Every finding on record at Atlantic Coast Rehab & Health

C #2683542Based on observations and interviews, the facility failed to maintain a clean, safe, and comfortable homelike environment by ensuring the floors and resident care equipment were free of debris, food residue, and tube feeding formula for two residents (Resident (R) 13 and R15). Additionally, exit doors on the high side of each wing were observed with visible gaps either along the bottom or sides, in need of weather stripping or door sweeps. These failures had the potential to diminish residents' quality of life and compromise the overall living environment.Findings include: During an observation on 06/22/26 at 1:25 PM, the floor in the room of R13 was observed with debris and multiple areas of food spillage and splatters across the floor. During an observation on 06/22/26 at 1:33 PM, housekeeping staff entered R15's room, which was shared with R13, and removed a next that had been next to R15's bed from the room. While removing the mattress, a large amount of light brown spillage was observed on the mattress. A cellophane wrapper was observed underneath the head of the bed near the wall, and dried tube feeding formula was observed on the floor underneath R15's bed. The base of the tube feeding stand was observed to have an accumulation of dried tube feeding formula spillage. During an observation and interview on 06/23/26 at 2:00 PM, Unit Manager (UM) 2 entered the room of R13 and R15. R13's food spillage remained on the floor in the area of the bed, and the cellophane wrapper and dried tube feeding spillage remained underneath R15's bed and on the tube feeding stand. UM2 was notified that the food spillage, debris, and tube feeding formula was also observed the day prior (06/22/26) on the floor of the room. The UM2 stated that R13 notified porter of the food on the floor. The UM2 attempted to clean the tube feeding stand but was unable to remove the spillage; UM2 replaced the tube feeding stand with a different one. During an observation of the environment on 06/23/26 at 2:11 PM, the door leading to the high side of Manor Wing between rooms [ROOM NUMBERS] was observed with a gap underneath and anapproximate one-half inch gap with visible light coming through in need of a door sweep orweather stripping. During an observation on 06/23/26 at 2:18 PM, the door on the high side of Crest Wing, leading to the outside between rooms [ROOM NUMBERS], was observed with an approximate one-inch gap with visible light coming through below the bottom of the door. On the right side of the door facing outside, there were also visible gaps where light was coming through in need of weather stripping or door sweeps. During an observation on 06/23/26 at 2:21 PM, the Sub-Acute Wing door on the upper hallway leading to the outside between rooms [ROOM NUMBERS] was observed with a gap at the bottom of the door with visible light shining through in need of a door sweep or weather stripping. On 06/25/26 at 1:10 PM, the Maintenance Director (MD) was notified of the surveyor's observations of the gaps in the doors at the high side of the Manor and Crest Units. The MD stated he would address it. The Nurse Consultant, Administrator, and Administrator in Training (AIT) were notified of the surveyor's observations regarding the gaps surrounding the unit doors leading to the outside on 06/25/26 at 4:30 PM. The Administrator stated that the gaps were because of the ambulance stretchers and that the doors would need adjustment. NJAC 8:39-4.1(a)11

Based on record review, interviews, and facility policy review, the facility failed to provide residents and their resident representatives (RR) written notices of transfer with all required information following emergent hospital transfers for two of four residents (Resident (R) 74 and R133) reviewed for hospitalization out of 30 sampled residents This failure placed residents and their RRs at risk of not being informed of the reason for the transfer, the transfer location, and their right to appeal the transfer, including how to file an appeal.Findings include: 1. Review of R74's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R74 was admitted to the facility on [DATE]. Review of R74's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/25, located under the MDS tab in the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated no impaired cognition. Review of Transfer/Bed Hold Notice Prior to Hospitalization or Therapeutic Leave, dated 08/01/25 and provided by the facility, revealed R74 was transferred to the emergency room for a femur fracture. Further review revealed the form did not include contact information related to the resident's appeal rights. During an interview on 06/25/26 at 2:52 PM, the Regional Social Services Director (RSSD) stated the transfer form in use was the only one utilized and reported that he/she was unaware it needed to include the information for appeal rights. During an interview on 06/25/26 at 5:51 PM, the Director of Nursing (DON) stated he/she was not that familiar with the facility transfer notice process, but he/she expected staff to have the correct information on the transfer forms. 2. Review of R133's admission Record, located under the Profile tab in the EMR, revealed R133 was initially admitted to the facility on [DATE] with diagnoses which included nontraumatic intracranial hemorrhage and acute respiratory failure with hypoxia. R133 was discharged to the hospital on [DATE]. Review of R133's annual MDS with an ARD of 05/10/26, located under the MDS tab in the EMR, revealed R133 had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Review of the Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed the resident was transferred to the hospital on [DATE] due to acute respiratory distress and did not return. Review of the EMR revealed no evidence that a written transfer/discharge notice was provided to the resident or resident representative at the time of transfer or shortly thereafter. During an interview on 06/25/26 at 1:36 PM, the DON and the Assistant Director of Nursing (ADON) stated they were not aware when a resident was sent to the hospital that a notice of transfer form should be provided to the resident or their responsible party. Review of the facility's policy titled, Transfer/Discharge/Bed Hold Policy and Procedure, dated April 2025, revealed, In case of emergency transfers, which don't allow for prior notification . representative shall be provided with the written notification within 24 hours of transfer. In addition, The written notice will include the following: . A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request . NJAC 8:39-4.1(a)31 NJAC 8:39-5.1(a)

Based on record review and interviews, the facility failed to ensure documented physician acknowledgment and timely response to Medication Regimen Reviews (MRRs) for three of five residents (Resident (R) 4, R13, and R14) reviewed for unnecessary medications out of a sample of 30 residents. Additionally, the facility failed to implement an effective system to monitor, track, and prevent the recurrence of medication administration errors identified on the MRRs. These failures resulted in R13 and R14 continuing to receive medications outside of prescribed parameters and had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation for all residents.Findings include: 1. Review of R4's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. Review of R4's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/26, located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of R4's Care Plan, located under the Care Plan tab of the EMR, initiated on 02/13/24, revealed R4 was care planned for antiplatelet (high risk), diuretic (high risk), hypoglycemic (high risk), psychotropic (high risk), and opioid medications. Review of R4's Medication Regimen Review (MRR), dated 01/06/26 and provided by the facility, revealed that concurrent use of Buspar (an anti-anxiety medication) and hydroxyzine (an antihistamine medication used to treat anxiety) for anxiety may be considered polypharmacy and per Beers Criteria (evidence-based guideline identifying medications that are potentially inappropriate for older adults) the use of hydroxyzine is not recommended due to an increased risk for anticholinergic side effects. Please document the risk and benefits for continued use. There was no documented physician acknowledgement, clinical rationale for continued use, risk versus benefits, or change in medications. Review of R4's MRR, dated 03/04/26 and provided by the facility, indicated the order for gentamicin ointment was incomplete and needed a duration and observations of potential side effects. There was no documented physician response to the MRR. Review of R4's MRR, dated 04/05/26 and provided by the facility, indicated that to ease medication pass, prednisone and vitamin B-1 could be scheduled at 9:00 AM or 5:00 PM and that behaviors needed to be identified and monitored and side effects monitored for the use of olanzapine (an antipsychotic medication), Buspar (an anti-anxiety medication), and Lexapro (an anti-depressant medication). The MRR also included directions on the use of Ozempic and a recommendation to consider discontinuing the parameters for administering verapamil (a blood pressure medication). There was no documented physician response to the MRR. Review or R4's MRR, dated 05/06/26 and provided by the facility, again revealed, Per Beers Criteria the use of hydroxyzine is not recommended due to an increased risk for anticholinergic side effects. Please document the risk and benefits for continued use. There was no documented physician acknowledgement, clinical rationale for continued use, risk versus benefits, or change in medications. During an interview on 06/25/26 at 3:34 PM, the Unit Manager (UM) 1 stated the physicians did not always sign off on the MRR sheet, but UM1 usually wrote a nursing note and wrote the correction, if any were made, to the medications. UM1 stated the physicians preferred to provide verbal responses. UM1 further stated he/she was unsure if he/she documented a progress note for each of R4's MRRs between January and May of 2026. During an interview on 06/25/26 at 5:51 PM, the Director of Nursing (DON) stated the physicians only visited the facility monthly, but he/she felt the facility's process was adequate. The DON stated that physicians provided verbal responses to the MRR recommendations and that any resulting medication changes were documented. However, the DON acknowledged it was inappropriate that R4's MRR had remained without a response as to any changes or documented rationale for the continued use of hydroxyzine for four months. 2. Review of R13's undated admission Record, in the EMR under the Resident tab, indicated the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, sequelae of cerebral infarction (stroke), hemiplegia (paralysis on one side of the body), and unspecified dementia with behavioral disturbance. Review of the facility's Consultant Pharmacist's Monthly Report for April 2026, provided by the DON, indicated that on 04/02/26 the consultant pharmacist identified that Morphine sulfate [an opioid medication] extended release was not always held as required by the physician's hold order. Please review (example: 04/01 and 04/02 at 9:00 AM – systolic blood pressure less than 90). Although a handwritten notation stating educated was present, it did not identify the author of the entry or evidence of who was educated or the content of the education.Review of R13's April 2026, May 2026, and June 2026 Medication Administration Record (MARs), located under the Orders tab in the EMR, indicated an order for morphine sulfate (MS) Contin 30 milligrams (mg) every 12 hours with instructions to hold the medication for systolic blood pressure (SBP) less than 90. The MAR showed the medication was administered despite SBP readings below the ordered parameter on the following dates:04/01/26 at 9:00 AM: SBP = 7604/02/26 at 9:00 AM: SBP = 6404/03/26 at 9:00 AM: SBP = 8605/17/26 at 9:00 AM: SBP = 8505/18/26 at 9:00 AM: SBP = 8705/19/26 at 9:00 AM: SBP = 8305/25/26 at 9:00 AM: SBP = 8406/04/26 at 9:00 AM: SBP = 86 During an interview on 06/25/26 at 12:50 PM, RN2 confirmed the medication was administered by an agency nurse in April despite the ordered parameters. RN2 confirmed that both agency and facility nursing staff administered the medication below the ordered parameters in May and June. During an interview on 06/25/26 at 2:30 PM, the DON stated staff received education regarding medication parameters and that the unit managers were responsible for follow-up. The DON failed to provide evidence of a system to ensure ongoing monitoring or compliance with medication practices outside of one Medication Error Report, dated 06/08/26, which identified, Medication administered when below parameters. The report indicated Nurse educated, but failed to include the date or time of the medication error or evidence of follow-up monitoring to ensure sustained compliance. During a follow-up interview on 06/25/26 at 3:30 PM, the DON confirmed the facility did not have an effective process to consistently monitor or track medication errors identified by the consultant pharmacist to ensure the errors did not continue. 3. Review of R14's undated admission Record, found in the EMR under the Profile tab, indicated R14 was admitted on [DATE] with diagnoses including functional quadriplegia and chronic systolic heart failure. Review of R14's February 2026, March 2026, April 2026, and June 2026 MARs revealed an order for midodrine hydrochloride (HCl) (medication used to increase blood pressure) 10 mg via gastrostomy tube (G-tube) three times a day for hypotension (low blood pressure); hold for SBP greater than 120. Further review revealed that there were times each month when staff administered the medication even though the resident's SBP was greater than 120. Review of the facility's Consultant Pharmacist's Monthly Reports, provided by the DON, identified repeated findings of medication administration errors involving the midodrine not being held in accordance with physician's orders:February 2026 (02/02/26): Midodrine is not always held as required by the physician's hold order. A handwritten notation of noted was present without a name or initials and without documentation of follow-up actions or staff education.March 2026 (03/02/26): Medication error(s) noted. Midodrine is not always held as required by the physician hold order. A handwritten notation of noted was present without a name or initials and without identification of responsible staff or corrective actions.April 2026 (04/02/26): Midodrine is not always held as required by the physician's hold order. A handwritten notation of educated was present without a name or initials; however, the facility did not document who received education or the content of the education.June 2026 (06/01/26): Midodrine is not always held as required by the physician's hold order. Documentation indicated, Noted. Spoke to nurses without a name or initials; however, the facility did not identify which nurses were involved or what corrective actions were implemented to ensure compliance. During an interview on 06/25/26 at 2:30 PM, the DON stated the unit managers were responsible for follow-up on pharmacist-identified concerns. After surveyor inquiry, the DON did not provide documentation demonstrating that medication administration errors were consistently addressed with identified staff or that a monitoring system was in place to prevent recurrence. NJAC 8:39-29.3

Based on observation, interviews, record review, and review of the facility policy, the facility failed to protect the resident's right to be free from physical abuse by a resident for one (Resident (R) 82) of two residents reviewed for abuse out of a total sample of 30. This deficient practice resulted when R105 hit R82, which had the potential to cause further harm to both R105 and R82.Findings include: 1. Review of R105's admission Record, located in the Profile tab of the electronic medical record (EMR), indicated that resident R105 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. Review of R105's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/26, located in the MDS tab of the EMR, revealed that R105 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating he/she had moderately impaired cognition. Review of R105's Care Plan located under the Care Plan tab of the EMR, revealed no history of aggression towards other residents. 2. Review of R82's admission Record, located in the Profile tab of the EMR indicated that R82 was admitted to the facility on [DATE] with diagnoses including depression and bipolar disorder. Review of R82's quarterly MDS with an ARD of 05/19/26, located in the MDS tab of the EMR, revealed that R82 had a BIMS score of a six out of 15, indicating he/she was cognitively impaired. During an observation on 06/22/26 at 2:36 PM, R105 was sitting in a chair across from the nurse's station. There was an empty chair next to R105. R82 was standing against the wall, in between R105 and the empty chair. R105 suddenly stood up and punched R82 with a closed fist in the nose. Registered Nurse (RN) 1, who was sitting at the desk called out to R105, stop, stop and stood up. RN1 approached R105 and escorted him/her to his room. R82 put his/her hand up to his/her nose briefly, then sat down in the chair and said nothing. Review of a 06/22/26 Progress Note, located under the Progress Notes tab of the EMR, revealed, [R82] was witnessed standing across from the nurse's station between chairs and [R105] stood up and punched [him/her] in the face. R82 stated [He/she] [R105] just got up and punched me. Both residents [were] immediately separated and brought to their rooms, Resident [R82] noted with Bruising to R [right] eye and laceration 1cm [centimeter] x 0.5 cm x 0.1cm to bridge of nose, scant bleeding. 911 called . Resident [R82] denies pain. Resident refused to go to [the] hospital. Resident is on anticoagulants. Resident's [spouse] made aware. Nursing staff and EMTS [emergency medical technicians] explained importance to resident and [spouse] to [sic] going to the hospital for evaluation. Resident continued to refuse. Resident is confused at baseline with Hx [history] of dementia. [Spouse] who is POA [Power of Attorney] stated Not to send to ER [emergency room] if resident does not want to go. During an interview on 06/23/26 at 9:20 AM, the Assistant Director of Nursing (ADON) stated he/she was made aware that R105 struck R82 by the nurse's station. He/she stated they separated the residents and implemented 15-minute checks for 48 hours for R105. The ADON further stated that R105 rarely came out of his/her room and staff were made aware when R105 left his/her room to ensure close supervision was provided. The ADON stated R105 had not had any previous incidents with other residents but had a history of aggressive behaviors toward staff. He/she stated R105 was very redirectable. During an interview on 06/23/26 at 9:30 AM, the Director of Nursing (DON) stated staff immediately separated R105 and R82. He/she stated R105 had an incident a year prior, but it was with a staff member; R105 had not been aggressive towards other residents and was very redirectable. The DON stated R105 has a diagnosis of schizophrenia and a history of visual and auditory delusions. The DON confirmed R105 was placed on 15-minute checks for 48 hours and close supervision when leaving the room. He/she stated both residents were assessed and R82 and his/her significant other refused for him/her to go to the hospital. Review of a policy document provided by the facility titled, Resident Abuse/Neglect Policy and Procedure, revised February 2026 revealed, All residents have the right to be free from mental, physical, sexual, and verbal abuse . the facility will not condone the abused/neglect of any resident by anyone . NJAC 8:39-4.1(a)5

Based on record review and staff interviews, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed for one of five residents reviewed for PASARR (Resident (R) 78) out of 30 sampled residents. This failure had the potential to affect the resident's ability to receive needed services. Findings include: Review of R78's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Review of R78's NJ Preadmission Screening and Resident Review, dated 03/25/26 and located in the resident's EMR under the Miscellaneous tab, revealed no diagnosis or indication of mental illness (MI) identified. Review of R78's Medical Diagnosis list in the EMR revealed bipolar disorder was present on admission. During an interview on 06/25/26 at 2:34 PM, the Admissions Director stated all the PASARR Level I documents came from the hospital, and they were uploaded into the electronic medical record. The Admissions Director stated the facility was responsible for reviewing the level I for accuracy. He/she reviewed R78's PASARR and the diagnosis for bipolar disorder and acknowledged the PASARR was not completed correctly and that the mental illness diagnosis should have been indicated. During an interview on 06/25/26 at 5:51 PM, the Director of Nursing (DON) stated he/she expected PASARRs to be completed accurately. NJAC 8:39-5.1(a)

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) User's Manual, the facility failed to develop a Post Traumatic Stress Disorder (PTSD) comprehensive care plan with measurable goals and interventions for two residents (Resident (R) 8 and R84) reviewed for care plans out of a sample of 30 residents. This failure had the potential to affect the facility's ability to provide consistent, individualized care and avoid trauma-related distress.Findings include: 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R8 was originally admitted on [DATE] with a diagnosis of autism and PTSD. Review of R8's Social Service History and admission Assessment, located under the Assessments tab of the EMR dated 05/08/19, revealed, . [R8] has a diagnosis of PTSD . there were two separate incidents that occurred in middle and high school. The middle school episode consisted of [R8] getting beat up one day after school resulting in a concussion, fractured orbital and broken nose. While in High School, [he/she] reportedly was 'raped by a male student after school and walked to the police department to report it' . [R8] received minimal counseling as [his/her] mother discontinued the sessions . Review of R8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/26, located under the MDS tab of the EMR, revealed that R8 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating he/she had moderately impaired cognitive function. The MDS further revealed that R8 had a diagnosis of PTSD. Review of R8's Care plan, located under the Care Plan tab of the EMR, dated 06/12/26, revealed it did not address the resident's PTSD. During an interview on 06/25/26 at 4:08 PM, the MDS Coordinator (MDSC) stated that when he/she completed the quarterly or annual MDS assessments, he/she reviewed the care plans to ensure all diagnoses indicated on the MDS were reflected on the care plan. The MDSC stated he/she was not aware of R8's history and reviewed the Social Service History and admission Assessment. The MDSC acknowledged this was an oversight and stated the care plan should have included R8's diagnosis of PTSD. During an interview on 06/25/26 at 4:25 PM, the Director of Nursing (DON) stated residents' care plans should be accurate and reflect all residents' diagnoses to comprehensively treat the resident. 2. Review of R84's admission Record located in the EMR under the Profile tab, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included PTSD. Review of R84's annual MDS with an ARD of 10/07/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed an active diagnosis of PTSD. Review of R84's Care Plan, dated 01/28/26 and located in the EMR under the Care Plan tab, revealed the resident was at risk for PTSD; however, there were no interventions in place for staff to be aware of potential stressors or triggers. During an interview on 06/25/26 at 5:51 PM, the Director of Nursing (DON) stated he/she expected PTSD to be care planned with appropriate interventions. Review of the Resident Assessment Instrument (RAI) User's Manual, dated October 2025, located at www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf, indicated . The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents . After completing the MDS and CAA [care area assessment] portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT [Interdisciplinary Team] must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs . NJAC 8:39-11.2(e)thru(i)

Based on record review, interviews, and policy review, the facility failed to ensure one of three residents reviewed for falls (Resident (R) 12) out of a sample of 30 residents had a current fall risk assessment, that fall interventions in place at the time of a fall, and that additional interventions were added to the care plan following an unwitnessed fall that resulted a nasal bone fracture. This failure placed R12 at risk for additional falls, injury, and a decline in overall well-being. Findings include: Review of R12's Administration Record, located under the Profile tab of the electronic medical record (EMR), revealed R12 was originally admitted on [DATE] with a diagnosis of fracture of nasal bones, subsequent encounter for fracture with routine healing. Review of the Fall Risk Assessment, located under the Assessment tab of the EMR, dated September 2022, revealed the resident was at a high risk for falls, with a score of 17 out of 20. The September 2022 assessment was the most current Fall Risk Assessment in the EMR. Review of the Orders tab of the EMR, revealed R12 had a physician order for Mat to floor at bedside while patient is in bed, with a start date of 05/26/24. Review of R12's Emergency Medical Services (EMS) report, provided by the facility, dated 04/08/26, revealed EMS arrived at the facility at 11:27 PM on 04/08/26. R12 left the facility with EMS at 11:56 PM. The Narrative, revealed, [R12] was found in the prone position in the doorway of [his/her] room. [R12] stated [he/she] was trying to get out of bed to go to the bathroom when [he/she] fell face first into the ground . [R12] was on blood thinners and had a 2 inch laceration to the left brow that went down to the musculature as it was visible. [R12] also had a deformed nose and swollen knuckles to the left index and middle finger . Review of the Unwitnessed Fall report, provided by the facility, dated 04/08/26, revealed Nurses were counting narcotics at change of shift when they heard resident yelling help from room. When nurses entered room resident was observed on [the] floor face down with large amount of blood around head. Call placed to 911 for transport to ER [Emergency Room] . The report revealed R12's mental status was confused but orientated to person. There was no predisposing environmental or situation factors. The report revealed side rails were up. There was no mention of a fall mat being in place. Review of the Fall Inspection Report, provided by the facility, dated 04/08/26, revealed R12 had a fall on 04/08/26 at 11:15 PM. The report revealed R12 was last seen in bed and one-half side was up. The call light was within reach, and the bed was in the lowest position and R12 was incontinent. The investigation causative factors included, Resident can be confused at times and will ask if it's time to eat during shift. The report revealed the last time R12 was changed was at 9:00 PM. Included in the report was an interview from R12's assigned CNA (Certified Nurse Aide) which revealed, 11:15 (PM) I heard the resident yelling on [sic] his room when I came I found the resident lying on the floor with blood and immediately reported to the nurse. The document was signed and dated. Review of the CNA (Certified Nurse Aide) Statement, dated 04/08/26 and included in the Fall Inspection Report provided by the facility, revealed R12 did not have a fall mat in place. Review of the Hospital Discharge summary, dated [DATE], revealed, a computed tomography (CT) scan indicated acute bilateral nasal bone fractures. Review of R12's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/26 revealed that R12 has Brief Interview for Mental Status (BIMS) score of 10 of 15, indicating he/she has moderately impaired cognitive function. The MDS revealed R12 had one fall with major injury since the prior assessment and required substantial/maximal assistance to transfer. Review of R12's Care Plan, located under the Care Plan tab in the EMR, with a revision date of 05/20/26, revealed [R12] is at risk for falls related to compromised functional status. The goal was identified as Risk of falls will be reduced, and [R12] will remain free from injury. Interventions included, fall mat to exit side of the bed, initiated 12/04/24 Interventions on the Care Plan after the 04/08/26 fall revealed send to ER to r/o [rule out] underlying injury (initiated 04/08/26), and neuro [neurological] checks as ordered (initiated 04/09/26). During an interview on 06/24/26 at 11:45 AM, the Assistant Director of Nursing (ADON) stated the facility did not complete quarterly or annual fall assessments and considered the MDS to be the fall assessment. The ADON stated the interventions after the 04/08/26 fall included sending R12 to the hospital and completing neurological checks. He/she confirmed that the last Fall Risk Assessment was completed in September 2022. During an interview on 06/24/26 at 3:44 PM, CNA5 stated he/she had assisted R12 to bed prior to R12's fall. CNA5 stated he/she did not recall whether the mat was in place at the side of the bed or not. During an interview on 06/24/26 at 4:00 PM, R12 stated he/she remembered the fall. R12 stated when he/she fell out of bed his bed was in the regular position, not high or low. He/she stated there was no fall mat on the floor. During an interview on 06/25/26 at 1:36 PM, the Director of Nursing (DON) stated fall assessments should be done quarterly, and the MDS was used for the quarterly fall assessment. He/she stated that after a resident falls, new interventions should be put in place. He stated the immediate interventions were to send R12 to the ER and start neuro checks upon R12's return. The DON stated he/she would be looking for more fall interventions for R12 but stated he/she currently had not added any more interventions. Review of the facility's policy titled, Accident/Incident Policy, reviewed January 2026, revealed, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling. NJAC 8:39-33.1(d)

Based on observation, interviews, record review, and policy review, the facility failed to ensure alternative interventions were attempted prior to the use of side rails, failed to document discussions regarding the risks and benefits of side rail use, and failed to obtain signed informed consent prior to implementing side rails for one of three residents (Resident (R) 78) reviewed for side rail use out of 30 sampled residents. This deficient practice placed R78 at risk for inappropriate restraint or side rail entrapment. Findings include: Review of R78's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and foot drop. Review of R78's Physician Orders, dated 03/25/26 and located under the Orders tab of the EMR, revealed that upper quarter-length side rails were ordered. Review of R78's admission Observation/Screening-Side Rail, assessment, dated 03/25/26 and located under Assessments tab in the EMR, revealed that rails were in use. Further review revealed no documentation that alternative interventions were explored prior to bed rail/side rail use and no documentation related to risks versus benefits or signed informed consent. Review of R78's Care Plan, located under the Care Plan tab of the EMR, initiated on 03/26/26, revealed R78 was not care planned for bed rails. Review of R78's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/26 and located under the MDS tab in the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. During an observation on 06/22/26 at 10:45 AM, R78 was in bed with side rails located on both sides of the bed. During an interview on 06/25/26 at 3:24 PM, Licensed Practical Nurse (LPN) 10 stated he/she completed the admission Observation/Screening-Side Rail assessment for R78. He/she stated the facility's beds came with side rails and that they did not explore alternatives prior to bed rail use. He/she stated if the resident or family wanted bed rails, they got them. He/she also stated there were no other forms, that they did not ask the resident to sign anything, and that he/she did not discuss risks vs benefits with R78. During an interview on 06/25/26 at 5:51 PM, the Director of Nursing (DON) reported he/she was unsure if staff explored alternatives prior to side rail use. The DON confirmed that staff were expected to discuss risks and benefits and obtain signed informed consent prior to the use of side rails. Review of the facility's policy titled, Side Rail Policy and Procedure, reviewed 01/05/26, revealed, This facility is dedicated to providing all residents with the utmost dignity, safety, and independence with all activities of daily living. Side rails may be used to assist the resident [to] maintain or attain his/her highest practicable level of physical, mental, and psychosocial functioning when determined by the interdisciplinary team as appropriate. If a side rail is used, the facility will ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements: Determine what attempted alternatives were trialed that were not adequate to meet the resident's needs and review the risks and benefits of side rail(s) prior to installation. Review the risks and benefits of side rail(s) with the resident or resident representative and obtain informed consent prior to installation. NJAC 8:39-27.1(a)

Based on observation, interviews, record review, and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one of six sampled residents (Resident (R) 15) identified for EBP on the Manor Wing. This deficient practice had the potential spread infection to residents and to affect all 57 residents residing on one of three units. Findings include: Review of R15's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed R15 was admitted to the facility on [DATE]. Review of R15's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/26, found in the MDS tab of the EMR, revealed R15 was dependent on staff for bed-to-chair transfers and personal hygiene. The MDS further revealed R15 had a feeding tube. Review of R15's Care Plan, found in the Care Plan tab of the EMR, revealed a care plan initiated on 12/05/05 for impaired functional status related to limited mobility and cognitive impairment. An intervention added on 05/06/26 directed staff to, Utilize mechanical lift (hoyer) for transfers & [and] 2-person assist . Additionally, R15 had a care plan initiated on 03/23/26 which stated, Resident is at higher risk of acquiring or spreading an MDRO [multidrug-resistant organism] and requires Enhanced Barrier Precautions (EBP) while performing high-contact care activities. Feeding Tube Present/In Use. Interventions included, Providers/Staff/Caregivers will wear a gown and gloves while caring for or using a feeding tube, and, Providers/Staff/Caregivers will wear a gown and gloves while caring for resident during high-contact resident care activities including: Transferring from one position to another [and] providing hygiene . During an observation on 06/22/26 at 1:40 PM, Unit Manager (UM) 2 entered R15's room while Certified Nursing Assistant (CNA) 1 and CNA 3 prepared to transfer R15 to bed using a Hoyer lift. UM 2 turned off the feeding pump, disconnected R15's feeding tube, and flushed the resident's gastrostomy tube (G-tube). CNA1 and CNA3 used the Hoyer lift and transferred R15 to bed. After R15 was in bed, UM 2 reconnected the feeding tube and placed gauze around the insertion site. CNA1, CNA3, and UM 2 did not wear gowns during the observation. During an interview at the conclusion of the observation, UM 2 was asked whether the doorway indicator for EBP applied to one or both residents in the room. UM 2 stated, We all messed up. UM 2 acknowledged that he/she and both CNAs should have donned the required PPE (personal protective equipment) while providing care to R15. During an interview on 06/24/26 at 1:03 PM, CNA1 stated he/she was aware PPE (gowns) were required when caring for R15 and confirmed he/she assisted CNA3 during the transfer without wearing a gown. During an interview on 06/24/26 at 1:24 PM, CNA3 stated he/she was unsure whether PPE was required when transferring R15. During an interview on 06/24/26 at 2:00 PM, the Infection Preventionist (IP) stated she was aware staff had failed to don PPE while caring for R15 and had subsequently provided one-on-one education to UM 2, CNA1, and CNA3. The IP stated that because R15 had a G-tube, staff should have worn PPE while providing care to the resident's G-tube and during the resident's transfer. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), reviewed August 2025, revealed, This facility will use Enhanced Barrier Precautions (EBP) during high-contact care activities for residents with chronic wounds or indwelling devices, regardless of their multidrug-resistant organism (MDRO) status . Purpose: To outline the implementation of Enhanced Barrier Precautions to disrupt the potential spread of multidrug-resistant organisms . EBP is used in conjunction with standard precautions and expands the use of personal protective equipment (PPE) to include a gown and gloves during high-contact resident care activities . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies . EBP should be used for any resident who meets the above criteria, wherever the resident resides in the facility. The policy further stated, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care for chronic wounds requiring a dressing. NJAC 8:39-19.4

Based on interviews, record reviews and a review of pertinent facility documentation, it was determined that the facility failed to a) ensure that a resident was protected from alleged abuse by a Certified Nursing Assistant (CNA) #1, and b) failed to implement facility's abuse policy when they became aware of an allegation that CNA #1 pushed the resident knocking them to the floor on 12/11/25. According to an undated document titled reference 12/11/25, which the facility provided to the surveyor, on 12/12/25, the facility administration reviewed video footage and statements from CNA #1 and LPN #1; and after the review, the Interdisciplinary Team (IDT) agreed to obtain formal statements about the incident from both Residents #1 and #2. The document stated that LPN #1 was alerted by the noise coming from Resident #2's room and went to the room, where she saw Resident #1 grabbing CNA #1. The document further stated that when LPN #1 could not de-escalate the situation, she left the room; upon her return, she found CNA #1 still in the room; and that she saw Resident #1 getting up off the floor. The document stated that the resident called 911 to be transported to the hospital for documentation of injuries they received post assault by CNA #1. The document further stated that the facility was aware of the resident's mental health history and that there is no merit to Resident #1's accusatory statement toward CNA #1, and that they asked the CNA to return to her scheduled shift. On 3/3/26, the facility provided the surveyor with email communications dated between 12/15/25 and 1/29/26 that Resident #1 sent to the Director of Social Services and to LNHA, in which the resident complained about the 12/11/25 incident. The email communications included, but were not limited to, the following: -12/15/25 at 8:30 AM, Resident #1 wrote CNA #1 assaulted me in Resident #2's room.-1/10/26 at 10:22 AM, . Resident #1 wrote Nothing about CNA #1's assault on me on 12/11 .that is so disrespectful and cruel .I need your help to exit this .facility .because you don't want residents that hold you accountably [accountable] .-1/29/26 . Resident #1 wrote, I was assaulted by [CNA #1], you took the word of the 'assailant over mine . These email communications showed that on 12/15/25, the resident informed the facility of an alleged abuse by CNA #1. The facility did not obtain statements from other staff members besides the alleged perpetrator, LPN #1, and the Nursing Supervisor. The facility did not interview or obtain statements from other residents on CNA #1's assignment. The facility allowed CNA #1 to continue working and had access to other residents before a full investigation was conducted. The facility also allowed CNA #1 to return Resident #1's unit despite the resident's repeated verbalization of angry feelings when they saw the CNA on their unit. The facility's failure to protect Resident #1 from alleged abuse posed a likelihood that serious injury, harm, impairment, or death could occur to residents and resulted in immediate jeopardy (IJ). The IJ began on 12/15/25 at 8:30 AM, when the facility failed to remove CNA #1 from all residents' care after Resident #1 notified both LNHA and the Director of Social Services that CNA #1 assaulted them. The facility was notified of the IJ on 3/5/26 at 2:15 PM. The facility submitted an acceptable Removal Plan (RP) on 3/10/26 at 11:21 AM. The survey team verified the implementation of the RP during the onsite survey and determined that the IJ was removed as of 3/11/26 at 3:32 PM. The evidence was as follows: The facility's policy titled Resident Abuse/Neglect Policy and Procedure indicated that the facility will not condone the abuse and neglect of any resident by anyone, including but not limited to, staff members. It further revealed under the heading of Protection, investigating and Reporting that Employees of the facility who are under investigation will be temporarily suspended until the Administrator has reviewed the results of the investigation.A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder.According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 2/6/26, the resident has a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact.A review of Behavior Note written by the Licensed Practical Nurse (LPN) #1 dated 12/11/25 at 6:45 PM, revealed that LPN #1 observed Resident #1 enter Resident #2's room and shortly after, the LPN heard yelling in Resident #2's room. The note stated that when LPN #1 went into Resident #2's room to see what was going on, she saw Resident #1 yelling and grabbing onto CNA #1's left upper arm. The Behavior Note stated that LPN #1 then asked Resident #1 to leave CNA #1 alone, but the resident continued to shout at the CNA up close to the CNA's face. LPN #1 further stated that she left Resident #2's room, notified the Nursing Supervisor, and called 911.A review of the emergency department's after visit summary dated 12/11/25 indicated that the reason for the resident's visit was battery and the diagnosis was abrasion of left upper extremity.On 3/3/26, the surveyor requested all investigation documents and witness statements related to the incident.According to the employee statement from CNA #1, she stated that the resident grabbed her in an aggressive manner to cause physical harm, but that she did not assault the resident.A review of LPN #1's statement dated 12/11/25 stated that she heard yelling in resident #2's room, she went into the room and witnessed Resident #1 grabbing CNA#1's left upper arm, and that she told the resident to stop; and that she exited the room to call 911 and to notify the nursing supervisor.The facility did not provide documented evidence that they had interviewed other residents who were usually on CNA #1's assignment until after the surveyor's inquiry on 3/3/26. The facility also did not obtain statements from other staff members besides the alleged perpetrator, LPN #1, and the Nursing Supervisor.The facility allowed CNA #1 to continue working with other residents, which allowed her access to other residents before a thorough investigation of the incident was completed.A review of CNA #1's assignment dated 12/11/25 revealed that CNA #1 continued to care for other residents before the facility conducted an investigation of the abuse allegation. CNA #1 also continues to work on Resident #1's unit despite the facility's admission; the resident still expresses anger when they see CNA #1 on their unit.A review of CNA #1's assignment revealed the following:On 12/11/25, evening shift on the Behavior Unit (Resident #1's unit).On 12/12/25, evening shift on the Long-Term Care Unit.On 12/15/25, evening shift on the Behavior Unit (Resident #1's unit).On 12/17/25, evening shift on the Behavior Unit (Resident #1's unit).On 12/18/25, evening shift on the Behavior Unit (Resident #1's unit).A review of the payroll documentation for CNA#1 revealed the following:12/11/25 arrived at 3:10 PM and departed at 11:03 PM.12/12/25 arrived at 2:54 PM and departed at 11:00 PM.12/15/25 arrived at 3:07 PM and departed at 10:56 PM.12/16/25 arrived at 2:54 PM and departed at 10:58 PM.12/17/25 arrived at 2:52PM and departed at 11:16PM.12/18/25 arrived at 2:56 PM and departed at 6:56 AM.On 3/3/26 at 10:40 AM, the surveyor interviewed Resident #1, who stated that they heard their friend (Resident #2) yelling out and crying and went to rescue them. Resident #1 further stated that as soon as they entered Resident #2's room, CNA #1 stated: what are you doing here? and that the CNA then grabbed both their arms and pushed them back and knocked them down. The resident told the surveyor that after they (the resident) got off the floor, they called 911, and that 2 police officers came to the facility. The resident further stated that they get upset when they see CNA #1 on the unit.On 3/3/26 at 1:43 PM, the surveyor attempted to interview Resident #2, but the resident could not remember any information about the 12/11/25 incident.On 3/3/26 at 11:18 AM during the interview, the Director of Social Services (DSS) stated that she interviewed Resident #1 regarding the incident and that there was something about the 12/11/26 incident that left [the resident] accusatory and volatile. The DSS further stated that the resident once told her that seeing CNA #1 gets them angry. When asked if the facility considered moving CNA #1 permanently to a different unit to accommodate Resident #1's feelings of anger, the DSS stated that if the facility moved staff out based on Resident #1's accusations, there would be no one left.On 3/3/26 at 11:00 AM, during an interview with the Licensed Nursing Home Administrator (LNHA), he stated that Resident #1 would not stop talking about the 12/11/26 incident. When the surveyor asked why CNA #1 continues to work on the unit where Resident #1 resides, despite the resident's continued feeling of anger when they see CNA #1 on the unit, the LNHA stated that they gave CNA #1 the option of returning to the same unit, and that the CNA has rights too.On 3/3/26 at 2:50 PM, the surveyor interviewed the ADON, who revealed that the resident had aggressive behavior and that Resident #1 is explosive. She further stated that CNA #1 was transferred off Resident 1#'s unit but not from the facility. She further stated that Resident #1 had a history of behaviors attacking staff. When asked why the facility did not follow their abuse allegation policy, the ADON stated that if the incident was with another resident, the process of investigation would have been different.On 3/3/26 at 4:39PM, the surveyor interviewed the Regional Nurse, who stated for an incident of abuse, we follow the abuse policy.However, the facility did not provide an explanation for why they did not implement their abuse policy when they became aware of the resident's allegation of abuse.An acceptable Removal plan (RP) was received on 3/10/26 at 11:21 AM, indicating the action the facility will take to prevent serious harm from occurring and recurring. The facility implemented a corrective action plan to remediate the deficient practice, to include: Resident #1, who appears to have no ill effect from this alleged incident; Resident #1 had a follow up consultation on 12/15/25 with the Statewide Clinical Outreach Program for the Elderly (S-COPE); ADON conducted Abuse policy re-education post incident for nursing staff on 12/15/25. On 3/5/26, the Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the [NAME] President of Clinical Services. On 3/5/26, the ADON and the Regional Nurse Consultant provided 1:1 re-education on Abuse Policy to the Registered Nurse Supervisor involved in the 12/11/25 incident. On 3/5/26, ADON began facility-wide education for all staff on Abuse Policy, to protect all residents from abuse. On 3/5/26, unit managers and Nursing Supervisors were re-educated by ADON on Abuse Policy and the requirement to report. On 3/9/26, the Social Worker conducted additional interviews on the two units assigned to the CNA; no new findings were identified.The surveyor verified the implementation of the RP on site and determined that the immediacy was removed as of 3/11/26 at 3:32 PM.

Based on interviews, medical record reviews, and review of pertinent facility documents on 3/5/26 and 3/11/26, it was determined that the facility failed to report to the New Jersey Department of Health an allegation of physical abuse that occurred on 12/11/25, after the resident notified staff that a Certified Nursing Assistant pushed them and knocked them down. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1). Findings Include:According to the admission Record (AR), Resident #1 was admitted to the facility with diagnose that included but were not limited to Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. According to the comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/6/26, Resident #1 had a Brief Interview Mental Status score of 15 out of 15, indicated that the resident was cognitively intact. A Behavior Note dated 12/11/25 at 6:45 PM included that a Licensed Practical Nurse (LPN) #1 heard yelling and shouting in Resident #2's room, where CNA #1 was providing care to Resident #2. The note further stated that when LPN #1 went into the room, she witnessed Resident #1 grabbing Certified Nursing Assistant (CNA) #1's arm; and that the LPN exited the room to call 911 and to notify the nursing supervisor. A review of a summary of the event document titled Reference 12/11/25, which was provided by the facility, revealed that Resident #1 called 911 and asked to be transported to the hospital to document the injuries they sustained after being physically assaulted . by CNA #1. The Emergency department After Visit Summary showed that the resident was treated for an abrasion of the left upper arm and received an injection of the Tetanus, Diphtheria, Pertussis vaccine (Tdap). A review of the Nursing Supervisor's witness statement dated 12/12/25 revealed that she was made aware of an incident that occurred between Resident #1 and CNA #1. Review of a document titled One - One Inservice dated 12/12/25, revealed that the facility provided in-service for staff on Abuse and Neglect policies and procedures training following the 12/11/25 incident, but there is no evidence that the facility notified NJDOH of the abuse allegation. A review of the facility's in-service for staff dated 12/15/25, titled As per [Facility Name] resident abuse/neglect policy and procedure, revealed that nursing staff were educated on the facility's abuse policy, but there is no evidence that the facility reported it to the New Jersey Department of Health. On 3/3/26 at 2:50 PM surveyor interviewed the Assistant Director of Nursing (ADON), who stated that the facility would notify Department of Health for alleged abuse, major injury, staff to resident abuse, the ADON further stated that she was not involved in the investigation of the 12/11/25 incident between Resident #1 and CNA #1; and that she believed the incident was considered a resident to staff incident, and not considered a staff - to - resident allegation. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice by not storing nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) and Bilevel positive airway pressure device (BiPap- a breathing device that helps a person breathe easier) equipment in bags which resulted in environmental exposure for 3 of 5 residents reviewed for oxygen use (Resident #22, 34, 89) . The deficient practice was evidenced by the following: 1.Upon initial tour of the facility on 2/10/2025 at 10:20 AM, surveyor #1 observed a nebulizer mask standing upright on a nebulizer machine located to the right of Resident #89 on the bedside table. The nebulizer mask was not bagged and exposed to the environment. Resident #89 was asleep and did not respond to surveyor #3's prompting. On 2/11/2025 at 9:16 AM, surveyor #3 observed a nebulizer mask standing upright on a nebulizer machine located to the right of Resident #89 on the bedside table. The nebulizer mask was not bagged and exposed to the environment. The surveyor reviewed the medical record for Resident #89. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), Diabetes Mellitus, Hemiplegia (paralysis or weakness on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/24/25 included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition as moderately impaired. A review of the January and February Medication Administration Treatment included the following physician orders (PO): A PO, with a start date 1/20/2025, for Ipratropium-Albuterol Solution 0.5miligrams (mg)/3 milliliters (mL) inhale orally via nebulizer four times a day for wheezing. On 2/12/2025 at 12:13 PM, surveyor #1 interviewed Certified Nursing Assistant (CNA #2) who confirmed that nebulizer supplies were to be in a bag when not in use. On 2/12/2025 at 12:31 PM, surveyor #1 interviewed Unit Manager Licensed Nurse Practitioner (UMLPN #1) who stated that nebulizers were to be stored in a bag to keep clean when not in use. On 2/12/2025 at 12:43 PM, surveyor #1 interviewed UMLPN #2 who confirmed that they were familiar with Resident #89. UMLPN #2 confirmed that nebulizers were to be bagged. On 2/12/2025 at 1:47 PM, surveyor #1 interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA) and Administrator in Training, who viewed the surveyors pictures and acknowledged that the nebulizers were not in a bag. When asked how nebulizers are to be stored when not in use the DON replied, in a bag. A review of the facility's Respiratory Equipment Policy and Procedure, last reviewed 8/5/2024, included: All nebulizer tubing and equipment shall be date and stored in an oxygen bag when not in use . N.J.A.C. 8:39-27(b) 49712 During the initial tour on 02/10/2025 at 09:56 AM, Resident #22 was observed lying in bed with nasal oxygen in use. Surveyor #2 observed a nebulizer mask laying open to air on the resident's bedside table. On 02/11/2025 at 10:30 AM Surveyor #2 observed Resident # 22 in bed with nasal oxygen tubing on and the Oxygen concentrator turned off. Surveyor #2 asked the Licensed Practical Nurse (LPN) # 2 if the resident should be on continuous oxygen. LPN # 2 stated yes and went in to check the resident. LPN #2 stated, this should not be turned off. LPN # 2 turned oxygen back on and noticed the concentrator was not working properly. LPN #2 then replaced concentrator and checked resident's vitals. According to the Admission Record, Resident #22 was admitted to the facility with diagnoses including but not limited to; Chronic Combined Systolic and Diastolic Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs). A review of the most recent comprehensive Minimum Data Set (MDS) dated [DATE], indicated Resident #22 was on oxygen while a resident. A review of the Order Summary Report dated 02/14/2025, revealed a physician order for DuoNeb solution (a medication used to relax the airway to increase air flow to the lungs),1 vial inhale orally via a nebulizer every six hours. The order also revealed to store the mask in a drawstring bag after each use. The Order Summary Report also revealed and order to administer oxygen at 2 liters/min via nasal cannula continuously. During an interview on 02/13/2025 at 11:16 AM with surveyor # 2 the Infection Control Preventionist said that all nebulizer masks should be placed in bags when not in use so that they don't pick up any bacteria. During an interview on 02/13/2025 at 12:36 PM with surveyor #2 the Director of Nursing, (DON) said that nebulizer mask should be kept in plastic bags due to infection control. The DON also said that staff should be checking the oxygen concentrators to make sure they are on and properly functioning. A review of a facility provided policy titled Respiratory Equipment Policy and Procedure revealed, all nebulizer equipment shall be dated and stored in an oxygen bag when not in use . NJAC 8:39-27.1(a) 51232 Upon initial tour of the facility on 2/10/2025 at 10:27 AM, Surveyor #3 observed Resident # 34 BiPAP machine and mask was on his/her dresser with the mask left uncovered and exposed to the environment. On 02/11/2025 at 10:35 AM, Surveyor #3 reviewed the electronic medical records (EMR) for Resident #34 as follows: According to the Admission Record Resident #34 was admitted to the facility with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD) (a progressive lung disease that makes it difficult to breathe) and Sleep Apnea (repeated interruptions in breathing during sleep). A review of Resident #34 most recent comprehensive Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care) dated 01/25/2025, revealed under section C-Cognitive Patterns, that the resident had a Brief Interview for Mental Status (BIMS) (tool used to assess cognitive function in individuals) score of 15 out of 15, indicating the resident's cognition was intact. A review of Resident #34 Physician Orders indicated the following: start date 01/19/2025, the BiPAP machine is to be used every night at bedtime and removed in the morning, in addition to being used as needed for shortness of breath (SOB). During an interview with Surveyor #3 on 02/10/2025 at 10:35 AM during the initial tour, Resident #34 said that he/she wears the BIPAP machine when he/she sleeps. During an interview with Surveyor #3 on 02/12/2025 at 1:15 PM, the Licensed Practical Nurse Unit Manager #1 (LPNUM #1) said that respiratory equipment should be properly bagged. During an interview with Surveyor #3 on 02/13/2025 at 12:45 PM, the Director of Nursing (DON) said that BiPAP masks should be stored in a plastic bag for infection control purposes. A review of the facility provided policy, with a review date of 08/05/2024, titled, Respiratory Equipment Policy and Procedure revealed under the section titled Procedure that, All nebulizer tubing and equipment shall be date and stored in an oxygen bag when not in use and replaced every 7 days. N.J.A.C. 8:39-27(b)

Based on observation, interview, and pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 02/10/2025 from 09:17 AM until 10:15 AM, the surveyor observed the following in the kitchen in the presence of the Prep [NAME] (PC) then the Regional Food Service Director (RFSD): 1.In refrigerator #1 on the bottom right shelf there were shelled eggs in a carton that were out of the cardboard box. The PC stated the eggs should be stored in the original container. 2. On a storage shelf, souffle cups were opened and exposed to air. The RFSD stated the cups should be covered. 3. In refrigerator #2 there were 20 small cups of mixed fruit that were labeled prepared 2/6/25 discard by 2/8/25 on a metal tray. The RFSD stated he is going to discard them as they are not labeled properly. 4. In freezer #4 there were hash brown patties that were opened and covered with plastic wrap. The hash brown patties were not labeled or dated. The RFSD stated he will discard the hash brown patties. 5. In refrigerator # 3 there were florets of broccoli stored in a blue crate in a black bag that was opened to air. There was no label and no date. The RFSD stated that the broccoli should be labeled and dated. 6. In refrigerator #4 an opened case of cranberry juice was not labeled or dated. The RFSD stated the cranberry juice should be labeled and dated. He stated the case was labeled, however when staff opened the case, the label was ripped off. During an interview on 02/14/25 at 10:29 AM, the Food Service Director stated the broccoli should have been labeled and dated. The eggs should have been in a cardboard box. The cranberry juice was labeled and dated however once box was opened the label ripped off. The surveyor reviewed the facility provided policy titled, Sun Cups (juices) with a revision date of 11/3/17 which reflected: all sun cups upon delivery are to be dated. The surveyor reviewed the facility provided policy titled, Labeling and Dating with no date which reflected all leftover perishable and non-perishable food products should be labeled and dated to assure all food is being served in a safe and sanitary manor. The surveyor reviewed the facility provided policy titled, Food Storage, with no date which reflected:14. Frozen Foods c. All foods should be covered, labeled, and dated. The surveyor reviewed the facility provided policy titled, Storage Areas, with no date which reflected that all paper products should be wrapped in original container or tightly wrapped when not in use. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner for 1 of 29 sampled residents, (Resident #109). This deficient practice was evidenced by the following: On 02/10/2025 at 10:39 AM, the surveyor observed the Certified Nursing Assistant (CNA) transport a resident (Resident #109) backwards in his/her geriatric chair from the resident hallway to the nurse station. According to the Admission Record Resident #109 was admitted to the facility with diagnoses including but not limited to: dementia and muscle weakness. A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care dated 12/20/24, revealed that Resident #109 had long and short-term memory deficits. The MDS further indicated that the resident required maximal assistance with activities of daily living. During an interview with the surveyor on 02/10/2025 at 10:41 AM, the CNA said that transporting a resident backwards in a chair should be avoided for safety reasons, as the resident would likely find it uncomfortable and unpleasant. During an interview with the surveyor on 02/10/2025 at 10:51 AM, the Unit Manager stated that residents should be transported forward all the time to keep the resident from getting disoriented. During an interview with the surveyor on 02/14/25 at 10:02 AM, the Director of Nursing stated there was no policy regarding transporting however he stated, absolutely not, when asked if a resident should be transported backwards. The surveyor reviewed the facility provided Resident Rights which reflected that the residents were to be treated with courtesy, consideration, and respect for your dignity and individuality. The surveyor reviewed the facility provided job description for a Certified Nursing Assistant which reflected that a. Respect for the patient/resident is consistently provided. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for a resident that required nebulized medications (liquid medicine that turns into a mist that can be easily inhaled) and a leg brace for 2 of 28 residents reviewed for care planning (Resident # 89 and 96). This deficient practice was evidenced by the following: 1. Upon initial tour of the facility on 2/10/2025 at 10:20 AM, surveyor #1 observed a nebulizer mask standing upright on a nebulizer machine located to the right of Resident #89 on the bedside table. The nebulizer mask was not bagged and exposed to the environment. Resident #89 was asleep and did not respond to surveyor #1's prompting. The surveyor reviewed the medical record for Resident #89. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), Diabetes Mellitus, Hemiplegia (paralysis or weakness on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/24/25 included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition as moderately impaired. A review of the January and February Medication Administration Treatment included the following physician orders (PO): A PO, with a start date 1/20/2025, for Ipratropium-Albuterol Solution 0.5miligrams (mg)/3 milliliters (mL) inhale orally via nebulizer four times a day for wheezing. A review of Resident #89's care plan did not reveal a focus area identifying nebulizer use. On 2/12/2025 at 12:31 PM, surveyor #1 interviewed Unit Manager Licensed Nurse Practitioner (UMLPN #1) who stated that they were not sure if nebulizer treatments should be identified on the care plan. On 2/12/2025 at 12:43 PM, surveyor #1 interviewed UMLPN #2 who confirmed that nebulizer treatments should be identified on the care plan. Upon reviewing Resident #89's care plan with surveyor #1, the UMLPN#2 was not able to locate nebulizer treatments. UMLPN #2 stated that they will update Resident #89's care plan. On 2/12/2025 at 1:47 PM, surveyor #1 interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA) and Administrator in Training, who confirmed that nebulizer treatments should have been on Resident #89's plan of care. A review of the facility's Admission and Baseline Care Plan (BCP) Policy, last reviewed 3/5/2024, included:1. [ .] This initial plan of care also serves as the BCP for the resident. I) This initial baseline plan of care will address the immediate needs of the resident including, but not limited to: safety, personal hygiene, dietary needs, medications [ .] 3. The BCP will be used as the foundation for care planning with additions/revisions being incorporated into the comprehensive care plan. Once the comprehensive care plan as been developed and implemented, any additional changes will be made to the comprehensive care plan based on the needs of the residents. N.J.A.C. 8:39-11.2 (e) 51232 On 02/10/2025 at 10:48 AM, Surveyor #2 observed Resident #96 wheeling herself in a wheelchair down the hallway on the Crest Unit, wearing an ankle foot orthosis (AFO) brace (supports and stabilizes the foot and ankle) on her left lower leg. On 02/11/2025 at 10:00 AM, Surveyor #2 reviewed the electronic medical records (EMR) for Resident #96 as follows: According to the Admission Record Resident #96 was admitted to the facility with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. A review of Resident #96 most recent comprehensive Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care) dated 01/16/2025, revealed under section C-Cognitive Patterns, that the resident had a Brief Interview for Mental Status (BIMS) (tool used to assess cognitive function in individuals) score of 15 out of 15, indicating the resident's cognition was intact. A review of the Admission Observation assessment dated [DATE], indicated that Resident #96 was admitted with a brace on his/her left leg. A review of Resident #96 Care Plan did not address or include specific instructions for the care of a brace on his/her left leg. A review of Resident #96 Physician Orders did not include current or discontinued orders for a brace on his/her left leg. During an interview with Surveyor #2 on 02/12/2025 at 1:12 PM, the Licensed Practical Nurse Unit Manager (LPNUM #1) said that there should have been an order in place, and it should have been included in the care plan when the resident was wearing a brace. During an interview with Surveyor #2 on 02/12/2025 at 1:23 PM, Resident #96 said that he/she had been wearing the AFO brace to his/her left lower leg prior to admission to the facility and that he/she wore it every day except when he/she was in the bed. He/she also mentioned that he/she applied it independently. During an interview with Surveyor #2 on 02/13/2025 at 10:35 AM, the Director of Rehabilitation (RD) said that she notifies the Director of Nursing (DON) and the unit manager (UM) to ensure that residents who wear a brace or splint have an order and a care plan in place for the device. A review of the facility provided policy, with a review date of 03/05/2024, titled, Admission and Baseline Care Plan (BCP) revealed under the section titled Procedure that, This initial baseline plan of care will address the immediate needs of the resident including, but not limited to: 1. (a) safety, (b) personal hygiene, (c) dietary needs, (d) medications, and (e) ambulation. 3. The BCP will be used as the foundation for care planning with additions/revisions being incorporated into the comprehensive care plan. Once the comprehensive care plan has been developed and implemented, any additional changes will be made to the comprehensive care plan based on the needs of the resident. A review of the facility provided policy, with a review date of 07/12/2024, titled, Splint and Brace Application Policy and Procedure revealed under the section titled Procedure that, OT will evaluate patient for need for splinting, hand roll, or etc. Request an MD order as indicted. Explain procedure to the patient and tell patient to report any adverse effects. Position the patient comfortably. Check patient's skin for decreased sensation, wounds etc. Apply splint, hand roll etc. as per orders. N.J.A.C. 8:39-11.2 (e)

Based on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide treatment and care, based upon current standards of practice specifically by having a urinary catheter drainage bag in contact with the floor, not documenting urinary outputs, and not providing a privacy bag for 2 of 3 residents (Resident # 89, 100) reviewed for Urinary Catheters. The deficient practice was evidenced by the following: On 02/10/2025 at 10:43 AM during the initial tour, Surveyor # 1 observed Resident # 100 in bed. At that time, Surveyor # 1 observed a catheter drainage bag in contact with the floor. A review of Resident # 100's Order Summary located in the Electronic Medical Record (EMR) revealed an order to, Monitor and document [trade name] catheter output every shift. If no output in 8 hours notify MD every shift. The order revealed a start date of 1/06/2025. A review of the Treatment Administration Record located in the EMR revealed blanks in the documentation portion for the following dates: 2/1/2025 - Day - Blank 2/9/2025 - Evening - Blank 1/29/2025 - Evening - Blank 1/31/2025 - Day - Blank On 02/13/2025 at 12:36 PM during an interview with Surveyor # 1, the Director of Nursing (DON) replied, No when asked if catheter drain bags should be in contact with the floor. The DON further replied, Infection when the surveyor asked why not. Lastly, the DON replied, If it's not documented it wasn't done. when the surveyor asked if urinary outputs are blank on the Treatment Administration Record, would you consider that administered. A review of the facility policy titled, Urinary Catheters with a review date of July 20, 2024 revealed under Standards of Care for the Resident with an Indwelling Urinary Catheter that, The catheter collection tubing should be kept from kinking, and the collection bag should always be kept below the level of the bladder (and not touching the floor). N.J.A.C. S 8:39-27.1 (a) 45209 2. Upon initial tour of the facility on 2/10/2025 at 10:20 AM, surveyor #2 observed from the hallway Resident #89's urinary catheter drainage bag with no privacy bag. The surveyor reviewed the medical record for Resident #89. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Metabolic Encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), Diabetes Mellitus, Hemiplegia (paralysis or weakness on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/24/25 included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition as moderately impaired. Review of Section H of the MDS identified Resident #89 with an indwelling catheter. A review of the Medication Administration Treatment (MAR) included the following physician orders (PO): A PO, with a start date of 1/20/2025, to Maintain privacy bag at all times check placement [every] shift. The date of 2/10/2025 was checked with nurses' initials which indicated that the privacy bag was in place. A PO, with a start date of 1/20/2025, to Monitor and document [indwelling catheter] output every shift. In no output in 8 hours notify [Medical Director]. Upon review of the January MAR the following date did not have an output entry: 1/26/2025 Evening shift. Upon review of the February MAR the following date did not have an output entry: 2/4/2025 Evening shift. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 1/21/2025, that the resident was at risk for urinary tract infection (UTI) [related to] catheter use. Interventions included: leg bag or privacy bag as warranted to maintain dignity/privacy and provide catheter care every shift as ordered and (as needed) Monitor for decrease in output. On 2/12/2025 at 12:13 PM, surveyor #2 interviewed Certified Nursing Assistant (CNA #1) who confirmed that urinary drainage bags were to be placed in a privacy bag. When asked how urinary output were monitored, CNA #1 responded that they will empty the bag, measure the amount, and report the output to the nurse who was responsible for documenting the amount. On 2/12/2025 at 12:31 PM, surveyor #2 interviewed Unit Manager Licensed Nurse Practitioner (UMLPN #1) who confirmed that either the CNA or the nurse can empty the urinary drainage bag and measure the amount, but the nurse was responsible for documenting the amount in the chart. When asked how urinary drainage bags are to be maintained at bedside, UMLPN #1 reported that they were to be in a privacy bag. When asked about blanks in the MAR, UMLPN#1 stated that there should never be blanks. On 2/12/2025 at 12:43 PM, surveyor #2 interviewed UMLPN #2 who confirmed that they were familiar with Resident #89. UMLPN #2 stated that urinary drainage bags were to be maintained in a privacy bag and that the nurses were responsible for documentation of the urinary output. Surveyor #2 provided pictures of the urinary drainage device as observed on initial tour. UMLPN#2 confirmed the finding. When asked if there should be blanks on the MAR, UMLPN#2 denied. On 2/12/2025 at 1:47 PM, surveyor #2 interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA) and Administrator in Training, who viewed the surveyors pictures and acknowledged that the urinary drainage device was not in a privacy bag and that urinary outputs were expected to be marked for every shift. A review of the facility's Urinary Catheters Policy, last reviewed 7/20/2024, included under the heading Standards of Care for the Resident with an Indwelling Urinary Catheter: [ .] Collection bags should be emptied from the spigot every shift using a separate collection container for each resident; a foley collection bag cover should be utilized to maintain resident dignity when in bed [ .]. A review of the facility's RN/LPN Job Description document included under the heading Documentation included: A. All documentation is done in a timely manner, using appropriate formats; B. All documentation is properly identified, signed, and dated; C. Documentation [ .]flow sheet information, and care plans are done legibly and filed appropriately [ .]. N.J.A.C. 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 1 out of 3 medication carts inspected under the Medication Storage Task. This deficient practice was evidenced by the following: On 02/12/2025 at 11:39AM in the presence of the Registered Nurse (RN)# 1, the surveyor inspected the medication cart on the subacute high side cart for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 15 Oxycodone-Acetaminophen (a narcotic medication used to treat pain) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 16 were left. At the same time on 02/12/2025 during the interview with the surveyor, RN #1 stated, I just gave that sorry, I should have signed that out. When asked to see what time the medication was given, RN # 1 pulled up the medication on the medication administration record and stated, 10:27 AM. During an interview on 02/13/2025 at 12:36 PM with the surveyor, the Director of Nursing said that narcotics should be signed out in the CDS when removed from the blister pack. Review of the facility's policy titled, Medication Preparation for Administering revised on 02/16/2022, revealed under Medication Administration that 4. As specified by federal and state regulations, controlled substances are documented as given at the time of administration. NJAC 8:39-29.7(c)

Based on observation, interview, and facility provided documentation, it was determined that the facility failed to ensure all medical supplies were stored in accordance with professional standards by having expired supplies in 1 of 2 medication storage rooms inspected. This deficient practice was evidenced by the following: On [DATE] at 11:13 AM the surveyor in the presence of a Licensed Practical Nurse (LPN)# 1, observed the following in the subacute medication storage room: 1. 6 unopened boxes of probe covers with an expiration date of [DATE]. 2. 2 opened boxes of colostomy bags with an expiration date of ,d+[DATE]. 3. 1 unopened box of paper medical tape with an expiration date of ,d+[DATE]. During an interview on [DATE] at 11:13 AM with the surveyor LPN #1 said there should not be any expired medical supplies in the storage room and she removed the items. During an interview on [DATE] at 12:36 PM with the surveyor the Director of Nursing (DON) said he was unaware of expiration dates on supplies, and he would be checking them from now on. The DON also said that there should not be expired items in the storage room. Facility unable to provide a policy on expired supplies. N.J.A.C 8:,d+[DATE].4 (g)

Based on observation and interview, it was determined that the facility failed to provide a sanitary environment by failing to a.) keep the garbage container area free of debris and b.) have a closed cover over the opening the garbage container. This deficient practice was evidenced by the following: On 02/11/25 at 01:09 PM, the surveyor observed the outside garbage area. There were wooden pallets, broken orange plastic pieces, a recliner chair with a rolled-up carpet on top of it, a geriatric chair, a medical glove, a gray container labeled trash, and a commode. These items were not in a container and were in proximity of vehicles. The surveyor observed a green garbage container filled with cardboard boxes. The garbage container was opened on one side exposing the cardboard boxes inside. On 02/12/25 at 11:27 AM, the surveyor observed the garbage area again. There were cardboard boxes spilling out of the garbage container, on the ground, and on top of the half-closed lid. On 02/12/25 at 11:53 AM, the Licensed Nursing Home Administrator (LNHA) stated that the trash is picked up twice per week and if there is overflow then the facility calls the company to pick up. On 02/13/25 at 09:29 AM, the LNHA stated that the garbage and refuse was cleaned up properly. He acknowledged that the cardboard should not have been on the ground and should have been covered. The LNHA stated that the facility did not have a policy that addressed the outside garbage containers. NJAC 8:39-19.7

Based on observation, interview and record review, it was determined that the facility failed to maintain a complete and readily accessible medical records. This deficient practice was identified for 1 of 29 residents reviewed, Resident #70 and was evidenced by the following: On 02/10/2025 at 11:20 AM, the surveyor observed Resident #70 in bed. Resident #70 states he/she feels great. The surveyor reviewed Resident #70's electronic health record and observed a Physician Order dated 1/29/25: hospice evaluation and treat. There was no other documentation in the electronic health record including the care plans and progress notes regarding hospice. Further review of the medical record revealed the resident was admitted to the facility with diagnoses which included dementia and malnutrition. The 1/8/25 minimum data set, an assessment tool, reflected that this resident was not cognitively intact and was not on hospice. On 02/11/25 at 09:13 AM, the surveyor reviewed the hospice binder and the consultation binder at the nurse station no paperwork for Resident # 70 observed. On 02/12/25 at 01:51 PM, during an interview with the Nurse Manager (NM), she stated that her and the Director of Nursing met with Resident #70's family and the family wanted to pursue hospice. The NM stated that there definitely should have been documentation in the electronic health record. She acknowledged that there was no documentation regarding hospice for this resident. On 02/13/25 at 09:47 AM, during an interview with the Director of Nursing, he stated there should have been documentation in the electronic health record regarding the hospice consult. On 02/13/2025 at 11:59 AM, the surveyor reviewed the electronic medical record and observed nurse's notes dated 02/12/2025 (after surveyor inquiry) regarding a conversation with Resident #70's family regarding hospice. A review of the facility provided policy titled, Medical Records Policy and Procedure, with no date reflected that the medical record shall be available and include at least the following information: consultation reports, if a part of a care plan is not implemented, the record shall explain why. NJAC 8:39-35.2 (d)(5)

Based on observation, interview and record review, it was determined that the facility failed to follow safety procedures to protect all residents from falls. Resident #12 experienced a fall and sustained a fracture of the pelvis. This deficient practice was identified for Resident #12, 1 of 3 residents reviewed for falls with injuries. In addition, the facility failed to maintain acceptable water temperatures for 1 of 11 sinks and showers in resident areas. The following evidenced this deficient practice: 1. During a tour of the nursing unit on 12/5/13 at approximately 10:40 a.m., the Unit Manager (UM) stated that Resident #12, who was interviewable, sustained a fractured pelvis while a resident at the facility. The UM stated that she believed that the resident had been ambulating and fell , sustaining the fracture. The UM also stated that Resident #12 ambulated with a rolling walker. During this interview, the surveyor observed that Resident #12 was in bed with his/her eyes closed. On 12/5/13 at 12:47 p.m., the surveyor observed that the resident was eating lunch while seated at the bedside. During this observation, Resident #12 offered no complaints to the surveyor. On 12/6/13 at 9:30 a.m., the surveyor observed Resident #12 who was in bed. When interviewed at this time, Resident #12 stated that he/she had no recollection of the fall that resulted in the resident's fractured pelvis. The resident could not recount any of the events of that day or that incident. On 12/9/13 at 11 a.m., the surveyor reviewed the resident's medical record. The medical record revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was ordered to receive physical and occupational therapies and had been ambulating with a rolling walker. According to an Interdisciplinary Progress Note (IPN), dated 5/2/13 at 7:15 p.m., the Registered Nurse (RN) supervisor was told by the resident's assigned nurse that Resident #12 had sustained a fall while in the shower room and the resident was complaining of pain in the "lower left lap" and groin areas. According to this same IPN, the RN supervisor observed the resident in a wheelchair in the resident's room. According to an IPN, dated 5/2/13 at 8 p.m., the resident's assigned nurse, a Licensed Practical Nurse (LPN), documented that she was approached at 6:40 p.m. by the resident's Certified Nursing Assistant (CNA) who said Resident #12 had sustained a fall. The note indicated that when the LPN questioned the CNA about what had occurred, she was told that Resident #12 had fallen in the shower room. The LPN documented that by this time, Resident #12 was in a wheelchair in the resident's bedroom and not in the shower. According to the LPN's note, the CNA said that the resident had fallen at 6:15 p.m. (25 minutes prior). The LPN's note indicated that she asked the resident what happened and the resident said the CNA told him/her to stand up and the chair rolled away. The resident complained of left hip/groin pain, was administered pain medication and was transported to the hospital for evaluation. The subsequent X-Ray and CT scan reports indicated that Resident #12 had sustained a displaced fracture in the "superior and inferior pubic rami of the left hemipelvis." Resident #12 returned from the hospital on [DATE] with an order for [REDACTED]. According to the 5/14/13 and 5/21/13 weekly "Team Meeting" notes, Resident #12 complained of pain during those weeks. The 5/28/13 weekly note indicated the resident had no further pain complaints. The 6/18/13 discharge from therapy meeting note indicated the resident had no pain complaints, did not remember how the fractured pelvis occurred and was ambulating with a rolling walker. The Incident Report (IR) was reviewed by the surveyor on 12/9/13 at 11:47 a.m. According to this report, the resident's description of the incident was that the shower chair had not been locked and the fall was sustained when the shower chair moved out from under the resident after the resident stood up. There was one statement attached to the report that was written by the CNA who was present at the time of the fall. This CNA documented that at the time of the fall, the shower chair was locked but that it tipped over and the resident fell . The CNA documented that he asked the resident if anything hurt and the resident denied pain at that time. The CNA wrote that the resident complained of abdominal pain a "couple of minutes" later when the resident was seated on the toilet. The Fall Committee Meeting Notes, dated 5/7/13, indicated that the probable cause of the fall was that the shower chair rolled backwards as the resident attempted to stand. The "summary" of the fall was that Resident #12 had finished receiving a shower and was seated in the shower chair which rolled back when the resident attempted to stand. On 12/11/13, the surveyor received the facility's Investigative Summary for the 5/2/13 fall and fracture of Resident #12. According to this Investigative Summary, an additional interview had been conducted with the CNA. According to this follow-up interview, the CNA said he had asked another nursing assistant to help him move Resident #12 from the floor into a regular chair in the shower room then into a wheelchair. The CNA and the nursing assistant then transferred Resident #12 onto the toilet. The CNA had stated that he told the nurse about the fall after the resident complained of pain while on the toilet and that the nurse immediately told him that the resident should not have been moved. The CNA acknowledged that he had done something wrong. An interview with the other nursing assistant confirmed the assigned CNA's account of the incident. This nursing assistant indicated he was unaware of whether or not a nurse had assessed Resident #12 for injuries at the time he assisted the CNA with the transfers. The documented interview with the LPN confirmed that the resident was assessed in a wheelchair in the resident's room. The LPN confirmed educating the CNA that Resident #12 should not have been moved prior to a nurse's assessment. A documented interview with the RN Supervisor confirmed that the resident was assessed in a wheelchair in the resident's room and that an interview with the CNA at that time confirmed that he had transferred and transported the resident before alerting nursing staff to the resident's fall. Resident #12 was transferred from the floor of the shower to a regular chair, then to a wheelchair, then to the toilet, then back to a wheelchair. The resident was then transported to the resident's bedroom before nursing staff was informed of the fall. The Investigative Summary indicated that all shower chairs were tested for brake function and all were operating properly. The Investigative Findings documentation determined that the CNA failed to lock the brakes on the resident's shower chair prior to asking the resident to stand. This CNA failed to notify the nurse of the fall in order to have the resident assessed for injuries prior to moving the resident. The Conclusion portion of the Investigative Summary indicated that the CNA failed to follow the proper safety precautions by not locking the shower chair brakes and did not follow the facility procedure for both informing the nurse of the incident in a timely manner and the failure to have the resident assessed prior to transfer. The CNA and LPN were no longer employed by the facility at the time of the survey. 2. When interviewed by the surveyor on 11/13/2013 at approximately 9:06 a.m., the Director of Maintenance (DM) stated that the water temperatures in the residents' rooms were monitored and logged. The DM stated that the temperatures had registered between 102 to 110 degrees Farenheit (F). During the building tour on 11/13/13 in the presence of the facility's DM, the water temperatures of six resident rooms, two shower/ tub rooms and two public bathroom were obtained by the surveyor in the presence of the DM. At 11:23 a.m., the water temperature at the sink in the Crest unit shower room sink was recorded by the Surveyor and DM at 126 degrees F. At this time, the DM reached under this sink and shut off the domestic hot water supply valve. The DM also notified the Unit Manager that the sink was shut off and not to be used and a sign was placed on the sink. NJAC. 8:39 -31.7(h) 27.1 (a)