that cognition the resident's cognition was severely impaired. Further review of the MDS revealed the resident received antianxiety and hypoglycemic (low blood sugar) medications.A review of the resident's individual comprehensive care plan (ICCP) did not include a care plan entry for antianxiety medication or for a diagnosis of diabetes mellitus including the medication Metformin (an oral diabetes medicine). A review of the order Summary Report (OSR), with an order date range of 7/2/25-8/31/25, included the following physicians' orders (PO):A PO, dated 7/2/25, for Lorazepam Oral tablet 1 milligram (MG) give 1 tablet by mouth every 8 hours as needed for anxiety. A PO, dated 7/3/25, for Metformin HCL oral Tablet 500 mg, give 1 tablet by mouth two times a day for diabetes. Administer with meals. On 8/26/25 at 10:12 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated residents who were receiving antianxiety and diabetic medications should have a care plan. The LPN/UM #2 further stated that it was important that care plans were updated for the resident's continuation of care and they showed the residents level of care. The LPN/UM #2 stated that the anti-anxiety medication and diabetes diagnosis should have been included in the comprehensive care plan completed 14 days after admission. On 8/26/25 at 11:33 AM, the surveyor interviewed the Director of Nursing (DON #2) who stated Resident #5 should have had a care plan for receiving anti-anxiety and diabetic medications. The DON#2 further stated that it was the responsibility of the nurse on the cart, the unit manager and the DON to update the care plans. DON #2 stated that care plans were important because they are an accurate reflection of the resident and should capture everything about the resident. On 8/26/25 at 1:21 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON #2 of the concern that Resident #5's care plan did not include the antianxiety medication or the diagnosis of diabetes mellitus. A review of the facility's Care Plans policy, undated, included that the interdisciplinary team, in coordination with the resident, his/her family or representative develops and maintains a care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan has been designed to: a.) incorporate identified problems; b) incorporate risk factors associated with identified problems;. N.J.A.C.8:39 - 11.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan (ICCP) for a resident with an order for a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea). This deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #14), and was evidenced by the following:On 8/21/25 at 11:13 AM, during the initial tour of the facility, the surveyor observed Resident #14 seated in their wheelchair in their room watching television. The surveyor did not observe a tracheostomy for Resident #14. On 8/22/25 at 12:45 PM, the surveyor observed Resident #14 seated in their wheelchair in their room. Resident #14 stated that when they were admitted to the facility he/she had a tracheostomy in place, but it was removed a couple years ago. On 8/22/25 at 10:42 AM, the surveyor reviewed the medical record for Resident #14. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; tracheostomy (surgical procedure to create an opening through the neck into the trachea), paralysis of vocal cords and larynx (vocal cords lose the ability to move impacting the voice), and dysphagia (difficulty swallowing). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/26/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A further review of section O respiratory treatments, revealed that Resident #14 did not have tracheostomy care.A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 10/16/20, resident has a tracheostomy related to impaired breathing mechanics. The ICCP included interventions to ensure that trach ties were secured at all times, suction as necessary and use universal precautions as appropriate.On 8/25/25 at 1:10 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, who identified that a ICCP should be updated as changes occurred in the resident's plan of care. LPN #1 stated that focus areas on the care plan included items specific to the resident such as falls, pain, code status, tracheostomy, and their diagnosis. LPN #1 stated that care plans should be updated or revised when there is a change in the resident's plan of care. LPN #1 confirmed that the resident no longer had a tracheostomy. LPN #1 stated that the resident's tracheostomy had been removed a few years ago. She acknowledged that the residents care plan should have been updated when the tracheostomy was discontinued to ensure proper patient care. On 8/26/25 at 12:31 PM, the surveyor interviewed the Director of Nursing (DON) #2, who stated that care plans were updated when there was any change in the resident's care. DON #2 confirmed that Resident #14's care plan should have been updated when the resident no longer had a tracheostomy. DON #2 further stated that it was the responsibility of the nurse on the cart, the unit manager and the DON to update the care plans. DON #2 stated that care plans were important because they are an accurate reflection of the resident and should capture everything about the resident.On 8/27/25 at 10:03 AM, the DON #2, in the presence of the Licensed Nursing Home Administrator (LNHA), and the survey team, acknowledged that a care plan should be updated and revised as soon as they are aware of any changes in the resident's care. DON #2 further stated that the importance of updating a resident's care plan is to know the residents current plan of care. A review of the facility's Care Plans policy, undated, included that care plans are revised as changes in the resident's condition may dictate. Care plans are reviewed at least quarterly. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to place a resident's urinary catheter drainage bag inside of a privacy bag to maintain resident dignity. This deficient practice was identified for 1 of 1 resident reviewed for urinary catheters (Resident #90), and was evidenced by the following:On 8/21/25 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #90 lying in their bed awake. The resident stated that they had an issue with their suprapubic catheter (a type of indwelling catheter that drains urine from the bladder into a collection bag). The surveyor observed the indwelling catheter drainage bag secured to the bed frame, not placed in a privacy bag, exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the resident's catheter drainage bag from the hallway. On 8/21/25 at 11:40 AM, the surveyor observed Resident #90 lying in their bed awake. The resident stated that the facility used to put their catheter drainage bag in a privacy screen, but they have not recently. The resident stated that it bothered them when the catheter drainage bag is not placed in a privacy bag. The surveyor observed the indwelling catheter bag secured to the bed frame, not placed in a privacy bag, exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the resident's catheter drainage bag from the hallway. On 8/22/25 at 9:00 AM, 8/25/25 at 9:44 AM, and on 8/26/25 at 10:34 AM, the surveyor further observed the indwelling catheter bag secured to the bed frame, not placed in a privacy bag, exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the catheter drainage bag from the hallway. On 8/25/25 at 10:11 AM, the surveyor reviewed the medical record for Resident #90. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; urinary tract infection (infection of the urinary system) and neuromuscular dysfunction of bladder (nerves controlling bladder function were damaged). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/5/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating a cognitively intact cognition. A further review of the MDS revealed the resident had an indwelling catheter. A review of the Order Summary Report included a physician's order (PO) dated 5/4/24, for a catheter: 18 French (Fr; size of the indwelling catheter) suprapubic (S/P) catheter. A further review revealed a PO to change suprapubic catheter with 18 French with 10 cubic centimeter (cc) balloon (a balloon inflated to keep catheter in place) monthly on the 28th and as needed. A review of the individual comprehensive care plan (ICCP) included a focus area dated 3/12/24, that the resident had a suprapubic catheter due to urinary retention. Interventions included but were not limited to; 18 French suprapubic catheter with 10 cc balloon, change and irrigate foley catheter as needed and as per facility policy, encourage fluids, and monitor for patency every shift. On 8/26/25 at 9:15 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #1 who stated the process for caring for a urinary catheter is to empty the catheter bag and to place it in a privacy bag. The CNA #1 further stated the importance of placing a catheter drainage bag into a privacy bag was for the privacy of the resident. On 8/26/25 at 10:38 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated that catheter drainage bags should be placed into a privacy bag. The LPN #1 further stated the importance of the catheter drainage bag to be in a privacy bag was for the resident's dignity. On 8/26/25 at 11:33 AM, the surveyor interviewed the Director of Nursing (DON #2), who stated that the catheter drainage bag should always be in a privacy bag for resident dignity reasons. On 8/27/25 at 10:03 AM, the DON #2, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that the catheter drainage bags should be maintained in privacy bags for dignity reasons. A review of the facility's Urinary Catheter Management Policy undated, included.this policy ensures residents receive care that minimizes infection risk, maintains catheter patency, and promotes dignity and comfort. A review of the facility's Resident Rights policy, undated, included.Dignity, the facility will treat you with dignity and respect in full recognition of your individuality. NJAC 8:39-4.1(a)(12)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. The deficient practice was identified for 2 of 2 residents (Resident #1 and #122) reviewed for Respiratory Care and was evidenced by:1.) On 8/21/25 at 11:13 AM, during the initial tour the surveyor observed Resident #122 awake and alert lying in bed wearing oxygen via nasal cannula (prongs that are placed in the nostrils) at three (3) liters (L). On 8/22/25 at 9:11 AM, the surveyor observed Resident #122 lying in bed with their eyes closed wearing oxygen via nasal cannula at 3L. On 8/25/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #122. 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 with hypoxia (lack of sufficient oxygen reaching the body's tissues or an environment with low oxygen levels) and dependence on supplemental oxygen. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/3/25, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the resident used continuous oxygen. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, undated included, the resident was on oxygen therapy related to (r/t) chronic obstructive pulmonary disease (COPD- lung diseases that cause ongoing inflammation and damage to the airways). Interventions included: oxygen settings: humidified oxygen (O2) via nasal prongs at four (4) L continuous. A review of the Order Summary Report (OSR), dated as of 8/1/25 to 8/31/25, included the following physician orders (PO): A PO, dated 6/26/25, for oxygen at 4L O2 via nasal cannula with humidification every shift for COPD. On 8/25/25 at 9:48 AM, the surveyor observed Resident #122 awake and alert wearing oxygen via nasal cannula at 3L. On 8/25/25 at 11:03 AM, the surveyor observed the resident's oxygen concentrator set at 3 1/2 liters. At that time, the surveyor interviewed the resident, who stated that he/she had not touched the oxygen concentrator but had an extended oxygen tubing via nasal cannula to ambulate in the room. Resident #122 reiterated that they did not touch the oxygen level and then stated that they thought the oxygen level was set too high. On 8/25/25 at 11:06 AM, the surveyor and the Licensed Practical Nurse (LPN) #1 reviewed the physician's order (PO) in the electronic medical record (EMR). At that time, LPN #1 confirmed the oxygen should be set at 4L. At that time, LPN #1 and the surveyor entered the resident's room. LPN #1 confirmed the oxygen concentrator was set at 3 1/2 L and that it should have been set at 4 L. She stated the nurses should be checking the oxygen concentrator to ensure the oxygen was on the correct liters of oxygen every shift. On 8/26/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) #2, who stated the nurses should check the resident's oxygen order at the beginning of the shift, so when they conducted rounds, they checked the concentrator to ensure it was on the correct setting. DON #2 stated that it was important the resident received the oxygen as ordered to maintain the sustainability of arrhythmic (irregular heartbeat) breathing and to ensure they had adequate oxygen flow, so they did not go into respiratory failure (not enough oxygen or too much carbon dioxide in the body). On 8/27/25 at 10:09 AM, the LNHA, in the presence of DON #2 and the survey team, stated that the oxygen concentrator should be set accurately. 2.) On 8/22/25 at 12:29 PM, the surveyor observed Resident #1 lying in bed with a tracheostomy tube (a surgical opening in the neck directly into the trachea [windpipe]). The resident did not respond to the surveyor when spoken to and the resident's oxygen concentrator (a medical device that extracts and concentrates oxygen from ambient air) was set at 30%, with humidification noted, delivered through a tracheostomy mask (a medical device that fits over a tracheostoma to deliver oxygen or aerosolized medication directly to the patient's trachea). On 8/22/25 at 9:06 AM, the surveyor reviewed the medical record for Resident #1. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; acute respiratory failure with hypoxia (oxygen deficient), and chronic obstructive pulmonary disease (lung condition characterized by airflow obstruction). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/24/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated that the resident's cognition was severely impaired and was rarely/never understood. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, dated 4/25/24, included that the resident had an altered respiratory status/difficulty breathing with an intervention to administer medication (oxygen) as ordered and maintain a clear airway. A review of the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 8/7/25, for oxygen, Change Humidifier Bottle when empty. Ensure bottle is always filled. Label and date. Use Sterile Water for Aerosol (humidification) Bottle. A review of the Treatment Administration Record (TAR) revealed that the above PO for changing the humidification bottle was signed out as administered on 8/25/25 for the day shift. On 8/25/25 at 09:05 AM, the surveyor observed Resident #1 lying in bed with their eyes closed. The oxygen concentrator was set to deliver the ordered 30% oxygen via tracheostomy collar, and the humidification bottle was noted to be empty. On 08/25/2025 at 11:55 AM, the surveyor observed Resident #1 in bed, with their eyes closed on tracheostomy collar at 30% oxygen with no humidification noted, the bottle was still empty. On 08/25/2025 at 1:05 PM, the surveyor observed Resident #1 in bed with their eyes open, but the resident was non-verbal, on a tracheostomy collar at 30% oxygen, and the humidification bottle was noted to be empty. On 8/26/25 at 12:37 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that nursing carried out respiratory care ordered by the doctor. When asked about the importance of humidification of oxygen for a patient with an order for it LPN/UM #1 stated that humidification keeps the mucus membranes moist and intact. LPN/UM #1 was then asked to verify the oxygen and humidification order for Resident #1 with the surveyor, which she confirmed was 30% oxygen on trach collar with humidification to be replaced when empty. When presented with timestamped pictures of the oxygen and humidification setup, LPN/UM #1 stated that the bottle is empty in the pictures and that it should contain the ordered sterile water for humidification. On 8/26/25 at 12:53 PM, the surveyor interviewed the Director of Nursing (DON) #2 who stated that nursing is responsible for carrying out respiratory orders and should have assessed the humidification bottle as determined by the physician's order. The DON #2 stated that when the order for humidification was signed out by the nurse on the TAR, it indicated that the nurse had looked at the humidification bottle and replaced it if necessary. DON #2 and the surveyor verified and confirmed the current orders for Resident #1 then reviewed the pictures taken on 8/25/25. The DON #2 stated that the pictures showed an empty humification bottle and that humidification is important to keep the airways and nares (nostrils) moistened and reduced irritation. On 8/26/25 at 1:14 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA) aware of the concerns that were identified with the resident's humidification orders. On 8/27/25 at 10:21 AM, the LNHA in the presence of DON #2 and the survey team stated that the humidification container should not be empty per the doctor's orders. A review of the facility's Oxygen Administration policy, undated, included 1. Verify that there is a provider order for this procedure. Review the physician's orders or facility protocol for oxygen administration . .Check the mask, tank, bubbler humidifier or refillable oxygen humidifier bottle, etc, to be sure they are in good working order and are securely fastened. Be sure there is distilled or sterile water in the bubbler humidifier or refillable oxygen humidifier bottle and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in bubbler humidifier or refillable oxygen humidifier bottle. NJAC 8:39-27.1(a)

Based on observation, interview, review of medical records and facility documents, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received prescribed treatments to prevent contractures for 1 of 3 residents (Resident #6) reviewed for limited range of motion. This deficient practice was evidenced by the following:On 8/22/25 at 1:34 PM, the surveyor observed Resident #6 lying in bed awake. When interviewed, the resident stated that he/she had a history of a stroke and could not move their left arm. The resident stated that he/she had a splint in one of the drawers, but the staff had not put it on for a long time. The resident's left upper extremity was covered with a thin blanket. On 8/22/25 at 1:47 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) #3 who stated that she had just finished providing personal care to Resident #6. CNA #3 further stated that the resident did not have any contractures and their skin was intact.On 8/22/25 at 1:18 PM, the surveyor reviewed the medical record for Resident #6. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; Cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (one sided weakness).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 6/25/25, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was fully intact. Further review of the MDS revealed that in the past seven calendar days, the resident had zero splint or brace assistance. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 1/16/24, with a goal of; I will tolerate appropriate splint and ROM (range of motion) for mobility. Interventions included: ROM/ Manual therapy, Contracture therapy. A review of the Order Summary Report (OSR), dated as of 3/6/24, included the following Physician's Order (PO): Apply left resting hand splint with AM care and remove in PM. Perform skin care checks before and after application and report to nurse any redness or abnormalities every day shift for splint. A review of the Treatment Administration Record (TAR) revealed a PO with a start date of 3/6/25 and a Discontinue Date of 8/25/25 to Apply Left resting hand splint in the AM and remove in the PM. It had been signed out as 'administered' daily from 8/1/25 through 8/25/25. On 8/25/2025 at 2:23 PM, the surveyor observed the resident lying in bed with their left hand lightly clenched in a fist without a splint on. The resident's nails were noted to be long bilaterally (both sides). The resident stated that the splint had not been applied for months. On 8/25/25 at 2:27 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated that she was covering the nursing unit while the resident's assigned nurse was away from the unit. LPN #5 stated that she had cared for the resident once prior. At that time, LPN #5 accompanied the surveyor into the resident's room and looked for the resident's left resting hand splint in the resident's drawers with resident permission. The resident stated it was blue. LPN #5 found the blue resting hand splint on top of a hamper between the resident's bed and the nightstand. LPN #5 stated that the splint was needed because the resident's left hand was contracted, and the splint was like a cushion to keep the resident's nails from digging into their skin and prevent further contracture. On 8/25/25 at 2:36 PM, the surveyor asked LPN #5 to review the resident's TAR in the presence of the surveyor. LPN #5 displayed the resident's TAR on the computer screen and stated that there was a green check mark on the TAR. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 presented and assisted LPN #5 to review the order with the surveyor. LPN/UM #1 stated that it looked like the resting hand splint was signed out as administered, but the resident sometimes refused, and nursing should then document the refusal. At that time, the LPN/UM #1 accompanied the surveyor into the resident's room. The LPN/UM #1 stated that the resident was supposed to have the splint on. The resident stated, It was not offered to me today. LPN/UM #1 then proceeded to put the resident's splint on the residents left hand. On 8/26/2025 at 10:45 AM, the surveyor observed the resident lying in bed with the left resting splint on. The resident voiced satisfaction.On 8/26/2025 at 11:59 AM, the surveyor interviewed the Director of Nursing (DON) #2 who stated that she had only worked at the facility for two days, but she expected that they would abide by the order from the therapy department for splint usage. DON #2 stated that the purpose of the splint was to improve or prevent further decline of a contraction. The DON #2 stated that if the splint were removed due to resident intolerance, it would have to be documented in a progress note so that therapy could address the situation appropriately. On 8/26/25 at 1:23 PM, in the presence of the survey team, the surveyor voiced the resident's concern to the Licensed Nursing Home Administrator (LNHA) and DON #2 regarding the lack of splint application despite the nursing documentation on the TAR which indicated that the resident's splint was applied daily from 8/1/25 through 8/25/25. On 8/27/23 at 10:03 AM, in the presence of the LNHA and the survey team, DON #2 stated that she did confirm that the resident wanted their splint and the nursing staff's falsification of documentation on the TAR regarding splint application was addressed.A review of the facility's undated Splinting policy included: Splints, either custom made or prefabricated, are used to provide proper body support, prevent unwanted motion, contracture management or reduction, pain management and facilitate motor activity.Process: Apply splint as ordered.Remove splint as ordered. If refusal occurs, document refusal. Check skin before and after splint use for any changes. A review of the facility's undated Charting and Documentation policy included: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.Entries may only be recorded in the resident's clinical record by licensed personnel.In accordance with state law and facility policy. NJAC 8:39-27.2(m)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a physician's order for an as needed (PRN) psychotropic drug was limited to 14 days for 1 of 5 residents (Resident #5) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 8/22/25 at 9:00 AM, the surveyor observed Resident #5 with his /her eyes closed sitting in a reclining chair in the day room. The surveyor reviewed the medical record for Resident #5.A review of the admission Record, (an admission summary), revealed the resident had diagnoses which included, but were not limited to, dementia, and encephalopathy (a medical condition that affects brain function, leading to changes in mental state, behavior, and cognitive abilities).A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/8/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed the resident received antianxiety medications.A review of the resident's individual comprehensive care plan (ICCP) did not include a care plan entry for an antianxiety medication.A review of the order Summary Report (OSR), with an order date range of 7/2/25-8/31/25, included the following physicians' orders (PO):A PO, dated 7/2/25, for Lorazepam Oral tablet 1 (one) milligram (MG) give 1 tablet by mouth every 8 (eight) hours as needed for anxiety. Further review of the above PO did not have a stop date of 14 days. A review of August 2025 electronic Medication Administration Record (eMAR) revealed a PO with a start date of 7/3/25 and a discontinue (d/c) date of 8/4/25, for Lorazepam 1 (one) mg, give 1 (one) tablet by mouth every 8 (eight) hours as needed for anxiety. Further review of the eMAR revealed the resident was administered the Lorazepam as needed after the 14 day period.On 8/25/25 at 12:15 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that the 7/2/25 PO for Lorazepam should have had a 14 day stop date. The CP confirmed that the 7/3/25 Electronic Pharmacist information Consultant (EPIC) report recommended the first order of prn (as needed) psychoactive medications was limited to 14 days, then after a rationale from the provider, the medication could continue with a duration of the 30, 60, or 90 days. The CP confirmed this was recommended again on the monthly CP report on 7/28/25.On 8/26/25 at 10:12 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) #2 who stated that the initial order for Lorazepam needed a 14 day stop date. On 8/26/25 at 11:33 AM, the surveyor interviewed the Director of Nursing (DON) #2 who stated that the new order for Lorazepam should have had a 14 day stop date. On 8/26/25 at 1:21 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON #2 of the concern that Resident #5's PRN order for lorazepam did not have a 14 day stop. A review of the facility's Psychotropic Medications policy, undated, revealed that PRN psychotropics medications are limited to fourteen (14) days and include: antidepressants, anti-anxiety and hypnotics. If the prescriber wants the PRN order to be extended, then he/she must document rationale in the medical record and indicate the duration of the PRN order. N.J.A.C. 8:39-27.1(a)

Complaint #: NJ185404 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 6/27/2025, it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation. This deficient practice was identified in 1 of 7 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility in April 2025 with diagnoses which included but were not limited to: Diabetes, Major Depressive Disorder, and Hypertension. According to the admission Minimum Data Set (MDS), an assessment tool dated 4/12/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. According to the facility's Investigation, Summary and Conclusion dated 4/11/2025, revealed the social worker was doing rounds and the resident reported that his/her Certified Nursing Assistant (CNA) was rough with him/her. Resident #1 stated yesterday when she helped me into the bed, she didn't wait for me to try and move over, she just shoved me. The investigation further revealed that Resident #1 was trying to be more independent due to going back home. The CNA did not want the resident to fall and helped the resident into the bed. A review of Resident #1's CP revealed no new updates or interventions related to the abuse allegation on 4/10/2025. On 6/27/2025 at 3:09 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the resident's care plan was not updated after the abuse allegation on 4/10/2025. The DON stated all nursing staff were responsible for updating the care plan and that it should have been updated after the abuse allegation. The DON further stated it was important to update the care plan because it tells staff how to care for the residents. Review of the facility's undated policy titled Care Plans revealed under Policy Statement, An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Under Policy Interpretation and Implementation, 4. Care plans are revised as changes in the resident's condition may dictate. NJAC 8:39-11.2 (e) (1) (2)

COMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to: a.) implement a care plan intervention for a physical therapy (PT) consult and b.) provide a resident with a Physical Therapy/Occupational Therapy (PT/OT) assessment after a fall as recommended by the Interdisciplinary Team (IDT). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 1/23/25 indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the resident's cognition was moderately impaired. Review of Resident #2's Order Summary Report indicated active orders as follows: -Occupational Therapy Evaluation as needed -Physical therapy evaluation as needed A review of Resident #2's care plan indicated a focus related to the resident having actual falls. Further review revealed the following intervention, [Physical Therapy] consult for strength and mobility, that was initiated on 1/8/25. Further review of the medical record did not indicate that a PT consult was completed after this date. A review of an Incident Report dated 1/16/25 revealed, under the Conclusion section, that the IDT met to discuss the unwitnessed fall and determined that, .PT/OT will assess resident . Further review of the medical record did not indicate that a PT/OT consult was completed after this date. A review of an Incident Report dated 1/30/25 revealed, under the Conclusion section, that the IDT met to discuss the unwitnessed fall and determined that, .PT/OT will assess resident . Further review of the medical record did not indicate that a PT/OT consult was completed after this date. On 2/14/25, at 1:42 P.M., the surveyor interviewed the Director of Rehabilitation Services who stated that she would expect that a resident who fell would have been referred for a PT/OT assessment to determine if the resident would benefit from additional skilled interventions. She further stated that her department relies on Nursing to refer a resident who needed an assessment. The Director further stated that her department did not receive a referral for Resident #2 for the 1/8/25, 1/16/25, or the 1/30/25 falls. On 2/14/25, at 2:55 P.M., the surveyor interviewed the Director of Nursing (DON). In the presence of the surveyor, the DON reviewed Resident #2's care plan and incident reports. When asked if the PT/OT referrals should have been made, she stated yes. When asked what the importance of completing an assessment was, the DON stated, To determine whether or not additional needs or improvements could be made for the resident. Review of the facility's undated Care Plans policy revealed under the Policy Interpretation and Implementation section that a comprehensive care plan was designed to .f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program . The section further revealed that, .Care plans are revised as changes in the resident's condition may dictate . N.J.A.C. 8:39-27.1(a); 37.1(b)

COMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit. This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. The AR further revealed the name of the resident's Attending Physician, who was also the facility's Medical Director. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 1/23/25 indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the resident's cognition was moderately impaired. Further review of Resident #2's medical record revealed Nurse Practitioner (NP) assessments; however, the surveyor was not able to locate any physician assessments for Resident #2. On 2/13/25, at 2:22 P.M., the surveyor conducted a telephone interview with the Medical Director (MD), who stated that he was familiar with Resident #2. When asked if he conducted any documented assessments of the resident, he stated that he observed the resident on the unit and he discussed the resident's care in meetings. He also stated that he went to the facility weekly, and that the facility has two Nurse Practitioners and an additional physician who are in the building during the week. Additionally, he added that patients were to be seen at time of admission and every other month. On 2/14/25, at 5:06 P.M., the surveyor informed the Chief Clinical Nurse/Administrator and the Director of Nursing (DON) of the concern that Resident #2 did not have any documented physician visits or admission assessment. The surveyor did not receive any additional documentation regarding this concern. A review of the facility's undated Medical Director policy, under the Policy Interpretation and Implementation Section, revealed, 1. Physician services are under the general supervision of the Medical Director . The policy further indicated that the MD was responsible for, .Ensuring adequate and appropriate physician services . and that the MD functions included, .Helping assure that residents receive adequate services appropriate to meet their needs . The policy failed to identify who was responsible for conducting initial comprehensive visits for residents. NJAC 8:39-23.2(d); 27.1(a)

COMPLAINT#: NJ00181569 Based on observation, interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 6 residents (Resident #4) reviewed and was evidenced by the following: Resident #4 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: seizures, severe protein-calorie malnutrition, and COPD. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 12/18/24 indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident's cognition was intact. Review of Resident #4's Order Summary Report indicated an order as follows: -Clonazepam [Klonopin] Oral Tablet 2 MG: Give 1 tablet by mouth three times a day for anxiety Review of Resident #4's Controlled Drug Administration Record Tablet, revealed that a Clonazepam 2 mg tablet was signed out on 12/13/24 at 9 P.M. A review of Resident #4's December 2024 Medication Administration Record (MAR) revealed a blank box for the above medication on 12/13/24 at 9 P.M. The surveyor reviewed a grievance that was reported on 12/17/24, by Resident #4, and revealed the following: Grievance Details - Resident stated not receiving the scheduled Klonopin on 12/13/24. Summary of Actions Taken - Indicated that the Supervisor reviewed the MAR and that no discrepancy was noted. On 2/14/25, at 10:04 A.M., the surveyor attempted to reach the Licensed Practical Nurse (LPN) that was assigned to Resident #4 on 12/13/24 during the evening shift, via telephone. The number provided by the facility was not in service and no alternate number was provided at the time of the survey. On 2/14/25, at 2:26 P.M., the surveyor interviewed the Director of Quality Experience (DQE), who reviewed the aforementioned grievance. The DQE stated that considered the grievance resolved on 1/23/25. She explained that her primary role is dealing with customer service issues. She stated that when she received information related to a grievance, she placed all information in the electronic system and then she would forward it to the Unit Manager (UM) responsible. She further added that she would then meet in-person with the UM who would inform her on what actions were taken and what the findings were and input that into the system. She would then follow-up with the resident and ensure that they were satisfied with the outcome, if they were not, she would file another grievance. The DQE stated that she recalled interacting with Resident #4 regarding this incident and she stated that the resident did not express any additional concerns, or she would have filed another grievance, which is what she would do if a resident expressed dissatisfaction with the outcome. On 2/14/25, at 2:55 P.M., the surveyor interviewed the Director of Nursing (DON). In the presence of the surveyor, the DON reviewed Resident #4's aforementioned grievance and the corresponding MAR. The DON stated that the UM was not available for interview, however, she recalled the resident. She stated that nurses are to sign the MAR after each medication is administered to reflect that this was done. She stated that although the UM verified the bingo card, and the narcotic count, she expected that the UM would have followed up with the assigned nurse regarding why the MAR was not signed. N.J.A.C. 8:39-27.1(a); 29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health within two hours for a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. The surveyor reviewed the medical record for Resident #47. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/4/24 at 12:16 PM, the LNHA confirmed the surveyor had all the investigations for the resident. A review of the investigations did not include the abuse allegation made by the resident. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked at the facility. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance form since the resident was alert and oriented. The surveyor requested the grievance form. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. On 3/6/24 at 8:51 AM, re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she would borrow money from the resident. The resident stated CNA #1 was paying them back, but then stopped. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 kept telling the resident Tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident felt that he/she did not give CNA #1 the money, they would no longer go above and beyond with care. On 3/6/24 at 10:46 AM, the surveyor asked the LNHA what the types of abuse were, and the LNHA responded physical, verbal, mental, financial, emotional. The surveyor asked the LNHA who was susceptible to abuse in the facility and the LNHA stated all residents were at risk for abuse in the facility. At this time, the surveyor reviewed the facility's abuse policy with the LNHA which indicated the facility had one business day to notify the DOH of abuse, and the LNHA confirmed the facility had one day to notify. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement. The LNHA confirmed the facility did not report the incident to the DOH. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated or reported to the DOH or any other authority. The LNHA also stated that the activities staff and social worker were the staff who purchased residents' personal needs if their families could not. 2. On 2/28/24 at 12:14 PM, the surveyor observed Resident #47 in bed, the resident was alert and oriented and able to be interviewed. The surveyor reviewed the medical record for Resident #47. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. A review of the Grievance Summaries dated 10/13/23 and resolved 10/13/23, included the following: Grievance details: resident states 11:00 PM to 7:00 AM (11- 7) shift [CNA #2] yelled at [him/her] saying you ring your call bell like we are your slaves and that's why everyone talks about you. Resident states that [he/she] asked for ice water and [CNA #2] said there is no ice you have to wait. Resident states that [he/she] told the [CNA #2] that [his/her] boots on [his/her] feet are hurting [him/her] and the CNA stated you slept all night with them on and now all the sudden they hurt you then took the straps off the boots to loosen them. Resident states that CNA left [his/her] light on, curtain open and door open and [he/she] had to ring [his/her] bell again for someone to close the door and turn the lights off. Summary of investigation: resident reported the aide on the 11-7 was disrespectful to [him/her] and yelled at [him/her]. Summary of findings: resident was upset by the interaction [he/she] had with the staff member. [He/she] did not know the employee's name but was able to describe her. Resident was not able to give any information on who answered [his/her] call light to turn the light off or close the door. Summary of actions taken: employee was removed from schedule and was educated. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/6/24 at 1:21 PM, the surveyor asked Resident #47 if he/she ever had any issues with a CNA, and the resident stated that CNA #2 who no longer worked at the facility. Resident #47 stated that he/she rang their call bell during the 11-7 shift because they wanted the air conditioner temperature changed, ice, and their catheter bag emptied. CNA #2 stated there was no ice; changed the catheter bag; and went into the hallway and said to someone [he/she] runs us like slaves. When CNA #2 returned to the room, the resident reported asking the aide why she would say that, and CNA #2 stated because you run us like slaves and everyone talks about you. The resident stated it was the night shift and he/she was usually asleep and not ringing the call bell. The resident stated CNA #2 was always nasty. On 3/6/24 at 2:29 PM, interviewed the LNHA regarding the grievance and the LNHA stated it was not investigated or reported to the DOH since CNA #2 speaks very loud, and the resident did not feel like CNA #2 was yelling at him/her. The LNHA stated initially it was looked at as abuse, but abuse was ruled out. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer and survey team confirmed this incident was not reported to the DOH. A review of the facility's undated Abuse Policy & Procedure included the administrator or designee will notify the Office of the ombudsman and the State Department of Health and Senior Services when abuse is suspected. Notification shall be documented within one business day and followed within 72 hours with written confirmation NJAC 8:39-4.1(a)5

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated. On 3/4/24 at 12:16 PM, the LNHA confirmed the surveyor had all the investigations for the resident. A review of the investigations did not include the abuse allegation made by the resident. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked at the facility. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance form since the resident was alert and oriented. The surveyor requested the grievance form. A review of the facility's undated Abuse Policy & Procedure included when an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown source is reported, the Administrator/Director of Nursing will immediately be notified. They will appoint a staff member to investigate the incident .The investigation shall consist of: a review of the complete Resident Abuse form for facility and F.R.I.D.A.Y. and Reportable Event Record Report for Department of Health [DOH]; interviews with the person(s) reporting the incident; interviews with any witnesses to the incident; an interview with the resident; an interview with staff members (on all shifts) having contact with the resident during the period of alleged incident; interviews with resident's roommate, family members, and visitors if applicable; interviews with other residents to which the accused employee provided care or services (if applicable); a review of circumstances surrounding the incident; review of pertinent emails. Witness statements shall be in writing. Witness will be required to sign and date such statements. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. On 3/6/24 at 8:51 AM, re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she borrowed money from the resident. The resident stated CNA #1 was paying back the money loaned, but then stopped. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 kept telling the resident Tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident felt that he/she did not give CNA #1 the money, they would no longer go above and beyond with care. On 3/6/24 at 10:46 AM, the surveyor asked the LNHA what the types of abuse were, and the LNHA responded physical, verbal, mental, financial, emotional. The surveyor asked the LNHA who was susceptible to abuse in the facility and the LNHA stated all residents were at risk for abuse in the facility. The LNHA stated at first Resident #47's complaint was CNA #1 would not return his/her phone calls, and then the facility was informed CNA #1 owed the resident money. The LNHA sated CNA #1 refused to come in for a statement, so she was terminated, and the grievance was the resident's statement. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated. The LNHA also stated that the activities staff and social worker were the staff who purchased residents' personal needs if their families could not. 2. On 2/28/24 at 12:14 PM, the surveyor observed Resident #47 in bed, the resident was alert and oriented and able to be interviewed. The surveyor reviewed the medical record for Resident #47. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. A review of the Grievance Summaries dated 10/13/23 and resolved 10/13/23, included the following: Grievance details: resident states 11:00 PM to 7:00 AM (11- 7) shift [CNA #2] yelled at [him/her] saying you ring your call bell like we are your slaves and that's why everyone talks about you. Resident states that [he/she] asked for ice water and [CNA #2] said there is no ice you have to wait. Resident states that [he/she] told the [CNA #2] that [his/her] boots on [his/her] feet are hurting [him/her] and the CNA stated you slept all night with them on and now all the sudden they hurt you then took the straps off the boots to loosen them. Resident states that CNA left [his/her] light on, curtain open and door open and [he/she] had to ring [his/her] bell again for someone to close the door and turn the lights off. Summary of investigation: resident reported the aide on the 11-7 was disrespectful to [him/her] and yelled at [him/her]. Summary of findings: resident was upset by the interaction [he/she] had with the staff member. [He/she] did not know the employee's name but was able to describe her. Resident was not able to give any information on who answered [his/her] call light to turn the light off or close the door. Summary of actions taken: employee was removed from schedule and was educated. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/6/24 at 1:21 PM, the surveyor asked Resident #47 if he/she ever had any issues with a CNA, and the resident stated that CNA #2 who no longer worked at the facility. Resident #47 stated that he/she rang their call bell during the 11-7 shift because they wanted the air conditioner temperature changed, ice, and their catheter bag emptied. CNA #2 stated there was no ice; changed the catheter bag; and went into the hallway and said to someone [he/she] runs us like slaves. When CNA #2 returned to the room, the resident reported asking the aide why she would say that, and CNA #2 stated because you run us like slaves and everyone talks about you. The resident stated it was the night shift and he/she was usually asleep and not ringing the call bell. The resident stated CNA #2 was always nasty. On 3/6/24 at 2:29 PM, interviewed the LNHA regarding the grievance and the LNHA stated it was not investigated or reported to the DOH since CNA #2 speaks very loud, and the resident did not feel like CNA #2 was yelling at him/her. The LNHA stated initially it was looked at as abuse, but abuse was ruled out. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer and survey team confirmed this incident was not reported to the DOH. A review of the facility's undated Abuse Investigations policy included all reports of resident abuse, neglect, misappropriation of resident property, and injuries of unknown source shall be promptly and thoroughly investigated . NJAC 8:39-4.1(a)5

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide the correct diet for 2 of 41 residents reviewed for altered consistency diets, Resident #58 and Resident #64. a.) Resident #58, who had a diagnosis of dysphagia (difficulty swallowing), a history of pocketing food (not swallowing food, but holding the food in their mouth) and was lethargic (decreased alertness) at meals, was fed a chopped diet instead of the physician ordered pureed diet. The resident choked on the food, became cyanotic (bluish color to the skin), and required emergency treatment. On [DATE] at 3:45 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The survey team accepted the removal plan on [DATE] at 1:56 PM. There was a systemic failure when multiple facility staff failed to identify and provide the correct physician ordered modified consistency diets to multiple residents; b.) The facility failed to follow their removal plan, which resulted in a subsequent IJ identified on [DATE] at 12:10 PM, for Resident #64, who had a diagnosis of dysphagia and was identified as at risk for silent aspiration, and was served mechanically ground vegetables instead of the physician ordered pureed vegetables; and c.) The facility failed to follow their removal plan for 2 of 2 residents, Resident # 64 and Resident #34, who received their meal tray without the two-person point review system for meal tray accuracy at the point of service, in accordance with the facility's removal plan. During the standard survey of [DATE], the facility Administration was notified of the IJ situation on [DATE] at 3:49 PM. The facility failed to ensure that the correct physician ordered mechanically altered diet consistency was provided to a resident who had a diagnosis of dysphagia, a history of lethargy at meals, and was at risk for aspiration. Resident #58 had an order for a puree diet and was provided a chopped consistency meal tray. A Certified Nurse Aide (CNA #4) fed the resident the incorrect diet. The resident choked, became unresponsive, and 911 was activated. The facility provided a removal plan on [DATE] at 1:56 PM. The IJ was continued at a lower scope and severity when it was identified the removal plan was not fully implemented. On [DATE], a CNA #6 distributed a late meal tray to Resident #34 without having the meal checked by two staff in accordance with the facility's removal plan. On [DATE], the facility Administration was notified of a subsequent IJ situation at 4:31 PM. The facility failed to ensure the implementation of the removal plan, dated [DATE], and ensure that the correct physician ordered mechanically altered diet consistency was provided to Resident #64 who had a diagnosis of dysphagia. The resident had an order for a puree diet. The cook plated the food incorrectly, and the resident was provided a meal tray that contained ground vegetables. CNA #3 fed the resident the incorrect diet. The removal plan was accepted on [DATE] at 11:22 AM. The implementation of the removal plan was not verified upon completion of the survey. Part A. Resident #58 This deficient practice was evidenced by the following: While the surveyor was interviewing a resident in their room on [DATE] at 9:32 AM, the surveyor overheard the shout of code. The surveyor proceeded to the doorway of the resident's room and observed CNA #4 transporting Resident #58 in a wheelchair. In a clear unobstructed view, the surveyor observed that Resident #58 was sitting motionless and upright. His/her face was blue in color and the resident was motionless. The surveyor observed that Resident #58 was transported to his/her room. The surveyor proceeded to Resident #58's room and observed the door to the room was not fully closed. The surveyor overheard voices coming from the inside of Resident #58's room stating that the resident was sleepy, it is a code, they were feeding [him/her], and [he/she] wasn't eating, and [he/she] was sleepy, and [he/she] choked. The surveyor reviewed Resident #58's medical record and noted the following: An Admission Record revealed the resident was admitted to the facility with diagnoses that included Dementia with Behavioral Disturbances and Muscle Weakness. A Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care dated [DATE], revealed the resident had a Brief Interview for Mental Status Score of 00' which indicated the resident was severely cognitively impaired. The MDS revealed the resident required extensive assistance of one person to eat meals and was totally dependent on staff for personal hygiene. The MDS indicated the resident had a swallowing disorder, loss of liquids/solids from mouth when eating or drinking, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain with swallowing, and was on a mechanically altered diet. The Care Plan revealed a Focus, initiated [DATE], that indicated the resident was on an altered diet texture due to his/her diagnoses of dysphagia and easier toleration. A goal, initiated [DATE], revealed the resident would be free from signs and symptoms of aspiration or dehydration. A Medication Review Report, dated [DATE], revealed the resident had a physician order for a NAS (No Added Salt) diet Pureed Texture, dated [DATE]. A review of the Progress Notes, dated [DATE] at 15:16 (3:16 PM), revealed a Health Status Note that was completed by LPN #1. The note revealed that around 9:30 AM, LPN #1 was informed by CNA #4 that Resident #58 was choking in the dining room and LPN #1 immediately did the [MEDICATION(S)] maneuver and swept out the remaining food in the resident's mouth and applied a re-breather mask (oxygen mask). A review of a quarterly Nutrition/Dietary Note, dated [DATE] at 10:57 AM and completed by the Dietitian, revealed Resident #58 continued on a NAS, puree diet which was appropriate and tolerated well. Resident was dependent for eating, weight was gradually trending downward due to decreased food intake, and that the resident was sleeping during meals. A review of the Census List (a listing of the resident's diets and used by dietary and nursing), dated [DATE], revealed that Resident #58 was on a NAS (no added salt), Pureed Diet (smooth textured diet). On [DATE] at 9:37 AM, the surveyor observed a meal tray at an unoccupied table with a meal ticket that reflected Resident #54's name and an order for a chopped diet consistency which also allowed soft sandwiches and soft snacks. The tray contained approximately 16 one-inch pieces of pancake, which appeared dry, and approximately six one-inch pieces of sausage patty with a plastic fork stuck into the pancakes. A four-ounce container of orange juice, an unopened container of pancake syrup, an unopened package of butter, an unopened package of cereal and unopened container of farina was also observed on the tray. The surveyor observed the first name printed on Resident #54's meal ticket was the same first name as Resident #58. During this observation, CNA #4 entered the dining room and approached the surveyor during the surveyor's observation of Resident #54's meal tray. CNA #4 held up the meal ticket that was located on Resident #54's meal tray and stated to the surveyor that she fed Resident #58 that meal tray. She stated she fed Resident #54's meal tray to Resident #58 and stated, I was feeding [Resident #58] and something must have gotten stuck in [his/her] throat. She further examined Resident #54's meal tray ticket and stated that wasn't Resident #58's tray, and that the resident received the wrong tray. She continued to state that she fed Resident #58 pancakes. On [DATE] at 9:40 AM, the surveyor continued the interview with CNA #4 in the dining room. CNA #4 stated, I accidentally gave [Resident #58] the wrong tray, I am not sure what [Resident #58] gets. CNA #1 stated that she was employed through an agency and had been at the facility for a while. CNA #1 stated she had taken care of Resident #58 in the past. On [DATE] at 9:41 AM, the surveyor observed Licensed Practical Nurse (LPN #1) at the second-floor nursing station. LPN #1 stated he was preparing the emergency transfer form for Resident #58. At that time, CNA #4 approached LPN #1, in the presence of the surveyor, and stated to LPN #1 that she accidentally gave Resident #58, Resident #54's tray. At that time, the surveyor interviewed LPN #1 about Resident #58's diet and LPN #1 stated that Resident #58's diet is a puree, full puree. On [DATE] at 9:42 AM, the surveyor brought CNA #1 into the dining room to observe Resident # 54's meal tray and the corresponding meal ticket located on the meal tray. CNA #1 observed the meal tray and meal ticket and stated that this was not Resident #58's name on the meal ticket and the the meal was the wrong diet. She stated, this was the wrong diet, this was not [Resident #58's name] and this was not even [Resident #58's] food at all. CNA #1 stated she was a full-time employee of the facility. On [DATE] at 9:43 AM, the surveyor interviewed LPN #1 who stated he performed the [MEDICATION(S)] maneuver on Resident #58 and got out little pieces of food. On [DATE] at 9:55 AM, the surveyor observed Resident #58 on a stretcher and was transported out of the facility by Emergency Medical Service (EMS). On [DATE] at 10:06 AM, the surveyor interviewed the second-floor unit manager (UM #1) who stated Resident #58 had been on a puree diet for a while and she showed the surveyor a book of recent diet orders. A review of the book revealed that there were no recent diet order changes for Resident #58. At that time, UM #1 provided a copy of Resident #58's CNA Kardex (resident specific care report used by nurse aides) information. The Kardex did not include information regarding the type of diet Resident #58 consumed. UM #1 also provided a copy of the [DATE] Daily Assignment Sheet, which revealed that CNA #4 was assigned to Resident #58 to provide care. On [DATE] at 10:26 AM, the surveyor, in the presence of two surveyors, interviewed CNA #4 who stated that she worked at the facility often and stated that she thought Resident #58 was on a puree diet. She stated she didn't pay attention to the resident's last name on the tray ticket. She stated the resident was drowsy and she woke the resident to feed him/her. She stated that she fed Resident #58 a piece of pancake and then noticed the resident was not breathing right. She stated she left the resident alone in the dining room to get the nurse. CNA #4 stated that she observed that the resident's meal was not puree; however, she thought the tray was correct because it matched the diet printed on the meal ticket. She further stated she did not cut the pancake or sausage any more than the way it was served on the tray. She fed Resident #58 pancake first and then sausage. She stated the diet Resident #58's was prescribed was not listed on her assignment sheet and she would have to ask the nurse if she needed to know. She stated that she would know the resident's diet by reading what was printed on the resident's tray ticket. On [DATE] at 10:41 AM, the interview continued, and CNA #4 stated Resident #58 was taken to the resident's room and during that time the resident was blue. She stated there were two other CNAs with her in the resident's room and she was not sure who they were. She stated the CNAs transferred the resident to the resident's bed and the nurse tried to do CPR, and after that the nurse stood the resident up and did the [MEDICATION(S)] maneuver and a piece of pancake flew out of the resident's mouth. On [DATE] at 11:07 AM, the surveyor interviewed the Food Service Director (FSD) who stated that a puree consistency diet was the consistency of baby food or applesauce with no lumps. He further stated that regular pancakes and sausage were not provided on a puree diet because a resident could choke. On [DATE] at 11:24 AM, the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) and facility Administrator. The DON stated the aides know their assignments and which residents need to be fed. The DON stated that the CNAs have access to the information in the kiosk (computer CNA assignment). The DON showed the surveyor the [DATE] Daily Assignment Sheet where CNA #4 was assigned to the Dayroom to feed residents. The DON further stated that when the trays arrived on the floor, CNAs were supposed to check the meal ticket and the diet to make sure the tray was accurate. She stated that they should also check the name of the resident and the meal ticket to ensure that the resident received the correct tray. The DON stated the CNAs were trained on the dining process and how to properly feed a resident during orientation and that the training was part of their annual competencies. The DON was interviewed regarding agency staff being included in the facility orientation training or annual competencies. The DON stated that she was not aware of the agency staff being provided with education at the facility. On [DATE] at 1:09 PM, the surveyor interviewed LPN #1 who stated that the CNAs should check that the resident's name band matched the meal ticket and that they should check even when they are familiar with the residents. He stated that the CNAs were also supposed to confirm the accuracy of the tray for the correct diet and check for missing items. A review of Resident #58's Speech Therapy Encounter Note, dated [DATE] and signed by the speech clinical fell ow (SCF), revealed that the SCF examined Resident #58's oral cavity and found right [MEDICATION(S)] (inside of check) pocketing and removed a bolus (ball like mixture of food). The patient was unsafe to continue feeding by mouth at that time and the nursing and the aides verbalized understanding and agreement. A review of Resident #58's Speech Therapy Encounter Note, dated [DATE] and signed by the Speech Clinical fell ow (SCF), revealed that the resident was on a puree consistency diet. On [DATE] at 2:57 PM, the surveyor, interviewed the Regional Manager of Speech Therapy (RMSP) who stated she cosigned the SCF notes and stated she had seen Resident #58 a handful of times. She stated the resident was not always arousable and that the resident was known to nursing for pocketing food. She stated any education would have been done with staff at that time and that there wasn't any documentation. She stated the strategies should be on the care plan and stated that she should not have been fed regular sausage and pancakes. On [DATE] at 12:30, the DON provided a copy of an undated Serving of Food policy, which revealed food shall be prepared and served in a manner that prevents foodborne illness and meets the individual needs of each resident. The policy further revealed that nursing staff and feeding assistants would serve resident trays and would help residents who require assistance with eating. Residents who could not feed themselves would be fed with attention to safety, comfort and dignity. Part B. Resident #64 There was a systemic failure when multiple facility staff failed to follow the removal plan accepted on [DATE] at 1:56 PM, which indicated a two person point of contact for review of meal tray at point of service. The facility served a resident a ground diet instead of a physician ordered puree diet. The facility's failure to ensure the resident, who had difficulty swallowing and was at risk for aspiration, received the appropriate altered diet. Serving the wrong consistency constituted an Immediate Jeopardy (IJ) to the resident's health and safety. This IJ was identified on [DATE] at 12:10 PM, in the main dining room, after the surveyor observed CNA #3 feeding Resident #64 a spoonful of ground Italian mixed vegetables. Resident #64 ingested the ground mixed vegetables and swallowed the mixture. The IJ was reported to the Administrator and the Director of Nursing (DON) on [DATE] at 4:31 PM and the removal plan was requested. The removal plan was accepted on [DATE] at 11:22 AM. This deficient practice was evidenced by the following: The surveyor reviewed Resident #64's medical record and noted the following: The Admission Record revealed the resident was admitted to the facility with diagnoses which included: Alzheimer's Disease, Cerebral Infarction (stroke) and Respiratory Disorders. The Quarterly Minimum Data set (MDS), an assessment tool dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3, which indicated that the resident's cognition was severely impaired. The MDS also indicated that the resident was on a mechanically altered diet (change in food or liquids texture). The Care Plan for Dysphagia, dated [DATE], revealed the resident had a history of Dysphagia. The goal was for the resident to be free from signs and symptoms of aspiration or dehydration. The intervention listed was for staff to serve the resident's diet as ordered. A Physician Order sheet, dated [DATE], revealed the resident was prescribed a puree diet with nectar thickened liquids. A review of the Nutrition/Dietary Note, dated [DATE] at 02:49, revealed the resident required a puree diet with nectar thick liquids. A Speech Therapy (ST) (SLP Evaluation & Plan of Treatment) report, dated [DATE], revealed the resident was referred to ST for an exacerbation of dysphagia. The evaluation was done to assess the least restrictive oral intake and to restore the resident's oral function. The report also revealed the resident had a past medical history of dysphagia. On [DATE] at 11:53 AM, the surveyor conducted a dining room observation to ensure the removal plan of [DATE] was implemented. At that time, the surveyor observed Resident #64 seated in his/her wheelchair being fed ground Italian mixed vegetables by CNA #3. The surveyor reviewed Resident #64's meal ticket that was lying on the table next to the resident's meal plate. The surveyor compared the resident's meal ticket to the meal the resident was being fed by CNA #3. The meal ticket revealed the resident was to be served puree ham, mashed sweet potatoes and puree Italian mixed vegetables; however, the resident's lunch meal plate contained, pureed ham, mashed sweet potatoes and ground consistency Italian mixed vegetables. CNA #3 immediately stopped feeding the resident and asked the surveyor if Resident #64's meal was incorrect. When interviewed by the surveyor, CNA #3 stated the vegetables were puree consistency. The surveyor requested for a nurse to come to the dining room. CNA #3 stated there was no nurse inside the dining room during meals. The surveyor observed the Nurse Consultant (NC #1) walking down the hallway and requested for her to come inside the dining room. NC #1 reviewed the resident's lunch meal and stated the vegetables looked to be either chopped or ground and were not a puree consistency. When interviewed by the surveyor at that time, NC #1 stated the resident was supposed to have been served a puree diet. NC #1 stated that if the resident was to ingest the ground vegetables, the resident could choke on the food. During an interview on [DATE] at 12:11 PM, in the presence of four surveyors, the FSD and Regional Manager, Cook/Supervisor #1, stated that he had worked at the facility as the PM (evening) Cook/Supervisor for 30 days. Cook/Supervisor #1 stated that he had a Safe Serve certification, but his certification had expired. When Cook/Supervisor #1 was asked to describe the difference in the consistency of a pureed meal verses a ground meal, Cook/Supervisor #1 stated a pureed consistency was like baby food and the ground consistency diets had little pieces inside. The surveyor showed Cook/Supervisor #1, Resident #64's lunch meal plate. Cook/Supervisor #1 stated the ham and sweet potatoes were pureed consistency and the Italian vegetables were ground consistency. Cook/Supervisor #1 stated that he was responsible for reviewing the resident's meal ticket prior to plating the resident's food. Cook/Supervisor #1 stated the Food Service Workers (FSWs) provided the second check to ensure residents received the correct diets. Also, the FSWs were responsible for comparing the meal tickets to what was on the plate. Cook/Supervisor #1 reviewed Resident #64's meal ticket in the presence of the surveyor and stated the resident's entire meal should have been a pureed diet and not ground vegetables. Cook/Supervisor #1 stated, it is my mistake and the mix-up occurred because the tray line wasn't set up properly. Cook/Supervisor #1 stated he could not remember which FSW checked Resident #64's plate because the kitchen was very busy. Cook/Supervisor #1 stated the mix-up was all his fault and he had just messed up. During an interview on [DATE] at 12:40 PM, in the presence of four surveyors, Activity Aide (AA #1) and CNA #3 stated they were trained by the facility on how to identify altered diets and to serve the residents their meal trays. AA #1 stated she removed Resident #64's meal tray from the cart and compared the meal ticket to what was on the plate. AA #1 stated that she did not see anything wrong with the meal on the plate. CNA #3 stated she also compared the meal ticket to the plated meal and did not find anything wrong with the meal she fed to the resident. CNA #3 stated the facility was giving them more and more responsibility and she was finding it difficult to remember everything she had been taught. A review of a Speech In-Service titled, Diet Textures, dated [DATE], revealed the second-floor staff were provide an in-service on all diet consistencies: pureed, ground, chopped, and regular. The in-service also included modified liquid level consistencies: nectar, honey and pudding. According to the attendance register, CNA #3 attended this in-service and another in-service on [DATE]. A review of the undated Pureed Diet guidelines revealed the facility provided pureed diets meats, and that starches and vegetables were pureed to a smooth consistency without lumps or solid materials. A review of the Tray line Service policy, updated ,d+[DATE], revealed the tray line positions and set up procedure were planned for efficient and orderly delivery. All meals were to be checked by food service personnel for accuracy, and the employee serving the meals prior to serving to the individual. Each meal will be checked for: correct name, room number, diet order, accuracy of the following therapeutic diet extension, and proper portion size. On [DATE] at 11:13 AM, the Chief Operating Officer (COO) provided the surveyor with a new tray line policy, dated [DATE]. The policy implemented a color coded meal ticket to increase awareness for diets that were altered food and liquid consistencies. Part C. Resident #34: The deficiency continued at a level D and was evidenced by the following: The facility staff did not follow the removal plan accepted on [DATE] at 1:56 PM which indicated a two person point of contact for review of meal tray at point of service. On [DATE] at 9:12 AM, the surveyor was at the second floor nursing station and observed a dietary staff member place a meal tray at the nursing station. The dietary staff stated to CNA #6, who was working at the computer, that the tray was for Resident #34. CNA #6 lifted the lid of the meal tray and looked at the meal. The surveyor followed CNA #6 to Resident #34's room where CNA #6 placed the meal tray in front of the resident on the bedside table which was located next to the resident's bed. At that time, the surveyor interviewed CNA #6, who stated she brought the resident the meal tray and confirmed that the tray was placed in front of Resident #34 without another staff member checking the tray. On [DATE] at 9:16 AM, the surveyor interviewed LPN #1 who was observed at the medication cart directly outside of Resident #34's room. The LPN stated that two CNAs were supposed to double check the meal trays with the nurse prior to giving the tray to the resident. He stated that was for any resident and any tray. On [DATE] at 9:24 AM, the surveyor interviewed CNA #6 who stated if she removed the tray from the cart, then she would be the one who would check the tray. She stated the tray for Resident #34 was a late tray and that she checked the tray to ensure everything was on it. A review of the Quarterly MDS, dated [DATE], revealed Resident #34 had a BIMS score of 9, which indicated moderate cognitive impairment. The MDS did not indicate that the resident had a swallowing disorder or was on a specialized diet. The Census List, dated [DATE], revealed Resident #34 was on a CCD/NCS, NAS diet (low carbohydrate, no concentrated sweets, no added salt). NJAC 8:,d+[DATE].4(a) (,d+[DATE]); 27,1(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide immediate emergency treatment to a resident that choked on food during the breakfast meal in the dining room. After the resident became unresponsive and cyanotic, the resident was removed from the dining room by the Certified Nurse Aide (CNA) and taken back to the resident's room, where the [MEDICATION(S)] maneuver ([MEDICATION(S)]) was performed and the food expelled. This deficient practice was identified for Resident #58, 1 of 1 resident who choked on [DATE], and a delay in emergency response placed the resident at a significant risk of death. The facility failed to ensure that emergency treatment was provided at the time and place of the resident's choking episode. On [DATE], at 9:32 AM, under the direction of a Licensed Practical Nurse (LPN #1), the resident was removed from the dining area by a CNA and transported down the hallway to the resident's room where LPN #1 performed the [MEDICATION(S)]. This failure constituted immediate jeopardy (IJ) to the resident's health and safety, with the potential to affect all residents who resided in the facility. The Administrator was made aware of the IJ on [DATE] at 4:35 PM, and a removal plan was accepted on [DATE] at 11:22 AM. The implementation of the removal plan was not verified upon completion of the survey. This deficient practice was evidenced by the following: On [DATE] at 9:30 AM, the surveyor began a tour of the second floor unit and introduced self to LPN #1. LPN #1 stated he was not the charge nurse and that there was not a specific charge nurse for the second floor on that day. While the surveyor was interviewing a resident in their room on [DATE] at 9:32 AM, the surveyor overheard the shout of code. The surveyor proceeded to the doorway of the resident's room and observed CNA #4 transporting Resident #58 in a high-back wheelchair (wheelchair). In a clear unobstructed view, the surveyor observed that Resident #58 was sitting motionless and upright. His/her face was blue in color. The surveyor observed that Resident #58 was transported to his/her room. The surveyor proceeded to Resident #58's room and observed the door to the room was not fully closed. The surveyor overheard voices coming from the inside of Resident #58's room stating that the resident was sleepy, it is a code, they were feeding [him/her], and [he/she] wasn't eating, and [he/she] was sleepy, and [he/she] choked. (Cross refer F808). On [DATE] at 9:41 AM, the surveyor observed LPN #1 at the second floor nursing station. LPN #1 stated he was preparing the emergency transfer form for Resident #58. LPN #1 stated at 9:43 AM, that he performed the [MEDICATION(S)] and got out little particles of food. At that time, LPN #1 did not indicate where he performed the [MEDICATION(S)]. On [DATE] at 9:55 AM, the surveyor observed Resident #58 on a stretcher and was being transported out of the facility by emergency medical service (EMS). On [DATE] at 10:26 AM, the surveyor, in the presence of two surveyors, interviewed CNA #4 who stated the resident was drowsy and that she had to wake the resident up to start feeding the resident. She stated the resident wasn't breathing right so she left the resident to go get LPN #1. CNA #4 stated that she was instructed by LPN #1 to take the resident to his/her room. She stated when the resident was taken to the his/her room, the resident was blue. She stated there were two other CNAs with her in the resident's room and she was not sure who they were. She stated the CNAs transferred the resident to the resident's bed and LPN #1 tried to do CPR. She stated LPN #1 then stood the resident up and did the [MEDICATION(S)] and a piece of pancake flew out of the resident's mouth. On [DATE] at 12:14 PM, the surveyor interviewed LPN #1 regarding the incident that occurred on [DATE] with Resident #58 in the dining room. LPN #1 stated he observed CNA #4 exit the dining room as he was headed toward the unit pantry, which was across from the nurses' station. He stated CNA #4 asked him to come and see Resident #58 because the resident had shortness of breath, or something like that. He stated at that time, he went into the dining room and noticed that Resident #58 had fixed eyes and was blue. He stated at that time he decided to remove the resident from the public and take him/her to the resident's room. He further stated the normal procedure was to start emergency care in the dining room and then take the resident to the room. The surveyor inquired if LPN #1 wrote a statement of the events and he stated that he still needed to write one. Immediately upon statement inquiry, LPN #1 changed his prior statement. LPN #1 now stated that as soon as CNA #4 showed him Resident #58, he could tell that the resident was choking. He stated that he performed the [MEDICATION(S)] and removed food from the resident's mouth in the dining room before the resident was taken to the room, where he performed the [MEDICATION(S)] again in the resident's room. At [DATE] at 1:38 PM, in the presence of two surveyors, LPN #1 requested to speak with the surveyor. LPN #1 stated that he wanted to clarify his statement made during the previous interview at 12:14 PM. LPN #1 stated he did not perform the [MEDICATION(S)] in the dining room and that he realized that he did not do the [MEDICATION(S)] on the resident until the resident was brought out of the dining room and taken into the resident's room. The surveyor inquired about the resident's status when he entered the dining room. LPN #1 responded that the resident's color was turning blue and that he didn't notice any breathing issues. The surveyor asked LPN #1 what he should have done. He responded that he was still trying to figure out what to do when he went into the dining room. After he looked at the resident, he stated he left to call the supervisor and 911. On [DATE] at 1:56 PM, during an interview with LPN #2, LPN #2 stated she heard a Code Blue and went to Resident #58's room, where LPN #1 was doing the [MEDICATION(S)] with the resident in a standing position. LPN #2 stated she saw a pretty big piece of pancake come out of the resident's mouth about this big and motioned with her hands to show a piece approximately one to two inches in circumference. On [DATE] at 2:17 PM, the surveyor interviewed the LPN/Unit Manager (UM #1) who stated that the nursing staff were required to assess a resident at the scene of the event. If the resident was choking, the nurse was to initiate the [MEDICATION(S)] Maneuver and call a Code Blue with an overhead page. She stated the recertification for CPR and [MEDICATION(S)] with the American Heart Association was just done at the facility. She stated they had a large group and when CPR certification was completed, a copy was given to the DON and she thought human resources also received a copy. On [DATE] at 11:07 AM and on [DATE] at 1:52 PM, in the Administrator's office, two surveyors along with the DON and Administrator, reviewed the facility's video surveillance footage on [DATE]. The two camera views reviewed were Camera 13 (dining room second floor) and Camera 15 (short hallway second floor). The time stamp on the video footage between the two cameras differed by approximately ,d+[DATE] minutes. This was acknowledged by the DON who stated she was informed by the computer department that the time stamps that were on the videos were approximately 15 minutes ahead of the actual time. The DON stated both cameras were timed and each camera had it's own time stamp. She stated the time on the cameras had been a problem lately. The facility provided a copy of the video footage from each camera view to the survey team. The video evidenced the following on [DATE]: Camera #13 (Dining Room): The video footage started at 09:31:53. At 09:31:54, CNA #4 placed a meal tray on the table where resident #58 was seated in a high back wheelchair (wheelchair). Resident #58 was the only resident seated at the table. From 09:32:46 to 09:40:02, CNA #4 was observed seated in a chair located to the right side of the resident's wheelchair, feeding Resident #58. At 09:40:05, CNA #4 stood up and walked toward the dining room entrance. At 09:40:11, CNA #4 walked out of camera view. Resident #58 remained seated unaccompanied at the table. There was no other staff observed in the camera view at that time. At 09:40:33, CNA #4 appeared in camera view and walked in the direction of the resident. At 09:40:37, LPN #1 entered the camera view and walked in the direction of the resident. At 09:40:38, CNA #4 returned to the resident's side. At 09:40:41, CNA #4 sat down in a chair located on the right side of Resident #58's wheelchair. At 09:40:41, LPN #1 arrived at resident's table. LPN #1 stationed himself to the rear and right side of the resident, in between the resident's wheelchair and where CNA #4 was seated. LPN #1 placed his left hand on the grab bar located on the back of Resident #58's wheelchair and peered around the right side of resident. His right arm was positioned on the armrest of the resident's wheelchair. At 09:40:45, LPN #1 used the grab bar to pull the resident's wheelchair backwards and away from the table. LPN #1 made a hand motion to CNA #4 who then started to stand from the chair. At 09:45:47, LPN #1 let go of the wheelchair and walked towards dining room entrance. At 09:45:48, CNA #4 turned the resident's wheelchair forward facing and pushed the resident towards the dining room entrance. At 09:40:50, LPN #1 walked out of camera view. At 09:40:56, CNA #4 walked out of camera view pushing the resident in the wheelchair. The following was observed on Camera #15 (Hallway): The video footage started at 09:56:31. At 09:56:,d+[DATE]:56:56, CNA #4 entered camera view in front of the nurses' station. At 09:56:58, LPN #1 walked out of camera view. At 09:57:23, LPN #1 entered camera view in front of nurses' station and then immediately went out of camera view. At 09:57:29, LPN #1 moved into camera view, behind the nurses' station, and then out of camera view at 09:57:34. At 09:57:32, Resident #58, seated upright in a wheelchair, appeared in the camera view with CNA #4 in front of the nurses' station. At 09:57:36, LPN #1 entered camera view, behind resident. LPN #1 motioned with hands towards CNA #4 to follow at 09:57:37. At 09:57:43, CNA #4 transported Resident #58 down the hallway. At 09:57:56, CNA #4 entered the resident's room with the resident, followed by CNA #8. At 09:58:01, LPN #1 stepped a foot into the resident's room, then stepped back out. He motioned with his arms while looking towards the nurses' station. At 09:58:05, LPN #1 entered the resident's room. At 09:58:10, LPN #1 exited the resident's room and ran down the hallway, out of camera view. CNA #5 entered the resident's room. At 09:58:31, LPN #1 entered camera view, carrying a portable oxygen tank. At 09:58:36, LPN #1 returned to the resident's room with the oxygen tank. At 09:58:44, CNA #5 exited the resident's room. At 09:59:03, CNA #8 exited the resident room, walked down the hall, toward the nurses' station, turned around, ran back to the resident's room, and re-entered the resident's room at 09:59:25. At 09:59:32, CNA #1 entered the resident's room. At 09:59:36, LPN #2 entered the resident's room. At 09:59:38, CNA #5 entered the resident's room and exited the room at 09:59:51 and pulled the door ajar. At 10:00:26, LPN #2 exited the resident's room, followed by CNA #1 At 10:01:07, the DON entered the resident's room with a back board and LPN #3 entered the room with a code cart. At 10:04:20, RN/S #1 entered the resident's room. At 10:10:51, emergency responders entered the resident's room. On [DATE] at 3:09 PM, the surveyor, in the presence of another surveyor and the Administrator, interviewed the DON during review of the surveillance footage. The DON stated she was called into the facility when she was notified the surveyors were in the building. She stated that she was the one that told LPN #1 to call 911 and that she also wrote a statement about the incident. On [DATE] at 3:19 PM, the DON stated that if a nurse walked into a situation and a resident was blue, that meant that the resident's airway was obstructed. The DON said the nurse should automatically call a code. She stated that a nurse can yell out to get assistance and tell a CNA to call a code so the nurse could remain with the resident and start emergency care. The DON stated LPN #1 should have stayed with the resident at all times. On [DATE] at 4:50 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated she was unsure of the exact time that she heard the code called overhead and went to Resident #58's room. She stated she checked the resident's pulse. The surveyor inquired if the DON assessed the resident. The DON stated she documented the resident assessment on the statement she completed for the investigation. A review of the Progress Notes, dated [DATE] at 15:16 (3:16 PM), revealed a Health Status Note that was completed by LPN #1. The note revealed that around 9:30 AM, this writer was informed by a CNA that [Resident #58] is having shortness of breath while eating at the 2nd floor dining room. Unfortunately, resident was choking and this nurse immediately did an helmrick manover [sic], sweep out the remaining food in [his/her] mouth and applied re-breathable mask due to low pulse sox (87%) [sic] . The Administrator provided the survey team with a copy the investigation for the choking incident that occurred on [DATE]. The investigation included an Individual Statement Form (ISF), completed [DATE] by the DON, which revealed the DON entered Resident #58's room and the resident was in bed with oxygen on via nasal cannula; the resident had a pulse; was taking shallow breaths; and the DON applied a non-rebreather mask to the resident as the other nurse was checking the resident's blood pressure and oxygen. She instructed LPN #1 to call 911. There was no evidence of a documented assessment completed by a Registered Nurse in Resident #58's medical record. Review of the ISF, dated [DATE] and completed by LPN #1, revealed Resident #58 was having shortness of breath while eating in the dining room and unfortunately the resident was choking and the nurse immediately performed the [MEDICATION(S)] Maneuver and swept the remaining food out of the resident's mouth. On [DATE] at 9:47 AM, the surveyor, in the presence of the survey team asked the DON and Administrator regarding any policies for oversight of the dining room at meal service and any policies related to emergency procedures for resident care. On [DATE] at 10:22 AM, the DON, in the presence of the survey team and Administrator, stated there were no policies regarding oversight of the dining room or related to emergency procedures related to resident care. On [DATE] at 10:47 AM, the DON provided the surveyor with a CPR policy and stated that was the only emergency policy and there was nothing specific for the dining room. On [DATE] at 1:01 PM, the surveyor, in the presence of the survey team, completed a telephone interview with the Registered Nurse/Supervisor (RN/S) who worked on [DATE]. She stated she worked double shifts on the weekend and her responsibilities included to conduct rounds of residents and that she was available for emergencies. She stated she did not monitor the dining room. She stated she was available when help was needed and when a code was called. RN/S stated that on [DATE] she thought she was on the first floor in a resident's room and did not hear a code being called. She stated she thought that a CNA told her around 9:30 AM and she responded as quickly as she could but the elevator was taking time to arrive. She stated by the time she arrived at Resident #58's room, the DON and a whole bunch of people were in the room. She stated if a resident was unresponsive, the nurse should have directed someone to call her, and that the nurse should have stayed with the resident until the she responded. She stated the nurse should not leave the patient. RN/S further stated that if a person was not breathing and if you knew the person was choking, the nurse should do the [MEDICATION(S)] on the spot. At [DATE] at 2:03 PM, the surveyor measured a distance of 94 feet from the dining room table where the resident was seated, to the resident's room. On [DATE] at 2:58 PM, the surveyor in the presence of the survey team, interviewed CNA #5. CNA #5 stated she was in the hallway when Resident #58 was brought out of the dining room. She stated CNA #4 and CNA #8 stated to her that Resident #58 was choking, and at that time, LPN #1 came down the hallway and instructed the CNAs to take Resident #58 to the resident's room. She stated when the resident was brought to the resident's room, she did not enter the room, but the door was open and she could see that LPN #1 started to stand the resident up. She stated that at that time, she left the area. She stated she wrote a statement. An ISF, dated [DATE] and completed by CNA #5, revealed she observed the CNAs and Resident #58 coming out of the day room and LPN #1 told the CNAs to take the resident to the resident's room. The statement further revealed that CNA #5 went to Resident #58's room and closed the door and remained outside in the hallway. On [DATE] at 10:52 AM, in the presence of the survey team, the surveyor interviewed, CNA #8. CNA #8 stated that on [DATE], during the breakfast meal, she assisted a resident to the bathroom, which was across from the dining room. She stated she then observed LPN #1 come out of the dining room with Resident #58 and stated the resident was turning blue and to call a code. She stated the nurse pushed the resident in a wheelchair to the resident's room. CNA #8 stated that she, CNA #1 and another CNA followed LPN #1 with Resident #58 to the resident's room and during that time, CNA #1 and the other CNA were telling LPN #1 that Resident #58 was choking. CNA #8 stated at that time the resident's nose was blue and the resident looked like he/she was struggling to get air. She stated LPN #1 instructed her to get oxygen and she left and brought it in the room. She said she told LPN #1 that the resident was choking and that LPN #1 proceeded to leave the room, leaving the three CNAs alone with the resident. At that time, CNA #8 stated the resident was making a gurgling sound, that sounded like choking, and that CNA #4 tried to hit the resident on the back. She further stated LPN #1 returned to the room and picked the resident up from the bed, performed the [MEDICATION(S)] and something came out. On [DATE] at 11:37 AM, the surveyor reviewed LPN #1's employee file and the Licensed Practical Nurse (LPN) Job Description, provided by the Human Resources Director (HRD). A Nursing Core Competency Annual Assessments revealed a hire date of [DATE] and was signed by LPN #1. The Administrator and Director signature was blank. The HR director stated the DON and Administrator should have signed it and there should be someone's initials next to each competency to indicate that it was done. She further stated that the 2019 competencies were not done, because if they were, they would be in the file. The unsigned job description revealed specific requirements for an LPN which included thorough knowledge of principles, methods and techniques involved in performing general nursing services and adapting or modifying standard nursing practices for care of specific cases. A Cardiopulmonary Resuscitation Initiation competency, dated [DATE], for LPN #1 revealed the competencies included critical elements to establish unresponsiveness and attempt to arouse the resident and call for help and stay with the resident. The competencies were checked off as met and there was no evaluators signature on the document. Review of a typed, undated letter, revealed LPN #1 successfully completed his/her CPR training course on [DATE] and was awaiting a card. The letter revealed a copy of a Basic Life Support Instructor (BLS #1) Certification card. On [DATE] at 4:23 PM, the surveyor interviewed BLS #1 by telephone. BLS #1 stated the typed letter was her certification that she completed a private course with LPN #1 on [DATE] and stated that she trained LPN #1 in CPR, the [MEDICATION(S)] Maneuver and use of an AED (automated external defibrillator that immediately diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the hospital records received at the NJ Department of Health on [DATE], Resident #58 arrived at the Emergency Department with EMS for evaluation of choking. EMS reported the patient choked on pancakes that morning at the facility, the [MEDICATION(S)] was performed and the patient coughed up the pancakes. The resident had a CAT (computerized axial tomography, an X-ray test that provided cross section views of anatomy) scan of the chest, dated [DATE], that revealed right upper lobe and bilateral lower lobe patchy opacity, in keeping with aspiration pneumonitis (lung inflammation caused by a substance entering the lungs). NJAC 8:,d+[DATE].1(a)

Complaint number: NJ 304 Based on observation, interview and record review, it was determined that the facility failed to protect all residents from abuse. Resident #15 was slapped in the face by a staff member. This deficient practice was identified for Resident #15, 1 of 2 residents reviewed for abuse, and was evidenced by the following: During a tour of the nursing unit on 6/6/14 the Unit Manager (UM) said Resident #15 was on Hospice, was confused, made repetitive requests to use the bathroom and liked to keep a hair comb nearby. The surveyor observed the resident in a geri-recliner in the day room, combing their hair with a yellow comb and sitting quietly. At 11:20 a.m., the UM told the surveyor that a Certified Nursing Assistant (CNA) had slapped Resident #15 the previous week and admitted to doing so. The UM said she had not been on duty at the time but was called at home. The UM said the CNA had been immediately removed from resident care and terminated. On 6/10/14 at 1:03 p.m. the surveyor observed the resident eating lunch in the dining room. The surveyor noted the resident's right arm sleeve had slipped off the shoulder and the surveyor asked if it could be adjusted by the surveyor. The resident nodded to indicate it was okay and after the surveyor fixed the sleeve, the resident said "thank you." On 6/13/14 at 10:43 a.m. Resident #15 was in the day room, yelling loudly at the staff, telling them to leave him/her alone (they were not touching the resident) and calling them derogatory names. When the staff attempted to redirect the resident from the name calling, the resident said "I don't give a God damn" and continued to loudly call the staff names. On 6/13/14 at 1:50 p.m. the surveyor reviewed the facility's incident investigation regarding Resident #15. According to the report, the incident occurred on 5/26/14 at 7 p.m. in the Day Room. The report indicated Resident #15 was slapped in the face by a CNA and was found with a reddened left cheek. The resident said "She smacked me in my face." Part B of the investigation indicated the resident was slapped "aggressively" by the CNA and the police were contacted. A statement from a staff member working on the unit at the time of the incident indicated she heard the resident say he/she was "smacked" in the face. This staff member indicated she asked the involved CNA if she had done this and the CNA said Resident #15 had "dug" into her face (the CNA's face) and "I just lost it." The staff member indicated the supervisor was made aware, the resident was assessed and the CNA was immediately removed. The investigation indicated the resident's cheek was reddened for a "short period" and then resolved. There was no further information about the length of time the resident's cheek was red. The statement of the involved CNA indicated Resident #15 had hit her on 5/9/14 and the nurse on duty had done nothing about it. The CNA statement indicated the resident had been hitting and scratching her and slapped her in the face. The CNA stated she then hit the resident. The "Employee Termination Notice" indicated the CNA was immediately terminated. According to the medical record, Resident #15 was admitted to the facility in May, 2013 and had [DIAGNOSES REDACTED]. The 5/21/14 Interdisciplinary care conference summary indicated the resident continued to have verbally and physically abusive behaviors towards the staff and episodes of yelling out and hitting or spitting at the staff. The summary indicated that during recreational activities the resident was noted to have periods of anxiety and agitation and could be disruptive. The surveyor could not locate a "Nursing Daily Flowsheet" (NDF) for 5/26/14. There was no documentation found in the medical record about this incident, including the resident's behavior or physical consequences of the assault. The first documentation in the NDF after the incident was on 5/27/14 at 1:10 p.m. which indicated the resident had no signs or symptoms of pain and no redness or bruising to the face. The surveyor reviewed the resident's Medication Administration Record [REDACTED]. On 6/16/14 at 9:28 a.m. the surveyor attempted to speak with Resident #15 who shrugged his/her shoulders when asked how the resident was doing that day. The resident did not speak to the surveyor. When interviewed on 6/16/14 at 9:35 a.m., the UM said the resident did not know staff by name and it was difficult to tell whether he/she recognized staff. The UM said the resident did not seem to have recall ability. The "Abuse Prevention" policy indicated the facility would not tolerate any form of resident abuse. The policy stated that abuse included the willful infliction of injury, intimidation or punishment with resulting physical harm or pain or mental anguish. The policy stated "this presumes that instances of abuse of any resident, even those in a coma, cause physical harm, pain or mental anguish." The physical abuse definition in the facility policy included slapping of a resident. The facility policy indicated all employees would receive initial orientation, prior to resident contact and ongoing training related to abuse and neglect. The facility policy indicated all prospective employees would be screened for a history of abuse, neglect and mistreatment of [REDACTED]. According to the employee's file, the involved CNA was hired on 3/24/14. The facility completed a criminal background check, contacted the nurse aide registry and obtained reference checks from previous employers prior to hire. According to documentation, this CNA received orientation training on Abuse and Dementia Care upon hire. Refer to F514 NJAC 8:39 - 4.1 (a) 5

Based on interview and record review it was determined that the facility failed to develop a plan of care based on the comprehensive assessment to address the needs of a resident who was at risk for falls. This deficient practice was identified in 1 of 6 residents reviewed for falls, Resident #1, and was evidenced by the following: A review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour conducted on 5/15/12 at 9 a.m., the Unit Manager identified the resident to be at risk for falls, and had fallen a few days prior sustaining an injury. A review of a form titled "Nursing Admission Data Collection" dated 5/8/12, revealed that the resident had short and long-term memory problems and required extensive assistance from staff for transferring from the bed to his wheel chair. According to the initial "Fall Assessment," the resident was identified as being at a high risk for falls. A review of the Nurse's Notes dated 5/12/12 (untimed), indicated that as the resident was leaving the Main Dining Room (MDR), the resident self propelled his wheel chair down the ramp located outside of the MDR and sustained a fall. When interviewed by the surveyor on 5/16/12 at 12:25 p.m., a nurse who identified himself as the primary nurse caring for the resident, stated that he was not aware that the resident was blind. The nurse added that this information was normally listed on the resident's care plan, however, this and the fact that the resident was a high risk for falls was never added to his care plan. The surveyor reviewed the care plan and found that there was no plan of care developed to address the resident's high risk of falls or the fact that the resident was legally blind until after the fall which occurred on 5/12/12. This concern was discussed with the staff and the Director of Nurses. NJAC 8:39-11.2(e)2 Refer to F323

Based on observation, interview and record review, it was determined that the facility failed to provide a safe environment free from potential hazards and accidents and ensure the positioning of a dependent resident in bed was done in a manner to prevent an avoidable fall. Resident #1 sustained a fall with injuries which included a fractured nose and abrasions. This deficient practice was identified for Residents #1, and #4, 2 of 9 residents reviewed for falls. In addition, the facility failed to maintain a safe environment on 1 of 2 nursing units. This deficient practice was evidenced by the following: 1. During the initial tour on 5/15/12 at 9 a.m., the Unit Manager (UM) identified Resident #1 as having Dementia and indicated he had fallen recently on 5/8/12 when he self propelled his wheelchair down the ramp from the Main Dining Room (MDR). The resident tumbled forward from the wheelchair he was seated in and fractured his nose, and sustained abrasions to the face. Later on 5/15/12 at 10:30 am, the resident was observed by the surveyor seated in a wheelchair by the nurse's station. The surveyor observed that the resident's nose was swollen and he had abrasions over and under the left eye. When interviewed at this time, the resident stated that he had fallen down "some steps." A review of a form titled "Nursing Admission Data Collection" dated 5/8/12 indicated that the resident was legally blind, had short and long term memory problems and required extensive assistance from staff for transferring from the bed to his wheel chair. According to the initial "Fall Assessment" any score above 10 represents a high risk for falls. Resident #1 had a score of 15 indicating that the resident was at a high risk for falls. According to the Nurse's Notes dated 5/12/12, Resident #1 ate the lunch meal inside the MDR and once he had finished eating, the resident wheeled himself out of the MDR down the ramp without any assistance from staff. The resident "tumbled" forward, and fell from his wheelchair, landing at the bottom of the ramp. The resident had blood coming from the "bridge" of the nose and an abrasion to the left eye. The resident was sent to the hospital and was diagnosed with [REDACTED]. A review of the "Incident/Accident Report" dated 5/12/12, revealed that Resident #1 tried to wheel himself down the corridor from the MDR and came down the ramp without any assistance from staff. This same report indicated that the wheelchair had "picked up speed" and the resident "panicked" and placed his feet onto the floor and fell forward. According to an interview, the staff member in the MDR did not see Resident #1 leave. The second staff member was transporting another resident back to their room. During an interview conducted on 5/16/12 at 1:30 p.m., a family member of the resident stated that she told the doctor the resident was blind and wore hearing aides at the time of admission. The family member stated that she had even made an attempt to give the doctor written documentation regarding the resident being blind but was told by the doctor that this would not be necessary. When interviewed by the surveyor on 5/16/12 at 12:25 p.m., a nurse who identified himself as the primary nurse caring for the resident stated that he was not aware that the resident was blind. The nurse added that this information was normally listed on the resident's care plan, however, this and the fact that the resident was a high risk for falls was never added to his care plan. During an interview conducted by the surveyor on the same date at 12:50 p.m., a nurse and 2 Certified Nursing Assistants (CNAs), who were identified as witnesses to the fall, stated that they were not aware that the resident was blind or at a high risk for falls. During an interview conducted by the surveyor on 5/17/12 at 10:20 a.m., a CNA assigned to care for the resident stated that she was not aware that the resident was blind. The CNA stated that the resident's care needs could be found on the "Resident's Profile" sheet in the Care Tracker. At this time in the presence of 2 surveyors, the CNA displayed the "Resident Profile" sheet on the Care Tracker and there was no information regarding the resident's care needs available for review. On 5/17/12 at 10:45 a.m., the UM stated she was not aware that Resident #1 was blind. The UM further stated to the surveyor that there were only 2 residents in the facility who were permitted to use the ramp independently. The UM added that the nurses were responsible for transferring information obtained from the "Nursing Admission Data Collection" form onto the resident's plan of care. At this time, the UM stated that there was no plan of care developed that addressed the resident's high risks for fall or his blindness until after the fall on 5/12/12. On 5/17/12 at 10:45 a.m., the Director of Nursing (DON) indicated this information should have been discussed at the morning care meeting and placed on the resident's care-plan and input into the "Care Tracker." The DON added that it was the responsibility of the UM, the Supervisors and herself to ensure this was done. When asked why this had not been done, the DON agreed it had not been done , but was unable to explain why it was not done. When interviewed by the surveyor on 5/17/12 at 2:00 p.m., the Director of Maintenance stated that the ramp had a grade of 4.1 percent. Refer to F279 2. Resident #4 was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident received all of his nutrition through a feeding tube. According to the resident's Minimum Data (MDS) of 3/22/12, the resident required an extensive assist of 2 staff members for transfers, was non-ambulatory, alert, but non-verbal. On 3/25/12 at 9:30 p.m., during evening care, one CNA, was caring for the resident and attempted to turn the resident and while turning him, the resident's lower half rolled from the bed, allowing the resident's feet to touch the floor. There was no injury noted. The CNA's use an electronic kiosk in the hallway called a Care Tracker for instructions on care. According to the Care Tracker, the resident requires 1-2 staff for his activities of daily living, however, the CNA caring for the resident on 5/17/12 at 11:30 a.m. indicated that the resident was large and weighed 198 pounds and was unable to assist at all and he definitely required 2 staff for transfers and positioning. The LPN on that Unit was also interviewed on 5/17/12 at 11:35 a.m. The LPN indicated that the resident was at least a 2 person assist and a 3rd person was even better. According to the DON on 5/18/12 at 10 a.m., when asked who was responsible to input the correct resident information into the Care Tracker, she replied, "...who ever does the initial assessment." No oversight or monitoring of this processes was offered to the surveyor. During the Life Safety tour on 5/15/12 in the presence of facility staff the following was noted: 3. At 9:55 a.m. the surveyor observed an oxygen concentrator plugged into a power strip in resident room 115. 4. During the initial tour on 5/15/12 at 10 a.m., a feeding tube pump was observed plugged into a power strip. 5. At 10:10 a.m. the surveyor observed the nurse call cord was tied around the grab bar in the 1st floor training toilet room. NJAC 8:39-27.1(a), 31.2(d)(e).