Every finding on record at Aster Creek Nursing and Rehabilitation Center

Complaint 2962681Based on interviews, review of the medical records, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a resident (Resident #2) was free from significant medication errors on 03/21/26. On 3/21/26 at approximately 11:55 AM the LPN administered the wrong medications; Amlodipine 10 mg (milligrams) (a prescription medication to treat high blood pressure), Aspirin 81 mg, Divalproex Na 125 mg (a prescription medication used to treat certain types of seizures/epilepsy), Zoloft 50 mg (a prescription medication used to treat Major Depressive Disorder (MDD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Posttraumatic Stress Disorder (PTSD), Premenstrual Dysphoric Disorder (PMDD), and Social Anxiety Disorder), and Iron 325 mg intended for another resident (Resident #1) to Resident #2. Resident #2 was assessed and sent to the emergency room and admitted for observation, returning to the facility on 3/23/26.The facility self-corrected and put themselves back in compliance to prevent serious harm from occurring or recurring on 3/28/26 when education on Rights of Med Pass for licensed facility staff nurses was completed. The IJ was Past Non-Compliance (PNC). This deficient practice was identified for 1 of 5 residents (Resident #2) reviewed for significant medication error.The evidence was as follows:A review of the facility's policy titled, Medication Administration revised 4/2025, included under Policy, It is the policy of the Nursing Department to administer medications to residents in a timely (within one hour of prescribed time) and accurate manner (observing 5 rights in giving medications) and to ensure that all medications are prescribed by a physician and administered by a licensed nurse. Under Purpose: To provide a safe, effective medication administration process. Under Procedure: 4. The licensed nurse is to identify the resident to whom he/she is to administer medications before commencing administration. This can be accomplished by checking the resident's name band.A review of the Facility Reportable Event (FRE) dated 3/21/26, submitted to the New Jersey Department of Health (NJDOH) included the following:On March 21, 2026, an agency nurse [initials redacted] asked Staff Registered Nurse (RN #1) [initials redacted] to identify Resident #1. RN #1 identified Resident #1 as the resident seated at the end of the table in the dayroom with grey hair in a ponytail. Shortly thereafter, the agency nurse reported that he believed he had administered medications intended for Resident #1 to the wrong resident, identified as Resident #2, who was seated in the middle of the table.The facility provided a summary of the investigation related to the FRE, which stated that the Certified Nursing Aide (CNA #1) had observed the agency nurse who was a Licensed Practical Nurse (LPN) administering medications to Resident #2. CNA #1 questioned the LPN as she knew that Resident #2 was not in his assignment. After being questioned by the CNA, the LPN reported himself to RN #1 and stated he believed he administered medications to the wrong resident.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia (significant, progressive decline in memory) and dysphagia (difficulty swallowing).According to the Minimum Data Set (MDS), an assessment tool dated 2/9/26, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated that the resident's cognition was moderately impaired.Resident #2's CP included the following:Under Focus date initiated 9/11/23: I [Resident #2] have impaired cognitive function/dementia. Under Goal: I [Resident #2] will develop skills to cope with cognitive decline and maintain safety by the review date. Under Interventions: Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Provide the resident with necessary cues - stop and return if agitated.A review of Resident #2's Order Summary Report (OSR) revealed the following physician's orders (PO):-Amlodipine Besylate Tablet 2.5 MG Give 1 tablet by mouth one time a day related to essential (primary) hypertension (HTN) (high blood pressure that has no single, distinct, or underlying medical cause) hold if Systolic Blood Pressure (SBP) less than 110.A review of Resident #2's vital signs indicate that at 3/21/26 at 12:10 PM, Resident #2 had a blood pressure of 137/60. On 3/21/26 at 12:37 PM, Resident #2's blood pressure was 99/47 before Resident #2 was transported to the hospital.According to the AR, Resident #1 was admitted to the facility with diagnoses which included but were not limited to: essential (primary) hypertension, kidney transplant status, and weakness.According to the MDS, an assessment tool dated 2/3/26, Resident #1 had a BIMS score of 15 out of 15 which indicated that the resident was cognitively intact.Resident #1's CP included the following:Under Focus date initiated 2/1/26: The resident has hypertension (HTN) r/t (related to) lifestyle choices, Smoking. Under Interventions: Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden, significant drop in blood pressure that occurs when standing up from a sitting or lying position) and increased heart rate (Tachycardia) and effectiveness.A review of Resident #1's OSR revealed the following PO:- Amlodipine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day for HTN.A review of the electronic Medication Administration Records (eMAR) showed that Resident #2 received their prescribed 2.5 mg of Amlodipine and due to the medication error, received another 10 mg dose of Amlodipine (for a total of 12.5 mg), as well as Aspirin 81 mg, Divalproex Na 125 mg (a prescription medication used to treat certain types of seizures/epilepsy), Zoloft 50 mg (a prescription medication used to treat Major Depressive Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Posttraumatic Stress Disorder, Premenstrual Dysphoric Disorder and Social Anxiety Disorder), and Iron 325 mg prescribed for Resident #1. On 5/13/26 at 10:11 AM, the surveyor interviewed CNA #2 who stated that to identify a resident there is a name tag on the resident's door, a staff member could simply ask the resident themselves or if the resident is unable to respond staff can check the resident's wristband or can check with another coworker.On 5/13/26 at 10:25 AM, the surveyor interviewed RN #2. RN #2 reported that to identify residents there are pictures of residents in Point Click Care (PCC), that resident names are outside the door of their rooms, to check wristbands, or to confirm with another staff member the resident's identity.On 5/13/26 at 10:50 AM, the surveyor interviewed the Unit Manager (UM) for Unit 4 of the facility. The UM stated that her expectations for staff at her facility, when it comes to med pass, is that medications are given in a safe and respectful manner which follows the guidelines for the policies and practices that are put in place. She further stated that she expects her staff to give the right medications to the right residents. On 5/13/26 at 11:11 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the LNHA in training. The DON stated she was notified by her UM via a phone call regarding the LPN administering the wrong medications to Resident #2. She stated that she had concerns about observing Resident #2 due to Resident #2's age and the type of medications that had been administered, as well as the potential side effects.On 5/13/25 at 11:49 AM, the surveyor interviewed the DON who stated there were pictures of the residents (referring to PCC) so she was unsure how or why the medication error occurred. She further stated that Resident #1 and Resident #2 are different ethnicities and skin tones and that the LPN did not follow the rights of medication by looking at the picture to identify the resident.On 5/13/25 at 12:55 PM, the surveyor interviewed the DON and LNHA with the LNHA in training present. The DON stated that the facility reviews medication pass during agency nurse orientation but that a direct med pass is not conducted. The LNHA stated that the medication error should not have occurred, whether an agency or a staff nurse, because all residents have pictures in PCC. He further stated that agency staff could also ask another staff member to verify a resident's identity. On 5/14/25 at 12:30 PM in a phone interview with the UM the surveyor confirmed the UM had conducted and signed off on the LPN's Nursing Agency Orientation Checklist. The surveyor questioned the UM on what that orientation consisted of and how long it took. The UM stated that it takes about ten minutes and it's a review and reading of the facility policies that are listed on the checklist, including Medication Pass competency 5 rights.The facility addressed the situation by immediately removing the LPN, contacting the agencies who supply the facility with agency staff and requesting that all licensed nurses from agencies have completed abuse and neglect training and medication pass competency validation prior to their first shift at the facility, and completing in-services to all their licensed facility staff nurses regarding the Rights of Med Pass on 3/28/26.The IJ began 3/21/26, when the LPN failed to identify the correct resident to administer medications to, which led to a significant medication error. The IJ is Past Non-Compliance. The surveyor verified the implementation of the facility's Removal Plan (RP) while onsite on 5/13/26 and determined that there is sufficient evidence that the facility corrected the noncompliance on 3/28/256 and is in substantial compliance at the time of the current survey for the specific regulatory requirements for F760. N.J.A.C. 8:39-29.2(d)

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to initiate a complete and thorough investigation after a cognitively intact resident made an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse. The evidence is as follows:A review of the facility's Abuse Prevention and Management policy, revised 4/2025, included; the facility prohibits the mistreatment, neglect, and abuse of residents/patients. by anyone including staff, family, friends, etc. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. The facility must provide a safe resident environment and protect residents from abuse . The Administrator and Director of Nursing (DON) are responsible for investigation and reporting. Upon receiving an incident or suspected incident of resident abuse, the Administrator/DON/designee will conduct an investigation to include but not limited to the following: Complete paperwork for investigation of abuse; Interview the person (s) reporting the incident; Interview the resident, if able; Interview the resident's attending physician and review of the resident's record; Interview staff members (on all shifts) having contact with the resident during the alleged incident; Interview the resident's roommate, family member, and visitors if applicable; Interview other residents to which the accused employee provides care or services; Review all circumstances surrounding the incident; Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors, family members who may be interviewable and have information regarding the allegation. Document results of the investigation in the Risk Management Notes or Follow Up section in the electronic file. Conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision, to substantiate, or not substantiate the allegation. Employee Suspension from Duty. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient, which names a specific employee, the employee is suspended until completion of the investigation. Witness reports shall be in writing or typed. Witnesses will be required to sign and date such report. The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly and objectively. The Administrator/DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate .On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11, who alleged that Licensed Practical Nurse (LPN #1) was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. On [DATE] at 12:06 PM, the surveyors interviewed the Director of Nursing (DON) regarding Resident #11's allegation, and she stated that Resident #11 has made allegations, and everything had been looked into and there has never been a patient as challenging. The DON further stated, I could be investigating the resident every day and there is only so much a person can take. The DON further stated that the Licensed Nursing Home Administrator (LNHA) had done the investigations. At that time, the DON further stated Resident #11 had cursed her out so badly last Wednesday or Thursday and told her that she should be ashamed of her staff. The DON stated when she asked what the resident was referring to the resident went on a rant about LPN #1 and LPN #2. The DON stated at that time, the LNHA arrived and stated to the resident, You will return to your room and calm down, and told the resident to go back to their room. The DON further stated that she never learned of the concern that Resident #11 had with LPN #1 and LPN #2 because the LNHA had told the resident to return to their room. On [DATE] at 1:39 PM, the surveyor interviewed the LNHA via phone in the presence of the survey team. The LNHA stated that Resident #11 had sent him an email in the middle of the night, and he recalled seeing it in the morning and couldn't remember the details at that time. The LNHA stated that he had gotten statements from both of the involved nurses (LPN #1 and LPN #2) about what occurred the night before and one of the nurses documented the event in the electronic health record [software name redacted]. The LNHA stated that he did not know if any residents had witnessed the event and had not obtained resident witness statements. The LNHA stated that he did interview the resident, but he did not get a written statement. When the surveyor asked if the allegation was reported to the New Jersey Department of Health (NJDOH) the LNHA stated nothing was done because we (the LNHA) could not substantiate what the resident said, and he did not think the allegation was a nature of abuse. The LNHA agreed to furnish the surveyor with the full investigation including the aforementioned email for surveyor review. The surveyor reviewed the medical record for Resident #11. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to; unspecified injury at C1 (cervical neck region) level of the cervical spinal cord, subsequent encounter paraplegia (paralysis of the lower body, typically caused by spinal injury or disease), personality disorder, mood disorder due to known physiological condition with mixed features, anxiety disorder, unspecified, adjustment disorder, unspecified, major depressive disorder, recurrent, and Post-Traumatic Stress Disorder (PTSD), unspecified.A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident did not experience any hallucinations or delusions and did not have any physical or verbal behaviors directed towards others or rejection of care. A review of the Individual Comprehensive Care Plan (ICCP) included the following focus areas:A focus area initiated on [DATE], which indicated Resident #11 will make false accusatory statements, verbally inappropriate with staff using vulgar language .Interventions included: .Ensure they [sic.] are 2 (two) staff members when rendering any care to the resident. Care in pairs .A focus area initiated on [DATE], which indicated Resident #11 makes false accusations, will take information and suggestions and twist the information to make the facility look deficient. Interventions included: Explain protocols in a clear manner, respond to his/her concerns in a timely manner, try not to be confrontational but report the facts as they occur, two staff members at a time should report to his/her room when he/she raises concerns. A review of the Progress Notes (PN) included a Behavior Note dated [DATE] at 9:31 PM, that was written by LPN #2 that was presented to the surveyor as part of the LNHA's investigation included in the LNHA's investigation revealed: Resident was in hallway going back and forth stating he was looking for staff. Staff approached resident and asked if he/she needed help resident told writer he/she needed a band-aid. While waiting for the band-aid the resident seen a staff member he/she did not like he proceeded to call LPN #1 a crack head and made mocking vomiting noises. Staff member ignored the residents' comments and continued to do her work. Resident was on the phone with someone stating if the person seen the crackhead. Resident continued his/her taunting then stated he/she got something for staff. Resident started talking about staff member's deceased son. The staff member told resident stop riding back and forth to the nurse's station if he/she doesn't need anything resident got confrontational then told writer that she should have corrected her, writer explain [sic.] I am not getting into this.On [DATE] at 2:35 PM, the DON provided the surveyor with the LNHA's full investigation which consisted of an email that was directed to the LNHA and was written by Resident #11 on [DATE] at 11:36 PM. The email included an allegation that LPN #1 screamed at the resident to stop passing back and forth in front of the nurses' station on the phone and called the resident an ugly cripple. The resident reportedly responded to LPN #1 and told her that she cared for the resident more than her two dead sons. To which LPN #1 responded, Watch your mouth, you [expletive redacted] piece of shit. A Behavior Note was also provided dated [DATE] at 9:31 PM, written by LPN #2, and a statement dated [DATE] at 9:30 PM, written by LPN #1 that were also included as part of the investigation.A review of The Individual Completing Form, that was completed by LPN #1 on [DATE], presented to the surveyor as part of the LNHA's investigation included, Resident #11 was riding back and forth past the nurse's station saying foul things to this writer while on his/her phone. The resident stated the good ppl (people) get into trouble not crack heads. Then tried to have someone on phone and pointing it to me. After a while, I said stop, why are you keeping riding by. I asked did he/she need his/her nurse. I said please don't speak to me. I walked away. He/she began to start yelling at the other nurse and CNA (Certified Nursing Assistant) told him/her to go to his/her room.On [DATE] at 2:50 PM, the surveyor interviewed the LNHA in the presence of the survey team. When asked if the LNHA obtained a written statement from LPN #2, the LNHA stated that he interviewed LPN #2, but he did not document it. When the surveyor asked if he was required to obtain a written statement in accordance with the facility abuse policy he stated, No, I don't think so because I had the Progress Note.On [DATE] at 3:08 PM, the surveyor interviewed LPN #2 regarding the Behavior Note she documented on [DATE] at 9:31 PM, regarding the encounter that she observed between Resident #11 and LPN #1. LPN #2 stated that Resident #11 came up to me when I was doing my charting and said did you hear that? Resident #11 then stated, Did you hear what LPN #1 called me? LPN #2 stated she told the resident that she did not hear anything. LPN #2 explained that the resident stated she was in cahoots with LPN #1 and was lying and proceeded to verbally come at me. LPN #2 stated the resident targeted LPN #1, and she usually walked off. LPN #2 stated that LPN #1 asked Resident #11 why they kept going back and forth to the nurses' station if they did not need anything.At that time, LPN #2 further stated that Resident #11 came up to her with what looked like a paper cut on their right hand close to their thumb area and she offered the resident Bacitracin (antibiotic ointment), but the resident declined and just wanted a band-aid. LPN #1 stated she went straight to the treatment cart and provided the resident with a band-aid. LPN #2 stated both she and CNA #2 were present. LPN #2 stated that Resident #11 then asked, did you hear what LPN #1 said to me, and LPN #2 proceeded to remove her ear bud and stated no, I did not hear anything, I was not paying attention, which made Resident #11 even madder. LPN #2 stated that the resident made statements that the nurses picked-on them because they were paralyzed. On [DATE] at 3:38 PM, the surveyor interviewed CNA #2 who stated she worked the 3:00 PM-11:00 PM shift. The CNA stated she saw Resident #11 going back and forth on their motorized wheelchair, so she stopped to fix the resident's urinary catheter that was stuck on the wheel. CNA #2 stated that Resident #11 was throwing words at the nurses, but she could not recall if the nurses said anything back to the resident. CNA #2 stated she had abuse training and if you encountered verbal abuse, you just have to listen and cannot go back and forth with the resident. CNA #2 stated the resident had a behavior pattern and was very boisterous. On [DATE] at 3:51 PM, the surveyor interviewed LPN #1 regarding the statement that she wrote on [DATE] at 9:30 PM. LPN #1 stated that Resident #11 approached her and stated that only the good people got into trouble, not the crack heads. LPN #1 asked the resident if they needed their nurse. LPN #1 explained that the resident was close with CNA #3, and she was suspended for insubordination after I had to change her assignment, and she refused and she thought that was what the resident had referenced when they stated only the good people got into trouble. LPN #1 stated, Resident #11 just kept going back and forth while they were on their cell phone saying terrible things to me about the loss of my sons. LPN #1 stated the resident held the phone up to her and stated look at this crackhead and threatened her, but she never responded, and just walked away. She stated that the resident followed her and taunted her. LPN #1 stated the administration called her and told her they were doing an investigation. She stated that they made her do a statement but never suspended her. LPN #1 further added that CNA #2 was present at that time and was trying to help the resident, but the resident just kept making pig sounds. On [DATE] at 4:12 PM, the surveyor interviewed CNA #3 who stated she provided care to Resident #11 and there was nothing extraordinary or problematic about the resident and the resident was not offensive towards her. CNA #3 stated that it went both ways between the resident and staff. CNA #3 stated Resident #11 was not fond of LPN #1, but she did not get involved in it. CNA #3 stated that the resident acted out if you were rude to them. CNA #3 stated that she heard the nurses and the resident exchange words but did not pay attention to it. CNA #3 stated if people argued, it was none of her business and that she just heard raised voices. CNA #3 stated if you went into the resident's room with an attitude the resident erupts. CNA #3 stated I just think that we need to treat the resident better. CNA #3 further stated, I have not seen any regular staff mistreat the resident.On [DATE] at 10:02 AM, the surveyor interviewed the Director of Social Services (DSS) who confirmed that she was aware of an incident on [DATE], where LPN #1 allegedly screamed at Resident #11 because the resident was going back and forth in front of the nurses station and allegedly called the resident an ugly cripple. She stated that she was also aware that LPN #1 told the resident to watch their mouth and allegedly called the resident a [expletive redacted] piece of shit. The DSS stated she was part of the investigation and obtained the statement. The DSS stated when verbal abuse was alleged, statements should be obtained from the caregivers who were involved. DSS stated that LPN #1 provided a statement to rule out any type of abuse. The DSS stated the facility was required to suspend the accused staff member until the investigation was completed. The DSS stated she did not recall if either LPN #1 or LPN #2 were suspended as a result of the allegation. The DSS indicated that the resident was care planned for fabrication. On [DATE] at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated Resident #11 came to the facility with a care plan in place for fabrication. LPN/UM #1 stated it was verified that there was no response from LPN #1. LPN/UM #1 stated if there was an allegation of verbal abuse we must immediately report it to the DON and take written statements from anyone who may have been in the vicinity at the time of the event. LPN/UM #1 stated that she reported any allegations to the LNHA, and the DON and they reported to the DOH.On [DATE] at 11:04 AM, the surveyor interviewed the LNHA who confirmed that he did not complete a full investigation which included a summary and conclusion in response to Resident #11's allegation against LPN #1 and LPN #2. The LNHA stated that he normally obtained witness statements in response to an allegation of abuse except for in the case of Resident #11, who was unique. The LNHA stated the DON informed him that she had gotten a call from LPN #1 and LPN #2 and they documented the allegation that night. The LNHA explained that LPN #2 had written a Progress Note that evening, but he guessed that LPN #1 had failed to document the event in the Progress Notes. The LNHA stated that he had spoken to LPN #1 and LPN #2 when they returned to work the next evening and had gotten the same story. The LNHA also acknowledged that he had failed to obtain a witness statement from LPN #2, as LPN #2 had written a Progress Note and he thought that sufficed. The LNHA stated if a resident accused a nurse of threatening to set the resident on fire or calling the resident a cripple, it was important to report the allegation to the DOH to ensure a proper investigation and to protect the resident. The LNHA stated if there was an allegation of abuse against a nurse, it was also important to suspend the nurse (perpetrator) if he did not have a conclusion by the next shift the nurse was scheduled to work. The LNHA revealed that to his knowledge, neither LPN #1 or LPN #2 were suspended in response to Resident #11's allegation because he concluded his investigation prior to the nurses next scheduled shift and there was no reason to punish them. The LNHA further revealed that he needed the staff to take care of his other residents. The LNHA stated he made conclusions regarding this particular resident much quicker, because Resident #11 made allegations against staff on a regular basis. The LNHA stated, the resident cried wolf, and sometimes the wolf will show up. The LNHA further stated that he realized the allegation could be true, but investigations he had done previously, made on behalf of Resident #11, have not been factual. On [DATE] at 1:50 PM, the surveyor attempted to meet with Resident #11 and was informed by the Registered Nurse (RN #2) who was assigned to the resident, that the resident was out of the facility at an appointment. RN #2 stated the resident had behaviors such as paranoia, bouts of anxiety with rapid speech, and the resident was accusatory. RN #2 stated the resident had not been abusive toward her, however, Resident #11 hated LPN #1. She stated that Resident #11 was the only resident that made complaints about LPN #1. RN #2 stated that two staff members were required to provide care to the resident as this was an intervention to provide witnesses and protect themselves from accusations. RN #2 stated she reported anything negative to the Unit Manager and the DON right away. RN #2 stated from her perspective, Resident #11 targeted LPN #1 and LPN #2 with remarks about the deaths of their family members. On [DATE] at 11:51 AM, the surveyor interviewed Resident #11 in the presence of another surveyor. Resident #11 stated he/she felt explosive when LPN #1 made statements to him/her that they were a fat, ugly, cripple. Resident #11 then explained that the facility did nothing about it at the time but confirmed that the administration then obtained statements from the resident after surveyor inquiry.On [DATE] at 12:51 PM, the surveyor interviewed the Medical Director (MD) via speakerphone with permission in the presence of the survey team. At that time, the MD confirmed that Resident #11 was her patient. The MD described Resident #11 as a very difficult patient. The MD explained that an investigation should be done in response to an allegation of abuse and staff should be interviewed and statements taken. The MD denied any knowledge of allegations of abuse from staff to resident. The MD stated that she did not think that the DOH should be notified of an allegation of abuse based on what she had seen. The MD stated that Resident #11 was not confused and was on top of things, so she did not think that there was any chance the resident could be abused because mentally the resident was awake, alert and knew what was going on. The MD stated that it would definitely be considered verbal abuse if the resident were called an ugly cripple or was threatened to be set on fire, but we would have to find out if it was true or not. On [DATE] at 1:23 PM, the surveyor requested a copy of the 400 Unit Daily Assignment Sheet dated [DATE] for the 3-11 shift, and the LNHA stated that he was unable to find it. The LNHA provided the surveyor with Timecard time stamps which indicated that on [DATE] LPN #1 clocked in at 7:08 AM and clocked out at 11:30 PM. Further review of the Timecard revealed that LPN #1 did not clock in again until [DATE] at 2:53 PM, and she clocked out at 7:15 AM on [DATE].A review of a Timecard time stamp dated [DATE], revealed that LPN #2 clocked in at 3:06 PM and clocked out at 11:28 PM. LPN #2 clocked in again on [DATE] at 3:04 PM, and clocked out on [DATE] at 7:19 AM.A review of LPN #1's personnel file revealed that there was no documented evidence of any allegations of resident abuse.A review of LPN #2's personnel file revealed that there was no documented evidence of any allegations of resident abuse. NJAC 8:39-4.1(a)(5)

Based on observation, interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being for allegations of staff-to-resident verbal abuse that occurred on [DATE], and [DATE], by failing to a.) protect all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident verbal abuse. The deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: Refer to F600, F609, F610On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN#1) was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. On [DATE] at 12:06 PM, the surveyors interviewed the Director of Nursing (DON) regarding Resident #11's allegation, and she stated that Resident #11 had made allegations, and everything had been looked into. The DON stated there has never been a patient as challenging and stated, I could be investigating the resident every day and there is only so much a person can take. The DON further stated that the Licensed Nursing Home Administrator (LNHA) had done the investigations. At that time, the DON further stated Resident #11 cursed her out last Wednesday or Thursday and told her that she should be ashamed of her staff. The DON asked the resident what they were referring to and the resident went on a rant about LPN #1 and LPN #2. The DON stated the LNHA heard the resident yelling, interceded and stated to the resident, You will return to your room and calm down. The LNHA had then instructed the resident to return to their room. The DON further revealed that the LNHA may have addressed it on Friday, but she would have to defer to the LNHA because she was out sick. The DON further revealed that she never learned of Resident #11's concern they had with LPN #1 and LPN #2 because the LNHA had told the resident to return to their room. On [DATE] at 1:39 PM, the surveyor interviewed the LNHA in the presence of the survey team on speaker phone with permission. The LNHA stated that Resident #11 had sent him an email in the middle of the night, and he recalled seeing it in the morning. The LNHA stated that he had gotten statements from both of the involved nurses LPN #1 and LPN #2 about what occurred the night before and one of the nurses documented the event in the electronic health record [software name redacted].The LNHA stated that he did not know if any residents had witnessed the event and had not obtained resident witness statements. The LNHA stated that he did interview the resident, but he did not get a written statement. When the surveyor asked if the allegation was reported to the New Jersey Department of Health (NJDOH) the LNHA stated nothing was done because we could not substantiate what the resident said, and he did not think the allegation was a nature of abuse. The LNHA agreed to furnish the surveyor with the full investigation including the aforementioned email for surveyor review. On [DATE] at 2:35 PM, the DON provided the surveyor with the LNHA's full investigation which consisted of an email that was directed to the LNHA and was written by Resident #11 on [DATE] at 11:36 PM. The email included an allegation that LPN #1 screamed at the resident to stop passing back and forth in front of the nurses' station on the phone and called the resident an ugly cripple. The resident reportedly responded to LPN #1 and told her that she cared for the resident more than her two dead sons. To which LPN #1 responded, Watch your mouth, you [expletive redacted] piece of shit. A Behavior Note was also provided dated [DATE] at 9:31 PM, written by LPN #2, and a statement dated [DATE] at 9:30 PM, written by LPN #1 that were also included as part of the investigation.On [DATE] at 3:08 PM, the surveyor interviewed LPN #2 regarding the Behavior Note she documented on [DATE] at 9:31 PM regarding the encounter that she observed between Resident #11 and LPN #1. LPN #2 stated that Resident #11 came up to me when I was doing my charting and said, Did you hear that? Resident #11 then stated, Did you hear what LPN #1 called me? LPN #2 stated she told the resident that she did not hear anything. LPN #2 explained that the resident stated she was in cahoots with LPN #1 and was lying and proceeded to verbally come for me. LPN #2 stated the resident targeted LPN #1, and she usually walked off. LPN #2 stated that LPN #1 asked Resident #11 why they kept going back and forth to the nurses' station if they did not need anything.At that time, LPN #2 further stated that Resident #11 came up to her with what looked like a paper cut on their right hand close to their thumb area and she offered the resident Bacitracin (antibiotic ointment), but the resident declined and just wanted a band-aid. LPN #1 stated she went straight to the treatment cart and provided the resident with a band-aid. LPN #2 stated both she and CNA #2 were present. LPN #2 stated that Resident #11 then stated did you hear what LPN #1 said to me, and LPN #2 proceeded to remove her ear bud and stated no, I did not hear anything, I was not paying attention, which made Resident #11 even madder. LPN #2 stated that the resident made statements that the nurses picked-on them because they were paralyzed. On [DATE] at 3:38 PM, the surveyor interviewed CNA #2 who stated she worked the 3:00 PM-11:00 PM shift. The CNA stated she saw Resident #11 going back and forth on their motorized wheelchair, so she stopped to fix the resident's urinary catheter that was stuck on the wheel. CNA #2 stated that Resident #11 was throwing words at the nurses, but she could not recall if the nurses said anything back to the resident. CNA #2 stated she had abuse training and if you encountered verbal abuse, you just have to listen and cannot go back and forth with the resident. CNA #2 stated the resident had a behavior pattern and was very boisterous. On [DATE] at 3:51 PM, the surveyor interviewed LPN #1 regarding the statement that she wrote on [DATE] at 9:30 PM. LPN #1 stated that Resident #11 approached her and stated that only the good people got into trouble, not the crack heads. LPN #1 asked the resident if they needed their nurse. LPN #1 explained that the resident was close with CNA #3, and she was suspended for insubordination after I had to change her assignment, and she refused, and she thought that was what the resident had referenced when they stated only the good people got into trouble. LPN #1 stated, Resident #11 just kept going back and forth while they were on their cell phone saying terrible things to me about the loss of my sons. LPN #1 stated the resident held the phone up to her and stated look at this crackhead and threatened her, but she never responded, and just walked away. She stated that the resident followed her and taunted her. LPN #1 stated the administration called her and told her they were doing an investigation. She stated that they made her do a statement but never suspended her. LPN #1 further added that CNA #2 was present at that time and was trying to help the resident, but the resident just kept making pig sounds. On [DATE] at 4:12 PM, the surveyor interviewed CNA #3 who stated she provided care to Resident #11 and there was nothing extraordinary or problematic about the resident and the resident was not offensive towards her. CNA #3 stated that it went both ways between the resident and staff. CNA #3 stated Resident #11 was not fond of LPN #1, but she did not get involved in it. CNA #3 stated that the resident acted out if you were rude to them. CNA #3 stated that she heard the nurses and the resident exchange words but did not pay attention to it. CNA #3 stated if people argued, it was none of her business and that she just heard raised voices. CNA #3 stated if you went into the resident's room with an attitude the resident erupts. CNA #3 stated I just think that we need to treat the resident better. CNA #3 further stated, I have not seen any regular staff mistreat the resident.On [DATE] at 10:02 AM, the surveyor interviewed the Director of Social Services (DSS) who confirmed that she was aware of an incident on [DATE] where LPN #1 allegedly screamed at Resident #11 because the resident was going back and forth in front of the nurse's station and called the resident an ugly crippled. She stated that she was also aware that LPN #1 told the resident to watch their mouth and called the resident a [expletive redacted] piece of shit. The DSS stated she was part of the investigation and obtained the statement. The DSS stated when verbal abuse was alleged, statements should be obtained from the caregivers who were involved. DSS stated that LPN #1 provided a statement to rule out any type of abuse. The DSS stated the facility was required to suspend the accused staff member until the investigation was completed. The DSS stated she did not recall if either LPN #1 or LPN #2 were suspended as a result of the allegation. The DSS indicated that the resident was care planned for fabrication. On [DATE] at 10:42 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated Resident #11 came to the facility with a care plan in place for fabrication. LPN/UM #1 stated it was verified that there was no response from LPN #1. LPN/UM #1 stated if there was an allegation of verbal abuse we must immediately report it to the DON and take written statements from anyone who may have been in the vicinity at the time of the event. LPN/UM #1 stated that she reported any allegations to the LNHA, and the DON and they reported to the DOH.On [DATE] at 11:04 AM, the surveyor interviewed the LNHA who acknowledged that he did not have a full investigation to present to the surveyor in response to Resident #11's allegation against LPN #1 and LPN #2. The LNHA stated that he normally obtained witness statements in response to an allegation of abuse except for in the case of Resident #11, who was unique. The LNHA stated the DON informed him after we talked that she had gotten a call from LPN #1 and LPN #2 and they documented the allegation that night. The LNHA explained that LPN #2 had written a Progress Note that evening, but he guessed that LPN #1 had failed to document the event in the Progress Notes. The LNHA stated that he had spoken to LPN #1 and LPN #2 when they returned to work the next evening and had gotten the same story. The LNHA also acknowledged that he had failed to obtain a witness statement from LPN #2, as LPN #2 had written a Progress Note and he thought that sufficed. When the surveyor asked the LNHA if a resident accused a nurse of verbalizing a threat to set the resident on fire or called the resident a cripple was it important to report the allegation to the NJDOH and ensure a proper investigation were completed in accordance with the facility abuse policy to protect the residents and the LNHA stated, Yes. When the surveyor asked if the accused nurse were required to be suspended immediately the LNHA stated that it was important to suspend the nurse if there was an allegation of abuse, and he did not have a conclusion by the nurse's next scheduled shift. A review of the Progress Notes (PN) included a Behavior Note dated [DATE] at 9:31 PM, that was written by LPN #2 that was presented to the surveyor as part of the LNHA's investigation revealed: Resident was in hallway going back and forth stating he was looking for staff. Staff approached resident and asked if he/she needed help resident told writer he/she needed a band-aid. While waiting for the band-aid the resident seen a staff member he/she did not like and proceeded to call LPN #1 a crack head and made mocking vomiting noises. Staff member ignored the residents' comments and continued to do her work. Resident was on the phone with someone stating if the person seen the crackhead. Resident continued his/her taunting then stated he/she got something for staff. Resident started talking about staff member deceased son. Staff member told resident stop riding back and forth to the nurse's station if he/she doesn't need anything resident got confrontational then told writer that she should have corrected her, writer explain [sic.] I am not getting into this.A review of The Individual Completing Form that was completed by LPN #1 on [DATE] that was presented to the surveyor as part of the LNHA's investigation included, Resident #11 was riding back and forth passed the nurse's station saying foul things to this writer while on his/her phone. The resident stated the good ppl (people) get in trouble & not crack heads. Then tried to have someone on phone and pointing it to me. After a while, I said stop, why are you keeping riding by. I asked did he/she need his/her nurse. I said please don't speak to me. I walked away. He/she began to start yelling at the other nurse & CNA (Certified Nursing Assistant) told him/her to go to his/her room.On [DATE] at 11:51 AM, the surveyor interviewed Resident #11 in the presence of another surveyor. Resident #11 stated he/she felt explosive when LPN #1 made statements to him/her that they were a fat, ugly, cripple. Resident #11 then explained that the facility did nothing about it at the time but confirmed that the administration then obtained statements from the resident after surveyor inquiry.At that time, Resident #11 then proceeded to describe an incident that occurred when Licensed Practical Nurse (LPN #5) was behind the resident in their room, and stepped close to the resident and proceeded to throw her hands up above the resident's head and stated, What are you going to do about it? The resident stated that he wrote an email to the Administrator and called the police. The resident stated that the police came to the facility and reviewed the video. Resident #11 stated, the cop confirmed, Yes, she was swinging her hands. The resident stated that LPN #5 cared for him once thereafter and it was okay. On [DATE] at 12:15 PM, the surveyor interviewed the LNHA regarding the allegation that Resident #11 made to the surveyors about LPN #5. The LNHA stated the resident called the police and they came out and reviewed the video footage and the police were unable to confirm the resident's allegation. When the surveyor asked if the allegation was reported to the NJDOH the LNHA stated, Probably not. The LNHA stated the resident made the report. The LNHA stated, I made the same mistake here, that I made there and confirmed that he had not done a complete and thorough investigation in response to the resident's allegation against LPN #5. The LNHA stated we watched the camera, and LPN #5 was by the door talking with her hands, but it did not look like she was trying to strike the resident. The LNHA stated that he did not recall if he suspended LPN #5 in response to the allegation. When the surveyor asked why the LNHA and the DON had not disclosed this allegation when they were initially interviewed about LPN #5 on [DATE] the LNHA stated, now that you brought it up, I remembered. On [DATE] at 12:21 PM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #11 called the police on LPN #5 at one point, and the police responded to the facility and reviewed the video footage. The DON stated that Resident #11 alleged that LPN #5 was in his/her space, but according to the video footage, the nurse talked with her hands, but she was not in the resident's space as the resident alleged. The DON stated I am overwhelmed as a DON with this resident. The DON confirmed that LPN #5 was not suspended to her knowledge. When the surveyor asked if an investigation was done or should have been done the DON stated we spoke to the resident, and the police reviewed the video and did not see anything. The surveyor then asked if the NJDOH should have been notified within two hours in response to the resident's allegation and the police being called into the facility to investigate the resident's concerns with LPN #5? The LNHA stated it depended on what the police were called for if it were required to be reported. On [DATE] at 1:23 PM, the LNHA provided the surveyor with an email that was sent to him by Resident #11 on [DATE] at 11:23 PM which indicated that LPN #5 had screamed at the resident and threw her hands into the resident's face and asked the resident, what are you going to do about it . The LNHA also provided the surveyor with a Police Report dated [DATE] at 11:22 PM, which revealed: .Officers reviewed the available footage to the best of our abilities. During the review of the footage, officers observed LPN #5 speaking with Resident #11 while standing in the doorway of the resident's room, with her hands moving while speaking. No physical altercation was observed in the footage All appeared in order.A review of the Assignment Sheet dated [DATE] for the 3-11 shift revealed that LPN #5 was assigned to Resident #11.A review of LPN #5's Time Card revealed that on [DATE] LPN #5 punched in at 8:01 AM and punched out at 11:25 PM. The surveyor reviewed the personnel file of LPN #5 which contained no documented evidence of any allegations of abuse. The surveyor attempted to phone LPN #5 for interview and was unable to reach her for comment. On [DATE] at 3:21 PM, during a later interview with the LNHA he stated the rationale for not reporting Resident #11's allegation against LPN #5 was the same for the residents' allegation against LPN #1 and LPN #2. The LNHA further stated whether it was right or wrong, when Resident #11 made an allegation, I have not been reporting it. The LNHA stated we were supposed to report any allegation of abuse to the NJDOH and the Office of the Ombudsman to make sure that we did a proper investigation. On [DATE] at 12:51 PM, the surveyor interviewed the Medical Director (MD) via speakerphone with permission in the presence of the survey team. At that time, the MD confirmed that Resident #11 was her patient. The MD described Resident #11 as a very difficult patient. The MD explained that an investigation should be done in response to an allegation of abuse and staff should be interviewed and statements taken. The MD denied any knowledge of allegations of abuse from staff to resident. The MD stated that she did not think that the DOH should be notified of an allegation of abuse based on what she had seen. The MD stated that Resident #11 was not confused and was on top of things, so she did not think that there was any chance the resident could be abused because mentally the resident was awake, alert and knew what was going on. The MD stated that it would definitely be considered verbal abuse if the resident were called an ugly crippled or was threatened to be set on fire, but we would have to find out if it was true or not. A review of the facility's Administrator Job Description policy, dated [DATE], revealed the Administrator was responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet residents' needs in accordance with federal, state and local regulations A review of the facility's Abuse Prevention and Management policy, revised 4/2025, included the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. The facility must provide a safe resident environment and protect residents from abuse . The policy further included, as part of the resident abuse prevention, that the administration would do the following: .Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property: Responding immediately to protect the alleged victim and integrity of the investigation Immediate suspension of suspected employee (s), pending outcome of the investigation The Administrator and Director of Nursing are responsible for investigating and reporting .Upon receiving an incident or suspected incident of resident abuse, neglect, or misappropriation of Resident property, or injury of unknown source, the Administrator/DON/designee will conduct an investigation to include but not limited to the following:Complete the paperwork for investigation of abuse, neglect, misappropriation;Interview the person (s) reporting the incident;Interview any witnesses to the incident;Interview the resident, if able;Interview the resident's attending physician and review of the resident's record;Interview staff members (on all shifts) having contact with the resident during the period of the alleged incident; .Interview other residents to which the accused employee provides care or services; Initiate a Risk Management Report as a New Active Incident in the electronic health record or on a paper incident report if facility does not utilize an electronic Risk Management reporting system.Initiate the investigation process. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewable and have information regarding the allegation Notify the Shift Supervisor/Charge Nurse/Manager immediately if an allegation of suspected abuse, neglect, mistreatment, misappropriation of property occurs, or injury of unknown source. This responsible Manager will then notify the Administer [sic.] and Director of Nursing immediately.Notify the designated state agency (s) within 2 (two) hours after identification of the alleged/suspected abuse, neglect and/or misappropriation incident by Electronic reporting system/fax/and or telephone based on Agency specific requirement for reporting. Initiate process according to the Federal/Stated regulations for abuse investigation and reporting and the Elder Justice Act for any incidents involving suspicion of a crime Report results of the investigation to the proper authorities as required by Federal/State law:Witness reports shall be in writing or typed. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be included with the Abuse investigation paperwork). The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly and objectively. The Administrator/DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate .NJAC 8:39-4.1(a)(5), 9.4(f)

Based on interviews, record review, and review of facility documents, it was determined that the facility failed to utilize an infection assessment tool for residents who were prescribed an antibiotic medication at the facility for 14 of 14 months reviewed.This deficient practice was evidenced by the following:A review of the facility's Antibiotic Tracking for January 2025 through February 2026 revealed antibiotics were prescribed as follows:In January 2025, nineteen antibiotics were prescribed.In February 2025, eight antibiotics were prescribed.In March 2025, eleven antibiotics were prescribed.In April 2025, twelve antibiotics were prescribed.In May 2025, ten antibiotics were prescribed.In June 2025, twelve antibiotics were prescribed.In July 2025, eight antibiotics were prescribed.In August 2025, nine antibiotics were prescribed.In September 2025, eleven antibiotics were prescribed.In October 2025, three antibiotics were prescribed.In November 2025, ten antibiotics were prescribed.In December 2025, eight antibiotics were prescribed.In January 2026, four antibiotics were prescribed.In February 2026, eight antibiotics were prescribed.On 3/9/2026 at 2:39 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that she worked part-time as the IP and as a Unit Manager (UM) for the 400 Unit. The IP stated that she has been the IP for the past two years. She further stated that just a few weeks ago she started learning the McGeer Surveillance Criteria. She added that since she began her role as the IP, she has not utilized a surveillance tool.On 3/9/26 at 3:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility just started implementing the use of the McGeer's Surveillance tool. She added that there was nothing in place, as far as surveillance prior. When asked how the facility determined that the prescribed antibiotics were appropriate, the DON stated that she did not know.A review of the facility's Infection Surveillance Plan, last reviewed May 2025, included, . A data collection tool and nationally recognized surveillance criteria will be used to conduct surveillance in a systemic fashion. A review of the facility's Antibiotic Stewardship policy, dated 11/14/25, included, Policy: It is the policy of this facility to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reducing the possible adverse events associated with antibiotic use.NJAC 8:39-19.4(d)

Based on observation and interview on 3/3/26, 3/4/26 and 3/5/26, in the presence of the Maintenance Director (MD), it was determined the facility failed to ensure the hot water supplied to resident rooms and showers were by means of the proper equipment capable of maintaining safe and comfortable temperatures. This deficient practice had the potential to affect all residents and was evidenced by the following: Observations on 3/3/26 at 10:00AM of the boiler room revealed, the hot water heater was broken and disconnected. The hot water for rooms and showers was piped from the boiler that made the hot water for heating the building. The boiler comes on and off, heating the water according to the air temperature at the thermostat, not the water temperature. In an interview at the time, the MD confirmed the observation and stated they needed to replace the hot water heater. He continued, when the hot water heater broke a plumber hooked the pipes from the hot water heater to the hot water boiler that heated the building. Observations on 3/3/26 during a facility tour between 9:30 AM and 2:22 PM revealed hot water temperature ranges as follows: 100, 85,75,70,88,110,100, and 105 degrees Fahrenheit. Observations on 3/4/26 between 10:00 AM and 11:27 AM of 18 hot water temperatures taken in resident room sinks and shower rooms revealed the temperatures ranged from 80 to 131 degrees Fahrenheit. The recorded temperatures were as follows: 90, 105, 93, 101, 90, 85, 85, 80, 131, 120, 110, 90, 91, 82, 88, 109, 89, and 85 degrees Fahrenheit. The temperature of 131 degrees Fahrenheit existed briefly and immediately began to decline to 90 degrees Fahrenheit.During an interview at the time, the MD stated it is a down time (for the boiler) and the temperature is not going to come back up until the boiler kicks back on. In an interview on 3/4/26 at 11:27 AM, the surveyor asked Resident #3 if the hot water temperature was comfortable. Resident #3 stated the water temperatures are not comfortable, sometimes they are freezing cold, sometimes they are luke warm and sometimes they are burning hot, it's different every day- they don't know what the problem is.In an interview on 3/5/26, the Administrator stated the facility was aware that the hot water heater was broken and they were planning to replace it. He continued, It has been like that since before he started, which was about five years ago.The facility's Administrator was informed of the deficient practice at the Life Safety Code exit conference on 3/5/26 at 4:08 PM.N.J.A.C. 8:39 -31.2 (e)

Based on observations, interview, record review and review of pertinent facility documentation it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a.) a resident with a diagnosis of Post Traumatic Stress Syndrome (PTSD) (Resident #11), b.) for resident that had a diagnosis of dementia (Resident #4) and c.) a resident who was prescribed continuous oxygen therapy (Resident #78) This deficient practice was identified for 3 of 26 resident records reviewed and was evidenced by the following:1.On 3/3/2026 at 11:05 AM during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to staff. A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified injury at C1 (cervical neck region), paraplegia, unspecified (paralysis of the lower body typically caused by spinal injury or disease), personality disorder, mood disorder due to known physiological condition with mixed features, anxiety disorder, unspecified, adjustment disorder, unspecified, major depressive disorder, recurrent, and Post-Traumatic Stress Disorder (PTSD) (a treatable mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events and symptoms include flash backs and high anxiety), unspecified. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/20/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident did not experience any hallucinations or delusions and did not have any physical or verbal behaviors directed toward others or rejection of care. A review of the Active Diagnoses section of the MDS revealed the resident had an active diagnosis of PTSD, in the last 7 (seven) days. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas: A focus area initiated on 5/15/2025, which indicated Resident #11 will make false accusatory statements, verbally inappropriate with staff using vulgar language .interventions included: .Ensure they [sic.] are 2 (two) staff members when rendering care to the resident. Care in pairs . A focus area initiated on 8/17/2025, which indicated Resident #11 makes false accusations, will take information and suggestions and twist the information to make the facility look deficient, interventions included: Explain protocols in a clear manner, Respond to his/her concerns in a timely manner, Try not to be confrontational but report the facts as they occur, Two staff members at a time should report to his/her room when he/she raises concerns. Further review of the ICCP revealed that there was no focus area with related interventions to address the residents' diagnosis of PTSD and related triggers. On 3/9/2026 at 2:16 PM, the surveyor interviewed the Registered Nurse (RN #2) who confirmed that as of 2/20/2026, Resident #11's diagnoses were updated to include PTSD. RN #2 stated that she did not know the exact basis for the resident's diagnosis, but stated that it may have been due to a motor vehicle accident the resident was involved in. RN #2 then proceeded to review the resident's Electronic Medical Record (EMR) and stated that she would have thought that the resident would have had a care plan in place for coping related to their PTSD, but she was unable to find one. RN #2 stated the resident's care plan should have been updated prn (as needed) and quarterly and was typically updated by the Unit Manager (UM), but the nurses could also update the care plan. On 3/9/2026 at 2:23 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated she thought that Resident #11 did have a care plan in place for PTSD. The surveyor asked LPN/UM #1 who added the diagnosis of PTSD to the admission Record and LPN/UM #1 stated, Our MDS Coordinator added a diagnosis of PTSD and did not care plan for it? LPN/UM #1 stated that was why the diagnosis of PTSD were not included in the resident's ICCP because she did not know about it. LPN/UM #1 stated the ICCP was updated after a Care Plan meeting every three months, or if a problem came up. LPN/UM #1 further stated I guess we could have updated the resident's ICCP after the resident made an allegation of abuse against Licensed Practical Nurse (LPN #1) and LPN #2 on 2/16/2026. LPN/UM #1 stated the purpose of updating the ICCP was to help identify the resident's symptoms and triggers and to help us structure the resident's activities in order to make things easier for him/her. On 3/9/2026 at 2:55 PM, the surveyor interviewed the Director of Nursing (DON) who stated she thought that Resident #11 did have a care plan in place for PTSD already, but the resident should have, so that we knew the resident's triggers and could provide better care for the resident. The DON stated that the Unit Manager was responsible for updating the resident's care plan after each occurrence so that we had a good picture of the resident's needs. On 3/10/2026 at 10:00 AM, the surveyor interviewed the MDS Coordinator who stated she updated the resident's admission Record on 2/20/2026, but she did not think that she updated the resident's care plan. The MDS Coordinator stated that she assumed the care plan was updated by nursing, as both nursing and MDS were supposed to review the care plans. The MDS Coordinator stated that she oversaw the care plan to ensure that everything was in place quarterly, annually, within 48 hours of admission, in response to a significant change in condition, and in response to any change that occurred with the resident. The MDS Coordinator further stated if the resident truly had PTSD, then he/she had to be care planned for it to ensure that goals were set and that we provided appropriate care. The MDS Coordinator then provided the surveyor with a copy of a Supportive Care Psychological Services Progress Note (SCPSPN) dated 2/20/26, which revealed the resident's diagnoses included Post-Traumatic Stress Disorder, and Major Depressive Disorder, and included related goals and interventions. The MDS Coordinator acknowledged that she updated the resident's admission Record to include Resident #11's diagnosis of PTSD after she reviewed the recommendations made in the SCPSPN, and she then failed to update the resident's ICCP afterward. On 3/10/2026 at 12:51 PM, the surveyor interviewed the facility's Medical Director (MD) on speakerphone with permission in the presence of the survey team. The MD confirmed that Resident #11 was her patient, and she did not know if the resident had a diagnosis of PTSD. The MD further stated the resident should have definitely been care planned for PTSD if psychiatry came in, to ensure that the resident's psychiatric needs were being met. On 3/10/2026 at 10:29 AM, the DON in the presence of the survey team, who stated that an ICCP for PTSD should have been initiated on 2/20/2026, rather than after surveyor inquiry. 2.On 3/4/26 at 2:07 PM, the surveyor observed Resident #4 lying in bed, dressed for the day. Various paper products and books were observed on the bed surrounding the resident. The paper items were organized in piles on the bed and in reusable shopping bags. The resident was unable to be interviewed at this time and closed their eyes and stated that they needed to resident. The surveyor reviewed the medical record for Resident #4. A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; diabetes, depression, unspecified dementia (unspecified severity and without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety), and bi-polar disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/18/26, section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 15, indicating the resident was cognitively intact. Section I of the MDS, (active diagnoses) documented a diagnosed of Non-Alzheimer's Dementia. A review of the resident's individualized comprehensive care plan (ICCP) did not include a focus area or interventions to address Resident #4's diagnosis of dementia. On 3/9/26 at 1:03 PM, the surveyor interviewed Resident #4's Registered Nurse #1 (RN#1) who confirmed the resident had a diagnosis of dementia. At that time, RN #1 and the surveyor reviewed Resident #4's ICCP. RN #1 confirmed that the care plan did not include interventions to address dementia care. On 3/9/26 at 1:24 PM, the surveyor interviewed Resident #4's Licensed Practical Nurse Unit Manager #1 (LPN/UM #1) who also confirmed Resident #4 had a diagnosis of dementia and that the care plan should reflect interventions related to those diagnoses. When asked who was responsible for creating and ensuring care plans were comprehensive, LPN/UM #1 stated the responsibility belonged to the unit manager. On 3/9/26 at approximately 3:20 PM the survey team met with the facility administration. The Director of Nursing (DON) confirmed that when a residents diagnosed with dementia the ICCP should include a corresponding focus and interventions addressing dementia. 3. On 3/3/26 at 10:59 AM, during initial tour of the facility, the surveyor interviewed LPN/UM #1 who identified Resident #78 as a resident on the unit that requiring the continuous use of oxygen (O2) therapy. On 3/4/26 at 1:55 PM, the surveyor observed Resident #78 in bed with their eyes closed while receiving O2 therapy via nasal cannula (flexible tubing with two prongs used to deliver supplemental O2 into the nostrils) at 2 liters per minute. On 3/5/26 at 12:22 PM, the surveyor again observed Resident #78 in their bed with their eyes closed while oxygen therapy continued to be administered via nasal cannula at 2 L/min. On 3/9/26 at 12:14 PM, the surveyor observed Resident #78 in bed with their eyes closed while oxygen therapy was being administered via nasal cannula at 2 L/min. The surveyor reviewed the medical record for Resident #78. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; unspecified atrial fibrillation (heart arrythmia), pressure ulcer of the sacral region (area between the base of the spine and the tailbone) and open wound on the left lower leg. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed the assessment was in process and was not available for review at that time. A review of the Order Summary Report (OSR), dated as of 3/9/26, included a physician's order (PO) dated 2/22/26, for O2 (oxygen) @ (at) 2L/min via n/c (nasal cannula) continuous every shift for O2 supplementation. A review of the resident's individualized comprehensive care plan (ICCP) revealed that the care plan did not include a focus area or interventions addressing Resident #78's use of continuous oxygen therapy. On 3/9/26 at 12:51 PM, the surveyor interviewed RN #1 who confirmed the resident had a physician's order for continuous oxygen therapy. At that time, the surveyor and RN #1 reviewed Resident #78's care plan together. RN #1 acknowledged the care plan should have included interventions addressing the resident's continuous oxygen use. On 3/8/26 at 1:29 PM, the surveyor interviewed the LPN/UM #1 who also confirmed Resident #78 had physician's orders to receive continuous oxygen therapy. LPN/UM #1 confirmed that a care plan should have been developed for Resident #78's oxygen use. She stated that it was her responsibility as well as the unit managers to initiate the resident's care plans and ensure they were comprehensive. On 3/9/26 at approximately 3:20 PM, the surveyor interviewed the DON who confirmed Resident #78 was being administered continuous oxygen therapy and that a ICCP should have been implemented for the use of oxygen therapy. The DON further added that it was important that care plans were accurate to ensure residents received proper care. A review of the facility's Care Planning policy with a revised date of 4/2025, included To foster the philosophy of the facility, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, the facility will develop a comprehensive, resident centered care plan for each resident. Care plan development, renewal and revision will be based upon the results of the resident assessment. the facility would .follow a uniform process for the comprehensive care plan upon Care Area Assessment (CAA) completion, and ensuring care plans are updated to reflect the resident's status . Ongoing updates to care plans: nursing staff will update the care plan related to physician's orders and/or changes in care needs . update acute care plans for the resident as they are warranted.include such initial needs/problems.Include a care plan related to the resident's primary diagnosis.All resident care and interventions must be carried out per the Care Plan. NJAC 8:39-11.2(e)(1)(2); 27.1 (a)

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident verbal abuse that allegedly occurred on [DATE] and [DATE], for a cognitively intact resident (Resident #11). This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: 1.On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. On [DATE] at 12:06 PM, the surveyors interviewed the Director of Nursing (DON) regarding Resident #11's allegation, and she stated that Resident #11 had made allegations, and everything had been looked into. The DON stated there has never been a patient as challenging and stated, I could be investigating the resident every day and there is only so much a person can take. The DON further stated that the Licensed Nursing Home Administrator (LNHA) had done the investigations. At that time, the DON further stated Resident #11 cursed her out last Wednesday or Thursday and told her that she should be ashamed of her staff. The DON asked the resident what they were referring to and the resident went on a rant about Licensed Practical Nurse (LPN #1) and LPN #2. The DON stated the LNHA heard the resident yelling, interceded and stated to the resident, You will return to your room and calm down. The LNHA had then instructed the resident to return to their room. The DON further revealed that the LNHA may have addressed it on Friday, but she would have to defer to the LNHA because she was out sick. The DON further revealed that she never learned of Resident #11's concern they had with LPN #1 and LPN #2 because the LNHA had told the resident to return to their room. On [DATE] at 1:39 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team on speaker phone with permission. The LNHA stated that Resident #11 had sent him an email in the middle of the night, and he recalled seeing it in the morning. The LNHA stated that he had gotten statements from both of the involved nurses LPN #1 and LPN #2 about what occurred the night before and one of the nurses documented the event in the electronic health record [software name redacted].The LNHA stated that he did not know if any residents had witnessed the event, and had not obtained resident witness statements. The LNHA stated that he did interview the resident, but he did not get a written statement. When the surveyor asked if the allegation was reported to the New Jersey Department of Health (NJDOH) the LNHA stated nothing was done because we could not substantiate what the resident said, and he did not think the allegation was a nature of abuse. The LNHA agreed to furnish the surveyor with the full investigation including the aforementioned email for surveyor review. The surveyor reviewed the medical record for Resident #11. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; unspecified injury at C1 (cervical neck region) level of the cervical spinal cord, subsequent encounter paraplegia (paralysis of the lower body, typically caused by spinal injury or disease), personality disorder, mood disorder due to known physiological condition with mixed features, anxiety disorder, unspecified, adjustment disorder, unspecified, major depressive disorder, recurrent, and Post-Traumatic Stress Disorder (PTSD), unspecified.A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident did not experience any hallucinations or delusions and did not have any physical or verbal behaviors directed towards others or rejection of care. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas:A focus area initiated on [DATE], which indicated Resident #11 will make false accusatory statements, verbally inappropriate with staff using vulgar language .Interventions included: .Ensure they [sic.] are 2 (two) staff members when rendering any care to the resident. Care in pairs A focus area initiated on [DATE], indicated Resident #11 made false accusations, would take information and suggestions and twist the information to make the facility look deficient. Interventions included: Explain protocols in a clear manner, respond to his/her concerns in a timely manner, try not to be confrontational but report the facts as they occur, two staff members at a time should report to his/her room when he/she raises concerns. A review of the Progress Notes (PN) included a Behavior Note dated [DATE] at 9:31 PM, that was written by LPN #2 revealed: Resident was in hallway going back and forth stating he was looking for staff. Staff approached resident and asked if he/she needed help resident told writer he/she needed a band-aid. While waiting for the band- aid the resident seen a staff member he/she did not like and then proceeded to call LPN #1 a crack head and made mocking vomiting noises. Staff member ignored the residents' comments and continued to do her work. Resident was on the phone with someone stating if the person seen the crackhead. Resident continued his/her taunting then stated he/she got something for staff. Resident started talking about staff member deceased son. Staff member told resident stop riding back and forth to the nurse's station if he/she doesn't need anything resident got confrontational then told writer that she should have corrected her, writer explain [sic.] I am not getting into this.On [DATE] at 2:35 PM, the DON provided the surveyor with the LNHA's full investigation which consisted of an email that was directed to the LNHA and was written by Resident #11 on [DATE] at 11:36 PM. The email included an allegation that LPN #1 screamed at the resident to stop passing back and forth in front of the nurses' station on the phone and called the resident an ugly cripple. The resident reportedly responded to LPN #1 and told her that she cared for the resident more than her two dead sons. To which LPN #1 responded, Watch your mouth, you [expletive redacted] piece of shit. A Behavior Note was also provided dated [DATE] at 9:31 PM, written by LPN #2, and a statement dated [DATE] at 9:30 PM, written by LPN #1 that were also included as part of the investigation.On [DATE] at 2:50 PM, the surveyor interviewed the LNHA in the presence of the survey team. When asked if the LNHA obtained a written statement from LPN #2 the LNHA stated that he interviewed LPN #2, but he did not document it. When the surveyor asked if he was required to obtain a written statement in accordance with the facility abuse policy he stated, No, I don't think so because I had the Progress Note.On [DATE] at 3:08 PM, the surveyor interviewed LPN #2 regarding the Behavior Note she documented on [DATE] at 9:31 PM regarding the encounter that she observed between Resident #11 and LPN #1. LPN #2 stated that Resident #11 came up to me when I was doing my charting and said, Did you hear that? Resident #11 then stated, Did you hear what LPN #1 called me? LPN #2 stated she told the resident that she did not hear anything. LPN #2 explained that the resident stated she was in cahoots with LPN #1 and was lying and proceeded to verbally come for me. LPN #2 stated the resident targeted LPN #1, and she usually walked off. LPN #2 stated that LPN #1 asked Resident #11 why they kept going back and forth to the nurses' station if they did not need anything.At that time, LPN #2 further stated that Resident #11 came up to her with what looked like a paper cut on their right hand close to their thumb area and she offered the resident Bacitracin (antibiotic ointment), but the resident declined and just wanted a band-aid. LPN #1 stated she went straight to the treatment cart and provided the resident with a band-aid. LPN #2 stated both she and CNA #2 were present. LPN #2 stated that Resident #11 then stated did you hear what LPN #1 said to me, and LPN #2 proceeded to remove her ear bud and stated no, I did not hear anything, I was not paying attention, which made Resident #11 even madder. LPN #2 stated that the resident made statements that the nurses picked-on them because they were paralyzed. On [DATE] at 3:38 PM, the surveyor interviewed CNA #2 who stated she worked the 3:00 PM-11:00 PM shift. The CNA stated she saw Resident #11 going back and forth on their motorized wheelchair, so she stopped to fix the resident's urinary catheter that was stuck on the wheel. CNA #2 stated that Resident #11 was throwing words at the nurses, but she could not recall if the nurses said anything back to the resident. CNA #2 stated she had abuse training and if you encountered verbal abuse, you just have to listen and cannot go back and forth with the resident. CNA #2 stated the resident had a behavior pattern and was very boisterous. On [DATE] at 3:51 PM, the surveyor interviewed LPN #1 regarding the statement that she wrote on [DATE] at 9:30 PM. LPN #1 stated that Resident #11 approached her and stated that only the good people got into trouble, not the crack heads. LPN #1 asked the resident if they needed their nurse. LPN #1 explained that the resident was close with CNA #3, and she was suspended for insubordination after I had to change her assignment, and she refused, and she thought that was what the resident was referencing when they stated only the good people got into trouble. LPN #1 stated, Resident #11 just kept going back and forth while they were on their cell phone saying terrible things to me about the loss of my sons. LPN #1 stated the resident held the phone up to her and stated look at this crackhead and threatened her, but she never responded, and just walked away. She stated that the resident followed her and taunted her. LPN #1 stated the administration called her and told her they were doing an investigation. She stated that they made her do a statement but never suspended her. LPN #1 further added that CNA #2 was present at that time and was trying to help the resident, but the resident just kept making pig sounds. On [DATE] at 4:12 PM, the surveyor interviewed CNA #3 who stated she provided care to Resident #11 and there was nothing extraordinary or problematic about the resident and the resident was not offensive towards her. CNA #3 stated that it went both ways between the resident and staff. CNA #3 stated Resident #11 was not fond of LPN #1, but she did not get involved in it. CNA #3 stated that the resident acted out if you were rude to them. CNA #3 stated that she heard the nurses and the resident exchange words but did not pay attention to it. CNA #3 stated if people argued, it was none of her business and that she just heard raised voices. CNA #3 stated if you went into the resident's room with an attitude the resident erupts. CNA #3 stated I just think that we need to treat the resident better. CNA #3 further stated, I have not seen any regular staff mistreat the resident.On [DATE] at 10:02 AM, the surveyor interviewed the Director of Social Services (DSS) who confirmed that she was aware about an incident on [DATE] where LPN #1 allegedly screamed at Resident #11 because the resident was going back and forth in front of the nurses station and allegedly called the resident an ugly crippled She stated that she was also aware that LPN #1 told the resident to watch their mouth, and allegedly called the resident a [expletive redacted] piece of shit. The DSS stated she was part of the investigation and obtained the statement. The DSS stated when verbal abuse was alleged, statements should be obtained from the caregivers who were involved. DSS stated that LPN #1 provided a statement to rule out any type of abuse. The DSS stated the facility was required to suspend the accused staff member until the investigation was completed. The DSS stated she did not recall if either LPN #1 or LPN #2 were suspended as a result of the allegation. The DSS indicated that the resident was care planned for fabrication (To make false statements). On [DATE] at 10:42 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated Resident #11 came to the facility with a care plan in place for fabrication. LPN/UM #1 stated it was verified that there was no response from LPN #1. LPN/UM #1 stated if there was an allegation of verbal abuse we must immediately report it to the DON and take written statements from anyone who may have been in the vicinity at the time of the event. LPN/UM #1 stated that she reported any allegations to the LNHA, and the DON and they reported to the DOH.On [DATE] at 11:04 AM, the surveyor interviewed the LNHA who confirmed that he did not complete a full investigation. The LNHA stated if a resident accused a nurse of threatening to set the resident on fire or calling the resident a cripple, it was important to report the allegation to the DOH to ensure a proper investigation and to protect the resident. The LNHA stated if there was an allegation of abuse against a nurse, it was also important to suspend the nurse (perpetrator) if he did not have a conclusion by the next shift the nurse was scheduled to work. The LNHA revealed that to his knowledge, neither LPN #1 or LPN #2 were suspended in response to Resident #11's allegation because he concluded his investigation prior to the nurses next scheduled shift and there was no reason to punish them. The LNHA further revealed that he needed the staff to take care of his other residents. The LNHA stated he made conclusions regarding this particular resident much quicker, because Resident #11 made allegations against staff on a regular basis. The LNHA stated, the resident cried wolf, and sometimes the wolf will show up. The LNHA further stated that he realized the allegation could be true, but investigations he had done previously, made on behalf of Resident #11, have not been factual. On [DATE] at 1:50 PM, the surveyor attempted to meet with Resident #11 and was informed by Registered Nurse (RN #2) who was assigned to the resident, that the resident was out of the facility at an appointment. RN #2 stated the resident had behaviors such as paranoia, bouts of anxiety with rapid speech, and the resident was accusatory. RN #2 stated the resident had not been abusive toward her however, Resident #11 hated LPN #1. She stated that Resident #11 was the only resident that made complaints about LPN #1. RN #2 stated that two staff members were required to provide care to the resident as this was an intervention to provide witnesses and protect themselves from accusations. RN #2 stated she reported anything negative to the Unit Manager and the DON right away. RN #2 stated from her perspective, Resident #11 targeted LPN #1 and LPN #2 with remarks about the deaths of their family members. 2. On [DATE] at 11:51 AM, the surveyor interviewed Resident #11 in the presence of another surveyor. Resident #11 stated he/she felt explosive when LPN #1 made statements to him/her that they were a fat, ugly, cripple. Resident #11 then explained that the facility did nothing about it at the time but confirmed that the administration then obtained statements from the resident after surveyor inquiry. At that time, Resident #11 then proceeded to describe an incident that occurred when Licensed Practical Nurse (LPN #5) was behind the resident in their room, and stepped close to the resident and proceeded to throw her hands up above the resident's head and stated, What are you going to do about it? The resident stated that he wrote an email to the Administrator and called the police. The resident stated that the police came to the facility and reviewed the video. Resident #11 stated, the cop confirmed, Yes, she was swinging her hands. The resident stated that LPN #4 cared for him once thereafter and it was okay. On [DATE] at 12:15 PM, the surveyor interviewed the LNHA regarding the allegation that Resident #11 made to the surveyors about LPN #5. The LNHA stated the resident called the police and they came out and reviewed the video footage and the police were unable to confirm the resident's allegation. When the surveyor asked if the allegation was reported to the NJDOH the LNHA stated, Probably not. The LNHA stated the resident made the report. The LNHA stated, I made the same mistake here, that I made there referencing the allegation Resident #11 made against LPN #1 and LPN #2 and confirmed that he had not done a complete and thorough investigation in response to the resident's allegation against LPN #5. The LNHA stated we watched the camera, and LPN #5 was by the door talking with her hands, but it did not look like she was trying to strike the resident. The LNHA stated that he did not recall if he suspended LPN #5 in response to the allegation. When the surveyor asked why the LNHA and the DON had not disclosed this allegation when they were initially interviewed about LPN #5 on [DATE] the LNHA stated, now that you brought it up, I remembered. On [DATE] at 12:21 PM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #11 called the police on LPN #5 at one point, and the police responded to the facility and reviewed the video footage. The DON stated that Resident #11 alleged that LPN #5 was in his/her space, but according to the video footage, the nurse talked with her hands, but she was not in the resident's space as the resident alleged. The DON stated I am overwhelmed as a DON with this resident. The DON confirmed that LPN #5 was not suspended to her knowledge. When the surveyor asked if an investigation was done or should have been done the DON stated we spoke to the resident, and the police reviewed the video and did not see anything. The surveyor then asked if the NJDOH should have been notified within two hours in response to the resident's allegation and the police being called into the facility to investigate the resident's concerns with LPN #5? The LNHA stated it depended on what the police were called for, if it were required to be reported. On [DATE] at 1:23 PM, the LNHA provided the surveyor with an email that Resident #11 sent to him on [DATE] at 11:23 PM which indicated that LPN #5 had screamed at the resident and threw her hands into the resident's face and asked the resident, what are you going to do about it . The LNHA also provided the surveyor with a Police Report dated [DATE] at 11:22 PM, which revealed: .Officers reviewed the available footage to the best of our abilities. During the review of the footage, officers observed LPN #5 speaking with Resident #11 while standing in the doorway of the resident's room, with her hands moving while speaking. No physical altercation was observed in the footage All appeared in order.A review of the Assignment Sheet dated [DATE] for the 3-11 shift revealed that LPN #5 was assigned to Resident #11.A review of LPN #5's Time Card revealed that on [DATE] LPN #5 punched in at 8:01 AM, and punched out at 11:25 PM. The surveyor reviewed the personnel file of LPN #5 which contained no documented evidence of any allegations of abuse. The surveyor attempted to phone LPN #5 for an interview and was unable to reach her for comment. On [DATE] at 3:21 PM, during a later interview with the LNHA he stated the rationale for not reporting Resident #11's allegation against LPN #5 was the same for his/her allegation against LPN #1 and LPN #2. The LNHA further stated whether it was right or wrong, when Resident #11 made an allegation, I have not been reporting it. The LNHA stated we are supposed to report any abuse to the NJDOH and the Ombudsman to make sure that we did a proper investigation. A review of the facility's Abuse prevention and Management policy, dated 4/2025, included: .Notify the Shift Supervisor/Charge Nurse/Manager immediately if an allegation of suspected abuse, neglect, mistreatment, misappropriation of property occurs, or injury of unknown source. This responsible Manager will then notify the Administer [sic.] and Director of Nursing immediately.Notify the designated state agency (s) within 2 (two) hours after identification of the alleged/suspected abuse, neglect and/or misappropriation incident by Electronic reporting system/fax/and or telephone based on Agency specific requirement for reporting. Initiate process according to the Federal/Stated regulations for abuse investigation and reporting and the Elder Justice Act for any incidents involving suspicion of a crime Report results of the investigation to the proper authorities as required by Federal/State law:Witness reports shall be in writing or typed. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be included with the Abuse investigation paperwork). The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly and objectively. The Administrator/DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate .NJAC 8:39-4.1(a)(5), 9.4(f)

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 after a cognitively intact resident made an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: Refer to F610On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. On [DATE] at 12:06 PM, the surveyors interviewed the Director of Nursing (DON) regarding Resident #11's allegation, and she stated that Resident #11 had made allegations, and everything had been looked into. The DON stated there has never been a patient as challenging and stated, I could be investigating the resident every day and there is only so much a person can take. The DON further stated that the Licensed Nursing Home Administrator (LNHA) had done the investigations. At that time, the DON further stated Resident #11 cursed her out so badly last Wednesday or Thursday and told her that she should be ashamed of her staff. The DON stated when she asked what the resident was referring to the resident went on a rant about Licensed Practical Nurse (LPN #1) and LPN #2. The DON stated the LNHA presented and stated to the resident, You will return to your room and calm down, and told the resident to go back to their room. The DON further stated that the LNHA may have addressed it on Friday, but she would have to defer to the LNHA because she was out sick. The DON further stated that she never learned of the concern that Resident #11 had with LPN #1 and LPN #2 because the LNHA had told the resident to return to their room. On [DATE] at 1:39 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team on speaker phone with permission. The LNHA stated that Resident #11 had sent him an email in the middle of the night, and he recalled seeing it in the morning. The LNHA stated that he had gotten statements from both of the involved nurses LPN #1 and LPN #2 about what occurred the night before and one of the nurses documented the event in the electronic health record [software name redacted].The LNHA stated that he did not know if any residents had witnessed the event and had not obtained resident witness statements. The LNHA stated that he did interview the resident, but he did not get a written statement. When the surveyor asked if the allegation was reported to the New Jersey Department of Health (NJDOH) the LNHA stated nothing was done because we could not substantiate what the resident said, and he did not think the allegation was a nature of abuse. The LNHA agreed to furnish the surveyor with the full investigation including the aforementioned email for surveyor review. The surveyor reviewed the medical record for Resident #11. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; unspecified injury at C1 (cervical neck region) level of the cervical spinal cord, subsequent encounter paraplegia (paralysis of the lower body, typically caused by spinal injury or disease), personality disorder, mood disorder due to known physiological condition with mixed features, anxiety disorder, unspecified, adjustment disorder, unspecified, major depressive disorder, recurrent, and Post-Traumatic Stress Disorder (PTSD), unspecified.A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. Further review of the MDS revealed the resident did not experience any hallucinations or delusions and did not have any physical or verbal behaviors directed towards others or rejection of care. A review of the Individual Comprehensive Care Plan (ICCP), included the following focus areas:A focus area initiated on [DATE], which indicated Resident #11 will make false accusatory statements, verbally inappropriate with staff using vulgar language .Interventions included: .Ensure they [sic.] are 2 (two) staff members when rendering any care to the resident. Care in pairs A focus area initiated on [DATE], indicated Resident #11 made false accusations, would take information and suggestions and twist the information to make the facility look deficient. Interventions included: Explain protocols in a clear manner, respond to his/her concerns in a timely manner, try not to be confrontational but report the facts as they occur, two staff members at a time should report to his/her room when he/she raises concerns. A review of the Progress Notes (PN) included a Behavior Note dated [DATE] at 9:31 PM, that was written by LPN #2 revealed: Resident was in hallway going back and forth stating he was looking for staff. Staff approached resident and asked if he/she needed help resident told writer he/she needed a band-aid. While waiting for the band aid the resident seen a staff member he/she did not like he proceeded to call LPN #1 a crack head and made mocking vomiting noises. Staff member ignored the residents' comments and continued to do her work. Resident was on the phone with someone stating if the person seen the crackhead. Resident continued his/her taunting then stated he/she got something for staff. Resident started talking about staff member deceased son. Staff member told resident stop riding back and forth to the nurse's station if he/she doesn't need anything resident got confrontational then told writer that she should have corrected her, writer explain [sic.] I am not getting into this.On [DATE] at 2:35 PM, the DON provided the surveyor with the LNHA's full investigation which consisted of an email that was directed to the LNHA and was written by Resident #11 on [DATE] at 11:36 PM. The email included an allegation that LPN #1 screamed at the resident to stop passing back and forth in front of the nurses' station on the phone and called the resident an ugly cripple. The resident reportedly responded to LPN #1 and told her that she cared for the resident more than her two dead sons. To which LPN #1 responded, Watch your mouth, you [expletive redacted] piece of shit. A Behavior Note was also provided dated [DATE] at 9:31 PM, written by LPN #2, and a statement dated [DATE] at 9:30 PM, written by LPN #1 that were also included as part of the investigation.On [DATE] at 2:50 PM, the surveyor interviewed the LNHA in the presence of the survey team. When asked if the LNHA obtained a written statement from LPN #2 the LNHA stated that he interviewed LPN #2, but he did not document it. When the surveyor asked if he was required to obtain a written statement in accordance with the facility abuse policy he stated, No, I don't think so because I had the Progress Note.On [DATE] at 3:08 PM, the surveyor interviewed LPN #2 regarding the Behavior Note she documented on [DATE] at 9:31 PM regarding the encounter that she observed between Resident #11 and LPN #1. LPN #2 stated that Resident #11 came up to me when I was doing my charting and said did you hear that? Resident #11 then stated, Did you hear what LPN #1 called me? LPN #2 stated she told the resident that she did not hear anything. LPN #2 explained that the resident stated she was in cahoots with LPN #1 and was lying and proceeded to verbally come for me. LPN #2 stated the resident targeted LPN #1, and she usually walked off. LPN #2 stated that LPN #1 asked Resident #11 why they kept going back and forth to the nurses' station if they did not need anything.At that time, LPN #2 further stated that Resident #11 came up to her with what looked like a paper cut on their right hand close to their thumb area and she offered the resident Bacitracin (antibiotic ointment), but the resident declined and just wanted a band-aid. LPN #1 stated she went straight to the treatment cart and provided the resident with a band-aid. LPN #2 stated both she and CNA #2 were present. LPN #2 stated that Resident #11 then stated did you hear what LPN #1 said to me, and LPN #2 proceeded to remove her ear bud and stated no, I did not hear anything, I was not paying attention, which made Resident #11 even madder. LPN #2 stated that the resident made statements that the nurses picked-on them because they were paralyzed. On [DATE] at 3:38 PM, the surveyor interviewed CNA #2 who stated she worked the 3:00 PM-11:00 PM shift. The CNA stated she saw Resident #11 going back and forth on their motorized wheelchair, so she stopped to fix the resident's urinary catheter that was stuck on the wheel. CNA #2 stated that Resident #11 was throwing words at the nurses, but she could not recall if the nurses said anything back to the resident. CNA #2 stated she had abuse training and if you encountered verbal abuse, you just have to listen and cannot go back and forth with the resident. CNA #2 stated the resident had a behavior pattern and was very boisterous. On [DATE] at 3:51 PM, the surveyor interviewed LPN #1 regarding the statement that she wrote on [DATE] at 9:30 PM. LPN #1 stated that Resident #11 approached her and stated that only the good people got into trouble, not the crack heads. LPN #1 asked the resident if they needed their nurse. LPN #1 explained that the resident was close with CNA #3, and she was suspended for insubordination after I had to change her assignment, and she refused, and she thought that was what the resident had referenced when they stated only the good people got into trouble. LPN #1 stated, Resident #11 just kept going back and forth while they were on their cell phone saying terrible things to me about the loss of my sons. LPN #1 stated the resident held the phone up to her and stated look at this crackhead and threatened her, but she never responded, and just walked away. She stated that the resident followed her and taunted her. LPN #1 stated the administration called her and told her they were doing an investigation. She stated that they made her do a statement but never suspended her. LPN #1 further added that CNA #2 was present at that time and was trying to help the resident, but the resident just kept making pig sounds. On [DATE] at 4:12 PM, the surveyor interviewed CNA #3 who stated she provided care to Resident #11 and there was nothing extraordinary or problematic about the resident and the resident was not offensive towards her. CNA #3 stated that it went both ways between the resident and staff. CNA #3 stated Resident #11 was not fond of LPN #1, but she did not get involved in it. CNA #3 stated that the resident acted out if you were rude to them. CNA #3 stated that she heard the nurses and the resident exchange words but did not pay attention to it. CNA #3 stated if people argued, it was none of her business and that she just heard raised voices. CNA #3 stated if you went into the resident's room with an attitude the resident erupts. CNA #3 stated I just think that we need to treat the resident better. CNA #3 further stated, I have not seen any regular staff mistreat the resident.On [DATE] at 10:02 AM, the surveyor interviewed the Director of Social Services (DSS) who confirmed that she was aware about an incident on [DATE] where LPN #1 allegedly screamed at Resident #11 because the resident was going back and forth in front of the nurses station and called the resident an ugly crippled She stated that she was also aware that LPN #1 told the resident to watch their mouth, and called the resident a [expletive redacted] piece of shit. The DSS stated she was part of the investigation and obtained the statement. The DSS stated when verbal abuse was alleged, statements should be obtained from the caregivers who were involved. DSS stated that LPN #1 provided a statement to rule out any type of abuse. The DSS stated the facility was required to suspend the accused staff member until the investigation was completed. The DSS stated she did not recall if either LPN #1 or LPN #2 were suspended as a result of the allegation. The DSS indicated that the resident was care planned for fabrication (making false reports). On [DATE] at 10:42 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated Resident #11 came to the facility with a care plan in place for fabrication. LPN/UM #1 stated it was verified that there was no response from LPN #1. LPN/UM #1 stated if there was an allegation of verbal abuse we must immediately report it to the DON and take written statements from anyone who may have been in the vicinity at the time of the event. LPN/UM #1 stated that she reported any allegations to the LNHA, and the DON and they reported to the DOH.On [DATE] at 11:04 AM, the surveyor interviewed the LNHA who acknowledged that he did not have a full investigation to present to the surveyor in response to Resident #11's allegation against LPN #1 and LPN #2. The LNHA stated that he normally obtained witness statements in response to an allegation of abuse except for in the case of Resident #11, who was unique. The LNHA stated the DON informed him after we talked that she had gotten a call from LPN #1 and LPN #2 and they documented the allegation that night. The LNHA explained that LPN #2 had written a Progress Note that evening, but he guessed that LPN #1 had failed to document the event in the Progress Notes. The LNHA stated that he had spoken to LPN #1 and LPN #2 when they returned to work the next evening and had gotten the same story. The LNHA also acknowledged that he had failed to obtain a witness statement from LPN #2, as LPN #2 had written a Progress Note and he thought that sufficed. When the surveyor asked the LNHA if a resident accused a nurse of verbalizing a threat to set the resident on fire or called the resident a cripple was it important to report the allegation to the NJDOH and ensure a proper investigation were completed in accordance with the facility abuse policy to protect the residents and the LNHA stated, Yes. When the surveyor asked if the accused nurse were required to be suspended immediately the LNHA stated that it was important to suspend the nurse if there was an allegation of abuse, and he did not have a conclusion by the nurse's next scheduled shift. On [DATE] at 1:50 PM, the surveyor attempted to meet with Resident #11 and was informed by Registered Nurse (RN #2) who was assigned to the resident, that the resident was out of the facility at an appointment. RN #2 stated the resident had behaviors such as paranoia, bouts of anxiety with rapid speech, and the resident was accusatory. RN #2 stated the resident had not been abusive toward her however, Resident #11 hated LPN #1. She stated that Resident #11 was the only resident that made complaints about LPN #1. RN #2 stated that two staff members were required to provide care to the resident as this was an intervention to provide witnesses and protect themselves from accusations. RN #2 stated she reported anything negative to the Unit Manager and the DON right away. RN #2 stated from her perspective, Resident #11 targeted LPN #1 and LPN #2 with remarks about the deaths of their family members. On [DATE] at 11:51 AM, the surveyor interviewed Resident #11 in the presence of another surveyor. Resident #11 stated he/she felt explosive when LPN #1 made statements to him/her that they were a fat, ugly, cripple. Resident #11 then explained that the facility did nothing about it at the time but confirmed that the administration then obtained statements from the resident after surveyor inquiry.On [DATE] at 12:51 PM, the surveyor interviewed the Medical Director (MD) via speakerphone with permission in the presence of the survey team. At that time, the MD confirmed that Resident #11 was her patient. The MD described Resident #11 as a very difficult patient. The MD explained that an investigation should be done in response to an allegation of abuse and staff should be interviewed and statements taken. The MD denied any knowledge of allegations of abuse from staff to Resident.#11 The MD stated that she did not think that the DOH should be notified of an allegation of abuse based on what she had seen. The MD stated that Resident #11 was not confused and was on top of things, so she did not think that there was any chance the resident could be abused because mentally the resident was awake, alert and knew what was going on. The MD stated that it would definitely be considered verbal abuse if the resident were called an ugly crippled or was threatened to be set on fire, but we would have to find out if it was true or not. On [DATE] at 1:23 PM, the surveyor requested a copy of the 400 Unit Daily Assignment Sheet dated [DATE] for the 3-11 shift, and the LNHA stated that he was unable to find it. The LNHA provided the surveyor with Timecard time stamps which indicated that on [DATE] LPN #1 clocked in at 7:08 AM and clocked out at 11:30 PM. Further review of the Timecard revealed that LPN #1 did not clock in again until [DATE] at 2:53 PM and she clocked out at 7:15 AM on [DATE].A review of a Timecard time stamp dated [DATE] revealed that LPN #2 clocked in at 3:06 PM and clocked out at 11:28 PM. LPN #2 clocked in again on [DATE] at 3:04 PM and clocked out on [DATE] at 7:19 AM.A review of LPN #1's personnel file revealed that there was no documented evidence of any allegations of resident abuse.A review of LPN #2's personnel file revealed that there was no documented evidence of any allegations of resident abuse. A review of the facility's Abuse Prevention and Management policy, revised 4/2025, included the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. The facility must provide a safe resident environment and protect residents from abuse . The policy further included, as part of the resident abuse prevention, that the administration would do the following: .Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property: Responding immediately to protect the alleged victim and integrity of the investigation Immediate suspension of suspected employee (s), pending outcome of the investigation The Administrator and Director of Nursing are responsible for investigating and reporting .Upon receiving an incident or suspected incident of resident abuse, neglect, or misappropriation of Resident property, or injury of unknown source, the Administrator/DON/designee will conduct an investigation to include but not limited to the following:Complete the paperwork for investigation of abuse, neglect, misappropriation;Interview the person (s) reporting the incident;Interview any witnesses to the incident;Interview the resident, if able;Interview the resident's attending physician and review of the resident's record;Interview staff members (on all shifts) having contact with the resident during the period of the alleged incident; .Interview other residents to which the accused employee provides care or services; Initiate a Risk Management Report as a New Active Incident in the electronic health record or on a paper incident report if facility does not utilize an electronic Risk Management reporting system.Initiate the investigation process. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who may be interviewable and have information regarding the allegation Notify the Shift Supervisor/Charge Nurse/Manager immediately if an allegation of suspected abuse, neglect, mistreatment, misappropriation of property occurs, or injury of unknown source. This responsible Manager will then notify the Administer [sic.] and Director of Nursing immediately.Notify the designated state agency (s) within 2 (two) hours after identification of the alleged/suspected abuse, neglect and/or misappropriation incident by Electronic reporting system/fax/and or telephone based on Agency specific requirement for reporting. Initiate process according to the Federal/Stated regulations for abuse investigation and reporting and the Elder Justice Act for any incidents involving suspicion of a crime Report results of the investigation to the proper authorities as required by Federal/State law:Witness reports shall be in writing or typed. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be included with the Abuse investigation paperwork). The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly and objectively. The Administrator/DON should analyze the report and consult with other resources such as the Medical Director to investigate medical circumstances, or the social worker, as appropriate .NJAC 8:39-4.1(a)(5)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to a.) ensure a continuity of care for a resident who was admitted to the facility with chronic venous hypertension with ulcer of bilateral lower extremity (a condition caused by prolonged, high pressure in the leg veins due to incompetent valves, resulting in chronic wounds, swelling (edema), and skin changes) and edema (swelling), and b.) ensure transportation was provided for an an outside medical appointment . This deficient practice was identified for 1 of 1 resident (Resident #8) reviewed for positioning and mobility. This deficient practice 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. On 3/3/26 at 10:54 AM, the surveyor observed Resident #8 resting in bed with eyes closed and their bilateral lower legs wrapped. On 3/4/26 at 12:24 PM, the surveyor made a follow-up visit to speak with Resident #8. Resident #8 was sitting upright in bed and stated that they saw an outside vascular doctor for bilateral lower leg edema. The resident further stated that the vascular doctor recommended bilateral leg elevation to improve circulation and edema. Resident #8 also added that they were having problems with their right hand and had a rheumatology appointment. The resident further stated that the appointment was cancelled because the facility did not provide transportation, and they were only made aware of the appointment the day before.On 3/04/2026 at 11:35 AM, the surveyor reviewed the medical record.Review of Resident #8's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: chronic venous hypertension with ulcer of bilateral lower extremity (a condition caused by prolonged, high pressure in the leg veins due to incompetent valves, resulting in chronic wounds, swelling (edema), and skin changes), peripheral vascular disease (a slow, progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart, commonly caused by atherosclerosis), polyneuropathy (a widespread, chronic condition causing damage to multiple peripheral nerves, most commonly leading to numbness, tingling, and weakness, often starting in the feet and hands), and an onset of idiopathic gout (a form of arthritis caused by the buildup of monosodium urate crystals in joints, resulting from an unknown or primary metabolic cause rather than secondary factors) after admission.Review of Resident #8's Minimum Data Set (MDS), an assessment tool dated 1/12/26, 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.A review of Resident #8's Care Plan reflected a focus area initiated 10/20/25 and revised on 11/3/25, that specified the resident was at risk for pressure ulcer/injury development related to the diagnosis of chronic venous hypertension. Interventions included monitoring, documenting, and reporting any changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size, and stage.A review of Resident #8's Order Summary Report (OSR) dated 10/1/25, included a physician's order (PO) dated 2/5/26 for bilateral Unna boots (a specialized, zinc-paste impregnated gauze compression bandage used to treat venous stasis ulcers, edema, and sprains by promoting venous return while allowing ankle mobility) for wound care and specified that the Unna boot not to be removed until seen by vascular.A review of a Provider's Progress Note (PPN) revealed an entry dated 2/13/26 at 11:35 PM, that Resident #8 saw the outpatient vascular specialist weekly for chronic venous insufficiency and lower leg edema.On 3/5/26 at 10:34 AM, a surveyor conducted an interview with Registered Nurse (RN #1). RN #1 reported that Resident #8 attends weekly appointments with a vascular specialist and they utilized bilateral Unna boots, which remain in place until the subsequent outpatient visit. She stated that the vascular specialist removed and reapplied the Unna boots during these appointments. Subsequently, nursing staff documents the presence of the Unna boots on the Treatment Administration Record (TAR).When questioned about the facility's process for staying informed of the vascular specialist's recommendations and treatment progress, RN #1 explained that appointments are scheduled by the Unit Manager (UM). The UM compiles a packet for each appointment, which included the resident's face sheet and a Report of Consultation form for the provider to document recommendations. She added that upon the resident's return from the appointment, the paperwork is usually submitted to the nurses' station for review. Should any recommendations or orders be identified, staff members would contact the physician for further instructions. RN #1 noted that if a resident returns without the necessary paperwork, the UM follows up with the physician's office.Additionally, RN #1 mentioned that Resident #8 scheduled their own vascular appointments. In such cases, the consultation form may not be provided to the resident. RN #1 ensures that she inquires about any treatment changes directly from the resident following these appointments.On 3/5/26 at 11:09 AM, the surveyor interviewed the UM who stated that she scheduled the medical appointments. She confirmed that she prepared an envelope containing the Report of Consultation form and provided them to the resident to take to the appointment. She then added that when the consultation form is not returned, they would call the consulting doctor's office to obtain the recommendations.On 3/5/26 at 11:27 AM, the surveyor interviewed RN #1 who explained that her intention was to contact the vascular physician to find out if they had information regarding the condition of the resident's legs and if there were any new recommendations. She added that the facility should be kept abreast of the condition of the residents' legs, treatment, and progress after each appointment. She stated that earlier that morning, she observed that one leg was wrapped in an Unna boot, and the other leg had a dressing. She stated that she did not know what kind of dressing the resident had on, but she needed to find out. She further stated that the UM should know what the follow-up care should be. On 3/9/2026 at 3:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses should follow-up with the consultants. She further stated that if the resident did not return to the facility with the Report of Consultation, the nurse should call the office to get the report to ensure the resident received the proper treatment.The surveyor reviewed the electronic medical record (EMR) and could not locate Resident #8's report of consultation from the weekly outpatient appointments with the vascular specialist.A further review of Resident #8's EMR revealed a PO dated 11/18/25, which reflected an order to refer Resident #8 to rheumatology and a PO dated 1/5/26, for allopurinol 100 MG tablet for gout.A review of a PPN dated 2/9/26 at 8:48 PM revealed that Resident #8 had a rheumatology appointment tomorrow morning (2/10/26) that was scheduled by the facility.A review of a PPN dated 2/13/26 at 11:35 PM, indicated that Resident #8 was scheduled to see a rheumatologist for positive Antinuclear Antibody (ANA), elevated Erythrocyte Sedimentation Rate (ESR), positive anti-Ro (SSA), but was unable to arrange transportation.On 3/5/26 at 11:09 AM, the surveyor interviewed Licensed Practical Nurse (LPN/UM #1) who stated that she made transportation arrangements for Resident #8's rheumatology appointment that was scheduled for 2/10/26, but she could not recall the entity she arranged it with. She added that normally she would call a transporter, ambulance, or they would arrange transportation via a ride share, if they are medically able to go with them. She stated that Resident #8 was medically able to go with a ride share. When asked if a ride share was arranged, she replied, noOn 3/5/2026 at 11:36 AM, the surveyor interviewed RN #1 who stated that she was not aware of the situation concerning the rheumatology appointment for Resident #8. She stated that she was under the impression that Resident #8 must make their own transportation arrangement because they did not have Medicaid or Medicare. When asked was there a list of resident appointments that the nurses refer to, RN #1 pointed out a calendar which was posted on the wall in the nurse's station. At that time, the surveyor noted March 2026 and February 2026 hanging up. There was a notation on the top of February 2026 that indicated that Resident #8 must pay for their own ride share.On 3/5/2026 at 11:43 AM, the surveyor interviewed the Social Worker who revealed that there were issues pertaining to Resident #8's insurance. She added that the issue was resolved a month ago but was raised again because the correct insurance number was not put in the medical record. They used the wrong Medicaid number. She noted that the facility corporate office had to help her with the process and further revealed that the facility should have arranged transportation and assumed the cost of the transportation to the Rheumatology appointment.On 3/9/26 at 3:24 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility was responsible for ensuring that the residents were transported to their physician appointment and that he has covered the cost of Resident #8's transportation in the past.On 3/10/26 at 10:28 AM, during a follow-up interview with the DON, the DON stated that Resident #8's Rheumatology appointment was rescheduled for 3/31/26 at 1:15 PM, and if the resident was still at the facility, the facility will assume the cost of the transportation.A review of the facility's Consultations policy, dated, revised 4/2025 included, Policy: To foster The Philosophy of the facility and in compliance with Federal and State regulations and in accordance with HIPAA regulations, it is the policy of the facility to obtain additional information or assessment from an outside source about slash for a resident to assist in care and treatment. Prior to consult. e. Make transportation arrangements Upon return from consult. A. Check consult sheet for consultant's findings, diagnosis, recommendations, date and signature of consultant.File or scan consult form in resident's medical record.NJAC 8:39-27.1 (a),

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the wasting of a controlled medication for 1 sampled resident (Resident #28) identified upon inspection of 1 of 2 medication carts (Unit 3-A cart). The evidence was as follows:On 3/4/2026 at 12:50 PM, the surveyor in the presence of Licensed Practical Nurse #3 (LPN #3) inspected medication cart A on Unit 3A. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #28's lorazepam 1 milligram (mg) tablet, a medication used for anxiety, did not match. There were two blister packs attached with a rubber band, one contained 30 tablets, and the other contained 27 tablets the declining inventory sheet indicated there should be 58 tablets remaining. LPN #3 stated she had administered the medications earlier. She then told the surveyor that after her medication pass she liked to double check the controlled substance counts to see if they were correct. In doing so she had accidentally dropped one of Resident #28's lorazepam tablets on the top of the medication cart. She stated that once the pill dropped on the top of the cart it was contaminated and had to be wasted, and both she and a nurse witness had to sign the declining inventory sheet that the medication had been wasted. LPN #3 stated she then went to get LPN #4 and together they wasted the tablet in the medication disposal container (product designed to neutralize pharmaceuticals), but LPN #4 had gotten called away to assist a resident and they had not yet returned to the medication cart to co-sign the wasting of the lorazepam tablet on the declining inventory sheet. When the surveyor asked LPN #3 when the declining inventory sheet should be signed, she stated immediately after wasting the medication. On 3/4/2026 at 1:05 PM, the surveyor interviewed LPN #4. LPN #4 stated she had wasted the lorazepam tablet with LPN #3 but had not signed the declining inventory sheet because she got distracted after being called to assist a resident. LPN #4 acknowledged she should have signed the declining inventory sheet immediately to ensure there was an accurate count of the resident's medication. On 3/4/2026 at 1:12 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager #2 (LPN/UM #2) who stated if a medication dropped on the top of a medication cart it must be discarded. The nurse would then get a witness and together dispose of the medication in the appropriate container, then both nurses would sign the declining inventory sheet as witnesses that the medication had been wasted. LPN/UM #2 reviewed the declining inventory sheet and acknowledged the nurses should have signed the declining inventory sheets immediately after wasting the lorazepam tablet. On 3/9/2026 at 3:47 PM, the surveyor interviewed the facility Director of Nursing (DON) who stated the nurses should have signed the declining inventory sheet immediately once they had wasted the medication. The surveyor asked why it was important to sign the declining inventory sheet immediately. The DON replied that it was important to make sure there was no miscount and no thought of diversion. A review of the facility Medication Storage policy with a revised date of 4/2025 did not address the process for disposal of controlled medications. A review of the facility Medication Administration policy with a revised date of 4/2025 did not address the process for disposal of controlled medications. A review of the facility provided policy titled Controlled Substance Accountability undated, included: Properly maintained records are essential to ensure complete and accurate accountability of all doses administered. Sign out the controlled substance on the declining inventory sheet IMMEDIATELY after pouring.Have another nurse witness and co-sign the wasting of any dose of a controlled drug. The reason for wasting should be documented. NJAC 8:39- 29.2(d), 29.7(c)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to properly dispose of garbage and refuse in 1 of 2 (one of two) garbage disposal areas. This deficient practice was evidenced by: On 3/3/26 at 8:49 AM, upon arrival at the facility, the surveyor observed the facility's garbage disposal area #1. The surveyor observed cigarette butt receptacles, three (3) grills, two (2) gas cylinders, seven (7) red and green crates, a flattened cardboard box, multiple plastic pails, a plastic bottle, and an intravenous (IV) pole stored in and around the garbage disposal area rather than being properly discarded of or stored in an appropriate designated area. On 3/4/26 at 10:14 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the trash disposal area and observed that Garbage Disposal Area #1 was not maintained in a clean and sanitary condition. Garbage was exposed to the environment, creating the potential for odors and pest infestation. During the tour, the surveyor interviewed the FSD regarding the facility's garbage disposal practices and the presence of multiple trash items in the garbage disposal area. The FSD stated that maintenance of the facility's garbage disposal areas was a shared responsibility between the dietary and housekeeping departments. The FSD further stated that all trash and discarded items were expected to be placed inside designated trash disposal containers and not discarded on the ground in order to maintain a safe and sanitary environment. The FSD acknowledged that the refuse observed in the area posed a safety hazard and could potentially contribute to pest control issues. On 3/5/26 at 9:21 AM, the surveyor interviewed the Housekeeping Director (HD) regarding the facility's trash removal practices. The HD stated that garbage should only be brought outside on the day it was scheduled to be collected by the garbage removal company and should not be stored in the garbage disposal area. The HD explained that storing garbage in the area could create a fire and safety hazard and may attract pests. When questioned about the trash removal or garbage pickup schedule, the HD was unable to provide a specific schedule and stated that garbage was collected when there was trash to be removed from the facility. On 3/5/26 at 9:27:59 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed that garbage should be disposed of properly to prevent attracting pests and unwelcomed visitors, such as rodents, and to maintain a safe and sanitary environment. The surveyor reviewed the facility's policy/procedure titled Housekeeping - Outdoor Trash Area, revised 5/2025, as provided by the FSD. The policy/procedure reflected that our nursing home is committed to maintaining a clean, safe and hygienic environment for our residents, staff, and visitors. The policy/procedure also included that no littering is allowed in or around the trash area, and . will perform routine checks to ensure that the outdoor trash areas is free of litter and debris' . NJAC 8:39-19.7(c)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that a handwashing sink was in a resident's (Resident #3) room (room [ROOM NUMBER]) was functional. This deficient practice was identified on 1 (one) of 2 (two) units (Unit #3).This deficient practice was evidenced by the following:On 3/9/26 at 12:37 PM, the surveyor entered Resident #3's room. Resident #3 was observed sitting upright in bed, eating their lunch. At that time, the surveyor noted that the resident's faucet was wrapped with clear tape. The resident stated that they were very particular about keeping their hands clean. Resident #3 added that when they needed to perform hand hygiene, they would call the staff for a wet cloth.A review of Resident #3's admission Record revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: bipolar disorder and a history of transient ischemic attack (temporary blockage of blood flow to the brain).A review of Resident #3's Quarterly Minimum Data Set (MDS), an assessment tool dated 2/3/20, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. A further review of the MDS revealed that the resident was occasionally incontinent of bladder and frequently incontinent of bowel.On 3/9/26 at 12:57 PM, the surveyor interviewed CNA #1, who stated that she was assigned to care for Resident #3. She stated that earlier that morning, Resident #3 voided in their brief, and she provided care for the resident by wiping their perineal area. She added that she also trimmed their fingernails. She stated that after she finished performing care, she washed her hands in the unit pantry because the resident's sink was not working. She further stated that she would usually wash her hands in the resident's room after care was performed.On 3/9/26 at 2:09 PM, the surveyor interviewed Registered Nurse #3, who stated that she had to wash her hands in another resident's bathroom because Resident #3 did not have a functional handwashing sink. She further stated that there should be running water in Resident #3's room and that it was important for good hygiene to prevent infection.On 3/9/26 at 2:54 PM, the surveyor interviewed the Director of Maintenance (DOM), who stated that the water had been shut off for about two months because the resident flooded their room several times and caused too much damage to the building. He added that the resident could not have access because they could not be trusted.On 3/9/26 at 3:24 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, I heard something about it a bit ago, but don't remember the details of it. He added that the room should be equipped with a functional sink.On 3/10/26 at 10:28 AM, the surveyor followed up with the LNHA, who stated that Resident #3's sink was now operational and that the water was turned back on and the tape was removed from around the faucet. He added that he was not sure as to why the sink was not in service for so long.A review of the facility's Maintenance Service policy, undated, included: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.A review of the facility's Resident Rights policy, revised 4/2020, included: Policy: Employees shall treat all residents with kindness, respect, and dignity. Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. dignified existence; b. safe and home-like environment.A review of the facility's Hand Hygiene policy, last reviewed 6/10/20, included: Hand Hygiene Methods.wet hands and wrists with warm running water.NJAC 8:39-27.1(a), 31.4(a), 4.1(a)(12)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) discard potentially hazardous foods past their date of expiration; b.) ensure potentially hazardous foods were stored at least six inches from the floor; c.) maintain multiuse food-contact surface cutting boards in a manner to prevent microbial growth; d.) maintain kitchen and storage areas in a sanitary manner; and e.) perform hand hygiene to prevent food borne illness. This deficient practice was evidenced by the following: Upon arrival to the facility on [DATE] at 8:45 AM, the surveyor observed eight boxes of bread that were delivered and placed directly on the ground in the parking lot. The bread boxes were stacked in two piles with two boxes directly on the pavement. On 10/1/24 at 8:50 AM, the surveyor accompanied by the Acting Director of Nursing (ADON) exited the facility and observed the bread delivery on the ground. The ADON confirmed food should not be stored directly on the ground. On 10/1/24 at 10:07 AM, the surveyor observed the Food Service Director (FSD) enter the kitchen, and the FSD stated he had just come from the stock room and hung up his coat. The surveyor interviewed the FSD, who stated that the bread company always delivered the bread and placed it directly on the ground in the parking lot outside the building. The FSD stated that it was acceptable for the bread to be stored on the ground since the bread was in a box. At that time, the surveyor and FSD began a tour of the kitchen. The surveyor observed no hand hygiene from the FSD after returning to the kitchen from the stock room and hanging up his coat. The FSD began to open the reach-in refrigerator, when the surveyor asked the FSD if he had just left the kitchen and hung up his personal jacket, was there anything he needed to do. The FSD acknowledged he should have performed hand hygiene. The FSD proceeded to perform hand hygiene using soap and water, lathering outside the flow of running water for twenty seconds, then used a paper towel to dry his hands. The FSD then obtained a clean paper towel to turn the sink faucet off, then used that paper towel to continue to dry his hands. The FSD then dropped the paper towel on the floor, picked it, disposed of it in the trash receptacle, and proceeded on the tour. The surveyor asked the FSD if he used the paper towel that he turned the faucet off with to dry his hands and then dropped it on the floor and picked it up, were his hands still clean? The FSD acknowledged he needed to perform hand hygiene again because his hands were considered dirty. On 10/1/24 at 10:18 AM, the surveyor and the FSD toured the kitchen and observed the following: 1. In the kitchen on the wall directly next to the reach-in refrigerator, a light powered bug trap. The bottom of the bug trap had over twenty dead bugs, and the area was opened, exposing the dead bugs to the kitchen area. The FSD acknowledged that the trap needed to be cleaned. 2. In the reach-in refrigerator, a container of egg salad with a use by date of 9/29/24. The FSD confirmed it needed to be discarded. 3. In the reach-in refrigerator, a container of macaroni salad with a use by date of 9/22/24. The FSD confirmed it needed to be discarded. 4. In the reach-in refrigerator, a one-pound opened container of cottage cheese with no opened date and an expiration date of 11/18/24. The FSD stated the kitchen used cottage cheese for thirty days. At that time, the surveyor showed the FSD the cottage cheese packaging which indicated use within seven days of opening. 5. The inside of the microwave had caked on debris on the roof and sides as well as the plate. The FSD acknowledged it needed to be cleaned. 6. On a drying rack, one large green cutting board deeply pitted and discolored. The FSD stated the grooves caused cross-contamination and led to bacterial growth. The FSD acknowledged it should be discarded. 7. In dry storage on the active can rack, one six-pound twelve-ounce (oz) can of vegetarian bean and sauce and one six-pound twelve-ounce can of red kidney beans, both dented. 8. In the walk-in freezer, the vinyl strip curtains located in the entrance to the freezer were missing three strips on the outer sides of the doorway. These curtains protected the inside of the freezer from outside dust particles as well as kept the cold air from escaping the freezer when the door was opened. The FSD acknowledged the vinyl strips maintained temperature and prevented dust particles from entering the freezer. 9. On a storage rack in the kitchen, one large brown, one large yellow, one large white, one large blue, and one large red cutting boards all pitted and discolored. The FSD stated he usually changed the cutting boards every eight to nine months, and acknowledged these cutting boards were ready to be replaced. 10. Outside the kitchen, freezer chest #2 had a build-up of ice accumulation around the sides. The FSD stated the ice affects the temperature, and the facility cleaned every six months. 11. Outside the kitchen, freezer chest #1 had a build-up of ice accumulation along the sides. On 10/1/24 at 10:30 AM, the surveyor and FSD toured a food storage room located in the 200-unit hallway and observed the following: 12. The storage room floor was soiled with black colored build-up and the tiles were coming up. The FSD stated that there was a flood in the room that past summer, so the flooring came up. When the surveyor questioned about the flood, the FSD stated it was not a flood, the air conditioner (AC) was running all summer so there was condensation on the floor. 13. Directly on the soiled floor was a box of corn flakes cereal and the emergency water. The FSD acknowledged the cereal and water should not be stored directly on the floor. 14. Directly on the soiled floor was a twenty-five pound of Japanese breadcrumbs. The bottom of the bag had a discolored brownish area that appeared to be discoloration from sitting on liquid. The bottom of the bag was also ripped, had bugs flying around it, and patches of a green fur-like substance that the FSD identified as mold. The FSD acknowledged that the breadcrumbs were not store appropriately and needed to be discarded. 15. On a storage rack, a white condiment bottle pump that was caked on with brownish/black substance. The FSD stated it needed to be discarded. On 10/8/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the ADON and survey team, acknowledged the concerns. A review of the undated facility provided Stock Room Storage Policy included .boxes must be stored six inches above the [floor] . A review of the undated facility provided Refrigerator Storage Policy and Procedure included .check for out dated food. If any discard. A review of the facility provided Infection Control Policy Procedures 2020 included Handwashing/Hand Hygiene .1. vigorously lather hands with soap and water creating friction to all surfaces, for a minimum of 20 seconds [ .] 2. rinse hands thoroughly under running water [ .] 3. dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel 4. discard towels into trash . NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 nursing units reviewed for environment (300 unit), and was evidenced by the following: 1. On 10/1/23 at 12:24 PM, during initial tour of the facility, the surveyor entered onto a ramp that led to the 300 nursing unit, and observed the following: 1. The handrail on right side of wall going up the ramp had three areas where it was not connected to itself, which left a gap in the system where the metal framing was exposed. This presented a safety hazard for residents that were unsteady on their feet. 2. The wallpaper was peeling and bubbling throughout the entire entrance to the 300 nursing unit. 3. The threshold that connected the ramp to the 300 nursing unit corridor had tile removed, missing and uneven elevations in areas presenting a tripping hazard. 4. The entrance to 300 nursing unit's doorframe had a hole in the wall by the doorframe. and around the hole was white crumbling debris. On 10/3/23 at 12:02 PM, the surveyor toured the 300 nursing unit, and entered hallway vestibule entrance and observed the following: 1. To the left side of hall at two joining walls, there was a split in the wallpaper along the corner seam from the floor to approximately four feet. The area behind the wallpaper was black and had white dust debris. 2. On the right side of the 300 nursing unit hallway, there was an interior soffit enclosure that had a rectangular cutout hole that exposed the interior of the soffit. On 10/7/24 at 12:00 PM, the surveyor observed on the 300 nursing unit in Resident room [ROOM NUMBER], the doorway threshold had cracked and sunken tiles, which caused the entryway into the room to be uneven. On 10/7/24 at 12:00 PM, the surveyor observed on the 300 nursing unit in Resident room [ROOM NUMBER], the doorway threshold had cracked tiles that were lifted and created a lip to the entrance of the room. On 10/7/24 at 12:37 PM, the surveyor interviewed with Housekeeping Director (HKD), who stated that housekeeping staff was responsible for mopping and cleaning the floors. The HKD stated that the Maintenance Director (MD) and upper management were responsible for changing the tiles and flooring. On 10/7/24 at 1:15 PM, the surveyor and the Licensed Nursing Home Administrator (LNHA) toured the 300 nursing unit, and the surveyor showed the LNHA the identified concerns. The LNHA acknowledged he was aware of the identified concerns, and he stated that the facility planned to remodel the nursing unit, but there was no definitive date. The LNHA acknowledged that the residents could cut their hands on the handrail or trip on the elevated thresholds or missing tiles. The LNHA confirmed the flooring presented an issue with safety and was a tripping hazard. The Maintenance Director was unavailable for an interview during survey. 40744 2. On 10/1/24 at 9:40 AM, during the initial tour of the facility, the surveyor observed Resident room [ROOM NUMBER]. On immediate entrance into the room, the surveyor noted a thick buildup of a brown substance on the floor. There was also a twelve-inch by twelve-inch (12 x 12) tile that was sunken down on the right side adjoining to another tile which was unleveled that created a tripping hazard. The crack in the sunken down tile, between the two tiles had a dark brown substance. The surveyor then entered the bathroom in Resident room [ROOM NUMBER]. On entrance to the bathroom, the surveyor noted a small tile that was missing the corner edge creating a small hole. In front of the toilet there was a loose tile, and around the base of the toilet towards the front was a dark brown substance. When exiting the bathroom, the surveyor noted an area in the corner by the hinged side of the bathroom door, an area of a grayish brown substance on the floor and in the corner by the door jamb was a black and white substance on the floor and on the door jamb. On 10/7/24 at 12:25 PM, the surveyor interviewed the Housekeeping Director (HKD) regarding the process for cleaning resident rooms. The HKD stated that the worst rooms were cleaned first, and the housekeepers had a daily focus. The HKD stated that the floors were mopped daily or twice daily, and that the 300 nursing unit had one housekeeper and one porter (cleaned equipment and emptied trash). On 10/7/24 at 12:50 PM, the surveyor reviewed a room checklist provided by the HKD, and Resident room [ROOM NUMBER] was marked as unsatisfactory. The checklist was dated 10/7/24, after surveyor inquiry. On 10/8/24 at 11:00 AM, the surveyor requested from the LNHA and Acting Director of Nursing (ADON) a clean homelike environment policy. On 10/8/24 at 12:10 PM, the surveyor reviewed the maintenance request logs provided by the facility. On 9/19/24, there was a maintenance request submitted for water leaking in a bathroom. The room number was not identified on the log, and the details written by maintenance were that there were no leaks, and the floor was just dirty. No additional information was provided. A review of the undated facility's Maintenance Service policy included .1. the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at tall times. 2. functions of the maintenance personnel include but are not limited to a. maintaining the building in compliance with the current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. 3. the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner .8. maintenance is responsible for maintaining the following records/reports .a. inspection of the building, b. work order requests, c. maintenance schedules . NJAC 8:39-31.4(a)

Based on observation and interview, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified for 1 of 1 garbage disposal areas, and the facility was previously cited for this during their last standard survey on 9/1/23. The evidence was as follows: On 10/1/24 at 10:46 AM, the surveyor and the Food Service Director (FSD) toured the facility's outside garbage disposal area and observed the following: 1. The cardboard dumpster had no lid and garbage debris was around it. The FSD stated the facility was trying to get the company to replace the lid. 2. The other three dumpsters had paper and food waste around it. 3. A storage container in the area had food and paper debris, wooden boards, and an unidentifiable large object around it. 4. The wooded area along the dumpster area had trash including food product, paper waste, broken wooden boards, and a mattress. 5. The fence along the inside of the garbage area had three pallets leaning against it, and the fence along the outside had an accumulation of both intact and broken pallets as well as other debris surrounding it. The fence itself was dirty and falling down. The FSD stated that someone came to pick up the pallets, but he did not know when. They had not come for the pallets in a minute. At the time of the observation, the surveyor interviewed the FSD who stated housekeeping staff maintained the garbage area, and it was important to maintain the area because of the woods and what comes out. The FSD acknowledged that the area needed to be cleaned. On 10/7/24 at 12:25 PM, the surveyor interviewed the Housekeeping Director (HKD), who stated both housekeeping and the kitchen maintained the garbage area. The HKD stated the day the surveyor identified the debris, housekeeping staff cleaned the area. The HKD stated that they tried to clean the area daily but sometimes forgot. The HKD stated that the guys who made deliveries threw the pallets by the fence and have been like that for a while; at least two or three months. The HKD stated it was important to maintain the garbage area, so no one got hurt or it did not attract rodents, and the HKD acknowledged the condition was unacceptable during the surveyor's observation. On 10/8/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Acting Director of Nursing (ADON) and survey team, stated all the surveyor's concerns were addressed. No additional information was provided. A review of the facility's Housekeeping - Outdoor Trash Area policy dated revised April 2024, included our nursing home is committed to maintaining a clean, safe, and hygienic environment for our residents, staff, and visitors .housekeeping staff are responsible for regularly cleaning and maintaining the outdoor trash area .the maintenance team will ensure the trash bins are in good condition and are adequately covered to prevent odors and pests. They will promptly repair or replace any damaged bins or equipment in the outdoor trash area. All staff members are expected to dispose of waste properly by placing it in designated trash bins. No littering is allowed in or around trash area .housekeeping staff will perform routine checks to ensure that the outdoor trash area is free of litter and debris. Any litter found in the vicinity will be promptly cleaned up to maintain a neat appearance . NJAC 8:39-19.3(a); 19.7(a)(b)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls at the facility. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #53), and was evidenced by the following: On 10/1/24 at 10:17 AM, during the initial tour of the facility, the surveyor observed Resident #53 in bed with blankets over their head. On 10/2/24 at 11:30 AM, the surveyor observed Resident #53 in bed. Resident #53 told the surveyor that they liked to stay in bed and they ate meals in their room. The surveyor asked the resident if they had any history of falling, and the resident said yes, but did not say if they were every injured during a fall. The surveyor observed no fall mats. On 10/2/24 at 12:15 PM, the surveyor reviewed the medical record for Resident #53. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but not limited to; depression, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (high blood pressure), and low back pain. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/9/24, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15; meaning the resident was cognitively intact. A review of Section GG for functional status revealed no impairment of upper or lower extremities, and that the resident was independent with toileting and hygiene. On 10/3/24 at 10:56 AM, the surveyor reviewed incidents and accidents which indicated that Resident #53 had a fall on 8/19/24. The resident was found on the floor in the room by the staff. The resident told staff that they tripped over their shoes and did not hit their head. Staff documented that no injuries were observed; and neurological (neuro) checks (evaluation of a person's nervous system) were initiated; and the resident's family and physician were notified. On 10/7/24 at 10:19 AM, the surveyor reviewed the resident's individualized comprehensive care plan (ICCP) which included a focus area dated 12/8/21 and revised 5/14/24, that the resident was at risk for falls related to psychotropic drug use. Interventions included to leave call bell within reach; ensure the resident was wearing appropriate footwear; keep pathways clear; and physical and occupational therapy to evaluate and treat as needed. The ICCP did not include the fall from 8/19/24, and was not revised following the fall. On 10/7/24 at 12:08 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the facility's post falls process. The UM/LPN said if a resident's fall was unwitnessed, neuro checks were started, a physical therapy evaluation was ordered if appropriate, and then we meet as a team to add interventions. The UM/LPN said the ICCP was revised with new interventions to implement. The surveyor asked the UM/LPN to review Resident #53's ICCP, and verify if the ICCP was revised after the resident's fall in August 2024. The UM/LPN confirmed the ICCP was not updated after the resident's fall. On 10/8/24 at 11:00 AM, the Licensed Nursing Home Administrator, in the presence of the Acting Director of Nursing (ADON) and survey team, acknowledged Resident #53's ICCP was not updated post fall until surveyor inquiry. A review of the facility's Care Planning policy dated revised April 2024, included that care plan development, renewal and revision will be based upon results of the resident assessment .when a problem, goal, approach or target date is added, changed or resolved it is indicated in the care plan . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who smoked cigarettes was assessed for safety. The deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #25), and was evidenced by the following: On 10/1/24 at 10:28 AM, during initial tour of the facility, the surveyor observed Resident #25 in their room watching television. Resident #25 stated that they were a smoker and went outside to smoke at 9:00 AM, 1:00 PM, and 4:00 PM. The resident also stated that the activities staff held on to their cigarettes and lighter. On 10/1/24 at 12:26 PM, the surveyor reviewed the medical record for Resident #25. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; hypertension (high blood pressure), depression, and hyperlipidemia (abnormally high levels of lipids or fats in the blood). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/2/24, indicated the resident had a brief interview for mental status score of 15 out of 15, indicating a fully intact cognition. A further review in Section J Health Conditions reflected the resident was a current tobacco user. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/20/22, that the resident was a smoker. Interventions included that the resident required supervision while smoking; will be assessed quarterly for smoking safety; instruct the resident about smoking risks and hazards and about smoking cessation aids that are available; instruct the resident about the facility policy on smoking locations, times, and safety concerns; have smoking supplies stored with the activity department; observe the resident's clothing and skin for signs of cigarette burns; the facility smoking contract has been reviewed with the resident and they have signed it; and to notify the charge nurse immediately if it was suspected that the resident had violated the facility's smoking policy. A review of the Smoking Safety Screen, located in the electronic medical record (eMR). revealed the most recent smoking safety screen was completed on 5/31/24. The Smoking Safety Screen indicated that the resident was a smoker and could smoke safely with supervision. A review of the resident's Smoking Contract was signed by the resident on 6/25/24. On 10/7/24 at 12:14 PM, the surveyor interviewed the Activities Director (AD), who stated that residents were assessed upon admission, quarterly, annually, and if there was a significant change for smoking which included safety. The AD stated that Resident #25 was a smoker and provided the surveyor with the most recent Smoking Safety Screen dated 5/31/24. The AD stated that there should have been a smoking assessment completed the first week of September, and they could not speak to why there was no Smoking Safety Screen completed. The AD stated the importance of completing a Smoking Safety Screen was for the safety of the resident, and to determine if there were any changes such as needing a smoking apron. On 10/7/24 at 1:35 PM, the surveyor interviewed the Acting Director of Nursing (ADON), who stated Smoking Safety Screenings should be completed upon admission. The ADON could not speak to when Smoking Safety Screenings should be completed other than upon admission. On 10/8/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the ADON and survey team, stated that the Smoking Safety Screenings were completed quarterly, or if there was a significant change. The LNHA also stated that the Smoking Safety Screening was due when the facility was changing Activities Directors, and we missed the September screening. The LNHA further stated that Resident #25's Smoking Safety Screening was completed on 10/7/24, after it was brought to our attention. The LNHA acknowledge a Smoking Safety Screening should have been completed in September. A review of the facility's Resident Smoking Policy dated revised 8/30/23, included the resident will be evaluated upon admission, re-admission, and quarterly or upon any significant change to a residents physical or cognitive status . NJAC 8:39-27.1(a)

Based on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to label, date, and initial a resident's oxygen tubing. This deficient practice was identified in 1 of 1 residents reviewed for respiratory therapy (Resident #49), and was evidenced by the following: On 10/1/24 at 10:07 AM, during initial tour of the facility, Resident #49 approached the surveyor in the main dining room on the second floor. During the observation, the resident had a walker and a portable oxygen tank. The tubing that supplied the oxygen that went from the resident to the tank did not have a date. The surveyor then entered the resident's room with the resident, and the resident had an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95 % pure oxygen) in the room. The concentrator had oxygen tubing that went from the concentrator and into a bag. The resident told surveyor that they wore that when in bed. On 10/1/24 at 10:37 AM, the surveyor observed Resident #49 in the bed. The resident was being administered oxygen at three liters per minute from an oxygen concentrator. The resident's oxygen tubing was not dated. On 10/1/24 at 11:20 AM, the surveyor reviewed the medical record for Resident #49. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with medical diagnoses that included but not limited to; chronic obstructive pulmonary disease (common lung disease that makes it difficult to breathe), respiratory failure, and anxiety. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/4/24, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A further review revealed the resident used oxygen. A review of the physician's orders (PO) included the following POs: A PO dated 12/15/23, for humidified oxygen when oxygen was in use every twenty-four hours as needed. To apply oxygen per nasal cannula (medical device that provides oxygen to a patient through their nose) at 3 liter per minute as needed every twenty-four hours for wheezing and shortness of breath. A PO dated 12/15/23, for the staff to change the oxygen tubing weekly and date the tubing and bag every night shift on Sunday. A review of the individual comprehensive care plan (ICCP) included a focus area dated 8/3/22 and revised 7/31/24, that the resident was able to apply the oxygen therapy when needed. Interventions included to change the oxygen tubing weekly. On 10/3/24 at 1:00 PM, the surveyor observed Resident #49 smoking under the supervision of the activities staff. The resident removed the oxygen prior to going outside to smoke and the oxygen remained in the building. Resident #49 went back into building and reapplied the oxygen. The surveyor observed that the tubing was not dated. On 10/7/24 at 12:16 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding oxygen tubing. The UM/LPN stated that oxygen tubing was changed every Sunday night and the tubing was dated. The surveyor informed the UM/LPN that on Monday, Tuesday, Wednesday, and Thursday of last week, the surveyor observed that Resident #49's oxygen tubing was not dated. The UM/LPN could not speak to why the tubing was not dated. On 10/7/24 at 2:01 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Acting Director of Nursing (ADON) about the multiple observations of Resident #49's oxygen tubing not dated. No additional information was provided. A review of the facility's Oxygen Administration policy dated revised 7/10/23, included .staff were to date and initial tubing and humidifiers when changing each week . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to use appropriate hand hygiene and proper disinfection while providing wound care to a resident. The deficient practice was observed for 1 of 1 residents reviewed for pressure ulcers/injury (Resident #8), and was evidenced by the following: On 10/1/24 at 10:40 AM, during initial tour of the facility, the surveyor observed Resident #8 sleeping in their bed. The surveyor observed the resident wearing bilateral heel protectors. On 10/2/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #8. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; acute respiratory failure with hypercapnia (a condition where you do not have enough oxygen in the tissues in your body), metabolic encephalopathy (short- or long-term change in how your brain functions), and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 8/13/24, indicated the resident had a brief interview for mental status score of 9 out of 15, indicating a moderately impaired cognition. A further review in Section M Skin Conditions reflected the resident had five venous and arterial ulcers present. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 3/25/24, that the resident had a potential for impairment to skin integrity/pressure injury development related to decreased mobility, dementia, and incontinence. In March 2024, the resident returned from the hospital with a sacral (lower back) wound, a left toe wound, and a left heal wound. Interventions included to monitor the resident for picking at their skin; podiatry consultation as indicated for foot care; pressure relieving mattress while in bed; weekly treatment documentation to include measurement of each area of the skin breakdown's width, length, depth, type of tissue and exudate (secretions), and any other notable changes or observations; wound consult as indicated; wound treatment as per physician orders. A review of the Physician Order Summary Report reflected the following physician's orders (PO):with a start date of 10/5/24: A PO dated 10/5/24, for Betadine External Solution 10% (povidone-iodine); apply to left dorsal foot (upper surface of the foot) arterial topically every day shift for wound care. First cleanse with Betadine; apply Betadine to base of the wound; leave open to air; and change daily. A PO dated 10/5/24, for Betadine External Solution 10% (povidone-iodine); apply to right dorsal foot arterial topically every day shift for wound care. First cleanse with Betadine; apply Betadine to base of the wound; leave open to air,; and change daily. A PO dated 10/4/24, for Dakins (1/2 strength) External Solution 0.25% (an antiseptic); apply to left lateral heel arterial topically every day and evening shift for wound care. First cleanse with 0.25% Dakins solution; apply skin prep to periwound (area around wound); apply Dakins moistened fluffed gauze to base of wound; secure with dry gauze and lightly rolled gauze; change twice a day (BID) and as needed soilage, or dislodgement. On 10/7/24 at 9:33 AM, the surveyor obtained verbal permission from Resident #8 to observe their wound care. The surveyor observed the Licensed Practical Nurse (LPN) began to perform wound care to the left and right foot. The LPN performed hand hygiene prior to donning (apply) gloves and gown at the start of the wound care. The LPN removed the old dressing and disposed of it in the trash receptacle. The LPN then doffed (removed) their gloves, and without performing hand hygiene, donned a new pair of gloves and cleansed the left dorsal foot wound with Betadine External Solution using a four-by-four (4 x 4) gauze. The LPN then cleansed the right dorsal foot wound with Betadine External Solution using a 4 x 4 gauze. The LPN then doffed her gloves and without performing hand hygiene, donned a new pair of gloves and cleansed the left heel wound with Dakins solution 25%, applied skin prep, applied 4 x 4 gauze moistened with Dakins solution, and gauze wrap to the left heel. The LPN then removed her gloves, and without performing hand hygiene donned a new pair of gloves and dated the dressing on the left heel. The LPN then removed both gloves once the wound care treatment was completed and performed hand hygiene. On 10/7/24 at 10:00 AM, the surveyor interviewed the LPN in the presence of the Unit Manager/LPN (UM/LPN), who stated that hand hygiene should have been completed in between each glove change. The LPN then acknowledged that they should have used alcohol-based hand rub or washed their hands using soap and water in between glove changes. The LPN acknowledge that they did not complete hand hygiene in between the glove changes during wound care. The UM/LPN confirmed that hand hygiene should have been performed in between glove changes. On 10/7/24 at 1:32 PM, the surveyor asked the Acting Director of Nursing (ADON) what their expectations were for staff for hand hygiene while performing wound care, and the ADON stated for the staff to do it properly. The ADON stated staff were to wash their hands prior to wound care, anytime they removed their gloves, and when wound care was finished. On 10/8/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the ADON and survey team, stated that the facility had began inservicing staff on handwashing. The LNHA acknowledge handwashing should be completed in between glove changes. A review of the facility's Infection Control Policy Procedures 2020 included Handwashing/Hand Hygiene .hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . NJAC 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness, b.) air dry kitchen equipment in a manner to prevent microbial growth, c.) maintain kitchen equipment in a sanitary manner, d.) maintain proper kitchen sanitation practices. This deficient practice was evidenced by the following. On 08/22/23 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following: 1. In the reach-in refrigerator, sliced yellow American cheese wrapped in clear plastic that was not dated or labeled with a used-by date. The FSD stated that the staff should have labeled and dated when the cheese was sliced. Ten cupcakes in a store-bought plastic container were not labeled or dated. The FSD stated that the cupcakes were from the recreation department and should not have stored them there. The FSD discarded the cupcakes. 2. On the front of the stove, underneath the grill top, there was a buildup of brownish-dried substance. The FSD stated that this is from grease catcher where the grease collects, spills out, and runs down the front of the oven. When the FSD opened the double oven doors, the right and left side doors dropped simultaneously. The FSD stated that the hinges were bad, and the oven doors would not stay closed. The FSD stated he had temporarily placed latches on both sides of the oven to keep the oven doors closed until the oven was fixed. The FSD stated there is a cleaning schedule for the kitchen, including the stove. 3. On a metal rack, four hotel pans were wet nested, and the FDS removed the pans and placed them near the sink to be washed. 4. During a tour of the dry storage area, there was an opened box of taco shells with three opened packages wrapped in clear plastic that were not labeled or dated. The FSD removed and discarded them. There was a 20-pound box of spaghetti with an opened package of spaghetti wrapped in plastic that was not labeled or dated. A 5-gallon plastic container, identified as panko by the FSD, was not labeled or dated. 5. At 10:00 AM, the surveyor observed the cook enter the kitchen without a hair net. The cook stated that he should have had a hair net on because it is very unsanitary as hair could get into the food. The FSD was made aware at that time. On 8/23/23 at 9:19 AM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and were informed of the findings. The LNHA stated the cook should have put a hair net on before he walked into the kitchen, the stove is on the list to be replaced, and the staff will have a schedule to keep the stove clean. A review of the facility's policy, Food Brought in from the Outside, dated 1/6/23, included a designated pantry space and refrigerators for residents' outside foods. A review of the facility's policy Use of Hair Nets and Beard Nets dated 3/10/23 included that hair nets and beard nets are necessary items required by the FDA and USDA in food handling settings .When entering the kitchen, always wearing a hair net and beard net when handling food .or any duty in the kitchen area is mandatory. They are an effective tool for preventing the spread of hair in food processing and food service. A review of the facility's policy Food Labeling and Dating for Kitchen, dated 6/10/23, included all food .should be labeled with the common name of the food, the date the food was made, and a use-by date. NJAC 8:39-17.2(g)

C#: NJ 5 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on 7/8/2021, 7/14/2021, and 7/19/2021, it was determined that the facility failed to provide a safe environment and assess a resident (Resident #4) who has a diagnosis of Dependence on Supplemental Oxygen and with a Physician's Order for continuous use of supplemental Oxygen when the resident's roommate (Resident #1) was smoking in their room with Resident #2 on 6/13/2021, while Resident #4's Oxygen was in use. The facility also failed to provide a safe environment and accurately reassess Resident #1 and Resident #2, who were identified as smokers and had multiple infractions and violated the facility's smoking policy and smoking contract agreement by smoking in their rooms. There was no documented evidence in the Care Plans to determine that interventions were in place and were evaluated for their effectiveness after each smoking violation and to ensure, Resident #1 was kept safe from harm on 6/13/2021 when Resident #1 and Resident #2 were both smoking in Resident #1's room and Resident #2 burned Resident #1 on the right arm with a lit paraphernalia pipe. The facility also failed to provide all staff educational training on the smoking policy, what to do if residents were found smoking in non-smoking areas and when Oxygen was being used after the 6/13/2021 smoking incident occurred. The facility's failure to revise and implement the residents' Care plans to avoid a smoking accident while a resident was on continuous use of supplemental Oxygen on three previous occasions created an unsafe environment for serious injury, combustion, and fire. The facility also failed to follow its Policies titled Resident Smoking Policy and Fire Prevention. This placed a threat to the safety and well-being of Resident #1, Resident #2, Resident #4, and all other residents residing at the facility, which resulted in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 7/14/2021 at 4:14 p.m. The Administrator and DON were presented with the IJ template that included information on the issue. The IJ began on 6/13/2021 at 1:30 a.m., upon the second smoking violation incident when Resident #4 was present and on continuous Oxygen and when Resident #1 was burned and continued until 7/15/2021 at 9:51 a.m. when the facility alleged completed implementation of the elements in their IJ Removal Plan. On 7/19/2021, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating all facility staff on smoking and reporting all smoking to administration for residents who smoke within the facility or in their rooms, in residents' rooms with Oxygen, and the danger of smoking with oxygen present. So the noncompliance remained on 7/19/2021, for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: Resident #1 was still in the facility but was on a 1:1 since he was caught smoking again on 7/18 during 15 minutes checks. This deficient practice occurred for 3 of 4 sampled residents (Resident #1, Resident #2, and Resident #4) and was evidenced by the following: According to the Timeline of Events (TLE) on 6/14/2021 at approximately 8:00 a.m., the DON was making rounds on the unit when Resident #1 reported to the DON that on Sunday 6/13/2021 at 7:00 a.m., Resident #2 was in Resident #1's room smoking a marijuana pipe. The FRE revealed Resident #1 told the DON that Resident #2 burn the resident on the right arm with the lit pipe. The TLE indicated that Resident #1 hit Resident #2 twice. The TLE also revealed that the DON assessed the right arm of Resident #1 and noted a red burn mark to the resident's right arm; the Physician was notified, a treatment was ordered, and it was in progress. The TLE also revealed Resident #1 did not report the incident to the nurse on the unit and was informed by the DON he/she need to report all incidents that occur, especially those resulting in injury. The FRE also revealed that the SW interviewed all three residents (Resident #1, Resident #2, and Resident #4). Further review of the FRE indicated Resident #2 was seen by the Psychiatrist, an appointment with the Psychologist was scheduled, and assessments were ongoing to prevent additional episodes. The FRE included an interview conducted by the SW dated 6/14/2021 that revealed the following: Resident #1 stated on 6/13/2021 at 7:00 a.m., Resident #2 placed a lit marijuana pipe on Resident #1's right arm and showed the Social Worker (SW) the burn marks on the arm. Resident #1 told the SW, Resident #2 burned him/her because the resident wanted Resident #1's [MEDICATION(S)]. Resident #1 further stated that he/she was sleeping when this happened; he/she woke up because the resident's roommate (Resident #4) said, do not do it. Resident #1 told the SW he/she did not report it earlier because the resident did not want to get the nurses in trouble. According to the FRE, interviews conducted by the SW dated 6/14/2021, Resident #2 denied the incident happened at first, and then the resident stated to the SW that he/she was just playing around and no one got hurt. The SW explained to Resident #2; the incident was serious since someone got hurt. Resident #2 stated he/she has too much time, so the resident gets into trouble. On 6/14/2021, the SW also interviewed Resident #4, the roommate of Resident #1, who stated he/she observed the incident of Resident #2 burning the arm of Resident #1 with a lit pipe at 7:00 a.m. on 6/13/2021 and told Resident #2 not to do it. Review of the Medical Records were as follows: 1. According to the Admission Record (AR), Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to: Uncomplicated Opioid Dependence, Uncomplicated Opioid Use, [CONDITION(S)] ([CONDITION(S)]) with (Acute) Lower Respiratory Infection, Unspecified Interstitial Pulmonary Disease, Chronic Respiratory Failure with [CONDITION(S)] and Dependence on Supplemental Oxygen. According to the Minimum Data Set (MDS), an assessment tool dated 3/17/2021, Resident # 4 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also showed Resident #4 was independent with Activities of Daily Living (ADLs) and was on oxygen therapy. A review of the resident's Care Plan (CP) initiated 12/8/2020 revealed under Focus: I have oxygen therapy r/t (related to) SOB (shortness of breath), hypoventilation syndrome. The CP also included under Goal: I will have no signs/symptoms of poor oxygen absorption through the review date. Also, under Interventions: included, . Encourage the proper use of Oxygen and [CONDITION(S)] (Bi-level Positive Airway Pressure- a device used to assist with consistent breathing while sleeping) @ (at) HS (Hour of Sleep), oxygen settings: O2 (Oxygen) via nasal prongs as ordered, (and) Provide extension tubing or portable oxygen apparatus Further review of Resident #4's CP initiated 12/8/2020, included under Focus: I have a dx (diagnosis) of [CONDITION(S)]. I have been hospitalized for respiratory distress on 1/31/2021, 3/3/2021, 4/6/2021, 4/24/2021, and 5/25/2021. The most recent return from the hospital 6/1/2021. The CP showed under Goal: I will be free of signs/symptoms of respiratory infections through review date. The CP also showed under Interventions: . Monitor for difficulty breathing (Dyspnea) on exertion. Remind me not to push beyond endurance . Monitor for signs/symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB at rest, Cyanosis, Somnolence. Notify MD (Physician) of changes .Oxygen settings: O2 via nasal prongs as ordered. A review of the Physician's Order (PO's) revealed Resident #4 had a physician's order (PO) dated June 2021 for Oxygen continuous at 2L (liters)/ (per) M (minute) (by) nasal cannula. A review of the Treatment Administration Record (TAR) for June 2021 reflected the above POs to administer supplemental Oxygen at 2 liters per minute continuously, which was signed to reflect that the resident received the supplemental Oxygen constantly via nasal cannula every shift as ordered. The Surveyor reviewed Resident #4's IPNs from May 2021 through June 2021; there was no documented evidence that the resident was assessed after the smoking incidents with Resident #1 and Resident #2 on 6/13/2021 at 1:30 a.m. and 7:00 a.m., and on 6/24/2021, while Resident #4 was present in the room on Oxygen. During an interview on 7/8/2021 at 11:00 a.m., the Surveyor observed Resident #4 sitting on the bed with his/her Oxygen on three liters by nasal cannula. Resident #4 stated the resident needs his/her Oxygen, so it is always on, and he was on three liters. According to the resident in June (he could not recall the day or date), Resident #2 took a pipe and put it onto Resident #1. Resident #4 stated the resident and Resident #1 were both in the room, and Resident #4 came over to visit Resident #1 before breakfast. 2. According to the AR, Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Current Episode Manic Severe with Psychotic Features [CONDITION(S)], Uncomplicated Opioid Dependence and Unspecified, Uncomplicated Nicotine Dependence. According to the MDS dated [DATE], Resident #1 had a BIMS score of 15/15, which indicated the resident was cognitively intact. The MDS also showed Resident #1 was independent with ADLs and was a current tobacco smoker. A review of the resident's CP initiated on 5/5/2021 reflected that Resident #1 was a smoker. The CP also revealed the resident smoked in (his/her) bathroom on 5/7/2021 and was counseled. Further review of the CP under Goal: showed, I will adhere to (the) facility smoking policy, I will not suffer injury from unsafe smoking practices through the review date 5/5/2021. Further review of the CP showed under Interventions: I require supervision while smoking, I will be instructed about smoking risks and hazards and about smoking cessation aids that are available, I will be instructed about the facility policy on smoking: locations, times, safety concerns, My smoking supplies are stored with the activity department. Notify charge nurse immediately if it is suspected that I have violated facility smoking policy, observe my clothing and skin for signs of cigarette [CONDITION(S)]. The Surveyor reviewed the Interdisciplinary Progress Notes (IPNs) for May, and June 2021, which reflected Resident #1 had two incidents of smoking in the bathroom. The IPNs reflected the following: A review of Resident #1's Interdisciplinary Progress Note (IPN) dated 5/7/2021 at 6:30 p.m., written by the Licensed Practical Nurse (LPN #2), revealed a strong smell of smoke was noted in the resident's bathroom. The IPN also revealed a lighter, and cigarettes were obtained and placed in the medication cart. According to the IPN Resident #1 admitted to smoking in his/her bathroom. A review of a second IPN showed a late entry note dated 6/20/2021 at 2:00 a.m., written by LPN #1. The IPN revealed at 1:30 a.m., on 6/13/2021, Resident #1 and Resident #2 were smoking in Resident #1's room while Resident #4 was asleep with the Oxygen on. According to the IPN, LPN #1 educated Resident #1 and Resident #2 about the dangers of smoking in the room with oxygen present. The IPN also indicated the room was searched, nothing was found, and Resident #2 returned to his/her room on another unit. The IPN also included that the incident was reported to the DON. A review of Resident #1's Physician's Orders dated 6/14/2021 revealed the following order: Apply [MEDICATION(S)] Cream to right upper forearm daily x 7 days for mild burn and redness. A review of the Treatment Administration Record (TAR) dated 06/2021 revealed the treatment was administered as ordered. During an interview on 7/14/2021 at 9:30 a.m., Resident #1 explained that he/she would lose smoking privileges for a week or two whenever the resident was caught smoking in his/her room. Resident #1 also stated, every time I smoke in my room (Resident #4) was there with (his/her) oxygen on, (Resident #4) smokes with me, sometimes we goes in the bathroom in the room and smoke. Resident #1 also stated, when (Resident #4) smokes (he/she) removes the oxygen and leaves it in the room and go to the bathroom. Resident #1 continued to explain staff has educated the resident about smoking in the room when they found out he/she was smoking. Resident #1 also stated, all staff probably found the resident smoking in his/her room at some point, because I do it a lot. During a phone interview on 7/19/2021 at 12:37 p.m., LPN #2 stated that on 5/7/2021, she smelled smoke coming from resident #1's room, and she told the Nursing Supervisor. The Surveyor attempted to contact the Nursing Supervisor at the time of the survey but received no response. The Surveyor reviewed the untitled facility's forms for smoking infractions, which revealed Resident #1 violated the smoking contract and had the following smoking violations: In the first smoking violation incident on 5/20/2021, the resident was found with smoking materials in his/her possession, including an e-cigarette and one unsmoked cigarette. The second smoking violation incident occurred on 5/24/2021 when Resident #1 was smoking in his/her room and was found with an empty pack of matches and one half-smoked cigarette. The third smoking violation incident occurred on 6/13/2021 at 1:30 p.m., and a fourth smoking violation incident occurred that same day at 7:00 a.m. when the resident was burned by Resident#2. However, there was only one form dated 6/16/2021, which staff confirmed was for the 6/13/2021 incident. After the 6/13/2021 incident, when the resident was burned, he/she was still found having a fifth smoking violation incident on 6/24/2021 of smoking in the residents room while Resident #4 was on Oxygen. The Surveyor reviewed the smoking binder presented during the survey; no smoking infractions were completed for Resident #1's violations on 5/7/2021, 5/21/2021, and 6/13/2021 for the 1:30 a.m. occurrence. 3. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Uncomplicated, Other Psychoactive Substance Dependence, Chronic Pain Syndrome, and Unspecified Anxiety Disorder. According to the MDS, dated [DATE], Resident #2 had a BIMS score of 15/15, which indicated the resident was cognitively intact. The MDS also showed Resident #2 was independent with ADLs and was a current tobacco smoker. A review of the Resident's CP initiated on 4/21/2021 reflected that Resident #2 was a smoker. The CP also showed under Goal: I will adhere to (the) facility smoking policy, I will not suffer injury from unsafe smoking practices through the review date. Further review of the CP showed under Interventions: I require supervision while smoking; I will be instructed about smoking risks and hazards and about smoking cessation aids that are available, I will be instructed about the facility policy on smoking: locations, times, safety concerns, My smoking supplies are stored with the activity department, Notify charge nurse immediately if it is suspected that I have violated facility smoking policy, observe my clothing and skin for signs of cigarette [CONDITION(S)]. The Surveyor reviewed the IPNs for May and June 2021, which revealed that Resident #2 had two smoking incidents in the bathroom. The IPNs reflected the following: A review of Resident #2's IPN dated 6/14/2021 revealed a note written by the Social Worker (SW) that indicated Resident #2 burned Resident #1 with a marijuana pipe. According to the IPN, the SW asked Resident #2 to go to the hospital due to the resident's dangerous behavior; however, the resident refused. The IPNs also included that the SW contacted the Crisis Center to screen and evaluate the resident. Resident #2 was to be sent to Crisis pending hospital placement. There was no documentation in the IPN about the 6/13/2021 incident at 1:30 p.m., indicating that the resident's assigned nurse was aware and the facility's policy and procedure were implemented for smoking in non-smoking areas. A review of the Smoking Contract signed by Resident #1 on 5/3/2021, and Resident #2 on 4/19/2021, reflected both residents agreed to the terms of the contract, which included 1. No Resident is permitted to have any cigarettes, cigars, pipes, lighters, matches or any flammable device that can be used to light up smoking items. 2. To protect the safety of all residents and staff, if it is reported or known that a Resident has smoking materials in their possession, located in his/her room, and or located in their belongings, the resident will be notified, and their room will be searched by at least two (2) representatives of the facility, with or without the resident's permission (and) 5. Smoking will ONLY be allowed in the designated area located on the patio off the main dining room. A review of an untitled statement written by the Housekeeping staff, dated 5/21/2021, indicated that he observed Resident #2 smoking in another resident's (Resident #1 & Resident #4) room on 5/21/2021 and 5/22/2021. During an interview on 7/14/2021 at 2:15 p.m., the Housekeeper staff explained on the night of 5/21/2021; I could smell smoke from the hallway; when I entered the room and opened the bathroom door, I saw Resident #1 and Resident #2 with a lit cigarette. The Housekeeping staff stated Resident #4 was in the room with the Oxygen on; I told them they could blow the building up. The Surveyor reviewed the untitled facility's forms for smoking infractions, which revealed Resident #2 violated the smoking contract and had the following smoking violations: In the first smoking violation incident on 5/20/2021, the resident was found with smoking materials in his/her possession, including a lighter, e-cigarette, and two e-cigarette cartridges. The second smoking violation incident occurred on 5/21/2021 when the resident was smoking in another resident's room. The third smoking violation incident occurred on 5/22/2021 when the resident was smoking in another resident's room. The fourth smoking violation incident occurred on 5/23/2021 when the resident accepted smoking materials from another resident and then gave them to staff. The fifth smoking violation incident occurred on 5/24/2021 when the resident was smoking in another resident's room. The sixth smoking violation incident occurred on 6/2/2021 when the resident was smoking in another resident's room. The Surveyor reviewed the smoking [NAME] presented during the survey; no smoking infractions were completed for Resident #2 at the time of the survey for the two smoking incidents occured on 6/13/2021. A review of a form titled Suspension of Smoking Privileges revealed the following: First Offense: Written Warning, Second Offense: 2 days suspension of smoking privileges. Third Offense: one-week suspension of smoking privileges. Fourth Offense: 30-day suspension of smoking privileges. Fifth Offense: indefinite suspension of smoking privileges. During an interview on 7/8/2021 at 12:42 p.m., the SW stated Resident #2 told her on Sunday, 6/13/2021, the resident took a marijuana pipe and placed it onto Resident #1's arm for fun. After the smoking incident, she educated the resident for over an hour. The SW explained she interviewed Resident #1, and the resident also thought it was funny. But (Resident #1) said it hurt at the time it happened. The SW also stated the nurses on the units check the residents' rooms after a smoking incident. The SW further explained before the incident on 6/13/2021; there were other issues with the residents smoking in the wrong places. According to the SW, when residents have smoking infractions, their smoking privileges were suspended for a month after the incident. During an interview on 7/8/2021 at 1:28 p.m., the DON stated after the 6/13/2021 incident; Resident #2 was constantly monitored by her when she does her rounds; it was her daily routine, but it was not documented anywhere. During an interview on 7/8/2021 at 1:44 p.m., the Activity Director (AD) stated all residents who smoke sign a Smoking Contract, and she does a Smoking Assessment on admission and quarterly for safety purposes. All smoking supplies were kept in her office in a locked cabinet. The AD explained residents' rooms are searched if there is a broken contract. The AD further explained the residents' rooms were thoroughly searched. According to the AD, during the search of Resident #2's room, she found an e-cigarette and cartridges for it and matches. During an interview on 7/8/2021 at 1:56 p.m., the Surveyor observed the resident right arm with redness and intact skin. Resident #1 stated, my friend (Resident #2) burned me; I was asleep and heard don't do that. Resident #1 explained Resident #2 had a glass pipe, marijuana pipe; it was clear with yellow oil in it, it hurt. The resident also stated Resident #2 came into the resident room and smoked Marijuana; it shocked me awake. Resident #1 also said the resident told the nurse right away but could not recall who the nurse was, which was a conflict between LPN #1 interview and the facility's statement. During an interview on 7/8/2021 at 2:53 p.m., LPN #1 indicated he did not know about Resident #1 and Resident #2 smoking in Resident #1's room. He was not aware of Resident #1 being burned by Resident #2 on 6/13/2021 until the DON told him about it at a later date. However, he could not recall the date at the time of the survey. However, during a second interview on 7/14/2021 at 9:55 a.m., LPN #1 admitted to being aware of Resident #1 smoking in the room. The LPN explained he wrote the incorrect date of 6/20/2021 in the resident's chart; he wrote the note on 6/14/2021, the day after the smoking incident occurred. LPN #1 further explained that at 1:30 a.m., he smelt smoke coming from Resident #1's and Resident #4's room. According to the LPN, he did not discover any smoking paraphernalia when he searched the room. He also did not notify Resident #2's nurse on unit 4 of the smoking incident to initiate a search in Resident #2's room. LPN #1 also explained he educated both Resident #1 and Resident #2 on the dangers of smoking with oxygen present; the building could go on fire, and it could cause an explosion. During an interview on 7/8/2021 at 3:02 p.m., when asked how the resident was monitored, Certified Nursing Assistant (CNA#1), assigned to Resident #2, stated she keeps an eye on the resident; if the resident leaves his/her room, she notifies the nurse. During an interview on 7/8/2021 at 3:31 p.m., the LNHA stated that staff were doing frequent checks of Resident #2 after the incidents in May. During an interview on 7/8/2021 at 4:15 p.m. the LNHA, stated Resident #2 should not have been smoking in the room with Resident #4. The DON stated the smoking could have caused a fire. Both the Administrator and the DON indicated that they spoke to Resident #2 every day about smoking. When asked by the Surveyor if there were education provided to staff after the incident, the DON stated that there were no staff educations on smoking after the 6/13/2021 incident. During an interview on 7/8/2021 at 5:45 p.m., the LNHA stated he tried to do q (every) 15 minutes checks on Resident #2, but the resident was too slick; therefore, the checks could not be done there were gaps in the documentation. The Administrator also stated the staff knew to watch Resident #2. However, no documentations were provided during the survey or observed in the resident's medical records indicating the checks were consistently implemented. During an interview on 7/14/2021 at 9:25 a.m., Resident #2 stated, I smoked Marijuana a lot before I came here. Now I only smoke Marijuana once in a while. I have a connection from the outside who brings it in for me. Friends and family bring me in vape marijuana. I usually smoke it on the patio. When I smoke, I have to sneak it. During an interview on 7/14/2021 at 10:38 a.m., the LNHA stated after the 6/13/2021 incident, Resident #2 was suspended for 30 days from smoking. However, after 2-3 weeks, the resident's smoking plan was reinstated for good behavior. The LNHA explained there were searches done on the resident's room. Still, there was nothing found, so since there were no issues, staff were monitoring Resident #2, just as an observation without documentation. The LNHA also explained he tried to monitor Resident #2, but it was impossible because Resident #2 was totally independent. The LNHA also stated if a resident had a smoking violation, it would be attached to the resident's smoking contract in the Smoking binder. During a tour on 7/14/2021 at 10:52 a.m., the Surveyor interviewed LPN #3, who stated, I can smell cigarette smoke in Resident #2's) bathroom. The LPN further stated, I'm an ex-smoker, so I know if someone's been smoking. The Surveyor then entered Resident #2's room at 10:53 a.m. and smelled a strong odor of cigarette smoke in Resident #2's bathroom. During an interview on 7/14/2021 at 10:53 a.m., in the presence of the LNHA, the DON stated she was not aware of Resident #1 and Resident #2 smoking in Resident #1's on 6/13/2021 at 1:30 p.m., in the presence of Resident #4 who was on Oxygen. The LNHA also indicated he was unaware of this incident. During an interview on 7/14/2021 at 12:53 p.m., the LNHA stated no investigations were done for the 5/7/2021 smoking violation for Resident #1 and the 6/13/2021 smoking violation at 1:30 a.m. for Resident #1 and Resident #2 he was unaware they occurred. During an interview on 7/14/2021 at 1:59 p.m., CNA #2, assigned to Resident #1, stated he was present when LPN #1 talked to Resident #1 and Resident #2 when they were smoking in the room with Resident #4's Oxygen on at 1:30 a.m. on 6/13/2021. On 7/14/2021 at 11:04 a.m., while in the lobby area, the Receptionist called the Surveyor over to the receptionist desk/office and stated, every time I smell cigarette smoke at the receptionist desk, ninety-nine percent of the time the smell is coming from Resident #2's room. I can smell it now. The Receptionist further explained Resident #2 hides his/her cigarettes on top of the resident's overbed light, behind the bed, and nightstand. The Receptionist further stated, for some reason, when Resident #2 smokes in his/her room, I can smell it in my office. I'm concerned because it can seriously hurt someone who is on Oxygen. A review of the facility policy titled Resident Smoking Policy revised date 3/29/2021 revealed the following: Under Policy included .maintains a smoke free facility. Residents are permitted to smoke only outdoors in the designated smoking area. No Resident is permitted to have lighters or matches on their person, in their room or any indoor area of the facility due to safety. Under Procedure included .4. A comprehensive Resident Care Plan will be written for each resident with individualized interventions .5. There is only one area designated as a Resident smoking area. The outside Resident smoking patio on the 2nd floor; off the upstairs main dining room .7. All Residents who smoke will be supervised during the smoking period. They will smoke only during established smoke times. They will not be allowed to possess any form of tobacco or any manner in which to ignite tobacco. The smoking times may be modified as needed, both for short term or long-term basis to ensure the safe and efficient operation of the facility and the safety and maximum quality of life for all Residents .9. The Activity Director, activity staff/designees will store the Resident's smoking items in a secured area and distribute these items to Residents, as needed .13. The use of e-cigarettes will only be allowed in the same locations as other smoking items. The activity staff/designee will hold the cigarette and nay other supplies that ware necessary for the use of the e-cigarettes .Residents receiving oxygen therapy, are not permitted in the designated smoking area while Oxygen is in use or if Oxygen is near them at any time. Review of the facility policy titled Fire Prevention, Updated 6/5/2021 revealed the following: Under Policy Statement included It is the policy of facility that all personnel participate in methods of fire prevention and to report any condition(s) that could result in a potential fire hazard. Under Procedure included Fire prevention is the responsibility of all personnel, residents, visitors and the public alike. Should a fire hazard, or other condition that could develop into a fire hazard be discovered, it shall be reported to the Director of Maintenance immediately. All personnel must be alert for: Smoking in unauthorized areas .the department director shall be responsible for the prompt investigation of such condition(s). Hazardous conditions must be corrected as soon as practical . On 7/19/2021, the surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating all the facility staff on the Smoking Policy and auditing Resident #1 and Resident #2 with Q (every) 15 minutes checks Q (every) shift and all smokers with daily room checks. So the noncompliance remained on 7/19/2021 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the following: Resident #1 was still in the facility but was on a 1:1 since he was caught smoking again on 7/18 during 15 minutes checks. N.J.A.C.: 8.39- 4.1 (5) N.J.A.C.: 8.39 -11.2 (2) (i)

COMPLAINT#: NJ 5 Based on observations, interviews, medical record reviews, and review of other pertinent facility documentation on 7/8/2021, 7/14/2021, and 7/19/2021, it was determined that the facility failed to update, revise and implement care plan interventions for residents who had multiple smoking infractions and violated the facility's smoking contract and smoking policy by smoking in their rooms. The facility also failed to follow its policy titled Residents/Patients Care Plans. This deficient practice was evident in 3 of 4 care plans reviewed (Resident #1 and Resident #2) and was evidenced by the following: Review of the Medical Records (MRs) were as follows: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 5/7/2021, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also showed Resident #1 was independent with ADLs and was a current tobacco smoker. The Surveyor reviewed the Interdisciplinary Progress Notes (IPNs) for May, and June 2021, which reflected Resident #1 had two incidents of smoking in the bathroom. The IPNs reflected the following: A review of Resident #1's Interdisciplinary Progress Note (IPN) dated 5/7/2021, written by the Licensed Practical Nurse (LPN #2), revealed the resident admitted to smoking in his/her bathroom. However, there was no documentation in the resident's medical record (MR) of education being provided, an investigation completed, or violation warning for the 5/7/2021 smoking violation. A review of a second IPN showed a late entry note dated 6/20/2021 at 2:00 a.m., written by LPN #1. The IPN revealed at 1:30 a.m., on 6/13/2021, Resident #1 and Resident #2 were smoking in Resident #1's room while Resident #4 had his/her oxygen on, and the resident was asleep. According to the IPN, LPN #1 educated Resident #1 and Resident #2 about the dangers of smoking in the room with oxygen present. The IPN also indicated, the resident's room was searched, there was nothing found, and Resident #2 returned to his/her room on another unit. The IPN also included that the incident was reported to the DON. A review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) dated 06/2021 revealed the treatment was administered as ordered. A review of the resident's Care Plan (CP) initiated on 5/5/2021 reflected that Resident #1 was a smoker. The CP also revealed the resident smoked in (his/her) bathroom on 5/7/2021 and was counseled. Further review of the CP under Goal: showed, I will adhere to (the) facility smoking policy, I will not suffer injury from unsafe smoking practices through the review date 5/5/2021. Further review of the CP showed under Interventions: I require supervision while smoking, I will be instructed about smoking risks and hazards and about smoking cessation aids that are available, I will be instructed about the facility policy on smoking: locations, times, safety concerns, My smoking supplies are stored with the activity department. Notify charge nurse immediately if it is suspected that I have violated facility smoking policy, observe my clothing and skin for signs of cigarette [CONDITION(S)]. Further review of Resident #1's CP showed no revision or updates to Resident #1's CP for the following smoking infractions: In the first smoking violation incident on 5/20/2021, the resident was found with smoking materials in the resident's possession, including an e-cigarette and one unsmoked cigarette. The second smoking violation incident occurred on 5/24/2021 when Resident #1 was smoking in his/her room and was found with an empty pack of matches and one half-smoked cigarette. The third smoking violation incident occurred on 6/13/2021 at 1:30 p.m., and a fourth smoking violation incident occurred that same day at 7:00 a.m. when the resident was burned by Resident#2. However, there was only one form dated 6/16/2021, which staff confirmed was for the 6/13/2021 incident. After the 6/13/2021 incident, when the resident was burned, he/she was still found having a fifth smoking violation incident on 6/24/2021 of smoking in the room while Resident #4 was on oxygen. At the time of the survey, the facility completed no smoking infractions forms for Resident #1's violations on 5/7/2021, 5/21/2021, and 6/13/2021 for the 1:30 a.m. occurrence. During a phone interview on 7/19/2021 at 12:37 p.m., LPN #2 stated that on 5/7/2021, she smelled smoke coming from resident #1's room, and she told the Nursing Supervisor. The Surveyor attempted to contact the Nursing Supervisor at the time of the survey but received no response. 2. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, dated [DATE], Resident #2 had a BIMS score of 15/15, which indicated the resident was cognitively intact. The MDS also showed Resident #2 was independent with ADLs and was a current tobacco smoker. The Surveyor reviewed the IPNs for May and June 2021, which revealed Resident #2 had two smoking incidents in the bathroom. The IPNs reflected the following: A review of Resident #2's IPN dated 6/14/2021 revealed a note written by the Social Worker (SW) that indicated Resident #2 burned Resident #1 with a marijuana pipe. According to the IPN, the SW asked Resident #2 to go to the hospital due to the resident's dangerous behavior; however, the resident refused. The IPNs also included that the SW contacted the Crisis Center to screen and evaluate the resident. Resident #2 was to be sent to Crisis pending hospital placement. A review of the Smoking Contract signed by Resident #1 on 5/3/2021, and Resident #2 on 4/19/2021, reflected both residents agreed to the terms of the contract, which included 1. No Resident is permitted to have any cigarettes, cigars, pipes, lighters, matches or any flammable device that can be used to light up smoking items. 2. To protect the safety of all residents and staff, if it is reported or known that a Resident has smoking materials in their possession, located in his/her room, and or located in their belongings, the resident will be notified, and their room will be searched by at least two (2) representatives of the facility, with or without the resident's permission (and) 5. Smoking will ONLY be allowed in the designated area located on the patio off the main dining room. A review of an untitled statement written by the Housekeeping staff, dated 5/21/2021, indicated that he observed Resident #2 smoking in another resident's (Resident #1 & Resident #4) room on 5/21/2021 and 5/22/2021. During an interview on 7/14/2021 at 2:15 p.m., the Housekeeper staff explained on the night of 5/21/2021; I could smell smoke from the hallway; when I entered the room and opened the bathroom door, I saw Resident #1 and Resident #2 with a lit cigarette. The Housekeeping staff stated Resident #4 was in the room with the oxygen on; I told them they could blow the building up. A review of the Resident's CP initiated on 4/21/2021 reflected that Resident #2 was a smoker. The CP also showed under Goal: I will adhere to (the) facility smoking policy, I will not suffer injury from unsafe smoking practices through the review date. Further review of the CP showed under Interventions: I require supervision while smoking; I will be instructed about smoking risks and hazards and about smoking cessation aids that are available, I will be instructed about the facility policy on smoking: locations, times, safety concerns, My smoking supplies are stored with the activity department, Notify charge nurse immediately if it is suspected that I have violated facility smoking policy, observe my clothing and skin for signs of cigarette [CONDITION(S)]. Further review of Resident #2's CP showed no revision or updates to Resident #1's CP for the following smoking infractions: In the first smoking violation incident on 5/20/2021, the resident was found with smoking materials in his/her possession, including a lighter, e-cigarette, and two e-cigarette cartridges. The second smoking violation incident occurred on 5/21/2021 when the resident was smoking in another resident's room. The third smoking violation incident occurred on 5/22/2021 when the resident was smoking in another resident's room. The fourth smoking violation incident occurred on 5/23/2021 when the resident accepted smoking materials from another resident and then gave them to staff. The fifth smoking violation incident occurred on 5/24/2021 when the resident was smoking in another resident's room. The sixth smoking violation incident occurred on 6/2/2021 when the resident was smoking in another resident's room. There were no smoking violations presented to the Surveyor for Resident #2 at the time of the survey for the two smoking incidents on 6/13/2021. During an interview on 7/8/2021 at 3:31 p.m., in the presence of the Licensed Nursing Home Administrator (LNHA), the Director of Nursing stated the (Minimum Data Set) MDS Coordinator was responsible for updating the CP. The DON stated the MDS Coordinator updates the CP after incidents, quarterly and annually. The DON agreed Resident #1 and Resident #2's CP should have been updated after each smoking violation incident. During an interview on 7/14/2021 at10:53 a.m., in the presence of the DON, the LNHA stated the MDS Coordinator would update the CP or anyone could update it. A review of facility policy titled, Residents/Patients Care Plans, with an original issue date 12/2020, revealed the following: Under Policy: included: Resident/patient Care Plan within the facilities is individualized, managed and directed by an interdisciplinary process team. The interdisciplinary team is inclusive of resident, resident's family and Care Plan team of the facility .Upon review of the clinical and personal needs of the resident/patient and the resident's/patient's acceptance into the facility; the goals and objectives for the resident will be established and will be done on an individualized basis in order to the resident's/patient's needs. Under Procedure: .4. Care Plans are a dynamic ongoing process and will be updated on a continual basis .7. Care Plan process will be monitored and directed by the team and Discharge Planner .9. All Care Plan issues or problems are to be identified on an ongoing basis, through the IDC team .10. The nurse is advised to communicate/listen to residents/patients clinical report on a daily basis regarding changes pertaining to their Care Plan. Whenever there are changes with residents/patients, then the resident abilities checklist should be modified including the Care Plan, ASAP by the IDC team . N.J.A.C.: 8:39-27.1 (a)

Complaint # NJ 9 CROSS REFERENCE F281 Based on observation, interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to provide sufficient supervision and ensure the safety of 1 of 6 Residents (Resident #1) who was at risk for elopement. Resident #1, who wore a Wanderguard (WG) and had a history of [REDACTED]. On 5/10/2017, at approximately 2:28 a.m., Licensed Practical Nurse (LPN) #1 heard the front door alarm (which alarms only in response to a WG being nearby), and approached the door, finding it off track. LPN #1 reset the alarm, but did not step outside of the door to look for a missing resident (Resident #1). LPN #1 notified the nursing supervisor Registered Nurse (RN #1) that the front lobby door was alarming and instructed RN #1 to perform a head count in the facility, but failed to notify RN #1 that the front lobby door was off track. After the head count was complete, Resident #1 was noted by staff to be missing and an internal facility search was done, an external facility search was started approximately an hour later. Resident #1 was returned to the facility by facility management at 5:50 a.m. The facility's failure to adequately supervise and ensure the safety of their residents placed Resident #1 and all residents identified as an elopement risk, in an Immediate Jeopardy (IJ) situation. The Director of Nursing (DON) was notified of the IJ on 5/31/2017 at 12:25 p.m. The IJ began on 5/10/2017 when Resident #1 left the facility premises unsupervised and was corrected on 5/22/2017 when all staff members were inserviced on the revisions of the elopement policy. Resident #1 was placed on 1:1 (staff to resident ratio), and subsequently transferred to another facility. Elopement drills were to be implemented. The Immediate Jeopardy to resident health and safety was past non-compliance and was corrected on 5/10/2017 as evidenced by the following: 1. There was 1 resident that was affected by the deficient practice. On 5/15/17, the resident was transferred to another facility that has a secured unit. 2. There are 6 residents that are at risk for elopement that have the potential to be affected by the deficient practice. All 6 residents have Wander Guards in place and are functioning. Checks for placement and functions are completed every shift. 3. In-service on elopement was given to staff on 5/10/2017. The Elopement Policy has been updated to include that when a Wander Guard alarm goes off that the staff is expected to immediately go outside and search the surrounding area. The Staff who initially investigates the alarm is to give a detailed report to all staff assisting in the search. All staff were in-serviced on the revisions of the elopement policy on 5/22/17. The Director of Maintenance will perform Elopement Drills monthly on each shift for the next 3 months. The elopement drill is a system to identify missing a resident with the guidelines of the elopement policy. With the elopement drill, a resident is reported missing. The charge nurse will alert all staff by the paging system. A department head will be placed in a predetermined location as the missing resident. A description of the missing resident is given to staff to locate. The NHA and the Maintenance Director will be the observer and critique the drill to evaluate if the elopement policy was followed. A meeting is held after the missing resident is found to provide immediate feedback and correction made. Analysis is done after the elopement drill to identify issues and concerns, corrections made and in-service given to protect residents at all times by identifying and preventing the possibility of elopement and locating residents who are reported missing. 4. Elopement Drill results will be reviewed by the NHA during monthly QI Meetings, These meetings are composed of the Nursing Home Administrator, Director of Nursing, Medical Director. The Nursing Home Administrator will be responsible to assure that all facets of the Plan of Correction are followed. NJAC 8:39-27.1(a)

A. Based on observation, interview and record review, it was determined that the facility failed to monitor and/or maintain potentially hazardous food (PHF) items which included milk and yogurt distributed from the main kitchen. The dairy products were stored in a refrigeration unit at temperatures above 40 degrees Fahrenheit. The immediacy was identified on 2/6/14 at 10:50 a.m., when the surveyor, in the presence of a dietary aide, observed dairy products that were to be served at the lunch meal, stored in a refrigeration unit in the kitchen. The unit was warm to touch and the temperature of the dairy products (individual milk and yogurt) ranged between 60.2 and 64.8 degrees Fahrenheit (F). PHF items are to be maintained at 41 degrees F or below. In addition, the surveyor observed several milk cartons with expired "use by" dates of 2/1/14. The Food Service Director (FSD) was notified at the time of discovery at 10:50 a.m. that the PHFs were at a dangerous temperature. On surveyor observation at 11:40 a.m., theses PHFs were not yet destroyed and kitchen staff were unaware of the issue and were ready to serve them to the resident's. The immediate jeopardy was identified on 2/6/14 at 10:50 a.m., and the immediacy was corrected on 2/6/14 at 11:40 a.m., after surveyor inquiry prompted the disposal of PHFs by facility staff. An acceptable plan of correction was accepted and partially verified on 2/6/14 at 4:30 p.m. and remaining interventions were verified by the survey team on 2/7/14 at 10:00 a.m. The deficient practice for the Immediate Jeopardy situation was evidenced by the following: On 2/6/14 the surveyor entered the kitchen and met with the FSD for the initial tour of the kitchen which began at 9:15 a.m. At 10:40 a.m. the surveyor observed dietary staff in the process of preparing the set up for the lunch meal. As the surveyor continued with the initial tour of the kitchen, the surveyor observed a refrigeration unit positioned in the center of the kitchen next to the tray line. At 10:50 a.m., the surveyor touched the exterior of the refrigeration unit with bare hands and noted the refrigerator unit was warm to touch. The surveyor opened the unit and noted a facility thermometer that read 60 degrees Fahrenheit (F). Upon further observation the surveyor observed the refrigerator unit although plugged in the outlet, had been dislodged and there was no electrical current running to the unit. The following food items were noted inside the refrigeration unit: dairy products consisted of milk cartons, ensure, soda, pudding cup thickened liquid cups and yogurt. At that time the surveyor asked the FSD to check the temperature of the dairy products. The FSD obtained the temperatures utilizing a facility thermometer. The following temperatures were recorded: Milk: 67.6 degrees F first reading/ 66.3 degrees F second reading Yogurt: 62.9 degrees F Ensure: 61.5 degrees F [MEDICATION NAME] milk: 60.4 degrees F Skim milk: 60.2 degrees F On 2/6/14 at 10:55 a.m. an interview the FSD revealed that the FSD checked the refrigeration unit that morning and the reading was 38 degrees F. The FSD was aware at 10:50 a.m. that the dairy products were at a dangerous temperature. The FSD did not remove the PHF items and did not inform the staff that the contents of the refrigeration unit needed to be destroyed. In addition, the dairy products were going to be used for the residents for the lunch meal. A review of the refrigerator temperature log reflected that a temperature of 38 degrees F was recorded at 6:00 a.m. on 2/6/14. The FSD further told the surveyor that a dietary aide stocked the refrigeration unit last night for the breakfast meal and revealed the remaining contents of the unit will be utilized for the lunch meal. On 2/6/14 at 11:10 a.m. the surveyor left the kitchen and returned to kitchen on 2/6/14 at 11:30 a.m. and observed that the dairy products from the refrigeration unit had not been removed and remained on the unit. During an interview with a DA on 2/6/14 at 11:40 a.m. the DA revealed that the dairy products were going to be used and served to the residents for the lunch meal. On 2/6/14 at 11:40 a.m., the surveyor informed the FSD to remove all foods items from the refrigeration unit as they were considered potentially hazardous foods. Food kept at temperature range of 60-125 degrees (F) would allow rapid bacteria growth. Facility administrative staff was notified of the issue. The following PHFs items were removed from the refrigeration unit at 11:40 a.m and discarded after surveyor intervention. All items were individual serving size: pudding: quantity 6 yogurt: quantity 35 apple juice: quantity 3 fat free milk: quantity 13 whole milk: quantity 30 In addition, the aforementioned 30 cartons of whole milk had an "use by" date of 2/1/14. During a subsequent interview on 2/6/14 at 12:10 p.m., the DA assigned to the tray line for the lunch meal confirmed that all the dairy products were placed in the refrigeration unit last night. The DA told the surveyor "we do not have to check for the date or the temperature. We never did. All we have to do is place the food on the tray." On 2/6/14 at 1:30 p.m. the surveyor interviewed another DA who confirmed that they do not check the refrigerator unit temperature. She told the surveyor that the FSD checked the temperature daily at 6:00 a.m. On 2/6/14 at 1:45 p.m. the surveyor interviewed the FSD who revealed that she checked all the refrigeration units daily at 6:00 a.m. The FSD revealed that she did not check the date on the dairy products. The FSD further stated that there was no system in place to check for outdated food items. The FSD told the surveyor, "Will start as of today." On 2/7/14 the surveyor reviewed Resident #9's medical record. According to a Minimum Data Set (MDS), an assessment tool dated 1/3/14, Resident #9 had a moderate cognitive deficit. However, according to the history and physical examination [REDACTED]. During an interview on 2/6/14 at 1:20 p.m., the surveyor asked the Resident #9 about the milk that was served during the breakfast meal. Resident #9 stated that he/she "always" checked the date of the milk before consuming it. The resident informed the surveyor the milk carton that was received with the breakfast meal today "the date was no good so the aide took it back." On 2/7/14, the surveyor reviewed Resident #10's medical record. According to the MDS dated [DATE], Resident #10 had no cognitive deficits. During an interview with Resident #10 on 2/6/14 at 1:30 p.m., the resident stated that the milk the resident was served today was not cold, it was room temperature. The resident informed the surveyor that he/she did not check the expiration date on the milk carton. This deficient practice was identified as an immediate and serious threat to the food safety for all residents residing in the facility. The immediate jeopardy was identified on 2/6/14 at 10:50 a.m. during the initial tour of the kitchen. The facility Administrator was informed on 2/6/14 at 1:00 p.m. that the lack of adequate and proper sanitation in the kitchen and unsafe food handling practices constituted Immediate Jeopardy. The immediacy was lifted when the facility disposed of all the food items in the refrigeration unit at 11:40 a.m. An acceptable plan of correction was accepted on 2/6/14 at 4:30 p.m. and verified by the survey team. Verification continued on 2/7/14. The plan of correction included the following: 1. All milk products that were outdated and out of temperature compliance were disposed of. All residents' units were checked for out of date products. 2. All residents who consumed milk products were to be evaluated by nursing staff each shift for three days for any gastrointestinal symptoms. 3. All cook supervisors/dietary staff have been inserviced regarding procedures for the maintenance of the milk box (refridgeration unit) and for checking for outdated product. Nursing staff was inserviced to check product expiration dates. 4. Food service staff will monitor milk box (refridgeration unit) daily for temperature and expiration date compliance and to assure the unit is plugged in. The Administrator will monitor the temperature of the refrigerators weekly. Quality Assurance will be completed quarterly. The deficiency continues at a lower scope and severity level E as indicated in Part B. B.) Based on observation, interview and record review, it was determined that the facility failed to: store, prepare and distribute food and/or maintain the kitchen in a sanitary manner to address cross contamination and; have a system in place to educate and train staff on how to clean and sanitize all kitchen equipment. The deficient practices were identified by the following: On 2/6/14 at 9:15 a.m. the surveyor conducted the initial tour of the kitchen with the Food Service Director (FSD). The surveyor observed the following: 1. The surveyor washed her hands and disposed of the paper towels in the trash bin by the sink. The surveyor observed small flying insects exit from the trash bin. Similar insects were also observed throughout the kitchen during the tour. The surveyor observed next to the sink, the juice machine's dispenser was not protected or placed in a drain system. A dead insect was observed inside the container by the dispenser. The motorized part of the juice machine was covered with dry food debris. 2. At 9:30 am. the surveyor observed the cooking area. The grill was covered with dry food particles. 3. The microwave was covered with dry food particles. The stove top was heavily soiled with grease and food debris. 4. The stove top, the burners, and the space between the burners were covered with splattered brown substance and dark food debris. The space below the rack inside the oven was covered with dark splattered food debris. 5. On the back wall of the kitchen the surveyor observed a metal storage rack. On the metal storage rack the surveyor observed the cooking sheets stacked in piles of four with heavily stained and rusted areas. The FSD told the surveyor the cooking sheets were old and needed to be changed and she received permission from the administrator to change them. 6. The surveyor observed four cutting boards on the second rack. Two of the cutting boards were cracked and chipped. The FSD removed the two cutting boards and disposed of them in the trash bin. The surveyor observed a small utility table in the kitchen. On the lower shelf a jar of peanut butter was opened but not dated. 7. The gadget in the refrigerator was dislodged not properly sealed. 8. The following were observed in the refrigerator: A pickle jar received 12/20 opened not dated. A jar of barbecue sauce with no sell by date opened not dated. Sweet relish received 1/16 opened not dated. A jar of mustard received 9/20 opened not dated. A jar of Italian dressing received 12/27 opened not dated. Butter received 12/27 opened not dated. The surveyor also observed 3 trays of food items dated 2/6, none of the foods items were labeled. 9. Cottage cheese received 1/24 was opened and not dated. Parmesan cheese dated 11/19/13 was opened and not dated. Cream cheese sell by date 2/14 was opened and not dated. Chicken breast two and one half cases pulled date 2/4/14 not on the menu for 2/6/14. The FSD told the surveyor that she guessed the cook pulled out too much and she would prepare them later on that day. 10. In the dry food storage the following were observed: Soup base opened not dated. Beef base opened not dated. Garlic powder opened not dated. A jar of barbecue sauce was observed on the shelf with the dry food items, opened not dated. A jar of oregano flakes opened not dated, one jar of dried basil, one bottle of egg yellow opened not dated. One jar of Teriyaki sauce received 10/22 opened not dated. One bottle of table syrup received 4/13 opened not dated. 11. At 10:15 a.m. as the surveyor continued with the initial tour of the kitchen, the surveyor observed a Dietary Aide (DA) by the 3 compartment sink. The 3 sink compartment was a Duo fed. According to the manufacturer instructions the water and the sanitizer should run consecutively. The surveyor asked the DA to check the sanitizer. The DA revealed that she just completed a two week training program. The DA filled the 3 sink compartment with water without regard to the water level. The chemical and the sanitizer did not mix. The water did not change colors. The DA washed three pans and placed them on the air drying rack. The FSD used the chemical indicator strip to test the rinse water. The chemical indicator strip did not change colors which indicated that the chemical sanitizer was not working. The FSD told the surveyor that she checked the rinse water this morning and the reading was 200. According to the manufacturer instructions the reading should be between 200 and 400. The surveyor observed two white one gallon plastic containers sitting on the floor under the three sink compartment. Both containers had a clear thin hose from the inside of the pail to inside of the dish machine. The pail was not labeled as to when it was delivered, opened or expired. When interviewed, the FSD stated the blue solution was for the wash cycle and the pink solution was for the rinse cycle. 12. A puddle of water was noted on the floor by the three compartment sink. The FSD told the surveyor she notified maintenance two weeks ago about the pooling water. The FSD could not provide a work order request for the leaking water. 13. The surveyor observed the dish machine in operation at 10:20 a.m. the surveyor asked the DA to operate the dish machine. According to the manufacturer, the wash cycle should read 160 F. and the rinse cycle 180 F. The DA loaded the dishwasher and activated the dish machine. The maximum temperature reached during the wash cycle was 140 degrees Fahrenheit (F) and the rinse cycle did not exceed 160 degrees F. An interview with the second DA revealed that she notified the FSD of the problem with the dish machine two weeks prior. She further stated that occasionally the dishes were not fully washed and would come out cold. A review of the dish machine's temperature log revealed temperatures within normal wash and rinse cycle for all days during the month of February. 14. The surveyor observed the DA packaging silverware. The DA did not have the required hair restraint on during the task. 15. The surveyor observed the cook preparing turkey burgers for the dinner meal. The cook did not change gloves during tasks. The surveyor observed the cook used gloved hands to sort turkey burgers on the grill. The cook then went to the dry storage room to get condiments to season the turkey burgers. The cook returned to the grill and proceeded to turn the burgers with the same gloves. Later the cook went to the water faucet to get water with the same gloves used to sort the turkey burgers on the grill. 16. The surveyor observed a tray of cooked Spanish beef and a tray of green beans left uncovered after being prepared. 17. The surveyor observed a sheet cake stored on a shelf directly above the cook top. On the cook top was a saucepan filled to the rim with boiling butter. 18. The surveyor observed the steam table located outside the kitchen in the dining room area. The interior well of the steam table contained two inches of dirty yellow standing hot water. A black substance was noted on the exterior surface of the steam table. On 2/7/14 at 12:30 p.m. the surveyor asked the FSD for the cleaning schedule. The FSD was unable to provide a cleaning schedule. She told the surveyor she was working to put a cleaning schedule in place. 19. On 2/7/14 at 9:15 a.m. the DA operated the dish machine in the presence of the surveyor, the wash cycle registered at 160 degrees F and the rinse cycle 180 degrees F. The FSD told the surveyor that the dish machine was repaired the previous night. The service technician told the FSD the calibrators had been clogged. 20. The surveyor asked the FSD again for the cleaning schedule. The FSD told the surveyor that she was working to put a system in place that would include a daily and a weekly cleaning schedule. The FSD further stated that the system would include the cleaning of the stove top, the grill and the oven. 21. The surveyor observed a large bin with food items for the dinner meal ready to be stored in the refrigeration unit. The surveyor randomly picked up two thickener cups from the bin and observed that the two thickener cups had a sell by date of 12/14/13. During the lunch meal observation conducted inside the MDR by the surveyor on 2/6/14 from 11:35 am until 11:55 am, the following was observed: 22. The steam table was heavily stained with dried colored substances. Inside the steam table's well contained water that was rust colored. The well had green colored floating substance and other various floating particles. 23. During the meal service distribution the FSW did not perform any hand hygiene prior to applying gloves. The FSW moved from surface to surface without performing any hand hygiene or changing gloves while serving the meal. 24. The FSW scoop handle was resting inside the mashed potatoes and macaroni and cheese dish. 25. Three of four dining room staff members served meals with bare hands, collected soiled plates between residents without performing any hand hygiene. 26. The condiment cart heavily coated with debris and stained with various colors of spillage. During a tour of the kitchen on 2/6/14 at 11:38 a.m. through 11:45 a.m. the surveyor observed the following: 27. The walk in refrigerator door was observed open and not latched. The surveyor pulled the handle and opened the door. The surveyor released the handle door did not close fully. The door rested open on top of the latching mechanism. 28. An open eight ounce juice container of cranberry juice was observed on the bread rack near loaves of bread. A Dietary Aide (DA) picked up the open juice container with bare hands and disposed of it in the trash can. The DA without performing handwashing touched clean cups and plates on a rack in the kitchen. The surveyor spoke to the DA about handling an open juice container then clean cups and plates. The DA then performed hand washing for 15 seconds under running water, then turned the faucet off with her bare hands. 29. The surveyor observed a wet stream of coffee from the opening of the kitchen to the steam table outside of the kitchen (approximately 20 feet). Three staff were observed standing in the area and no staff addressed the issue. 30. A milk delivery person was observed entering the kitchen pushing a two-wheeled cart with work gloves on. The gloves were visibly soiled with black and brown material. The delivery person entered the walk-in refrigerator without removing the gloves. With the same gloves on, the delivery person rearranged the items on the shelves in the walk-in refrigerator. He handled milk, cottage cheese and bags of cheese with the gloves on. NJAC 8:39-17.2 (g)

A. Based on observation, interview and record review, it was determined that the facility failed to: provide proper positioning for a resident actively receiving enternal feeding via gastrostomy tube, and; ensure that a Hospice Aide had received proper training in the area of enteral feedings. This resulted in an immediate jeopardy situation for 1 of 2 residents (Resident #5), receiving enteral feedings who was dependent on staff for all care needs, had severe cognitive impairment and a history of poor swallowing capability. The immediate jeopardy was identified on 2/10/14 at 9:15 a.m., when the surveyor entered the resident's room and observed a Hospice Aide (HA) providing care to Resident #5. The resident, lying completely flat in bed with both legs elevated, was actively receiving enteral feeding which placed the resident at immediate risk of aspiration. It was corrected at 9:15 a.m. after inquiry by the surveyor and the position of required elevation was implemented by the HA at the time. The immediate jeopardy was identified on 2/10/14 at 9:15 a.m. and the immediacy was corrected at that time. A plan of correction was submitted to the team on 2/11/14 at 12:20 p.m. was reviewed, accepted and verified by the team. The deficient practice for the immediate jeopardy situation was evidenced by: During the initial tour conducted on 2/6/14, the Unit Manager (UM) stated Resident #5 was cognitively impaired, non-verbal and was totally dependent upon staff for all care needs. At this time, Resident #5 was observed lying in bed with both eyes closed. The resident was observed receiving enteral feeding via a gastrostomy tube and positioned with the head of bed at 45 degrees. On 2/10/14, the surveyor reviewed Resident #5's medical record. According to the Admission and Discharge sheet Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) an assessment tool dated 12/14/13, indicated Resident #5 had severe cognitive impairment, required extensive assistance from staff for turning from side to side while in bed and transferring from the bed and into a chair. The MDS also identified the resident required nutrition via a feeding tube. Resident #5's care plan dated 12/10/13 indicated Resident #5 was unable to consume any food by mouth and was at risk for aspiration. The interventions listed on the resident's care plan required for staff to maintain the resident's head of the bed at a 45 degree angle during and one hour after the feeding was completed. On 2/10/14 at 9:15 am, the surveyor entered Resident # 5's room and observed the resident lying completely flat in bed with both legs elevated. The resident was in the process of receiving morning care from a HA. The resident was actively receiving an enteral feeding via a gastrostomy tube while lying in a flat position. There was approximately 100 milliliter (ml) of enteral feeding that had infused and 900 ml remained in the bottle at the time of discovery. When interviewed by the surveyor at this time, the HA stated she arrived at 9:00 a.m., and rolled the resident's head of bed down and began to provide care. Upon surveyor inquiry about the resident's position, the HA elevated the head of the resident's bed to a 45 degree angle. When the surveyor asked the HA about the proper position of a resident who was actively receiving enteral feeding she did not give the surveyor a response. At 9:16 a.m. the surveyor informed the Unit Manager of the aforementioned incident. During an interview conducted on 2/10/14 at 9:20 a.m., the UM confirmed Resident #5 should not have been lying in a flat position in bed, while the enteral feeding was actively infusing. The UM revealed placing the resident in a flat position could cause the resident to aspirate the enteral feeding. In addition, the UM stated the HA should have informed the resident's nurse that she was about to begin morning care, then the nurse would turn off the enteral feeding. During a subsequent interview on 2/10/14 at 2:05 p.m., the HA confirmed she was aware the proper position of a resident who was actively receiving enteral feeding was that the head of bed should be elevated 45 degrees. A review of the facility's contract with the Hospice provider indicated that the facility would be responsible for orientation of hospice staff of the required resident needs and policies of the facility. The skill set for the HA was void of how to care for and to position a resident with enteral feeding needs. When interviewed on 2/10/14 at 1:30 pm, the Director of Nursing (DON) and the Administrator were made aware of the aforementioned incident. The DON stated that it was the responsibility of the Hospice agency to provide orientation to their staff. When interviewed further, the DON stated orientation was not provided by the facility for the HA. A review of the facility's policy for Enteral Nutrition dated 2011 revealed that a resident receiving enteral feed was to be kept at a 30-45 degrees to avoid aspiration. The immediate jeopardy was corrected on 2/11/14 at 12:20 p.m. based on an acceptable plan of correction which was verified by the survey team. The plan included the following: 1. Immediate repositioning of the resident was done. Vital signs and assessment was conducted with on going monitoring every shift over the next three days for adverse reaction. 2. The physician and responsible party were notified. 3. All residents on enteral feeding were evaluated by nursing staff and all nurses and Certified Nursing Assistants and HA staff were re-educated on resident's individual care needs. 4. All staff were re-educated on proper procedures and guidelines for the positioning of residents on a tube feeding. All hospice staff were re-in-serviced on the same. 5. Assigned nurse will continue to monitor hospice provider staff to ensure compliance and round frequently to observe. 6. Orientation will be conducted and verified regarding the provision of tube feeding care prior to working at the facility. Monitoring will continue between providers to ensure compliance and the Director of Nursing will monitor monthly and report the results quarterly to the Quality Assurance committee. This deficient continues at scope and severity of H based on the evidence in Part B. B. Based on observation, interview, and record review it was determined that the facility failed to consistently implement effective pain management for 2 of 6 residents (Resident #1 and #9) reviewed for pain. Resident #1 exhibited episodes of moderate to severe pain inconsistenly treated over a 4 month period of time and was evidenced by the following: 1. The surveyor reviewed Resident #1's medical record on 2/7/14. The resident's 1/13/14 annual Minimum Data Set (MDS) assessment tool indicated the resident had no deficits in cognition or decision making and frequently experienced pain of a 6 (Pain scale 0-10 whereby 0 signified the absence of pain and 10 signified the worst pain). The pain level was noted to frequently affect the resident's sleep and activities of daily living. A care plan that addressed pain management was initiated on 2/11/10 and last revised on 1/1/14. The care plan indicated the resident had pain related to a Hernia, [MEDICAL CONDITION], and a History of Back and Hip Pain. Care plan interventions included but were not limited to; administer [MEDICATION NAME] as ordered, monitor effectiveness, and need to modify medication regimen; administer pain medication as ordered routinely, monitor for breakthrough pain. The February, 2014 Physician order [REDACTED]. twice daily; [MEDICATION NAME] 650 mg. every 4 hours as needed for mild pain; [MEDICATION NAME] Hcl (a short acting narcotic [MEDICATION NAME]) 10 mg. every 8 hours as needed for moderate/severe pain. The surveyor reviewed Resident #1's Medication Administration Records (MAR) for the months of September, 2013 through January, 2014 showed that nursing staff documented that five scheduled doses of [MEDICATION NAME] 10 mg. were not administered during September, 2013, two doses were not administered during December, 2013 and nine doses were not administered during January, 2014 because the medication was not available in the facility. The surveyor interviewed Resident #1 on 2/7/14 at 10:40 a.m. The resident confirmed that medications were frequently not available. The resident stated [MEDICATION NAME] can take up to 3 days to refill. The resident also stated other medications, such as antidepressants, anti-anxiety, and cholesterol lowering medications had run out in the past. The resident stated the unit nurses have told the resident that multiple calls were made to the pharmacy and physician in an effort to receive medication refills. The resident stated "I feel like someone has a blow torch on my back and down my leg" in response to the surveyor's inquiry of how the resident feels when [MEDICATION NAME] was not available. The surveyor interviewed the Unit Manager Licensed Practical Nurse (UM) on 2/7/14 at 10:55 a.m. The UM stated "we have problems getting new or refilled medications on time." The UM stated she tracked the medications and ordered refills when a week's worth of medication was on hand. The UM further stated other nurses sometimes ordered refills when three days worth of medication is on hand, "then we have problems." The UM stated Administration was aware of the problem with late medication delivery. The surveyor interviewed the Licensed Practical Nurse (LPN) on 2/10/14 at 11 a.m. The LPN stated [MEDICATION NAME] was the medication most often delivered late. She identified that the problem occurred when a new prescription was needed for the controlled medication. She stated the pharmacy contacted the physician and requested a new script, but did not contact the facility nurse. She stated the nurse would call the pharmacy when the medication was not received and was told by the pharmacy that they are waiting for the physician to send a prescription. The facility nurse then would call the physician to request the prescription. She stated this could take several days to complete. The LPN stated the physician had instructed the nurse to give [MEDICATION NAME] until the [MEDICATION NAME] arrived at the facility. The surveyor interviewed the resident again on 2/10/14 at 1 p.m. The resident confirmed that [MEDICATION NAME] was offered until the [MEDICATION NAME] was available. The resident stated [MEDICATION NAME] was also offered by the nurse. The surveyor interviewed the Director of Nursing (DON) on 2/11/14 at 11:00 a.m. regarding the unavailable medications and delay in delivery from the pharmacy. The DON provided additional information on 2/12/14 at 9:30 a.m. in the form of a letter dated 2/11/14 from the provider pharmacy to the facility (faxed at 8:20 p.m.). The letter indicated a meeting was held at the beginning of October at the request of the Administrator and DON regarding lateness in deliveries. The letter indicated that the pharmacy had initiated a plan to correct the problem in October, 2013 to address timely delivery of narcotic prescriptions and other medications. The letter indicated that a plan to address the late deliveries appeared to have corrected the concerns since the pharmacy received "no further requests or concerns." There was no evidence provided that the plan of to address the late deliveries was successfully implemented. On 2/12/14 at 9:30 a.m. the DON provided the surveyor with the facility's policy for Pain Assessment and Documentation, initiated 2/2005 and revised 5/2009. The policy included that the facility "...will attempt to reduce or eliminate pain....." and "...pain assessment and management issues will be conducted at least quarterly and care plans will be evaluated, updated and initiated as needed." 2. On 2/7/14 the surveyor reviewed Resident # 9's medical record. The Admission and Discharge Summary indicated Resident # 9 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 1/3/14 revealed the resident had a severe cognitive impairment and required assistance with transfers and activities of daily living. The Interim Care Plan (ICP) (not dated) reflected the resident was at risk for pain. The goal was that Resident #9 would be as comfortable as possible. Interventions included; administer pain medication as ordered and observe for effectiveness, monitor pain frequency and intensity, establish causative factors and ways to alleviate them. A review of Resident # 9's physician's orders [REDACTED]. A Pain Assessment Form (not dated) indicated Resident #9 experienced intermittent pain in toes and chronic back pain. The pain was relieved by pain medication and the current [MEDICATION NAME] regimen was [MEDICATION NAME] 5/325 mg one tablet by mouth every six hours as needed for moderate/severe pain and Tylenol 325 mgs two tablets every six hours as needed for mild pain. A review on an IPN dated 1/2/14 during the 7:00 a.m. to 3:00 p.m. shift documented that Resident #9 complained of "frontal lobe pain" headache" and requested [MEDICATION NAME]. The nurse encouraged relaxation which was not effective. The nurse then administered [MEDICATION NAME] one tablet by mouth for a pain level of 9 out of 10 (10 being the worst pain). The resident was re-evaluated 30 minutes later and the pain had decreased to a level of 3 out of 10, a positive result. In addition, the nurse rendered treatment to the resident's bilateral lower extremities without difficulty. A subsequent physician's orders [REDACTED]. An IPN dated 1/3/14 during the 7:00 a.m. to 3:00 p.m. shift reflected the note was a late entry (but did not indicate for what date) and documented that the pharmacy called and stated the resident's physician would not sign for the [MEDICATION NAME] to be renewed. The physician did not feel that the resident needed the [MEDICATION NAME] for pain relief, therefore the [MEDICATION NAME] will be discontinued as per the conversation with the pharmacy. The IPN further reflected the nurse placed a call to the physician with no return call. There was no documentation that reflected a pain assessment was completed at that time. A review of an Interdisciplinary Progress Note (IPN) dated 1/6/14 at 10:30 a.m., reflected Resident #9 complained of pain. Tylenol (a non-narcotic [MEDICATION NAME]) was given and the Licensed Practical Nurse (LPN) documented that the resident stated "That's not gonna help." This nurse reminded the resident that the [MEDICATION NAME] was discontinued in December. The Nurse Practioner (NP) was in to to see the resident. The resident did not complain of "anything" at that time and that NP wasn't going to order anything extra. During an interview with Resident #9 on 2/10/14 at 9:55 a.m., the resident stated that he/she gets migraines everyday and Tylenol "doesn't help." The resident revealed that he/she received another medication for migraines that helps sometimes, but didn't know the name of the medication. When the LPN was interviewed by the surveyor on 2/11/14 at 10:00 a.m., in the presence of the Administrator and Director of Nursing (DON) she revealed that on 1/6/14 the NP was made aware that Resident #9 had pain and she didn't want to re-order [MEDICATION NAME]. The surveyor asked the LPN where the resident had pain on 1/6/14. The LPN stated that she didn't ask the resident that. She revealed it could be the resident's back or legs because the resident had chronic back pain. The LPN revealed the facility's policy was to determine where the pain was and what the level of pain the resident had. The LPN confirmed she did not evaluate Resident #9's pain on 1/6/14. A physician's orders [REDACTED]. A subsequent IPN on 1/17/14 at 1:55 p.m., indicated the resident complained of pain to the lower back that was level 8 of 10 pain level. The IPN reflected that [MEDICATION NAME] one tablet was administered at 8:30 a.m., with mild relief. There was no indication that [MEDICATION NAME] was prescribed for back pain. A review of an IPN dated 1/27/14 at 12:30 p.m., documented that the NP called and prescribed [MEDICATION NAME] 5/325 mg one tablet by mouth daily as needed for back pain as well as an x-ray of the [MEDICATION NAME] and lumbar spine. A review of the the physician progress notes [REDACTED].#9 complained of back pain and/or a pain assessment was completed. A review of a physician's orders [REDACTED]. A review of an x-ray report dated 1/28/14 indicated Resident #9 had an axial [MEDICAL CONDITION] and osteoporotic compression fractures of T10 and T11. A review of a physician's orders [REDACTED]. The surveyor requested information regarding Resident #9's pain management from the Director of Nursing (DON) on 2/11/14 at 10:00 a.m. On 2/12/14 at 9:55 a.m., during an interview with the DON she stated she had no further information regarding Resident #9's pain management. A review of the facility's Pain Assessment and Documentation policy revised 5/2009 reflected all resident's will be assessed for pain during the admission and re-admission assessment process and thereafter whenever warranted by changes in the resident's condition, including self reporting of pain. In addition, the physician will be notified of any resident reporting and/or exhibiting signs symptoms of pain who does not have an active order to address pain or relief. Physician notification, outcome and resident response will be documented in the resident's medical record. There is no documented evidence this policy was consistently followed. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision and protective devices for residents at risk for falls and injury. This deficient practice was identified for Residents #2, #3, #6, and #11, 4 of 8 residents reviewed for accident hazards. Resident # 3 sustained a fractured left hip; Resident # 11 sustained a hematoma with laceration to the head; Resident # 6 fell four times with one fall resulting in trauma to the head; and Resident #2 sustained a laceration requiring sutures and antibiotic therapy. This deficient practice was evidenced by: 1. During the initial tour conducted on 2/6/14, the Unit Manager (UM) stated that Resident #3 was alert and oriented. The UM stated Resident #3 had sustained a fractured hip from a fall and that prior to the fall Resident #3 was able to ambulate with the use of a rolling walker. At that time, Resident #3 was observed lying in bed. The resident greeted the surveyor and continued watching television. On 2/7/14 the surveyor reviewed Resident #3's medical record. The Admission Face Sheet indicated Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 9/13/13, reflected Resident #3 was alert and oriented with mild memory impairment. In addition, the MDS revealed the resident required extensive assistance from staff for turning from side to side while in bed, and supervision from staff while ambulating in the room and throughout the facility. A review of a Interdisciplinary Progress Note (IPN) dated 11/5/13 at 12:20 p.m. revealed Resident #3 was found by staff on the floor by the ramp near the main dining room. When assessed by the nurse, Resident #3 had complained of left leg pain. The first responders were notified and Resident #3 was transported to the hospital. Further review of the IPN revealed Resident #3 was admitted to the hospital with [REDACTED]. A review of the hospital's x-ray report revealed Resident #3 had sustained an acute comminuted fracture of the left hip. A review of the hospital Discharge Summary dated 11/8/14, revealed Resident #3's physician discussed with the resident the need for surgical intervention and the risks and benefits of surgical repair of the hip. This IPN revealed Resident #3 refused to have surgery. The resident stated he/she has had multiple surgeries in the past and did not want anymore. A review of an Incident/Accident Report dated 11/5/13 at 12:20 p.m. revealed Resident #3 was found by a Certified Nursing Assistant (CNA) on the floor of the ramp near the main dining room. According to the documentation on the pain assessment that was completed at the time of fall the resident described the pain as "throbbing." A review of a Fall Risk assessment dated [DATE] in the presence of the UM revealed Resident #3 was identified as a low risk for falls. During further interview, the UM stated the resident had no prior Fall Risk Assessments. When interviewed by the surveyor on 12/7/14 at 10:00 a.m., the UM stated prior to the fall Resident #3 could walk on flat surfaces but was unsteady when he/she walked up and down the ramp. The UM stated that was the reason for the staff supervision. During the same interview, the UM stated a staff member should have been with Resident #3. The UM stated the resident continued to complain of pain and received pain medication regularly. The UM added that she could not offer any reason as to why staff did not supervise the resident. When interviewed on 2/7/14 at noon, Resident #3 stated he/she fell while going for a walk to the main dining room. The resident stated he/she could not remember the details of the fall. Resident #3 stated his/her hip still hurt and they take medication for the pain. According to the physician's orders [REDACTED]. Resident #3 received an "as needed" order for Percocet to be administered every 6 hours for severe pain. A review of the 11/2013 Medication Administration Record (MAR) revealed Resident #3 was administered Percocet twice daily from 11/10/13 through 11/23/2013 after the fall. A review of the facility's policy for At Risk For Falls, Frequent Fall and Falling Star Program revealed the policy's purpose was to decrease the risk of future harm to residents who experience falls. The purpose of the policy indicated that falls would be monitored for patterns and trends in order to decrease occurrences. A program would be developed to assist staff in the identification of residents at risk so that those residents with a history of frequent falls would be more closely monitored. The policy indicated that residents would be assessed for "Fall Risk" upon admission, quarterly and as needed. The appropriate safety devices will be implemented, on an as needed basis, such as: a low bed, or place the bed in the lowest position, bed or chair alarm, mat on the floor. Residents who fall will be recorded on the monthly and the individual tracking and trending log. The falls would be reviewed at the clinical Interdisciplinary Team (IDT) meeting. If a resident is at risk for falls the resident would be placed on the falling leaf program. Residents placed on the falling leaf program would have a leaf placed by their name at the entrance to the room. They will be issued an orange bracelet to wear to help staff identify residents at risk for falls. 2. During the initial tour of the facility on 2/6/14 at 9:00 a.m. the Licensed Practical Nurse (LPN) told the surveyor that Resident #11 sustained a fall after returning from dialysis treatment. On 2/10/14 at 9:40 a.m. the surveyor reviewed the medical record of Resident #11 which revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 2/10/14 at 9:50 a.m. the surveyor observed the resident seated in a wheelchair in the room. The resident had a seatbelt in place for safety. Further review of the medical record revealed Resident #11 had two falls. According to the IPN's the resident fell at the facility on 1/24/14 and 1/27/14. The IPN's revealed that both falls occurred after the resident returned from dialysis treatment. According to the IPN dated 1/24/14 at 2:30 p.m., a CNA observed the resident in the room at 10:10 am. A review of the Incident/Accident report dated 1/24/14 at 11:10 a.m. revealed the nurse found the resident on the floor at 11:10 a.m. There was no documented evidence that an assessment was done prior to 11:10 a.m. after the resident returned from dialysis. Another IPN dated 1/27/14 at 12:00 p.m. revealed the resident sustained [REDACTED]. Further review of the IPN revealed that another resident alerted the staff of the fall. The resident was found on the floor "with a lump on the forehead the size of a golf ball" and had a laceration to the head. The IPN further revealed the resident was disoriented. The resident was transferred to the hospital and admitted with the [DIAGNOSES REDACTED]. When interviewed on 2/10/14 at 10:15 a.m., the UM told the surveyor that staff was not aware that the resident had returned from dialysis. During a subsequent interview on 2/10/14 at 9:50 a.m. the LPN told the surveyor that Resident #11 leaves the facility between 5:45 a.m. to 6:00 a.m. for dialysis treatments and returned to the facility between 9: 00 a.m. and 9:30 a.m. Review of Resident #11's care plan for falls dated 02/09/10 revealed that the facility did not revise the care plan after the fall of 1/24/14 to include specific interventions that would address further incidents. The CNA's care plan was not revised to alert direct care staff that the resident needed to be monitored closely after dialysis treatment. According to an Interdisciplinary Care Conference notes dated 1/31/14, the transport company was not informed of the incident until 1/31/14. A communication form that would serve as a face to face report was not implemented until 2/7/14. There were no preventive measures in place prior to 1/27/14 to prevent recurrence. A review of the Fall Risk Assessment completed on 1/27/14 revealed that the Fall Risk Assessment was not accurate. The resident received a score of 8 meaning not a high fall risk. The resident had a fall on 1/24/14 and 1/27/14. The resident should have received a score of 10 under section B referring to history of falls. Review of the care plan on the above mentioned date and time revealed a "problem onset" dated 02/09/10 that identified that Resident #11 was at "Risk for falls related to impaired mobility status, generalized weakness, bilateral below knee amputation." There was no documented evidence that the IDT team met after the first fall on 1/24/14 and identified that the lack of communication posed a potential hazard to the resident's safety. New interventions to prevent further injury were not implemented until 1/28/14 when the following was added the care plan; the transportation company was to notify nurse of return and the nurse was to evaluate. 3. On 2/7/14 at 9:35 a.m., the surveyor reviewed Resident #6's medical record which revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. According to the MDS dated [DATE] and 1/24/14, Resident #6 had a severe cognitive deficit and was non-ambulatory. A review of Resident #6's Care Plan initiated on 2/9/10 and last revised on 11/6/13, revealed the resident was at risk for falls due to unsteady gait, impaired cognition, impulsiveness, poor safety awareness, psychotropic drug use, and history of falls. Review of IPN's from 7/9/13 to 2/11/14 revealed the resident had four falls at the facility on the following dates: 7/13/13 at 5:30 p.m., on 9/3/13 at 3:00 p.m., on 11/6/13 4:30 p.m. and on 11/28/13 3:10 p.m. On 7/13/13 at 5:30 p.m. an IPN revealed Resident # 6 was found on the floor on his/her back in front of the resident's wheelchair with waist restraint still attached to the wheelchair in the resident's room. There was no apparent injury. There was no documentation that reflected the facility investigated the fall. The causative factor was not identified and the care plan was not revised. Review of an Incident/Accident Report dated 9/3/13 at 1:30 p.m., and IPN dated 9/3/13 at 3:00 p.m., revealed that the resident was found on the bathroom floor laying on the right side with a lump on the right side of the head. The report recommended frequent checks and bed and chair alarm. There was no documentation that indicated the care plan was updated to reflect the aforementioned interventions. According to the CNA's statement dated 9/3/13 obtained during the course of the facility's investigation, the CNA left the resident unattended in the bathroom to assist another resident. During an interview on 2/7/14 at 11:45 a.m., the UM confirmed that the resident was left unattended in the bathroom. An IPN and Incident and Accident report dated 11/6/13 at 4:10 p.m. Resident #6 slid out of wheel chair and released the backward placed seat belt. There was no documentation as to how the resident released the back ward seat belt. A review of an Incident/Accident Report dated 11/28/13 at 3:10 p.m., revealed the Resident #6 was found by CNA on floor in shower room. The resident was unable to explain what happened. There was no documentation that reflected how the resident sustained [REDACTED]. On 2/10/14 at 2:50 p.m. a review of the shower policy provided by the facility indicated in the "Guidelines" section; "Stay with the resident throughout the shower. Never leave the resident unattended." On 2/11/14 at 11:30 a.m. the surveyor reviewed the resident's care plan. Fall interventions initiated 02/09/10 and last revised 11/6/13 included; to assist with transfer, wear proper foot wear, place on falling star program, encourage to stay in supervised areas and after meals encourage to sit in view of nursing station. A review of the Physician order [REDACTED]. 1/31/14 revealed a physician's orders [REDACTED]. The restraint was ordered to be removed every two hours during meals and toileting. On 2/11/14 at 9:15 a.m. the CNA assigned to Resident #6 told the surveyor that the resident could not release the seatbelt. On 2/10/14 at 9:25 a.m. the surveyor observed the resident seated in the dayroom. The rear seat belt was not in place and/or secured. During an interview on 2/10/14 at 9:30 a.m., the CNA revealed that the resident was not able to release the seat belt. On 2/10/14 at 9:30 a.m., the surveyor escorted the same CNA to the dayroom and the CNA confirmed that Resident #6's seat belt was not secured. In addition, the CNA told the surveyor that she had released the resident's rear seatbelt at 7:30 a.m., prior to breakfast and it should have been re-applied by someone who was assigned in the dayroom after breakfast. The surveyor interviewed the UM on 2/10/14 at 9:35 a.m. The UM revealed that the CNA assigned to the day room for breakfast or the CNA assigned to care for the resident should have re-applied the rear seatbelt after breakfast. The UM was not able to state which staff member was assigned to the dayroom for breakfast. A review of the CNA's assignment sheet lacked evidence that a specific staff member was assigned to the dayroom for breakfast. There was no documented evidence of a system in place to ensure that seat belt devices once released for meals were re-applied. The CNA's care plan did not reflect staff's responsibility with regards to the seat belt application after meals. On 2/12/14 at 12:30 p.m. a review of the facility fall policy updated on 10/2013 revealed that a fall risk assessment was to be completed on admission, quarterly and immediately after a fall occurred. There was no evidence that reflected that was completed. 4. The surveyor toured the nursing unit on 2/6/14 at 9:30 a.m. with the unit Licensed Practical Nurse (LPN). The surveyor observed Resident #2 seated in the unit day room in a standard wheelchair with no visible added padding. An alarm was affixed to the wheelchair. The LPN stated the resident had fragile skin and sustained frequent skin tears. Additionally, the LPN stated the resident fell recently and banged his/her leg. The surveyor reviewed the resident's medical record on 2/7/14. The 6/14/13 annual and 1/14/14 quarterly MDS identified the resident had mild cognitive deficits and required extensive assist with transfer and ambulation. A review of the skin integrity care plan, initiated 11/10/10, included a 6/14/12 intervention wheel chair parts were padded/electric tape. A care plan for risk of bleeding and bruising initiated 1/6/12 included an intervention to assess surroundings for need to modify areas that may increase risk for bruising (padding corners, etc). The surveyor reviewed an Incident/Accident Report dated 10/22/13 at 9:05 a.m., which reflected a CNA transferred Resident #2 from the bed to the wheelchair. The resident sustained [REDACTED]. An IPN dated 10/22/13 at 9:05 a.m., reflected Resident #2 sustained a "large laceration" on the right shin when the leg was "bumped" on the wheelchair leg rest during transfer from the bed to wheelchair. The resident was transferred to the hospital emergency department. The resident required sutures to close the laceration and subsequent treatment with antibiotics to prevent infection. On 2/6/14 at 9:30 a.m., on 2/7/14 at 10:00 a.m., on 2/10/14 at 9:45 a.m., the surveyor observed Resident #2 seated in the wheel chair without additional padding to corners of the wheel chair in place. The surveyor inspected the resident's room in the presence of the CNA on 2/10/14 at 11:20 a.m. The nightstand adjacent to the resident's bed had a sharp 2 inch strip of molding protruding away from the perimeter of the wood table top. Additionally, the top drawer of the two drawer nightstand was broken into two pieces which were placed perpendicular into the open space of the top drawer. The edges of the broken drawer pieces were sharp. The CNA stated she had reported the broken night stand to the Unit Manager. The surveyor reviewed the Maintenance Request Log located at the nursing station. The book contained January, 2014 and February, 2014 repair requests. There was no repair request in the Log to fix the nightstand in Resident #2's room. The surveyor spoke with the Director of Nursing (DON) on 2/11/14 at 10 a.m. regarding the resident's care plan interventions to prevent skin injury, the history of laceration from the wheelchair leg rest, disrepair of the resident's nightstand with exposed sharp edges, and the lack of padding on the wheelchair. The DON responded on 2/12/14 at 10:25 a.m. stating the resident received a new nightstand and the wheelchair will be padded with foam. NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to provide a safe environment free from potential hazards and accidents by not consistently implementing identified safety interventions. On 11/2/2012 at 3:30 a.m., the wheelchair was not removed from a resident's room when the resident was in bed and the resident attempted to transfer from the bed to the wheelchair and fell , fracturing his/her hip. This deficient practice was observed for 1 of 9 resident (Resident #2) identified for falls. Evidence was as follows: Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the residents Minimum Data Set of 10/20/12, the resident was alert and oriented with some confusion and had memory problems. The resident required an extensive assist of one staff member for ambulation, and was a high risk for falls. On 10/4/12 at 8:15 p.m. and again on 10/18/12 at 4 p.m. the resident had falls while attempting to transfer from the bed to the wheelchair. On 10/22/12, the IDT met to review Resident #2's falls and felt since all interventions were in place including, call bells, proper footwear, clear walkways, assist with toileting, bed and chair alarms, and the resident still had a fall, it was determined that the falls happened when the resident was attempting to transfer from the bed to the wheelchair and the only additional intervention would be to remove the wheelchair from the resident's room when the resident was in bed, because the resident would not attempt to transfer out of bed if the wheelchair was unavailable. A Physicians order was written on 10/3/12 at 2 p.m., "Remove chair from room when in bed." This order was added to the resident's Treatment Administration Record (TAR) and the Medication Administration Record (MAR) to alert the Nursing staff. It was also added to the resident's care plan and the Certified Nursing Assistants care plan as well. According to the Interdisciplinary Progress Note (IPN) on 11/2/2012 at 3:30 a.m., Resident #2 was found on the floor of her room, hitting her right side, sustaining right hip swelling, the leg was externally rotated, with the right leg appearing shorter. According to the IPN, the resident had "excruciating pain", cold compresses were applied and Percocet was given for pain. The physician and family were notified and the resident was transferred to the hospital and admitted with a fractured right hip for surgery. According to the facility investigation and statement of the CNA and Registered Nurse, the resident was in bed, trying to get out of bed to the wheelchair. The resident stood up and when attempting to sit in the wheelchair, which was not locked, the resident lost his/her balance and fell to the floor. According to an interview with the Director of Nursing on 12/18/12 at 12 Noon, "he was sick about what happened," referring to the wheelchair being left in the room on the night of the fall (11/2/12). The DON indicated that staff were disciplined and Inservices were completed for all Nursing staff. NJAC-8:39-27.1(a).