Every finding on record at Aristacare at Whiting

Based on observation, interview, and documentation review, it was determined that the facility failed to prohibit the use of portable electric space heaters in an unsafe manner and in accordance with product fire safety guidelines to maintain a safe environment free of fire hazards in accordance with CFR 483.25(d). This deficient practice posed the likelihood of serious injury, serious harm, serious impairment or death for all 127 residents residing at the facility and was evidenced by the following:Observations on 08/12/2025 at 10:35 AM, in the presence of the Maintenance Director (MD) and Regional Director of Maintenance (RDM), revealed a portable electric space heater that was plugged into an unapproved electrical adapter, was ON and unattended under the wood desk next to combustible storage in the second floor Social Worker (SW) office. An interview with the Maintenance Director (MD) confirmed that the heater did not belong to the facility and stated electric space heaters were not permitted in the facility because they were a fire hazard. The MD confirmed the heater was ON, plugged into an unapproved electrical device and was hot to the touch.The facility's failure to prohibit the use of an electric space heater which was utilized unsafely posed the likelihood of serious harm and injury and a risk for fire. This resulted in an Immediate Jeopardy situation (IJ). The IJ began on 8/12/25 at 10:35 AM when the Life Safety Code Surveyor (LSCS) observed the unattended electric space heater in the SW's office. The facility Administration was notified of the IJ on 8/12/2024 at 3:15 PM. The facility submitted an acceptable Removal Plan (RP) on 8/13/25 at 12:11 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 8/13/25 at 1:34 PM. The evidence was as follows:A review of the facility's undated policy titled, Portable Space Heater Systems, revealed, Portable space heaters are not encouraged and/or used in our setting Exception 2: Only if the heating elements do not exceed 212 degrees [Fahrenheit] and/or have a safety shut off if it overheats.A review of the heating unit's owner manual revealed, SAFETY INSTRUCTIONS: WARNING NEVER leave the operating unit unattended Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains at least 3 feet (0.9 m) from all sides of the heater. WARNING For residential use only. WARNING A heater has hot and arcing or sparking parts inside. WARNING ALWAYS plug heater directly into a wall outlet/receptacle. NEVER use with an extension cord or relocatable power tap (outlet/power strip).On 08/12/2025 at 10:35 AM, the LSCS, in the presence of the MD, toured the second floor which had a full census of residents residing in rooms 300-309. The LSCS entered the SW office and observed an unattended portable electric space heater located underneath a desk. The heater was turned ON and plugged into a standard grade multi-outlet (power strip). The electric heater was standing on the carpet within approximately 8-inches of combustible materials surrounding which included a cardboard box, loose knitted blankets, and the wooden desk. At that time, the LSCS interviewed the RDM and the MD who confirmed the findings. The MD stated that the unit was hot to touch and was plugged into an unapproved electrical device. The MD stated that he does not even allow these heaters in the building as they are a fire hazard and everyone knows. The MD unplugged the electric space heater and removed it from the SW's office. At 10:41 AM, the SW entered the office confirmed the space heater was hers and that she had it because I get cold.At 11:20 AM, the MD, in the presence of two LSCS's and the RDM, attempted to obtain the temperature of the space heater's heating element, but was unable to obtain an accurate reading using the facility's provided non-contact infrared thermometer. At that time, the LSCS tested the temperature of the heating element and obtained a temperature of 230 degrees Fahrenheit when tested with the same device. The RMD and the MD confirmed the observation. An acceptable RP was received on 8/13/25 at 12:11 PM which indicated the action the facility would take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included; Portable heater was removed from the building; Maintenance Director checked all rooms for additional heaters; Employee was disciplined; All staff were educated on the new policy of NO portable space heaters being allowed and Auditing and monitoring were set-up to maintain a safe environment free of fire hazards from unapproved and non-compliant portable electric heaters on all resident sleeping units.The survey team verified the implementation of the RP during the continuation of the on-site survey on 8/13/25 at 1:34 PM.NJAC 8:39-31.2(e), 31.7(f)

Complaint NJ #: 182491 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 9 of 9 days reviewed. This deficient practice was evidenced by the following: Review of the PBJ Staffing Data Report for Quarter 2 2025 (January 1 - March 31) revealed the facility had no Registered Nurse (RN) hours for the following dates:01/05/202501/19/202502/15/202502/22/202502/23/202503/01/202503/08/202503/15/2025Review of the Employee Daily Schedule by Shift, provided by the facility, for the aforementioned dates verified that there was no RN scheduled to work 8 consecutive hours.During an interview with the surveyor on 08/13/2025 at 12:31 PM, the Director of Nursing (DON) stated there should be a RN in the facility for 8 consecutive hours daily. During an interview with the surveyor on 08/14/2025 at 09:42 AM, the Corporate Clinical Officer acknowledged that there were no RN in the facility daily for 8 consecutive hours on the above dates.A review of the facility provided policy titled, Staffing, with no date, reflected the facility uses staffing guidance as per the Department of Health and Senior Services (DOHSS) and Center for Medicare and Medicaid Services (CMS). The staffing coordinator produces the schedule to meet the needs of the residents and to follow the regulatory guidance by DOHSS and CMS. A review of another facility provided policy titled, Staffing, with no date, reflected the facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. NJAC 8:39-25.2(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and b.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 8/8/25 at 9:18 AM, the surveyor toured the kitchen with the Assistant Food Service Director (AFSD) and observed the following: 1. At the time of observation, the dish machine was not running. The surveyor requested to view the logs of temperature checks. Log review showed no temp check for 8/6/25, 8/7/25, and 8/8/25 for the AM. The AFSD stated, They didn't do them. 22. On a large metal rack there were items that the AFSD said were drying. On the rack the surveyor observed a plastic bin with 12 white plastic coffee carafe lids. The lids had splatters of brown substance. The surveyor asked if they were clean and the AFSD said yes. The surveyor asked again and the AFSD told surveyor he would run them in the dishwasher. 33. The surveyor observed seven large stainless-steel trays on the large metal rack and the AFSD said they were drying. Four of the trays had dried, crusty particles. The AFSD said they were clean, but he would run then through the dishwasher again. 44. Six clear white two quart pitchers and one pitcher had a small amount of pink liquid in the bottom of the pitcher. The AFSD said he would run that again 55. Dietary aide refrigerator had a broken handle and it was covered with black tape. 66. One large cardboard box of thawed bacon (one quarter left in box) with an expiration date of 8/6/25. The AFSD threw the bacon away in the presence of the surveyor. 77. One large plastic container of thickener with the plastic scoop in the product. The AFSD told the surveyor, It shouldn't be there, but I was going to use it anyway. 88. Deep freezer chest with had six 10-pound logs of ground beef and two 10-pound packs of ribs. No received or expiration dates. 99. Walk in refrigerator had three heads of lettuce on a shelf with wet brown substance on them. No received or expiration date. The AFSD threw them away in the presence of the surveyor. 110. One small stainless-steel tray, one quarter full of tuna salad, no expiration date. On 8/9/25 at 09:40 AM, the surveyor met with the Food Service Director and reviewed the findings in the kitchen. The FSD provided surveyor with the kitchen policy. The surveyor reviewed the policy titled, Label and Dating System Protocol, an undated policy. The policy stated all fresh and frozen foods must be dated with the date it was received into the kitchen. NJAC 17.2 (g)

Based on observation, interview, and review of facility documents it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. The deficient practice was identified for 2 of 3 Units identified under the Environmental Task.The deficient practice was evidenced by the following: On 08/11/2025 at 08:59 AM during rounds on the 2 East unit, the surveyors observed: 1. Scratches in the wall with missing paint behind the bed in room [ROOM NUMBER]. 2. A missing tile on the floor near the resident's bed in room [ROOM NUMBER]. 3. A broken bottom drawer of a dresser in room [ROOM NUMBER]. 4. A broken outlet plate with sharp edges in room [ROOM NUMBER] 5. Broken blinds in rooms [ROOM NUMBERS]. 6. A broken middle drawer to the nightstand in room [ROOM NUMBER]. 7. Cracked and missing foam from the handle of the reclining chair in room [ROOM NUMBER]. 8. There where 5 broken covers for overhead lights in the hallways. During an interview on 08/13/2025 at 10:46 AM with the surveyors, the Unit Manager Licensed Practical Nurse (UMLPN) of the 2 East unit said that she does rounds on the unit and reports any environmental concerns to maintenance. The UMLPN said maintenance will usually fix any concerns the next day unless they are waiting for replacements. During an interview on 08/13/2025 at 12:47 PM with the surveyors, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) said there should not be any broken furniture, peeling paint, or broken fixtures in the residents' rooms or hallways, due to it not being a safe environment. A review of a facility provided policy titled Homelike Environment revealed, Residents are provided with a safe, clean comfortable and homelike environment. N.J.A.C. 8:39-31.4(a) On 08/08/2025 at 10:11 AM during the initial tour of the facility, the Surveyor entered room [ROOM NUMBER]. At that time, the surveyor observed a plate that was intended to cover the call device wall input. The plate was not attached to the call device input and was instead, suspended from the call device cord. On the same date at 10:27 AM during the initial tour of the facility, the first-floor shower room had a tan incontinence brief on the floor and a potentially used white incontinence brief located in a linen cart left inside the bathroom portion of the shower room. On 08/11/2025 at 10:12 AM while in room [ROOM NUMBER], the surveyor observed a broken handle hanging by one screw on the dresser cabinet. The trash can in the room had a used incontinence brief inside with no bag liner. On 08/13/2025 at 3:13 PM during an interview with the surveyor, the Director of Nursing (DON) replied, Yes when asked if trash cans should have bag liners in them. The DON confirmed that soiled incontinence briefs should not be disposed of in resident trash cans and left. A review of the facility policy titled Homelike Environment revealed that, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. N.J.A.C. 8:39-31.4

Based on observation, interview, and review of facility documentation it was determined the facility failed to provide adequate behavior monitoring for a resident receiving psychotropic medications. This deficient practice was identified in 1 of 5 residents reviewed for unnecessary medication (Resident #12) and was evidenced by the following:On 8/8/25 at 10:10 AM, the resident was observed self-propelling in a wheelchair in the room.The surveyor reviewed Resident #12 medical record.A review of the admission Record revealed Resident #12 was admitted with medical diagnoses which included but were not limited to schizoaffective disorder (combination of schizophrenia and mood disorder), depression, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and pain in right hip.The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 6/2/25. The resident had a Brief Interview of Mental Status (BIMS) of 11, meaning the resident had moderate cognitive impairment.A review of the Physician Order Summary (POS) revealed the resident was prescribed the following medications:Depakote (for bipolar disorder) Oral Tablet Delayed Release 500 milligrams (MG) Give 500 mg by mouth in the morning related to Schizoaffective disorder, bipolar type. Depakote Tablet Delayed Release 250 MG give 1 tablet by mouth at bedtime related to Schizoaffective Disorder, Bipolar Type give with 500mg for total dose of 750mg.Seroquel (antipsychotic) Oral Tablet 25 MG give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar type.Seroquel Tablet 100 MG Give 1 tablet by mouth at bedtime related to schizoaffective disorder, bipolar type give with 50mg to equal 150mg.Seroquel Oral Tablet 50 MG give 1 tablet by mouth at bedtime related to bipolar disorder, current episode hypomanic with 100mg tab to equal 150mg.A review of the Individualized Comprehensive Care Plan included a focus of aggressive behaviors and anxiety/nervousness with additional behaviors. Interventions included administering medications as physician ordered and monitor and document behavioral episodes.The surveyor reviewed the monthly medication reviews and pharmacist recommendations completed by the Consultant Pharmacist (CP). For the July 2025 review the CP recommendation was for the residents targeted behaviors to be counted and documented in the psychoactive summary that was completed monthly by nursing. The surveyor then reviewed the March 2025 psychoactive summary which had documented paranoid delusions and suicidal thoughts as behaviors, but number of episodes were not documented. Review of the May 2025 summary did not have any documented behaviors. The June 2025 summary showed paranoia as the resident's behavior, but number of episodes were not documented. On 8/13/25 at 10:10 AM, the surveyor interviewed LPN #1 regarding behavior documentation. LPN #1 stated behaviors were documented in the progress notes, the physician would be alerted and the residents family.The surveyor then interviewed the UM/LPN regarding behavior monitoring. The UM/LPN stated behaviors were documented on the Medication Administration Record as a Y for behaviors or an N for no behaviors. On 8/13/25 at 11:19 AM, the surveyor reviewed Resident #12 MAR. The MAR did not include behavior documentation. The surveyor then reviewed the progress notes for behavior notes and none were found.On 8/13/25 at 12;00 PM, the surveyor requested behavior documentation for Resident #12 from the Director of Nursing (DON). The surveyor was provided three notes of behavior documentation following a room change. No other behavior documentation was provided.On 8/14/25 at 10:00 AM, the surveyor asked the DON if the notes provided completed due to the room change and the DON said yes. The surveyor asked if the documentation should be on the MAR, and the DON responded yes.On 8/14/25 at 11:00 AM, the surveyor reviewed the policy titled, Behavior Management-Clinical Protocol, an undated policy. The policy indicated that as part of resident assessments the staff will identify individuals with a history of impaired cognition, or mental illness (bipolar disorder or schizophrenia). Number two, included that the nursing staff would document nature, duration and associated features of behavior.NJAC-27.1 (a)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 25 residents reviewed, Resident #10. This deficient practice was evidenced by the following:The surveyor reviewed the admission Record for Resident #10 which reflected that the resident was admitted with diagnoses that included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (high blood pressure with severe kidney damage where the kidneys have almost completely stopped working) and essential Primary hypertension (high blood pressure.)The surveyor reviewed the physician's orders revised on 7/17/2025 which revealed Hemo-dialysis M-W-F send patient with Dialysis binder fill out vital signs and medications given prior to leaving.The surveyor reviewed Resident #10's Care Plan (CP) which revealed I, (Resident #10) need hemodialysis r/t renal failure 3 X Weekly (M-W-F)@ Fresenius in [NAME] River, chair time 2:45 Date initiated: 06/09/2022.The surveyor reviewed the Resident #10's Dialysis communication binder that revealed Resident #10 is attending dialysis as order. The surveyor reviewed Resident #10's Annual MDS dated [DATE]. Section O titled Special treatments, procedures, and programs did not check the spot labeled Dialysis or Hemodialysis, indicating that the Resident #10 does not currently receive dialysis. The facility policy titled Electronic Transmission of the MDS revealed under POLICY INTERPRETATION AND IMPLEMENTATION 5. The MDS Coordinator is responsible for ensuring that appropriate edits are made.During an interview with Licensed Practical Nurse (LPN) on 08/13/2025 at 10:46 AM the LPN said that Resident 10 has been on dialysis since he/she came to us and was not aware of any time periods where dialysis was stopped. When interviewed on 08/13/2025 at 11:02 AM, the MDS coordinator said yes he/she is on dialysis and yes I competed it, it should be coded under section O, which it's not. The MDS coordinator further said, it's important because he/she is on dialysis and it's a transcription error on my part.On 03/13/2025 at 12:31 PM the surveyor interviewed the Licensed Nursing home Administrator (LNHA) in the presence of the Regional Director of Nursing (RDON) who said the MDS should be current and reflect accurate information for the residents, and it is important to accurately show their acuity.NJAC 8:39-2(e)1

complaint # 2563750Based on interview and record review, it was determined that the facility failed to develop and implement a care plan that meets the needs identified on the comprehensive assessment care for 1 of 25 residents reviewed for comprehensive care plans, Resident #14. This deficient practice was evidenced by the following:On 08/08/2025 at 09:37 AM during initial tour of the facility the surveyor observed Resident # 14 in bed with the door to their room open. There was a mesh stop sign attached to one side of the door and not connected to the other side. On 08/11/2025 at 09:11 AM the surveyor observed Resident # 14 sitting on their bed with the door open, the mesh stop sign was not connected to both sides of the door. A review of Resident # 14's admissions record revealed that, Resident # 14 was admitted with but not limited to bipolar disorder (a mental health condition characterized by extreme mood swings), Dementia (a decline in cognitive function that affects, memory, thinking and social abilities), and anxiety disorder. A review of Resident #14's admission Minimum Data Set (MDS) dated [DATE] revealed under section E that Resident # 14 has physical and verbal behaviors directed towards others. A review of the current Care Plan (CP) for Resident #14 revealed an intervention that was initiated on 07/14/2025 for a stop sign in front of resident's room to stop others from wandering into the room. During an interview on 08/13/2025 at 10:46 AM with the surveyor the Unit Manger Licensed Practical Nurse (UMLPN) said that care plan consists of focus areas for falls, pain, behaviors, all care areas, and certain medications. The UMLPN said that Resident # 14 was care planned to have a stop sign across their door to keep other residents out of the room. When asked if the stop sign is not in place was the care plan being followed, the UMLP replied, NO During an interview on 08/13/2024 at 12:47 PM with the surveyor, the Director of Nursing (DON) replied, yes when asked if staff should be following residents' care plans. A review of a facility provided policy titled, Care Plans revealed [facility name] care planning/interdisciplinary team, in coordination with the resident, his/her family develops and maintains a care plan for each resident. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for respiratory equipment. This deficient practice was identified for 1 of 3 (Resident #3) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 08/08/2025 at 9:49 AM, Resident #3 was observed in the room. The surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece) on a cabinet next to the resident's bed. The surveyor observed the tubing dated 07/31/2025. On 08/11/2025 at 8:38 AM, the surveyor observed the tubing of the nebulizer machine dated 07/31/2025. A review of the medical record revealed Resident # 3 had diagnoses that included but were not limited to respiratory failure and asthma. A review of a Physician Order Sheet (POS) revealed a physician's order dated 06/01/2025, reflected that Resident # 3 was to receive ipratropium 0.5 milligrams(mg)-albuterol (a medicine that helps opens the airways) 3 mg/3 ml (milliliter) nebulization, inhale 3 milliliters by nebulization route 4 times per day. During an interview with the surveyor on 08/13/2025 at 9:12 AM, the Licensed Practical Nurse (LPN) stated the nebulizer tubing should be changed weekly on the 11 to 7 shift. The LPN went on to say the tubing should have had a different date. She stated that it is a strong possibility that the tubing was not changed but she cannot speak for the 11 to 7 shift. A review of a facility policy titled, Administering Medications through Small Volume (handheld) nebulizer, not dated, reflected 20. change equipment and tubing weekly. NJAC 8:39-15.1(a)

NJ00182491, NJ00182879 NJ00186106Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 2 of 2 residents (Resident #144, and #27) reviewed and was evidenced by the following: Complainant stated pain medications ordered nightly were given late. The surveyor reviewed the resident’s medical records. Review of the admission Records indicated Resident #144 was admitted to the facility with medical diagnoses that included but were not limited to fracture of left humerus (arm), congestive heart failure and depression. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 2/1/25 revealed the resident had a Brief Interview of Mental Status (BIMS) of 9, meaning the resident had moderate cognitive impairment. Review of section J of the MDS for pain assessment indicated the resident was on a pain regime and the resident had pain frequently in last five days and that the pain frequently interrupted day to day activities. A review of the physician orders showed an order for Oxycodone (narcotic pain medication) 5 milligram (mg) one tablet to be given every night at nine PM. Review of the medication administration record showed that the oxycodone was signed out as administered every night for the month of January 2025. A review of Resident #144 Medication Administration Audit Report for January 2025 revealed the Oxycodone for pain management was administered past the required time frame as follows: January 10, 2025-due at 9 PM administered at 10:07 PM January 19, 2025-due at 9 PM administered at 10:01 PM January 31, 2025-due at 9 PM administered at 10:30 PM On 8/13/25 at 10:15 AM the surveyor interviewed the Subacute unit Licensed Practical Nurse (LPN#1) regarding medications times. LPN #1 told the surveyor the nurses had one hour before to one hour after the ordered administration time. LPN #1 said if later than one hour after the order time it would be considered late. On 8/13/25 at 10:35 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) on the second floor. The surveyor asked what time a 9 PM medication should be given. The UM/LPN responded, You have one hour before to one hour after the prescribed time. A review of Resident #27's quarterly Minimum Data Set (an assessment tool) dated 05/11/2025, revealed that Resident #27 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review Resident # 27's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to psoriatic arthritis. A review of Resident #27 physician's orders revealed the following orders but not limited to Oxycontin ER 20 MG Give 1 tablet by mouth every 12 hours for chronic pain. A review of Resident #27's Medication Administration Audit Report for January 2025 reflected that the Oxycontin ER was administered past the required time frame as follows: 05/02/2025 at 12:00 PM administered at 02:55 PM 01/02/2025 at 09:00 PM administered at 10:52 PM 01/04/2025 at 09:00 AM administered at 10:25 AM 01/05/2025 at 09:00 AM administered at 10:07 AM 01/06/2025 at 09:00PM administered at 10:03 PM 01/07/2025 at 09:00 AM administered at 11:09 AM 01/08/2025 at 09:00 AM administered at 10:13 AM 01/10/2025 at 09:00 PM administered at 10:13 PM 01/11/2025 at 09:00 AM administered at 10:29 AM 01/13/2025 at 09:00 PM administered at 11:39 PM 01/15/2025 at 09:00PM administered at 10:08PM 01/18/2025 at 09:00 AM administered at 10:10 AM 01/18/2025 at 09:00 PM administered at 10:24 PM The surveyor reviewed the policy titled, “Administering Medications”, which stated medications must be administered in a safe and timely manner. Number eight of the policy stated medications must not be prepared in advance and must be administered within one hour of their prescribed time. NJAC 8:39-29.2 (d)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to implement appropriate infection control for respiratory equipment. The deficient practice was identified for 2 of 2 residents (Residents # 1, 149) reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 08/08/2025 at 10:06 AM during the initial tour in Resident # 149's room, the surveyor observed a nebulizer chamber (piece of a small machine that turns liquid medicine into a mist that can be easily inhaled) disassembled and drying adjacent to a worn pair of socks on top of the nightstand. The tube for the nebulizer was on top of the socks.On 8/08/2025 at 10:13 AM during the initial tour while in Resident # 1's, the surveyor observed a nasal cannula (tube used to deliver oxygen through the nares) on top of a nightstand next to a graduated urinal. The nasal cannula was not in a bag. On 08/11/2025 at 10:13 AM while in Resident # 149's room, the surveyor observed a trash can with no bag liner in front of the nightstand. In the trash can was a soiled incontinence brief. On top of the nightstand, a nebulizer was disassembled drying on a towel above the trash can.A review of Resident # 1's Diagnoses located in the Electronic Medical Record (EMR) revealed a diagnosis of but not limited to Acute Respiratory Failure with Hypoxia (a severe medical condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low oxygen levels in the body).A review of Resident # 1's Physician's Orders located in the EMR revealed and order for continuous oxygen at 2 liters per minute via nasal cannula.A review of Resident # 1's Care Plan revealed a focus of but not limited to, I [Redated Name] have oxygen therapy related to Congestive Heart Failure.A review of Resident # 149's Physician's Orders located in the EMR revealed an order for O2 trials in progress every shift for monitor for 5 Days reapply O2 [oxygen] at 2 LPM [liters per minute] via nasal cannula SPO [Blood oxygen saturation] less than 92 and an order for Ipratropium-Albuterol Solution [medication used to improve breathing] 0.5-2.5 (3) MG/3ML 3 ml [milligram/milliliter) inhale orally via nebulizer four times a day for [Chronic Obstructive Pulmonary Disease].A review of Resident # 149's Care Plan revealed a focus of but not limited to, The resident will be free of [signs and symptoms] of respiratory infections through review date. The focus was initiated on 7/30/2025.A review of Resident # 149's Diagnoses located in the EMR revealed a diagnosis of but not limited to muscle wasting and atrophy.On 8/13/2025 at 12:24 PM during an interview with the surveyor, The Director of Nursing (DON) was asked by the surveyor if nebulizer chambers should be left to dry adjacent to urinals and worn socks. She replied, No.A review of the facility policy titled, Administering Medications through Small Volume (Handheld) Nebulizer revealed under Steps in the Procedure that, 19. When equipment is completely dry, store in a plastic bag.N.J.A.C. S 8:39-19.4 (a)

Based on observations, documentation review, and interviews on 8/12/2025 and 8/13/2025 in the presence of the Regional Director of Maintenance (RDM) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning in accordance with State Operations Manual (SOM) Appendix PP Subsection 483.90(g). This deficient practice had the potential to affect all residents and was evidenced by the following:An observation on 08/12/2025 at 10:05 AM revealed the call station pull cord closest to the toilet in room [ROOM NUMBER] was wrapped around the grab bar, prohibiting the station from being activated. When the cord was unwrapped and tested, it failed to initiate a call. The call station for Bed A in the same room did not function when activated. An observation at 10:10 AM revealed the master call station at the second floor nursing station reading 324 CALL FAIL. In an interview at 10:11 AM the MD stated that he was aware of some call stations not operating since 08/10/2025. MD had received a phone call from the building reporting some call bells not working. Upon investigating, MD found call bells making ghost calls, (calls that do not correspond with the room making a call). The MD was asked what the policy was when a call bell did not work. The MD responded, if it could not be repaired, a tap bell was offered. NO tap bells or other means of communication were observed within any of the rooms with non-functioning call bells. Observations from 08/12/2025 to 08/13/2025 found non-functioning call bells in the following rooms: 105, 116, 118, 124, 300, 303, 304, 305, 307, 311, 314, 315, 316, 318, 330, 324, 325, 326, 327, 329, and 331. The first floor courtyard and smoking area pull station did not have a cord installed, this area served all residents. In an interview on 08/12/2025, at 10:25 AM, the MD was asked if he saw any tap bells. The MD responded, No. A review of documentation provided by the MD revealed communication between the MD and the call bell service company explaining problems with the call system on 08/10/2025, 08/11/2025, 08/12/2025 and 08/13/2025. A review of the policy and procedure for call bells on 08/13/2025 at 1:40 PM revealed the following partial list of Guidelines:3. Report any defective call lights to Maintenance and follow-up with a work order.4. Residents may be offered with a tap bell or a special type of call bell to use if and when applicable.b. The call bell system has a failure or that room call bell is not working. The facility's Administrator was informed of the deficient practice at the Life Safety Code Exit conference on 08/13/2025 at 3:10 pm. NJAC 8:39-31.2(e), 31.8(c)9

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 03/18/2024 from 9:18 AM to 9:45 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the kitchen and observed the following: In the walk-in freezer, the surveyor observed a spinach quiche, two packages identified by the FSD as pulled pork, and a pie with no labels or dates. The FSD stated that there should be a use by label if out of the package. He further stated that the above referenced items were not correct. A review of facility provided policy titled Labeling and Dating System Protocol rev 5/23/23, revealed All fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has a Purveyor shipping label on it. Also included was All food in freezer storage - 6 months. N.J.A.C. 18:39-17.2(g)

Based on observation, interview and review of facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment for resident rooms on 3 of 3 nursing units of the facility observed (1 East, 2 East, and 2 West). The evidence of this deficient practice includes: 1.) On 03/18/2024 from 9:33 AM to 11:41 AM, during the initial tour of the 2 [NAME] nursing unit, the surveyor made the following observations: The vinyl wall covering in resident room [ROOM NUMBER] behind bed B was partially removed and pulled away falling off the wall. room [ROOM NUMBER] the plastic/vinyl wall bumper behind bed A was broken with pointed edges. The bath tub in room [ROOM NUMBER] contained brown and grey stains and the overflow plate was covered with a white crusty material. The wall behind bed A in room [ROOM NUMBER] had an approximately 12 inch by 4 inch area with gouges missing paint and revealing the bare drywall. room [ROOM NUMBER] had four holes approximately one inch in diameter in the wall directly under the ceiling and to the right of the bathroom door. room [ROOM NUMBER] bathroom door was missing a door knob with a hole where the door knob would be placed and had the paint removed along the edge of the door by the door knob opening, the call bell control panel was hanging down off of the mounting bracket on the wall exposing the wires in the wall, and the wall behind bed A was damaged with two large holes approximately four to five inches wide and peeled wallpaper. On 3/25/2024 at 12:35 PM, the surveyor, in the presence of the survey team, interviewed the Director of Maintenance (DOM), who stated that environmental concerns fall under the maintenance department's responsibility. He included that maintenance department is notified of reeded repairs through an electronic work order program utilized by the facility. The DOM was presented with photos of the above observations, and he acknowledged the need for repairs. Review of the facility's undated Maintenance Service policy included but was not limited to: maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The following functions are performed by maintenance, but are not limited to: .b. maintaining the building in good repair and free from hazards .g. maintaining the paging system in good working order NJAC 8:39-4.1(a) 43936 Complaint # NJ152908, NJ156248, NJ152672 2.) On 03/18/2024 at 10:29 AM during the initial tour of the facility, Surveyor # 2 observed resident room [ROOM NUMBER]. At that time, there was no trash bag in the garbage can. On the same date at 11:24 AM during the initial tour of the facility, Surveyor # 2 observed room [ROOM NUMBER]. At that time, Surveyor # 2 observed stains on the privacy curtain that was located between the beds in the room. On 03/20/2024 at 1:29 PM, Surveyor # 2 observed room [ROOM NUMBER]. At that time, Surveyor # 2 observed the dresser in the room. The front of the bottom drawer was detached and left leaning against the side of the dresser. In addition, Surveyor # 2 observed the floor base board was missing behind the bed and in the corner near the bathroom door. The unfinished dry wall was exposed. On 03/25/2024 at 12:30 PM, during an interview with Surveyor # 2, the Director of Maintenance confirmed that if a dresser or bed was broken it would be maintenance's responsibility to fix it. The Director of Maintenance said he was unaware of the broken dresser and missing floor base board in room [ROOM NUMBER]. He concluded by saying he will have his staff repair it immediately. On 03/25/2024 at 12:44 PM during an interview with Surveyor # 2, the Director of Housekeeping said that resident rooms are cleaned every day. He further said that privacy curtains are changed once a month or as needed. Lastly, he confirmed that his staff are to put a new trash bag in a garbage can when they empty it. A review of the facility provided document titled, Work Order #4648 revealed a note, REPAIRED DRESSER DRAWER with a completed status of 03/26 at 12:58 PM. The document confirmed the repair was completed after the surveyor brought the observations to the attention of the Director of Maintenance. A review of the undated facility provided document titled, Maintenance Service revealed under, Policy Interpretation and Implementation that, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 48964 On 03/19/2024 at 11:20 AM Surveyor #3 observed Resident #71 in his/her room and noted seven missing floor tiles in front of the sink. Resident #71 stated the tiles were missing forever and it bothers him/her as the wheelchair gets stuck and hard to propel with the difference in the floors. On 03/21/2024 at 10:34 AM Surveryor #3 noted seven floor tiles remain missing in Resident #71's room in front of the sink On 03/25/2024 09:49 AM Surveyor #3 noted seven missing floor tiles in Resident #71's room in front of sink. On 03/25/24 at 12:30 PM Surveyor #3 interviewed the maintenance director, who stated when the staff sees something, they put it in TELS, (TELS is a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions), and then it comes to him. He stated that he was not aware of anything needing attention in room [ROOM NUMBER]. He also stated there was nothing in TELS regarding this room. He further stated that the tiles should not be pulled up like that. On 03/27/24 at 10:12 AM Surveyor #3 reviewed facility provided work order #4651 indicates work order was created on 03/26/24 at 12:53pm. A review of the undated facility provided document titled, Maintenance Service revealed under, Policy Interpretation and Implementation that, 2. b. Maintaining the building in good repair and free from hazards. N.J.A.C. 8:39-4.1(a)11, 31.4(a)

Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 5 of 51 days reviewed under the Sufficient and Competent Nurse Staffing Task. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 07/10/2022 through 07/16/2022, 01/08/2023 through 01/14/2023, 03/10/2024 through 03/16/2024 revealed the facility had no RN coverage for all shifts on 07/16/2022, 01/08/2023, 01/14/2023, 03/10/2024, and 03/16/2024. A review of the facility provided schedules for those dates did not reveal any RN coverage. Additionally, facility provided schedules for 07/17/2022 and 03/17/2024. 07/17/2022 did not reveal any RN coverage. The schedule for 03/17/2024 revealed the Director of Nursing was present in the facility however the resident census on that day was 136. On 03/26/2024 at 1:40 PM during an interview with the surveyor, the Director of Nursing said they have Registered Nurses at times but sometimes they leave for various reasons. A review of the undated facility policy titled, Staffing revealed under 'Policy Interpretation and Implementation that, 1. This facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the deliver of resident care services. NJAC 8:39-25.2(h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the accountability of the narcotic shift count logs were completed in accordance with facility policy. The deficient practice was identified on 2 of 4 medication carts reviewed (1 East Low side cart and 2 [NAME] High side cart) during the Medication Storage Task. The deficient practice was evidenced by the following: On 03/19/2024 at 10:05 AM during an interview with the surveyor, Licensed Practical Nurse (LPN) # 4 said that narcotic shift count logs are to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirm an accurate count of the narcotics (opium, opium derivatives, and their semi-synthetic substitutes) in the medication cart. She also confirmed that shift count logs should not be missing any documentation or signatures. Further, she said that the inventory sheet should be filled out when she prepares to administer a narcotic. At that time, the surveyor, in the presence of LPN 4, reviewed the 1 East low side medication cart Narcotic Bingo Card Log which revealed the following: On 3/10/24 the 3-11 shift section revealed that positive, negative, and End Shift total sections were blank. On 3/13/24 the 11-7 shift section revealed that positive and negative sections were blank. On 03/19/2024 at 10:33 AM during an interview with the surveyor, LPN # 2 stated that the narcotics shift log should be counted and signed by the incoming and outgoing nurses together. At that time, LPN # 2 stated, I forgot to sign it in this morning. At that time, the surveyor in the presence of the LPN # 2, reviewed the 2 [NAME] High side medication cart's CONTROLLED DRUGS CARD COUNT document which revealed the following: On 03/04/2024, in the 7A-3P Shift section, the positive and negative count section was blank. On 03/05/2024, in the 7A-3P Shift section, the positive and negative count section was blank. On 03/06/2024, in the 3P-11P SHIFT section, the Nurse on (11-7) [3-11] section was blank. On 03/07/2024, in the 7A-3P SHIFT section, the Nurse off (11-7) section was blank. On 03/11/2024, in the 7A-3P Shift section, the positive and negative count section was blank. On 03/19/2024, in the 7A-3P SHIFT section, the Nurse On (7-3) section was blank. On 03/19/2024 at 11:14 AM during an interview with the surveyor, LPN # 6 said all nurses assigned to carts are responsible for the organization and maintenance of the medication cart. She further stated that narcotic shift to shift count logs are to be completed by two nurses (the incoming and outgoing nurses) at the same time once they confirm an accurate count of the narcotics in the cart. She also confirmed that logs should not be missing any documentation, signatures. On 03/19/2024 at 1:33 PM during an interview with the surveyor, the Director of Nursing (DON) said controlled substance shift to shift logs are to be completed with two nurses at the change of shift. The DON said this occurs after they both complete a count of the controlled substance in the medication cart to show they [narcotics] are accounted for. She confirmed that the purpose is for accountability of the controlled medications. A review of the facility's undated policy titled; Controlled Substances revealed that nursing staff will count controlled drugs at the end of each shift. The nurse coming on duty and nurse going off duty will make the count together. They will document and report any discrepancies to the Director of Nursing services. NJAC 8:39-29.3(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure required monthly visits by the Consultant Pharmacist (CP) for the months of November 2023, December 2023, and January 2024. This irregularity was identified for 3 of 3 residents reviewed for CP review, Residents #63, #83, and #27. This deficient practice was evidenced by the following: 1.) On 03/21/24 at 11:37 AM, the surveyor reviewed the CP progress notes. During review it was identified that the CP reviewed Resident #63 medications January 2023 through October 2023 every month. There was no available documentation for November 2023, December 2023, or January 2024. A review of the Admission Record for Resident #63 indicated the resident had medical diagnoses which included but were not limited to hypertension (high blood pressure), anxiety disorder, and intellectual disabilities. Review of the annual Minimum Data Set (MDS), an assessment tool dated 01/20/24 revealed the resident had a Brief Interview of Mental Status of 3, meaning the resident had severe cognitive impairment. On 03/26/24 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON) regarding the CP. The DON told the surveyor, The consultant pharmacist stopped coming. The surveyor asked what process was put in place for the three months the facility did not have a CP. The DON replied, We did medication pass with nurses and looked at the new admissions medications. The DON told the surveyor the facility at that time was in the process of getting a new Consulting Pharmacist. On 03/26/24 at 12:30 PM, the surveyor requested documentation supporting the facility securing a new CP following the October CP reviews. No information was provided. On 03/28/24 at 12:31 PM, the surveyor reviewed the policy titled, Pharmacy Consultant Policy and Procedure, an undated policy. Under number five of the policy, it indicated that the Consultant Pharmacist is responsible to provide drug regimen review reports to the Administrator, DON, and to the Nurse Managers monthly. 48964 2.) On 03/21/2024 at 09:49 AM the surveyor reviewed the CP progress notes. During review it was identified that the CP reviewed Resident #83's medication from April 2023 through October 2023 every month. There was no available documentation for November 2023, December 2023, or January 2024. On 03/21/2024 at 09:49 AM the surveyor reviewed the progress notes for Resident #83 which indicated the resident had medical diagnoses that included but were not limited to history of deep vein thrombosis (blood clot), sacral stage 4 ulcer (wound on backside), and quadriplegia (paralysis). Review of quarterly MDS dated [DATE] revealed a Brief Interview of Mental Status of 15, indicating intact cognition. On 03/26/24 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON) regarding the CP. The DON told the surveyor, The consultant pharmacist stopped coming. The surveyor asked what process was put in place for the three months the facility did not have a CP. The DON replied, We did medication pass with nurses and looked at the new admissions medications. Review of facility provided, undated policy titled, Pharmacy Consultant Policy and Procedure, number five of the policy indicatd, the Consultant Pharmacist is responsible to provide drug regimen review reports to the Administrator, DON, and to the Nurse Managers monthly. N.J.A.C. 8:39-29.3(a)1 49707 3.) A review of the CP progress notes revealed Resident #27's medications were reviewed August 2023 through October 2023 every month. There was no available documentation for November 2023, December 2023, or January 2024. A review of the Admission Record for Resident #27 indicated that, the resident had medical diagnoses which included but were not limited to essential hypertension (high blood pressure), anxiety disorder, bipolar disorder (a disorder associated with episodes of mood swings) disabilities, type 2 diabetes mellitus, and major depressive disorder. A review of the annual Minimum Data Set (MDS), an assessment tool dated 10/18/23 revealed the resident had a Brief Interview of Mental Status score of 15/15, meaning the resident had no cognitive impairment. On 03/26/24 at 10:05 AM, during an interview with the surveyor, the DON stated, The consultant pharmacist stopped coming. The surveyor asked what process was put in place for the three months when the facility did not have a CP. The DON replied, We did medication pass with nurses and looked at the new admissions medications. The DON said the facility at that time, was in the process of getting a new Consulting Pharmacist. A review of the undated facility-provided policy titled, Pharmacy Consultant Policy and Procedure, number five of the policy indicated, the Consultant Pharmacist is responsible to provide drug regimen review reports to the Administrator, DON, and to the Nurse Managers monthly. N.J.A.C. 8:39-29.3(a)1

Based on observation, interview, and record review it was determined that the facility failed to notify the resident and/or resident representative in writing of the reason for transfer or discharge to the hospital for 3 of 3 residents reviewed for hospitalization Residents #43, #129, and #230. This deficient practice was evidenced by the following: 1.) On 03/20/24 the surveyor reviewed the Electronic Medical Record (EMR) which indicated Resident #129 was admitted to the facility for short term rehabilitation. Further review showed there was a Discharge/Return Anticipated Minimum Data Set (MDS), an assessment tool completed on 12/22/23 following a transfer to the hospital for right shoulder pain. Review of the Admission Record indicated Resident #129 had medical diagnoses which included but were not limited to the following: acute respiratory failure, kidney disease, and anxiety. The surveyor reviewed the most recent MDS which revealed the resident had a Brief Interview of Mental Status of 3, meaning the resident had severe cognitive impairment. On 03/20/24 at 12:58 PM, review of the progress notes showed that on 12/21/23 at 9:00 PM Resident #129 was found in the room on the floor. The resident complained of right shoulder pain at that time. The resident's physician and family were notified via telephone and shoulder x-rays were ordered. Further review of the progress notes showed that on 12/22/23 at 09:00 AM, the resident complained of pain to right shoulder, right arm and right wrist. Resident #129 was sent to the hospital on 12/22/23 following the complaints of pain. On 03/25/24 at 01:01 PM, the surveyor interviewed the Director of Social Work (DSW) regarding notification of hospitalization in writing to the resident and/or resident representative and ombudsman. The DSW stated, The last receptionist would send the hospitalization to the Ombudsman's office in bulk at the end of the month. The DSW could not locate the confirmation of the faxes. The surveyor asked about the notification to the resident and/or resident representative in writing. The DSW stated, The receptionist was supposed to do both resident representative and ombudsman, but she wasn't doing that. The receptionist is now going to be sending it to the resident representative. On 03/27/24 at 11:53 AM, the surveyor reviewed the policy titled Preparing a Resident for Transfer or Discharge, an undated policy. The policy statement revealed that the facility shall prepare a resident for a transfer or a discharge. Number three of the policy indicated that the receptionist would send out an email notice of the discharge. The policy did not indicate who received the email notice. 44833 2.) On 03/25/2024 the surveyor reviewed Resident #43's EMR. Review of the Admission Record indicated Resident #43 was admitted to the facility with diagnosis which included but were not limited to essential hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD, a chronic lung disease), and heart disease. Further review indicated Discharge/Return anticipated MDS for 4/12/23 following transfer to the hospital for tachycardia (rapid heart rate) and another dated 12/10/23 after being found unresponsive in bed. The surveyor reviewed the most recent MDS which revealed the resident had a Brief Interview of Mental Status of 15 out of 15 indicating intact cognition. Review of the progress notes showed that on 4/12/23 at 12:56 PM, the resident was admitted to the hospital with severe sepsis shock (infection in the blood stream), and another progress note dated 12/10/23 at 10:46 PM, which indicated the resident was admitted to the hospital with hypotension (low blood pressure). 48964 3.) On 03/21/2024, the surveyor reviewed Resident #230's EMR. Review of the progress notes indicated that Resident #230 was admitted to the facility for short term rehabilitation following a hospitalization which included abdominal surgery for an ileostomy (the lower small intestine is brought through the abdominal wall via a surgical opening). The notes further indicated that on the day of planned discharge, bright red blood was noted in the ileostomy bag. Resident #230's physician was notified, and the resident was transferred to the emergency room for evaluation and admitted for ileostomy dysfunction. Review of the admission MDS, dated [DATE], indicated a BIMS of 15, indicating intact cognition. Further review showed there was a Discharge/Return Anticipated MDS completed on 01/18/2024 following the transfer to the hospital. On 03/25/24 at 01:01 PM, the surveyor interviewed the Director of Social Work (DSW) regarding notification of hospitalization in writing to the resident and/or resident representative and ombudsman. The DSW stated, The last receptionist would send the hospitalization to the Ombudsman's office in bulk at the end of the month. The DSW could not locate the confirmation of the faxes. The surveyor asked about the notification to the resident and/or resident representative in writing. The DSW stated, The receptionist was supposed to do both resident representative and ombudsman, but she wasn't doing that. The receptionist is now going to be sending it to the resident representative. On 03/27/24 at 11:53 AM, the surveyor reviewed the policy titled Preparing a Resident for Transfer or Discharge, an undated policy. The policy statement revealed that the facility shall prepare a resident for a transfer or a discharge. Number three of the policy indicated that the receptionist would send out an email notice of the discharge. The policy did not indicate who received the email notice. NJAC 8:39-9.6 (e)

Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 1 of 1 unsampled resident, (Resident # 95) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 03/20/2024 the surveyor reviewed the MDS history in the electronic medical record which revealed: Resident #95 was discharged on [DATE]. Resident #95's discharge MDS was completed on 12/27/2023. The history indicates that Resident #95's discharge MDS was transmitted on 03/18/2024. On 03/21/2024, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the discharge MDS on Resident #95 should've been completed within 14 days of discharge and transmitted within one week after completion. She also stated, it's late and the MDSs are usually transmitted once they're completed, this one got missed. Review of facility provided policy MDS Submission Timeframes included: The following submission timeframe for MDS records will be observed by this facility: Discharge - final completion date + 14 days According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2023, page 2-17, discharge return-not anticipated must be completed no later than the discharge date + 14 calendar days with the transmission date no later than MDS completion date +14 days. On 03/27/2024, the surveyor interviewed the Director of Nursing who provided a QAPI and stated that the QAPI was done the day the surveyor brought the issue to their attention. NJAC 8:39-11.2 (e) 3

Based on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 3 residents reviewed for PASRRs (Resident #71) and was evidenced by the following: On 03/19/2024 the surveyor reviewed Resident #71's Electronic Medical Record (EMR) which included review of the PASARR level 1 completed on 08/09/2022 which was negative and marked no for any diagnoses of mental illness. Review of the Admission Minimum Data Set (MDS), an assessment tool, dated 07/06/2022, indicated a Brief Interview of Mental Status (BIMS) score of 15/15, indicating intact cognition and review of section I did not include any psychiatric diagnoses. A review of the Quarterly MDS dated [DATE], indicated bipolar disorder and psychotic disorder noted in Section I. A review of the Quarterly MDS dated [DATE], indicated bipolar disorder and psychotic disorder noted in Section I. A review of Resident #71's care plans revealed a focus of I have expressed to my therapist that I am angry, frustrated experiencing psychotic delusions that a nurse was trying to hurt him/her over the weekend with a goal of I will have a decrease on psychotic delusions thru next review date and a focus of I have a diagnosis of Bipolar with use of psychotropic medication. No additional PASRR including the diagnoses of bipolar disorder and psychotic disorder was located. On 03/19/24 the surveyor interviewed the Director of Social Service (DSS) who stated that the level 1 PASSR was not redone with the new diagnosis. On 03/25/24 the surveyor reviewed the facility provided policy pertaining to PASRR which does not address a resident with a new psychological diagnosis after admission. On 03/25/24 at 01:29 PM the surveyor interviewed the DSS who stated prior to surveyor inquiry, it was not in their policy to redo the PASRR upon new diagnosis. On 03/27/24 at 10:48 AM the surveyor interviewed the Director of Nursing who stated that after surveyor inquiry an updated PASRR as completed for Resident #71 and the DSS did an audit of the entire building. NJAC 8:39.5.1(a)

Based on observations, interview, and review of facility documentation it was determined that the facility failed to 1. Obtain physician orders for a resident's discharge home, 2. follow physicians' orders during medication observation and 3. follow physician orders by obtaining an air mattress for a resident at risk for pressure ulcers. This deficient practice was identified for 3 of 29 residents reviewed (Resident #61, #96 and #128) and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1.On 03/20/24 at 10:15 AM, the surveyor reviewed Resident #128 Minimum Data Set (MDS) list, an assessment tool. The MDS list revealed that Resident #128 was admitted to the facility on [DATE] and a Discharge/Return Not Anticipated MDS was completed on 02/27/24. Review of the Admission Record indicated that Resident #128 had medical diagnoses which included but were not limited to heart disease, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pacemaker (artificial device to stimulate the heart muscle), and anxiety. Review of the most recent MDS, a discharge assessment tool revealed the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. On 03/20/24 at 10:31 AM, the surveyor reviewed the progress notes which showed the following physician note written on 02/26/24: The resident is seen and examined at the bedside for a full assessment, evaluation of current chronic medical conditions, and for medical clearance prior to a planned discharge as requested by the Social Worker and the disciplinary team. Another note written on 02/26/24 by the social worker showed the following: Note Text: Resident is discharging 02/26/24 at 2 PM. Resident going home with a friend, who will provide transportation. On 03/20/24 at 10:36 AM, the surveyor reviewed the progress notes which showed the following note documented on 02/27/24: Discharge instructions reviewed with resident. Medication list explained, resident voiced understanding. Folder with medication list and discharge summary placed in black computer bag. At 01:30pm the resident was picked up by son. Transferred to car via wheelchair with all personal belongings. No acute distress noted at the time of discharge. On 03/20/24 at 10:46 AM, the surveyor reviewed the care plan which showed the following focus: plan of care will be resident centered around the goal of returning to the community after completion of short-term rehabilitation. On 03/21/24 at 10:08 AM, the surveyor reviewed documentation provided by the facility which included progress notes, physician orders, and the physician discharge summary. The discharge instructions included medications and follow up instructions and were signed by the resident at the time of discharge. The surveyor could not locate a physician's order for discharge after review of the physician orders. On 03/25/24 at 1:11 PM, the surveyor interviewed the Director of Nursing (DON) regarding residents being discharged home. The surveyor asked what a resident would need to be discharged home. The DON stated that residents should have a discharge order, medications should be arranged, and discharge instructions reviewed with the resident or resident representative. The surveyor asked about the need for a discharge order for Resident #128 and the DON responded, Definitely should have a physician order for discharge, we started in-servicing making sure the discharge orders are in the chart. A review of the policy titled, Preparing a Resident for Transfer or Discharge, an undated policy. The policy statement was that the facility shall prepare a resident for a transfer or discharge. Under the section policy interpretation and implementation, the policy did not include obtaining a physician order as part of the policy. 44833 2. On 03/21/2024 at 9:14 AM, during medication administration observations, the surveyor observed Registered Nurse (RN) #1 administer medication to Resident #61. Along with other ordered medications, RN #1 administered one drop of artificial tears solution 0.2-0.2-1% (eye drops) into the resident's left eye and one drop into the resident's right eye. At 9:16 AM, the surveyor, along with RN #1, reviewed the physician's order (PO) for artificial tears in the electronic medical record (EMR). At this time RN #1 confirmed the PO indicated for one drop to be administered in the right eye, and not both eyes. RN #1 at this time acknowledged that medications should be administered as ordered. A review of Resident #61's Admission Record indicated the resident was admitted to the facility and had diagnosis which included but was not limited to: blepharitis (inflammation of the eyelid which affects the eyelashes or tear production) of the right lower eye lid. A review of the physician Order Summary Report (POS) indicated an active order with start date of 12/20/23 for artificial tears ophthalmic solution 0.2-0.2-1% instill one (1) drop in right eye two times a day related to unspecified blepharitis right lower eye lid. A second order was initiated dated 3/21/24 for artificial tears ophthalmic solution 0.2-0.2-1% instill one (1) drop in both eyes two times a day related to unspecified blepharitis right lower eye lid after surveyor's observation and inquiry. A review of the resident's care plan indicated a care focus initiated 9/29/23 for glaucoma with a goal to maintain optimal quality of life within limitation imposed by visual function. A review of the February and March 2024 Medication Administration Record (MAR) indicated artificial tears were administered and signed by the nursing staff twice daily. On 03/25/24 at 1:15 PM, the surveyor interviewed the DON who stated nurses should follow physician's orders when administering medication. She acknowledged it was not appropriate for RN #1 to administer the eye drops into both eyes if the order called for administration in the right eye. 3. On 3/18/24 at 10:21 AM, during the initial tour of the facility, the surveyor observed Resident #96 in their room, laying in their bed. The resident was laying on a mattress that did not have an air or pressure regulating device and was observed to be a standard mattress with no pressure reducing device. The resident informed the surveyor that they have a wound from lying in bed. On 3/20/24 the surveyor reviewed Resident #96's EMR. Review of the Admission Record indicated the resident was admitted to the facility and had diagnosis which included but was not limited to pressure ulcer of the sacral region (bed sore at the portion of the spine between lower back and tailbone). A review of the most recent Quarterly MDS dated [DATE] indicated the resident had a Brief Interview of Mental Status score of 15 out of 15 indicating intact cognition. A review of the physician Order Summary Report (POS) indicated an active order with start date 2/26/24 for an air mattress to be checked for function and placement every shift. A review of the resident's care plan revealed a care focus area for required use of an air mattress due to pressure ulcer with revision date 5/30/23 with interventions including to visually inspect the air mattress for over inflation or deflation each time when entering the room. Further review of the care plan indicated a focus area for pressure ulcer to sacrum with revision date 9/10/23 and intervention including air mattress check function and placement every shift. A review of the February and March 2024 Treatment Administration Record (TAR) revealed air mattress placement and function checks were conducted and signed as completed by the nursing staff every shift as ordered. On 3/21/24 at 8:36 AM, the surveyor observed Resident #96 in bed with a standard mattress and no pressure reducing device. On 3/25/24 at 10:50 AM, the surveyor observed Resident #96 in bed with a standard mattress and no pressure reducing device. At 10:53 AM, the surveyor asked RN #1 to identify the type of mattress being used for the resident. RN #1 along with the surveyor entered the resident's room at which point RN #1 acknowledged the mattress being used was not an air mattress or pressure reducing device as ordered. RN #1 further stated she was going to notify the appropriate department to bring an air mattress for the resident's bed. At 10:56 AM, the resident informed the surveyor that they think they should have one (air mattress) and that they never refused the use of one. At 10:58 AM, RN #1 informed the surveyor the resident should have an air mattress because it was ordered, and she was not sure why the resident did not have one. On 3/25/24 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the resident should have an air mattress as ordered, and it was not really being checked by the nursing staff as ordered. On 3/25/24 at 11:08 AM, the Assistant Director of Nursing (ADON) notified the surveyor that an air mattress was being brought to the resident's room by the housekeeping/maintenance department. Review of the facility's undated Administering Medications policy included but was not limited to: medications must be administered in accordance with the orders, including any required time frame. NJAC 8:39-11.2 (a) (b)

COMPLAINT # NJ 7 REPEAT DEFICIENCY Based on observations, interviews, review of medical records, and review of other pertinent facility documents on 11/22/20, it was determined that the facility staff failed to ensure residents living on the dementia unit were protected from physical/sexual abuse by failing to consistently monitor a resident (Resident #1) with a known history of sexual encounters and sexual seeking behavior with residents. The facility also failed to appropriately monitor and supervise Resident #1, as ordered by the physician, when on 11/21/20 on the 3:00 p.m. to 11:00 p.m. shift, from 5:00 p.m. until 11:00 p.m., the facility staff failed to assign a 1:1 monitor for Resident #1 due to a staffing shortage. The facility also failed to follow their policy titled Abuse for 1 of 3 residents (Resident #1) sampled for abuse. This placed all residents living on the Dementia unit in an Immediate Jeopardy (IJ) situation. The IJ was identified on 11/22/20 at 3:45 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation, which ran from 11/21/20 at 5:00 p.m. to 11/21/20, until 11:00 p.m., when the facility provided an acceptable Removal Plan to remove the immediacy. This deficient practice was further evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 10/22/20, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating Resident #1 had severe cognitive impairment. The MDS also indicated Resident #1 required limited assistance for Activities of Daily Living (ADLs). During a survey on 9/24/20, the first day of the survey an IJ was called for Resident #1's inappropriate sexual seeking behaviors and sexual encounters with residents on the dementia unit. The removal plan to remove the immediacy included placing the resident on 1:1 monitoring for safety. Review of the Physician's orders dated 11/1/20, verified a doctors order for Resident #1 to be placed on 1:1 supervision at all times every shift to ensure appropriate behaviors, with an initiated date of 9/24/20. Review of the Care Plan (CP) initiated date of 9/28/20, revealed a Focus that Resident #1 has been identified as a potential seeker for sexual interaction. Interventions included but were not limited to: Strict 1:1 supervision by staff to prevent inappropriate interactions. On 11/22/20 during a tour of the Dementia unit at 9:40 a.m., a staff member was observed sitting outside of Resident #1's room. The staff member identified herself as a part-time Activities Aide (AA). She reported she was scheduled to be a monitor today and came in at 9:00 a.m., and was working until 5:00 p.m. Her responsibility was 1:1 monitoring to make sure that Resident #1 stays in the room and is occupied. According to the AA she signs in the Log book every 15 minutes showing that she is monitoring Resident #1. Review of the facility's Log book titled 15 minute Checks for Safety failed to show any documentation or signatures on 11/21/20, from 5:00 p.m. until 11:00 p.m., that Resident #1 was monitored 1:1. Review of the facility staffing schedule dated 11/21/20 for the 3 p.m. to 11 p.m., revealed 6 nurses and 1 nursing supervisor and 6 CNAs scheduled for the evening shift. During an interview on 11/22/20 at 1:47 p.m., the Licensed Practical Nurse (LPN#1) reported she worked the 3:00 p.m. to 11:00 p.m. shift on 11/21/20, on the Dementia Unit. She reported the staffing included only one Licensed Practical Nurse (LPN) and two CNAs (Certified Nursing Assistants) for a census of 38 residents. The LPN stated she called the Supervisor and told him they were short staffed. She explained to the Supervisor that the unit usually has 2 nurses and 4 Aides scheduled, however on 11/21/20, there were only 2 Aides and 1 nurse scheduled. LPN reported that she was unable to provide 1:1 monitoring of Resident #1 by sitting outside his room, but did monitor the resident while passing her medications on the same hallway and stated: I'm in rooms less than 4 minutes. During an interview on 11/22/20 at 2:18 p.m., the Unit Manager (UM) of the Dementia unit reported Resident #1 was being monitored 1:1 by the staff sitting outside or inside of the residents room. She stated that she can only speak that they are monitoring the resident when she's here. Activity staff helps monitor as needed, I monitor as needed, so care and feedings can be done. During an interview on 11/22/20 at 3:00 p.m., the 7:00 a.m. to 7:00 p.m., shift Supervisor reported that he was aware that the unit was short staffed and he did speak to the LPN scheduled to work on the dementia unit on 11/21/20. She started her shift at 3:00 p.m., and she voiced concerns of the staffing shortage at the beginning of the shift. The Supervisor also stated that he was aware that a resident on the dementia unit was on 1:1 monitoring for sexual misconduct but stated we didn't have enough staff for it. I couldn't ask someone to sit there because care needed to be done. He further stated that the 1:1 was in place for awhile so I figured the staff would handle it and keep a watch at the same time. The Supervisor further stated that he was able to help with the passing of medications but did not do any 1:1 monitoring himself. He also stated that he did not contact the Administrator or the DON regarding the issue with the 1:1 monitoring due to the staffing shortage on 11/21/20. During an interview on 11/22/20 at 3:25 p.m., the Admin and the DON reported that they were aware there was a staffing shortage for 11/21/20, and stated phone calls were made but we were unable to get anyone to cover for 1:1 coverage. The DON further stated that they could have handled it between the nurses, CNAs and the Supervisor to split the time to monitor him between all of them, it needed to be a team approach. She also stated that she did not give the staff permission to monitor Resident #1 from a distance. During a post survey phone interview on 12/2/20, at 11:45 a.m., the staffing coordinator reported that 1 nurse had called out for the evening shift on 11/21/20, and due to the call out, a nurse was moved to 1 East to cover the unit. That floor always requires 2 nurses. The staffing coordinator also reported that they are frequently short staffed on weekends since a lot of the staff are per diem (works as needed no set schedule). The per diem staff is only required to work one weekend out of the month and Saturday 3 p.m. to 11 p.m., shift is the hardest shifts for staffing coverage. Review of the facility policy titled Abuse, dated October 27, 2017, revealed the following under Policy: It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Abuse Policy under section D Identification included but was not limited to the following: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute 'abuse' will be investigated. The IJ was identified on 11/22/20 at 3:45 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation. The IJ ran from 11/21/20 at 5:00 p.m. to 11/21/20 until 11:00 p.m., and was removed when the facility provided an acceptable Removal Plan to remove the immediacy. The plan included placing a rotating schedule at the reception desk so staff can reach out to administration to provide 1:1 coverage when the staff is short. A revisit occurred on 11/28/20, to verify the Removal Plan was in place. The 1:1 monitoring order was discontinued by the Medical doctor on 11/27/20, after a consultation with the Psychiatrist and Resident #1 was placed on half hour checks. N.J.A.C. 8:39-4.1(a)5

COMPLAINT # NJ 9 Based on observations, interviews, review of medical records and review of other pertinent facility documents on 9/24/20 and 9/28/20, it was determined that the facility failed to ensure residents were protected from actual physical/sexual abuse, and failed to adequately monitor and supervise a known sexual encounter seeking resident (Resident #1) with a known history of sexual encounters with residents. When on 9/20/20, Resident #1 was observed by 2 Certified Nursing Assistants (CNAs) in another resident's room, with his/her pants unzipped and opened and Resident #4 was observed in front of Resident #1 naked. The facility also failed to investigate when on 9/20/20, Resident #5 alerted a CNA that a male (Resident #1) entered her room and exposed himself. The facility also failed to follow their policy titled Abuse and notify the police for 1 of 5 residents (Resident #1) sampled for abuse. This placed all residents living on the Dementia unit in an Immediate Jeopardy situation. The IJ was identified on 9/24/2020 at 5:07 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation, which ran from 9/20/20 until 9/24/2020 at 5:58 p.m., when the facility provided an acceptable Removal Plan to remove the immediacy. This deficient practice was further evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 7/22/2020, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating Resident #1 had severe cognitive impairment. The MDS also indicated Resident #1 required limited assistance for Activities of Daily Living (ADLs). 2. According to the AR, Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS, an assessment tool dated 7/8/2020, revealed that Resident #2 had a BIMS score of 9/15, which indicated that the resident had moderate cognitive impairment. The MDS also indicated Resident #2 required extensive assistance for ADLs. 3. According to the AR, Resident #4 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS, an assessment tool dated 7/12/2020, revealed that Resident #4 had a BIMS score of 5/15, which indicated that the resident had severe cognitive impairment. The MDS also indicated that Resident #4 needed limited assistance for ADLs. Review of the Care Plan (CP) dated 9/11/20, revealed a Focus that Resident #4 was an affectionate person and enjoyed having a close relationship with Resident #1 and they spend time together and at times may demonstrate benign affection. Interventions included but were not limited to: Monitor to ensure affection remains benign. 4. According to the AR, Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS, an assessment tool dated 9/14/2020, revealed that Resident #5 had a BIMS score of 7/15, which indicated that the resident had moderate cognitive impairment. The MDS also indicated that Resident #4 needed limited assistance for ADLs. According to the documentation on the Facility's Reportable Event Record/Report (FRE), reported to the New Jersey Department of Health (NJDOH) by the DON on 7/29/20, with an event date of 7/28/20 at 9:30 p.m., the report indicated the type of incident as Resident to Resident abuse between Resident #1 and Resident #2. According to the witness statement with the FRE the Licensed Practical Nurse (LPN #1) reported that on 7/28/20 at approximately 9:30 p.m., when she entered the resident's room she observed Resident #1 standing at the head of Resident #2's bed with his penis out and in Resident #2's face. Resident #1 was startled and fell to the floor on his buttocks. The LPN initiated a room change and interviewed the residents and Resident #2 at that time, had a BIMS score of 13/15. Resident #1 had a BIMS of 3/15, and did not recall the engagement, and stated I was sitting on the floor picking pieces putting something together. The Reportable Event Summary for 7/28/20, showed that both residents were interviewed by the Social Worker (SW) on 7/29/20, regarding the events of the preceding evening. Both residents denied concerns or distress. Both denied recalling events reported. In addition, the FRE dated 7/28/20, showed the following interventions were implemented after the incident, Resident #2 was moved to another room, and both residents will remain without roommates. Mood and behavior monitoring would be on going for both residents including monitoring for any signs and symptoms of social isolation. Physicians and families for both residents were notified and plans of care were updated. Companionship was to be supervised in common areas and both residents were referred for psychosocial services for further recommendations. According to the documentation on the Facility's Reportable Event Record/Report (FRE), reported to the New Jersey Department of Health (NJDOH) by the DON on 9/8/20, with an event date of 9/6/20 at 5:00 p.m., the report indicated the type of incident as Sexual General Actions between Resident #1 and Resident #2. According to the witness statement with the FRE the Registered Nurse (RN #1) reported that on 9/6/20, she knocked on the resident door then entered the room and saw that Resident #1 was standing and pulling up his pants. Resident #2 was in the wheelchair sitting close to Resident #1's groin. Resident #2 said hurry up. To Resident #1. The nurse then questioned the Certified Nursing Assistant (CNA #1) if the residents was supposed to be together in this room. The CNA stated no, then she went into the room and removed Resident #2 from the room. Resident #2 was then moved to a different unit and the incident was reported to the families. According to the witness statement with the FRE, CNA #1 reported that on 9/6/20, the nurse reported to the CNA that there was another resident in the room with Resident #1. When the CNA entered the room, she observed Resident #1 pulling up their pants and Resident #2 was next to Resident #1. The CNA then removed Resident #2 from the room and returned the resident back to their room. According to the Reportable Event Summary for the event of 9/6/20, the DON reviewed the security camera and observed Resident #2 entering Resident #1's room at 5:04 p.m., RN #1 enters the same room at 5:08 p.m., then walked back out and is seen speaking with CNA #1 in the hallway. CNA #1 then brought Resident #2 out of the room at 5:09 p.m. Review of documentation on the FRE by the Unit Manager (UM) dated 9/7/20, after interviewing Resident #1 and Resident #2, revealed that Resident #1 denied recollection of events from the prior night and the resident denied any distress and appeared in good spirits. Resident #2 also denied recollection of events from the previous night and denied any distress or emotional upset. In addition, the Reportable Event Summary dated 9/9/20, the DON reported that the Interdisciplinary Team (IDT) met on 9/7/20 to discuss the events of 9/6/20, between Resident #1 and Resident #2, and the following interventions were put in place; a room change was implemented, Care Plans were updated, Power of Attorney (POA) and Medical Doctors (MD) for both residents were made aware of the incidents. Resident #1's CP was updated with the following intervention on 9/8/20, staff should ensure that the resident avoids socializing with previous roommate to avoid any social interactions which require consent. During an interview on 9/24/20 at 10:30 a.m., Resident #1 reported to the surveyor regarding the 9/6/20 incident that he/she remembered that day and stated, .everything went very quickly. Resident #1 came out of using the bathroom and Resident #2 had his pants down and was naked. I said whoa what are you doing? Resident #1 said Resident #2 laughed then the nurse came in. Then things moved fast. They moved my roommate out after that to a different room. When the surveyor asked if they were having a relationship Resident #1 responded I'm not that way. During the interview Resident #1 was alert, oriented to the surroundings, and answered appropriately. During an interview on 9/24/20 at 11:38 p.m., the Social Worker (SW) verified that in addition to the incident on 9/6/20, between Resident #1 and Resident #2, there was another encounter between the two residents on 7/28/20, when they were roommates. According to the SW a staff member walked in and found Resident #1 standing over Resident #2 with his pants down on 7/28/20. As an intervention Resident #2 was moved to a different hall but stayed on the same unit. The SW interviewed the residents after the incident and they both said they did not remember the incident. They both denied it. During an interview on 9/24/20 at 1:05 p.m., the DON reported that after one of the two incidents between Resident #1 and Resident #2, she consulted with the Psychiatrist by phone and we did not consider abuse because neither of the 2 were in physical or mental distress. The Psychiatrist did not see either of the 2 residents after the incident on 7/28/20 or 9/6/20, because they seemed mentally fine, no distress. The DON also stated that the 2 residents were never asked if they were having a relationship because the BIMS score for Resident #1 was 3/15, therefore we did not feel it was an option. The DON reported that after the incident on 9/6/20, the intervention was to move Resident #2 to a different unit. The DON stated, they both were upset when they were separated. There was no documentation provided that revealed the consultation with the Psychiatrist's professional opinion. Review of Resident #1's CP showed a focus of a potential for mood instability related to wanting to socialize with peers dated 7/29/20. Interventions included but were not limited to: Activities that are meaningful and of interest, behavioral health consults as needed, and companionship to be supervised in common areas. Review of Resident #1's Care Plan (CP) revealed a Focus of being an affectionate person and enjoying having a close relationship with a friend (Resident #4) and may demonstrate benign affection with an initiated date of 9/11/20. Interventions included but were not limited to: Monitor, document and make POA aware of any changes in behavior, assure residents are frequently monitored when spending time together, close supervision to ensure interactions remain appropriate, and monitor to ensure affection remains benign. Review of the MR failed to show any documentation of Psychosocial consults for Resident #1 or Resident #2 until 9/10/20. According to the Facility document dated 9/10/20, the Psychologist documented that Resident #1 was diagnosed with a Dysthymic disorder (A persistent depressive disorder) with low grade depression and dementia without behavioral disturbances, Alzheimer's type, moderate to severe memory problems suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found to reveal the Psychologist was notified of the alleged sexual abuse events. In addition, the Psychosocial consults did not include reference to informed consent for sexual encounters. During an interview on 9/24/20 at 1:05 p.m., the DON reported that Resident #1 also was involved in another incident on 9/20/20, with Resident #4 on the dementia unit. A staff member was doing checks on the resident and observed Resident #1 in Resident #4's room and both were found undressed in Resident #4's room. Review of the progress notes dated 9/20/20, failed to reveal an assessment by the Registered Nurse (RN), and there was no documentation that the police were notified, or that the resident was sent to the emergency room for an evaluation after the alleged sexual abuse with Resident #1 on 9/20/20. The progress notes also failed to show that Resident #4 was assessed by the Medical Doctor, the psychiatrist or psychologist, and that the facility had obtained consent for sexual encounters with Resident #1. Reference: N.J.S.A 52:27G-7.1: Report of suspected abuse: (New Jersey refers to this paragraph as the Mandatory Reporter). This section requires that Any caretaker, social worker, physician, registered or licensed practical nurse, or other professional or staff member employed at a facility, and any representative of a managed care entity who, as a result of information obtained in the course of that individual's employment, has reasonable cause to suspect or believe that an institutionalized elderly person is being or has been abused or exploited, shall report such information to the ombudsman or to the person designated by the ombudsman to receive such a report. If an individual reporting suspected abuse or exploitation pursuant to this subsection has reasonable cause to suspect or believe that the institutionalized elderly person is or has been the victim of a crime, the individual shall additionally report such information to the local law enforcement agency and to the health administrator of the facility. During an interview on 9/24/20 at 2:19 p.m., the DON reported that Resident #4 was not sent to the hospital for an evaluation on 9/20/20, because the LPN assessed the resident and there was no injury or signs or symptoms of distress. He/she was not in any distress and was not abused, as evidenced by the skin and psychosocial assessment by the nurse. It was not abuse, they were just expressing their sexual expressions determined by no injury or distress. The patients were calm and happy. In addition, the DON stated, the families were okay with it. During an interview on 9/24/20 at 2:50 p.m., the Social Worker (SW) reported that another incident occurred on 9/20/20. Resident #1 entered Resident #5's room and exposed his/herself to Resident #5. Resident #5 reported to the SW that the incident made him/her uncomfortable but Resident #5 did not remember details when interviewed on 9/22/20, two days after the incident. During an interview on 9/24/20 at 3:35 p.m., CNA #1 reported she had witnessed Resident #1 and Resident #2 engaged in oral sex on 9/6/20, around 5:30 p.m. When CNA #1 entered the room, she observed Resident #1's penis in Resident's #2's mouth. Resident #1 quickly removed his penis from Resident #2's mouth and ran into the bathroom. The CNA asked if Resident #2 was okay and he/she responded that he/she did not mind it. The CNA removed Resident #2 and returned him/her to their rooms and reported the incident to the nurse. The CNA also reported that the DON did not interview her regarding the incident. CNA #1 also reported, that on 9/20/20 around 8:15 p.m., she and another CNA were looking for Resident #1 because the resident was on frequent checks and the resident was not in his/her room. When CNA #1 walked into Resident #4's room, she saw Resident #1 and Resident #4 together. Resident #1 was sitting on the bed with his pants unzipped and open, and Resident #4 was standing up and completely naked. Resident #1 responded by covering his/her groin and Resident #4 ran into the closet. CNA #1 also reported that earlier in the day around 5:30 or 6:00 p.m., she observed Resident #1 and Resident #4 kissing in Resident #4's room. She had her tongue down his throat. CNA #1 stated she reported everything to the nurse. In addition, CNA #1 reported that Resident #5 had reported to her on 9/20/20, that A tall man came into his/her room with his privates out. Resident #5 then wanted the room door closed because he/she was upset by the incident because he/she was undressing when he entered the room. The CNA identified the man as Resident #1. During an interview on 9/24/20 at 3:15 p.m., the DON stated that Resident #1 was put on close supervision after 7/28/20. They check on him hourly to assure benign affection. However, the facility staff was unable to provide documentation sheets of hourly checks after the 7/28/20 and 9/6/20 incidents. Review of the facility's document titled hourly checks for safety showed Resident #1 was started on hourly checks on 9/21/20 at 11:00 p.m., through 9/23/20. Review of the Physician Order Sheet (POS) showed Resident #1 was placed on 1:1 observation on 9/24/20 during the survey. Review of the facility policy titled Abuse dated October 27, 2017, revealed the following under Policy: It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Abuse Policy under section D Identification included but was not limited to the following: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute 'abuse' will be investigated. Abuse Policy under section G Reporting and Response, included but was not limited to the following: It is the policy of this facility that abuse allegations . are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect ., are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours . In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Under External Reporting Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State agency. A follow up investigation will be submitted to the state agency within five (5) working days. Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. Under F. Protection: It is the policy of this facility that the residents will be protected from the alleged offenders. The IJ was identified on 9/24/2020 at 5:07 p.m., when the Administrator (Admin) and the Director of Nursing (DON), were notified of the IJ situation which ran from 9/20/20 until 9/24/2020 at 5:58 p.m., when the facility provided an acceptable Removal Plan to remove the immediacy which included placing Resident #1 on 1:1 monitoring. A revisit occurred on 9/28/2020 to verify the Removal Plan was in place. N.J.A.C. 8:39-4.1(a)5