Every finding on record at Aspen Hills Healthcare Center

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain clean laundry that was stored in the service corridor in a safe and sanitary manner and b.) follow the recommendations for the use Personal Protective Equipment (PPE) during incontinence care for residents who required Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control (CDC), Infection Prevention guidelines and standards of clinical practice.This deficient practice was identified for 7 residents (Resident # 183, #21, #78, #90, #162, #145, and #42) observed for incontinence care and was evidenced by the following:Reference: Enhanced Barrier Precautions (EBP) are an infection prevention and control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes, including the routine use of gloves and gowns during all high-contact resident care. https://www.nj.gov/health/cd/documents/topics/hai/EBP_in_Nursing_Homes_Algorithm.pdfReference: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html1.) On 12/16/2025 at 10:01 AM, during the initial tour of facility, the surveyor observed an uncovered cart containing clean bed linens, hospital gowns, mechanical lift slings, and reusable chucks pads in the service corridor on the ground floor. The blue-colored front covering of the cart was folded upwards exposing the clean linens inside the cart to the environment. During the same tour, another cart was observed uncovered in the service corridor and contained several mechanical lift slings. The pink-colored cart cover was folded upwards exposing the slings inside. Several slings were observed on top of the folded pink cover which held it in place.On 12/18/2025 at 10:10 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that clean linens needed to be covered.On 12/22/2025 at 9:13 AM, during an interview with the surveyor, the Environmental Services Director (EVSD) stated that clean linen should be covered.A review of the facility policy Clean and Soiled Linen Policy reviewed in February 2025, included: Clean linen shall be stored in a clean, dry, enclosed area. 2.) On 12/17/2025 at 10:04 AM, during an incontinence tour with Licensed Practical Nurse/ Unit Manager #2 (LPN/UM #2) the surveyor observed an EBP (Enhanced Barrier Precautions) sign outside of Resident #183's room. LPN/UM#2 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned (put on) gloves but did not put on a gown. LPN/ UM #2 pulled away Resident #183's bed linen and exposed the resident's incontinence brief on the front side. The surveyor observed the incontinence brief was dry. The surveyor asked LPN/UM#2 to expose the back of the brief. RN/UM #1 who was present, turned the resident to the side and unfastened the incontinence brief and exposed the back of the resident. The incontinence brief was observed to be dry. LPN/UM #2 then fastened the brief. LPN/UM #2 then washed their hands for 20 seconds.A review of the admission Record revealed Resident #183 was admitted to the facility with diagnoses which included but not limited to gastrostomy status (having a surgically created opening in the stomach for feeding, medication, or drainage through a tube).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/18/2025, reflected the resident had a feeding tube.A review of the Physician's Orders active as of 12/17/2025, revealed an order for Enhanced Barrier Precautions for feeding tube every shift that started on 12/21/2024. A review of the resident's comprehensive care plan with a focus area revised on 11/21/2024, that the resident was at a higher risk of acquiring an MDRO related to feeding tube and required EBP while performing high-contact care activities.On 12/17/2025 at 10:07 AM, during an incontinence tour with Licensed Practical Nurse/ Unit Manager #2 (LPN/UM #2), the surveyor observed an EBP sign outside of Resident #21's room. LPN/ UM#2 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned gloves but did not put on a gown. LPN/ UM #2 pulled away Resident #21's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be dry. LPN/UM #2 fastened the brief. LPN/UM #2 then washed their hands for 20 seconds.A review of the admission Record revealed Resident #21 was admitted to the facility with diagnoses which included but not limited to fracture of the right femur (bone from the hip to the knee).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/26/2025, reflected the resident had an unhealed pressure ulcer and surgical incision wounds. A review of the Clinical Physician Orders active as of 12/17/2025, revealed an order to maintain enhanced barrier precautions related to wounds every shift that started on 11/20/2025. A review of the resident's comprehensive care plan initiated on 11/20/2025, had a focus to indicate the resident was at a higher risk of acquiring an MDRO and required EBP while performing high-contact care activities related to wounds.On 12/17/2025 at 10:10 AM, during an incontinence tour with Licensed Practical Nurse/ Unit Manager #2 (LPN/ UM #2), the surveyor observed an EBP sign outside Resident #78's room. LPN/UM#2 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned gloves but did not put on a gown. LPN/UM #2 pulled away the Resident #78's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be dry. LPN/UM #2 then fastened the brief. LPN/UM #2 then washed their hands for 30 seconds.A review of the admission Record revealed Resident #78 was admitted to the facility with diagnoses which included but not limited to: ESBL (Extended Spectrum Beta-Lactamase Resistance) (enzymes made by certain bacteria that make them resistant to many common antibiotics) in urine. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/3/2025, reflected the resident had an MDRO infection. A review of the Clinical Physician Orders active as of 12/17/2025, revealed an order to maintain enhanced barrier precautions related to MDRO ESBL in urine every shift that started on 10/28/2025. A review of the resident's comprehensive care plan initiated on 10/28/2025, indicated a focus for the resident at higher risk of acquiring or spreading an MDRO and required EBP while performing high-contact care activities related to infection or colonization (when germs live on the body without causing illness) with ESBL in urine.On 12/17/2025 at 10:20 AM, during an incontinence tour with Licensed Practical Nurse/ Unit Manager #1 (LPN/UM #1), the surveyor observed an EBP sign outside of Resident #90's room. LPN/UM #1 sanitized their hands with an ABHS and donned gloves but did not put on a gown. LPN/UM #1 pulled away Resident #90's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be wet without any malodorous odor. LPN/UM #1 stated that the resident would be changed and fastened the brief. LPN/UM #1 performed hand hygiene with ABHS for 20 seconds.A review of the admission Record revealed Resident #90 was admitted to the facility with diagnoses which included but not limited to gastrostomy status. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/29/2025, reflected the resident had a feeding tube. A review of the Clinical Physician Orders active as of 12/17/2025, revealed an order for Enhanced Barrier Precautions related to peg tube (feeding tube) and CRE (Carbapenem-Resistant Enterobacteriaceae) (an MDRO) in urine every shift that started on 7/23/2025. A review of the resident's comprehensive care plan revised on 8/20/2025, included a focus that placed the resident at a higher risk of acquiring or spreading an MDRO due to feeding tube and history of CRE in urine and required EBP while performing high-contact care activities.On 12/17/2025 at 10:31 AM, during an incontinence tour with Licensed Practical Nurse/Unit Manager #1 (LPN/UM #1), the surveyor observed an EBP sign outside Resident #162's room. LPN/ UM #1 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned gloves but did not put on a gown. LPN/UM #1 pulled away Resident #162's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be dry. LPN/ UM #1 fastened the brief. LPN/ UM #1 performed hand hygiene with ABHS for 25 seconds.A review of the admission Record revealed Resident #162 was admitted to the facility with diagnoses which included but were not limited to ESBL in urine.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/4/2025, reflected the resident was always incontinent of the bowel and bladder.A review of the Clinical Physician Orders active as of 12/17/2025, revealed an order to maintain enhanced barrier precautions related to unhealed wounds and MDRO ESBL in urine every shift which started on 12/8/2025. A review of the resident's comprehensive care plan revised on 12/8/2025, indicated a focus for the resident at higher risk of acquiring or spreading an MDRO and required EBP while performing high-contact care activities related to unhealed wounds and infection or colonization with ESBL in urine.On 12/17/2025 at 10:39 AM, during an incontinence tour with Licensed Practical Nurse/Unit Manager #1 (LPN/ UM #1), the surveyor observed an EBP sign outside Resident #145's room. LPN/UM#1 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned gloves but did not put on a gown. LPN/UM #1 pulled away Resident #145's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be wet. LPN/UM #1 stated that the resident would get changed. LPN/UM #1 fastened the brief. LPN/ UM #1 performed hand hygiene with ABHS for 20 seconds.A review of the admission Record revealed Resident #145 was admitted to the facility with diagnoses which included but not limited to Methicillin-Resistant Staphylococcus Aureus (MRSA) (an MDRO) of the nasopharynx (the top part of the throat).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/9/2025, reflected the resident was on oxygen therapy. A review of the Physician's Orders active as of 12/17/2025, revealed an order to maintain enhanced barrier precautions related to MDRO MRSA of the nasopharynx started on 6/18/2025. A review of the resident's comprehensive care plan revised on 6/26/2024, indicated a focus for the resident at higher risk of acquiring or spreading an MDRO and required EBP while performing high-contact care activities related to history of MRSA in the nasopharynx.On 12/17/2025 at 10:47 AM, during an incontinence tour with Licensed Practical Nurse/Unit Manager #1 (LPN/ UM #1), the surveyor observed an EBP sign outside Resident #42's room. LPN/UM#1 sanitized their hands with an alcohol-based hand sanitizer (ABHS) and donned gloves but did not put on a gown. LPN/UM #1 pulled away Resident #42's bed linen and exposed the resident's incontinence brief on the front and back sides. The surveyor observed the incontinence brief to be dry. LPN/UM #1 fastened the brief. LPN/UM #1 performed hand hygiene with ABHS for 20 seconds.A review of the admission Record revealed Resident #42 was admitted to the facility with diagnoses which included but not limited to MRSA of the nares and Klebsiella (an MDRO) in the urine.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 9/26/2025, reflected a personal history of infectious diseases.A review of the Physician's Orders active as of 12/17/2025, revealed an order to maintain enhanced barrier precautions related to MDRO MRSA of the nares and Klebsiella in urine started on 8/29/2025. A review of the resident's comprehensive care plan revised on 6/26/2024, included a focus for the resident who was at higher risk of acquiring or spreading an MDRO and required EBP while performing high-contact care activities related to history of MRSA in the nares and Klebsiella in urine.On 12/17/2025 at 10:53 AM, the surveyor asked LPN/UM #1 if they should have worn gloves and gown during the incontinence rounds of residents on EBP. LPN/UM #1 stated that they should have worn a gown and gloves during the incontinence rounds of residents on EBP.On 12/18/2025 at 10:10 AM, the Director of Nursing (DON) stated that EBP required staff to wear gloves and gowns when performing high-contact activities including incontinence care.A review of facility policy, Enhanced Barrier Precautions (EBP) dated 2/4/2025, included: This facility will use Enhanced Barrier Precautions during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multidrug-resistant organism (MDRO) status. In addition, EBP will be implemented for residents who have an infection or colonization with a CDC-targeted MDRO.N.J.A.C. 8:39 - 19.4 (a); 21.1 (d)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 2 of 38 residents (Resident #90 and Resident #10) reviewed for standards of practice and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.) On 12/16/2025 at 11:40 AM, the surveyor observed Resident #90 awake in bed. The resident was able to communicate their needs and stated that they had no complaints.On 12/17/2025 at 8:10 AM, the surveyor reviewed the medical record for Resident #90.A review of the admission Record reflected the resident was admitted to the facility with diagnoses which included but were not limited to: congestive heart failure, hypertension (high blood pressure) and hypotension (low blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/9/2025, reflected a brief interview for mental status (BIMS) score of 7 out of 15, which indicated a severely impaired cognition. A review of the individualized person-centered care plan reflected a focus area initiated on 5/25/2025, for potential impaired cardiac status related to pacemaker. Interventions included giving medications according to physician's orders and monitoring the resident for elevated blood pressure.A review of the Order Summary Report (OSR) active as of 12/17/2025, included a physician's order dated 7/2/2025, for Midodrine HCl Tablet 10 milligram (mg), give 1 tablet by mouth every 8 hours for Hypotension (low blood pressure). Give for SBP (systolic blood pressure) (the pressure in the arteries when the heart beats and pumps blood, represented by the top number of a blood pressure value) less than 90. Monitor per BP (blood pressure) policy. Take last daily dose no less than 4 hours before bedtime.A review of the corresponding August 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 90 and should not have been administered in accordance with the physician's order on the following times and dates:12:00 AM - 8/15/20258:00 AM - 8/3/2025, 8/9/2025, 8/25/2025, 8/26/2025, 8/30/2025, 8/31/20254:00 PM - 8/28/2025, 8/29/2025A review of the corresponding September 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 90 and should not have been administered in accordance with the physician's order on the following times and dates:12:00 AM - 9/13/2025, 9/26/2025, 9/30/20258:00 AM - 9/8/2025, 9/20/2025, 9/21/2025, 9/28/20254:00 PM - 9/5/2025, 9/16/2025, 9/18/2025, 9/19/2025, 9/29/2025A review of the corresponding October 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 90 and should not have been administered on the following times and dates:12:00 AM - 10/7/2025, 10/11/2025, 10/24/2025, 10/25/2025, 10/27/20258:00 AM - 10/11/2025, 10/13/2025, 10/18/20254:00 PM - 10/6/2025, 10/7/2025, 10/12/2025, 10/16/2025, 10/20/2025A review of the corresponding November 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 90 and should not have been administered in accordance with the physician's order on the following times and dates:12:00 AM - 11/2/2025, 11/11/2025, 11/13/2025, 11/14/2025, 11/17/20258:00 AM - 11/2/2025, 11/7/2025, 11/8/2025, 11/9/2025, 11/12/2025, 11/17/2025, 11/24/20254:00 PM - 11/7/2025, 11/8/2025, 11/16/2025, 11/17/2025, 11/18/2025, 11/26/2025A review of the corresponding December 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 90 and should not have been administered in accordance with the physician's order on the following times and dates:12:00 AM - 12/10/2025, 12/13/2025, 12/15/20258:00 AM - 12/8/2025, 12/15/20254:00 PM - 12/4/2025, 12/6/2025, 12/12/2025, 12/15/2025 2.) On 12/16/2025 at 10:31 AM, the surveyor observed Resident #10 in bed, awake but unable to communicate their needs. On 12/17/2025 at 8:30 AM, the surveyor reviewed the medical record for Resident #10.A review of the admission Record reflected the resident was admitted to the facility with diagnoses which included but not limited to: congestive heart failure and hypertension. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/4/2025, reflected a mental status with severely impaired cognitive skill and memory impairment.A review of the individualized person-centered care plan reflected a focus area initiated on 10/21/2025, for risk of complications related to cardiorespiratory status. Interventions included administering medications as ordered and monitoring for adverse effects and changes in blood pressure/ heart rate.A review of the Order Summary Report (OSR) active as of 12/17/2025, included a physician's order dated 12/10/2025, for Midodrine HCl Tablet 2.5 mg, give 1 tablet via peg-tube every 12 hours for hypotension. Monitor BP per policy. Take daily dose no less than 4 hours before bedtime. Hold for SBP more than 120.A review of the corresponding December 2025 Medication Administration Record (MAR) revealed the resident received Midodrine HCl when the SBP was above 120 and should not have been administered in accordance with the physician's order on the following times and dates:6:00 AM - 12/13/20256:00 PM - 12/12/2025, 12/18/2025On 12/22/2025 at 8:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that blood pressure parameters should be followed because they are physician orders.A review of the facility policy dated June 2025 titled Physician Order Entry included under Medication Orders: No drugs or biologicals shall be administered except upon the order of a physician, nurse practitioner, or physician assistant.N.J.A.C. 8:39 - 11.2 (b); 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that treatment to prevent or reduce range of motion limitations were provided for 1 of 2 residents (Resident #121) reviewed for positioning and mobility. This deficient practice was evidenced by the following:On 12/16/2025 at 11:34 AM, the surveyor observed Resident #121 sitting in a wheelchair near the nurses' station, with the right hand clenched and closed.On 12/18/2025 at 10:30 AM, the surveyor reviewed the medical record for Resident #121 which revealed the following:A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) of the right dominant side, contracture (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching) of muscles, and dementia (the loss of cognitive functioning).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/30/2025, indicated that the resident's cognitive skills were severely impaired. A review of the resident's Individual Comprehensive Care Plan (ICCP) identified a focus area dated 7/30/2019, for impaired range of motion to right upper extremity with potential for further contractures. Interventions included applying right palm guard as ordered, monitoring skin integrity with each application and removal and monitor for signs of discomfort during care.A review of the Order Summary Report (OSR) dated as of 12/18/2025, included a physician's order (PO) dated 4/14/2024 for a palm guard to be worn on the resident's right hand for six to eight hours per day during waking hours, as tolerated. A review of the December 2025 Treatment Administration Record (TAR) confirmed a physician's order dated 4/14/2024, for the application of a palm guard on the resident's right hand for six to eight hours per day during waking hours. Further review of the TAR revealed that on 12/16/2025 and 12/18/2025, the day shift nurses documented the application of the resident's right-hand palm guard. However, on both dates, the surveyor did not observe Resident #121 wearing the palm guard. Additionally, there was no documentation in the electronic medical record (EMR) that indicated that the resident had refused the device before the surveyor inquiry.On 12/18/2025 at 10:54 AM, the surveyor observed Resident #121 sitting in their wheelchair near the nurses' station. The resident's right hand was clenched closed, and they were not wearing the palm guard.On 12/18/2025 at 11:21 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #2 who stated that she was familiar with the care required for Resident #121. The CNA further stated that the resident accepted all care that was provided on that day.On 12/18/2025 at 11:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #2 who stated that the resident had accepted all care provided that morning. She further stated that the resident had a roll in their right hand and further described the roll as a rolled-up washcloth. The LPN #2 stated that the resident needed it for their right-hand contracture, and she had applied it to the resident that morning.At that time, the surveyor and LPN #2 walked over to the resident who was not wearing a palm guard. The LPN #2 confirmed that the resident did not have anything in their right hand. The LPN #2 stated that she had placed a rolled-up washcloth in the resident's hand. She searched the resident's chair and the surrounding area for the washcloth but was unable to find it. The LPN #2 further stated that she would constantly check the resident to determine if it was being worn. On 12/18/2025 at 11:47 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurses should follow the physician's orders and should attempt to apply the palm guard. She also stated that once the palm guard is applied, the nurse would sign the treatment administration record (TAR). She further stated that if the resident refused, the TAR should reflect that, and a progress note should be written.On 12/18/2025 at 12:00 PM, the surveyor observed LPN #2 and another staff member attempting to apply the palm guard to the resident's right hand.On 12/18/2025 at 12:07 PM, the surveyor interviewed the Acting Director of Rehabilitation, who stated that the nursing staff was trained on applying the palm guard and it should be applied for six to eight hours during waking hours. She further stated that the resident could have an increase in the contracture, pain, or skin breakdown if the palm guard was not worn as ordered. A further review of the December 2025 TAR revealed that on December 1st through day shift, and on December 18th, 2025, on all three shifts, the nurses signed the TAR indicating that the palm guard was applied to the right hand, with the exception of the day shift on December 13th. On 12/23/2025 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) who stated that it was the responsibility of the nurse to apply the palm guard. She also stated that the PO should be followed because the palm guard was ordered for a reason. The DON further stated that once the palm guard is applied, the nurse would sign the TAR, which indicated that the resident accepted it. She also stated if the resident declined the palm guard, the doctor should be notified. She added that looking at the TAR for the month of December, it was unclear how many hours the resident wore the palm guard, and the order should have been clarified.On 12/19/2025 at 12:00 PM, the surveyor conducted a follow-up visit with the resident who was observed sitting calmly and quietly in a wheelchair, in the dayroom, with a palm guard on their right hand. A review of the facility's PHYSICIAN ORDER ENTRY policy, effective June 2025, included, It is the policy of the facility to write physician's orders to establish a plan of care to follow for the care of the resident. PURPOSE: To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner/physician's assistant. A review of the facility's POLICY FOR SPLINT APPLICATION policy, reviewed on 5/2025, included, It is a policy of this facility to apply splints, braces, hand rolls etc. as per physician's orders.Discuss with patient, nursing, family, caregiver a wearing schedule, care of the splint and splint safety precautions and obtain an MD order for the wearing schedule.Document the wearing schedule in resident's medical records. Alert rehab department if there is a need to readjust wear schedule or splint if needed.NJAC 8:39-27.1(a)

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that the resident's meal preferences were implemented, and the resident was notified in advance of the menu changes for 1 (one) of 2 (two) residents (Resident #121) observed during the lunch meal on one of five nursing units (Laurel). This deficient practice was evidenced by the following:On 12/16/2025 at 9:57 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the registered dietician developed the menu for a four-week cycle, Week 1 (one), Week 2 (two), Week 3 (three), and Week 4 (four). She further stated that the facility was operating on Week 1(one) menu.On 12/19/2025 at 10:00 AM, the surveyor reviewed the lunch menu for Week 1(one), Friday, which revealed: pureed baked fish fillet, pureed chicken tenders, pureed moistened steamed rice, mashed potatoes, pureed stewed tomatoes, pureed capri vegetable blend, bread, pureed bread, pureed cinnamon baked apples, and coffee or hot tea.On 12/19/2025 at 1:04 PM, the surveyor observed the lunch meal tray for Resident #121.The resident's meal ticket indicated that the resident preferred the following: pureed baked fish fillet with white sauce, and pureed moistened steamed rice, pureed bread, pureed cinnamon-baked apples, iced tea 8 ounces (Oz), milk 4 Oz, apple juice 4 Oz, and no straws.On the resident's tray was pureed baked fish fillet with a brown sauce, mashed potatoes, pureed bread, stewed tomatoes, pureed cinnamon-baked apples, 4 0z milk, and a straw.On 12/19/2025 at 1:49 PM, the surveyor interviewed the FSD, who stated that the menu was changed and she had not notified the resident. She further stated that most often, she is on the tray line to ensure that the trays are accurate. The FSD was shown a picture of Resident #121's lunch tray, and she confirmed the findings. The FSD noted that the resident should have gotten the pureed, moistened steamed rice, and if it was not available, then the resident should have been made aware. She also stated that the straw should not have been included on the resident's tray. The FSD added that there is a checker at the end of the tray line, and they would make the final check before the tray is placed on the cart to ensure the tray was accurate.A review of the facility's Dining and Food Preferences policy, revised 9/2025 included: The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. NJAC 8:39-17.4(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to implement the recommendations from a resident's Pre-admission Screening and Resident Review (PASARR) level 2 determination into the resident's plan of care. This deficient practice was identified for 1 (one) of 7 resident (Resident #12) reviewed for mood and behavior and was evidenced by the following:On 12/16/2025 at 11:03AM, the surveyor observed Resident #12 sleeping in bed.On 12/18/2025 at 9:21AM, the surveyor reviewed the medical record for Resident #12. A review of the admission Record, an admission summary, revealed that resident #12 had diagnoses which included, but were not limited to: schizoaffective disorder (a chronic mental illness), and cerebral infarction (Brain tissue death due to a blocked blood vessel). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 09/30/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Section A, Question A1500, of the MDS identified Resident #12 as having a state level 2 Preadmission Screening and Resident Review (PASARR), indicating the presence of a serious mental illness. A review of the PASARR Level II Determination Notification letter by the New Jersey Department of Human Services Division of Mental Health and Addiction Services dated 10/20/2021, revealed that Resident #12 had mental health treatment needs that could be met in a nursing facility. The letter recommended the following interventions: 1. Psychiatric consult upon admission to the nursing facility2. Routine follow up visits with the Primary Care Physician and Psychiatrist3. Medication Monitoring4. Supportive Counseling5. Routine Laboratory Testing6. Formulate and implement a behavioral modification plan to address any behavioral disturbances7. Provide education to client and Family on Mental illness and medication8. Develop a Crisis Intervention/Safety Plan with the client On 12/19/2025 at 10:57AM, the surveyor interviewed the Director of Social Work (DSW) who stated a positive PASARR level II indicated that the resident had a major mental health illness. When asked who was responsible for implementing care plans, the DSW stated that responsibility depended on the identified needs of the resident and could involve Activities, SW, Nursing, and Administration, depending on what was required to be on the care plan. The DSW further stated that all departments created their own care plan according to the resident's needs. The DSW stated that if a resident had a significant mental illness (SMI) identified on the Medicaid PASSAR I then a PASARR II was to be completed and implemented on the care plan. The DSW also confirmed that the PASARR Level II recommendations should be included in the resident's care plan and that their care plan should be updated immediately. On 12/22/2025 at 1:30PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), and the survey team, acknowledged that the PASARR II recommendations needed to be included in the resident's care plan. A review of the facility's Pre-admission Screen and Resident Review policy, revised February 2025, included: The facility will incorporate the recommendations from PASARR Level 2 determination and the PASARR evaluation into the resident's assessment. NJAC 8:39-, 27.1(a), 40.3(d)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide the necessary respiratory care and services by not ensuring: a) respiratory equipment was changed in accordance with the physician's order for1 (one) of 5 (five) residents reviewed for respiratory care (Resident #94), b) oxygen administration was documented on the treatment administration record (TAR) for 1 (one) of 5 (five) residents reviewed for respiratory care (Resident #94), and c.) oxygen equipment was applied and maintained in a safe and sanitary manner for 2 (two) of 5 (five) residents (Resident #94 and Resident #7) reviewed for respiratory care. This deficient practice was evidenced by the following: 1.) On 12/16/2025 at 11:56 AM, the surveyor observed Resident #94 in their bedroom, seated on their bed watching television. A nebulizer machine (turns liquid medication into a fine, inhalable mist that is breathed deep into the lungs to treat respiratory conditions) was present on the resident's bed with the mask bagged. The nebulizer tubing was dated 11/15/25. An oxygen concentrator (a medical device that pulls in air, removes nitrogen, and delivers concentrated, purified oxygen to a user via a nasal cannula or mask) was observed next to the resident's bed; however, no oxygen tubing was attached to the device. At the time of observation, the resident stated that they used the nebulizer about three to four times a day and also used the oxygen concentrator when they experienced shortness of breath. On 12/17/2025 at 11:35 AM, the surveyor reviewed the medical record for Resident #94 which revealed the following: A review of the admission Record (admission summary) revealed that Resident #94 had diagnoses which included, but were not limited to: chronic obstructive pulmonary disease (COPD), a progressive lung disease that blocks airflow, making breathing difficult and anemia (a condition in which the blood cells or hemoglobin, had reduced oxygen-carrying capacity, leading to fatigue and shortness of breath). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 8/13/2025, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) identified a focus area, dated 6/23/2023 that the resident had a potential for impaired respiratory status. Interventions included monitoring pulse oximetry (a noninvasive method using a small clip-on device placed on the index finger to measure blood oxygen saturation and pulse rate) as ordered, and providing supplemental oxygen as needed. A review of the Order Summary Report (OSR), dated as of 12/17/2025, included the following physician orders (PO): A PO, dated 8/12/2025, to change respiratory equipment, oxygen, and nebulizer tubing, every night shift on Friday. A PO, dated 8/13/2025, for albuterol sulfate 2.5 mg/3ml, inhale orally via a nebulizer, every six hours as needed for shortness of breath. A PO, dated 10/13/2025, for formoterol fumarate 20 mcg, inhale orally via a nebulizer two times per day for COPD. A PO, dated 8/12/2025, for oxygen via nasal canula (clear tubing with two prongs that sit in the nostrils to deliver supplemental oxygen) at 2 liters per minute, as needed for shortness of breath, and as needed for pulse oximetry below 90 %, and to notify the doctor if pulse oximetry is below 90%. On 12/17/2025 at 12:12 PM, the surveyor conducted a follow-up visit with Resident #94. The resident was awake, seated on their bed. The surveyor observed that the nebulizer tubing was still dated 11/15/2025, and the oxygen concentrator continued to lack the nasal cannula tubing. At that time, the resident stated that they used the nebulizer machine about three to four times per day and that they used the oxygen nightly for shortness of breath, with the last use on the night of 12/16/25. The resident further stated that they did not know the location of the oxygen tubing. The surveyor then observed Resident #94 ambulate to the nurses' station and the resident asked the Licensed Practical Nurse (LPN) #1 if he knew where the nasal cannula tubing for the concentrator was located. LPN #1 stated that he was unaware of the whereabouts of the nasal cannula tubing but indicated he could provide a new nasal cannula if needed. The resident then approached the Certified Nurse Aide (CNA) #1 and asked her if she knew where their nasal cannula tubing was located. CNA #1 searched the resident's room but was unable to locate the oxygen tubing. CNA #1 then retrieved supplies from the supply closet and returned with two nasal cannulas, one short nasal cannula tubing and one long nasal cannula tubing. The CNA #1 connected the nasal cannula tubing to the oxygen concentrator, then turned the device on, and assisted the resident with applying the nasal cannula. The concentrator flow rate was set between three and four liters. 12/17/2025 at 12:38 pm, the surveyor observed the resident in the hallway without the nasal cannula in place. The resident stated that they were short of breath prior to oxygen application and reported feeling much better after receiving the oxygen. A review of the November 2025 Treatment Administration Record (TAR) revealed an entry to change the respiratory equipment tubing weekly on Friday, during the 11 PM - 7 AM night shift. On 11/21/2025, there was no nursing signature on the TAR, to indicate that the respiratory equipment tubing was changed. On 11/28/2025, the night shift nurse signed that the respiratory tubing was changed. A review of the December 2025 TAR revealed an entry to change the respiratory equipment tubing weekly on Friday, during the 11 PM - 7 AM night shift. On 12/5/2025, 12/12/25, the night shift nurse signed that the respiratory tubing was changed. A review of the December 2025 medication administration record (MAR) revealed that the resident received medications via the outdated nebulizer tubing as follows: The formoterol fumarate was signed that it was administered daily on 12/1 through 12/17/25 at 9:00 am and 9:00 pm. The albuterol sulfate PRN (as needed) was administered on 12/6, 12/9, and 12/11/2025. A further review of the MAR for December 2025 revealed that there was no documented evidence that the physician's order for oxygen 2 liters via nasal canula was administered. On 12/17/2025 at 12:28 PM, the surveyor interviewed the CNA #1 who stated that the resident used supplemental oxygen approximately three times per week after smoking a cigarette, with the last use occurring a couple days prior. The CNA #1 further stated that the LPN typically changed the oxygen tubing and set the oxygen flow. The CNA #1 reported she was unaware of the prescribed oxygen flow setting. On 12/17/2025 at 12:45 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 who stated that Resident #94 used oxygen after smoking a cigarette. He reported that he last assisted the resident with oxygen application approximately two weeks ago by turning the oxygen concentrator on. He further stated that earlier that day, he observed the CNA obtain new tubing and later heard the oxygen machine turn on from the nurse's station. LPN #1 stated that the pulse oximetry should be checked before administering the oxygen, and the new oxygen tubing should have been dated and initialed by the nurse. He further stated that the nebulizer and oxygen tubing should be changed every seven days, or as needed. On 12/17/2025 at 1:14 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated, stated the nurse should change the respiratory equipment tubing as ordered, and they should initial and date the tubing at the time that it is changed, and sign the TAR accordingly. The LPN/UM further stated that it should always be the nurse who changes and sets up the oxygen tubing. She also noted that the nurse should check the pulse oximetry before and after applying the oxygen so they can document the resident's oxygen level on the treatment administration record (TAR) in order to know if the oxygen was effective. At 1:37 PM, the surveyor, accompanied by LPN/UM #1, went to the resident's room. The LPN/UM #1 confirmed that the nebulizer was dated 11/15/2025 and it needed to be changed. She removed the nebulizer tubing at that time. The LPN/UM #1 also confirmed that the nasal cannula tubing that was connected to the oxygen concentrator machine was not dated. She stated that she believed that the CNA was just trying to help by obtaining and connecting the tubing, but the CNA should have left it alone. On 12/18/2025 at 9:21 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the respiratory equipment tubing should be changed weekly, or as needed, for infection control purposes, and it should be checked by the nurse every shift to ensure that it was changed. She also stated that after the tubing was changed, it should be accurately documented on the treatment administration record, and it should not be signed off if the task was not completed. She also added that it was the responsibility of the nurse to connect the oxygen tubing to the concentrator and turn the oxygen on, and ensure that it was on the proper setting, and the CNA should not have touched the oxygen concentrator. The DON further stated that when the resident received oxygen, the pulse oximetry should be checked prior to administering the oxygen. She further stated that the condition of the resident should also be documented when oxygen PRN was applied and should also be signed off on the MAR if the resident received it. 2.) During the initial tour of the facility on 12/16/2025 at 10:58 AM, surveyor #2 observed Resident #7 wearing a nasal cannula. The surveyor did not observe the nasal cannula to be labeled and dated. The surveyor reviewed the medical record for Resident #7. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Chronic Respiratory Failure with Hypoxia (inability of the respiratory system to properly exchange gases, leading to low oxygen levels in the blood). The most recent Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/28/2025 included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of Section O of the MDS revealed the resident required oxygen therapy. On 12/19/2025 at 10:46 AM, surveyor #2 interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who confirmed all nasal cannula should be dated when they were changed on the overnight shift. On 12/22/2025 at 1:41 PM, surveyor #2 interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), Registered Dietitian (RD), and [NAME] President of Clinical Services (VPCS), who acknowledged that nasal cannulas were to be labeled and dated. A review of the facility's Oxygen Use policy, reviewed 5/2025, included, oxygen use within the facility shall be managed in a manner that is consistent with accepted standards of care, provider direction, and applicable regulations. Staff shall follow practices related to safety, monitoring, and documentation.Supplies shall be managed in a manner consistent with facility infection control practices. NJAC 8:39- 27.1 (a)

Complaint #: 2594123 Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure residents were protected from physical abuse after a cognitively impaired resident (Resident #2) was found with a bruise to their left clavicle (collar bone) of unknown origin on 8/17/25. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #2). On 8/17/25, staff observed a faint discoloration and minor swelling to Resident #2's left clavicle at approximately 12:20 PM. At the time, the Licensed Practical Nurse/Supervisor (LPN/S #1) did not immediately initiate an investigation. On 8/18/25, Resident #2 complained of pain and had limited range of motion to their left arm. Resident #2's physician was made aware, and an X-ray was ordered revealing Resident #2 had a closed, displaced fracture of the resident's left clavicle. An interview with the Assistant Director of Nursing (ADON) on 10/30/25 at 2:15 PM, confirmed that LPN/S #1 did not initiate an investigation on 8/17/25, when the resident's bruised collar bone was first discovered, and staff continued to work until 8/18/25, when an investigation was initiated, and staff were suspended pending the outcome of the investigation. The facility's failure to immediately implement their abuse and neglect policy, and not immediately protect Resident #2 who had an injury of unknown origin placed Resident #2, as well as all residents at risk for abuse. This posed the likelihood of serious physical harm and psychological, injury, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/17/25 at 12:20 PM, when a bruise of unknown origin was identified on Resident #2, and the facility did not immediately implement their abuse policy and protect the resident. The facility was notified of the IJ on 10/30/25 at 5:45 PM. The facility submitted an acceptable Removal Plan (RP) on 10/31/25 at 12:12 PM. The surveyors verified the implementation of the RP on-site during the continuation of the survey on 10/31/25 at 1:35 PM. The evidence was as follows: Refer F610A review of the facility's policy titled Resident Abuse/Neglect Policy and Procedure, revised February 17, 2025, included its purpose was to ensure prevention, protection, prompt reporting, and interventions in response to alleged, suspected, or witnessed abuse, neglect, mistreatment, misappropriation of property, or exploitation of any facility resident. All employees are expected to and must immediately report any injury sustained by a resident, whether or not the nature of the injury is known.Protection, Investigation and Reporting: A. Protection: 1. While an alleged abuse/neglect investigation is being conducted, accused individuals not employed by the facility will be denied access to the resident. Employees of the facility who are under investigation will be temporarily suspended until the Administrator has reviewed the results of the investigation.B. Notification: 1. Any staff member witnessing or receiving an allegation of abuse/neglect of any resident shall notify the Nursing Supervisor immediately after witnessing the incident or receiving the allegation of abuse/neglect. 2. The Administrator/GO (Grievance Officer) and the DON (and/or designees) shall then be immediately notified of the incident, and an investigation will be initiated. A review of the Facility Reported Event (FRE) submitted to the New Jersey Department of Health (NJDOH)) dated 8/19/25, revealed the following: On Sunday 8/17/25, Resident #2 was noted with discoloration to the clavicle area due to combative and aggressive behavior during care. On Monday 8/18/25, the resident presented with decreased range of motion (ROM) and showed signs and symptoms of pain to the left arm. The physician was notified, and an X-ray was ordered to rule out a left clavicle fracture. The resident was sent to the emergency room for orthopedic evaluation. A review of the facility's Investigation Summary include for the Investigative Findings that Resident #2 was alert and confused with intermittent times of clarity and was interviewed on 8/19/25. When asked what happened, the resident acted out to nursing staff by leaning forward and stretching [their] arms in front of [the resident]. The resident stated that [they] fell but was unable to describe further. When asked how [the resident] got [themself] up, the resident stated, my knees. The facility concluded that the resident had a history of independent ambulation and a history of falls. Based on staff and resident interviews and skin assessments, there were no significant findings to indicate abuse. On 10/30/25 at 10:25 AM, the Director of Nursing (DON) provided a folder that included an Incident Report dated 8/17/25, and a written statement from LPN/S #1 dated 8/17/25. A review of the Incident Report dated 8/17/2025 at 12:00 PM, completed by LPN/S #1, included type/nature of the incident was other with a location reported as the resident's room. Under nursing description, there was a box to indicate if the incident had been witnessed and LPN/S #1 did not check the box. The description of the findings were, during afternoon rounds, resident is noted with faint red/purple discoloration to left collar bone area with minor swelling that was not present earlier in the shift/during AM care. LPN/S #1 also checked the box indicating that the resident was unable to give a description. Under Immediate action taken, LPN/S #1 documented the following: [Registered Nurse (RN)] assessment; ROM is at baseline; and the resident was physically combative, paces ad lib with poor safety awareness, likely self-sustained. Attached to the Incident Report was a form titled Keep checklist attached to included forms. There was a place on the form to circle which one applied: either Fall or Skin and neither were circled. The first item on the check list was [Certified Nursing Aide (CNA)] statement form (see attached). LPN/S #1 had placed a check mark beside the statement, however there was no CNA statement included. Another item on the checklist was Fall Risk Assessment completed in [electronic medical record] and LPN/S #1 had indicated N/A(not applicable), indicating there had been no fall. Additionally on the checklist was RN assessment prior to moving patient (including note) to which LPN/S #1 had indicated N/A and written No RN note in [electronic medical record] no fall noted. The written statement of witnessed events dated 8/17/25, and authored by LPN/S #1, revealed that she was on the unit and observed Resident #2 being physically aggressive and resistant during morning care. LPN/S #1 documented that the resident was attempting to pull their shirt and clothes off while the CNA was attempting to dress them. LPN/S #1 stated she had assisted the CNA and allowed for de-escalation.On 10/30/25 at approximately 10:30 AM, the surveyor reviewed the electronic medical record (eMR) for Resident #2. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to; severe dementia with agitation, type 2 diabetes, difficulty walking and a history of falls. According to the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/1/25, Resident #2 had short and long-term memory problems with severely impaired cognitive decision making. A further review in Section E. Behaviors, included that Resident #2 had physical behaviors directed toward others, such as hitting, kicking and scratching four to six days out of seven; verbal behaviors toward others threatening such as, screaming and cursing at others one to three days out of seven; and other behavioral symptoms not directed toward others daily. A review of the individualized Care Plan (CP) included a focus area initiated 11/16/23, that the resident usually required a moderate amount of assistance with Activities of Daily Living (ADLs) related to weakness, impaired mobility/balance, incontinence, impaired safety awareness.participation fluctuates secondary to their mood/behavior disturbances. Interventions included for both upper and lower body dressing substantial/maximal assistance [with] helper lifts or holds trunk or limbs and provides more than half the effort. A further review of the CP included a focus area initiated 8/3/23, that Resident #2 had a history of refusing medications, showers, care and allowing staff to clean their room with interventions which included to assist the resident in understanding that the need for interventions being attempted are to improve overall status, attempt to identify potential contributing factors to refusal (pain, gastrointestinal upset or difficulty swallowing medications or fear). Provide alternatives as able to decrease potential for refusals. A review of the Progress Note (PN) dated 8/17/25 at 6:44 AM, included hospice care, comfort measures in place no signs or symptoms of pain or distress. A further review of the PN included an Incident Note dated 8/17/25 at 12:20 PM, written by LPN/S #1, that during afternoon rounds [Resident #2] was noted with a faint red purple discoloration to the left collar bone area (clavicle) with minor swelling that was not present during the beginning of the shift. [Resident #2] was unable to give a description. [Resident #2] paces ad lib with poor safety awareness and is physically combative with staff, likely sustained during care. An RN assessment was completed, and ROM was at baseline. There were no symptoms of pain at this time. A message was left for family, the nurse practitioner was notified, and vital signs were within normal levels. On 10/30/25 at 1:15 PM, the surveyor observed Resident #2 in the hallway standing at the nurse's desk. Resident #2 was stating they were hungry, and the Licensed Practical Nurse Unit Manager (LPN/UM #1) provided the resident with a sandwich, but the resident was dissatisfied and began raising their voice and cursing at other residents around them. Resident #2 then started to eat the sandwich and began to calm down. The surveyor asked the resident if they had recently hurt their collar bone, and the resident responded Yes and that they had been riding their bike and had flipped over the handlebars. When asked if staff hurt them when they helped the resident get dressed, the resident responded No. On 10/30/25 at 1:40 PM, the surveyor interviewed CNA #3, who stated the resident was sweet but could be feisty and that they could get agitated randomly and had no particular triggers. CNA #3 stated the resident was on hospice care and a hospice home health aide was responsible for dressing and grooming the resident. When asked if she had witnessed the resident being difficult during care or dressing, she responded No and that she had changed the resident yesterday after an incontinence episode and the resident had cooperated without any issue. On 10/30/25 at 1:52 PM, the surveyor interviewed LPN/UM #1 who stated Resident #2 was confused and could be combative even when unprovoked. LPN/UM #1 also stated that the resident spoke in fragments and not complete sentences and could become agitated when staff attempted to assist with dressing or eating because the resident believed they could do it themself. When asked how the facility treated an injury of unknown origin, LPN/UM #1 stated that it must be reported, and an investigation initiated immediately. LPN/UM #1 stated that she would interview the staff caring for the resident, as well as the resident about how the injury occurred. LPN/UM #1 further stated the facility needed to determine if the injury was self-inflicted or if staff injured them during transfer or care, and the injury should be reported to the DON, the family, and the physician. On 10/30/25 at 2:15 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated she was working on 8/17/25, and had only been made aware of Resident #2's skin discoloration and their inability to move their arm on 8/18/25. When asked if the resident had an RN assessment completed on 8/17/25, as the Incident Report documented, she replied she was unsure and could not provide a copy to the surveyor, and the ADON stated she began an investigation on 8/18/25. When asked if this was considered an injury of unknown origin, the ADON stated Yes because the resident was unable to describe how the injury occurred. The ADON stated that any skin changes, skin tears, breakdown or bruising should be reported immediately to the nursing supervisor. The ADON confirmed that an investigation and incident report should be initiated immediately on initial observation, and for an investigation of an injury of unknown origin, the ADON stated that the first thing to do was to find out who was assigned to care for the resident and that they would be taken off the schedule pending the findings of the investigation. When asked if the staff assigned to care for Resident #2 had been removed from the schedule, the ADON stated on 8/18/25, as part of her investigation CNA #1, CNA #2, and the Hospice Aide (HA #1) had been suspended. The ADON confirmed that the staff from 8/17/25, the day the discoloration was first identified, should have been suspended that day (8/17/25) pending investigation for the injury of unknown origin. On 10/30/25 at 3:55 PM, the surveyor interviewed the DON, the Licensed Nursing Home Administrator (LNHA) and the ADON, and the ADON stated that immediately on 8/17/25, on initial discovery of the bruise on the clavicle, an investigation should have been initiated to rule out abuse. The DON confirmed that the staff should have notified the DON immediately and that all staff should have been removed from the schedule until the investigation has been completed and abuse ruled out. The DON also stated that statements should have been taken from staff who had cared for the resident for the last 24 hours, both nurses and CNAs. The DON confirmed both CNA #1, CNA #2, and HA #1 were suspended on 8/18/25. At this time the surveyor requested the timecards for the nurses and the CNAs for 8/16/25, 8/17/25, and 8/18/25, as well as the results of the radiology report for Resident #2's x-ray of their left clavicle. At that time, the LNHA stated, on 8/18/25, was when [HA #1] identified Resident #2 was unable to raise their arm. That's when we decided uh oh! we need to investigate this. Until then the bruise was related to combative behavior. The DON and ADON confirmed they only became aware of the resident's complaint of pain and decreased ROM on Monday 8/18/25. On 10/30/25 at 4:15 PM, the surveyor re-interviewed the DON, who contradicted her initial statement regarding when staff should have been removed from the schedule and stated, Sunday (8/17/25) we would not send staff home because we believed the injury was sustained during care. On 10/30/25 at 5:10 PM, the ADON confirmed neither of the nurses assigned to Resident #2 worked on 8/18/25. On 10/30/25 at 5:35 PM, the DON confirmed HA #1 worked the dayshift on 8/17/25, and returned on 8/18/25, and that HA #1 cared for one other resident on 8/17/25 and 8/18/25. The DON stated that Resident #2 had a skin assessment completed by the ADON as part of the investigation, however it was not initiated until 8/18/25. On 10/30/25 at 5:36 PM, the surveyor reviewed the timecards for CNA #1 and CNA #2 that were provided as follows: CNA #1:Worked two shifts on 8/16/25 (3:00 PM to 11:00 PM and 11:00 PM and 7:00 AM), and clocked in on 8/16/25 at 2:52 PM, and clocked out at 8/17/25 at 7:51 AM. Worked two shifts on 8/17/25 (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM), and clocked in on 8/17/25 at 2:52 PM, and clocked out at 8/18/25 at 7:30 AM.Worked one shift on 8/18/25 (11:00 PM to 7:00 AM), and clocked in on 8/18/25 at 10:53 PM, and 8/19/25 at 7:36 AM.CNA #1 worked three shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit. CNA #2:Worked one shift on 8/17/25 (7:00 AM to 3:00 PM), and clocked in on 8/17/25 at 6:58 AM, and clocked out at 3:23 PM.Worked one shift 8/18/25 (7:00 AM to 3:00 PM), and clocked in on 8/18/25 at 6:59 AM, and out at 3:23 PM.CNA #2 continued to work two shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit. On 10/30/25 at 5:37 PM, the surveyor reviewed the radiology report, dated 8/18/25 11:51 PM, which revealed there was an acute fracture of the mid clavicle. On 10/31/25 at 10:37 AM, the surveyor conducted a telephone with HA #1, who confirmed she had taken care of Resident #2 on both 8/17/25 and 8/18/25. HA #1 stated to the surveyor that her speaking of the English language was not very good and asked if she could answer the surveyor's questions via a translator. Using a colleague to translate, HA #1 stated she was responsible to assist the resident every morning with getting dressed and washed. When asked if she observed any bruises on Resident #2 on 8/17/25, she stated No, but on 8/18/25, when attempting to dress Resident #2, she observed the bruise and stated the resident did not complain of pain, but did have trouble moving their arm when trying to get dressed. HA #1 stated the resident was a nice person and was cooperative when rendering care. HA #1 stated she worked alone the morning of 8/17/25, and did not receive help from LPN/S #1. This contradicted the written statement provided by LPN/S #1 for the incident report dated 8/17/25. HA #1 stated she reported the bruise and the resident's trouble moving their left arm to CNA #3 because she was unable to find the resident's nurse. On 10/31/25 at 11:00 AM, the surveyor attempted to conduct a telephone with the RN assigned to care for Resident #2 on 8/17/25, but the RN did not answer the call. A message was left but the RN did not return the surveyor's call. On 10/31/25 at 11:05 AM, the surveyor attempted to conduct an interview with CNA #2, who was assigned to care for Resident #2, but she did not answer the call. A message was left but CNA #2 did not return the surveyor's call. A review of the written statement provided by CNA #2, included in the facility investigation performed by the ADON dated 8/17/25, revealed CNA #2 stated she did not perform morning care for Resident #2 on 8/17/25, [HA #1] had. She had no knowledge of any bruises on the resident that day. On 10/31/25 at 11:08 AM, the surveyor conducted a telephone interview with CNA #3, who stated she was not assigned to care for Resident #2 that day, but remembered it was a Monday and she was helping to serve breakfast in the dayroom when HA #1 brought Resident #2 into the dayroom for breakfast. CNA #3 stated HA #1 told her she thought something was wrong with the resident because she had a hard time getting the resident dressed, and that it seemed the resident was in pain because they could not lift their arm to put their shirt on, and together they informed the nurse. CNA #3 could not identify which nurse she informed. On 10/31/25 at 11:31 AM, the surveyor attempted to conduct a telephone with LPN/S #1, but she did not answer the call. A message was left but LPN/S #1 did not return the surveyor's call. On 10/31/25 at 11:36 AM, the surveyor interviewed CNA #1, who stated she would normally work a double shift on the weekend (the 3:00 PM to 11:00 PM shift, then stay for the 11:00 PM to 7:00 AM shift). CNA #1 confirmed she was assigned to care for Resident #2 on 8/17/25 and 8/18/25. On the morning of 8/17/25, she provided incontinence care to Resident #2 and changed their brief and changed their soiled sheets. CNA #1 stated the HA would come in later in the morning and help the resident to get dressed. CNA #1 stated the resident was not combative or aggressive that morning. An acceptable Removal Plan was received on 10/31/25 at 12:12 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including on 8/17/25, an incident report was completed by LPN/S #1 when discoloration was noted to left collar bone. On 8/18/25, the ADON and LNHA initiated an investigated to rule out abuse, the physician was notified, and an X-ray was obtained which revealed a left clavicle fracture. On 8/18/25, the NJDOH and Ombudsman were notified, and the CNA and HA were suspended. On 10/30/25, the [NAME] President (VP) of Clinical Services and LNHA reviewed the abuse policy with no changes, and the VP of Clinical Services re-educated the DON and the LNHA on the abuse policy. On 10/30/25, the ADON/designee began a facility wide education for all staff on the abuse and neglect policy. On 10/31/25, the Unit Managers and Nursing Supervisors were re-educated on the abuse policy and requirement to report and suspend staff pending the outcome of investigations. The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey and determined the IJ for F 600 was removed as of 10/31/25 at 1:35 PM. NJAC 8:39-4.1(a)(5)

Complaint #: 2594123 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to immediately implement its abuse and neglect policy by immediately investigating an injury of unknown origin that was discovered on 8/17/25, to protect the resident to rule out abuse. On 8/17/25, a cognitively impaired resident (Resident #2) was noted to have discoloration and minor swelling to the left clavicle (collar bone), and it was determined to be a clavicle fracture on 8/18/25. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #2). On 8/17/25, staff observed a faint discoloration and minor swelling to Resident #2's left clavicle at approximately 12:20 PM. At the time, the Licensed Practical Nurse/Supervisor (LPN/S #1) did not immediately initiate an investigation. On 8/18/25, Resident #2 complained of pain and had limited range of motion to their left arm. Resident #2's physician was made aware, and an X-ray was ordered revealing Resident #2 had a closed, displaced fracture of the resident's left clavicle. An interview with the Assistant Director of Nursing (ADON) on 10/30/25 at 2:15 PM, confirmed that LPN/S #1 did not initiate an investigation on 8/17/25, when the resident's bruised collar bone was first discovered, and staff continued to work until 8/18/25, when an investigation was initiated, and staff were suspended pending the outcome of the investigation. The facility's failure to immediately implement their abuse and neglect policy by not immediately investigating an injury of unknown origin placed Resident #2, as well as all residents at risk for abuse. This posed the likelihood of serious physical and psychological harm, injury, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/17/25 at 12:20 PM, when a bruise of unknown origin was identified on Resident #2, and the facility did not immediately implement their abuse policy to investigate. The facility was notified of the IJ on 10/30/25 at 5:45 PM. The facility submitted an acceptable Removal Plan (RP) on 10/31/25 at 12:12 PM. The surveyors verified the implementation of the RP on-site during the continuation of the survey on 10/31/25 at 1:35 PM. The evidence was as follows: Refer F600A review of the facility's policy titled Resident Abuse/Neglect Policy and Procedure, revised February 17, 2025, included its purpose was to ensure prevention, protection, prompt reporting, and interventions in response to alleged, suspected, or witnessed abuse, neglect, mistreatment, misappropriation of property, or exploitation of any facility resident.All employees are expected to and must immediately report any injury sustained by a resident, whether or not the nature of the injury is known. Employees under investigation would be denied access to the resident and temporarily suspended until the LNHA had reviewed the results of the investigation .Notification: Any staff member witnessing or receiving an allegation of abuse/neglect of any resident shall notify the Nursing Supervisor immediately after witnessing the incident or receiving the allegation of abuse/neglect. The Administrator/[Grievance Officer (GO)] and the [Director of Nursing (DON)] and/or designees shall then be immediately notified of the incident, and an investigation will be initiated.When an allegation of abuse/neglect is made, the Administrator/GO or his/her designee shall lead an investigation that includes the following: 1. If the allegation is physical abuse, a complete physical assessment of the resident must be completed and documented in the medical record.2. If abuse/neglect is suspected or confirmed, the resident shall be assessed to determine the need for counseling.3. The Administrator or his/her designee will form an investigatory team that will thoroughly investigate the allegation and document the investigation. an incident report will be completed. Interviews will be conducted and statements obtained from all staff members, residents, family, volunteers, and others that may have witnessed or have knowledge with respect to the alleged incident. All such statements will be in writing and placed in the investigatory file related to the alleged incident. the employee file of any accused staff will be reviewed.medical records of the resident including but not limited to documentation related to the physical assessment of the resident, as well as any assessment relating to the resident's psychosocial condition, will be reviewed. and findings documented and placed in the investigatory file. A review of the Facility Reported Event (FRE) submitted to the New Jersey Department of Health (NJDOH)) dated 8/19/25, revealed the following: On Sunday 8/17/25, Resident #2 was noted with discoloration to the clavicle area due to combative and aggressive behavior during care. On Monday 8/18/25, the resident presented with decreased range of motion (ROM) and showed signs and symptoms of pain to the left arm. The physician was notified, and an X-ray was ordered to rule out a left clavicle fracture. The resident was sent to the emergency room for orthopedic evaluation. A review of the facility's Investigation Summary include for the Investigative Findings that Resident #2 was alert and confused with intermittent times of clarity and was interviewed on 8/19/25. When asked what happened, the resident acted out to nursing staff by leaning forward and stretching [their] arms in front of [the resident]. The resident stated that [they] fell but was unable to describe further. When asked how [the resident] got [themself] up, the resident stated, my knees. The facility concluded that the resident had a history of independent ambulation and a history of falls. Based on staff and resident interviews and skin assessments, there were no significant findings to indicate abuse. On 10/30/25 at 10:25 AM, the Director of Nursing (DON) provided a folder that included an Incident Report dated 8/17/25, and a written statement from LPN/S #1 dated 8/17/25. A review of the Incident Report dated 8/17/2025 at 12:00 PM, completed by LPN/S #1 included type/nature of the incident was other with a location reported as the resident's room. Under nursing description, there was a box to indicate if the incident had been witnessed and LPN/S #1 did not check the box. The description of the findings were, during afternoon rounds, resident is noted with faint red/purple discoloration to left collar bone area with minor swelling that was not present earlier in the shift/during AM care. LPN/S #1 also checked the box indicating that the resident was unable to give a description. Under Immediate action taken, LPN/S #1 documented the following: [Registered Nurse (RN)] assessment; ROM is at baseline; and the resident was physically combative, paces ad lib with poor safety awareness, likely self-sustained. Attached to the Incident Report was a form titled Keep checklist attached to included forms. There was a place on the form to circle which one applied: either Fall or Skin and neither were circled. The first item on the check list was [Certified Nursing Aide (CNA)] statement form (see attached). LPN/S #1 had placed a check mark beside the statement, however there was no CNA statement included. Another item on the checklist was Fall Risk Assessment completed in [electronic medical record] and LPN/S #1 had indicated N/A(not applicable), indicating there had been no fall. Additionally on the checklist was RN assessment prior to moving patient (including note) to which LPN/S #1 had indicated N/A and written No RN note in [electronic medical record] no fall noted. The written statement of witnessed events dated 8/17/25, and authored by LPN/S #1, revealed that she was on the unit and observed Resident #2 being physically aggressive and resistant during morning care. LPN/S #1 documented that the resident was attempting to pull their shirt and clothes off while the CNA was attempting to dress them. LPN/S #1 stated she had assisted the CNA and allowed for de-escalation. On 10/30/25 at approximately 10:30 AM, the surveyor reviewed the electronic medical record (eMR) for Resident #2. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to; severe dementia with agitation, type 2 diabetes, difficulty walking and a history of falls. According to the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/1/25, Resident #2 had short and long-term memory problems with severely impaired cognitive decision making. A further review in Section E. Behaviors, included that Resident #2 had physical behaviors directed toward others, such as hitting, kicking and scratching four to six days out of seven; verbal behaviors toward others threatening such as, screaming and cursing at others one to three days out of seven; and other behavioral symptoms not directed toward others daily. A review of the individualized Care Plan (CP) included a focus area initiated 11/16/23, that the resident usually required a moderate amount of assistance with Activities of Daily Living (ADLs) related to weakness, impaired mobility/balance, incontinence, impaired safety awareness.participation fluctuates secondary to their mood/behavior disturbances. Interventions included for both upper and lower body dressing substantial/maximal assistance [with] helper lifts or holds trunk or limbs and provides more than half the effort. A further review of the CP included a focus area initiated 8/3/23, that Resident #2 had a history of refusing medications, showers, care and allowing staff to clean their room with interventions which included to assist the resident in understanding that the need for interventions being attempted are to improve overall status, attempt to identify potential contributing factors to refusal (pain, gastrointestinal upset or difficulty swallowing medications or fear). Provide alternatives as able to decrease potential for refusals. A review of the Progress Note (PN) dated 8/17/25 at 6:44 AM, included hospice care, comfort measures in place no signs or symptoms of pain or distress. A further review of the PN included an Incident Note dated 8/17/25 at 12:20 PM, written by LPN/S #1, that during afternoon rounds [Resident #2] was noted with a faint red purple discoloration to the left collar bone area (clavicle) with minor swelling that was not present during the beginning of the shift. [Resident #2] was unable to give a description. [Resident #2] paces ad lib with poor safety awareness and is physically combative with staff, likely sustained during care. An RN assessment was completed, and ROM was at baseline. There were no symptoms of pain at this time. A message was left for family, the nurse practitioner was notified, and vital signs were within normal levels. On 10/30/25 at 1:52 PM, the surveyor interviewed LPN/UM #1 who stated Resident #2 was confused and could be combative even when unprovoked. LPN/UM #1 also stated that the resident spoke in fragments and not complete sentences and could become agitated when staff attempted to assist with dressing or eating because the resident believed they could do it themself. When asked how the facility treated an injury of unknown origin, LPN/UM #1 stated that it must be reported, and an investigation initiated immediately. LPN/UM #1 stated that she would interview the staff caring for the resident, as well as the resident about how the injury occurred. LPN/UM #1 further stated the facility needed to determine if the injury was self-inflicted or if staff injured them during transfer or care, and the injury should be reported to the DON, the family, and the physician. On 10/30/25 at 2:15 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated she was working on 8/17/25, and had only been made aware of Resident #2's skin discoloration and their inability to move their arm on 8/18/25. When asked if the resident had an RN assessment completed on 8/17/25, as the Incident Report documented, she replied she was unsure and could not provide a copy to the surveyor, and the ADON stated she began an investigation on 8/18/25. When asked if this was considered an injury of unknown origin, the ADON stated Yes because the resident was unable to describe how the injury occurred. The ADON stated that any skin changes, skin tears, breakdown or bruising should be reported immediately to the nursing supervisor. The ADON confirmed that an investigation and incident report should be initiated immediately on initial observation, and for an investigation of an injury of unknown origin, the ADON stated that the first thing to do was to find out who was assigned to care for the resident and that they would be taken off the schedule pending the findings of the investigation. When asked if the staff assigned to care for Resident #2 had been removed from the schedule, the ADON stated on 8/18/25, as part of her investigation CNA #1, CNA #2, and the Hospice Aide (HA #1) had been suspended. The ADON confirmed that the staff from 8/17/25, the day the discoloration was first identified, should have been suspended that day (8/17/25) pending investigation for the injury of unknown origin. On 10/30/25 at 3:55 PM, the surveyor interviewed the DON, the Licensed Nursing Home Administrator (LNHA) and the ADON, and the ADON stated that immediately on 8/17/25, on initial discovery of the bruise on the clavicle, an investigation should have been initiated to rule out abuse. The DON confirmed that the staff should have notified the DON immediately and that all staff should have been removed from the schedule until the investigation has been completed and abuse ruled out. The DON also stated that statements should have been taken from staff who had cared for the resident for the last 24 hours, both nurses and CNAs. The DON confirmed both CNA #1, CNA #2, and HA #1 were suspended on 8/18/25. At that time, the LNHA stated, on 8/18/25, was when [HA #1] identified Resident #2 was unable to raise their arm. That's when we decided uh oh! we need to investigate this. Until then the bruise was related to combative behavior. The DON and ADON confirmed they only became aware of the resident's complaint of pain and decreased ROM on Monday 8/18/25. On 10/30/25 at 5:35 PM, the DON stated that Resident #2 had a skin assessment completed by the ADON as part of the investigation, however it was not initiated until 8/18/25. On 10/30/25 at 5:36 PM, the surveyor reviewed the timecards for CNA #1 and CNA #2 that were provided as follows:CNA #1:Worked two shifts on 8/16/25 (3:00 PM to 11:00 PM and 11:00 PM and 7:00 AM), and clocked in on 8/16/25 at 2:52 PM, and clocked out at 8/17/25 at 7:51 AM. Worked two shifts on 8/17/25 (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM), and clocked in on 8/17/25 at 2:52 PM, and clocked out at 8/18/25 at 7:30 AM.Worked one shift on 8/18/25 (11:00 PM to 7:00 AM), and clocked in on 8/18/25 at 10:53 PM, and 8/19/25 at 7:36 AM.CNA #1 worked three shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit. CNA #2:Worked one shift on 8/17/25 (7:00 AM to 3:00 PM), and clocked in on 8/17/25 at 6:58 AM, and clocked out at 3:23 PM.Worked one shift 8/18/25 (7:00 AM to 3:00 PM), and clocked in on 8/18/25 at 6:59 AM, and out at 3:23 PM.CNA #2 continued to work two shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit.An acceptable Removal Plan was received on 10/31/25 at 12:12 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the immediacy including on 8/17/25, an incident report was completed by LPN/S #1 when the discoloration was noted to the resident's left collar bone. On 8/18/25, the ADON and LNHA initiated an investigation to rule out abuse, the physician was notified, and an X-ray was obtained which revealed a left clavicle fracture. On 8/18/25, the NJDOH and Ombudsman were notified, and the CNAs and HA were suspended. On 10/30/25, the [NAME] President (VP) of Clinical Services and LNHA reviewed the abuse policy with no changes, and the VP of Clinical Services re-educated the DON and the LNHA on the abuse policy and investigation. On 10/30/25, the ADON/designee began a facility wide education for all staff on the abuse and neglect policy. On 10/31/25, the Unit Managers and Nursing Supervisors were re-educated on the abuse policy and requirement to report and suspend staff pending the outcome of investigations. The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey and determined the IJ for F 600 was removed as of 10/31/25 at 1:35 PM. NJAC 8:39-4.1(a)(5)

Complaint #: 2594123Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an injury of unknown origin within two hours of initial identification. The injury was discovered on 8/17/25, when Resident #2 was noted to have discoloration and minor swelling to the left clavicle (collarbone). The injury was later diagnosed as a fracture on 8/19/25, and the facility failed to rule out possible abuse as required by policy. This deficient practice was identified for 1 of 5 residents (Resident #2) reviewed for abuse.The evidence was as follows:On 8/17/25, staff at the facility identified an injury of unknown origin for Resident #2 at approximately 12:20 PM. At the time, no immediate investigation was initiated and the NJDOH was not notified. Two days later, the injury was then determined to have resulted in a closed, displaced fracture of the resident's left clavicle. During survey on 10/30/25, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) both stated they had not been informed of the injury when it was first discovered on 8/17/25. They explained that the Licensed Practical Nurse/Supervisor (LPN/S) who identified the injury should have reported it to them immediately so that an investigation could begin, and all notifications completed including to the NJDOH. However, this did not occur. As a result, an investigation was not started until 8/19/25, approximately over 24 hours after the injury had been first noted. A review of the Facility Reported Event (FRE) dated 8/19/25, submitted to the NJDOH revealed the following:On 8/17/25, Resident #2 was observed with discoloration to the clavicle area, noted during care when the resident was combative and aggressive. On 8/18/25, the resident was noted to have decreased range of motion in the left arm and exhibited signs and symptoms of pain. The physician was notified, and an X-ray was ordered. On 8/19/25, X-ray results confirmed a left clavicle fracture. The physician was notified, and the resident was transferred to the emergency department for evaluation. During an interview with the surveyor on 10/30/25 at 2:15 PM, the ADON stated that an investigation should have been initiated immediately regarding Resident #2's left clavicle discoloration, the cause was of unknown origin. She noted that an investigation was eventually started on 08/18/25, after LPN #1, who provided care to the resident on 08/18/25, reported that the resident had decreased range of motion in the left arm. The ADON stated that the staff providing direct care to the resident should have been placed off duty on 08/17/25 pending the investigation. She further stated that, after reviewing the nursing note and considering the resident's inability to describe how the incident occurred, she realized that the facility's policy might not have been followed. The ADON also stated that the NJDOH and the Ombudsman should have been notified on the same day or the following day, but she was unsure of the exact timeframe for reporting, which she believed to be within 72 hours.During an interview with the surveyor on 10/30/25 at 3:55 PM, the DON stated that the incident involving Resident #2's discoloration to the left clavicle occurred when she was not in the building and that it should have been reported to the NJDOH and investigated immediately.On 10/31/25 at 11:03 AM, the surveyor attempted to contact the RN #1 by telephone regarding Resident #2's incident to conduct an interview. According to the ADON, the RN only worked on weekends. The RN did not answer the phone, and a voicemail message was left requesting a return call.On 10/31/25 at 11:31 AM, the surveyor attempted to contact the LPN/S by telephone regarding Resident #2's incident to conduct an interview. According to the ADON, the LPN/S only worked on weekends. The LPN/S did not answer the phone, and a voicemail message was left requesting a return call.A review of a facility policy dated 2/25 titled, Resident Abuse/Neglect Policy and Procedure, revealed that, All employees are expected to and must immediately report any injury sustained by a resident, whether or not the nature of the injury is known.The Department of Health and Senior Services, and the office of the ombudsman if the resident is 60 or over, will be notified immediately (as soon as possible but not to exceed two hours) of the incident, followed by a written report within 5 days of the incident and if the alleged violation is verified, the facility shall take all appropriate corrective action. NJAC 8:39-9.4(f)

Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: 1. For the week of Complaint staffing from 03/05/2024 to 03/11/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -03/05/23 had 11 CNAs for 170 residents on the day shift, required at least 21 CNAs. -03/06/23 had 14 CNAs for 168 residents on the day shift, required at least 21 CNAs. -03/07/23 had 14 CNAs for 166 residents on the day shift, required at least 21 CNAs. -03/08/23 had 17 CNAs for 166 residents on the day shift, required at least 21 CNAs. -03/09/23 had 20 CNAs for 165 residents on the day shift, required at least 21 CNAs. -03/10/23 had 19 CNAs for 165 residents on the day shift, required at least 21 CNAs. -03/11/23 had 16 CNAs for 163 residents on the day shift, required at least 20 CNAs. 2. For the week of Complaint staffing from 04/02/2023 to 04/08/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -04/02/23 had 14 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/03/23 had 15 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/04/23 had 16 CNAs for 173 residents on the day shift, required at least 22 CNAs. -04/05/23 had 14 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/06/23 had 19 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/07/23 had 20 CNAs for 172 residents on the day shift, required at least 21 CNAs. -04/08/23 had 15 CNAs for 172 residents on the day shift, required at least 21 CNAs. 3. For the week of Complaint staffing from 08/27/2023 to 09/02/2023, the facility was deficient in CNA staffing for residents on 6 of 7-day 0shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in CNAs to total staff on 1 of 7 evening shifts as follows: -08/27/23 had 7 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/27/23 had 12 total staff for 180 residents on the evening shift, required at least 18 total staff. -08/27/23 had 4 CNAs to 12 total staff on the evening shift, required at least 6 CNAs. -08/28/23 had 15 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/29/23 had 17 CNAs for 180 residents on the day shift, required at least 22 CNAs. -08/31/23 had 16 CNAs for 186 residents on the day shift, required at least 23 CNAs. -09/01/23 had 17 CNAs for 185 residents on the day shift, required at least 23 CNAs. -09/02/23 had 14 CNAs for 185 residents on the day shift, required at least 23 CNAs. 4. For the week of Complaint staffing from 09/10/2023 to 09/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -09/10/23 had 13 CNAs for 194 residents on the day shift, required at least 24 CNAs. -09/11/23 had 16 CNAs for 194 residents on the day shift, required at least 24 CNAs. -09/12/23 had 17 CNAs for 193 residents on the day shift, required at least 24 CNAs. -09/13/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/14/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/15/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. -09/16/23 had 15 CNAs for 192 residents on the day shift, required at least 24 CNAs. 5. For the week of Complaint staffing from 11/19/2023 to 11/25/2023, the facility was deficient in CNA staffing for residents on 7 of 7-day shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in total staff for residents on 1 of 7 overnight shifts as follows: -11/19/23 had 9 CNAs for 186 residents on the day shift, required at least 23 CNAs. -11/20/23 had 13 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/21/23 had 13 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/22/23 had 14 CNAs for 185 residents on the day shift, required at least 23 CNAs. -11/23/23 had 15 CNAs for 183 residents on the day shift, required at least 23 CNAs. -11/23/23 had 16.5 total staff for 183 residents on the evening shift, required at least 18 total staff. -11/23/23 had 10 total staff for 183 residents on the overnight shift, required at least 13 total staff. -11/24/23 had 11 CNAs for 183 residents on the day shift, required at least 23 CNAs. -11/25/23 had 12 CNAs for 183 residents on the day shift, required at least 23 CNAs. 6. For the week of Complaint staffing from 01/07/2024 to 01/13/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -01/07/24 had 12 CNAs for 185 residents on the day shift, required at least 23 CNAs. -01/08/24 had 13 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/09/24 had 13 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/10/24 had 17 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/11/24 had 20 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/12/24 had 22 CNAs for 184 residents on the day shift, required at least 23 CNAs. -01/13/24 had 14 CNAs for 184 residents on the day shift, required at least 23 CNAs. 7. For the week of Complaint staffing from 02/18/2024 to 02/24/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -02/18/24 had 13 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/19/24 had 10 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/20/24 had 12 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/21/24 had 14 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/22/24 had 15 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/23/24 had 16 CNAs for 183 residents on the day shift, required at least 23 CNAs. -02/24/24 had 13 CNAs for 182 residents on the day shift, required at least 23 CNAs. 8. For the week of Complaint staffing from 03/17/2024 to 03/23/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -03/17/24 had 13 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/18/24 had 12 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/19/24 had 12 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/20/24 had 15 CNAs for 177 residents on the day shift, required at least 22 CNAs. -03/21/24 had 17 CNAs for 174 residents on the day shift, required at least 22 CNAs. -03/22/24 had 16 CNAs for 174 residents on the day shift, required at least 22 CNAs. -03/23/24 had 12 CNAs for 174 residents on the day shift, required at least 22 CNAs. 9. For the week of Complaint staffing from 04/28/2024 to 05/04/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -04/28/24 had 15 CNAs for 181 residents on the day shift, required at least 23 CNAs. -04/29/24 had 11 CNAs for 181 residents on the day shift, required at least 23 CNAs. -04/30/24 had 13.5 CNAs for 181 residents on the day shift, required at least 23 CNAs. -05/01/24 had 15 CNAs for 181 residents on the day shift, required at least 23 CNAs. -05/02/24 had 16 CNAs for 180 residents on the day shift, required at least 22 CNAs. -05/03/24 had 14.5 CNAs for 180 residents on the day shift, required at least 22 CNAs. -05/04/24 had 16 CNAs for 179 residents on the day shift, required at least 22 CNAs. 10. For the 2 weeks of staffing prior to survey from 05/26/2024 to 06/08/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -05/26/24 had 14 CNAs for 184 residents on the day shift, required at least 23 CNAs. -05/27/24 had 13 CNAs for 183 residents on the day shift, required at least 23 CNAs. -05/28/24 had 11 CNAs for 183 residents on the day shift, required at least 23 CNAs. -05/29/24 had 16 CNAs for 182 residents on the day shift, required at least 23 CNAs. -05/30/24 had 15 CNAs for 182 residents on the day shift, required at least 23 CNAs. -05/31/24 had 18 CNAs for 182 residents on the day shift, required at least 23 CNAs. -06/01/24 had 15 CNAs for 182 residents on the day shift, required at least 23 CNAs. -06/02/24 had 11 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/03/24 had 15 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/04/24 had 14 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/05/24 had 16 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/06/24 had 9 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/07/24 had 15.5 CNAs for 187 residents on the day shift, required at least 23 CNAs. -06/08/24 had 14 CNAs for 189 residents on the day shift, required at least 24 CNAs. On 06/13/24 at 10:28 AM, during an interview with the surveyor, the 3rd floor Unit Manager (LPN/UM #4) when asked how staffing has been, replied, So-so, it could be better some days. At that time the LPN/UM #4 provided the Dogwood Court Assignment Sheet for the 7-3 shift that revealed a census of 58 residents with four CNA's indicating a ratio of 1 CNA to 15 residents. During an interview with the surveyor on 06/18/24 at 10:24 AM, CNA #3 stated that he/she had 14 residents on his/her assignment. When asked, can you get all your work done on your 8 hours shift, CNA #3 stated, If I move fast enough, we only have 2 CNAs on the unit. On 06/13/24 at 10:41 AM, Resident #161 stated that call bells are not answered timely, and his/her roommate has waited up to 7 hours for assistance. Resident #161 added that at times, he/she must find help for her roommate and other residents when call bells go unanswered for long periods of time. On 06/13/24 at 11:59 AM, during an interview with the surveyor, Resident #145 stated that he/she must wait a long time for assistance. During an interview with the surveyor on 06/18/2024 at 11:03 AM, the Staffing Coordinator indicated that it is difficult to meet the staffing requirements. The Staffing Coordinator said that she was aware of the minimum staffing requirements for CNA's which is 1 to 8 residents for 7-3 shift, 1 to 10 residents for the 3-11 shift, and 1 to 14 for the 11-7 shift. We use agency staffing that is unreliable. We are not always able to meet staffing requirements. During an interview with the surveyor on 06/18/2024 at 12:14 PM, CNA #2 stated, I typically have between 12-15 residents on day shift. Weekends are the same. Today, I have 3 Hoyer lifts which requires 2 CNA's to safely transfer; it is difficult to get assistance when staffing is limited. When asked, if he/she was able to complete all assignments during his/her shift, he/she replied, no. On 06/19/2024 at 12:33 PM, in the presence of the survey team, the Director of Nursing (DON) stated the facility staffing is determined by the New Jersey Department Of Health (NJDOH) requirements which are, 1:8 for 7-3 shift, 1:10 for 3-11 shift and 1:14 for 11-7 shift. The DON acknowledged that the facility was not meeting those requirements. The DON added that based on a full census of 204 residents, the staffing plan for CNA's is 4-5 on larger units: Dogwood and Birch during the day, 3 CNA's for SMART Unit, 2 CNA's for Oak unit, a 1 CNA for Laurel Unit. A review of the Facility assessment dated [DATE], under supportive documentation, revealed the following: Under Direct Care Staff (Certified Nurse Aides) 8 Aides Birch Court 7-3 and 5 Aides on 3-11; 3 Aides on 11-7 8 Aides Dogwood 7-3 and 5 Aides on 3-11; 3 Aides on 11-7 4 Aides on SMART Unit all three shifts 2 Aides on Laurel Unit all three shifts 4 Aides on Oak Court 7-3 and 3-11; 3 aides on 11-7 A review of a policy provided by the facility titled, Nursing Policy and Procedure, with a revision date of June 2020 and a review date of January 2024, revealed; It is the policy of this facility to determine the appropriate staffing on a unit based on the census, acuity, shift and needs of the residents and staffing ratio required by the NJDOH. NJAC 8:39-5.1(a), 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 7 sampled residents, (Resident #11, Resident #30, Resident #49, Resident #60, Resident #69, Resident #120 and Resident #128) identified upon inspection of 2 of 4 medication carts (Birch Unit A cart, and Birch Unit B cart). This deficient practice was evidenced by the following: On 6/18/2024 at 1:10 PM, the surveyor in the presence of the Licensed Practical Nurse #3 (LPN #3) inspected Birch unit, A cart. The surveyor and LPN #3 reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic inventory sheet, the surveyor identified the following concerns: Resident #60's pregabalin 75 milligram (mg) capsule, a medication used for nerve pain, did not match the physical inventory. The blister pack contained #20 capsules and the declining inventory sheet indicated there should be 21 capsules remaining. Resident #69's pregabalin 100 mg capsules also did not match. The blister pack contained 13 capsules and the declining inventory sheet indicated there should be 14 capsules remaining. At that time, the surveyor interviewed the LPN #3 who stated she had administered the medications earlier to both residents and had not signed the declining inventory sheet for the doses she had administered. The LPN acknowledged the declining inventory sheet should be signed when the medication was removed from the packaging. On 6/18/2024 at 1:29 PM, the surveyor in the presence of the Licensed Practical Nurse #1 (LPN #1) inspected Birch unit, B cart. The surveyor and LPN #1 reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns: Resident #11's oxycodone immediate release (IR) 5 mg tablet, a medication used for severe pain, did not match the physical inventory. The blister pack contained 10 tablets and the declining inventory sheet indicated there should be 12 tablets remaining. Resident #30's lorazepam 1 mg tablet, a medication used for anxiety, did not match the physical inventory. The blister pack contained #13 tablets and the declining inventory sheet indicated there should be 14 tablets remaining. Resident #49's pregabalin 225 mg capsule, did not match the physical inventory. The blister pack contained 9 capsules and the declining inventory sheet indicated there should be 10 capsules remaining. Resident #120's oxycontin extended release (ER) 20 mg tablet, a medication used for severe pain, did not match the physical inventory. The blister pack contained #27 tablets and the declining inventory sheet indicated there should be 28 tablets remaining. Resident #128's Xtampza ER 9 mg capsule, a medication used for severe pain, did not match the physical inventory. The blister pack contained #21 capsules and the declining inventory sheet indicated there should be 22 capsules remaining. At that time, the surveyor interviewed LPN #1 who stated she had given the medications earlier and should have signed the declining inventory sheets when she removed the medications from their packaging. On 6/18/2024 at 1:56 PM, the surveyor interviewed the Unit Manager Licensed Practical Nurse #3 (UM/LPN #3) who stated the nurse should be signing the declining inventory sheets at the time they remove the medication from inventory. On 6/20/2024 at 11:09 AM, the survey team met with facility Administration. The Director of Nursing stated nurses should be signing the declining inventory sheets as soon as the medication was removed from the packaging. A review of the facility's undated Medication Dispensing; Controlled Substances policy included . Accountability of controlled dangerous substances . When a CDS (controlled Dangerous Substance) medication is administered . the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. A review of the facility's undated Medication Administration General Guidelines for the Administration of Medications policy included . Administration of controlled Dangerous substances is also recorded on the declining inventory form. NJAC 8:39-29.2(d), 29.7(c)

Based on observation, interview, and review of other pertinent facility documents, 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 [DATE] from 9:30 to 10:23 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On an upper shelf, a previously opened bag of egg noodles had no opened or use by dates. The FSD removed the noodles from storage. 2. In the paper storage area on a middle shelf a previously opened plastic bag of coffee filters was stored opened and exposed. The FSD removed the filters from storage. 3. A clean and sanitized stand-up mixer in the food production area was covered with plastic and not in use per the FSD. The FSD removed the plastic covering. The surveyor observed unidentified food debris on the support arm of the mixer behind the bowl and above the beater shaft. The FSD stated, I'll have that re-cleaned and sanitized. 4. After observing the Starter Refrigerator, the surveyor went to the designated hand washing sink in the kitchen. Upon completion of hand washing and drying their hands the surveyor attempted to throw their used hand towel into the trash. There was no waste can at the sink. The FSD stated that the waste can was removed from the area. to be emptied and showed the surveyor the waste can that was located near the tray line. Observation of the waste can contents did not reveal any used hand towels in the contents. 5. The Beverage Box contained two (2) Ready Care Vanilla shakes (a nutritional supplement) that had a date of ,d+[DATE]. When interviewed the FSD stated, They are good for 14 days once pulled from the freezer. They are old. I'm discarding them. 6. In Walk-In refrigerator #4 on a lower shelf a previously opened roll of liverwurst was wrapped in plastic wrap. The liverwurst had no dates. The FSD removed the liverwurst to the trash. On [DATE] at 9:18 AM, the surveyors made the following observations in the Laurel Unit designated resident pantry: 1. Review of the [facility name] DATES/TEMPERATURE SHEET with MONTH: ,d+[DATE], revealed the following: Freezer Temps: 0 Degrees or Below ALL ITEMS MUST BE DATED 2. Observation of the freezer revealed that the freezer did not contain an internal thermometer to monitor the freezer temperature. In addition, no freezer temperatures were recorded on the temperature sheet. 3. The surveyor observed a single slice of pizza on the bottom shelf of the refrigerator. The pizza was in a zip lock bag and had no dates. On the shelf of the refrigerator door two (2) separate plastic portion control cups contained an unidentified white sauce and one contained a red/orange sauce that appeared to be hot sauce. The portion control cups had no dates. On interview Licensed Practical Nurse (LPN #5) agreed that all foods require a name and use by date. The surveyor made LPN #5 aware that freezer temperatures had to monitored, in addition to refrigerator temperatures. LPN #5 replied, Ok. The surveyor reviewed the facility policy titled [facility name] Policy and Procedure Food Safety Education, [DATE]. The following was revealed under POLICY: Residents are permitted to store and consume food that is obtained from outside the center. As a result, it is the policy of this facility to: Provide storage space for outside food/beverages that are distinct from the facility food storage units. The policy also had an attachment that revealed the following: All food and beverage items stored in the facility pantry/refrigerator must be thrown out: 1. On the manufacturer's expiration date. 2. 72 hours after the date it was brought in. 3. Upon spoiling. In addition, the attachment also revealed that Facility is responsible for discarding any expired, spoiled, or unlabeled food that is discovered and All food and beverage items being stored in the facility pantry or refrigerator must be: Labeled with the resident's name and Labeled with the date brought in (unless the items are in their original containers marked with a manufacturer's expiration date). The surveyor reviewed a facility policy titled Receiving, with Revised dated of ,d+[DATE]. The following was revealed under the heading Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. The following was revealed under Procedures: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The surveyor reviewed the facility policy titled Equipment, Revised ,d+[DATE]. The following was revealed under the heading Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. The following was revealed under the heading Procedures: 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and free of debris. The surveyor reviewed the facility policy titled Food Storage: Dry Goods, Revised ,d+[DATE]. The policy revealed the following under Policy Statement: All dry goods will be appropriately stored in accordance with the FDA Food Code. The following was revealed under the heading Procedures: 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. NJAC 18:,d+[DATE].2 (g)

Based on observation, interview, review of the medical record and review of other facility records, it was determined that the facility failed to follow a physician's order for a urinalysis to rule out a urinary tract infection (UTI). This deficient practice was identified for 1 of 2 resident's (Resident #43) reviewed for catheter/UTI. This deficient practice was observed by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. On 06/13/2024 at 11:16 AM, during the initial tour of the facility the surveyor observed Resident #43 lying in bed. Resident #43 has a urinary catheter. The catheter bag was observed to have cloudy urine in the catheter tubing. A privacy bag in place. Resident #43 denied any urinary pain when interviewed. According to the most recent Admission Record, Resident #43 was admitted to the facility with the following but not limited to diagnoses: Unspecified abdominal pain, unspecified dementia, retention of urine, personal history of urinary tract infections, and extended spectrum beta lactamase (ESBL) resistance (an enzyme found in some strains of bacteria. ESBL producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections). According to the quarterly Minimum Date Set (MDS), an assessment tool, dated May 27, 2024, Resident #43 had a brief Interview for Mental Status score of 9/15, which indicated moderate cognitive impairment. According to section GG Resident #43 required was dependent on staff for most activities of daily living except eating. Section H revealed that Resident #43 had an indwelling catheter and Section I revealed that Resident #43 had an active diagnosis of retention of urine. A review of the electronic medical record (EMR) of Resident #43 under the Orders section of the EMR revealed that Resident #43 had the following order dated 06/03/2024: UA reflex to PCR UTI W/ABR for Dysuria /R/o UTI. The surveyor then reviewed the Results section of the EMR to obtain the results of the 06/03/2024 ordered urinalysis to assess Resident #43. A review of the results section did not contain a urinalysis conducted on or after 06/03/2024. A review of Resident #43's comprehensive care plan revealed the following Focus: Potential for UTI AEB (as evidenced by) hx (history) of UTI. Resident #43 had the following care plan Goal: [resident name] will remain free from s/s (signs/symptoms) UTI, revised on: 01/04/2024. Resident #43 had the following but not limited to Interventions/Tasks: Monitor labs as ordered, keep MD aware of abnormalities. Date Initiated: 05/25/2022. On 06/18/24 at 01:40 PM, the surveyor requested a copy of the 06/3/2024 UA and copy of urinary catheter policy from the facility Director of Nursing (DON). On 06/19/2024 at 09:36 AM, the surveyor conducted an interview with the facility DON. The DON could not provide the surveyor with a copy of the results of Resident #43's urinalysis ordered on 06/03/2024 by the physician assistant (PA). The DON explained, I realized that there was no documentation since 5/30 2024. I reached out to the PA to find out why the UA/PCR was ordered. The PA said that it was written in error. We educated him and he admitted that it was written in error. The surveyor then asked if facility staff addressed the order from 06/03/2024 prior to the surveyor making the facility aware that there was no result for the lab. Did anybody in the facility address the order? The DON responded, No. The surveyor then asked the DON what the facility practice was for responding to a physician/practitioner order. The DON replied, The nurse should ask the Unit Manager. The unit manager was not aware that there was an order for the UA/PCR. The surveyor asked the DON if the order should have been addressed on 06/03/2024. The DON acknowledged that yes it should have been addressed on the 3rd by facility staff. The DON agreed that the facility staff should have addressed the order on 6/3/2024 because the order was visible under the Orders tab in the EMR and that the 11-7 nurse should have picked up on the order during their 24 hour chart check. The facility was unable to provide a policy or procedure for physician orders when requested by the surveyor. NJAC 8:39-27.1(a)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow appropriate infection control procedures: 1) during the provision of a wound treatment and 2) during medication administration. This deficient practice was identified for 1 of 1 nurses Registered Nurse (RN #1) who administered a wound treatment to 1 of 2 residents (Resident #177) reviewed for pressure ulcers and for 1 of 3 nurses Licensed Practical Nurse (LPN #2) observed during the medication administration observation. This deficient practice was evidenced by the following: 1. On 06/18/2024 at 10:21 AM, Surveyor #1 observed a stop sign posted outside of Resident #177's room which indicated the resident was on Enhanced Barrier Precautions (EBP), which required use of both gown and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDRO), bacteria that are resistant to three or more classes of antimicrobial drugs, to staff hands and clothing. The sign cautioned that everyone must: Clean their hands, including before entering and when leaving the room, and providers and staff must also wear gloves and gowns for the following high-contact resident care activities: .wound care: any skin opening requiring a dressing. Beneath the stop sign there was a cart that contained Personal Protective Equipment (PPE), (equipment worn to protect the body from infection). The surveyors entered the room and observed the resident seated in a wheelchair at the bedside. The resident stated that he/she had a wound near their tailbone and was agreeable to permit the surveyors to observe wound treatment. On 06/18/2024 at 10:58 AM, Surveyor #1 observed RN #1 wash her hands for 15 seconds before she donned (put on) gloves, and failed to donn a gown as indicated on the signage outside of Resident #177's room, before she proceeded to remove the resident's soiled sacral (triangular bone at the base of the spine) dressing. At 10:59 AM, RN #1 performed hand hygiene with alcohol based hand rub (ABHR) before she donned gloves and proceeded to cleanse the resident's sacral wound with Dakin's Solution (a mixture of sodium peroxide and hydrochloric acid). RN #1 patted the wound dry, applied Skin Prep (adhesive aid) to the border of the wound, and cut a piece of calcium alginate (highly absorbent dressing) to size before she placed it in the wound bed and covered it with a border foam dressing. At 11:03 AM, after RN #1 finished Resident #177's wound treatment she opened the door with her gloved hand, doffed (removed) her gloves and discarded them, before she proceeded to obtain a disinfectant wipe from the treatment cart and wiped down the marker used to date the dressing and the scissors used to cut the wound treatment to size. RN #1 then donned gloves without first performing hand hygiene, placed the scissors in a plastic bag, reached into her pocket with her gloved hands and obtained the keys to the treatment cart and accessed the treatment cart, and the computer that was located on top of the treatment cart. At 11:05 AM, RN #1 doffed her gloves and washed her hands for ten seconds before she signed the treatment as administered in the computer. At 11:07 AM, RN #1 obtained the garbage bag from Resident #177's room that contained soiled wound treatment supplies and placed the bag in the soiled utility room. At 11:08 AM, the surveyor observed RN #1 as she washed her hands for 13 seconds. At 11:10 AM, when interviewed about what PPE needed to be worn during a wound treatment for a resident on Enhanced Barrier Precautions, RN #1 stated staff were required to wear both a gown and gloves to protect their clothing. RN #1 then stated, I did not put a gown on, did I ? When interviewed about hand hygiene requirements RN #1 stated she was required to clean her hands prior to entry, before dressing removal, and after the wound treatment for 20 seconds. RN #1 stated she sang Happy Birthday once to ensure that she had washed her hands for a full 20 seconds. RN #1 stated hands would not be cleaned if they were washed for less than 20 seconds. RN #1 further stated there was a chance of contamination if she failed to wash her hands after she doffed her gloves post wound treatment and then reached into her pocket and obtained the keys to the treatment cart, cleaned her scissors, marker and then accessed the treatment cart and computer. On 06/18/2024 at 11:26 AM, Surveyor #1 interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated both a gown and gloves were needed for Enhanced Barrier Precautions to prevent infection. LPN/UM #2 stated with direct care and touch, a gown should be worn as it could put the resident at risk for infection when care was rendered. LPN/UM #2 stated that hands were required to be washed for 30 seconds. LPN/UM #2 stated staff were required to wash their hands when gloves were doffed to ensure nothing got under the gloves. LPN/UM #2 further stated the main goal was infection prevention. On 06/18/2024 at 3:35 PM, Surveyor #1 interviewed the Infection Preventionist (IP) who stated for Enhanced Barrier Precautions staff should minimally wear a gown and gloves when wound care was rendered for a sacral wound. The IP stated if a gown were not worn there was a concern the nurse could give the resident an infection of some sort. The IP stated that if a resident were colonized (germs are on the body but do not make you sick) with an infection than the nurse risked infection as well. The IP stated the main concern was the patient. At that time, Surveyor #1 interviewed the IP regarding handwashing. The IP stated that staff were required to wash their hands for a minimum of 20 seconds and sing Happy Birthday twice. The IP stated if hands were washed for less than 20 seconds, then your hands were obviously not cleaned and you did not kill or get off the germs that were possibly still on your hands. The IP stated you could possibly contaminate everything you touched if your hands were not washed after you doffed your gloves post wound treatment because there was a possibility that an organism could be spread to the scissors or items that were cleaned and spread to the next person. The IP stated the keys to the treatment cart were touched multiple times a day and were then passed off with the possibility for infection to spread down the line. On 06/19/2024 at 12:40 PM, Surveyor #1 interviewed the Director of Nursing (DON) in the presence of the survey team, who stated Enhanced Barrier Precautions required both gloves and gown for the protection of the patient and staff during a sacral wound treatment. The DON stated hand hygiene should be performed for 20 seconds or more, as there was a potential for contamination if hands were washed for less than 20 seconds. The DON stated there was a chance of cross contamination if hands were not washed after gloves were doffed post wound treatment. On 06/19/2024 at 11:09 AM, the DON provided Surveyor #1 with RN #1's Hand Hygiene Competency Validation and Wound Treatment Observation Competency both of which were dated 04/02/24. A review of a Wound Treatment Observation a tool the facility uses (revised 06/2022) revealed the following: .Perform hand hygiene before beginning the procedure (rub hand [sic.] with soap for 20 seconds) Put on gloves, loosen tape and remove soiled dressing, place in garbage. Wash hands and don gloves. (Rub hands with soap for 20 seconds). Pour cleaning solutions on gauze sponges. Cleanse wound and pat dry. Wash hands and don gloves (rub hands with soap for 20 seconds). Apply treatment as ordered. Cover wound with clean dressing (add the labeled dressing or tape). Remove gloves and Perform Hand hygiene. (rub hand [sic.] with soap for 20 seconds) *Sanatize [sic] pen Reposition resident if necessary and place call light within easy reach. Perform hand hygiene (rub hand [sic.] with soap for 20 seconds) Sanatize [sic.] over bed table. Perform Hand Hygiene (rub hand [sic.] with soap for 20 seconds) Discard garbage in soiled utility room. Perform hand hygiene (rub hand [sic.] with soap for 20 seconds) . 39460 2. On 6/17/2024 from 8:05 AM through 8:31 AM, Surveyor #2, during the Medication Pass observation of LPN #2, made the following observations: LPN #2 was standing at her medication cart when Surveyor #2 approached her for medication pass observation. LPN #2 prepared the oral medications for Resident #135, set them aside and began preparing for the resident's insulin (a medication used to treat high blood sugar) injection. LPN #2 donned (put on) disposable gloves and administered the insulin to Resident #135. Once administered, LPN #2 doffed (removed) her gloves and without performing hand hygiene, proceeded to hand Resident #135 the prepared cup of oral medications as well as a cup of water. After completing medication pass for Resident #135, LPN #2 documented the medication administration in the computer and touched both the keyboard and the mouse, again without performing hand hygiene. LPN #2 then grasped the medication cart with both hands and wheeled the cart to the room of Resident #81. LPN #2 then proceeded to prepare Resident # 81's oral medication, without performing hand hygiene. LPN #2 then proceeded into Resident #81's room, administered their oral medications and after she exited Resident #81's room she performed hand hygiene using alcohol based hand rub (ABHR) at the medication cart. On 6/17/2024 at 8:31 AM, Surveyor #2 interviewed LPN #2 who acknowledged she should have performed hand hygiene before donning gloves and after doffing her gloves and between caring for Resident #135 and Resident #81, and confirmed not doing so was an infection control issue. On 6/20/2024 at 9:45 AM, Surveyor #2 interviewed the facility's Infection Preventionist (IP) who stated LPN #2 should have performed hand hygiene before preparing the insulin syringe. The IP stated the nurse should have done hand hygiene first, then she should have gotten the insulin pen primed and ready, then used hand hygiene again and donn gloves, administered the mediation, removed her gloves and again performed hand hygiene, either washing with soap and water or using ABHR. The IP stated nurses should always use hand hygiene between residents. On 6/20/2024 at 11:09 AM, the survey team met with the facility Administration which included the ADON who confirmed that staff should perform hand hygiene before and after wearing gloves and it must be performed between caring for each resident to prevent infection. A review of the facility provided Medication Administration General Guidelines for the Administration of Medications policy undated, included . The nurse washes his/her hands appropriately before and after medication administration . A review of the facility provided Medication Pass Observation form revised 6/17, included . Hand washing (alcohol based hand rub or soap and water . between every resident even if patient contact is not made . immediately before and after use of gloves . A review of the facility provided untitled Hand Hygiene policy last reviewed 1/24, revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. . the preferred method of hand hygiene is with alcohol-based hand rub . .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents .before donning sterile gloves . before preparing or handling medications .Before handling clean or soiled dressings, gauze pads, etc.; . after removing gloves .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and after removing gloves. Hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. A review of the facility policy, Enhanced Barrier Precautions (Created 03/25/24/Revised 06/19/24) revealed the following: Enhanced Barrier Precautions (EBP)-refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact activities. .Examples of high-contact resident care activities requiring a gown and gloves for Enhanced Barrier Precautions include: .Wound care for chronic wounds requiring a dressing NJAC 8:39-19.4(n)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter drainage bag off the floor to prevent the spread of infection and according to the facility protocol. This was identified for 1 of 2 residents (Resident #18) reviewed for indwelling urinary catheters. This deficient practice was evidenced by the following: On 10/04/2022 at 10:34 AM, the surveyor observed Resident #18 in a wheelchair in the hallway near the nurse's station. The surveyor observed a urinary catheter drainage bag was attached to his/her wheelchair and the urinary drainage bag had direct contact with the floor. On 10/06/2022 at 12:00 PM the surveyor observed Resident #18 in bed. The surveyor observed the urinary catheter drainage bag had direct contact with the floor on the window side of the bed. A review of the medical record revealed Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS), an assessment tool, dated 07/04/2022, revealed that Resident #18 was identified as having an indwelling urinary catheter. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the surveyor on 10/17/22 at 11:01 AM, the Licensed Practical Nurse Unit Manager stated that the urinary catheter drainage bag should not be on the floor. During an interview with the surveyor on 10/17/22 at 11:43 AM, the Director of Nursing stated that a urinary catheter drainage bag should not be on the floor. A review of a facility Foley Catheter Protocol with a reviewed date of 1/2022, included: 10. Urinary catheter Bag must not touch the floor or be placed above resident's bladder. NJAC 8:39-19:4(a) (1-6)

C#: NJ 6 Based on interviews, medical record reviews, and reviews of other pertinent facility documents on 5/3/2022, it was determined that the facility failed to provide a resident with Intellectual Disabilities and Autistic Disorder staff assistance needed to meet the Resident's needs at an appointment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed and was evidenced by the following: Review of Resident #3's Electronic Medical Record (EMR) was as follows: According to the Admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Admission Minimum Data Set (MDS) dated [DATE], Resident #3's ability to express ideas and wants is sometimes understood. The Resident sometimes understands and adequately responds to simple, direct communication only. Further review of the MDS revealed that Resident #3 needed extensive assistance and 2-person physical assistance with transfers, toileting, and personal hygiene. The MDS also showed Resident #3 was incontinent of bowel and bladder and needed staff assistance with balance during transitions and walking. A review of Resident #3's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's Progress Notes dated 4/18/2022 at 2:26 p.m. written by the Licensed Practice Nurse (LPN) revealed that the Resident was picked up by transport for a follow-up ortho (orthopedics) appointment at 11:25 a.m. and remained out at this time. A review of the Assignment Sheet dated 4/18/2022 revealed the appointment was listed, but no staff name was listed to accompany the Resident to the appointment. A review of the April Transportation Log (ATL) revealed a Date of 4/18/2022, under Resident, showed Resident #3's name with Appt. (Appointment) Type as Ortho (Orthopedics), and under the column titled Escort (staff), revealed a blank space. During an interview on 5/3/2022 at 2:08 p.m. with Resident #3, when the surveyor asked the resident direct questions, the Resident could not answer the questions accurately and would reply, yeah, and I have to ask my mom. During an interview on 5/3/2022 at 2:19 p.m., the LPN assigned to Resident #3 on 4/18/2022 the surveyor asked if the Resident needed staff to accompany him/her on an appointment; she stated the Resident definitely needed someone to go with him/her. The LPN further said the process is the Unit Secretary communicated with the Staffing Coordinator, and she scheduled what staff would go on the appointment with the Resident. She explained she reminded the Staffing Coordinator in the morning that the person (Resident) needed an aide (Certified Nursing Assistant, CNA). The LPN said as the nurse; it is my responsibility to make sure staff goes with the Resident, and I would remind the Staffing Coordinator that morning of the appointment. During a second interview on 5/3/2022 at 2:25 p.m., when the surveyor asked the LPN if Resident #3 had staff go on the 4/18/2022 appointment with him/her, the LPN replied, I can't remember if staff went with (him/her). She further stated that Resident #3 would not be able to answer questions during an appointment, the Resident talks about his/her mom, and it would not be safe for Resident #3 to go to the appointment alone. During an interview on 5/3/2022 at 4:09 p.m., the Director of Rehabilitation/ Physical Therapist stated that Resident #3 is not able to transfer without assistance and needs physical assistance to perform functional mobility and Activities of Daily Living (ADLs). When the surveyor asked him if it was unsafe for Resident #3 to go to a doctor's (physician) appointment alone, he replied, Oh yes, for safety, he/she should have an escort the Resident needs supervision. The DOR/PT continued to say that Resident #3 needed verbal cueing to perform proper technique and sequencing of tasks for safety. When the surveyor asked him if Resident #3 could answer questions, he stated not coherently; the Resident did not make sense. During an interview on 5/3/2022 at 5:10 p.m., the Director of Nursing (DON) stated the Assignment Sheet would be noted for the appointment with an escort, but since there is no name listed, Resident # 3 did not have an escort. It was decided on a case-by-case basis if a resident needed an escort for an appointment. When the surveyor showed her the ATL, the DON stated since the column titled Escort was blank, Resident #3 did not have an escort. During a post-survey telephone interview on 5/5/2022 at 8:25 a.m., the Physician Assistant (PA) at the Orthopedist appointment on 4/18/2022 stated that when Resident #3 was brought to her examination room, the Resident came unassisted by the facility staff and would not cooperate during the X-ray. The Resident could not communicate and kept saying I'm fine repetitively. When I tried to examine the incision, she stated that the Resident had his/her hands up, wouldn't let the PA examine him /her, and was scared, so I stopped the examination. It was my first meeting with the Resident. The PA further stated she did not know Resident #3's mobility status because no therapy note was sent with the Resident. During a post-survey telephone interview on 5/9/2022 at 8:42 a.m., the Office Supervisor/Assistant Operations Manager (OS/AOM) at the Orthopedist appointment on 4/18/2022 stated that Resident #3 was dropped off by transport and alone. Transport said to her that the Resident was not cooperative. The Resident had a 1:00 p.m. appointment. She further stated Resident #3 could not communicate his/her needs to staff. The OS/AOM said she told the Resident that X-ray staff would be with him/her soon, but the Resident had no response. At 2:45 p.m., she did speak with the nurse, and she informed her that Resident #3 needed staff with him/her. The OS/AOM further stated that Resident #3 was scared, complained, shouted, I want to leave, and refused the X-ray and examination, so the appointment was not done, and the facility was made aware. During a post-survey telephone interview on 5/9/2022 at 11:20 a.m. with the X-ray Supervisor at the Orthopedist appointment on 4/18/2022, she stated Resident #3 was confused, scared, and didn't understand what needed to get done. Resident #3 was unable to communicate and stayed in the wheelchair the whole time. We locked the wheelchair; the Resident could not do it him/herself. We didn't know his/her mobility. She further stated that Resident #3 pushed me out of the way, so we stopped. The x=ray was unable to be completed. The facility failed to ensure that Resident #3 had facility staff assistance at the Orthopedist appointment on 4/18/2022. N.J.A.C.: 8:39-27.1 (a)

Complaint Intake #NJ 8 Based on interviews, record reviews, and facility policy reviews, it was determined that the facility failed to prevent complications from enteral (tube) feedings for one (Resident #1) of three residents reviewed for tube feedings. This deficient practice resulted in Resident #1 being found cyanotic (blue), and being admitted to the hospital and diagnosed with aspiration pneumonia (tube feeding in airway and lungs) due to lying flat in bed while the tube feeding was infusing. Resident #1 was then found in respiratory distress and was admitted to the hospital with aspiration pneumonia a couple of months later. Findings included: 1. A review of Resident #1's face sheet indicated the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was not able to be cognitively assessed due to being nonverbal and nonresponsive. The MDS indicated the resident was dependent on staff for all nutrition, toileting, hygiene, and repositioning. A review of Resident #1's care plan, dated [DATE], indicated the resident was receiving enteral (fed via a tube) feedings and was at risk for aspiration (feeding entering the lungs and airway). The care plan indicated the resident's head of the bed (HOB) was to be elevated. A review of Resident #1's dietician order note, dated [DATE] at 2:26 PM, indicated the resident was receiving [MEDICATION(S)] 1.5 milliliters (ml) 1000 ml total volume daily to be changed at 5:00 PM and infused at 50 ml per hour via gastrostomy tube (G-tube). A review of Resident #1's nurses notes, dated [DATE] at 1:50 PM, indicated the physician ordered the resident be sent to the emergency room to rule out possible aspiration. The notes indicated the unit manager (UM) and the resident's guardian were made aware. The notes did not indicate the details of the events requiring the resident to be hospitalized . A review of Resident #1's hospital History and Physical (H&P), dated [DATE], indicated the resident was admitted to the intensive care unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's nurses notes, dated [DATE] at 1:05 AM, indicated Resident #1 was observed being repositioned with the tube feeding on. The resident was found to be in respiratory distress with an oxygen saturation level of ,d+[DATE]%. 911 was called, and the resident was transferred to the hospital. A review of Resident #1's hospital H&P, dated [DATE], indicated the resident was admitted into the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's nurses notes, dated [DATE] at 3:15 PM, indicated the resident was readmitted to the facility. The notes did not indicate if any special aspiration precautions were to be taken. During an interview on [DATE] at 8:09 AM, Certified Nursing Assistant (CNA) #2 stated Resident #1 must have the HOB always elevated. CNA #2 stated the nurse caring for the resident needed to turn off the tube feeding before the resident could be changed or given a bath. CNA #2 could not remember the last time an in-service was provided about tube feedings or aspiration precautions. An interview on [DATE] at 8:40 AM revealed CNA #3 was working on [DATE]. CNA #3 stated CNA #1 left the resident lying flat with the tube feeding infusing. The CNA stated the resident then turned blue, and nurses had to perform life-saving measures. CNA #3 stated the UM was informed the resident was lying flat. CNA #3 stated no in-service was given, just a talk about the incident, and CNA #3 and was not sure if CNA #1 was counseled. CNA #3 stated the UM talked to the staff after Resident #1 was taken to the hospital about always having the HOB elevated, but CNA #3 could not recall an in-service being provided about tube feedings or aspiration precautions. During an interview on [DATE] at 8:44 AM, the Dietician stated Resident #1 was at high risk for aspiration and needed to have feeding turned off prior to medication administration, residuals checked, and the head of the bed (HOB) always elevated. The Dietician stated Resident #1 was hospitalized multiple times for issues with the G-tube and therefore needed specialized precautions. The Dietician stated adjustments were made to the tube feeding rates by the dietician to reduce risk of aspiration, and nursing was responsible for implementing aspiration precautions. An interview on [DATE] at 9:00 AM revealed CNA #1 cared for Resident #1 on [DATE]. CNA #1 denied remembering the resident lying flat, only that the resident was having difficulty breathing. CNA #1 stated LPN #1 was informed, and the resident was sent to the hospital. CNA #1 stated the resident's HOB should have always been elevated. CNA #1 stated the nurses dealt with the feeding. An interview on [DATE] at 9:35 AM revealed CNA #4 was assigned to care for Resident #1 for the first time this day and was not aware of any aspiration precautions in place for the resident. CNA #4 was not aware the resident was on tube feeding. CNA #4 stated in-services and training on tube feedings or aspirations precautions had not been provided since the start of employment a week prior. An interview on [DATE] at 9:40 AM revealed Registered Nurse (RN) #1 was working on [DATE]. RN #1 stated Resident #1 was left lying flat and aspirated. RN #1 stated the code light was pushed by LPN #1, and RN #1 went to the room. RN #1 stated, not going to lie to you, the head of the bed was flat, and when RN #1 entered the room, LPN #1 raised the HOB up to 30 degrees then ran to go grab a suction machine because there was not one in the room. RN #1 stated the tube feeding was still infusing, and RN #1 turned it off. RN #1 stated the resident was turned to their side, and feeding was in the resident's mouth. RN #1 stated CPR was then performed. RN #1 stated RN #1 and the unit manager performed CPR, and LPN #1 called 911. RN #1 stated the resident was revived when EMS arrived. EMS then transported the resident to the ER. RN #1 stated the resident aspirated. RN #1 stated Resident #1's HOB should have been up. RN #1 stated aspiration precautions must be followed to prevent situations like that one. RN #1 stated all staff were talked to after the incident. RN #1 stated that the incident was considered a change of condition, and a detailed progress note of all the events should have been documented. RN #1 stated a code sheet was not used, and all documentation should have been entered by LPN #1 in the resident's progress notes. RN #1 reviewed Resident #1's progress notes and risk management reports and confirmed no documentation for the incident was done. RN #1 stated detailed documentation of all incidents, especially changes in condition such as the event on [DATE], had to be documented and exactly what happened described to keep an accurate record of the resident's medical condition and changes in condition. An interview on [DATE] at 11:00 AM revealed the UM was working on [DATE]. The UM stated they arrived at the room at the back end of things. The UM clarified and stated he entered the room when the resident was already placed at 30 degrees. The UM stated that when the UM entered the resident's room, the resident's HOB was at about 30 degrees and the resident was purple. The UM stated the resident was turned on their side, and the UM noticed the feeding was still infusing. The UM stated the feeding was turned off, and finger sweeps revealed feeding was coming out of the resident's mouth. The UM stated no compressions were performed, only respiratory measures which included suctioning. The UM stated the resident was revived and sent to the hospital. The UM stated the CNAs had reported the resident was lying flat. The UM did not recall which CNAs. The UM stated the entire unit was talked to after the incident but did not recall if any documentation had been done about the education provided. The UM stated the staff were in-serviced about keeping the HOB elevated for Resident #1 and aspiration precautions. The UM could not provide in-service records. The UM did not recall documenting the in-service. The UM reviewed Resident #1's progress notes and risk management reports and confirmed no documentation was entered regarding the incident on [DATE]. The UM stated detailed documentation was necessary to give the reader a clear description of what happened and to document any deviations from baseline. The UM reviewed Resident #1's care plan and confirmed the care plan for aspiration precautions had not been revised upon readmission on [DATE]. The UM confirmed a new care plan was not created for the actual aspiration. The UM stated a revision in the plan of care was needed to ensure the incident did not happen again. The UM reviewed Resident #1's progress notes for [DATE] and indicated the resident was sent to the hospital again for possible aspiration. The UM stated the tube feeding was infusing while the resident was being repositioned. The UM stated the note did not indicate who repositioned the resident. The UM stated if the care plan had been updated on [DATE], the incident on [DATE] could have been prevented. The UM confirmed the care plan, as of [DATE], had still not been updated or a care plan for actual aspiration created. The UM was not aware of how aspiration precautions were communicated with staff, other than the nurses verbally communicating the information to the CNAs and the care plan. During a concurrent interview and record review on [DATE] at 3:10 PM, the Assistant Director of Nursing (ADON) stated they were responsible for all in-services and training for staff. The ADON stated CNAs were trained in tube feedings and competencies verified upon hire, after 90 days of hire, and annually. The ADON reviewed CNA #1's employee file and confirmed competencies for tube feedings were not documented for CNA #1. The ADON reviewed the competency checklist for new hires and confirmed tube feeding competency was not a part of the checklist. The ADON provided the last in-service on tube feedings titled, ADL coding PCC/Incontinence Care/Tube Feeding, dated [DATE]. The in-service sign-in sheet had 18 signatures; CNA #1's signature was the last signature on the sheet. The educational material provided with the sign-in sheet did not have any education regarding tube feeding. The ADON confirmed the tube feeding information was not a part of the in-service package. The ADON was not informed by the UM that an incident had occurred on [DATE] with Resident #1 and did not provide an in-service to the staff regarding aspiration precautions or tube feedings. The ADON was not informed that an incident had occurred on [DATE] and did not provide an in-service to the staff regarding aspiration precautions or tube feedings. During an interview on [DATE] at 3:45 PM, the Director of Nursing (DON) provided a policy titled, Gastric-Tube Feeding Management, and was undated. The DON stated there was no policy for CNAs on the management and care of tube feedings. The DON stated the nurses managed the tube feedings and just told the CNAs what needed to be done. The DON stated the facility had no policy on aspiration precautions, and the staff just followed the plan of care. The DON did not wish to review Resident #1's medical record and stated the incidents occurred before the DON was employed by the facility. The DON stated all information needed could be accessed by reading the documentation. An interview on [DATE] at 9:25 AM revealed CNA #5 had been employed with the facility since [DATE]. CNA #5 stated the ADON went to the units on [DATE] to inform all CNAs that residents with tube feedings needed to have their HOB always elevated. CNA #5 stated the only precautions that needed to be taken for residents on tube feeding or aspiration precautions was to have the head of the bed elevated straight up and keep them NPO (nothing by mouth). CNA #5 did not know of any precautions regarding tube feeding infusing during care or baths. CNA #5 did not know how to tell if a resident was on aspiration precautions. An interview on [DATE] at 9:35 AM revealed Technical Nursing Assistant (TNA) #1 had been employed with the facility since [DATE]. TNA #1 stated training for tube feeding and aspiration precautions had never been provided until [DATE], when the nurse educator went to the unit to tell them residents with tube feedings had to have the HOB always elevated. TNA #1 stated during her orientation and training, the CNA did not have any tube feeding residents assigned; therefore, they did not go over that. TNA #1 did not know what aspiration precautions were. TNA #1 did not know the degree limitations for the HOB and stated to just keep them elevated. TNA #1 did not know of any precautions regarding tube feeding infusing during care. TNA #1 stated the nurses managed the tube feeding and could turn it on and off. TNA #1 stated that the way to know if a resident was on a tube feeding was if I see a tube. A review of the facility's policy, titled, Gastric Tube Feeding Management, undated, did not provide and procedures for management of feeding when providing care or repositioning. The DON stated the facility did not have a policy on documentation. New Jersey Administrative Code S8:39 - 27.1(a)

Complaint Intake #NJ 8 Based on interviews and record reviews, it was determined that the facility failed to develop, implement, and revise a comprehensive care plan needed to outline interventions to care for one (Resident #1) of three sampled residents on tube feedings and at risk for aspiration. Resident #1 was left lying flat and aspirated (tube feeding entered the airway and lungs) on 08/11/2021. A care plan was not developed for aspiration pneumonia, and Resident #1 was sent to the hospital again on 10/29/2021 to rule out aspiration pneumonia. Findings included: 1. A review of Resident #1's face sheet indicated the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was not able to be cognitively assessed due to being nonverbal and nonresponsive. The MDS indicated the resident was dependent on staff for all nutrition, toileting, hygiene, and repositioning. A review of Resident #1's care plan, dated 02/24/2021, indicated the resident was receiving enteral (fed via a tube) feedings and was at risk for aspiration (feeding entering the lungs and airway). The care plan indicated the resident's head of the bed (HOB) was to be elevated. A review of Resident #1's dietician order note, dated 07/15/2021 at 2:26 PM, indicated the resident was receiving [MEDICATION(S)] 1.5 milliliters (ml) 1000 ml total volume daily to be changed at 5:00 pm and infused at 50 ml per hour via gastrostomy tube (G-tube). A review of Resident #1's nurses notes, dated 08/11/2021 at 1:50 PM, indicated the physician ordered the resident be sent to the emergency room to rule out possible aspiration. The notes indicated the unit manager (UM) and the resident's guardian were made aware. The notes did not indicate the details of the events requiring the resident to be hospitalized . A review of Resident #1's hospital History and Physical (H&P), dated 08/11/2021, indicated the resident was admitted to the intensive care unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #1's care plan indicated no revisions or new care plans were created for the aspiration that occurred on 08/11/2021. A review of Resident #1's nurses notes, dated 10/29/2021 at 1:05 AM, indicated Resident #1 was observed being repositioned with the tube feeding on. The resident was found to be in respiratory distress with an oxygen saturation level of 89-90 percent. 911 was called and the resident was transferred to the hospital. A review of Resident #1's hospital H&P, dated 10/29/2021, indicated the resident was admitted into the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's nurses notes, dated 11/06/2021 at 3:15 PM, indicated the resident was readmitted to the facility. The notes did not indicate if any special aspiration precautions were to be taken. A review of Resident #1's care plan indicated no revisions or new care plans were created for the suspected aspiration on 10/29/2021. During an interview on 12/14/2021 at 8:09 AM, Certified Nursing Assistant (CNA) #2 stated Resident #1 must have the HOB always elevated. CNA #2 stated the care plan was accessible to CNAs to review, but Resident #1 did not have a care plan for aspiration precautions and CNA #2 would ask the nurse for direction. During an interview on 12/14/2021 at 8:44 AM, the Dietician stated Resident #1 was at high risk for aspiration and needed to have feeding turned off prior to medication administration, residuals checked, and the head of the bed (HOB) always elevated. The Dietician stated Resident #1 was hospitalized multiple times for issues with the G-tube and therefore needed specialized precautions. The Dietician stated adjustments were made to the tube feeding rates by the dietician to reduce risk of aspiration, and nursing was responsible for implementing aspiration precautions. An interview on 12/14/2021 at 9:00 AM revealed CNA #1 cared for Resident #1 on 08/11/2021. CNA #1 denied remembering the resident lying flat, only that the resident was having difficulty breathing. CNA #1 stated Licensed Practical Nurse (LPN) #1 was informed, and the resident was sent to the hospital. CNA #1 stated the resident's HOB should have always been elevated. CNA #1 stated the nurses dealt with the feeding, and the CNA was not aware of a care plan for the tube feeding. During an interview on 12/14/2021 at 9:35 AM, CNA #4 stated the CNA was assigned to care for Resident #1 for the first time this day and was not aware of any aspiration precautions in place for the resident. CNA #4 was not aware the resident was on tube feeding. CNA #4 did not know how to access the resident's care plan. During an interview on 12/14/2021 at 9:40 AM, Registered Nurse (RN) #1 reviewed the resident's care plan and confirmed a care plan was not in place for aspiration precautions. RN #1 stated a care plan for aspiration precautions should have been in place prior to the 08/11/2021 incident and revised after the resident returned from the hospital, to prevent the resident from aspirating again. RN #1 confirmed a care plan was still not in place at the time of the interview. During an interview on 12/14/2021 at 11:00 AM, the Unit Manager (UM) reviewed Resident #1's care plan and confirmed the care plan for aspiration precautions had not been revised upon readmission on 08/29/2021. The UM confirmed a new care plan was not created for the actual aspiration that occurred. The UM stated a revision in the plan of care was needed to ensure the incident did not happen again. The UM reviewed Resident #1's progress notes for 10/29/2021 and indicated the resident was sent to the hospital again for possible aspiration. The UM stated the tube feeding was infusing while the resident was being repositioned. The UM stated the note did not indicate who repositioned the resident. The UM stated if the care plan had been updated on 08/29/2021, the incident on 10/29/2021 could have been prevented. The UM confirmed the care plan, as of 12/14/2021, had still not been updated or a care plan for actual aspiration created. The UM stated the licensed nurses were responsible for updating the care plan. During an interview on 12/14/2021 at 3:45 PM, the Director of Nursing (DON) did not wish to review Resident #1's medical record and stated the incidents occurred before the DON was employed by the facility. The DON stated all information needed could be accessed by reading the documentation. The DON stated the facility did not have a policy for care plans because the care plan was a standard of practice. New Jersey Administrative Code S8:39-11.1

Complaint Intake #NJ 8 Based on interviews and record reviews, the facility failed to ensure certified nursing assistants were trained and able to demonstrate competency in skills and techniques necessary to care for one (Resident #1) out of three sampled residents on tube feedings and at risk for aspiration. Findings included: 1. A review of Resident #1's face sheet indicated the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was not able to be cognitively assessed due to being nonverbal and nonresponsive. The MDS indicated the resident was dependent on staff for all nutrition, toileting, hygiene, and repositioning. A review of Resident #1's care plan, dated 02/24/2021, indicated the resident was receiving enteral (tube) feedings and was at risk for aspiration (feeding entering the lungs and airway). The care plan indicated the resident's head of the bed (HOB) was to be elevated. A review of Resident #1's dietician order note, dated 07/15/2021 at 2:26 PM, indicated the resident was receiving [MEDICATION(S)] 1.5 milliliters (ml) 1000 ml total volume daily to be changed at 5:00 PM and infused at 50 ml per hour via gastrostomy tube (G-tube). A review of Resident #1's nurses notes, dated 08/11/2021 at 1:50 PM, indicated the physician ordered the resident be sent to the emergency room to rule out possible aspiration. The notes indicated the unit manager (UM) and the resident's guardian were made aware. The notes did not indicate the details of the events requiring the resident to be hospitalized . A review of Resident #1's hospital History and Physical (H&P), dated 08/11/2021, indicated the resident was admitted to the intensive care unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's nurses notes, dated 10/29/2021 at 1:05 AM, indicated Resident #1 was observed being repositioned the with tube feeding on. The resident was found to be in respiratory distress with an oxygen saturation level of 89-90%. 911 was called and the resident was transferred to the hospital. A review of Resident #1's hospital H&P, dated 10/29/2021, indicated the resident was admitted into the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/14/2021 at 8:09 AM, Certified Nursing Assistant (CNA) #2 stated Resident #1 must have the HOB always elevated. CNA #2 could not state other needed interventions to prevent aspiration. CNA #2 could not remember the last time an in-service was provided about tube feedings or aspiration precautions. CNA #2 stated competency training on tube feedings or aspiration precautions were not part of the new hire orientation. An interview on 12/14/2021 at 8:40 AM revealed CNA #3 was working on 08/11/2021. CNA #3 stated CNA #1 left the resident lying flat with the tube feeding infusing. The CNA stated the resident then turned blue, and nurses had to perform life saving measures. CNA #3 stated the unit manager was informed the resident was lying flat. CNA #3 stated no in-service was given, just a talk about the incident. CNA #3 stated the UM talked to the staff after Resident #1 was taken to the hospital about always having the HOB elevated but could not recall an in-service being provided about tube feedings or aspiration precautions. An interview on 12/14/2021 at 9:00 AM revealed CNA #1 cared for Resident #1 on 08/11/2021. CNA #1 denied remembering the resident lying flat, only that the resident was having difficulty breathing. CNA #1 stated LPN #1 was informed, and the resident was sent to the hospital. CNA #1 stated the resident's HOB should have always been elevated. CNA #1 stated the nurses dealt with the feeding, and CNA #1 and did not recall the last in-service or training given. An interview on 12/14/2021 at 9:35 AM revealed CNA #4 was assigned to care for Resident #1 for the first time this day and was not aware of any aspiration precautions in place for the resident. CNA #4 was not aware the resident was on tube feeding. CNA #4 stated in-services and training on tube feedings or aspiration precautions were not provided during the hire process a week prior. CNA #4 stated competencies were not assessed for tube feedings and aspiration precautions. An interview on 12/14/2021 at 9:40 AM revealed Registered Nurse (RN) #1 was working on 08/11/2021. RN #1 stated Resident #1 was left lying flat and aspirated. RN #1 stated Resident #1's HOB should have been up. RN #1 stated aspiration precautions must be followed to prevent situations like that one. RN #1 stated all staff were talked to after incident. RN #1 did not remember any recent in-services on tube feeding or aspiration precautions. During an interview on 12/14/2021 at 11:00 AM, the Unit Manager (UM) stated the CNAs had reported the resident was lying flat. The UM did not recall which CNAs. The UM stated the entire unit was talked to after the incident but did not recall if any documentation had been done about the education provided. The UM stated the staff were in-serviced about keeping the HOB elevated for Resident #1 and aspiration precautions. The UM could not provide in-service records. The UM did not recall documenting the in-service. The UM stated education and competency verification was necessary to prevent complication from enteral feedings such as aspiration pneumonia. During a concurrent interview and record review on 12/14/2021 at 3:10 PM, the Assistant Director of Nursing (ADON) was responsible for all in-services and trainings to staff. The ADON stated CNAs were trained on tube feedings and competencies verified upon hire, after 90 days of hire, and annually. The ADON reviewed CNA #1's employee file and confirmed competencies for tube feedings were not documented for CNA #1. The ADON reviewed the competency checklist for new hires and confirmed tube feeding competency was not a part of the checklist. The ADON provided the last in service on tube feedings titled, ADL coding PCC/Incontinence Care/Tube Feeding, dated 09/06/2021. The in-service sign-in sheet had 18 signatures; CNA #1's signature was the last signature on the sheet. The ADON confirmed the facility had close to 200 employees. The educational material provided with the sign-in sheet did not have any education regarding tube feeding. The ADON confirmed the tube feeding information was not a part of the in-service package. The ADON was not informed by the UM that an incident had occurred on 08/11/2021 with Resident #1 and did not provide an in-service to the staff regarding aspiration precautions or tube feedings. The ADON was not informed that an incident had occurred on 10/29/2021 and did not provide an in-service to the staff regarding aspiration precautions or tube feedings. During an interview on 12/14/2021 at 3:45 PM, the Director of Nursing (DON) provided a policy titled, Gastric-Tube Feeding Management, which was undated. The DON stated there was no policy for CNAs on the management and care of tube feedings. The DON stated the nurses managed the tube feedings and just told the CNAs what needed to be done. The DON stated the facility had no policy on aspiration precautions, and the staff just followed the plan of care. The DON did not wish to review Resident #1's medical record and stated the incidents occurred before the DON was employed by the facility. The DON stated all information needed could be accessed by reading the documentation. An interview on 12/15/2021 at 9:25 AM revealed CNA #5 had been employed with the facility since 12/09/2021. CNA #5 stated the ADON went to the units on 12/14/2021 to inform all CNAs that residents with tube feedings needed to have their HOB always elevated. CNA #5 stated the only precautions that needed to be taken for residents on tube feeding or aspiration precautions was to have the head of the bed elevated straight up and keep them NPO (nothing by mouth). CNA #5 did not know of any precautions regarding tube feeding infusing during care or baths. CNA #5 did not know how to tell if a resident was on aspiration precautions. An interview on 12/15/2021 at 9:35 AM revealed Technical Nursing Assistant (TNA) #1 had been employed with the facility since January 2021. TNA #1 stated training for tube feeding and aspiration precautions had never been provided until 12/14/2021, when the nurse educator went to the unit to tell them residents with tube feedings had to have the HOB always elevated. TNA #1 stated during her orientation and training the CNA did not have any tube feeding residents assigned; therefore, they did not go over that. TNA #1 did not know what aspiration precautions were. TNA #1 did not know the degree limitations for the HOB and stated to just keep them elevated. TNA #1 did not know of any precautions regarding tube feeding infusing during care. TNA #1 stated the nurses managed the tube feeding and could turn it on and off. TNA #1 stated the way to know if a resident was on a tube feeding was if I see a tube. During a follow-up interview and record review on 12/15/2021 at 9:45 AM, the ADON provided an untitled and undated document and stated the document was the complete in-service given on tube feedings. The document indicated, All CNAs to ask nurse to turn the feeding off before providing care. Head of bed should be up while in bed except when providing care. Notify nurse if notice any changes. The ADON could not state the degree limitations for the HOB and stated, straight up. The ADON stated the facility did not have a policy for aspiration precautions, and the document provided was created by the ADON. During an interview with the Administrator and DON on 12/15/2021 at 3:40 PM, the Administrator stated all staff were in-serviced regularly. The DON confirmed the ADON did not have appropriate documentation of in-services, competencies, or trainings. The DON did not wish to comment further. New Jersey Administrative Code: §8:39-43.1

Complaint Intake #NJ 8 Based on record review and interviews, it was determined that the facility failed to maintain complete and accurate documentation in accordance with acceptable standards of practice for one (Resident #1) of three residents sampled for a change in condition. Specifically, Resident #1 required life-saving measures and was sent to the hospital via emergency medical services and the incident requiring the transfer was not documented. Findings included: 1. A review of Resident #1's face sheet indicated the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was not able to be cognitively assessed due to being nonverbal and nonresponsive. The MDS indicated the resident was dependent on staff for all nutrition, toileting, hygiene, and repositioning. A review of Resident #1's care plan, dated 02/24/2021 indicated the resident was receiving enteral (tube) feedings and was at risk for aspiration (feeding entering the lungs and airway). The care plan indicated the resident's head of the bed (HOB) was to be elevated. A review of Resident #1's dietician order note, dated 07/15/2021 at 2:26 PM, indicated the resident was receiving [MEDICATION(S)] 1.5 milliliters (ml) 1000 ml total volume daily to be changed at 5:00 PM and infused at 50 ml/hr via gastrostomy tube (G-tube). A review of Resident #1's nurses notes, dated 08/11/2021 at 1:50 PM, indicated the physician ordered the resident be sent to the emergency room to rule out possible aspiration. The notes indicated the unit manager and the resident's guardian were made aware. The notes did not indicate the details of the events requiring the resident to be hospitalized . A review of Resident #1's hospital History and Physical (H&P), dated 08/11/2021, indicated the resident was admitted to the intensive care unit (ICU) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes did not indicate if any special aspiration precautions were to be taken. An interview on 12/14/2021 at 8:40 AM revealed Certified Nursing Assistant (CNA) #3 was working on 08/11/2021. CNA #3 stated CNA #1 left the resident lying flat with the tube feeding infusing. The CNA stated the resident then turned blue, and nurses had to perform life-saving measures. CNA #3 stated the unit manager was informed the resident was lying flat. An interview on 12/14/2021 at 9:00 AM revealed CNA #1 cared for Resident #1 on 08/11/2021. CNA #1 denied remembering the resident lying flat, only that the resident was having difficulty breathing. CNA #1 stated the Licensed Practical Nurse (LPN) #1 was informed, and the resident was sent to the hospital. CNA #1 stated the resident's HOB should have always been elevated. CNA #1 stated the nurses dealt with the feeding. During an interview on 12/14/2021 at 9:40 AM, Registered Nurse (RN) #1 stated the incident on 08/11/2021 was considered a change of condition, and a detailed progress note of all the events should have been documented. RN #1 stated a code sheet was not used, and all documentation should have been entered by LPN #1 in the resident's progress notes. RN #1 reviewed Resident #1's progress notes and risk management reports and confirmed no documentation for the incident was done. RN #1 stated detailed documentation of all incidents, especially changes in condition such as the event on 08/11/2021, had to be documented and exactly what happened described to keep an accurate record of the resident's medical condition and changes in condition. During an interview on 12/14/2021 at 11:00 AM, the Unit Manager (UM) reviewed Resident #1's progress notes and risk management reports and confirmed no documentation was entered regarding the incident on 08/11/2021. The UM stated detailed documentation was necessary to give the reader a clear description of what happened and to document any deviations from baseline. The UM stated a revision in the plan of care and accurate documentation was needed to ensure the incident did not happen again. During an interview on 12/14/2021 at 3:45 PM, the Director of Nursing (DON) stated all information detailing the incident on 08/11/2021 could be accessed by reading the documentation. The DON stated the nurses documented by exception, meaning the nurses only documented when something abnormal happened. The DON did not wish to further review Resident #1's medical record and stated the incidents occurred before the DON was employed by the facility. The DON stated the facility did not have a policy on documentation and stated documentation was a standard of practice but did not want to elaborate on what that meant. New Jersey Administrative Code §8:39-13.1

COMPLAINT # NJ 0 Based on interviews, medical record (MR) review and other pertinent facility documentation on 7/10/2018 and 7/11/2018, it was determined that on 3/29/2018, the facility failed to ensure that a moderately cognitively impaired resident who had a known history of wandering in the facility was appropriately supervised and or monitored by facility staff to prevent an elopement for 1 of 7 sampled Residents, (Resident #2), when the Certified Nursing Assistant (CNA#1) allowed Resident #2 to exit the locked unit unescorted, which resulted in the Resident exiting the building and being missing from the facility form 3/29/2018 through 4/07/2018, a total of 10 days. The Resident was observed outside of the locked unit by the Certified Home Health Aide (CHHA) / Certified Nursing Assistance (CNA) following CNA #1. The Resident was found on 4/07/2018, by the West Springfield Police Department of Massachusetts and was returned to the facility on [DATE]. This deficient practice placed Resident #2 and all other Residents who were at risk or who had a known history of wandering and or elopement, in an Immediate Jeopardy (IJ) situation. The IJ was past noncompliance (PNC) for 3/29/2018, when the facility implemented acceptable interventions for a Plan of Correction. The deficient practice was evidenced by the following: 1. According to the Admission Record, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In addition, Resident #2's physician's orders [REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 1/19/2018, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating the Resident was moderately cognitively impaired. The MDS also indicated that Resident #2 required limited assistance with activities of daily living (ADLs) and was able to ambulate. According to the Facility Reportable Event (FRE) dated 3/29/2018, the FRE indicated that the Unit Manager was alerted by the Unit Clerk that the resident was spotted at Dunkin Donut. The FRE also revealed that Resident #2 was residing in the secured unit of the facility. Further review of the FRE revealed that CNA #1 left the secured unit without assuring the unit door was secure. The Conclusion of the FRE indicated than CNA #1 left the Oak Unit (locked unit) without assuring the unit door was secure as he/she was previously trained and aware of the elopement risk for residents residing on the unit. The document continued to revealed that the error in CNA #1's judgement and lack of action of assuring the door was secured provided Resident #2 with the opportunity to slip through the door and walk down the hallway to the lobby of the main entrance. There was no documentation provided indicating that CNA #1 was previously trained on elopement risk for Resident's residing in the locked unit. The surveyor reviewed Resident #2's nurses note (NN) dated 3/28/2018 at 2:22 a.m. The NN revealed Resident #2 was being aggressive towards facility staff on the 11:00 p.m. to 7:00 a.m. shift. Further review of the NN indicated that the resident stated, I'M Leaving . I'M going to leave this place. In addition, Resident #2's NN dated 4/09/2018 at 1:10 p.m., included the following late entry for 3/29/2018 at 11:30 a.m. Resident exited the facility unattended and it was reported to the administrator, elopement protocol initiated. Pemberton Township Police, Guardian, attending MD (Medical Doctor), and Department of Health notified. Further review of Resident #2's NN dated 4/08/2018 at 10:17 a.m., revealed Resident #2 returned to the facility at 6:00 a.m. According to Resident #2's Care Plan (CP) with an initiated date of 11/03/2017, and a revision date of 4/09/2018. The CP revealed that the resident was at risk for elopement related to wandering and exit-seeking at times and there was a potential for injury related to wandering. In addition, the CP revealed that Resident #2 whereabouts on the unit should be monitored. The CP also implied Resident #2 should be redirected when noted near exits or exit seeking behavior was observed. Further review of Resident #2's CP revealed the Resident eloped on 3/29/2018. The CP interventions dated 11/03/2017, included Encouraged to maintain in supervised area and elopement assessment per-protocol. Further review of the CP showed an initiated date of 4/08/2018, the CP revealed that Resident #2 had a wanderguard bracelet to the right ankle. The surveyor reviewed of a facility's document titled Statement, dated 3/29/2018 and untimed, written by CNA #1. The CNA documented that he/she does not remember seeing a patient (resident) following him/her upon exiting the locked unit. In addition, CNA #1 specified in the statement that if a patient (resident) had followed me the alarm should have alerted me and other employees that a patient (resident) was leaving. CNA #1 continued to explain that the CNA could have safely redirected the resident back to the unit. The surveyor reviewed a second Statement, dated 3/29/2018 and untimed, written by the Unit Clerk (UC). The UC documented that between 8:00 a.m. and 9:00 a.m., CNA #2 asked the UC if Resident #2 was still a resident at the facility. The UC continued to explain that CNA #2 stated that someone texted CNA #2 stating they saw someone who looked like Resident #2 walking on Route 38. The UC documented he/she notified the UM for the locked unit. A review of a facility's document, unnamed and dated 3/29/2018 at 8:00 a.m., written by the Assistant Director of Nursing (ADON), indicated that the ADON came in at approximately 8:00 a.m. and noticed the front door to be open slightly. The ADON also documented that at the same time she notified the receptionist. The surveyor reviewed the facility inservice documents signed by facility staff with an initiated date of 3/29/2018 and an end date of 3/31/2018. The In-Service document titled Residents with behaviors indicating they want to leave facility or exit seeking. The document included but was not limited to the following under Education: If a resident is indicating that they wish to leave the facility and/or is exit seeking, a resident on the locked unit, must be placed on every 15 minute checks The surveyor reviewed a second facility's In-Service document titled Residents in the locked unit. The document included but was not limited to the following under Education: When arriving or exiting the locked/secured Unit-Oak, all staff must insure that no residents are following behind them. In addition, all staff must insure that the door is secured and locked. During an interview with the Assistant Director of Nursing (ADON) on 7/10/2018 at 10:25 a.m., the ADON stated that he/she came in to the facility around 7:45 a.m., and observed the first door leading out of the lobby slightly ajar. In addition, the ADON stated that there was no one in the vicinity and the head Receptionist arrived at this time and the ADON and Receptionist called maintenance who came and fixed the door right away. The ADON continued to explain that she did not notify anyone else of the door because when she/he looked out the door she/he could see anyone that was in the vicinity. The ADON also stated that the Receptionist no longer works at the facility. That Receptionist was unavailable for interview. During an interview with the Director of Maintenance (DOM) on 7/10/2018 at 11:00 a.m., the DOM stated that all the facility exit doors have a code alert. According to the DOM a staff can only exit the locked unit with a swipe card which is on the individual's badge. Also, the DOM stated that once a resident exits the locked unit with a wander guard even if escorted by a staff with a swipe badge the alarm system will alarm and must be reset with a code. The DOM indicated that the current system on the locked unit has been in place prior to the 3/29/2018 elopement incident. In addition, the DOM explained to the surveyor that there has been a censor added to the exit door and with the new system, when an employee uses the swipe card and put in a code the system would still alarm if the door is not reset by the person at the receptionist desk. The DOM further explained even if the individual attempted to exit the building without being let out by the front desk and has no wanderguard the censor will alarm. During an interview with the Unit Manager (UM) on 7/10/2018 at 12:05 p.m., the UM stated that he/she did not notice Resident #2 on the unit at the beginning of the shift but received a call around 9:00 a.m., from the UC, that somebody thought they saw Resident #2 at the Dunkin Donut, and a searched was initiated and the Administrator was notified. During an interview with CNA #3 on 7/10/2018 at 1:02 p.m., the CNA stated that he/she saw Resident #2 just after 7:00 a.m. The CNA continued to explain that Resident #2 came to the nurse's station and asked CNA #3 for a drink of water and walked back towards his/her room after receiving the water. During an interview with CNA #2 on 7/10/2018 at 1:25 p.m., the CNA stated that he/she received a text message between the hours of 7:30 a.m. and 8:00 a.m., from a friend who previously worked at the facility asking if Resident #2 was still at the facility. CNA #2 continued to explain that the CNA replied that Resident #2 should still be in the facility and notified his/her supervisor to call down to the resident's unit to see if Resident #2 was still in the facility. In addition, the CNA stated that the supervisor no longer works at the facility. That supervisor was unavailable for interview. During an interview with a Certified Home Health Aide (CHHA) /CNA on 7/10/2018 at 1:35 p.m., the CHHA stated that he/she observed Resident #2 following CNA #1 between the hours of 7:40 a.m. and 8:00 a.m. During an interview with CNA #1 on 7/11/2018 at 9:26 a.m., the CNA stated that he/she did not notice any resident exit the locked unit at the time he/she did. CNA #1 also explained that he/she did not hear the alarm sound to notify him that Resident #2 had exited the unit or he/she could have redirected the resident back to the locked unit. During a second interview with the ADON on 7/11/2018 at 11:15 a.m., the ADON stated that he/she was responsible for in-serving staff. In addition, the ADON stated that all staff working in the facility were in-serviced, including agency staff, on 3/29/2018. The ADON specified that based on the facility's Elopement Risk Assessment policy, the nurse should assess the resident upon admission, quarterly, and when the Resident has a significant change. The ADON also indicated that when Resident #2 verbalized exit seeking behavior this was a significant change and the nurse should have done an elopement assessment. During an interview with the Director of Social Services (DOS) and Social Worker (SW), in the presence of the Assistant Director of Nursing (ADON), on 7/11/2018 at 11:32 a.m., the SW stated that Resident #2 was moved to the locked unit due to the resident's behavior. In addition, the DOS explained that Resident #2's wanderguard was discontinued because the resident was no longer exit seeking and was now on a locked unit. During a third interview with the ADON on 7/11/2018 at 12:20 p.m., the ADON stated that the main reason Resident #2 eloped out of the building was the Resident followed CNA #1 out of the locked unit. In addition, the ADON stated that the facility found a door alarm necessary to exit the building. In addition, the ADON explained to the surveyor that facility staff were in-serviced to ensure if Residents say they want to get out of the facility that staff take the Resident's verbalization seriously and initiate monitoring on the twenty-four (24) hour report right away so the resident can be evaluated for any changes and the doctor can evaluate the resident. During the exit conference with the Director of Nursing (DON) and Administrator on 7/11/2018 at 1:00 p.m., the DON indicated that interventions implemented for Residents who are exit seeking included the following: An assessment will be conducted of the Resident, the resident will be placed on (q) every 15- minute checks and a code alert will be applied onto the resident. The DON stated that the incident will be documented on the twenty four (24) hour report and the Interdisciplinary Care Team (IDCT) will meet and discuss the issue. Quality Assurance will evaluate quarterly. A review of a facility's policy titled Elopement Risk assessment dated ,[DATE], included but was not limited to the following: Purpose: To assess all residents for risk of elopement and provide appropriate interventions when the risk of elopement exists. Under Policy: 4. The nurse will indicate if the resident is or is not at risk for elopement and the appropriate interventions that have been initiated, reviewed or modified in the summary of assessment area of the elopement risk assessment. 7. If a resident is identified as at risk for elopement based on the assessment one or more of the following measures will be put into place: Resident will have a Code Alert transponder sensor placed on their body, wheelchair or walker. Resident will be placed on secured unit. Resident's profile will be developed and maintained at the front desk. The IJ PNC was corrected on 3/29/2018, when the facility put the following corrective actions in place: 1. All staff at the facility were inserviced on 3/29/2018, through 3/31/2018, on when arriving or exiting the locked/secured Unit-Oak, all staff must insure that no residents are following behind them. In addition, all staff must insure that the door is secured and locked. 2. All staff at the facility were inserviced on 3/29/2018, through 3/31/2018, on if a resident is indicating that they wish to leave the facility and/ or is exit seeking, a resident on the locked unit, must be placed on every 15 minute checks. If a resident is on an unsecured unit, an elopement risk must be completed and a wanderguard applied as necessary. Until a wanderguard is available, resident must be placed on 1:1. If any member of the staff not behaviors, they must report behavior to (the) nurse immediately. 3. CNA #1 had an Individual Education, inservice on the above completed on 3/30/2018. 4. The facility updated the alarm system called the Napco Gemini Alarm System to the lobby on 3/29/2018, which alarm at the Oak unit nurse's station, when triggered. 5. Resident #2 had a wanderguard applied, placed on 1:1 observation up on readmission to the facility on [DATE], and q 15- minute checks at the time of discharge on 6/08/2018. NAACP 8:39-33.1(d)